How to implement the "separation of management and operation" is the focus of public hospital system reform. "Separation of management and administration" is the goal of the 17th Party Congress to reform the health administration system. However, in practice, how to recognize and implement the "separation of management and administration" is not yet clearly understood. At present, the mainstream model of "separation of management and operation" is that of Shanghai and Wuxi, in which a new government agency is set up to take on the responsibilities of funder of public hospitals, realizing the combination of management of people, affairs and assets, and separating this agency from the health administration department in the government sequence. These reform pilot areas believe that the separation of management and administration has solved two problems, one is the lack of owners; the second is the problem of the Health Bureau, "pro old man can not control his own son", which is what we call the contradiction between the administrative power of the public **** and the right of the owner to income. This logic is not theoretically valid.
First of all, the above model did achieve results, but the main reason, not because of the split of the organization, but a series of comprehensive measures, including: the dispersed in other departments of the hospital management functions centralized; increased the establishment of the department of medical services and management strength; equipped with excellent cadres; a substantial increase in the hospital infrastructure investment, and the power of the infrastructure to the department of medical services, so that the department of medical services have the authority to make the hospital. The medical department has the authority to supervise the hospitals, and the local leaders are bound to support the work of the newly established organizations in all aspects in order to show the achievements of the reform.
Secondly, the solution to the problem of the lack of owners is not a function of "separation of management and operation", but rather a real exercise of the function of "running hospitals" that was not exercised. Owners representative is not in place, and management and operation is not separate is not necessarily related. The reforms in these regions were driven by specific government leaders, giving the Hospital Authority many powers that the Health Bureau did not have in the past. On the other hand, the current "separation of management and operation" model does not really realize the owner in place, because there is no institutional guarantee that the owner has the right objectives, and the question of who will manage and evaluate the Hospital Authority has not been resolved. Such as Shanghai Shenkang in the establishment of the early stage, to capital operation as the main work, to the value of state-owned assets as the goal of value-added, which is contrary to the goal of public hospitals. If only the split of the organization, without clarifying the responsibilities and rights of the newly established medical department, it will not be able to achieve the management objectives.
Thirdly, the separation of management and operation solves the problem of "pro old man can't control his own son", which is contrary to our previous analysis, public hospitals itself does not exist in the contradiction between the administrative power of the public **** and the right of the owner to profit. Whether it is the "referee athlete" analogy, or the "pro son wild son" analogy, are still copying the idea of state-owned enterprises. If the government favors state-owned enterprises in the regulation of the industry, it will destroy the equal opportunity for profit among all types of capital. However, hospitals do not have this problem. Because public hospitals and a large number of private hospitals are non-profit, not a subject of interest, there is no return on capital, and there is no question of "equal opportunity for return on capital". Public hospitals undertake policy functions, the Government's interests and the interests of public hospitals are the same, the fundamental reason for the poor management of public hospitals is precisely that public hospitals have their own interests, and such interests and the Government's objectives are not consistent. The reason why there will be "pro old son" can not manage "pro son" illusion, precisely because the old son and son of the goal is not consistent. Reform is precisely to change this situation, not to strengthen it.
Fourth, the public hospital "management" and "run" functions can not be separated? No. Because if they are separated, there will be no need to run public hospitals. The logic of the public hospital itself is a combination of internal and external governance, with the government assuming the functions of both management and administration, with full governance and multi-objective assessment. As there is a high degree of information asymmetry in the healthcare system, and human life is irreversible, in this case, after-the-fact supervision is unable to achieve the purpose of supervision. The special characteristics of the healthcare system determine that the government should be involved in the whole process of hospital supervision from pre-planning, supervision and evaluation. In this sense, management is management. If we give up the responsibility of "running" public hospitals, we will not be able to realize the purpose of "management". Separating the management from the operation will precisely erase the greatest institutional advantage of public hospitals. The international experience is that as long as the Government organizes public hospitals, it is bound to assume the functions of both management and operation, and none of them is separated from management and operation. In view of this, it is suggested that the interpretation of "separation of management and operation" be carefully studied, and that "separation of management and operation" be interpreted as "separation of the policy of organizing public hospitals from the policy of supervising other hospitals, with different types of hospitals assuming different responsibilities and being given different policy requirements. Different types of hospitals should be given different responsibilities, given different policy requirements, and given different means of supervision. For public hospitals, a combination of administrative, economic and legal means, and a combination of internal and external governance are to be adopted; for other hospitals, mainly industry management and external governance are to be adopted". The essence of the separation of management and operation is not a question of the management system, but a question of government departments improving the level of scientific management, refining the means of management, and treating public and private hospitals differently.
This differentiation has a theoretical basis. Public hospitals assume governmental functions, its own face of the population, business objectives and private hospitals are not the same, do not have the premise of competing on the same platform, so there is no question of letting public hospitals and private hospitals to compete together. Moreover, the competition in the field of health care should not be reflected in the level of hospitals, but in the level of factors of production. The "equal treatment" of public and private hospitals should not be reflected in medical insurance, access, subsidies, etc., but should be reflected in the same standards of qualification of medical personnel, and participate in the bidding of drugs and other factors of production. Secondly, as mentioned above, the system of public hospitals itself is characterized by the unity of management and operation, if separated, precisely the policy effect of organizing public hospitals will not be obtained.
From the situation of other countries, the government's management of medical institutions is no more than three means: economic, legal and administrative. In the management of public hospitals and private hospitals, the frequency and manner of the use of these three means are not the same, which is why we need to private hospitals and public hospitals "management and operation of the separation".
For example, in terms of economic instruments, the government can directly manage public hospitals through resource planning and financial management, but private hospitals are mainly regulated through external means such as taxation and health insurance. The Irish Ministry of Health emphasizes that all valuable equipment purchased with financial support from the Ministry of Health is under the unified control of the Ministry of Health. The German government indirectly realizes the quality management of hospitals through the insurance foundation. Economic means of management of private hospitals is mainly reflected in the cost control through tax policy. In terms of administrative means, unlike other industries where administrative means are less frequently utilized, administrative means play a large role in the medical field. In the medical reform has just started, the law is not perfect, administrative means is particularly important. And to regional health planning, price management, industry access, the appointment of the director of these aspects, administrative means have an irreplaceable role. Is it good to run a medical department within the health sector, or outside the health sector? This question should be examined together with the overall health care management system reform. The current health sector does not meet the requirements of a large ministry. The ideal model should be to set up a large ministry under which the functions of running health care, managing health care, health insurance, drugs and public **** health are all located. Therefore, whether it is better to set up within or outside the health sector in the current situation is a question of path rather than goal. The key is not the institutional setup, but the newly established hospital management department's responsibilities and rights are in place, whether the goal is clear, it is recommended to focus on this issue from this perspective.
[1] The General Office of the State Council forwarded the State Administration for Industry and Commerce on the industrial and commercial administrative organs and the market run as soon as possible to decouple the views of the notice of the State Council Office of the State Council [1995] No. 40.