【作者】 张彦琦；

【导师】 易东；

【作者基本信息】 第三军医大学 ， 流行病与卫生统计学， 2008， 博士

【摘要】 卫生事业是社会发展的重要组成部分,作为卫生事业可持续发展的核心载体,卫生服务系统其可持续发展是经济和社会可持续发展的重要保障和重要组成部分。重庆市直辖以来,经济快速发展、人民生活水平及对健康需求的不断提高,卫生事业也得到了快速发展并不断调整完善。在此期间也逐渐暴露出其内在固有矛盾,影响和制约了卫生事业的发展和功能。本研究通过对重庆市卫生事业在直辖10年来的发展动态进行全方位的总结和分析研究,找出这10年中重庆市卫生事业发展的不足与优势,用系统动力学方法建立重庆市卫生服务系统可持续发展宏观系统动力学模型。以该模型作为卫生事业可持续发展卫生政策模拟“实验室”,通过对系统结构、相关政策、外部环境等的模拟研究,获得卫生事业可持续发展系统动态行为特征与内部运行机制,对重庆市卫生事业可持续发展能力进行评价,提出解决阻碍卫生事业可持续发展问题的政策建议,为进一步优化重庆市卫生资源配置提供可靠的参考数据,为决策部门在国家新医疗改革方案出台后,制订具体的规划和实施细则提供一系列有较强针对性的政策性意见或建议,供决策部门参考。同时本研究首次在卫生事业可持续发展研究中引入系统动力学的研究方法,构建宏观系统动力学模型,并进行系统模拟,在卫生事业政策研究数据分析方法上进行了一些探索,拓展了卫生事业政策研究数据分析方法,并积累了宝贵的经验。本研究资料来源包括常规统计资料:1997-2006《重庆市卫生统计资料汇编》、1998-2007年《重庆市统计年鉴》、《中国卫生统计年鉴》、国家统计局网站(http://www.stats.gov.cn/tjsj/ndsj/)公布的数据;专项调查资料:国家第二次(1998年)、第三次(2003年)卫生服务调查资料,1997-2003年及2005年重庆市卫生总费用测算资料,2004年《重庆市社会发展综合评价研究报告》、2005年重庆市新型合作医疗家庭健康询问调查资料;以及有关卫生政策、法规专著文献与文件资料等。本研究研究方法包括了定性与定量的分析方法。运用描述性统计、计量经济学模型(主要包括Gini系数、Lorenz曲线、Theil指数、数据包络分析)对重庆市自然和经济状况、居民卫生服务需求和需要、卫生资源供给和利用情况进行分析。运用系统动力学建模方法、系统思考、专家咨询、回归分析、统计预测、计量经济学模型等构建重庆市卫生服务系统可持续发展系统动力学模型构建并模拟运行。运用系统分析、文献归纳、专家咨询、系统动力学方法进行模型政策干预实验与评价。主要研究结果发现:1.慢性非传染性疾病成为危害居民生命健康的主要原因,疾病谱的变化和人口老龄化,使我市卫生服务需求呈现增长的趋势。农村居民的卫生服务需要和需求量高于城市居民,但医疗费用增长过快成为阻碍居民,特别是农村居民利用卫生服务最主要的原因之一。公共卫生服务需求增大,传染病问题日趋严重,部分原已得到控制的传染病重新抬头,艾滋病的预防刻不容缓。2.目前,我市已基本形成与经济社会发展相适应的城乡三级卫生服务体系、公共卫生服务体系和医疗保障体系。但从卫生资源的配置和利用来看,存在卫生资源总量相对不足,总体水平不高,卫生资源布局与结构不合理,公平性差,利用效率低下,卫生总费用筹资结构不合理,政府卫生投入不足,卫生服务机构发展不平衡、医疗费用增长过快,医疗保险覆盖面小、保障水平低、制度设计不够合理等诸多问题,都严重阻碍了我市卫生事业的可持续发展。3.构建系统动力学模型,包含114个变量和方程,模型有效。系统动力学模型及模拟结果显示我市卫生服务系统现存问题产生的原因,是在经济体制改革和卫生体制改革的复杂环境下,政府卫生投入的萎缩和投入分配的结构不合理使卫生服务机构发展不平衡,大型医疗机构与基层医疗机构服务目标错位,恶性竞争。按照目前的发展状况,个人现金卫生支出占THE的比重的增长态势虽得到控制,但数值仍然较大,个人负担的医疗费用仍然很高,看病贵的问题没有得到根本改善。妇幼健康指标朝着好的方向发展,但传染病发病率的增长趋势不容乐观。城市医院和卫生院的人力卫生资源得到优化但与国家标准相比差距仍然很大。城市医院卫生资源与卫生院卫生资源的结构性矛盾有所改善,但仍然较为突出。4.3组政策干预实验模拟了政府卫生投入不同程度增加以及不同的分配方案对卫生服务系统产出的影响。干预实验结果显示:在卫生总费用良性增长的基础上,政府预算卫生支出增长80%～100%,优先发展农村卫生服务体系和医疗保障体系,适当控制城市卫生服务体系的发展。增加部分按比例分配到公共卫生服务体系、城市医疗卫生服务体系,农村卫生服务体系和医疗保障体系的比例可以设定为1.8:1.2:3:4,观测指标可以取得较好的综合优化效果。政策建议:重庆市卫生事业改革发展的定位应当以建立统筹城乡的、全民覆盖的以提供基本医疗卫生服务为主要目标的卫生服务体系,在未来的改革中,打破城乡、所有制等界限,建立城乡一体化的医疗卫生体制。政策干预重点的选择上首先应当大力扶持成本低效益好的基本医疗服务和公共卫生服务。在政策干预方式上,要重点强化政府职责,一方面强化政府的筹资和分配功能,加大对基层医疗机构、医疗保障和公共卫生的投入;一方面要对医疗卫生服务的地域布局、层级结构、服务目标、服务价格和质量等方面结合市场经济的运行机制全面干预。同时要树立大卫生观念,统筹兼顾,多相关事业协调发展。更多还原

