悬浮的项目包:中国农村基本公共卫生服务的制度演进与实践逻辑

The Suspension of a Program Package:The Institutional Evolution and Practice Logic of Basic Public Health Service in Rural China

基本公共卫生服务是国家基本公共服务体系和医疗卫生改革的重要组成部分,通过项目制的治理方式实现自上而下的运行实践。在财政管理体制上,基本公共卫生服务专项资金通过“因素法”在中央和地方各级政府间分配管理,最终由县级主管部门统筹支出。在“以县为主”的医疗卫生公共服务体系下,层级化的服务分工、项目化的经费补助与指标化的绩效考核紧密联系。在乡村基层实践中,项目制内含的技术治理和规范化取向通过档案管理渗透到服务供给过程中,档案成为上下“共谋”的操作对象。这一过程中,项目意图和群众需求产生偏差,标准化的信息系统与多元化的乡土社会发生错位,服务实践与日常生活和村庄治理有所分离,造成了项目包“悬浮”于乡土社会的意外后果。

The basic public health service,as an important part of national basic public service system and the reform of medical and health system,is implemented through the program system from top to bottom.In terms of fiscal system,the earmarked funds for basic public health service,allocated from multi-level governments by factors,are centralized to county department and then assigned to health institutions which are responsible for the healthcare service.Under a county-based health care system,the hierarchical division of labor,program-based subsidies,as well as indexing performance evaluation are closely linked with each other.In local practice in rural areas,the technical rationality and the orientation of standardization contained in the program system together infiltrate into the process of service delivery through archive management.As a result,the archive becomes the manipulative tool in the collusion between officials and village doctors.In the process mentioned above,the program intention significantly deviates from public demand.These standardized archives are then mismatched with ambiguous rural society,and healthcare is furthermore separated from daily life and local governance,resulting in the unexpected and unwanted consequence of the suspension of program package over rural society.