【作者】 张乐；

【导师】 徐凌忠； 屈卫东；

【作者基本信息】 山东大学 ， 社会医学与卫生事业管理， 2014， 博士

【摘要】 研究背景职业健康问题是全球所面临的严重问题之一,是经济发展,特别是工业化进程的产物,但因其外部性、公共产品的特征,仅仅依靠市场机制这只“无形的手”无法有效解决这一难题,因此作为公共服务的提供者,政府在职业病防治领域负有高度的责任,职业病防治工作是政府公共服务的重要组成部分。但片面的发展观和以经济增长为核心的政绩考核机制,均制约了我国职业病防治工作的开展。因此,在职业病防治领域,政府失灵与市场失灵并存,而前者突出表现在管理不力和效率低下。目前我国已处于职业病的高发期和矛盾凸显期,职业病患者人数、死亡人数均位居世界首位,职业病已成为重大的公共卫生问题和社会问题。职业病防治形势日益严峻的现实,迫使我们产生以下疑惑“我国职业病防治工作是否有效,绩效几何”,因此,以何标准衡量我国职业病防治工作所取得的成绩,如何客观、公正的对我国职业病防治投入、产出以及结果进行综合评价,成为各级政府关注的问题,也是职业病防治领域理论研究者以及实践工作者亟待解决的问题。但目前国内外关于职业病防治绩效评价的研究极少,而职业病防治绩效评价的实施对强化责任、监控进程、界定成败影响因素和提供实证依据有着十分重要的意义,因此本研究致力于解决这一难题,通过绩效评价提高职业病防治资源的利用效率,改善职业病防治的服务质量,切实维护劳动者的健康权益。研究目的基于上述背景,本研究以职业病防治绩效评价为主题,旨在通过构建职业病防治绩效评价体系,对我国职业病防治的绩效做出科学、公正的评价,并确定关键制约因素以及其内在根源,从而为相关部门采取针对性的改进措施提供客观依据。具体目标为：1、构建以行政区域为对象的职业病防治绩效评价体系,包括指标体系的构建、基础数据集的建立、评价模型的确定以及评价标准的形成等。2、通过对样本地区的实证研究,对构建的评价体系进行检验,并对样本地区进行诊断缺陷,发现薄弱环节,为针对性改进措施的实施提供依据。3、确定制约我国职业病防治绩效的内在根源。研究方法针对以上研究目的,本研究按照一般与特殊相结合,理论与实证相结合,系统与局部相结合,内在与外在相结合的方法论原则,采用理论方法与实证方法两大类手法,通过对行政区域职业病防治绩效进行评价,提出进一步完善和发展我国职业病防治体系的政策建议,以供决策者参考。本研究所采用的对应研究方法如下：1、首先通过相关政策分析、文献复习和专题访谈确定了职业病防治绩效概念模型；2、通过小组研讨、专家访谈和现场调研对指标进行初选,然后通过两轮Delphi专家咨询和离散趋势分析筛选出最终指标,进而采用主客观赋权法确定各指标的权重,然后经过专家咨询和论证,确定指标的标准值和收集方式等；3、在文献复习的基础上,通过专家咨询确定职业病防治绩效不可控因素,然后利用偏最小二乘回归法构建这些因素与职业病防治绩效指数的回归模型,然后,通过建立样本地区内部影响因素矩阵,计算出“环境有利度”；4、选择山东省九个地级市为样本,将构建的职业病防治绩效评价体系运用于实证研究,利用从样本地区收集的资料,分别应用克朗巴赫α系数、主成分分析和聚类分析,检验指标体系的信度、效度和区分度,采用综合指数法评价样本地区的职业病防治绩效；5、采用规范分析的方法,借鉴经典的委托代理模型以及成本收益模型,对我国职业病防治绩效不佳的内在根源进行探讨。主要研究结果本研究的主要研究结果包括：1、建立了职业病防治绩效的概念模型,包括投入、活动、产出、结果、影响及环境等维度。2、构建了职业病防治绩效评价指标体系,包括投入、产出和结果三个一级指标,其中投入维度包括有形投入和无形投入两个二级指标,产出维度包括服务提供、行业自律和依法行政三个二级指标,结果维度包括健康促进和社会影响两个二级指标,共计22个三级指标,并确定了各指标的权重和标准值。与之相对应,基础数据集、评价模型以及评价标准的形成,最终形成职业病防治绩效评价体系。3、为了确保职业病防治绩效评价结果的横向可比性,本研究构建了职业病防治绩效不可控因素模型,包括政治、经济、社会和技术等维度,共计十个指标,其中,人均GDP、规模以上工业万元增加值能耗、财政赤字率、第二产业比重、城镇登记失业率以及职业病危害因素接触率与职业病防治绩效呈负相关,R&D投入占GDP的比例、规模以上工业产值中高新技术产业比重、卫生技术人员千人拥有量、大专以上文凭所占比重与职业病防治绩效呈正相关。并在此基础上计算出这些不可控因素对样本地区的“环境有利度”。4、建立了职业病防治绩效评价指标体系使用指南,针对三级指标制定了具体的测量公式、数据收集方式以及评价的标准值。5、利用构建的职业病防治绩效评价体系对山东省9个地级市职业病防治的现状进行了综合评价,评价结果显示：按照绩效从高到低依次排序为济南市、潍坊市、聊城市、烟台市、莱芜市、济宁市、威海市、枣庄市和菏泽市。本研究将绩效分为好、较好、一般、较差和差五类,按照分类标准,前七个市绩效类别为“一般”,枣庄市和菏泽市绩效类别为“较差”。6、中央政府与地方政府的信息不对称以及目标函数的不一致,使得其在职业病防治领域存在严重的委托代理问题,主要表现在地方政府倾向于选择放松职业病防治,甚至直接非正当干预职业病防治工作的开展,成为一些企业的保护伞。7、目前我国职业病防治体系及制度的不完善,使得用人单位缺乏自觉开展职业病防治工作的积极性。结论和建议通过理论分析和实证研究,结合我国相关政策,提出如下政策建议：1、落实各级政府和相关部门的责任,加强组织领导是前提2、加强职业病防治能力建设是基础3、加强对用人单位的监管,强化其责任主体的地位是重点4、加强政策引导,提高职业病防治各相关责任体的内在动力是关键(1)制定有利于职业健康的产业政策,充分发挥产业政策导向和市场机制的作用,鼓励和引导用人单位采用先进的技术、装备和工艺。(2)完善中央政府与地方政府之间的转移支付机制,建立中央政府-地方政府安全健康生产基金,中央政府根据地方政府的政策执行情况,按照一定比例从税收中返还给地方政府。(3)完善我国工伤保险制度,对工伤保险金的使用范围进行相应的改革,建立弹性工伤保险金制度。(4)实行更为严格的考核和责任追究制度,严格落实职业病防治目标考核制度,对各级政府、相关职能部门以及用人单位完成年度职业病防治指标情况进行严格考核,并建立相应的奖惩制度。(5)实施用人单位职业健康公示和承诺制度,用人单位必须定期公示本单位职业健康的基本信息。创新与不足本研究的创新有以下几个方面:1、理论创新目前关于我国职业病防治绩效不佳的原因的探讨众多,但大都浮于表面,本研究借鉴经典的经济学原理,从委托代理以及成本-收益两个方面,分别对政府和用人单位开展职业病防治工作的内在动力进行探讨,从而确定了我国职业病防治绩效不佳的内在根源,那就是无论是地方政府还是用人单位都是“经济人”,它们均缺乏自觉开展职业病防治活动的积极性。2、实践创新目前的研究多集中在对用人单位职业卫生管理效果的评价上,本文的研究目标定位于区域性的职业病防治绩效评价,构建了一套科学、合理的职业病防治绩效评价体系,并进行了实证研究,对于强化责任、监控进程、界定成败影响因素和提供实证依据有着十分重要的实践意义。3、方法创新如何剔除不可控因素的干扰一直是评价领域的一个难题,本研究通过PLS模型构建了不可控因素与职业病防治绩效的回归方程,并结合内部影响因素模型,定量测量职业病防治绩效不可控因素的作用,计算出每个评价区域的“环境有利度”,从而可以剔除这些不可控的环境因素的影响,实现了区域之间的横向比较。但是职业病防治绩效评价是一个复杂的系统工程,同时,由于作者能力和精力所限,本研究尚存在一些不足之处：(1)由于职业病是一个笼统的概念,它包含很多种疾病,不同的职业病危害需要采取的防治措施不同,因此所需要的资源也相应不同。本研究没有对其进行细分,因此,需要进一步的完善。(2)本研究利用“环境有利度”对职业病防治绩效进行校正,但也仅限于综合绩效指数,而没有对三级指标进行校正。(3)本研究虽然剔除了一些不可控因素的干扰,但由于本研究以行政区域为评价对象,因此,不能采取实验或准实验研究的方法(因为没有那个区域完全不采取职业病防治措施),进行严格的因果论证,虽然是条件所限,但仍是缺憾之处。(4)目前我国职业健康形势不佳是受到政治、经济、社会、文化等多方面制约引起的,本研究仅从经济学角度对其进行探讨。更多还原

【Abstract】 BACKGROUNDOccupational health problem is one of the serious problems world widely, which is the product of economic development, especially the industrialization progress. Since it is characterized with public service and externalities, the "invisible hand" of the market mechanism can’t solve it effectively, therefore as a provider of public services; the government has high degree of responsibility in the field of occupational disease prevention and control, which is an important part of government public services. But one-sided development concept and performance evaluation mechanism have restricted the work of occupational disease prevention and control. Therefore, in the field of occupational disease prevention and control, government failure