【作者】 许宗余；

【导师】 姚岚；

【作者基本信息】 华中科技大学 ， 社会医学与卫生事业管理， 2011， 博士

【摘要】 研究目的通过对不同举办形式社区卫生服务机构在既定运行模式下的功能实现情况进行比较,分析举办形式和运行机制相关要素对机构功能实现的影响,为改革和完善社区卫生服务机构运行机制提供参考,并就推进社区卫生综合改革提出相关政策建议。研究方法采用文献研究,收集整理社区卫生服务有关政策、理论研究、实践进展、现况调查和课题研究报告等资料,分析社区卫生运行机制有关理论成果和实践经验。采用现况调查和SWOT分析等方法,研究不同举办形式社区卫生服务机构的特点,分析社区卫生运行机制有关要素的优势和挑战。采用卡方检验、秩和检验、多元线性回归分析等方法,分析举办形式和运行机制相关要素对社区卫生服务机构功能实现的影响。研究结果对社区卫生有关资料进行研究,并选取6个社区卫生服务体系建设重点联系城市444所社区卫生服务中心的2009年常规监测数据进行分析。结果显示,运行机制相关要素中的收支两条线管理、纳入医保定点、药品零差率销售和举办形式对基本公共卫生服务项目开展率的影响有统计学意义(p＜0.05)；独立法人、医保定点、药品零差率销售、收支两条线管理以及药品配备数量、临床医师数、床位数等因素对服务量影响有统计学意义(P＜0.05)。实行收支两条线管理、药品零差率销售、绩效工资对服务效率的影响有统计学意义(P＜0.05)。将单因素统计有意义的因素纳入多元线性回归分析模型,结果显示,机构年门诊量受独立法人、收支两条线管理等因素的影响(回归模型F=223.41,P＜0.0001)；居民建档量受第一名称注册、药品配备数量、临床医师数影响(回归模型F=119.54,P<0.0001)；免疫接种量受独立法人、收支两条线管理等因素影响(回归模型F=116.40,P<0.0001)；儿童保健量受独立法人、收支两条线管理等因素的影响(回归模型F=41.62,P<0.0001)；高血压管理量受第一名称注册、药品零差率销售等因素的影响(回归模型F=50.48,P<0.0001)；医生人均年门诊量受收支两条线管理等因素的影响(回归模型F=71.75,P<0.0001)；居民建档率受药品配备数量、绩效工资管理等因素的影响(回归模型F=174.96,P<0.0001)；规划内免疫接种比例受收支两条线管理、药品配备数量的影响(回归模型F=73.93,P<0.0001)。以举办形式和运行机制关键要素为依据对既定运行模式社区卫生服务机构功能实现情况进行分析。举办形式、机构性质、收支两条线管理对既定运行模式下的社区卫生服务机构功能实现有显著性影响(P值均小于0.05)；绩效工资对政府办、差额拨款、实行收支两条线管理的社区卫生服务机构功能实现无显著性影响(P>0.05)。研究结论社区卫生服务机构的功能实现受举办形式和运行机制相关要素等诸多因素的影响,且不同服务指标的影响因素各异。举办形式对社区卫生服务机构功能实现有显著性影响,政府办的社区卫生服务机构的基本公共卫生服务开展率和门诊量均高于医院办和企业办机构,但在既定运行模式下,政府办与医院办的机构在医疗服务效率和基本公共卫生服务方面并没有显著性差异。实行收支两条线管理可以有效促进社区卫生服务机构的功能实现。在政府办或医院办、差额拨款、是否实行绩效工资等方面具有相同特征的机构中,实行收支两条线管理的机构在服务量和工作效率方面均明显好于未实行收支两条线管理的机构,显示无论是政府办还是医院办的机构,实行收支两条线管理后,并没有出现养懒人、低效率的现象。因此,应坚持政府主导,鼓励社会参与,对不同举办形式的机构一视同仁,切实把社区卫生工作重点放在完善政策措施,落实经费补助,加强对机构的绩效考核与服务监管等方面,发挥不同举办形式社区卫生服务机构的作用。积极推进社区卫生综合改革,在完善经费投入、人事分配、药品零差率销售和基本公共卫生服务经费补助机制、绩效考核等配套政策的基础上,稳步推行收支两条线管理,维护社区卫生服务机构公益性质。更多还原

