我国是一个农业大国

我国是一个农业大国 我国是一个农业大国。尽管近年来工业化和城镇化的发展速度很快，农业人口的非农化率不断上升，1998年，农业人口占全国总人口的比重比1980年下降了6个多百分点，但仍占总人口的68.05%，比世界平均水平(43.47%)高出近25个百分点。农业人口理应成为社会保障改革关注的主要对象，但由于农业生产的特殊性，农业问题的复杂性，以及政府的政策取向等因素的影响，在社会经济发生深刻变化的背景下，农村的社会保障建设没有得到相应的重视，特别是农村人口的医疗保障几乎成了农村社会保障的盲点。这一问题的解决不能脱离我国农村的实际。本文从考察农村医疗保障的历史和现状入手，探讨建立农村医疗保障安全网的对策。 一、农村医疗保障的历史考察 在传统的农业社会中，土地是最基本，也是最重要生产资料，家庭是基本的生产单位。与这种生产方式和生产力水平相适应的社会保障形式是家庭保障。农民的社会保障风险主要来自三个方面:一是土地的收成;二是政府的政策，主要是税收政策;三是子孙的道德风险，主要是养老的风险。从社会保障和社会稳定的角度来看，传统社会有自己的维系机制和安全网政策。首先是推行休养生息政策，以安民养民;其次是倡导伦理道德和宗法，以巩固家庭保障功能;最后是建立以仓储制度和漕运制度为基础的救荒体系。在封建社会，所谓“贤君”、“仁政”无外乎是上述三项工作做得比较好。 从传统社会中农民的社会保障风险及其解决办法可以看出，医疗保障并不是特别重要。究其原因，主要有三点:一是相对于“生存”和“养老”而言，医疗保障问题并不是最紧迫的;二是就疾病风险本身而言，传统社会中农民的疾病风险并不是太大。主要是因为在相对封闭和独立的社会背景下疾病的外部效应并不突出，农民患病，特别是患恶性疾病的风险不太大。当然，在当时公共卫生条件和医疗条件相对较差的情况下，一旦有疫情发生，后果也是相当严重的;三是一般家庭能够承受医疗保障的负担。 除家庭保障外，政府和社会也承担了部分的医疗保障责任，主要是解决穷人的医疗问题。早在南北朝时期，封建王朝就设立了“六疾馆”，以救济贫病之人，这是我国最早的官办慈善救济机构。宋代是官办慈善事业的鼎盛时期，所谓“宋之为治，一本仁厚，振贫恤患之意，视前代尤为切至”。蔡京为相时，曾在全国普遍设立“安济坊”，专门救治贫病老人，它取意于苏轼早年在杭州以私人ith. 3, fill embankment before base and completed the inspection and acceptance of works. 4, before the requirement level elevation sign layout according to the drawing, every nail on the level of a certain distance, elevation of forklift parts according to the design requirements set. 5, according to the site conditions determine the routes of earth-moving machinery, vehicles, and prior checks, reinforce and widen if necessary and other preparatory work. (B) construction processes and methods; 1, process: before filling, and statistics to the existing buildings and trees, the soil on the cave or on the surface of roots, trash and other debris to be cleared. 2, have the soil inspection work. Species of fill, size, check there is no debris, and soil moisture content control within the design range. Tier 3, fill casting: each layer thickness according to soil, density to determine requirements and equipment performance. 4, as needed when rolling, wheel (RAM) track lapping each other, prevent leaks RAM leakage. Aspect is high, filling segments. Each layer into slope-shaped seams, ground track about overlapping 0.5-1.0M, is less than the distance from the upper and lower joints 1M. 5, fill out the base surface, we will do the edge compaction quality assurance work. After the earth-moving, does not require trimming of the slope would be preferable to filling edge fill 0.5 m wide called slope rides on and shoot, wide filling 0.2m. 6, in machinery construction not rolling the filling position, manual blade filled with frog-type ramming machine or diesel hierarchical dynamic compaction-compacting. 9, rain during construction: (1) in the rain during embankment construction, we will be completed as soon as possible a continuous; face do not seek too large, hierarchical segment-by-film basis, important or special backfill, as completed by the rain. (2) in the rain at the time of construction, check all the rain 捐款设置的义诊“安乐坊”。此外，政府还设有惠民药局以提供义诊处方，此处方后改名为“太平惠民和剂局方”。元代在医疗保障方面有了进一步发展，医疗救济被提升为官医提举司与广济提举司，前者是医师，后者管医疗救济事务。另外，在各地普设“医学”为医疗总管。惠民药局继续提供医疗救济工作 。明清时期，随着工商业的发展和资本主义经济关系的萌芽，民间慈善事业空前活跃，其中不乏慈善医疗机构，如乾隆三年(1738)，苏州士绅吴三复在吴县境内盘门外设置普济院，专门收养病妇。 此外，值得一提的是，家族内部对贫病成员的救济也是一种重要的医疗保障形式。宋仁宗皇佑二年(1050)范仲淹知杭州府时，将官俸所入买田收租协济族众，是为族田义庄之滥觞。后代官僚富商纷纷效仿，建置族田义庄，到明清时期盛极一时。族田义庄的一大功能就是赡给“疾病疲癃”。