China is a developing country with a large rural population. How to deepen the reform of rural health system, promote the development of rural health undertakings and improve the health level of rural residents is directly related to the realization of the strategic objectives of national economic and social development and the stability of rural society. China began to carry out medical reform pilot from 1994, and medical reform entered the stage of organization and implementation from 1998. In July 2000, the national conference on the reform of the basic medical insurance system for urban workers and the medical and health system was held, and the reform of the rural medical and health system was fully launched. However, on the whole, the reform has not achieved much, rural health work is still weak, and there are many problems and new challenges. I. Several Problems Puzzling China's Rural Medical and Health System Reform Since the founding of New China, rural health undertakings have made great progress, and remarkable achievements have been made in rural county, township and village health service networks, cooperative medical care systems and rural health team building, which have played an important role in safeguarding the health of rural residents and promoting rural economic development and social progress. However, with the deepening of China's economic system reform and the gradual establishment of the socialist market economic system, the original rural medical and health system based on collective economy has lost its vitality, and farmers' medical care has lagged behind China's economic development. 1, rural public health investment is seriously insufficient. The increase of rural public health expenditure is mainly driven by the increase of personnel funds, while the official expenses and operational expenses have hardly increased or even decreased. Among the official expenses and operational expenses of rural public health, government expenditure has gradually decreased, from 258 million yuan in 199 1 year to 184 million yuan in 2000. Excluding the price factor, the average annual growth rate is-10.7%. Therefore, public health institutions can "generate income" through "paid services" and solve the problem of insufficient funds for business activities (see attached table 1[ 1]). The funds for preventive health care services in rural areas are seriously insufficient, and the preventive health care work is weakened. Some infectious diseases, parasitic diseases and endemic diseases that have been eliminated or controlled have rebounded in some places, and new diseases have become popular to varying degrees. Attached table 1: structural trend analysis of rural public health expenditure199199219931994199519961997. * Total health expenditure 7.49 8.27 9.1410.4012.7013.9015.6817.3317.67. 9611.4813.4515.217.49 official and business expenses 2.58 2.654338+02.08 2.1. According to statistics, the total national health expenditure in198 was 377.65 billion yuan, of which the government invested 58.72 billion yuan, while the health expenditure for rural areas was 9.25 billion yuan, accounting for only 15.9% of the government's investment. In that year, the urban population was about 379 million people, and each person enjoyed the government medical and health services equivalent to 130 yuan on average; The rural population is 866 million, and the per capita access to government medical and health services is 10.7 yuan, and the former is 13 times that of the latter. The problem of farmers' lack of medical care and medicine is serious. Zhu Qingsheng, vice minister of health, said that there are indeed many people in rural areas of China who look down on the disease. According to the results of statistics and rural investigation, it is estimated that 40%-60% people are poor or return to poverty due to illness because they look down on illness. In the central and western regions of China, it is estimated that 60%-80% of the people who died at home because they could not afford to look down on the disease and stay in the hospital [2]. The World Health Organization usually uses three indicators to measure the health level of residents in a country (or region), namely maternal mortality, infant mortality and life expectancy per capita. According to the statistics of the Ministry of Health, there is an obvious gap between urban and rural areas in maternal and child mortality in China (Table 2[3]). Table 2 of Maternal Mortality in Cities in 2002: The total maternal and child mortality in the monitored areas is 200120022001200220012002 maternal mortality (165438+10,000). 50.243.233.122.361.958.2 neonatal mortality (‰) 21.420.710.69.723.923.2 infant mortality (‰). 30.0 29.213.612.2 33.8 33.15 The child mortality rate (‰) was 35.9 34.916.314.6 40.439.6, which was 22.3/6539.6. The infant mortality rate is 12.2‰ in urban areas and 33. 1‰ in rural areas, which is 2.7 times higher than that in urban areas. The main results of the third national health service survey conducted by the Ministry of Health in 2004 showed that in the past five years, the average annual income of urban residents increased by 8.9% and that of rural areas increased by 2.4%, while the medical and health expenditure in urban areas and rural areas increased by 13.5% and1.8% respectively. For example, Sen (1989), the winner of the Nobel Prize in Economics, pointed out in the late 1980s that although the income of agricultural products and farmers in China increased substantially after the reform, it was relatively stagnant or retrogressive in vital statistics. [4] It can be seen that the medical problems of farmers have seriously restricted the further development of rural social economy in China. 