and market failure coexist, while the latter was prominent in poor management and low efficiency.Recently, China is in a period of high incidence and prominent contradictions of occupational disease, both the incidence and death toll of occupational disease patients ranked first in the world, so occupational disease has become a major public health problem and social problem. But the serious situation of occupational disease prevention and control at present forces us to doubt that if the work of occupational disease prevention and control effective and how much is the performance". So what criteria should be used to measure the achievement and how to evaluate the input, output and result of the occupational disease prevention and control objectively and impartially, become the concern of governments, and is also a problem to be solved urgently for theoretical researchers and practical workers. But there are very few researches on performance evaluation of occupational disease prevention and control, which is of extremely significance for strengthening responsibility, monitoring process, defining the success or failure factors and providing empirical basis. So this research is committed to solve this problem, and through the performance evaluation to improve the efficiency of resource utilization and the service quality, and to safeguard the health rights and interests of the workers.OBJECTIVEBased on the above background, this research whose theme is performance evaluation of occupational disease prevention and control aims to address the following questions:1. To construct a performance evaluation system for regional occupational disease prevention and control, including the construction of index system, the establishment of basic database, the determination of evaluation model, and the formation of the evaluation standard, etc.2. To inspect the constructed evaluation model through the empirical study in the sample areas, and then affirm the achievement and diagnosis defects, and to find the weaknesses, so as to provide basis for the implementation of targeted measures.3. To explore the inner reasons restricting the performance of occupational disease prevention.METHODOLOGYAccording to methodological principle of combining common with specialty, theory with practice, system with part, internal aspects with external, and utilizing theoretical method and demonstrating methods, this research evaluates the performance of occupational disease prevention and control in sample areas, and then providing policy and suggestions for further improvement of occupational disease prevention and control system.1. To identify the conceptual model of occupational disease prevention and control performance through the related policy analysis, literature review and thematic interviews. 2. To screen the primary indicators through group discussions, expert interview and field research, and then screen out the final indicators through two rounds of Delphi expert consultations and discrete trend analysis, and then the subjective and objective empowerment method is adopted to determine the weight of each index, and finally determine the standard and collection method of the indicators through expert consultation and demonstration.3. To screen the uncontrollable factors influencing the performance of occupational disease prevention and control through literature review and expert consultations, and then the PLSR method is used to make sure the impact degree and property quantitatively.4. This study selects nine prefecture-level cities in Shandong province as samples, and put the constructed index system into practice. Using the data collected from the sample areas, cronbach coefficient and principal component analysis are applied to test the reliability and validity of the index system. Synthetical index method is used to evaluate the performance of occupational disease prevention and control comprehensively.5. Using the classic principal-agent model and cost-benefit model for reference, the normative analysis method is adopted to analyze the root of poor performance of the occupational disease prevention in China.RESULTSThe main results of this research are as follows:1. The concept model of occupational disease prevention and control performance