虽然族田义庄最终仍为少数地主所支配控制，没有改变封建地主土地所有制，但客观上它是一个族姓的公产，具有经济共同体的形式，而且就社会效益而言，是贫穷族众得到了实惠。明清时期族田义庄的发展不是偶然的，它有深刻的历史背景，族田义庄的协济办法是与当时半自给半商品经济的个体农民经济想适应的，而且对农民的经济生活乃至个体农户的农业生产都产生了一定影响。由于族田义庄对社会秩序和农业生产起了一定的稳定作用，国家对这种制度采取了保护措施，一方面维护其存在，另一方面优免其差徭 新中国成立后，随着社会性质和社会制度的改变，农村的生产组织形式和分配方式发生了根本变化。同时，随着党和政府对社会主义本质和发展社会主义生产力认识的不断深入，农村工作战略经历了重大调整，农村的生产力水平、生产组织形式和分配方式也随之发生变化。与之相适应，农村的医疗保障模式可分为两个发展阶段，一是20世纪50年代至70年代的合作医疗时期;二是80年代至今农村医疗保障的调整和重构时期。 合作医疗是农业集体化和平均分配制度的产物，而归根结蒂是行政干预的结果。在各级政府的直接干预下，伴随着农业合作化和人民公社的兴起，从1955年起，合作医疗在广大的农村地区迅速建立，“到70年代末期，医疗保险几乎覆盖了所有的城市人口和85%的农村人口，这是低收入发展中国家举世无双的成就” 。合作医疗是一种成本效益很高的医疗保障制度。据世界银行测算，中国人口的预期寿命比基于一国收入和教育所预测的数值要高十多岁，而医疗卫生开支占GDP的比例比预测的数值低近一个百分点，因而被世界银行列入“更好的结果，更低的开支”这一类国ith. 3, fill embankment before base and completed the inspection and acceptance of works. 4, before the requirement level elevation sign layout according to the drawing, every nail on the level of a certain distance, elevation of forklift parts according to the design requirements set. 5, according to the site conditions determine the routes of earth-moving machinery, vehicles, and prior checks, reinforce and widen if necessary and other preparatory work. (B) construction processes and methods; 1, process: before filling, and statistics to the existing buildings and trees, the soil on the cave or on the surface of roots, trash and other debris to be cleared. 2, have the soil inspection work. Species of fill, size, check there is no debris, and soil moisture content control within the design range. Tier 3, fill casting: each layer thickness according to soil, density to determine requirements and equipment performance. 4, as needed when rolling, wheel (RAM) track lapping each other, prevent leaks RAM leakage. Aspect is high, filling segments. Each layer into slope-shaped seams, ground track about overlapping 0.5-1.0M, is less than the distance from the upper and lower joints 1M. 5, fill out the base surface, we will do the edge compaction quality assurance work. After the earth-moving, does not require trimming of the slope would be preferable to filling edge fill 0.5 m wide called slope rides on and shoot, wide filling 0.2m. 6, in machinery construction not rolling the filling position, manual blade filled with frog-type ramming machine or diesel hierarchical dynamic compaction-compacting. 9, rain during construction: (1) in the rain during embankment construction, we will be completed as soon as possible a continuous; face do not seek too large, hierarchical segment-by-film basis, important or special backfill, as completed by the rain. (2) in the rain at the time of construction, check all the rain 家 。由于农村人口占我国总人口的绝大多数，因此，农村人口在一些可以进行国际比较的医疗卫生指标中的权重很大，世界银行的评估在一定程度上是对农村合作医疗制度的肯定。事实上也是如此。农民的人均预期寿命从20世纪30年代的34岁提高到了70年代末的68岁，增长了一倍。合作医疗连同村级保健站、“赤脚医生”被国际社会誉为中国农村医疗卫生的“三件法宝”，对于解决农村地区缺医少药的问题，有效保障农村人口的身体健康起到了重要作用。 但是，进入80年代后，随着家庭联产承包责任制的实行和集体经济成分的减少，合作医疗出现了严重滑坡。卫生部1998年进行的“第二次国家卫生服务调查”结果显示，全国农村居民参加合作医疗的比重仅为6.5% 。那么，这样一种高成本效益的医疗保障制度为什么会在短短二三十年内大起大落呢,笔者以为，合作医疗的消退有一定的必然性。合作医疗毕竟是特定历史条件下的产物，其经济基础过于脆弱，缺乏可持续发展的能力。没有可持续发展的经济支撑，合作医疗制度的滑坡在所难免。 合作医疗在农村地区消失殆尽以后，农民的医疗保障又回到了自费式的家庭保障模式。据调查，1998年农村的自费医疗占农村医疗保障的87.44% ，也就是说，绝大多数的农村人口没有任何形式的医疗保险，这在农民的市场风险和疾病风险日益增大的情况下是很危险的，也是很不公平的。如何构建新的农村医疗保障安全网，以填补合作医疗退出后的“真空”，切实保障广大农村人口的身体健康，是农村医疗保障急需解决的问题，也是本文将要探讨的内容。 通过对农村医疗保障历史的考察，我们可以得出以下几点结论: 第一，一定的社会保障形式是与一定的生产力水平、生产组织形式和分配制度相适应的。在自给自足的小农经济时代主要是家庭保障和自费医疗。