【作者】 张容瑜；

【导师】 尹爱田； Lizheng Shi；

【作者基本信息】 山东大学 ， 社会医学与卫生事业管理， 2012， 博士

【摘要】 研究背景基本医疗卫生制度是保证为全体居民提供安全、有效、方便、可及的卫生服务,保障全体居民人人享有基本医疗卫生保健的公共政策,目前世界上包括英国、德国、日本等100多个国家都已经建立了基本医疗卫生制度。2009年4月6日,《中共中央国务院关于深化医药卫生体制改革的意见》出台,提出建立健全覆盖城乡居民的基本医疗卫生制度,其内容包括基本医疗保障制度、基本药物制度、基本医疗卫生服务制度、基本公共卫生服务制度,旨在缓解“看病难、看病贵”问题,保证居民合理就医,减轻患者就医费用负担。随之公布的《2009-2011年深化医药卫生体制改革实施方案》,明确2009-2011年期间,各级政府需要投入8500亿元。目前,我国农村地区高血压流行越来越严重,高血压门诊费用、购药费用造成的经济负担越来越沉重,高血压患者的就医行为存在就医时机延误、健康意识单薄、就医机构趋高等问题；高血压已成为危害农村居民健康与经济风险的重要原因。四项基本医疗卫生制度可以通过体系建设、经济补偿、服务提供等方式,引导高血压患者合理就医,进而降低患者就医费用。2007年-2010年期间,山东省新农合制度中的报销比例不断提高,基本药物制度分批试点;山东八县开展农村地区慢性非传染性疾病控制项目,重点在于通过基本医疗卫生服务和基本公共卫生服务两大体系的建设,改善贫困人口和脆弱人群的健康状况。循证卫生决策伴随着循证医学的发展而发展起来,采用的很多方法都是循证医学的方法,以循证卫生决策为标志的卫生事业管理基础与应用研究,已成为国际上卫生政策研究和制定的趋势,其焦点问题是循证决策的复杂机制及其方法体系对本土化卫生政策制定的支持作用。慢性病的预防和管理是一个国家卫生系统和卫生政策的试金石。2005年-2011年,基本医疗卫生制度从探索讨论、奠定基础到确立实施,始终围绕着“基本”、“均等”和“公平”,那么,山东省八县农村卫生政策的发展是否有效地保证了患者合理就医行为和费用?研究目的本研究将以山东八个项目县为样本,探讨卫生政策要素对农村高血压患者就医行为和费用的影响。具体研究目的如下：(1)通过理论研究,探讨基本医疗卫生制度、就医行为和费用控制三者的逻辑关系以及卫生政策的系统评价方法。(2)通过实证研究,测量和描述卫生政策要素、山东省农村高血压患者为代表的慢性病居民的就医行为、就医费用及其存在的问题,研究卫生政策要素对农村高血压患者就医行为和就医费用的影响。(3)通过政策分析,探讨如何促进农村慢性病居民建立科学合理的就医行为,进而减少不合理的慢性病费用。资料来源本研究资料主要来源于文献复习和现场调查。文献资料来源于电子期刊、纸质图书和国家、省宏观卫生统计资料；调查数据来源于《山东省农村卫生人员培训与慢病控制项目》中2007年的基线调查和2010年的终末调查的数据,包括入户调查、机构调查、专家咨询和关键人物访谈等。采用多阶段分层随机整群抽样方法,根据社会经济发展水平和地理位置,在山东省抽取8个县(市、区),每县随机抽取2个乡镇,每个乡镇随机抽取2个村,对村中家庭进行系统抽样,调查家庭中所有25岁以上居民。基线调查共抽取了16个乡镇,40个村,调查了20087人。终末调查每县随机选择1个项目乡镇,从项目乡镇随机抽取1个项目村；从8个项目县中随机抽取4个县,从选中的项目乡镇中再抽取1个非项目村作为对照村。终末调查共抽取了12个乡镇,14个村,调查了6216人。研究方法本研究在文献综述和专家咨询的基础上,构建了基本医疗卫生制度与就医行为、就医费用的逻辑框架；建立了卫生政策要素指标体系,包含四个范畴的指标；建立了就医行为、遵医行为、就医费用、健康理念等范畴的指标体系；所有的指标分为县、村(乡),患者3个水平。本研究采用Andersen[171]1968年提出医疗服务利用的行为模型,主要应用多水平线性模型,在控制人口、社会、经济、生理状态、以及身体状况等变量的基础上,分析政策变量对于高血压患者就医行为、遵医行为和就医费用的影响。研究方法包括系统分析法、文献综述发、专家咨询法、多因素统计分析方法等,分析采用EXCEL、SPSS、和HLM软件。主要结果与发现本研究系统地运用卫生政策理论构建基本医疗卫生制度各项政策要素、就医行为、就医费用之间的逻辑关系模型；运用定量方法对农村卫生政策和患者就医行为进行测量；全面地采用多水平线性模型定量评价卫生政策要素对于农村高血压患者就医行为和就医费用的影响；判断就医行为和就医费用的敏感政策因素,构建三者的作用关系和就医行为、费用的政策导向模式；较好地避免了生态谬误和原子论式的谬误,探索了卫生政策评价的定量方法。1.基本医疗卫生制度与就医行为、费用的逻辑关系以及农村卫生政策指标体系基本医疗保障制度和基本药物制度直接作用于患者的医疗费用,但是需要配套良好的基本医疗卫生服务和基本公共卫生服务；卫生服务通过作用于患者的就医理念和健康行为,间接达到医疗费用控制的目的。农村卫生政策指标体系包括四个范畴,基本医疗保障(农村地区主要是实行新农村合作医疗制度)、基本药物、基本医疗卫生服务体系和基本公共卫生服务体系,本研究较好地保证了政策指标的信度和效度。2.山东省八县农村高血压流行特征以及卫生政策的发展(1)2010年干预人群高血压患病率(38.7%),低于2007年基线人群(44.3%),以及2010年调查人群(38.88%),差异均具有统计学意义(P<0.05)。(2)①基本药物：样本县中宁阳、寿光和莱城划为第一批试点县区。②基本医保：2007-2010年,新农合参合率上升到99.6%,各县相继把高血压纳入报销范围,门诊报销比例不断上升,报销方式以即时报销为主。③基本医疗：2007年-2010年,样本县农村每千人口卫生人员数、卫生室数以及人均慢病支出稳步上升,项目中干预组村总培训人次数、总督导次数、村医高血压知识得分均数、卫生服务体系反应性均高于对照组,除村总培训人次数外,差异均具有统计学意义。④基本公卫：2007-2010年,样本县农村干预组媒体宣传等健康教育指标、高血压管理、高血压随访等管理类指标、基本公卫制度督导指标得分均高于对照组,差异具有统计学意义。3.卫生政策要素对农村高血压患者的就医行为、遵医行为的影响模型及导向模式(1)基本医疗保障、基本药物政策对于高血压患者就医行为的影响：①基本医保中的慢病补偿政策执行年数越长,即时报销有利于高血压患者下沉到乡镇及以下的就诊机构,乡镇及以下就诊机构的2010年合作医疗报销费用高于其他级别机构；②基本药物制度的实施,新农合的门诊报销比例越高,有助于患者遵医指数的提高。(2)基本医疗卫生服务体系、基本公共卫生服务体系对于高血压患者就医行为的影响：①基本医疗指标中的村医高血压知识得分,基本公卫中的媒体宣传、健康大讲坛有助于患者慢病健康意识的提高;基本公卫中的人均宣传产品数、高血压随访人次有助于患者高血压知识得分的提高：高血压随访人次越多,有助于患者遵医指数的提高；②基本医疗中的卫生服务体系反应性,患者的慢病健康意识和遵医指数越高,有利于患者及时就诊；基本医疗中的卫生服务体系反应性越高,有利于高血压患者下沉到乡镇及以下的就诊机构。4.卫生政策要素对农村高血压患者的就医费用的影响模型及导向模式(1)基本医疗保障、基本药物政策对于高血压患者就医费用的影响：①基本药物制度的实施、通常药物来源于乡镇及以下卫生机构,基本医保中的慢病补偿政策执行年数越长、门诊报销比例越高、即时报销都推动过去一年就医费用的上升；②基本药物制度的实施、通常药物来源于乡镇及以下卫生机构,门诊报销比例越高推动每月维持血压药物费用以及合作医疗报销费用的上升；③基本药物制度的实施、慢病补偿政策执行年数越长、门诊报销比例越高、即时报销都推动新农合实际补偿比例的上升。而每月维持血压药物开支越高,新农合实际补偿比例越低。(2)基本医疗卫生服务体系、基本公共卫生服务体系对于高血压患者就医费用的影响：①2007-2010年村总培训人次越多、患者遵医指数越高推动过去一年就医费用的上升,而村医高血压知识得分和高血压管理率越高,则导致过去一年就医费用的下降；②遵医指数越高推动每月维持血压药物费用的上升；高血压管理率越高,导致每月维持血压费用的下降；③2007-2010年村总培训人次、村总督导次数越多,导致合作医疗报销费用的下降；媒体宣传越多导致合作医疗报销费用的上升。5.多水平模型应用于农村卫生政策效应评价多水平模型较少应用于国内卫生政策效应评价。本研究将其用于卫生政策要素分析,根据数据的层次结构构建多个水平的的回归模型,将数据的变异分解到多个水平上,从而使个体水平的随机误差项更为单纯,并避免生态谬误和原子论式的谬误,达到分析各层次政策效应的目的。结论及政策建议本研究主要结论：(1)需求释放是当前实施农村慢病基本保障政策的直接结果；(2)政策组合是建立高血压患者合理就医行为及费用的核心条件；(3)个体干预是形成高血压患者合理就医行为及费用的必要手段；(4)政策评价是确保高血压患者合理就医行为及费用的有力工具。本研究提出以下建议：(1)加强合理就医行为的政策诱导：①扩大保障范围,提高报销比例；②加强药品经销,降低药品价格；③夯实服务网络,提高医疗水平；④促进健康教育,系统管理慢病。(2)统筹基本卫生政策的制定规划。(3)强化基层医疗机构的执行能力。(4)规范卫生政策措施的实际操作。更多还原

