【作者】 赵大海；

【导师】 程晓明；

【作者基本信息】 复旦大学 ， 社会医学与卫生事业管理， 2008， 博士

【摘要】 研究背景卫生资源配置,是指一个国家或区域,如何将筹集到的卫生资源分配到不同的领域、地区、部门和人群中去。卫生资源配置的方式,同其他经济资源配置一样,不外乎行政和市场两种手段。目前世界各国卫生资源配置的方式,已没有一个纯粹是行政或市场方式,而更主要的是同时发挥市场机制和政府机制作用的混合模式。区域卫生规划作为市场和政府机制的有机结合方式,得到国外大多数发达国家的推崇。本文对法国、英国、瑞典、澳大利亚、日本、新加坡和美国等国卫生资源配置的现行政策进行了综述,其结果提示:上述各国目前均采用市场和政府相结合的区域卫生规划方式来配置卫生资源,虽然各国在卫生资源配置中均有一定的问题,但至少到目前为止,还没有一个比区域卫生规划更有效的方式来配置卫生资源。我国于20世纪80年代,利用世界银行的卫Ⅲ贷款,在浙江省金华市、江西省九江市和陕西省宝鸡市实施了“区域卫生发展项目”的试点工作。1997年《中共中央、国务院关于卫生改革与发展的决定》对实施区域卫生规划进行了较为完善的阐述。1999年国家计委、财政部和卫生部联合发布了《关于开展区域卫生规划的指导意见》,对区域卫生规划的实施背景、目标、原则、规划编制内容、方法以及相应的政策措施等都进行了明确的规定。至2001年底,全国31个省(市、区)先后完成了卫生资源配置标准的制定,相应的超过两百个地级市也完成了区域卫生规划的编制工作,并对各自区域的卫生资源逐步展开调整。青海省是我国西部地区一个地广人稀、经济欠发达的省份,其于2000年完成了卫生资源配置标准的制定,2000年底各州(地、市)均完成了各自区域卫生规划的编制工作,并于2001年开始实施。到2005年底,青海省“十五”区域卫生规划工作已结束。本课题为《青海省区域卫生资源配置研究》,为青海省“十一五”卫生规划重点课题。本课题受青海省卫生厅的委托,主要是对青海省“十五”期间卫生资源配置及区域卫生规划执行情况进行系统评价,并在总结经验的基础上,对青海省“十一五”卫生资源配置标准进行预测。本博士论文所涉及的内容,主要是对青海省“十五”期间医疗卫生资源配置及区域卫生规划执行情况进行评价。研究目的本研究旨在结合青海省实际情况,通过定性和定量的论证,对青海省“十五”期间医疗卫生资源配置现状进行评价,以期发现焦点问题及探索原因,为青海省“十一五”医疗卫生规划提供政策参考和依据。研究方法本研究主要应用政策分析方法、卫生统计学分析方法、公平性评价方法、综合评价方法、焦点组访谈方法以及ROCCIPI技术分析方法,采用定量和定性相结合的方法来进行研究。具体应用如下:1.政策分析方法:运用政策分析的方法,本研究对卫生部、青海省政府以及青海省卫生厅等发布的各类有关卫生资源配置或区域卫生规划的文件与政策进行分析。将上述文件或政策中对各级医疗机构发展规划及配置标准的要求及规定,同青海省各级医疗机构卫生资源配置的现状进行对照比较分析。2.卫生统计学分析方法:运用卫生服务需求测算公式,本研究对2005年青海省医疗卫生资源的需求数量进行了测算,将其同《2001-2005年青海省区域卫生规划及卫生资源配置标准》对2005年青海省医疗卫生资源总量的预测数据进行比较,以此验证该规划的科学性;利用《2001-2005年青海省区域卫生规划及卫生资源配置标准》对2005年青海省医疗卫生资源总量的预测数据同2005年青海省医疗卫生资源实际配置情况进行比较,以此来考核该规划的实际执行情况。3.公平性评价方法:运用基尼系数的方法,本研究对青海省2001年和2005年医疗卫生资源配置公平性进行量化测算。4.综合评价方法:运用TOPSIS综合评价方法,本文对青海省2001年和2005年医疗卫生资源配置的效率和质量进行综合评价。5.焦点组访谈法:采用焦点组访谈的方法,本文对青海省医疗机构卫生资源配置以及区域卫生规划开展中遇到的问题进行探讨,以期找出问题的原因及解决问题的对策。6.ROCCIPI技术分析方法:ROCCIPI是一种政策与立法的技术分析方法,该方法通过揭示规则(Rule)—机会(Opportunity)—能力(Capacity)—交流(Communication)—利益(Interest)—过程(Process)—意识(Ideology)七个要素之间相互联系的特定思维模式去透视各种社会问题,寻求最佳的对策。利用ROCCIPI技术分析方法,本文对青海省区域卫生规划实施过程的问题进行原因分析,结合专家评议等方法,对提出的建议和对策进行可行性论证。主要结果1.各级医疗机构卫生资源配置现状分析结果表明:青海省级综合医院各类医疗卫生资源配置现状基本达到国家规定的要求,影响其发展的最主要问题是高层次医学人才的培养问题;州(地、市)级综合医院,除卫生技术人员不足外,其他基本能达到国家规定的配置标准,海东地区医院,目前各类医疗卫生资源配置均较低,应尽快补足;社区卫生服务中心各医疗卫生资源配置现状基本达到国家规定的最低配置要求,其面临的主要问题是其机构数量过少;影响县医院和乡镇卫生院发展的主要问题是卫生技术人员不足;村卫生室在房屋建筑面积、设备等方面均存在一定的问题,但限制其发展的最主要问题是乡村医生收入过低。2.本研究利用卫生服务需求法,对2005年青海省各级医疗机构病床和医生需求数量进行了测算,结果显示:《2001-2005年青海省区域卫生规划及卫生资源配置标准》对2005年青海省病床和医生数量的预测数值同本研究中测算出的数值吻合度较高;结合本文对各级医疗机构设置以及大型医疗设备的配置原则及规划内容的分析,本研究认为《2001-2005年青海省区域卫生规划及卫生资源配置标准》是科学的,也是符合青海省实际情况的。3.《2001-2005年青海省区域卫生规划及卫生资源配置标准》对2005年青海省各类医疗卫生资源的预测和规划同2005年青海省实际医疗卫生资源配置情况比较结果提示:《2001-2005年青海省区域卫生规划及卫生资源配置标准》执行情况不理想。4.本研究利用基尼系数方法,对青海省2001和2005年医疗卫生资源在人口和区域上的分布进行了分析,结果显示:在人口分布中,2001年和2005年青海省医疗卫生资源配置都一直是比较公平的,尤其是床位和卫生技术人员的人口公平性系数在2001年和2005年均小于0.1,为高度公平;在地理面积分布中,除医疗机构外,其余各类医疗卫生资源,在地理面积配置上一直为高度不公平,且2005年较2001年医疗卫生资源在地理面积上分布的不公平程度更为严重。5.本文利用TOPSIS法对青海省2001和2005年医疗卫生资源利用效率和质量进行了分析。结果表明:2005年较2001年医疗卫生资源利用效率有所提高,但质量有所下降。研究创新1.文献研究提示:到目前为止,尚未见有对2001-2005年我国第一次区域卫生规划执行情况的系统评价报告,尤其是以一个省为单位从卫生机构、床位、人员、设备等卫生资源配置各方面进行区域卫生规划系统评价的研究更未见有报道。2.本文根据青海省村卫生室门诊就诊率及均次纯收入等指标,测算出了乡村医生要达到相应收入需要的村卫生室理论服务人口数。政府可以按照村卫生室实际服务人口数量及乡村医生数量,对每个乡村医生进行收入补贴,以保证青海氏绱逡缴幕臼杖?另外政府将根据青海省各区域的实际情况,采取不同的激励措施,以保证乡村医生对开展公共卫生服务的积极性。3.对于青海省社区卫生服务中心和村卫生室开展的公共卫生服务,本文提出:根据其合理的服务半径,配备不同的交通工具并相应的给予交通补贴,以保证上述两机构公共卫生服务的正常开展。4.本文运用卫生服务需求的测算方法结合国家对医疗卫生资源配置的现行政策,验证出《青海省2001-2005年区域卫生规划及卫生资源配置标准》对2005年医疗卫生资源配置的预测总体为科学和合理的,并通过该规划及标准对2005年的预期同2005年医疗卫生资源配置的实际情况进行比较,得出了《青海省2001-2005年区域卫生规划及卫生资源配置标准》未得到真正贯彻的结论。5.本研究运用ROCCIPI技术分析方法对《青海省2001-2005年区域卫生规划及卫生资源配置标准》未得到真正贯彻的原因进行了分析,得出了需要进行区域卫生规划立法的建议。更多还原