在农业集体经济时代以合作医疗为主。后集体经济时代最大的特点就是各地的生产力水平，主要体现为收入水平，参差不齐;生产组织形式和分配制度强调效率。这些基本特性决定了新的农村医疗保障模式应是一个多元化的、充分考虑成本效益的制度。 第二，新的农村医疗保障模式应建立在继承和发展旧模式的基础上。从前面的分析我们可以看出，尽管合作医疗和传统的家族协济所反映的生产关系有本质的不同，但两者的形式有相似的地方，那就是财产公有，风险分担，只是分散风险的程度不同，前者以地缘为基础，而后者以血缘为基础。因此，合作医疗比家族协济的效果好得多。但不管怎样，两者有一定的承继关系。这也告诉ith. 3, fill embankment before base and completed the inspection and acceptance of works. 4, before the requirement level elevation sign layout according to the drawing, every nail on the level of a certain distance, elevation of forklift parts according to the design requirements set. 5, according to the site conditions determine the routes of earth-moving machinery, vehicles, and prior checks, reinforce and widen if necessary and other preparatory work. (B) construction processes and methods; 1, process: before filling, and statistics to the existing buildings and trees, the soil on the cave or on the surface of roots, trash and other debris to be cleared. 2, have the soil inspection work. Species of fill, size, check there is no debris, and soil moisture content control within the design range. Tier 3, fill casting: each layer thickness according to soil, density to determine requirements and equipment performance. 4, as needed when rolling, wheel (RAM) track lapping each other, prevent leaks RAM leakage. Aspect is high, filling segments. Each layer into slope-shaped seams, ground track about overlapping 0.5-1.0M, is less than the distance from the upper and lower joints 1M. 5, fill out the base surface, we will do the edge compaction quality assurance work. After the earth-moving, does not require trimming of the slope would be preferable to filling edge fill 0.5 m wide called slope rides on and shoot, wide filling 0.2m. 6, in machinery construction not rolling the filling position, manual blade filled with frog-type ramming machine or diesel hierarchical dynamic compaction-compacting. 9, rain during construction: (1) in the rain during embankment construction, we will be completed as soon as possible a continuous; face do not seek too large, hierarchical segment-by-film basis, important or special backfill, as completed by the rain. (2) in the rain at the time of construction, check all the rain 我们一个道理，旧的医疗保障模式有许多合理的地方。在农村地区由传统转向现代的过程中，任何单一的医疗保障模式都是独木难支的。以优良的传统美德为基础的家庭保障和社会互助是可资利用的社会资源;而合作医疗是一种有中国特色的农村医疗保障模式，曾发挥过重要的历史作用，尽管现在恢复起来有很大难度，但合作医疗形式不能放弃。同时我们也应该看到，旧的医疗保障模式有许多需要改造和发展的地方。以家庭保障为主的保障模式显然难以承受现代社会的风险;合作医疗也有一定的缺陷，首先，它的经济基础比较脆弱，需要寻找可持续性的经济支撑;其次，它具有高度的强制性;最后，它也是一种平均分配制度。因此，现阶段对合作医疗的改造主要是要消除它的时代痕迹，使之更适合农村的现状，从而充分发挥其低投入、高效益的特点。但是，合作医疗毕竟只是一种低水平、小范围的医疗保障形式，尽管它现在很符合我国的国情，但从医疗保障社会化的发展方向来看，它最终会被其他的保障形式(如社会保险、商业保险等)所取代。 第三，政府的适当干预必不可少。在小农经济时代，自然灾害对农业生产的影响很大，但历史学家研究发现，自然灾害并不是农民最害怕的，他们担心的是，灾变发生以后，政府能不能及时予以救济。如果政府的救济不能及时到位，势必引发社会动荡。因此，历代的封建政府都有自己的救荒救济政策。我国目前正处在社会经济的转型时期，社会成员面临着前所未有的各种风险和不确定性，政府采取干预措施，保障社会成员的安全和权益至关重要。当然，象六、七十年代强制推行合作医疗那样的绝对干预措施也是不可取的，同时也是不可能的。 二、农村医疗保障的现实问题 如上所述，目前，我国农村医疗保障制度正处在调整和重构时期，它所面临的形势非常严峻，具体来说，存在以下一些主要问题: 第一，费用增长过快，超过了农民的承受能力。尽管改革开放以来农民的收入有了显著提高，但收入的增长速度赶不上医疗费用的增长速度。1990至1999年间，农民人均纯收入增长了2.2倍，而同期的门诊费用和住院费用分别增长了6.2倍和5.1倍，特别是1999年，平均每一出院者的住院医疗费超过了农民的人均收入(见表1)。医疗费用的增幅大大超过了农民的承受能力。 表1 农民人均收入与医疗费用比较 单位:元 ith. 3, fill embankment before base and completed the inspection and acceptance of works. 