【作者】 赵新平；

【导师】 冯学山；

【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】 研究背景在近几年应急处置传染性非典型肺炎（SARS）、禽流感等突发公共卫生事件的工作中，暴露了我国疾病控制体系和人力资源配置方面存在的不少问题，还不能适应当前和未来疾病控制服务及应急的需求，因而，加强疾控体系建设已成为我国政府急需研究与解决的一个重点工作，中西部地区的县级疾病控制中心（CDC）也是我国疾控体系建设的重点，在加强基础设施建设的同时，如何根据现阶段的国情，在合理界定中西部县CDC职能基础上、配置有限的卫生人力资源显得尤为重要。本课题是卫生部“世行贷款／国外赠款中国传染性非典型肺炎及其它传染病应对项目”中的一个实施性研究课题。选择了中西部的江西、青海、云南三省作为研究现场。研究目的1．调查中西部三省县尤其是贫困县CDC机构运行和提供疾病控制服务的现状2．调查并评估中西部三省县级CDC，尤其是贫困县CDC的人力资源配置状况3．调查并评价调查并评价中西部三省县级CDC，尤其是贫困县CDC的公共卫生应急事件的需求和能力4．界定贫困县CDC的基本职能、工作类别和工作项目及评估履行现状5．评估中西部县CDC人力配置的影响因素6．研制贫困县CDC人力资源最低配置标准7．提出相应政策建议和改革措施研究方法本研究主要采用文献文件与常规统计资料采集、县CDC问卷抽样调查、知情人深入访谈、专题小组和选题小组讨论、改良的Delphi法、差距分析、多因素统计分析等定量与定性研究综合集成的方法。定量资料根据数据类型及分布情况，采用相应方法进行统计描述与推断，以及建立多元回归模型，制定人力配置标准；定性资料采用类属分析法与归纳综合法加以分析，并以引语、图表方式做具体描述。主要结果1．从社会经济水平和居民的健康状况比较，本研究所选的中西部三省和调查县具有一定的代表性。在三个省调查县之间比较，社会经济指标以青海省相对处于劣势；而在国贫县、省贫县和非贫困县之间未见有明显差别。2．政府投入不足，基本上仅能解决员工工资，目前三个省的调查县CDC开展的疾病控制服务有限，并且都在不同程度地搞创收、开展有偿服务，但仍有至少半数的县CDC处于不同程度的收不抵支、负债运行的状况，尤其在贫困县。3．中西部三省的县级CDC人员数量、卫技人员数量及其职称构成未见明显差别，而不同经济类型县在每万人口县CDC的卫技人员数量、人员年龄结构、学历结构、专业背景结构、人员减少途径等方面有差别。4．县CDC人员数量不足和人浮于事现象并存，人员结构不尽合理，年龄断层，非专业人员太多，中专学历、临床与药学专业的人员较多，真正能够胜任疾控工作和应急任务的人员太少，素质不高，没有人才储备。防疫站分家后的CDC人员结构更加不合理，CDC又常常成为塞进非专业人员的机构。5．中西部国贫县的财政基本上是“吃饭财政”、“捉襟见肘”的财政，政府财政对县CDC的经济补偿不足，从而也限制了人员编制。县CDC机构内部管理机制不健全，缺少相应的人员引进、录用标准、以及对在职人员的绩效评估。6．由于经费匮乏，目前三省6个国贫县CDC和乡镇卫生院人员培训的方式主要是“以会代训”、“以一传十”的短期培训，这虽对完成下达的工作任务有一定的作用，但培训的广度和深度不够，难以提高人员的整体业务素质。7．三省调查县虽已基本建立应急处置公共卫生突发事件组织领导体系和工作网络，但人力资源的数量、质量难以满足应急需求，资金和物质的储备机制尚未完善，乡镇、村级的信息基础建设薄弱，整体处突能力脆弱，很难保证一旦遇到诸如“非典”突发事件时能够真正地“拉得出，打得响，打得赢”。8．将卫生部制定的全国县CDC的7项基本职能，24个工作类别，207个工作项目，通过选题小组讨论后再经过专家咨询，界定中西部县CDC基本职能、工作类别和项目，调整为8项基本职能，21项工作类别和89项工作项目。9．咨询专家和县CDC工作人员对目前国贫县CDC履行8项基本职能及其工作类别和项目情况的总体评价普遍较低。若按新界定的CDC基本职能、工作类型和任务的要求，现有的县CDC人力资源难以满足当前和未来疾病控制服务以及应急处置公共卫生突发事件的需求。10．三个省的县CDC都期望在未来5年内能减少非专业人员和无职称人员的比例，提高人员的专业学历和职称，改变目前以中专学历为主的人员结构。综合本次定性和定量分析的结果表明：影响县CDC人力配置的因素是多方面的，不仅受到当地人口的影响，还受到经济社会发展水平、辖区面积、地理地貌特征、交通便利程度、现有卫技人员结构、基层预防保健工作网络、以及机构和人事制度改革等诸多因素的综合作用和影响，以往单纯以服务人口多少配置卫生人力的做法存在明显的缺陷。11．县CDC人力资源配置参考标准方程为：Y=1．67+2．5×10^-6×辖区面积-0．11×每个乡的乡镇卫生院数+4．38×10^-3×人口+0．0169×县CDC机动车辆数+ 0．0156×县CDC联网电脑数-0．14×县CDC大专学历人员百分比-0．12×县CDC公卫专业人员百分比-0．081×是高原地貌。12．在现阶段我国公共卫生体系改革和疾控机构调整存在众多不确定因素情况下，县CDC基本职能的界定与人员配置标准的研制都应有一定的时效性，且不宜预期太长。应用本研究提出的县CDC人员配置参考标准需有一定的前提、范围及支撑条件。政策建议1．强化政府职能，增加对公共卫生服务的投入各级政府需进一步加大资金和政策支持的力度，建立合理规范的责任分担和筹资机制。政府应按界定的疾控机构基本职能和公共卫生应急需求，合理配置相应的人力资源，购买相应的疾病控制和公共卫生服务包。2．改革县CDC人事管理制度，提高人员素质循序渐进地深化疾控机构人事管理与制度改革，加大CDC用人自主权，建立并严格执行人员准入制度，公开、规范用人程序和标准，建立竞争、监督和激励三个机制，形成良性循环；建立卫生人才交流中心，对新聘人员实行人事代理制度，对分流人员集中管理，提供安置信息和指导。多种培训形式结合，提高县CDC人员能力。3．合理提供有偿服务，加强监督管理目前暂时不能规避CDC开展有偿服务，要在切实落实CDC应有的职能和工作任务的前提下，允许其提供有偿的、适宜的疾病预防控制服务，但要加以监督管理。4．明确公共卫生服务相关机构的职能和范围，加强各机构的合作明确疾病控制与卫生监督、医疗服务、妇幼保健、计划生育等相关部门的职能、管理范围等，加强相关机构和部门的协调合作。县、乡、村的疾病控制机构的协调，尤其要加强业务指导与监督的管理体制，同时也应建立相应的激励机制，从而提高工作积极性。5．完善公共卫生应急体制的建设，重点进行能力建设必须强化政府在应急处置突发公共卫生事件中的重要职能和管理工作，改变财神跟着瘟神转的局面，对中西部贫困农村地区公共卫生应急体系建设，各级政府在人财物配置方面要继续给予倾斜支持，还要加强监管。在加强中西部农村地区CDC建设的同时，CDC及有关机构要立足提高日常疾控服务与管理的能力，平战结合，将常态管理与应急管理有机结合起来，防患于未然。6．切实履行基本职能CDC基本职能、工作类别和内容的界定具有时效性和区域性特征，在不同时期对不同社会经济发展水平地区各级CDC的基本职能进行界定。目前国家实施的国债项目对改善中西部县CDC的硬件和工作条件起到了一定的推动作用，而在实验室的检测和工作能力建设与提高方面，需考虑进一步的人才培养和培训计划。在加强县CDC建设的同时，要大力扶持乡村两级预防保健工作网底的建设与发展，保证疾控服务的可及性和可得性。7．对中西部县CDC人力配置标准的应用本研究制定的中西部县CDC人力配置标准的应用有一定的前提，包括县CDC人事制度改革，拥有人事自主权，建立严格准入制度，分流原来的占岗不工作的人员，并且工作能切实履行制定的基本职能、工作类别和项目。目前，宜将本研究提出的人力配置预测值作为县CDC人员需要量的最低限度配置标准；如果通过有力、有效的措施使县CDC的基本职能落实到位的话，可逐步按上限值配置。更多还原

