【作者】 王云霞；

【导师】 卢祖洵；

【作者基本信息】 华中科技大学 ， 社会医学与卫生事业管理， 2013， 博士

【摘要】 研究目的在分析我国36个重点联系城市（区）社区卫生服务机构经济运行现况及近五年动态发展过程的基础上，从横向和纵向两个方面，对重点联系城市社区卫生服务机构运行的相对效率进行测算，并探讨可能影响经济运行状况和效率的因素，明确我国社区服务机构运行及发展过程中存在的问题和挑战，提出针对性的政策建议，为改善社区卫生服务机构的运行状况、提高运行效率提供依据。研究方法在系统查阅国内外文献的基础上，采用现场调查的方式，对36个重点联系城市（区）的社区卫生服务体系建设情况进行连续动态监测，监测时间为2007年至2011年。调查对象为重点联系城市及辖区卫生局、社区卫生服务机构，以及抽查处方，“一机构一表”的调查方式为搜集较为准确的信息资料奠定了基础。运用的统计分析方法包括描述性统计分析和统计推断、聚类分析、DEA的方法、Malquist生产率指数和Tobit回归模型等。数据资料采用EpiData3.0进行双重录入，运用的软件主要包括SAS9.0、SPSS12.0、Stata11.0和Deap2.1。研究结果1.社区卫生服务机构经济运行情况2011年，重点联系城市社区卫生服务中心建成率达到89.83%，站达到91.1%，92.13%的街道均设置社区卫生服务中心，社区卫生服务网络初步建成。同年，制定社区基本用药目录、统一采购集中配送制度、基本药品零差率销售制度的辖区实施率分别达到82.06%、92.38%和95.95%，合理用药指标和处方费用得到改善。社区卫生服务机构公共卫生服务和基本医疗服务提供总量不断增加，但基本医疗服务在各级医疗服务机构中所占比例无明显提高。社区卫生服务中心收支基本平衡、略有结余，社区卫生服务站呈现亏损状态。从收入构成来看，社区卫生服务机构财政补助收入所占比例有所提高，中心和站分别达到32.98%和16.41%。2.社区卫生服务机构经济运行效率的测算与变化趋势分析总体评价模式的效率值高于医疗服务评价模式，而医疗服务评价模式高于公共卫生服务评价模式；社区卫生服务中心的效率值高于站。总体模式下的Malmqusit生产率指数，社区卫生服务中心近五年均大于1，社区卫生服务站除2009年的生产率较2008年有所提升外，其它年份均有所下降；医疗服务模式下，社区卫生服务中心全要素生产率在2010年和2011年连续衰退，社区卫生服务站仅在2010年有过提升；公共卫生服务模式下，中心的全要素生产率持续提升，站在2011年有所下降。3.东中西部地区社区卫生服务机构经济运行状况和效率分析东西部地区社区卫生服务中心总收支基本平衡、略有结余，中部地区社区卫生服务中心总收支基本平衡、略有亏损。各地区的社区卫生服务站均呈现亏损态势。中西部地区中心药品收支结余较高，达到20%。东部地区服务提供总量和人均医疗服务提供量高于中西部地区，东西部地区社区卫生服务机构运行相对效率高于中部地区。研究结论社区卫生服务网络已经建成，但在政策落实、人员配置和服务功能方面仍需进一步优化。社区卫生服务中心财务运营状况良好，社区卫生服务站不容乐观。不同评价模式、不同机构类型、不同时间社区卫生服务机构的效率水平和生产率指数不尽相同。不同区域比较，东西部地区社区卫生服务机构的运行状况和效率好于中部地区，应因地制宜，分类指导。创新与不足在样本量方面，本研究采用了目前国内最大的社区卫生服务机构的连续性样本；在研究思路方面，本研究首次按照总体效率、医疗服务和公共卫生服务三个效率评价模式，同时采用DEA、Malquist生产率指数和Tobit回归模型对我国社区卫生服务机构经济运行的效率进行测度，并探讨可能影响效率的因素。然而，在资料来源上，本研究仅选取了36个城市区作为研究对象，结果仍存在一定的局限性。在有关公共卫生服务效率的研究中，目前也尚未有较为成熟和权威的评价体系。更多还原

