【作者】 郝晓宁；

【导师】 李士雪；

【作者基本信息】 山东大学 ， 社会医学与卫生事业管理， 2007， 博士

【摘要】 背景自20世纪60年代起，许多国家开始重视社区卫生服务的组织建设和功能完善。进入21世纪以来，针对人口老龄化、医疗费用居高不下、非传染性慢性病增多等一系列的医学难题，开展社区卫生服务、寻找适当的社区卫生服务模式已成为新时期全球卫生体制改革的必然趋势。到目前为止，社区卫生服务已在世界很多国家中相继开展。社区卫生服务是现代社会的一种卫生服务模式，是政府为了保障基本公共卫生服务与基本医疗服务而提出的一项重要举措，是坚持社区卫生服务公益性、落实国家基本医疗服务保障制度和维护健康权利的根本体现。它既可使卫生资源配置更加合理、利用更加有效，又可使基层卫生机构的功能得到更好的定位，使卫生事业改革和发展有着广阔的前景。我国发展社区卫生服务始于1997年。《中共中央、国务院关于卫生改革与发展的决定》中明确指出：“要改变城市卫生服务体系，积极发展社区卫生服务，逐步形成功能合理、方便群众的卫生服务网络”。此后，社区卫生服务在全国迅速开展。经过十年的发展，各地根据卫生服务需求的变化，基本建立起城市社区卫生服务网络；社区卫生服务的组织类型呈现多元化局面，举办主体形式多样。从全国各地社区卫生服务的开展情况来看，社区卫生服务是卫生事业的发展方向这一观念，已经得到了普遍认同。但是由于各地社会经济发展水平的差异，社区卫生服务的发展还相当不平衡，并面临着许多发展中的问题。当前主要存在的问题是：一是大多数社区卫生服务机构对服务目标定位不明确，服务对象边缘化。二是现行组织管理体系导致社区卫生服务的公益性质淡化，“六位一体”的功能发展很不平衡。三是社区卫生服务观念与服务方式相对落后。四是社区卫生服务机构缺乏现代管理制度，活力不足，效率不高。所有这些问题严重地制约了社区卫生服务的开展和发展。改革现有的管理模式，探索适应现代经济生活发展的社区卫生服务运行机制势在必行。近年来国内对社区卫生服务的研究已经开展了不少工作，但是，目前的研究多数集中于“应该怎样”，即社区卫生服务政策与策略的研究，社区卫生服务的基本现状分析，社区卫生服务的基本功能、服务项目、人力资源建设及社区卫生服务的绩效评价等方面，而“怎样做”即对城市社区卫生组织形式与服务模式建设的研究相对较少，尽管文献上也报道了一些相关研究，但多是分散的，局部的，片面的，对社区卫生服务管理模式和运行机制系统整体的研究尚不多见，对社区卫生服务组织管理体系与运行机制构建的研究不够深入具体。借助于中英城市社区卫生服务与贫困救助项目(UHPP)与科技部、卫生部“社区重大疾病预防控制与运行机制研究”十五攻关课题子项目资助，我们进行了此项研究，主要目的是通过对社区卫生服务运行机制这一理论问题进行研究，运用组织管理、制度设计理论，联系现代社区卫生服务的本质特征与我国现实国情，探索建立适应现代社会经济发展与健康需求变化的社区卫生服务运行机制。在目前宏观发展的政策环境下，满足随社会经济发展及需求变化人们对于社区卫生服务的需求，达到规范社区卫生服务行为、规范医务人员行为、解决看病难看病贵问题的目的。对社区卫生服务顺利发展提供制度与管理保障，为促进社区卫生服务体系建设提供理论支持与实践指南。研究方法本研究采用文献复习法，对国外社区卫生服务的运行机制与组织形式以及我国社区卫生服务的进展、各地具体组织形式及管理体系进行了比较研究，同时结合10个国家级社区卫生服务示范区的现场调查及收集资料，利用组织设计理论、管理学基本原理、系统论与控制论、物流系统论与供应链原理和新制度经济学等方法，遵循国家法律法规，提出社区卫生服务的组织管理体系构建与相应运行机制及制度设计。经过几轮专家论证，确定了用于改革实践的实施方案。根据卫生部推荐结果，选择深圳市宝安区公明街道作为试点地区，进行实证干预试验；并通过现场督导、关键人物访谈、头脑风暴、问卷调查等一系列方式，对试点运行情况进行了实证研究，根据实际运行与反馈，不断修正和完善设计方案。对试点运行情况，通过现场调查机构改革运转情况，利用关键人物访谈法补充了解改革带来的效果变化，并利用实证研究方法对改革的效果进行了评估。研究结果1．构建了新型社区卫生服务管理体系与运行机制。社区卫生服务管理中心是社区卫生服务机构的管理主体。在卫生局领导下，实施管理职能，对辖区内社区卫生服务机构进行管理。进行人事制度改革，推行全员聘用制，因岗设人；改革分配制度，实行绩效考核管理制度；改革机构财务机制，实施收支两条线管理；建立物流配送与药品集中采购机制；实行民主监督机制，对社区卫生服务工作进行监督。2．建立了新型社区卫生服务模式。推行以“全科医生团队”模式为服务方式的方法，即以全科医生为核心，配备全科护士、公共卫生医师等组成服务系统，为居民提供全方位的服务。提高社区医生的服务能力，改变服务方式，改变医生行为；建立并完善社区首诊制与社区双向转诊制度，使得居民能在社区内得到及时、有效的治疗。3．开发了一系列与社区卫生服务新型管理体系相适应的规章制度，为社区卫生服务的可持续性发展提供制度保障。4．通过实证研究，对研究成果进行现场实验，对实验结果进行了评价研究。尽管试点试验只开展了半年时间，有些制度改革的远期效果尚未表现出来，但是从评价结果看，新方案运行后疾病控制率得到提高，控制的成本／效果比显著改善，门诊费用下降，群众满意率增高。结论与建议本研究构建了新型社区卫生服务组织管理体系以及与之相适应的具体的制度，并通过试点干预试验对方案的科学性、可行性与可操作性进行了验证。定性、定量研究结果表明方案设计合理，能够有效地保障社区卫生服务顺利发展，促进其更好的满足人民群众的健康需要。方案设计的组织体系与制度保障，能切实带来机构行为发生变化。试点地区通过实施人事制度改革与绩效考核管理，激发了医生完成慢性病管理、预防保健等公共卫生服务项目的工作热情，社区首诊与双向转诊运转良好，社区卫生服务机构效率提高，病人得到实惠。对社区卫生服务发展的政策建议：1．明晰政府在社区卫生服务中的权责：发展并形成社区卫生服务的政策支持环境；对于公益性质的社区卫生服务，政府应该承担公共卫生服务的付费责任；建立完善社区卫生服务机构与政府及群众之间的问责关系制度。2．继续完善并推进社区卫生服务改革的相关内容：完善社区卫生服务的管理模式；继续推进人事制度改革，完善岗位竞争机制；健全社区卫生服务机构的绩效考核机制；改革社区卫生服务模式，提高社区医生的服务能力，提供基本医疗和公共卫生服务；完善社区卫生服务的筹资机制；建立并有效实施社区卫生服务民主监督机制。创新与不足创新：1．本研究以相关法规法令、结构与行为理论、组织设计理论、系统论与控制论、物流系统论与供应链原理和新制度经济学等理论为基础，构建了新型的社区卫生服务组织管理体系、服务模式和五个运行机制，开发了一系列配套的管理制度，为社区卫生服务可持续发展提供制度保障。2．本研究在方案设计的理论基础上进行了实施性研究，通过试点干预试验，对方案的科学性、可行性与可操作性进行了验证；利用实证研究方法，结合现场调查对方案实施的前后效果进行了评估。3．成果应用：本研究开发的一系列管理制度已经被卫生部妇幼保健与社区卫生司采用，并在全国29个社区卫生服务重点联系城市中应用；试点地区深圳市宝安区公明街道关于机构人员技术能力提高与相关制度环境建设支持的结果与方法，已于2007年9月被卫生部应用到全国10个城市13个试点区进行更大范围的推广。本研究已在《中国卫生经济》等杂志上发表论文8篇。不足：由于本研究评估的时间，距离干预试验启动只有半年时间，一些制度改革的远期效果尚未表现出来；同时，因为本研究只选择了一个地区作为改革试点，而各地社会经济背景千差万别，因此在推广该模式时还需要充分考虑当地的实际情况。以上这些不足，是我们今后继续研究的重点。更多还原

【Abstract】 BACKGROUDFrom the 60’s in the 20th century, more and more attention has been paid to the organization and the function implementation of Community Health Service (CHS). Especially for present century, it is the inevitable trend to develop CHS and find an appropriate management mode to deal with such problems as the people ageing, fee-for-service keeping rising, non-infectious chronic disease increasing, and so on. Today,many countries have conducted CHS throughout the world.The role of CHS is to guarantee people the rights of primary medical and public health service so as to improve health, prompt and keep social equity and stabilization. CHS can improve rational