【Abstract】 Objective:The impact of relevant factors, associated with the operational mechanism and the ownerships, on the CHS institutions performing functions were analyzed through comparing how the CHS institutions with different ownerships fulfilled their functions under given operational mechanism models. It aims at providing guidance for reforming and improving the operational mechanism of CHS institutions and putting forward relevant policy recommendations for pressing ahead comprehensive reform of community health.Contents and methods:Policies, theoretical studies, practice progress, field survey and research reports associated with community health services were collected and collated by use of literature searching method, so as to analyze the theoretical outcomes and practice experiences in relation to the operational mechanism of community health.. The field survey and SWOT technology were adopted to study the characteristics of CHS institutions with different ownerships, and analyze the advantages and challenges facing the elements corresponding to the operational mechanism of community health. Chi-square test, Rank Sum test and Multiple Linear Regression analysis were applied to analyze how the factors relevant to different ownerships and operational mechanism models affect CHS institutions performing their functions.Results:Through analyzing the regular monitoring data of 444 CHS centers in six key liaison cities of the Establishment Program of CHS System, aside from studying other materials related to community health, following outcomes were found:1)among all the factors related to the operational mechanisms, implementation of Separation from Revenues and Expenditures Budget Management, CHS institutions being covered by the health insurance agencies, CHS institutions selling medicines with Zero-Margin profits and the ownerships of CHS institutions were significantly associated with the provision rates of essential public health service programs (p<0.05); 2)such characteristics as being independent enterprises, being covered by the health insurance agencies, selling medicines with Zero-Margin profits, implementing Separation from Revenues and Expenditures budget management, number of equipped medicines, number of clinical physicians, and number of beds for CHS institutions were significantly correlated with the service quantity (P<0.05); 3) implementating Separation from Revenues and Expenditures budget management and performance-based payment, and selling medicines with Zero-Margin profits were significantly associated with the working efficiency (P<0.05). Through Multiple linear regression analysis by including all the independent variables that were significantly associated with respective dependent variables, it demonstrated that the number of outpatient visits was affected by the factors as being independent enterprises and implementing Separation from Revenues and Expenditures budget management (F=223.41, P<0.0001); the number of established health records for residents was affected by such factors as the first registered title of community health institutions, and the number of equipped medicines and clinical physicians (F=119.54, P<0.0001); the number of immunization injections was influenced by such factors as being independent enterprises and implementation of Separation from Revenues and Expenditures budget management (F=41.63, P<0.0001); the volume of child care was affected by such factors as being independent enterprises and implementation of Separation from Revenues and Expenditures budget management (F=41.62, P<0.0001); the number of managed patients with hypertension was affected by such factors as the first registered title and selling medicines with Zero-margin Profits (F=50.48, P<0.0001); the average number of outpatient visits per physician was affected by such factor as implementation of Separation from Revenues and Expenditures budget management (F=71.75, P<0.0001); the rate of establishing residents’ health records was affected by such factors as the number of equipped medicines and implementation of performance-based payment (F=174.96, P<0.0001); the proportion of planned immunization injection was influenced by such factors as implementation of Separation from Revenues and Expenditures budget management and the number of equipped medicines (F=73.93, P<0.0001). Basing on the ownerships and the key factors related to the operational mechnisms, the status of CHS institutions performing their functions under given operational models were analyzed. The ownerships, attributes of CHS institutions and implementation of Separation from Revenues and Expenditures budget management were significantly associated with CHS institutions performing their functions under the givern operational models (all the P values were less than 0.05). The performance-based payment was not significantly associated with the government-owned CHS institutions (in which, Separation from Revenues and Expenditures Budget management and Balance Allocation policy were implemented too) performing their functions (P>0.05).Conclusions:Whether community health services fulfil their functions is affected by many factors associated with the ownerships and operational mechanisms, and the impact varied across different service indicators. Generally, the type of ownerships had significant impact on CHS institutions performing their functions. The state-owned CHS institutions had better performance in terms of the provision rates of essential public health services and the number of outpatient visits, if compared with those governed by the hospitals and enterprises. However, under some specific operationals models, no significant difference, in terms of medical service efficiency and essential public services delivery, was observed between the govern-owned and hospital affiliated CHS institutions. Implementation of Separation from Revenues and Expenditures budget management could efficiently promote CHS institutions to fulfil their functions. With the similar factors as implementing the Balance Allocation policy and performance-based payment, both the government-owned and the hospital-owned CHS institutions provided better service quantity and efficiency than their counterparts through implementing Separation from Revenues and Expenditures budget management. This demonstrated that, health professionals didn’t become lazy and the service efficiency didn’t decrease either in both the government-owned and the hospital affiliated CHS institutions after implementing Separation from Revenues and Expenditures budget management. Thus, emphasis should be placed on the government playing the leading role, encouraging social participation, treating all the CHS institutions with different ownerships equally, as well as attaching the importance to improving the policies, enforcing the reimbursement policy, and enhancing institutional performance evaluation and service monitoring and management, so as to enable all the CHS institutions to play their full roles. Besides, it necessitates pressing ahead the comprehensive reforms on community health actively. On basis of improving such policies as public input, human resources system and bonus allocation, Pharmaceutic Zero-margin profits, reimbursement mechanism for public health services, Separation from Revenues and Expenditures budgets management.更多还原