【Abstract】 BackgroundIn the public health emergence response to SARS and bird flu, many problems of the disease control system and human resource allocation have been exposed in these years. The system and human resource couldn’t adapt to the demands of disease control and emergence response in current and future situation. Strengthening disease control system has become an important work for Chinese government to research and dissolve. County level Centers for Disease Control and Prevention （CDC） in middle and west China are the emphasis work. With the construction of infrastructure, it is especial important for county CDCs to allocate the limited human resource on the base of the essential functions definition in middle and west China. Our research is one Operational Research of WB/Foreign donation SARS and Other Infectious Diseases Response Program （MOH）. We selected three provinces, Jiangxi, Yunnan and Qinghai as study sites in middle and west China.Research Objectives1. To investigate the present situation of disease control services at county level CDCs especially in the poor counties of three provinces in middle and west china.2. To investigate and evaluate the present situation of human resources at county level CDCs especially poor counties of three provinces in middle and west china.3. To evaluate the emergency response demand and capability at county level CDCs especially in the poor counties.4. To define the basic functions, work categories and items of poor county CDCs in middle and west china.5. To analyze the factors which influence the allocation of human resource in middle and west china.6. To set the minimal standard of human resource allocation for CDCs in poor counties in middle and west china. 7. To put forward relevant policy suggestions and reformation tasks for improving the human resource.Research MethodsQuantitative study methods （including literatures, documents and routine statistic data collection, questionnaire investigation for CDCs） , qualitative study methods （including in-depth interview, focus group discussion and nominal group discuss ） and Delphi method are used together to collect data. Difference analysis and multi-factor statistical methods are applied to analyze and interpret the data. Statistical description and estimation were applied to analyze the quantitative data; Framework approach to code, categorize, interpret the qualitative data and set the multiple regression model for human reseource allocation standard. Oration and tables were used to express opinions and expectations of the interviewers.Research findings1. Comparing the social economic and health indexes, the investigated three provinces and counties are representative. The results of questionnaire investigation indicate that most of human allocation indexes have difference between three provinces. The situation of Qinghai province is relatively worse than the others. There is no much difference between national, provincial poor county and normal county.2. Though all of sample CDCs provided pay-for-service in different degree, more than half were unbalanced and got into debt, especially in the poor counties. It is the only choice for CDC to provide paid-service. It could partly maintain the survival of CDC but it would affect the service quality and the performance of the basic function ultimately. The equity and accessibility of disease prevention and contorl will get more frustration.3. There was difference between numbers of total staff and health-tech staffs per 10,000 persons, age proportion, education proportion, professional training background proportion of health-tech staffs, and, ways of staffs reducing in different type of county CDCs.4. Health-tech professionals were insufficient while non-professionals were overstaffed. The structure of the health-tech staff is unreasonable, such as the age gap, too many non-professionals, technical secondary school, clinic and pharmacy staff. The performance of them was hard to meet the basic functions of CDC and there was no