【作者】 姚克勤；

【导师】 张亮；

【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】 进行城市社区卫生服务的人力配置标准研究,确定科学合理的社区卫生人力配置标准重要而且迫切。2007年,深圳市率先在全国开展了社区公共卫生服务包的设计研究和试运行工作。2008年,深圳市科技局立项并重点资助“深圳市社区公共卫生服务包运行成本分析”课题,2009年,深圳市科技局立项并资助“基于社区公共卫生服务包的社区卫生人力配置标准研究”,支持对社区公共卫生服务包的人力成本进行测算,这一工作恰好应对了国家新医改方案的主旨精神。一、目的“人人享有卫生保健和全民族健康素质不断提高”是社会主义现代化建设的重要目标之一,卫生人力资源开发是达到这一目标的重要保障条件。卫生部《中国2001—2015年卫生人力发展纲要》(卫人发[2002]35号)提出我国卫生人力资源开发与发展的目标,同时从总体上规定了全国社区卫生人力资源的配置标准,即“到2015年在全国卫生队伍中,应有30%以上的人员从事社区卫生工作,在社区工作的医生中,全科医师数不低于三分之一。”社区卫生人力资源的科学配置是社区卫生服务持续健康发展的基础与前提,社区卫生人力资源配置标准研究意义重大。本研究就是在分析国内外卫生领域成本研究的基础上,借鉴传统的医疗服务成本测算方法和先进的作业成本法部分原理,基于社区公共卫生服务包的工作任务,计算每万服务人口所需的人力货币成本,进而测算出应该配备的卫生技术人员数量,从而达到科学配置社区卫生人力资源的目的。二、方法根据2007年运行的社区公共卫生服务包(简称“服务包”)内容为文本依据,按社区健康服务中心公共卫生服务流程的特点,制作了包括中心主任、公共卫生医师、全科医师、全科护士等人员从事公共卫生服务的调查问卷。问卷主要调查公共卫生每一作业任务完成需要的时间和服务频次。经过预调查,检测了问卷的合理性、了解了调查的难度,并清晰了质量控制环节之后,在全市分区、按规模大小抽取了99间社区健康服务中心作为样本展开了正式调查。本研究引入“人·天”作为中间成本单位,降低市场物价与人力平均薪金变动对服务包人力成本的影响,提高成本数据的通用性；引入“有效工作时间系数”,剔除服务空白时间,测定有效工作时间系数；估算社区卫生服务人员每年有效工作时间；形成服务包人力时间成本的计算公式,即某一服务包的人力时间成本(人·天)=该服务包“服务内容”所包含的各个细项工作的人力时间成本的总和,其中“某个细项工作的人力时间成本”=[完成该细项所需要的单位时间(分钟)×完成此细项工作需要参与的人数×服务量(或按要求需要达到的服务量)]÷420÷有效工作时间系数,从而计算每万服务人口应该配备的卫生技术人员数量。三、结果按照服务包运行的实际流程,对样本社区健康服务中心的公共卫生服务作业时间进行了测算,研究得出,社区诊断服务包的全部项目和基本项目的人力资源成本分别是64.57人·天和64.16人·天,社区健康教育与健康促进服务的全部项目和基本项目的人力资源成本分别是118.80人·天和116.73人·天,社区预防接种与传染病防制的全部项目和基本项目的人力资源成本分别是750.38人·天和679.72人·天,社区妇女保健服务包的全部项目和基本项目的人力资源成本分别是1554.73人·天和583.30人·天,社区儿童保健服务包的全部项目和基本项目的人力资源成本分别是452.43人·天和352.93人·天,社区慢性病综合防治服务包的全部项目和基本项目的人力资源成本分别是764.39人·天和756.18人·天,社区老年保健服务包的全部项目和基本项目的人力资源成本分别是295.27人.天和287.41人·天,社区康复服务包的全部项目和基本项目的人力资源成本分别是357.07人·天和240.64人·天,社区心理卫生服务包的全部项目和基本项目的人力资源成本分别是72.85人·天和67.24人·天。因此,考虑到工作人员每年实际的工作时间,则各个服务包应该配备的工作人员分别为0.28、0.52、3.00、2.58、1.56、3.34、1.27、1.06和0.30,社区公共卫生服务包所需人员约为13.90人,按照医护比1：1的比例,医生护士各为6.95人。四、结论(一)主要研究发现1、总体成本不高：2008年,深圳市社区公共卫生服务基本项目包运行人力成本,如按每万服务人口计算,人力成本为45.40万元,占70.20%；服务包全部服务项目运行人力成本为63.89万元,占76.83%。从全市社区公共卫生服务包运行的总成本来看,基本项目运行总成本为91943.58万元,仅占同期全市财政一般性支出889.86亿元的1.03%,即使是服务包的全部项目,运行总成本为118231.45万元,也只占财政支出的1.33%。2、财政缺口较大：从本次研究来看,相对于服务包运行的必要成本来说,在为每万服务人口提供服务包基本项目时,仍然有44.67万元的经费缺口。3、人力配备有空间：本次测算社区公共卫生服务包基本服务所需达到的人力资源为每万服务人口4.30名卫生技术人员。完善社区公共卫生功能、保证社区公共卫生服务包完整良性运行,其人力配备空间尚需较大幅度的提升。(二)政策建议1、现实人力配备数量不足,需加快充实社区医务人员队伍。2、要打造社区卫生人才战略工程。3、要加大社区健康服务中心正常运营的经费投入。五、创新与不足(一)创新：1、在人力成本测算中借鉴了传统的医疗服务成本测算方法和先进的作业成本法的优点,同时规避了两者的缺点；2、在社区公共卫生服务包人力成本计算中引入了“人·天”单位。(二)不足：受研究周期、时间及学术水平的限制,社区公共卫生服务的人力资源配置标准的讨论还不够深入,可以在以后的研究中继续完善。更多还原

