【作者】 于竞进；

【导师】 郝模；

【作者基本信息】 复旦大学 ， 社会医学与卫生事业管理， 2006， 博士

【摘要】 “非典”危机提示，我国的疾病预防控制体系过于薄弱，难以满足保障人民健康安全，促进经济发展，构建和谐社会的要求。疾病预防控制体系建设已经成为今后若干年中政府工作的重点之一。为此，需要明确我国疾病防制体系的究竟存在哪些问题，在这些问题中何谓首要问题，首要问题的危害程度、根源和机制，针对根源和机制的标本兼治策略和方案，以及需要什么技术支撑等。目前，国内尚缺乏这方面的系统研究。为此，秉卫生部科研基金资助，开展了疾病预防控制体系建设方面的研究。研究目标本次研究旨在：(1)定量确认我国疾病预防控制体系面临的首要问题及其影响，分析首要问题的根源和障碍；(2)定量明确解决首要问题的治本策略，推荐重塑疾病预防控制体系的改革建议和操作逻辑步骤；(3)围绕治本策略，研制重塑疾病预防控制体系的关键措施，包括：界定我国各级疾病预防控制中心应承担的公共职能，研制省市县三级疾病预防控制中心的人力配置标准，研制疾病预防控制体系财力配置标准和基本设施建设标准。(4)研究基层卫生防保组织疾病预防控制职能、人力和经费配置。研究方法和资料来源1、指导性研究方法论文应用“政策制定科学程序”作为指导性研究方法。该方法共包含7个逻辑相联的步骤，具体包括(1)客观论证政策性问题；(2)科学分析问题的影响因素和根源；(3)针对问题根源科学制定相应政策；(4)严格论证政策可行性；(5)严密政策执行的科学逻辑顺序：(6)科学的政策评价机制；(7)有效的反馈完善机制。本次研究主要涉及程序中的前三步。2、资料来源和收集方法(1)样本地区和样本机构研究采用多阶段随机抽样方法选取样本地区和样本机构。考虑到我国地区的差异性，依据经济发展水平，在东部地区选择浙江、江苏作为样本省，在中部地区选择河北山西作为样本省，在西部地区选取四川、贵州作为样本省。此外，考虑到直辖市是一个特殊群体，在四个直辖市中选择上海作为省级样本；考虑到疾病预防控制工作与人口密度、地理情况有密切关系，选择青海作为省级样本。在每个样本省中，随机选取10个样本市，在每个样本市中随机选取1个样本县。每个样本地区中，选择疾病预防控制中心(卫生防疫站)作为样本机构。样本机构一共包括8个省级疾病预防控制中心、80个市级疾病预防控制中心和80个县级疾病预防控制中心。针对样本机构，一共进行了5个轮次的调查，每个轮次的调查内容均不同，有效调查样本量也不尽相同，详见论文各个部分。(2)资料收集方法1)文献分析广泛收集国内外疾病预防控制体系承担职能、人力配置、经费配置相关期刊论文、书籍、政府文件、统计报表以及政府公告等，收集途径包括CBMDISC、Medline、图书馆、政府机构和政府网络等。其中，文献收集时限为国内1990—2001年，收集范围为《中国初级预防保健》、《中国农村卫生事业管理》、《中国卫生资源》、《中国卫生事业管理》、《中国公共卫生》、《中国卫生经济》、《卫生经济研究》和《中国卫生软科学》八种主要卫生管理杂志，收集方式为普查阅读，共获得相关文献205篇。2)现况调查调查样本疾病预防控制中心和基层预防保健组织近5年来人力数量、人力岗位结构、人力学历结构、人均年收入、人力流动情况、机构费用支出、政府经常性拨款、政府专项拨款、有偿服务收入等基本信息；同时，结合研究进展，进一步调查样本机构各项公共职能和服务项目的开展与否、开展程度、现有人力、期望人力，以及现有投入支出和期望投入支出，等等。一般而言，一个疾病预防控制中心或基层预防保健组织，一次调查填报一份调查表格。3)专家咨询组织具有丰富实践经验和理论造诣的CDC专家、疾病防制行政部门专家和疾病防制领域内的政策研究专家，通过头脑风暴法、焦点小组讨论等方式，提出并修正疾病预防控制体系公共职能和服务项目，论证和完善人力配置和经费配置的影响因素。专家咨询共进行了5轮，共计54人次。4)专家会议论证用于确定各级CDC和基层预防保健组织各自应承担的公共职能和服务项目，确定人力配置和经费配置测算公式，以及人力配置的地区差异调整方法等。专家会议论证开展了1次，与会专家来自全国各省省疾病预防控制中心和省卫生厅疾病控制处。定性资料由项目负责人汇总、归纳，并尽量予以量化。定量资料的分析，除一般描述性统计方法外，在模型构建和模拟过程中，还使用了因子分析和多元回归等多元统计方法；在人力和经费配置标准测算过程中，进行了现状—研究结论、国内—国外，东中西三类地区、省市县基层四级组织机构之间的比较分析。3、资料质量保证方法定性资料由项目负责人和有经验课题组成员负责收集、整理和分析。定量资料在收集时由课题组成员培训调查表填报人员，由专人负责审核调查表填报逻辑错误，有错误的调查表将视情况采取退回重填和电话校对两种方法予以修正；定量资料在录入时编写计算机程序予以逻辑勘误；定量资料在分析时由专人负责。所有定量资料采用编程方法进行整理和分析，不改动原始数据库。研究结果1、公共职能偏废是当前我国疾病预防控制体系存在的首要问题，必须采取有力措施促使疾病预防控制体系公共职能的贯彻落实。导致我国疾病预防控制体系公共职能偏废根源有两方面，一是我国政府对疾病预防控制体系投入总量不足且投入方式低效，表现为政府筹资职能缺位；二是政府允许疾病预防控制机构资金自筹的财政管理机制，使有偿服务成为各级疾病预防控制中心的工作重点，表现为政府管理职能缺位。2、解决问题的治本策略，首先是明确政府承担疾病预防控制的筹资职能，保障疾病防制机构适宜投入，使得目前收不抵支的公共产品得到补偿，合理解决从事疾病防制工作的人员的待遇；同时，通过加强管理和改革投入方式增加服务效率。重塑我国疾病预防控制体系，需遵循以下改革步骤：(1)提高政府对疾病预防控制工作的重视程度，(2)确保政府对疾病预防控制工作的适宜投入，(3)增加财政投入的稳定性和投入效率，(4)改革管理体制以提高疾病预防控制中心的运作效率，(5)改革劳动人事制度稳定和吸引高素质人才，(6)稳妥处理疾病预防控制中心的非公共产品服务。3、疾病预防控制中心公共职能包括7职能、25类别、78内容和255项目，国家、省、市、县四级疾病预防控制中心工作任务和职责各有不同；基层卫生组织应当承担13项传染病防治工作项目、13项慢病防治工作项目、7项卫生信息管理工作项目。公共职能界定结果得到了各级各地疾病预防控制中心普遍认同。4、按照界定的公共职能项目，我国疾病预防控制中心公共职能落实程度普遍不高，并随地区差异和级别不同而异；在各项公共职能中，突发公共卫生事件应急处置职能落实程度最高，健康危害因素监测与控制职能落实程度最低。这种现象与人力投入和财力投入有着直接联系。5、为完成3—5年内期望落实的疾病预防控制公共职能和具体项目，省级疾病预防控制中心平均人力配置标准的基准值为336人，为现有编制的61.1％；市级疾病预防控制中心人力配置标准基准值为102人，为现有编制的84.3％；县级疾病预防控制中心人力配置基准值为33人，为现有编制的76.7％。依此类推，全国省市县三级疾病预防控制中心需配置人力140016人，较2002年底疾病预防控制中心(或防疫站)人力(206815人)减少32.3％，如考虑全国专业站(所)的59044人，则总计减少47.3％。按人口计，该人力配置水平仅相当于美国的11.8％和俄罗斯的8％。6、为完成10年内期望落实的疾病预防控制公共职能和具体项目，省级疾病预防控制中心平均需配置的人力基准值为386人，较现有人力减少17.7％；市级疾病预防控制中心人力配置基准值为113人，较现有人力减少9.7％；县级疾病预防控制中心人力配置基准值为38人，较现有人力减少20.8％。依此类推，全国省市县三级疾病预防控制中心则需配置人力合计为159086人，较2002年底疾病预防控制中心(防疫站)人力(206815)减少23.1％，如考虑专业站(所)的59044人，则总计减少40.2％。按人口计，该人力配置水平仅相当于美国的12.9％和俄罗斯的8.7％。从稳定和易操作角度，10年疾病预防控制中心人力配置标准更具合理性。在四级疾病预防控制中心人力配置基础上，社区卫生服务机构(城镇)和乡村两级卫生机构(农村)疾病预防控制人力配置标准为3—6人／万人口。全国基层需要39—78万从事疾病预防控制职能的人力。7、为实现3—5年阶段目标，在用非公共产品服务收入补偿人员分流情况下，疾病预防控制中心的经费缺口，需要在现投入基础上追加65.5亿／年左右。3—5年后完成非公共产品服务项目和人员的完全剥离，政府为安置分流人员，需要在上述投入基础上，追加36.5亿元／年左右。