How to treat the sudden turn of medical reform today? To this end, this newspaper first published two groups of reports. The first group focuses on the micro-level, showing the radical market-oriented reform in Suqian, Jiangsu, the rural cooperative medical care in Wuyuan, Jiangxi, and the tortuous restructuring process of a hospital. This group of reports focuses on the historical context of medical reform and how the medical reform in China came about. We try to restore a general background.
Today, it has been 20 years since the medical reform, and we stand at the crossroads again, looking back at history at this node. Perhaps we can see that the simple negation and affirmation of China's medical reform, a "intractable disease", are too rash, and more patience, wisdom and courage are needed to reflect on the problem and find a good solution.
In the midsummer of 2005, the controversy about China's medical reform intensified. "It is difficult and expensive to see a doctor" has become a heart disease for the people. According to the data of the third national health service survey released by the Ministry of Health, about 48.9% residents in China do not seek medical treatment because of illness, and 29.6% residents should be hospitalized instead of hospitalized.
Is the medical reform left or right? Whether the government is leading or the market has the final say, the two sides are arguing endlessly and undercurrents are surging.
Little known is that the debate on this issue has been going on for a long time. With the medical reform process for 20 years, it has finally reached a critical moment that must be solved.
1980' s: give the policy without giving money.
The time limit of medical reform is generally calculated from the reform of 1985, but if we trace back to the source, the first sentence of starting medical reform in China is: "Health departments should also act according to economic laws!"
This statement was issued on 1979 New Year's Day. In an interview with Xinhua News Agency, Qian Xinzhong, then Minister of Health, proposed to "manage health undertakings by economic means".
At this time, the reform and opening up has just begun. In rural areas, the household contract responsibility system has been popularized, while in cities, everything seems very deserted. Qian Xinzhong's speech at the moment is bold and avant-garde.
In fact, the Ministry of Health began to "warm up" this reform as early as a year ago. At the Nanchang meeting held in March of that year, the Ministry of Health clearly put forward the economic management of hospitals, but it really started until 1979.
"At that time, Minister Qian Xinzhong and Vice Minister Ji Zongquan were the main promoters," recalled an old cadre of the Ministry of Health. "They take turns talking about this and encouraging the health system to' let go'."
The landmark event was that the Ministry of Health and other three ministries jointly issued the Notice on Strengthening the Pilot Work of Hospital Economic Management. Since then, the Ministry of Health has launched the "Five Awards" (that is, setting tasks, beds, personnel, business technical indicators, economic subsidies, and rewards for completing tasks), and began to try out "fixed subsidies, economic accounting, and assessment rewards" for hospitals. Five hospitals in Heilongjiang, Jilin, Shandong, Hebei and Zhejiang were listed as "demonstration".
For this reform, Qian Xinzhong thought it was "of great significance to promote medical and health modernization", but many people opposed it.
Almost from the beginning, this reform has been hotly debated. The Health Newspaper under the Ministry of Health compiled seven articles with different opinions in the "Situation Report" of June 1979+065438+ 10/6.
"The main purpose of these articles is to start from the fundamental attributes of hospitals and think that medical and health care should be a social welfare undertaking, and its economic attributes should not be emphasized." A veteran cadre of the health system recalled.
However, the hospital management under the traditional planned economy mode has exposed many disadvantages at this time, and the reform has become the general trend. From 198 1 to 1989, a central document is issued every three or four years, and the key document is 1984. The Ministry of Health drafted the Report on Several Policy Issues of Health Work Reform, which pointed out that
It is under this policy that 1985 became the starting year of medical reform, while the previous one can only be regarded as hospital reform. A veteran cadre of the Ministry of Health said, "The core idea of the officially launched medical reform is to decentralize and benefit, expand hospital autonomy, and basically copy the model of state-owned enterprise reform."
Although it is also proposed in this document that the central and local governments should gradually increase their investment in medical and health care, the situation is undergoing subtle changes in practice.
A leader of the Policy and Regulation Department of the former Ministry of Health told this reporter that the background at that time was that everything had to be done, and medical care could not be the first consideration. Therefore, the means of reform was clear from the beginning-"no money for policy".
During this period, there were two typical reforms, one was the "Sheikh experience" of changing the management mechanism, and the other was the "Kunming experience" of socialization of logistics services, which was highly respected in the national health system.
According to the statistical data at that time, the efficiency and general hygiene of hospitals have been continuously improved. 1985 The utilization rate of hospital beds at or above the county level was 87.9%, which remained until the early 1990s. In rural areas, with the implementation of the contract responsibility system, a large number of rural clinics are contracted to rural doctors. According to the statistics of 1988, it is operated collectively by the village or the masses.