has been constructed, including input, activity, output, the results and environment.2. The index system for performance evaluation of the occupational disease prevention and control has been constructed, including three first-level indexes, that is input, output and result; and the input dimension includes two secondary indexes, that is tangible inputs and intangible inputs, the output dimension includes three secondary indexes, that is service provide, administration according to law, self-discipline, the result dimension includes two secondary indexes, that is health promotion and social impact, all in all22third-level index. The weight and standard of each index are also determined.3. hi order to ensure the transverse comparison of the performance evaluation results of occupational disease prevention and control, this study constructs a uncontrollable factors model for occupational disease prevention and control, including the dimensions of political, economic, social, technology and so on with a total of10indicators. Per capita GDP, industrial added value of ten thousand Yuan, fiscal deficit, the proportion of secondary industry, urban registered unemployment rate and the occupational-disease-inductive factors contact rate are negatively correlated with the performance of occupational disease prevention and control, and the proportion of R&D investment in GDP, the proportion of high and new technology industry in gross value of industrial output over the scale, the number of health and technical personnel per thousand people, the proportion of college degree or above diploma are positively correlated with the performance of occupational disease prevention and control. Through calculating the "environmental benefit degree" for each sample areas, the performance results are adjusted.4. The guidelines for index system for performance evaluation of the occupational disease prevention and control has been constructed, in which the specific measurement formula, data collection method and evaluation standard for the third-level index are listed.5. With the constructed index system, this study carries on empirical study in nine cities in Shandong province, the evaluation results are as follows:The performance order from high to low in turn is Jinan, Weifang, Liaocheng,Yantai, Laiwu, Jining, Weihai, Zaozhuang and Heze. The performance level in this study is divided into good, relatively good, general, relatively poor and poor, so the performance level of occupational disease prevention and control for the former seven cities is general, and the level for Zaozhuang and Heze is relatively poor.6. Because of the information asymmetry between the central government and local government as well as the inconsistent objective function, there are serious agency problems exist in the field of occupational disease prevention and control. The local governments tend to relax the occupational disease prevention, and even directly intervene in the occupational disease prevention and control work, becoming the umbrella of some illegal enterprises.7. The employers lack the enthusiasm of carrying out the work of prevention and control of occupational disease consciously because of the imperfect system and institution for the prevention and control of occupational diseases.CONCLUSIONS&SUGGESTIONSThrough theoretical analysis and empirical research, combined with relevant policies in China, this paper puts forward the following suggestions:1. To implement the responsibility of the government and relevant departments at all levels and strengthen organizational leadership is the premise.2. To strengthen the ability construction of of occupational disease prevention and control is the foundation.3. To strengthen the supervision employers, and guarantee their main responsibility body status is the emphasis.4. To improve the intrinsic motivation of each related responsibility body for occupational disease prevention and control through policy guidance is the key pomt.(1) To give full play to the role of the industrial policy guidance and market mechanism, so as to encourage and guide the employers to use the advanced technology, equipment and process.