【Abstract】 BackgroundThe allocation of health resources, means a country or region, will be how to carry out the allocation of health resources to different areas, regions, departments and the crowd. Allocation of health resources, together with the allocation of resources with other economic, as usual there are two means, that is, administrative and market. With a modern economic system, the current world health resource allocation approach, no one is purely administrative or market, but what is more important is the mixed-mode mechanism. Regional Health Planning, combined with the mechanism of government and market, has been supported by the majority of developed countries.In this paper, we have introduced the conditions of the regional health planning approach to the allocation of health resources in the developed countries such as France, the United Kingdom, Sweden, Australia, Japan, Singapore and the USA. We have come to a conclusion that although the countries in the allocation of resources have some problems, but at least so far, have not found more effective way to allocate health resources.In the 1980s, by the World Bank’s H3P, the Health Ministry of China implemented the "regional health development projects" pilot work in Jinhua, Jiujiang and Baoji city. In 1997, the CPC Central Committee and the State Council published the decision of health reform and development, which explained the implementation of regional health planning on a relatively perfect. In 1999, the State Planning Commission, Ministry of Finance and Ministry of Health jointly issued the paper of the development of regional health planning guidance, which defined clearly on the implementation of regional health planning background, objectives and principles, contents and methods of planning and the preparation of the corresponding policies and measures.To the end of 2001, China’s 31 provinces (cities, districts) has completed the allocation of health resources in the development of standards, corresponding to more than 200 cities also completed the establishment of regional health planning, health resources in their respective areas and gradually started adjustment.Qinghai, as a sparsely populated region of China’s western region, in 2000, completed the allocation of health resources in the development of standards, the states or cities have completed their respective regional health planning at the end in 2000, the implementation began in 2001. By the end of 2005, the regional health planning of Qinghai has been concluded.The topics as "study on the allocation of regional health resources in Qinghai ", was the "the 11th Five-Year" plan focused on health issues in Qinghai Province.This subject Commissioned by the Office of Health of Qinghai province will carry out the system evaluation on the status of the allocation of health resources and the implementation of regional health planning from 2001 to 2005. On the basis of summing up experiences, we will predict the criteria to the allocation of health resources for Qinghai province in the 11th 5-year plan.The doctoral thesis involved, mainly in the evaluation on the allocation of medical health resources and the implementation of regional health planning in Qinghai Province during the 10th 5-year plan.ObjectiveThis study was designed to, being accordant with the actual situation in Qinghai province, through qualitative and quantitative evaluation, carry out the status assessment on the allocation of health resources during the 10 5-year plan, identify problems and explore the reasons, for the purpose of providing the information basis for the Qinghai government in the 11th