In this process, the financial investment in health began to decrease gradually in the whole proportion. Taking Jiangsu Province as an example, the proportion of provincial financial subsidies to total hospital salaries is 60.39% in 1985 and 3 1% in 1988.
The same is true for the whole country. Statistics show that in 1980, government health expenditure accounted for 1/3 of the total health expenditure, and in 190 it decreased to 1/4.
"Things are often like this, and the enthusiasm for starting is very high. Once the overall situation is rolled out, the drawbacks will come out. " A leader of the Policy and Regulation Department of the former Ministry of Health said frankly.
At that time, a series of chaos began to appear, and doctors went to acupoints and turned on rice cookers, which became a hot topic at that time.
"But the debate during this period was not fierce," recalled Yu, former director of the Department of Medical Administration of the Ministry of Health. "Other ministries often complain when they see the poor quality of hospital services and Minister Chen (). Many people say that this is caused by incomplete marketization. "
1990s: great debate
1992 spring, China set off a new wave of reform.
In this context, medical reform is once again put on the agenda. "After a year or two, other departments, industries and various industrial departments have been established, and even their own sites have been dug away by others, and the market and the masses will not need your products." Chen Minzhang, then Minister of Health, said at the symposium of health directors of seven provinces and cities in East China. "
"Building depends on the country, eating depends on ourselves". At this time, all walks of life are popular, and the health system has joined the team. 1September 1992, the State Council issued "Several Opinions on Deepening Medical Reform".
Chi Baolan, then director of the Department of Medical Administration of the Ministry of Health, later requested at the meeting that the hospital should make new achievements in "assisting medicine with industry" and "giving priority to assistance".
Since then, new things such as roll call surgery, special care and special wards have mushroomed in the medical system. It is at this stage that the debate within the health system is flourishing day by day. Around "whether hospitals fall into the eyes of money" and around government-led or market reform, the two views begin to be tit for tat.
Within the Ministry of Health, the Department of Policies and Regulations and the Department of Medical Administration have become the representative departments of the two opinions. According to the procedure, the Policy and Regulation Department is responsible for drafting documents. "That is the secretary team of the minister, responsible for macro thinking, while the medical and political department is mainly hospital management and responsible for practice." Yu said, former director of the Department of Medical Administration of the Ministry of Health.
Oppose the marketization of medical services. He believes that the practice in the economic field cannot be simply transplanted to the field of health services. "If we ignore this point, it will lead to the investment of money-making resources in any link. Whoever has more money will enjoy better medical services, without considering the publicity of medical care and the minimum social equity."
This argument is no longer confined to the inside. His views were later published in February 2 1993+ 1, the internal reference of Xinhua News Agency, and were presented to the desks of state leaders.
The focus of the debate broke out at the national medical and political work conference in May, 1993. Yin Dakui, then vice minister of health, clearly expressed his opposition to the marketization of medical services in his report, which was immediately considered as "conservative and opposed to reform". The views of the two factions were at loggerheads at the meeting.
An interesting episode is that the debate at this health conference even spread abroad. After hearing the news, Xiao Qinglun, a professor at Harvard University, flew from the United States to China and made a special trip to protest to Health Minister Chen Minzhang: "China must never go the way of the United States. The commercialization of the American medical industry is too serious, and ordinary Americans are miserable. "
What happened in the medical field at this time, which led to such a big debate? Perhaps we can see some clues from the following examples.
Zhang Haochen, vice president of Pharmaceutical Industry Information magazine, works in a public hospital in Henan. "That mess, run private hospitals like run township enterprises. Public hospitals cooperate everywhere to run specialties, and doctors and experts go everywhere. "
Yi Lee devoted himself to medical device business from 65438 to 0993, which coincided with the marketization of drug circulation channels. "I don't know how many millionaires this medicine has created." According to the "regulations", Yi Lee paid commissions to doctors and hospitals, and became rich in a blink of an eye, accumulating tens of millions of yuan.
Ding Huiwen, a medical expert, was the business dean of the First Affiliated Hospital of Xi Medical University. At that time, the government's financial subsidies only accounted for about 10% of the hospital's total income. The situation of the top three hospitals where he works is relatively stable, but many small and medium-sized hospitals are facing the dilemma of not paying wages.