【Abstract】 Research PurposesWe aimed to calculate the relative efficiency of CHSIs from both horizontal and vertical, andexplore the factors that may affect the economic status and efficiency, on the basis of analyzingthe economic operation status and dynamic development process of the past five years on thecommunity health service institutions (CHSIs) among the36key contact Cities. Furthermore, wetried to make sure the problems and challenges during the CHSIs development, and put forwardspecific policy recommendations to provide a basis for improve the CHSIs operational status andefficiency.Research MethodsOn the basis of system access to domestic and foreign literature, we continuously monitoreddynamic development of community health service system construction among36key contactcities (districts) from2007to2011by site survey. The subjects were health authorities of citiesand areas, CHSIs as well as prescriptions.“One institution on questionnaire” laid the foundationto collect more accurate information. The statistical methods included descriptive statistics andstatistical inference, cluster analysis, data envelopment analysis (DEA), Malquist productivityindex and Tobit regression. EpiData3.0double-entry was used, and the software includes SAS9.0,SPSS12.0and Deap2.1.Research Results1.Economic operation status of CHSIIn2011, the completion rate of community health service centers (CHSCs) and stations(CHSSs) were respectively89.93%and91.90,92.13%of the streets are set community healthservice centers, and the community health service network initially built. At the same year, theimplementation rate of development of a community list of essential medicines, unifiedprocurement and centralized distribution system, essential medicines zero sales system reached82.06%,92.38%and95.95%, respectively. And rational drug use indicators and prescriptioncosts improved. The total service of CHSIs is increasing, but the proportion of basic health services in all levels of health care services system was not significantly improve. The CHSCshad a basic balance of income and expenditure, and the CHSSs showed a deficit. The financialassistance income proportion increased in CHSIs, and the center and the station wererespectively32.98%and16.41%, but the proportion of health insurance income was still low.2. Estimates of economic efficiency and temporal analysis on CHSIsThe efficiency value of the overall evaluation mode was higher than that of the medicalservice evaluation mode, and the efficiency value of medical services evaluation mode washigher than that of the public health services evaluation mode; The CHSCs efficiency value washigher than that of the CHSSs. In the overall mode, the malmqusit productivity index in the fiveyear was greater than1in CHSCs, and the malmqusit productivity index in CHSSs was smallerthan1except in2009; in the care delivery model, the total factor productivity index in CHSCscontinuously recession in2010and2011, and the CHSSs only improved in2010; in the publichealth service mode, the CHSCs’ total factor productivity continued to improve, and theCHSSs was declined in2011.3Analysis of economic situation and efficiency analysis about CHSIs of eastern, central andwestern regions.The CHSCs of the eastern and western regions had a balance between income andexpenditure with slightly surplus, and the CHSSs of centers regions had a balance betweenincome and expenditure with slightly deficit. The CHSSs had a deficit status in any of the region.The drug revenue expenditure surplus was higher in the CHSCs of the central and westernregions, which was up to20%. The total amount of service and per capita health care providingwas higher in eastern part than that of central and western regions; and the relative efficiency ofCHSIs in the eastern and western regions were higher that in the central region.ConclusionsCommunity health service network has been built, but still need to be further optimized interms of policy implementation, staffing and service functions. The CHSCs operated in goodcondition, while the CHSSs’ operation was not optimisitc. In different evaluation mode, differenttypes of institutions and different time, the efficiency and productivity index in CHSIs is not thesame. Between different regions, the efficiency of CHSIs was higher in the eastern and westernregions than that in the central region.Innovation and limitationsIn terms of sample size, this study used a largest continuous sample of CHSSIs; about theresearch ideas, this study first estimated the relative efficiency according to the overall mode,medical services mode and public health services mode, and it was also the first time adoptingDEA, malquist productivity index and Tobit regression. However, because of the data source, theresults of this study were still unable to fully representative of the general situation of thedevelopment of the National Community Health Service. And in terms of the efficiency of thepublic health service, evaluation system was not mature and authoritative.更多还原