信仰的变革与回归:倡议联盟框架下中国医疗卫生政策变迁研究

摘要

Based on the advocacy coalition framework,the game between policy alliances with different beliefs is regarded as a key factor contributing to the long-term policy changes. At the same time, the policy changes are seen as the product of the antagonism of the core faith of the alliance, the policy-oriented learning and the internal and external shocks of the coalitions. The change of China's health care policy has always been accompanied by the debate on whether fairness or efficiency should be given priority between"government-led"and"market-oriented"coalitions. Its evolving characteristics are consistent with the explanatory logic of the advocacy coalition framework. Based on the advocacy coalition framework this paper makes a comprehensive of review of the historical literature on Chinese medical and health policy,it founds out that advocacy coalitions with different beliefs are critical to the re-form and return of the health care policy, policy-oriented learning promotes the gradual change of the policy, while internal and external shocks provide opportunities for policy paradigm change. Besides,the more passive and lack of active initiatives of policy change,the government's bias of the public welfare feature of the medical business coupled with the underdevelopment of market economy are the main causes for lagging medical policy and frequent industry chaos. To this end,it is recommended to highlight the forward-looking policy,strengthen the internal drive,create a more liberal debate environment for the coalitions,promote the learning of policy orientation among coalitions to en-hance the scientific and effective medical and health policy change.%倡议联盟框架将具有不同信仰的政策联盟之间的博弈作为解释长时段政策变迁的关键性因素,同时将政策变动视为联盟间核心信仰的对立、政策取向的学习和联盟内外部震荡共同作用下的产物.我国医疗卫生政策变迁历程始终伴随着"政府主导型"和"市场主导型"联盟关于公平与效率谁具有优先性的论辩,其演变特征与倡议联盟框架的解释逻辑基本一致.本文以倡议联盟框架为理论视角,对中国医疗卫生政策历史文献进行综合考察后发现:具备不同信仰的倡议联盟是推动医疗卫生政策变革与回归的关键,政策取向的学习推动政策渐进性变迁,内外部震荡则为政策的范式性变迁提供了契机,而政策变革的被动性有余、主动性不足,政府对医疗卫生事业公益属性认识偏差,加之市场经济发育不良是造成医疗政策滞后、行业乱象频发的主要原因.因此,建议通过增强政策的前瞻性、强化内在驱动,为联盟创造更加自由的论辩环境,加强联盟间政策取向的学习等手段以提升医疗卫生政策变革的科学性和有效性.