为实现10年阶段目标，并完成非公共产品服务项目和人员的完全剥离，疾病预防控制中心需要在现投入基础上追加85亿／年左右。城镇社区卫生服务机构和农村乡村两级卫生机构疾病预防控制经费配置标准为5-12万元经费／万人口，全国约65-156亿元。创新和应用1、以公共产品为导向，明确了我国疾病预防控制体系功能定位和国家、省、市、县各级疾病预防控制中心和基层卫生防保组织在疾病预防控制工作上的功能定位。其中，关于传染病防治工作的功能定位被2004年修订的《中华人民共和国传染病防治法》采纳(见附件3)。2、依据功能定位，重新界定了疾病预防控制体系(国家、省、市、县、基层)应当承担的公共职能和具体工作项目，包括7职能、25类别、78内容和255项目。该界定已经于2003年7月底全国卫生工作会议上征求意见，于2003年12月25日在卫生部网站公示，2004年4月全国疾病预防控制工作会议文件(见附件2)。3、明确了以完成疾病预防控制公共职能和具体项目为目标的省、市、县疾病预防控制中心和基层防保组织人力配置和经费配置标准。依据人力配置研究结果，形成了《各级疾病预防控制中心组织编制规定》，该规定在2003年7月底全国卫生工作会议上征求意见，2004年4月全国疾病预防控制工作作为会议文件，在2004年5月全国卫生人事工作会议上征求意见，经卫生部递交中共中央编制委员会办公室审议(见附件5)。4、明确了以完成疾病预防控制公共职能和具体项目为目标的省、市、县疾病预防控制中心基本设施建设标准。其中，关于实验室能力建设和条件要求的研究结果，形成了《省、地、县级疾病预防控制中心实验室建设指导意见》，2004年7月23日由卫生部办公厅和国家发展改革委办公厅以卫办疾控发[2004]108号文联合发布。5、提出了重塑我国疾病预防控制体系的治本策略和改革步骤。依据研究结果，形成了《关于组建卫生部疾病预防控制局的建议》，已报卫生部报中共中央编制委员会办公室研究(见附件1)。6、再次确认了我国疾病防制体系面临的首要问题是公共职能偏废；论证了公共职能偏废问题的根源和作用机制，完善了疾病防制体系公共职能偏废问题的根源和作用机制模型。在上述研究结果的基础上形成了《关于疾病预防控制体系建设的若干规定》，该规定经财政部同意，2005年1月5日以中华人民共和国卫生部第40号部长令发布。2005年起卫生部启动了省、地两级疾病预防控制管理人员培训，省地县三级现场流行病学和实验室管理人才培训工程，相关研究结果为主要培训内容。更多还原

【Abstract】 SARS crisis reveals that the disease prevention and control system (hereinafter "the system") in China is too weak to meet the requirements for guaranteeing population health, facilitating economic development and establishing harmonious society. To enhance the system has been regarded as the priority in the next years by the government. Hence, it is necessary to find out what on earth the weaknesses of the existing system are, which of these weaknesses are principal, the harm, root and mechanism of the principal problem, to work out corresponding strategies and schemes, and to determine what technical supports are needed. Moreover, the first step for strengthening the system is to define its public functions and to demonstrate the manpower, financial resources and apparatus needed for accomplishing these functions. In this regard, inadequate systematic researches have been found in the country. Therefore, with the financial support from the research funds of the Chinese Ministry of Health (MOH), the task force conducts the present study.Study ObjectivesThe present study is aimed to (1) demonstrate quantitatively the principal problems confronted by the system and their impact, root and impediment; (2) work out quantitatively the fundamental strategies for resolution to these principal problems, make recommendations for reform and logistic procedures of reestablishing the system; (3) determine the key measures to reestablish the system with focus on the fundamental strategies, which includes defining the public functions of the Center for Disease Prevention and Control (CDC) at each administrative level, working out the manpower standard for the provincial, prefecture and county CDC, and developing the standards for financial resources and infrastructure of the system; (4) work on the function, manpower and financial resource needed for the primary health facilities to undertake the tasks of disease prevention and control.Research Methods and Data Sources1. Instructive research methodThe present study adopts the "scientific procedure for policy making" as the instructive research method, which includes the following 7 logistically relevant steps: (1) demonstrate the policy issues objectively; (2) analyze the influencing factors and root of these issues scientifically; (3) work out the policies targeting on the root of these issues scientifically; (4) demonstrate the feasibility of the policy strictly; (5) strictly and completely follow the scientific and logistic procedure of policy implementation; (6) scientific