(2) To improve the transfer payment mechanism between the central government and local government, and establish special fund for occupational disease prevention and control, the central government returns a certain proportion tax to the local government according to its policy implementation.(3) To improve the work injury insurance system in our country, and reform the using range of work injury insurance, and construct the elastic work injury insurance system.(4) To construct a stricter inspection and responsibility system, and strictly carry out the target appraisal system for for all levels of government, the relevant functional departments and the companies, and check the completion of the annual index of occupational disease prevention and control, and establish corresponding system of rewards and punishments.(5) To implement publicity and commitment system of occupational health for the companies, and the companies must publicize the basic information of the occupational health regularly.INNOVATIONS&LIMITATIONSThe innovations of this research are as follows:1. theoretical innovationAt present the discussion about the the cause of the poor occupational health status in China is numerous, but most of them are superficial. This study is largely inspired by the classical economics principle, and principal-agent and cost-benefit theory are used respectively to explore the intrinsic motivation of the government and company to carry out the work of occupational disease prevention and control; so as to determine the the internal origin of the poor occupational health condition in our country, that is both the local government and companies are "economic man", they all lack the enthusiasm of carrying out the occupational-disease-prevention activities consciously.2. practice innovationAt present, the studies focus on the effect of occupational disease prevention and control for companies, but this study targets at performance evaluation of regional occupational disease prevention and control, and has constructed a set of scientific and reasonable performance evaluation system of occupational disease prevention and control, and this study has conducted empirical study, which is of extremely practical significance for strengthening responsibility, monitoring process, defining the success or failure factors and providing empirical basis.3. methodology innovationHow to eliminate the influence of environmental factors has always been a difficult problem in the field of evaluation, this study has constructed the regression equation between uncontrollable factors and performance of the occupational disease prevention and control by the PLS model, and the internal influencing factors model is used to measure the uncontrollable factors quantitatively, and calculate the "environmental benefit" of each areas, in order to eliminate the impact of these uncontrollable environmental factors, and realize the transverse comparison between regions.But the performance evaluation of occupational disease prevention and control is a complex systematic engineer, and because of the complexity of the problem and limitations of the author, this study still exist some shortcomings that need further research and improvement. The limitations of this research are as follows:1. Due to occupational disease is a general concept, it contains many kinds of diseases, and different prevention measures are needed to taken for different occupational disease hazards, therefore the resources needed are also different accordingly. This study failed to consider this, therefore we should make further improvement to optimize it.2. The "environmental benefit degree" is used to adjust the performance of occupational disease prevention and control, but this is just limited to the comprehensive index, and no adjustment of the third-level indicators.3. Although this study eliminated the interference of some uncontrolled factors, this study aims to evaluate the administrative areas, therefore, we cannot take the method of experimental or quasi-experimental research for the strict causal reasoning, although this is due to the limited conditions, but is still missing.4. At present poor occupational health situation in our country is influenced by the restriction of political, economic, social and cultural aspects, this study only explores it from the perspective of economics.更多还原