and effective allocation of resources, and also can make the medical units to shift and find their right orientation in health service system.In 1997, the government of China made it clear in The Decision On Reform And Development Of Health Care that we should change the urban health service system and develop community health service so as to form a service network which is reasonable and convenient to people. From then on, the CHS has developed quickly. After ten years, the urban community health service network was established. The organization types are different and the holders of the units are diversity.Nowdays, it is generally identified with the idea that the CHS is the trend of health care development. But the economy level among different areas is so different that the development of CHS is unbalanced and facing many problems.The present problems as follows: a)many CHS units didn’t have their clear service mission and the target population edging, b) the current management system weakened the commonweal character of the CHS units, c) the conception and the service mode of the CHS were lagged behind, d) the modern management regulations and systems were missing that the CHS efficiency was not high. All these problems severely restricted the development of the CHS. It is crucial to reform the present management mode and to probe for the appropriate mechanism that suit for the modern times’ development.In these years, there are some studies on CHS. However these researches mainly focused on such aspects as "should be", that is the political policy, basic status analysis, basic function and items, human resource, and so on. But studies on "how to do" which means the organization types and the service mode construction were relatively less. And most were local, some are merely review and summarization. It is scarce of the study on the mechanism and management mode as a whole and systemically one.We implemented this investigation with the aid of relevant projects carried out by the Urban Health and Poverty Project (UHPP), and were the bran-item of the ministry of Science and Technology and the Ministry of Health of the PRC. We explored to construct an appropriate management system and regulations that fit with the development of modern time’s economy and the changes of health demands. And in this research we used such theory as system design, management and organization and whatever, to develop a new system which can ensure the CHS to exert its function. So it can meet the health demands changes of people, standardize the behavior of the medical units and the GPs, and provide sustainable and practical guiding on theory.METHODOLOGYLiterature review was used to study the mechanism and management mode of CHS abroad and the development of domestic CHS. Combined with the survey and the data collected in 10 national CHS demonstrate-districts, we design the CHS management system with adapted regulations based on such materials as the theory of organization and management, theory of management, system theory and cybernetics logistics system and dilevery chain theory, and the new system economy theory. Experts’ argumentations were used to confirm the design and the plan. With the recommendation of the Ministry of Health, Gongming Street of Bao’an District in Shenzhen was selected to be the experiment sample to carry out intervention experiment. Field supervision and direction, key informant interview, questionnaire interview and field evaluation were used to analysis the reform. The design was revised and complemented with information feedback.Field interview was used to investigate the data of the units, and key informant interview as the complement to find out the effect of the reform. Field test was used to evaluate the reform effect in the experiment unit. RESULTSa) Set up the new management system and operational mechanism of CHS.The CHS management center is the main body to manage the