mechanism of policy assessment; and (7) effective mechanism of feedback and improvement. The present study is primarily associated with the first 3 steps.2. Data sources and collection methods(1) Sample areas and institutionsThe present study includes CDCs at different administrative levels, stations (or institution) of disease prevention and control, community health service centers, township hospitals and village clinics. In recognition of the geographic difference over the country, 8 provinces (municipal city) are selected based on the economic status, i.e. Shanghai, Zhejiang, Jiangsu, Hebei, Shanxi, Sichuan, Qinghai, and Guizhou. The provincial CDC, 10 prefecture CDCs, and 10 county CDCs are selected for each province. Totally, the present study conducts five rounds of investigations with different contents and valid samples.(2) Data collection methods1) Literature reviewComprehensive literature search has been conducted to collect internationally and domestically published articles, books, government documentation, statistics, and government bulletins about function, human and financial resource allocation of the system by searching databases (such as CBMDISC, Medline), libraries and visiting government agencies and websites. In total, 205 articles published between 1990 and 2001 in 8 key journals of health management in China (i.e. Chinese Primary Health Care, Chinese Rural Health Service Administration, Chinese Health Resources, Chinese Health Service Management, Chinese Journal of Public Health, Chinese health economics, Health Economics Research, and Soft Science of Health) are selected.2) Survey of current statusThe survey has been conducted in sample institutions to collect information about the quantity, allocation, and education status of human resource, annual income per capita, expense, regular and special funds appropriated by the government and revenues from services besides public goods etc in the last 5 years. With development of the research, further investigation is conducted in the sample institutions to find out whether or not, to what extent public functions and services are provided and to collect information about the currently available manpower, expected manpower, current and expected input and output, etc. In general, every CDC or primary health care facility needs to fill out one form for each survey.3) Experts’ consultationExperts with abundant field experience and theoretical accomplishment from CDC, administration of disease prevention and control, and specialists of policy analysis in the field of disease prevention and control are convened for consultation. Through brainstorm and group interview, they recommend and modify the public functions and services of the system, demonstrate and complete the influencing factors of the human and financial resources allocation. There are 6 rounds of experts’ consultation with 54 person times in total.4) Demonstration conferenceThe demonstration conference is convened once to confirm the public functions and services of CDCs at all administrative levels and primary health care facilities, the computational formula of the human and financial resources allocation, and the resolution to adjust geographic variance of human resource allocation. The participants are experts from provincial CDCs and division of disease control and prevention of provincial health departments all over the country.It is the principal of the study that collects, summarizes, and quantifies the qualitative information. In addition to the descriptive statistical methods, multivariable statistics