3. The quality of rural health workers is low, and talents are scarce. Health technicians are an important part of health resources and an important symbol reflecting the health service level of a country and region. By the end of 2000, there were 1067269 rural doctors nationwide, an increase of more than 290,000 compared with 776859 in 1990; ② The average number of rural doctors in each village is 1.56, which is 55% higher than 1.0 1 person in 1990; ③ The qualified rate of rural doctor training was 86.01%; Among them, the qualified rate of rural doctors aged 45 and below receiving "two-oriented education" (systematic and standardized secondary medical education) reached 82.27%; The qualified rate of rural doctors aged 46 and above receiving technical secondary school level and item-by-item business training reached 89.77%. [5] According to the summary of health statistics of China in 2004 by the Ministry of Health, there are zero senior health technicians with doctoral or master's degrees in township hospitals nationwide, with bachelor's degree 1.6%, junior college degree 17. 1%, secondary school degree 59.5%, and high school education below 2 1.8%. The above data reflect the current situation of rural health technicians in China: lack of highly educated talents and low quality of health personnel. Schedule 3: Education of health technicians: doctor, master, junior college, technical secondary school or below, general hospital O.317.9 29.5410.7 9.310.617.10.59.520. 5438+000% (Note: Data source: China Health Statistics Summary of the Ministry of Health in 2004) 4. It is difficult to implement the new rural cooperative medical system. Establishing a new rural cooperative medical system is an important measure for the CPC Central Committee and the State Council to effectively solve the "three rural issues" and coordinate the coordinated development of urban and rural areas, regions, economy and society under the new situation. However, after the pilot work, many problems were found. First of all, farmers lack understanding of the new rural cooperative medical system and have many doubts. There are factors that publicity and education are not in place, and the more important reason is that farmers have insufficient confidence in the stability and systematicness of the national rural health policy, and the expected benefits are slim. Secondly, the high drug price is unbearable for farmers. After the reform and opening up, although farmers' income has increased and the problem of food and clothing has been solved, it is becoming more and more difficult to see a doctor. In 2003, the per capita income of farmers in China was 2622 yuan, while the per capita hospitalization expenses of farmers were 2236 yuan. In other words, if a farmer is hospitalized, his annual income may be spent on medical expenses. Third, the management of rural medical institutions is chaotic. By the end of 2003, there were 5150,000 village clinics in China, including 277,000 village clinics, 36,000 joint venture clinics, 26,000 township hospitals and 58,000 individual clinics. [6] A considerable number of village clinics are also not worthy of the name. Therefore, private or family-owned medical service outlets make farmers feel insecure about their capital investment. Orientation and direction of rural health reform In order to promote the reform of rural medical and health undertakings, the state has also adopted a series of policies, such as separation of medicines, bidding and purchasing of medicines, classified management of medical institutions, integration of rural health service management, and establishment of a new rural cooperative medical system. But none of them have fundamentally solved the medical and health problems of farmers. The effectiveness of the reform is far from people's expectations, and the unclear orientation and direction of rural health reform is an important reason. First of all, we should adhere to the idea that rural medical and health care is a product of social welfare and a welfare public welfare undertaking. "The problems of agriculture, rural areas and farmers have always been fundamental issues related to the overall situation of our party and country" [7]. The government has an unshirkable responsibility for the development of rural health undertakings, mainly relying on government financial support, but it is by no means simple marketization. The supply of public goods in China has always been divided between urban and rural areas. Providing farmers with basic and guaranteed public goods is conducive to breaking the basic pattern of urban-rural division, promoting the coordinated development of urban and rural areas, and adapting the party's basic rural policies to the process of reform and development. Since 1980s, the rural cooperative medical system has basically disintegrated, and most farmers have become self-funded medical groups. Because the growth rate of farmers' income can't keep up with