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題名：中國鄉鎮醫院醫生執業穩定性之研究
作者：于鎬源
作者(外文)：Hao-Yuan Yu
校院名稱：中原大學
系所名稱：商學博士學位學程
指導教授：李正文
學位類別：博士
出版日期：2021
主題關鍵詞：鄉鎮醫院；農村醫療服務；執業穩定性；工作滿意度；離職意向；Township hospital；Rural medical service；Practice stability；Job satisfaction；Turnover intention
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摘 要
鄉鎮醫院在中國的醫療衛生服務體系中扮演著非常重要的角色，既是醫療服務體系運行的堅實基礎，也是占總人口數量70%的農村居民健康的有力保障。然而，自20世紀80年代以來，鄉鎮醫院醫生流失的現象愈發嚴重，對醫院的有效運轉產生了極大的衝擊，影響了醫療衛生服務品質的提升，嚴重制約農村基層醫療衛生服務事業的健康發展，更是阻礙了醫改政策貫徹落實的進程。
與鄉鎮醫院骨幹醫生流失相對應，八十年代的中國剛剛開始改革開放，國家財政力量薄弱，在醫療服務上的投入嚴重不足，允許社會資本進入醫療服務行業成為一個有效的解決方案，尤其是幾十年來西方國家在公共服務領域成功的民營化經驗也為解決這一事關民生的供需矛盾提供了理論與實踐的支持。因此，民營化被引入中國基本醫療服務行業，這在一定程度上緩解了當時中國醫療服務供給嚴重不足的狀況。但是，因為受到國家政治體制的制約，民营医院在員工招聘層面，無法和城市中的公立醫院相抗衡，醫生嚴重缺乏。因此，沒有職業發展前景，長期處於低收入水準的鄉鎮醫院醫生成為民營醫院重要的醫生來源。從而造成了鄉鎮醫院骨幹醫生的大量流失，農村醫療服務供給不足狀況反而更加惡化。
在這樣的背景下，中央政府以及各級地方政府對基層醫療機構的發展扶持投入大幅增加。但政府投入支持的重點主要集中在改善醫院的設備，環境等基礎設施，而對於改善醫生執業穩定性方面的投入依然嚴重不足，也使得鄉鎮醫院人才流失率始終居高不下的趨勢難以扭轉。醫生執業的稳定性是影響醫療衛生服務品質的關鍵因素，沒有穩定執業的醫生，鄉鎮醫院就不能很好的開展醫療衛生服務工作，無法為民眾提供良好的醫療服務，更是難以在三級醫療衛生服務網路中起到承上啟下的關鍵作用，國家的政策就不能真正落實。
有鑑於此，研究如何吸引並穩定一支高水準的醫生隊伍到鄉鎮醫院工作，對落實國家完善基層醫療衛生保障，具有重要的意義。本研究根據市場經濟相關理論，結合公共服務理論，從鄉鎮醫院醫生的工作環境、醫院管理能力、生活環境、薪酬福利、職業發展和繼續教育機會等幾個方面，結合改革開放以來鄉鎮醫院醫生的流動性特徵，對中國貴州省部分地區的鄉鎮醫院醫生離職意願進行了充分的考察與操作層面的微觀分析。充分運用訪談，問卷調査與文獻資料的查閱等方法獲取真實有效的一手資料，採用文獻研究法，實證研究法對所得數據進行前期處理，最後採用SEM模型對本研究所提出的假設進行驗證，以明確鄉鎮醫院醫生執業穩定性和各研究假設之間的關係。
本研究的結果認為，如果要維持高水準的醫療服務，高水準醫生就要有較高的執業穩定性。在中國現有的醫院運行體制的框架下，鄉鎮層面的醫療服務市場化程度越高，醫生的執業穩定性就越高，醫療服務的品質就越高。希望藉此為鄉鎮醫院吸引和穩定人才，進一步完善設施以及更好的促進中國鄉鎮醫療服務供給水準提供有益的幫助。
關鍵字: 鄉鎮醫院、農村醫療服務、執業穩定性、工作滿意度、離職意向
Abstract
Township hospitals play a very important role in China's medical and health service system, which is not only a solid foundation for the operation of the medical service system, but also a strong guarantee for the health of rural residents who account for 70% of the total population. However, since the 1980s, the brain drain of doctor in township hospitals has become more and more serious, which has a great impact on the effective operation of hospitals, affected the improvement of the quality of medical and health services, seriously restricted the healthy development of rural grass-roots medical and health services, and even hindered the implementation of medical reform policies.
Corresponding to the loss of key doctors in township hospitals, China has just started the reform and opening up in the 1980s. The national financial strength is weak, and the investment in medical services is seriously insufficient. Allowing social capital to enter the medical service industry has become an effective solution, especially the successful experience of privatization in the field of public services in western countries over the past decades has also provided theoretical and practical support for solving the contradiction between supply and demand, which is related to people's livelihood. Therefore, privatization has been introduced into China's basic medical service industry. This, to a certain extent, alleviated the serious shortage of medical service supply in China at that time. However, due to the constraints of the national political system, private hospitals cannot compete with public hospitals in the city in terms of staff recruitment, and there is a serious lack of doctors. Therefore, there is no prospect for career development, and doctors in township hospitals, who have long been at a low-income level, have become an important source of doctors in private hospitals. As a result, a large number of backbone doctors in township hospitals have been lost, and the situation of insufficient supply of rural medical services has worsened.
In this context, the central government and local governments at all levels of the development of grassroots medical institutions to support investment increased significantly. However, the government's investment mainly focuses on the improvement of hospital equipment, environment and other infrastructure, and the investment in improving the stability of doctors' practice is still seriously insufficient, which makes it difficult to reverse the trend of high brain drain rate in township hospitals. The stability of doctors' practice is the key factor affecting the quality of medical and health services. Without stable doctors, township hospitals cannot carry out medical and health services well, and cannot provide good medical services for the public. It is even more difficult to play a key role in connecting the preceding and the following in the three-level medical and health service network, and the national policies cannot be truly implemented.
In view of this, research on how to attract and stabilize a team of high-level doctors to work in township hospitals is of great significance to the implementation of the country's improvement of primary medical and health care. According to the theory of market economy and the theory of public service, this study focuses on the working environment, hospital management ability, living environment, salary and welfare, career development and continuing education opportunities of doctors in township hospitals, combined with the mobility characteristics of doctors in township hospitals since the reform and opening up, the turnover intention of doctors in township hospitals in some areas of Guizhou Province was fully investigated and analyzed from the operational level. Full use of interviews, questionnaire survey and literature review methods to obtain real and effective first-hand data, using literature research method, empirical research method to preprocess the data, and finally using SEM model to verify the hypotheses put forward in this study, in order to clarify the relationship between the practice stability of doctors in township hospitals and the research hypotheses.
The results of this study suggest that if high-level medical services are to be maintained, high-level doctors must have high practice stability. Under the framework of China's existing hospital operation system, the higher the degree of marketization of medical services at the township level, the higher the practice stability of doctors and the higher the quality of medical services. It is hoped to provide beneficial help for township hospitals to attract and stabilize talents, further improve facilities and better promote the supply level of township medical services in China.
Keywords: Township hospital, Rural medical service, Practice stability, Job satisfaction, Turnover intention
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