such as factor analysis and multiple regressions is adopted for the analysis of quantitative data in the process of model establishment and simulation. Comparative analysis is conducted between the status in quo and the research conclusion, the domestic and overseas, among eastern, middle, and western parts of the county, and among four levels (i.e. province, prefecture, county, and grassroots) in the determination of standards for human and financial resources allocation.3. Data quality assuranceThe principal of the study and some experienced members of the task force are responsible for collecting, cleaning up, and analyzing the qualitative data.The quantitative information is collected through investigation forms, which are filled out by persons trained directly by the members of the task force. There are personnel designated to review the logic of the returned forms. The logistic mistakes, if any, are corrected either by returning the investigation forms to be filled out again or by clarifying via telephone. Computer program is developed to detect the logistic mistakes in the process of quantitative data entry. Designated personnel are responsible for quantitative data analysis. All the quantitative data are cleared up and analyzed without making changes to the original dataset.Study results1. The principal problem with the current system is the inadequate fulfillment of its public functions, which has to be resolved by taking strong efforts. There are two fundamental reasons for this problem. Firstly, the financial investment from the government to the system is insufficient and inefficient, which represents the improper financing of the government. Secondly, the current system of finance makes cost recovery the top priority for all CDCs because raising money by themselves is permitted, which represents the improper management of the government.2. The fundamental strategies to resolve the abovementioned problem are as follows. Firstly, what has to be recognized is that it is the responsibility of the government to raise funds for disease prevention and control, and to ensure sufficient investment in the related institutions to recover the cost for providing the public goods. At the same moment, the wages and compensation for persons working in the field of disease prevention and control should be guaranteed. Secondly, the operating efficiency has to be improved by enhancing management and reforminggovernmental investment mode. The following reform steps have to be followed in order to reestablish the system in China: (1) more attention from government should be given to the disease prevention and control; (2) appropriate investment from government for the disease prevention and control should be ensured; (3) the stability and efficiency of governmental investment should be increased; (4) the management mechanism should be reformed to improve the operating efficiency of CDCs; (5) personnel reform measures should be taken to attract and retain persons with high capability; (6) the services besides the public goods delivered by CDCs should be disposed with carefulness.3. The public functions of CDCs are allocated into 7 aspects, 25 categories, 78 contents and 255 items. The tasks and responsibilities of CDCs are different at national, provincial, prefecture and county level respectively. The health institutions at the grassroots level are supposed to undertake 13 items of infectious diseases prevention and control, 13 items of chronic non-communicable disease prevention and control, and 7 items of health information management. Such an