The hierarchical management of hospitals is only to offset some negative effects, and it is implemented under the promotion of the Department of Medical Administration. The then Minister of Health said, "This is a good idea. What the Ministry of Health wants to approve and oppose can be reflected through evaluation. Hospitals have also formed orderly cooperation and competition under the control of the government. "
But hierarchical management is only a technical means. How to solve the "route" dispute? Throughout the1990s, the voice of marketization has been in a dominant position.
According to statistics, as of 2000, China's health service was still developing at a high speed under the condition of insufficient state investment. Li Weiping, a researcher at the Institute of Health Economics of the Ministry of Health, said that the number of health institutions in 1980 was180,000, and by 2000 there were 320,000.
2000: The Horn of Property Rights Reform
At the first dawn of 2000, many people spent their time watching, and the land of China was full of longing for the new century.
Also in this year, Suqian City, Jiangsu Province started the hospital reorganization which was later called "marketization".
-selling hospitals.
The source of this move comes from February of that year, when the State Council published some draft guiding opinions on the reform of urban medical and health system. The Opinions clarified several principles such as separation of medicine.
In this opinion, Suqian was "inspired" by such items as "encouraging all kinds of medical institutions to cooperate and merge", "setting up medical service groups, liberalizing medical service prices of for-profit medical institutions, operating independently according to law, and paying taxes according to regulations", which was also the name of Suqian medical reform brewed by 1999.
In the past five years, except for two public hospitals in Suqian, all the other 133 public hospitals have been auctioned, and the Suqian government introduced itself that "the medical industry basically realized the complete withdrawal of government capital".
In this regard, this newspaper reported the case on July 2 1 2005 with the title "Suqian Medical Reform, Five Years of Great Changes".
In fact, before 1999, 18 township hospitals and three municipal hospitals had been auctioned in Haicheng, Liaoning, and all township hospitals had been sold in Xiaoshan, Zhejiang. Linyi, Shandong, Tongjiang, Sichuan and Shehong also began to auction hospitals.
All this is mainly due to insufficient financial input. The absolute amount of government health expenditure has increased year by year, but its proportion in the total health expenditure has been declining: from 65,438+32.2% in 0,978 to 65,438+05.2% in 2002, with a decrease of 65,438+07 percentage points in 24 years.
Ding Ningning, director of the Social Development Research Department of the State Council Development Research Center, analyzed that "health expenses mainly come from local finance", and local financial resources are unwilling to invest, which has continuously aggravated the uneven distribution of medical resources in China.
"The impulse of local finance to unload the burden is one of the important driving forces for the marketization of medical reform," said a researcher. "Even if it is simply analyzed from the interest pattern, local governments, hospital managers and investors are all beneficiaries, and the interests of the health sector are undoubtedly damaged. Very simply, the hospital was sold and the jurisdiction was undoubtedly greatly reduced. "
At this juncture, in 2003, the SARS epidemic swept across the country, and China began to reflect on the loopholes in the public health system, and then began to review the entire health cause.
In August 2003, as soon as the SARS epidemic ended, the Ministry of Health appointed three officials to investigate Suqian, once the most market-oriented medical reform city. As a result, Ge Zhijian, director of Suqian Health Bureau, got a classic criticism that has been widely quoted so far-"Are you still the director of health?"
However, within the Ministry of Health, the opinions of "government-led faction" and "market-led faction" are similar, and both government-led and market-led have sufficient reasons. For Suqian's medical reform, the leaders of the Ministry of Health finally left a sentence-Suqian's medical reform has two opinions and continues to investigate.
The dispute over Suqian's reform was another confrontation between the two factions, which ended in shelving. Shortly thereafter, Wu Mingjiang, then director of the Policy and Regulation Department of the Ministry of Health, said at a medical reform seminar held by the Chinese People's Political Consultative Conference that the state would "take a step back" in the reform of the medical system and the government would only run some public hospitals.
"This speech is considered to be the clarion call for property rights reform." An expert in the medical system said. There are even rumors that "governments at all levels will only keep one or two large hospitals that provide basic medical services, and other hospitals will gradually open to external capital".
In 20041October 20th, 165438, a medical investment consultant couldn't wait to announce in the media: "Let the hospital reform come more violently!"
"It's so exciting," said an expert employed by American medical investment group. At least $6 billion of capital is waiting to buy hospitals in China. "China's medical market may experience explosive growth similar to that of the United States in the 1970s."
China Medical Institutions Investment and Financing Forum also revealed to the media at the end of 2004 that nearly 10 billion yuan of private and foreign capital will participate in the restructuring of nearly 100 hospitals in China. At that time, statistics showed that by 2005, the total market value of China medical industry would be 640 billion yuan.