4, before the requirement level elevation sign layout according to the drawing, every nail on the level of a certain distance, elevation of forklift parts according to the design requirements set. 5, according to the site conditions determine the routes of earth-moving machinery, vehicles, and prior checks, reinforce and widen if necessary and other preparatory work. (B) construction processes and methods; 1, process: before filling, and statistics to the existing buildings and trees, the soil on the cave or on the surface of roots, trash and other debris to be cleared. 2, have the soil inspection work. Species of fill, size, check there is no debris, and soil moisture content control within the design range. Tier 3, fill casting: each layer thickness according to soil, density to determine requirements and equipment performance. 4, as needed when rolling, wheel (RAM) track lapping each other, prevent leaks RAM leakage. Aspect is high, filling segments. Each layer into slope-shaped seams, ground track about overlapping 0.5-1.0M, is less than the distance from the upper and lower joints 1M. 5, fill out the base surface, we will do the edge compaction quality assurance work. After the earth-moving, does not require trimming of the slope would be preferable to filling edge fill 0.5 m wide called slope rides on and shoot, wide filling 0.2m. 6, in machinery construction not rolling the filling position, manual blade filled with frog-type ramming machine or diesel hierarchical dynamic compaction-compacting. 9, rain during construction: (1) in the rain during embankment construction, we will be completed as soon as possible a continuous; face do not seek too large, hierarchical segment-by-film basis, important or special backfill, as completed by the rain. (2) in the rain at the time of construction, check all the rain 1990 1995 1999 1990-1999年平均增幅(%) 农民人均纯收入平均每一人次门诊医疗费平均每一出院者住院医疗费 686.3110.9473.3 1577.7429.61273.0 2210.3479.02891.1 13.8024.5322.25 资料来源:陈佳贵主编:《中国社会保障发展》(1997-2001)，第291页，社会科学文献出版社2001年。 第二，绝大多数的农村人口没有任何形式的医疗保险。据调查，有医疗保险(包括合作医疗、商业医疗保险、公费医疗、半公费医疗、统筹医疗等形式)的农村居民仅占农村总人口的12%左右，其余均为无保险人士。中国“农村人口日益依赖政府提供卫生保健的系统，这一系统的费用一部分来自财政收入，但相当大一部分通过向患者受费来收回成本，而这一点与其他低收入国家占主导地位的制度不同”。中国在卫生保健领域曾创造过“举世无双的成就”，但80年代以后，农村人口又面临着前所未有的风险，因此，世界银行中国的医疗保障制度“一直是低收入国家的一个例外” 第三，医疗服务质量低下。虽然就医疗水平而言，农村和城市不可同日而语，但农村地区医疗服务质量之低足实让人吃惊。主要表现在农村医护人员专业素质低、医疗设施简陋、医疗条件差、医疗事故频发等方面。同时，农村地区还是伪劣药品的主要市场。据卫生部门对安徽省肥西县的调查，截至1999年6月，全县村级医疗点中约40%无执业许可证;从业人员中约45%没有专业学历。该县董岗乡13家村卫生室均没有高压灭菌设备，没有紫外线灯管;抽检14份消毒标本，竟有12份有致病菌生长;抽检24种药品，不合格的有6个批次，此外还有一些来路不明的药品。同年，该县农村孕妇死亡率高达万分之六。应该看到，肥西县只是全国农村的一个缩影。农村人口的生命健康面临严峻挑战，一些健康指标开始恶化。 第四，医疗卫生资源配置不合理，农村人口的医疗可及性差。首先表现在医疗卫生资源在城乡之间配置不合理，农村人口占有的卫生资源大大低于全国平均水平。通过表2的数据可以清楚地看到这种差别。其次，就农村现有的医疗卫生资源来说，其配置也是不合理的。主要表现在乡镇卫生院人员臃肿而技术力量薄弱;村级医疗点的分布不尽合理，出现了医疗服务的死角和盲点。据ith. 3, fill embankment before base and completed the inspection and acceptance of works. 4, before the requirement level elevation sign layout according to the drawing, every nail on the level of a certain distance, elevation of forklift parts according to the design requirements set. 5, according to the site conditions determine the routes of earth-moving machinery, vehicles, and prior checks, reinforce and widen if necessary and other preparatory work. (B) construction processes and methods; 1, process: before filling, and statistics to the existing buildings and trees, the soil on the cave or on the surface of roots, trash and other debris to be cleared. 