【Abstract】 The study on the human resource allocation standard of the urban community health services is important and urgent. In 2007, Shenzhen spearheaded design research and commissioning work on the community public health service package. In 2008, Shenzhen Technology Bureau key funded the project named Shenzhen community public health service package operation cost analysis.2009, Shenzhen Technology Bureau funded "the research on the community health human allocation standard based on community package, support for community public health service package human cost estimates, this work just remain consistent with the new national medical scheme purpose spirit.Objective"Health Care and Health Quality Enhances Unceasingly for All" is one of the important targets of the Socialist modernization.Health human resources development is one of the important security conditions. "2001-2015 program for the development of human health of China-MOH" puts forward the goals of the development of the health human resource, and the regulation of human resource allocation standard overall the national, namely "above 30% of the national health teams engaged in community health work and no less than one-third of the community doctor are general practitioner. The Scientific configuration of the community health human resource is the basis and premise if the sustained and healthy development of CHS, the study on the community human resource allocation standard is significant.The study based on the analysis of the domestic and overseas research on the cost of the health sector, refer to traditional methods and Activity-Based Costing, according to the task of the community health package, compute the necessary monetary human costs and the number of personnel of the services per million population, so as to achieve the purpose of the scientific community health human resources configuration.Methods According to the 2007 Shenzhen community health service package, combined with the characteristics of the process of the community public health service, make questionnaire for the CHC director, public health doctor, general practitioner, general nurse etc. The questionnaire mainly includes the time of each task completion and service frequency. The pre-survey test rationality of the questionnaire, understand the difficulty of the investigation, and clear quality control links. After per-survey, according to the size sample 99 community health service centers in 6 districts to launch a formal investigation.The study introduces "person·day" as an intermediate unit costs to lower the impact of market prices and the average salary changes, improve the universal of the cost data; introduce "effective work time factor", remove the service gaps time, use the factor of effective work time; estimated annual effective community health service staff working hours; form a service package of human time cost formula:a human time cost service package (person·day)= the sum of the human time cost of the sub-services of the service package, the sum of the human time cost of the sub-services=[the time required of the unit (minutes)×the the number of participants take x the the required amount of service]÷420÷coefficient of effective working time, through the conversion of the base to get the results of the human cost of the service package.ResultsAccording to the process of the community health service package, the study estimates the time of the public health service completion in sample center. The study results that, the human resource cost of the all and the basic items of the community diagnosis service package respectively is 64.57 person·day and 64.16 person·day; the human resource cost of the all and the basic items of the community health education and health promotion services package respectively is 118.80 person·day and 116.73 person·day; the human resource cost of the all and the basic items of the community inoculation and infectious diseases control services package respectively is 750.38 person·day and 679.72 person·day; the human resource cost of the all and the basic items of the community women health service package respectively is 1554.73 person·day and 583.30 person·day; the human resource cost of the all and the basic items of the community children health service package respectively is 452.43 person·day and 352.93 person·day; the human resource cost of the all and the basic items of the community chronic comprehensive prevention and control service package respectively is 764.39 person·day and 756.18 person·day; the human resource cost of the all and the basic items of the community elderly health service package respectively is 295.27 person·day and 287.41 person·day; the human resource cost of the all and the basic items of the community rehabilitation services package respectively is 357.07 person·day and 240.64 person·day; the human resource cost of the all and the basic items of the community mental health services package respectively is 72.85 person·day and 67.24 person·day. So considering the staff’s actual work time of every year, the human resource number of each service package should be 0.28,0.52,3.00,2.58,1.56,3.34, 1.27,1.06,0.30, the human resource number of community public health service package should be about 13.90, according to doctors and nurses ratio 1:1, the doctor and nurse’s number respectively is 6.95 and 6.95.ConclusionThe main findings1. The overall cost is not high. In 2008, the human resource cost of the basic item of Shenzhen community public health service package is Y 454,000 per 10,000 service population, accounted 70.20% for total cost; the human resource cost of the all item of Shenzhen community public health service package is Y 638,900 per 10,000 service population, accounted 76.83% for total cost. In the total cost of the community public health service package operation, the cost of the basic item is Y919,435,800, accounted only 1.03% for the same period fiscal general expenditure Y88,986,000,000, the cost of the all item is￥1,182,314,500, accounted only 1.33%.2. Fiscal gap is bigger. Judging from this research, relative to the necessary cost of the service package operation, there is still Y446,700 fiscal gap in the cost of the basic item.3. Human allocation space is exist. The study show the number of the health human resource of the community health basic item service package is 4.3 per 10,000 service population. To perfect the community public health functions and ensure community public health service package complete benign operation, it must be done to allocate enough health human resource.Policy recommendations1.It needs to improve community health personnel team construction to solve personnel shortage at present.2.It is essential to create CHS talent strategy project.3.It is necessary to increase the funds investment to support the normal operation of CHS center.Innovation1. The study takes advantage of traditional method of cost accounting and ABC and avoids their shortage when calculating the cost of human resources of medical services.2. In the calculation of community public health service package, the term "person·day" is applied.ShortageBecause the limitation of research circle, time and academic level, the study of community public health service package of human resources need further discussion and improvement in the future.更多还原