the growth rate of medical expenses, the problem of farmers' contempt for illness is more prominent. For farmers, "health is wealth and disease is poverty". Therefore, rural medical and health undertakings should be regarded as basic public goods and need strong support from the state finance. Only when the government effectively provides rural public health services, resolves rural social contradictions and reduces social risks can the country maintain long-term stability and the social economy develop continuously. Secondly, we should establish the concept of people-oriented and farmers-oriented and narrow the gap between urban and rural areas. For the sustainable development and long-term interests of China's social economy, the policy of "rest and recuperation" is implemented in the vast rural areas to increase farmers' income and improve their ability to resist natural and man-made disasters. For example, in 2004, the No.1 Document of the Central Committee decided to implement "two exemptions and three subsidies" for farmers (canceling agricultural specialty taxes except tobacco leaves, reducing agricultural taxes, implementing direct subsidies for grain farmers, subsidies for improved varieties and subsidies for the purchase of large-scale agricultural machinery and tools), which directly benefited China farmers 45,654.38 billion yuan. At the same time, it is a camera decision in public economic decision-making to subsidize grain farmers, stimulate grain production and increase farmers' income through financial transfer payments and tax relief. In the past seven years, the emergency rectification intervention for the slow growth of farmers' income and the decline of grain output in China has achieved remarkable results. In terms of rural medical and health care, document 2005 1 stipulates: "Adhere to the policy of focusing health care on rural areas, actively and steadily promote the pilot of new rural cooperative medical care and rural medical assistance, implement the rural medical and health infrastructure construction plan, accelerate the training of rural medical and health personnel, and improve the level of rural medical services and the ability to respond to public health emergencies." It also needs substantial measures to benefit farmers. The third is to enhance the awareness of adhering to the law and strengthening health legislation. The reform of rural medical and health undertakings must have a clear direction and a stable policy, and it is forbidden to do it overnight. Otherwise, farmers will be suspicious, wait and see, and even contradict the state's principles, policies and measures. Our government has issued a number of supporting reform documents, formulated regional health planning, community health service, rural health service management integration, health supervision system, health personnel system and other reform documents, and formed a policy system to comprehensively promote the reform and development of China's urban medical and health system. From 5 June to 10, 2002, the Central Committee of the Communist Party of China and the State Council issued the Decision on Further Strengthening Rural Health Work, held a national rural health work conference, and decided to establish a new rural cooperative medical system. However, due to the complexity of the field of medical and health reform, it needs deep-seated joint management and involves the vital interests of farmers. Therefore, legislation must be adopted to ensure the reform and construction of multi-level medical security system and rural medical and health undertakings. Moreover, the state's financial investment in the public medical and health system and the transfer payment for rural medical and health care should also be guaranteed by law to prevent the randomness and repetition of the state's decision-making intentions. In terms of the operation and fund management of the rural cooperative medical system, it is also necessary to formulate fair, just and open rules and regulations, set up non-profit rural medical security management departments and supervision and examination institutions attended by farmers, governments, institutions and experts to ensure the normal operation of the cooperative medical system. Iii. Countermeasures for Strengthening Rural Medical and Health Reform To achieve the goal of "establishing a rural health service system and a rural cooperative medical care system to meet the requirements of the socialist market economic system and the level of rural economic and social development by 20 10" [8], we must make overall plans and make rational decisions. 