【Abstract】 BackgroundThe overall goal of basic health care system as a public policy system is to provide the people with secure, efficient, convenient and affordable health care services, and take the entitlement of basic health services to everyone. Nowadays, Over100countries included Britain, Germany and Japan have built the basic health care system. On April6th2009, China Government put forward《Opinions of the CPC Central Committee and the State Council on Deepening the Health Care System Reform》, and aimed to establish and improve the basic health care system covering urban and rural residents. Through establishing health care system, which included a public health service system, a health care service system, a medical security system, and a secured pharmaceutical supply system, the problem of "difficult and costly access to health care services" shall have been remarkably relieved, residents’rational health-seeking behaviors shall have been ensured, and residents’burden of medical costs shall be effectively reduced. Subsequently,《The State Council’s Notice on Printing and Circulating the Recent Key Scheme for Implementation of Medicinal and Public Health Reforms (2009-2011)》 was issued, which pointed out that during2009-2011period, all levels of governments would invest total￥850billion on Health.At present, the prevalence of Hypertension in rural China is becoming serious, while the disease economic burden becoming heavier and heavier. A number of problems exist in the health-seeking behaviors of patients with hypertension, such as delay to see a doctor, low awareness of health, choosing high level medical institutions. Hypertension has become the major cause of rural residents’health and economic risk. The "four in one" basic health care system aimed to guide reasonable health care seeking behavior of patients and reduce medical costs through establishing system, financial compensation, and providing services etc. From2007to2010, the reimbursement rate of New Cooperative Medical System had been gradually raised, and the pilot counties of basic medicine system had been grew in batches. Also, the eight counties in Shandong developed the project "NCD community-base intervention in Shandong Province", which aimed to improve the health status of poor and vulnerable population, through establishing the two provided system of basic medical care services and basic public health services.Evidence-based decision-making in health develops along with the development of Evidence-based Medicine (EBM), and uses many methods of EBM. The research of health services management applied Evidence-based Decision-making, has been an international trend of health policy research and formulation. And the focus is that how to support the health policy localization with the complicated mechanisms and methodologies system of Evidence-based decision-making. Prevention and management of chronic disease is a litmus test for health-systems strengthening in low-income and middle-income countries [16]. From2005to2011, the basic health care system experienced the three stages of public discussion, laying foundation, and implementation. During the process, the health system establishing adhere to "basic","equalization", and "equity", So a question is put forward that if the development of health policy in eight counties of Shandong ensure the reasonable health-seeking behaviors and medical expenditure of patients?ObjectivesThe research taken the eight project counties in Shandong as samples is designed to study the impact of health policy elements on the health-seeking behaviors and medical expenditure among patients with hypertension. The specific objectives are as follows:(1) To explore the logical relationship among the basic health care system, health-seeking behaviors and medical expenditure control, and the systematic evaluation methods of health policy through theoretical analysis.(2) To measure and describe the rural health policy elements, health-seeking behaviors and medical expenditure of rural patients with hypertension, and the existing problems, to explore the influence of health policy elements on health-seeking behaviors and medical expenditure through empirical study.