deposit of human resource in county CDCs. The quality study of the six sample counties shows that after the epidemic station separating, the personnel structure got worse. At some poor counties, CDCs were forced to accept the non—professionals, which deteriorates the unseasonable structure.5. The finance input shortage is a very important and longstanding influencing factor in human resource allocation of county CDC. Basically the poor county finance is olny mouth-feeding budget which result in economy compensation shortage and restrict the CDC manning scale. There is a lack of proper interior institution management mechanism, staff enrolling standard and performance evaluation. The personnel reformation and institution reformation is just at the beginning and it is a trudge and short of motivity. It should be cognizant of the necessity, long-lasting and difficulty for in-depth reformation and needs the time, social and policy supporting.6. Lacking outlay, the training for CDCs and town hospital health workers was mainly made through the meeting or one-pass-to-ten. It maybe has some pushing effect on fulfilling tasks, but it is very difficult for health workers to improve their ability building and performance with such training mode lack of deepness and extent.7. All of the sample counties have established the public health emergency response lead team and network. But the manpower, financial and material resources are insufficiency and the emergency response ability is limited. It is difficult to guarantee the effective response when facing the emergency such as SARS.8. 8 essential public health functions, 21 work cata40 work categories of poor county CDCs within coming 5 years were identified by nominal group discussion and Delphi method. At present national poor county CDCs are only coping with the routine work. It has little chance for them to develop the chronic disease prevention, health information system building and management, health risk factor surveillance and health education. In fact, 116 sample county CDCs assessed by themselves that they have fulfilled 64%-69% of 8 basic functions. The experts evaluated that the CDCs had fulfilled 40-50% of 8 basic functions and work categories. If according the latest defined basic function, work categories and items, their human resource couldn’t meet the present and future demand of disease control service and emergency response.9. 116 county CDCs in 3 provinces all expect to reduce the proportion of heath staff without professionals or title, improve the proportion of heath-tech staff with professional training background and titles, to change a majority of technical secondary school background staff in county CDCs.10. Quality and quantity studies show that there are various factors to influence the human resource allocation of county CDCs. The factors includes not only the population, social economic development level, square, geographic features, traffic condition, CDC health-tech staff quality, the operation of basic rural preventive and medical service network, but also the institution and personnel reformation. So it is not proper to allocate the human resource only by population.11. The following equation can be a reference to guide the human resource allocation of county CDC: Y= 1.67 +2.5×10^-6×square—011×the number of township health centers in each township + 4.38×10^-3xpopulation + 0.0169xthe vehicle number of CDC+0.0156×the number of computers connected to internet of CDC—0.14×the proportion of junior college staffs—0.12×the proportion of staffs with major of public health—0.081×located in tableland12. At present with many unsure factors during public health system reformation