allocation of the public functions has been widely accepted by CDCs nationwide.4. It is common for the CDCs all over the country that the abovementioned pubic functions have only been fulfilled to a very limited extent, which further varies with geographic distribution and administrative levels. Among all the public functions, the rapid response for public health emergencies is the most fulfilled while the surveillance and control of health risk factors is the least. The reason is thought to be directly related to the human and financial resources allocation.5. In order to fulfill the expected public functions of disease prevention and control and the detailed items in next 3-5 years, the benchmarked manpower value in average for provincial, prefecture, county CDCs is 336, 102, 33 respectively, which makes up to 61.1%, 84.3%, and 76.7% of the present positions respectively. Similarly, it is estimated that 140,016 persons are needed for all CDCs (including provincial, prefecture and county CDCs), which is 32.3% less than that at the end of 2002 (206,815 persons). The present estimate will be 47.3% less than the addition of the number at the end of 2002 and all the special institutes nationwide (59044 persons). Given the total population in China, the present manpower standard is only equivalent to 11.8% in United States and 8% in Russia.6. In order to fulfill the expected public functions of disease prevention and control and the detailed items in next 10 years, the benchmarked manpower value in average for provincial, prefecture, county CDCs is 386, 113, 38 respectively, which is 17.7%, 9.7%, and 20.8% smaller than the number of present positions respectively. Similarly, it is estimated that 159,086 persons are needed for all CDCs (including provincial, prefecture and county CDCs), which is 23.1% less than that at the end of 2002 (206,815 persons). The present estimate will be 40.2% less than the addition of the number at the end of 2002 and all the special institutes nationwide (59044 persons). Given the total population in China, the present manpower standard is only equivalent to 12.9% in United States and 8.7% in Russia. This manpower standard is more rational, stable and easier for operation than the abovementioned. Based on the manpower standard for provincial, prefecture and county CDCs, it is estimated that the standard for community health service facilities in urban areas and township hospital, village clinics in rural areas is 3-6 persons per 10,000 population.Thus, in total, 390,000-780,000 persons are needed for disease prevention and control at grassroots level nationwide.7. Under the condition that revenues from the services besides public goods are used for compensating reduced stafftrimmers, about 6.56 billion Yuan (RMB) is needed additionally every year for CDCs to accomplish the targets in the next 3-5 years. Three to five years later, when all the services besides public goods and reduced stafftrimmers are completely separated from CDCs, the government has to pay extra 3.65 billion Yuan (RMB) annually for settlement of those reduced stafftrimmers. When all the services besides public goods and reduced stafftrimmers are completely separated from CDCs, the government has to pay extra 8.5 billion Yuan (RMB) annually for CDCs to accomplish the 10-year targets. It is estimated that the financing standard for community health service facilities in urban areas and township hospital, village clinics in rural areas is 50,000-120,000 Yuan (RMB) per 10,000 population. Thus, in total, 6.5-15.6 billion Yuan (RMB) is needed nationwide.Innovation