(3) To explore that how to establish scientific and reasonable health-seeking behavior of rural patients with non-communicable chronic diseases, and reduced unreasonable medical expenditure of NCDs through policy analysis.Data ResourcesThe resources of the study include the literatures and investigation. The literatures come from the library of Shandong University, including e-books, e-magazines, books and macroscopically health statistics data at provincial and national levels. The investigation datum roots in baseline investigation (2007) and terminal investigation (2010) of Shandong rural health workers training and chronic non-communicable diseases control program, including household investigation, institution investigation and informational interview.This study mainly used quantitative study methods, conducted two cross-sectional surveys of rural adults aged25and above in Shandong province using a multistage random cluster sampling strategy. In the first stage, eight counties were selected as study sites according to the geography and economic distribution; in the second stage, two townships were selected randomly within each county; in the third stage, two villages were sampled randomly within each township; in the fourth and final stage, all households within each selected village were listed and being selected randomly. In the base-line survey,16townships,40villages, and20087residents were sampled. In the terminal survey,1project township and1project village are selected randomly from each county. And4counties were selected randomly from the8counties; within these4counties, a non-project village was selected randomly from the selected project township as control village. In the terminal survey,12townships,14villages, and6216residents were sampled. MethodsBased on literatures review and experts consultation, this study constructed the logical framework among the basic health care system, health-seeking behaviors and medical expenditure, the rural policy indicators system of the "four in one" basic health care system, and the series indicators of health-seeking behaviors, compliance behaviors, medical expenditure and health consciousness, etc. All the indicators are sorted by levels, county level, village or township level, and patient level. This study chose the health care utilization model put forward by Andersen [171] in1968as the theoretical framework. The study applied the Hierarchical Linear Model (HLM) to analyze the impact of policy variables on the health-seeking behaviors, compliance behaviors and medical costs among patients with hypertension, with controlling the influence of other confounding factors, such as demographic, socio-economic and physiological factors, etc.The study methods included systematic analysis, literature review, expert consultation, and multivariate statistical analysis method, etc. Data analysis was conducted using EXCEL, SPSS, and HLM software.Results and findingsThis study constructed the logical model among various policy elements of basic health care system, health-seeking behavior and medical expenditure using health policy theory, and measured rural health policy and patients’health-seeking behavior using quantitative method. The study also across-the-board evaluated the impact of rural health policy on health-seeking behavior and medical expenditure using HLM, controlled for regional economic levels, patient-level socio-demographic variables, and illness characteristics (e.g., hypertension complications). The study screened out the relative sensitivity policy factors affecting patients’behavior and expenditure, established the interaction mechanisms of the three and the policy-oriented model of health-seeking behavior and medical expenditure. This study explored the quantitative methods of health policy evaluation, and avoided ecological fallacy and atomistic fallacy. 