1, straighten out the rural health management system and implement the integrated management of rural health organizations. According to the rural health management system with counties (cities) as the main body, governments at all levels take overall responsibility for rural health work and strengthen leadership over rural health work. Implementing the integrated management of rural health organizations and establishing the management position of township hospitals in rural health services, which is the responsibility of county (city) governments, is conducive to solving the contradiction of lack of supervision and management of rural health services. Under the unified management with township hospitals as the main body, two levels of rural health institutions can form a service system with hierarchical management, complementary functions and coordinated development. Only through the unified management of township hospitals can the county-level health administrative departments realize the whole industry management of rural health work and put rural health undertakings on the track of healthy development. The core of integrated management of rural health organizations lies in management, revitalizing existing health resources, mobilizing enthusiasm and strengthening preventive health care and public health service functions. Strengthen the county's support and supervision functions for rural health services, improve the comprehensive service capacity of rural health institutions, and comprehensively improve the service quality and management level of rural health institutions. 2. Increase investment in rural health and support the construction of rural medical and health infrastructure. At present, the proportion of health expenditure in China's fiscal expenditure is 1.6%- 1.7%. Of this part of fiscal expenditure, 70% of medical expenses are used in cities and 30% in rural areas; In China, 70% of the population is in rural areas, which means that 30% of the population occupies 70% of health resources, including government expenditure. Under the condition of market economy, the field and guiding role of governments at all levels in rural medical and health undertakings can not be replaced by other sources of health expenses (including community financing, social financing, service charges, etc.). Therefore, the financial investment in health care should be appropriately tilted to rural areas and support for rural health care should be increased. The state finance should subsidize the infrastructure construction and equipment purchase of rural health institutions in poor areas. The implementation of counterpart support and mobile medical system, in medical equipment, personnel training, technical guidance, mobile medical care, two-way referral, discipline construction, cooperative management and other aspects of support. And focus on supporting the construction of county-level medical and health institutions and township (town) hospitals. In order to improve the effectiveness of investment, the focus of financial support should be adjusted to support public health, preventive health care, personnel training and the establishment of medical security system. 3, rational layout, unified planning, effective use of existing health resources. With the changes of rural economy, transportation, regional and grass-roots organizations, the original tertiary medical institutions are not reasonable or even redundant. There are all kinds of maladjustments that need adjustment and reform. First, break the layout of administrative divisions, solve the problem of repeated setting of township hospitals, and adhere to the principle of "one township, one hospital" and "one village, one room". The establishment of township hospitals and village clinics should consider the number of people they serve and the size of the service radius. Second, township hospitals and township family planning guidance stations should enjoy * * * to solve the waste of resources caused by their coexistence. Third, for those township hospitals that are too close to county-level medical institutions and have poor viability, they should be merged and transferred to realize resource sharing and avoid low-level redundant construction. The fourth is to control the number of rural doctors and improve their quality. Strictly implement the access system for rural doctors. Fifth, under the premise of defining the service function, strictly control the purchase of high-end equipment and reduce the idle waste of resources. 4. Reform the training mode of rural health personnel and strengthen the construction of continuing education system. The key to rural health development is talent. In view of the current situation of low quality and lack of talents of rural health personnel in China, firstly, it is necessary to cultivate applicable talents and encourage medical college graduates and on-the-job or retired health technicians from urban health institutions to serve in rural areas. The state can arrange special funds to entrust medical colleges and universities to train general practitioners for rural areas, or medical colleges and local governments can jointly hold specialized classes for rural areas, that is, schools and local governments sign agreements or contracts, and all students are assigned to work in county, township and village medical and health institutions. The second is to strengthen the continuing education system and strengthen the professional knowledge and skills training of rural health technicians. At present, there is still a big gap between the age structure, education level, medical knowledge quality, operational skills and service attitude of rural doctors in various parts of China and the standards of general practitioners. It is necessary to strengthen the general medical education and training for on-the-job rural doctors in various ways, encourage qualified rural doctors to receive medical education, and strive to make most rural doctors in China have the qualification of practicing assistant doctors or above by 20 10.