制度逻辑与组织策略:对农村地区基本公共卫生服务制度执行偏差的一种新解释

Institutional Logic and Organizational Strategy:A New Explanation of the Deviations in the Implementation of National Basic Public Health Services in Rural Areas

基本公共卫生服务制度是一项保障全体人民健康、实现健康公平的重要制度安排,但该项制度在农村地区的执行成效与制度期待具有较大张力,存在制度执行偏差。本文搭建了“制度逻辑-组织策略”的研究框架,力图为该问题提供一种新的解释。本文发现:基本公共卫生服务制度具有多重逻辑,当该项制度嵌入基层医疗组织形成的组织场域时,制度的多重逻辑与基层医疗组织的实践逻辑产生了冲突,给基层医疗组织带来较大制度压力。为缓解制度压力,基层医疗组织采用“拼凑应对”的组织策略实现与基本公共卫生服务制度的适度脱耦,并在这一过程中通过关系动员的方式完成了合法性重建。这一系列的策略行动导致了制度执行偏差。因此,应以价值路径的重塑探寻矫正基本公共卫生服务制度执行偏差的可能方向,缓释制度工具逻辑与价值逻辑之间的张力,实现国家、社区与农村居民的健康共治,以回应制度的内在价值诉求。

The basic public health service system is an important institutional arrangement to safeguard the health of all citizens and achieve health equity,but the system in rural areas is not as effective as expected and there are deviations in the system implementation.This paper builds a framework of“institutional logic-organizational strategy”in an attempt to provide a new explanation for the aforementioned issue.The paper finds that the basic public health service system has multiple institutional logics.When the system is applied to primary care organizations,the multiple institutional logics of the system conflict with the practical logics of the primary care organizations,bringing great institutional pressure on the primary care organizations.In order to alleviate the institutional pressure,primary care organizations adopted the organizational strategy of“patchwork response”to achieve a moderate degree of decoupling from the basic public health service system,and completed the legitimacy reconstruction by relational mobilization.These strategic actions lead to deviations in the implementation of the system.Therefore,it is supposed to explore possible solutions to correct the deviations in the implementation of the basic public health service system by reshaping the value path,so as to alleviate the tension between the instrumental logic of the system and the value logic,and realize the shared governance of the state,the community and the rural residents,in order to respond to the inherent value demands of the system.