1. The logical relationship among the three and the indicators system of rural health policyThe basic medical security system and the secured pharmaceutical supply system directly affect the patients’medical expenditure, in matching of improved basic medical care services system and basic public health services system. Health services indirectly affect medical expenditure, through influence patients’health consciousness, and health-related behaviors. The rural health policy indicators system included four categories:basic medical insurance elements (New Rural Cooperative Medical System, NCMS), basic medicine elements, basic medical care services elements and basic public health services elements. And the policy indicators in this study have good reliability and validity.2. The epidemiology of hypertension and development of health policy in sampled counties of Shandong Province(1) The hypertension prevalence of2011intervention group (38.7%) is lower than that of2007baseline population (44.3%) and that of2010investigated population (38.88%), and the differences were statistical significance (P<0.05).(2)①Basic medicine elements:Among the sampled counties, Ningyang, Shouguang, and Laicheng were selected as the first batch of pilot counties.②Basic medical insurance elements:During2007-2010period, the participation rate of New Rural Cooperative Medical System had risen to99.6%, and hypertension is brought into extend of reimbursement by project counties one after the other. The rate of outpatient reimbursement had been gradually rise and visit-wise submission for reimbursement had been the main submission mode among the sampled counties.③Basic medical care service elements: During2007-2010period, the average number of health workers, village clinics per thousand rural people and the government expenditure of NCDs per people had been raised gradually. The total number of village doctor training times, higher authority supervising times, the average score of hypertension knowledge of village doctor, and the responsiveness of medical care services system among intervention group are all higher than that among control group, and the differences are statistically significant except the difference of training times between the two groups.④Basic public health service elements:During2007-2010period, the scores of health education indicators such as media publicity, management indicators such as hypertension management and follow-up, and supervising indicators of public health services among intervention group are all higher than that among control group, and the differences are of statistical significance.3. The policy motivation and oriented model of rural health policy elements influencing health-seeking behaviors and compliance behaviors among patients with hypertension(1) Impact of basic health insurance or basic medicine elements on health-seeking behavior among patients with hypertension:①For patients with hypertension, more years of implementing general reimbursement incentives for chronic diseases and visit-by-visit submissions were associated with seeing a doctor at a low-level institution, such as township hospitals and village clinics; The reimbursement of expenses by NCMS in township hospitals and village clinics during2010is higher than that in other level institution.②The implement of basic medicine system, and higher NCMS reimbursement rate for outpatient services contributed to improving patient compliance.(2) Impact of basic medical care services or basic public health services elements on health-seeking behavior among patients with hypertension:①Higher average score of hypertension knowledge of village doctors within a village, develop of media educations and health lectures contributed to improving patients health consciousness of NCDs. More promotion materials per people and more hypertension follow-ups contributed to increase of patients’scores of hypertension knowledge. Also, more hypertension follow-ups were associated with higher patient compliance index.