CHS units. And it takes on the function to supervise and manage all the units in the district.Developed the personnel reform and implement engagement system over all staff. Changed the distribution way and substituted it for the performance assessment method. Reformed the financial mechanism and separated the revenue and payout. Constructed logistic mechanism and management on medicine acquisition. Put into practice of the democracy supervision mechanism to monitor the work of CHS.b) Established the new CHS serving pattern.Set up the "GP serving team" to provide whole service for the resident, which was made up of one GP, one community nurse and one to a half pubic health physician. Changed the behavior and improve the diagnose ability of the doctor. Set up the system of "seeing a doctor" first in CHS and consummate the "bio-transfer-diagnose" mechanism.c) Developed a series of regulations that fit to the new management system of CHS to guarantee the sustainable development of community health service.d) Evaluation study was carried out on reform effect by field test. As it is only a half year after the reform when the evaluation began, the future effect of some regulations can’t be observed. The results show that the rate of disease management has been improved, the ration of E/C changed significantly, the fee-for-outpatient has dropped and the satisfaction has improved.CONCLUSION AND RECOMMENDATIONSIn this research we constructed the organization and management system and the adapted regulations, and test the feasibility and maneuverability through the intervention experiment. The results of qualitative and quantitative analysis show that the design is scientific and can ensure the CHS to serve people much better.The conclusion is that the organization system and the regulations of the project design can bring the action change of the unit. Through exerting the personnel reform and performance assessment in the experiment unit, the local GPs have devoted more than before to complete the public health items, such as chronic disease management, prevention and health care and so on. The mechanism of "seeing a GP first in the community" and "bio-transfer-diagnosis" is running well. The fee for service per person-time has dropped. And the extent of patient’s satisfaction in whole in the experiment unit is higher than the controlled one.The recommendations are as follows: Firstly, define the responsibility of the government. Secondly, keep improving and advancing CHS operation mechanism.INNOVATION AND LIMITATIONInnovation:a) For the first time, we constructed the new management system, service mode and five operation mechanisms based on such regulations and theories, as relevant law and rules, organization behavior theory, system design, system theory and cybernetics, and logistics system and delivery chain theory.b) We bring the scheme which has been constructed into effect. And through the intervention experiment we test the feasibility and maneuverability. The field test was used to evaluate the reform effect.c) A series of management systems we developed through the study were adopted by the Department of the Women and Children & Community Health Service of Ministry of Health of the PRC, and were put into effect in 29 cities which were CHS key engaged cities. The method and the results about improving the personnel technical ability and constructing the system environment have been applied to 13 experimental districts in 10 cities. And 8 papers have been published.Limitation:As it is only a half year after the reform when the evaluation began, the future effect of some regulations can’t be observed. And for only choosing one place as the experiment unit, it still needs to be considered the different economic level and policy circumstance in different areas when disseminating the reform fruit to the whole country. More attention shall be paid to all these limitations in further study.更多还原