and disease control framework adjusting, it is temporary for the definition of basic functions and the human resource allocation standard of county CDCs. Meanwhile it is not suitable to predict for too long time. It needs supporting and premise to apply the human resource allocation standard proposed by this research.Suggestions1. Government at all levels should pay highly attention to the public health system and CDC construction, and strengthen their financial support to public health sector and CDC. Establish a reasonable responsibility-sharing and money-raising mechanism. In its process to a socialistic market economy, government should allocate human resource reasonably and buy the special package of disease prevention control services and public health services according to identified basic CDCs functions and public health need.2. Government should in-depth reform human resource management system gradually. With strengthening the government macro-adjustment, county CDC should be entitled with more power and establish more rigid regulations about enrolling staffs. To set up the competing, supervising and promoting mechanism and form into good circulation. Establish health professionals center to manage newly engaged professionals as an agent and give help to the duty-off persons providing information. Strengthen the outlay to ameliorate the quality and stucture of the personnel by various position training.3. In next several years, county CDC should perform its own function round and well, and it is necessary that supervision should be intensified, which is one premise of getting the permission of providing paid service on health care and disease control.4. It needs to define the functions and work purview of public health related institutions for stressing on the corporation together. Strengthening the instruction and management of the township-village two-tier network of preventive services as well as county CDC.5. With strengthening the public health emergency response lead team and network, it needs to establish a emergency response and routine management mechanism. The manpower, financial and material resources should be sufficiency; the fund should account in the county finance budget, and there need input from the higher government for the poor areas.6. It should be identied the essential fuctions, work categories and items in different social economic areas and periods. Concerning the essential functions of county CDC and the requirement of emergence response in the middle and west regions, it is necessary to improve the proportion of heath-tech staff with professional training background as well as increasing laboratorial and administrative staff moderately. Guarantee the construction and development of the township-village two-tier network of preventive services as well as county CDC. Guarantee the accessibility and feasibility of disease control service.7. There should be some changes to the long term mode of identifying the CDC’s manning scale according only to population. The human resource allocation standard, which is proposed by the research with its application premise, can be a reference to governments, in particular for those in the middle and west regions. One of the preconditions to realize the reasonable human resource allocation is to reform the human resource management system. County CDC should be entitled with more power and establish more rigid regulations about enrolling staffs. Currently, the predicted staff number of the standard can be set as the lowest limit of CDC’s staffs. Given that CDCs perform their functions sounder and better, CDCs’ staff number can be set to the upper boundary of the standard.更多还原