②Higher responsiveness of health services system, patients health consciousness of NCDs, and patient compliance index were associated with timely treatment. And higher responsiveness of health services system was associated to receiving medical services at a low-level institution.4. The policy motivation and oriented model of rural health policy elements influencing medical expenditure among patients with hypertension(1) Impact of basic health insurance or basic medicine elements on medical expenditure among patients with hypertension:①The increased of total medical expenditure of last year was associated with these policy elements:The implement of basic medicine system, institutions received medicine usually being township hospitals and village clinics, more years of implementing general reimbursement incentives for chronic diseases, higher reimbursement rate of outpatient services, and visit-by-visit submissions.②The increased of medicine expenses per month and reimbursement of expenses by NCMS were associated with these policy elements:The implement of basic medicine system, institutions received medicine usually being township hospitals and village clinics, and higher reimbursement rate of outpatient services.③The increased of actual compensation rate of NCMS was associated with these policy elements:The implement of basic medicine system, more years of implementing general reimbursement incentives for chronic diseases, higher reimbursement rate of outpatient services, and visit-by-visit submissions; And the increased of medicine expenses per month contributed to lower actual compensation rate of NCMS.(2) Impact of basic medical care services or basic public health services elements on medical expenditure among patients with hypertension:①More village doctor training times during2007-2010period, and higher patient compliance index contributed to the increase of total medical expenditure of last year. Higher average scores of hypertension knowledge of village doctors within a village and hypertension patient management rate contributed to the decrease of total medical expenditure of last year.②Higher patient compliance index was associated to the increase of medicine expenses per month, and Higher hypertension patient management rate was associated to the decrease of medicine expenses per month.③The decrease of NCMS reimbursement of expenditure was associated with these policy elements during2007-2010period:More village doctor training times, authority supervising times and less media promotion.5. Applying HLM in the evaluation of rural health policy effectsHLM was less applied in domestic the evaluation of health policy effects. This study applied the method to analyze the health policy elements, construct the multi-level regression model according to the data level and structure. The variances were decomposed into different levels, and the individual level random error become simpler. Through using HLM, the study achieved the goal of analyzing policy effects of different level, and avoided ecological fallacy and atomistic fallacy.Conclusions and recommendationsThe main conclusions are as follows:(1) Demand release is the direct effect of implementation of rural basic security policy for NCDs.(2) Policy combination is the key condition to form reasonable health-seeking behavior and medical expenditure among patients with hypertension.(3) Individual intervention is the necessary means to form reasonable health-seeking behavior and medical expenditure among patients with hypertension.(4) Policy evaluation is the essential instrument to ensure reasonable health-seeking behavior and medical expenditure among patients with hypertension.The main policy suggestions are as follows:(1) Strengthen the policy motivation of reasonable health seeking behavior:①expand the extend of reimbursement, and raise reimbursement rate;②intensify medicine distribution, and reduce the price of medicine;③reinforce the network of services, and improve service levels;④promote health education, and manage diseases systematically.(2) Make overall planning and give overall consideration for establishing basic health care system.(3) Strengthen the implementation ability of health units at the grass-roots level.(4) Constitute criterion of health policy measures and regulate actual operation.更多还原