health plan.MethodsThe main methods of this study included the policy analysis, health statistics method, comprehensive evaluation method, as well as focus group interviews and the ROCCIPI technical analysis method, combing the use of quantitative and qualitative study. Specific applications were as follows:1. Policy analysis method. Using the policy analysis method, we have made an analysis on the papers which issued by the Ministry of Health, government of Qinghai province and the health department of Qinghai province. The data from the criteria from the above mentioned documents with the actual allocation of medical health resources in Qinghai in 2005 were compared.2. Health statistics analysis method. Using the calculation formula for health services needs, we have calculated the demand data for various medical health resources in Qinghai in 2005. We have compared the calculation numbers and the corresponding data from the criteria in the regional health planning in Qinghai in order to verify the correction of the regional health planning. We have compared the data of the allocation of medical health resources criteria in the regional health planning in Qinghai and the actual data of the medical health resources allocation in Qinghai province, in order to verify the implementation of the regional health planning.3. Fairness evaluation method. Using the Gini coefficient method, we have conducted a quantitative comparison on fair allocation of medical health resources in Qinghai Province in 2001 and 2005.4. Comprehensive evaluation method. With the help of TOPSIS comprehensive method, we have carried out the evaluation on the allocation of medical health resources in Qinghai Province in 2001 and 2005 in order to do the comprehensive evaluation at efficiency and quality level.5. Focus group interviews. We have used focus group interviews to find the problems on the allocation of medical health resources, as well as regional health planning encountered in the conduct explored, with a view to identifying the causes and solutions to the problems.6. ROCCIPI technical analysis method. ROCCIPI is a method by which we can carry out an analysis to a social problem from the angles as follows, rule, opportunity, capacity, communication, interest, process and ideology. We have used ROCCIPI technical method to find and explain the reasons for the problems of the implementation of the regional health planning combining expert appraisal methods, to carry out the feasibility study on the recommendations made by the project.Main Results1. Through the status analysis on the allocation of medical health resources in all levels of medical institutions, we have got a conclusion as follows. The status of the allocation of medical health resources in province-level general hospitals can meet the state’s requirements. Its impact on the development of the most important problem is high-level medical personnel cultivation. As for the state (to the city) level general hospitals, with the exception of health human resources understaffed, other basic configuration can meet the basic standards, but as for Haidong district hospitals, its medical health resources were low and should be complementary. For community health center, the status allocation of the medical resources can meet the state’s minimum configuration requirements, the main problems is their institution number was too small. The main problems of the development of the county hospitals and the township hospitals were understaffed health human resources. There were some problems