and application1. With public goods as the focus, the present study clearly defines the function of the system, the disease prevention and control tasks for national, provincial, prefecture, and county CDCs and the health institutions at grassroots level. The 2004 Revised Infectious Disease Law adopted the definition of functions in the field of infectious diseases prevention and control (see Appendix 3).2. The present study defines the public functions and the detailed items of the system (state, province, prefecture, county, and grass roots) including 7 aspects, 25 categories, 78 contents and 255 items, which has already been distributed for comments in the National Health Conference at the end of July 2003, uploaded to the website of MOH at December 25, 2003 for public remarks, and adopted as the documents at the National Conference of Disease Prevention and Control in April 2004 (see Appendix 2).3. The present study works out the standards of human and financial resources allocation for provincial, prefecture, and county CDCs and the health institutions at grassroots level, which are aimed to define the public functions and the detailed items of the system. Based on the study results of human resource allocation, MOH issued the Prescript for Personnel and Position for all CDCs, which has already been distributed for comments in the National Health Conference at the end of July 2003, adopted as the documents at the National Conference of Disease Prevention and Control in April 2004, distributed for comments in the National Health Personnel Conference in May 2004, and submitted to the office of Institution and Staffing Commission of the Central Committee of the Chinese Communist Party for review (see Appendix 5).4. The present study works out the standards of infrastructure for provincial, prefecture, and county CDCs, which are aimed to define the public functions and the detailed items of the system. The study results regarding laboratory establishment and improvement have been used to develop the Guidance for Laboratory Establishment of Provincial, Prefecture and County CDCs, which had been issued jointed by the Department of General Administration, MOH and thecorresponding department under the State Development and Reform Commission at July 23, 2004 (Paper No. 108).5. The present study recommends the fundamental strategies and reform steps for reestablishing the system. Based on these study results, MOH developed recommendations to establish the Administration of Disease Prevention and Control, which had been submitted to the office of Institution and Staffing Commission of the Central Committee of the Chinese Communist Party for review (see Appendix 1).6. The present study demonstrates and reconfirms that the principal problem with the existing system is the inadequate fulfillment of its public functions, of which the root and mechanism are thoroughly discussed and the simulation model is set up and improved.The Prescript for the Disease Prevention and Control System Establishment has been developed based up the abovementioned study results, which has already been distributed in the No. 40 Order of Health Minister at January 5 2005 with the agreement from the Ministry of Finance. Starting from 2005, MOH launches the training course of the management skills for provincial and prefecture staffs, the training course of field epidemiology for provincial, prefecture, and county staffs, and the training workshop for laboratory management skills. The related results of the present study are widely applied in these training activities.更多还原