2, have the soil inspection work. Species of fill, size, check there is no debris, and soil moisture content control within the design range. Tier 3, fill casting: each layer thickness according to soil, density to determine requirements and equipment performance. 4, as needed when rolling, wheel (RAM) track lapping each other, prevent leaks RAM leakage. Aspect is high, filling segments. Each layer into slope-shaped seams, ground track about overlapping 0.5-1.0M, is less than the distance from the upper and lower joints 1M. 5, fill out the base surface, we will do the edge compaction quality assurance work. After the earth-moving, does not require trimming of the slope would be preferable to filling edge fill 0.5 m wide called slope rides on and shoot, wide filling 0.2m. 6, in machinery construction not rolling the filling position, manual blade filled with frog-type ramming machine or diesel hierarchical dynamic compaction-compacting. 9, rain during construction: (1) in the rain during embankment construction, we will be completed as soon as possible a continuous; face do not seek too large, hierarchical segment-by-film basis, important or special backfill, as completed by the rain. (2) in the rain at the time of construction, check all the rain 国家统计局提供的数据，1999年全国没有设置医疗点的行政村有73600个，占行政村总数的一 成多，而有些村却有两个或两个以上的诊所。 ith. 3, fill embankment before base and completed the inspection and acceptance of works. 4, before the requirement level elevation sign layout according to the drawing, every nail on the level of a certain distance, elevation of forklift parts according to the design requirements set. 5, according to the site conditions determine the routes of earth-moving machinery, vehicles, and prior checks, reinforce and widen if necessary and other preparatory work. (B) construction processes and methods; 1, process: before filling, and statistics to the existing buildings and trees, the soil on the cave or on the surface of roots, trash and other debris to be cleared. 2, have the soil inspection work. Species of fill, size, check there is no debris, and soil moisture content control within the design range. Tier 3, fill casting: each layer thickness according to soil, density to determine requirements and equipment performance. 4, as needed when rolling, wheel (RAM) track lapping each other, prevent leaks RAM leakage. Aspect is high, filling segments. Each layer into slope-shaped seams, ground track about overlapping 0.5-1.0M, is less than the distance from the upper and lower joints 1M. 5, fill out the base surface, we will do the edge compaction quality assurance work. After the earth-moving, does not require trimming of the slope would be preferable to filling edge fill 0.5 m wide called slope rides on and shoot, wide filling 0.2m. 6, in machinery construction not rolling the filling position, manual blade filled with frog-type ramming machine or diesel hierarchical dynamic compaction-compacting. 9, rain during construction: (1) in the rain during embankment construction, we will be completed as soon as possible a continuous; face do not seek too large, hierarchical segment-by-film basis, important or special backfill, as completed by the rain. (2) in the rain at the time of construction, check all the rain