in the development of the village clinics, including housing construction area and the basic facility, etc. But the most important problem of the village clinics was rural doctors’ low income.2. By the comparison between the calculation numbers from the formula for health services needs and the corresponding data from the criteria in the regional health planning in Qinghai, and the content analysis on allocation of the medical institutions and the large medical equipment, we have verified that the regional health planning in Qinghai was scientific, and it is consistent with the actual situation of Qinghai.3. By the comparison between the data of the allocation of medical health resources criteria in the regional health planning and the actual data of the medical health resources allocation in Qinghai province in 2005, we have got a conclusion that implementation of the regional health planning in Qinghai was not very good.4. As for the fairness evaluation, we have concluded that the fairness degree on the allocation of all types of medical health resources in the distribution of population either in 2001 or in 2005 in Qinghai Province was very good, especially for beds and medical personnel; the fairness degree on the allocation of all types of medical health resources except the medical institutions, was very bad.5. With the help of TOPSIS comprehensive method, we have concluded that the utilization efficiency on medical health resources in 2005 has been improved, but the quality has declined, compared to 2001.Innovation1. So far, we have not found the relative system evaluation report on the evaluation about the implementation of China’s first regional health planning as the unit of a province. We have not found the relative literature about the evaluation on the allocation of medical health resources during the period of 2001 to 2005.There is no official authority on China’s regional health planning implementation of the evaluation system.2. Based on the attendance rate and average net income per attendance in the village clinics in Qinghai province, we have calculated the theory numbers of the reasonable village population that can achieve the corresponding income if it was only clinic considered. Government, according to the actual concrete numbers of the village population and the doctors in rural areas, should carry out the income subsidies to the village doctors and take different incentives in different areas to ensure that village doctors in the public health service can have initiative.3. As for the community health service centers and village clinics in the public health services, we have suggested that the government should supply the corresponding traffic tools and transport subsidies according to their reasonable service radius, in order to ensure that these two organizations can carry out the public health operations.4. With the help of the demand formula on the allocation of health resources, we have verified the paper of the regional health planning in Qinghai was scientific. Through the comparison between the criteria in the regional health planning in Qinghai and the actual data of the medical health resources allocation in Qinghai province in 2005, we have got a conclusion that implementation of the regional health planning in Qinghai was not very good .5. By the ROCCIPI method, we have made an analysis on the crux that the regional health planning in Qinghai was not to be implemented. We have concluded that it was necessary to strengthen regional health planning legislative proposals.更多还原