【Abstract】 The health enterprise is the important component of the society development. The health service system is the base of health enterprise and its sustainable development is the important guarantee and component of the economy and society sustainable development. Since Chongqing’s direct jurisdiction, its economy has been developing and people’s living standard and health demand have been rising quickly. The contradiction in health enterprise has emerged and has restricted its development. In this study we summarized the development of health enterprise since Chongqing’s direct jurisdiction, analyzed the predominance and deficiency of it and established macro system dynamic (SD) model of Chongqing’s health service system. Based on the SD model, we made a series simulation experiments to analysis the dynamic behavior and internal mechanism of the system and to evaluate the sustainable development ability of Chongqing’s health enterprise. With the study results, we proposed a series policy suggestions to improve the development of the system and provided credible data support aimed at optimizing the health resources allocation. At the same time, we made some methodological exploration with the SD model first used in the study on sustainable development of health service system and extended the methods on the study.The data used in this study included conventional statistical data including Health Statistical Data Collection of Chonging during 1997-2006, Statistical Yearbook of Chongqing during 1998-2007, Health Statistical Yearbook of China, and the data announced on the website of National Bureau of Statistics (http://www.stats.gov.cn/tjsj/ndsj/); special investigation data including the data of investigation of health service in 1998 and 2003, the data of the total health expenditure (THE) in Chongqing during 1997-2003 and 2005, the report of society development synthetic evaluation study in Chongqing in 2004, the data of survey of new rural cooperative medical system family health inquiry of Chongqing in 2005, and some other data and information such as health policies, monographs, literatures etc. The methods used in this study included qualitative and quantitative methods. We used descriptive statistics and econometrics model (such as Gini coefficient, Lorenz curve, Theil index and Data Envelop Analysis) to analyzed the natural and economical situation in Chongqing, the health service need and demand of people, health resources supply and utilization. We also used SD methods, system thinking, expert consultation, regression analysis, statistical prediction and econometrics model to established the SD model of Chongqing’s health service system sustainable development, and then we used the model by simulating runs. At last, we used the methods of systematical analysis, literature concluding, expert consultation and SD methods to made a series of policy intervention experiments to evaluate the effect of the model.The main results of this study included:1. The chronic non-infectious diseases have been the main causations harming people’s health. The change of disease spectrum and population aging bring the increase of health service need and demand. The health service need and demand in rural are more than those in urban. The too fast growth of medical care expenditure has been one of the severest obstacles preventing people, especially people in rural, from using the health service. The demand of public health has been increased. The problem of infectious diseases has been still serious because some infectious diseases which had been controlled revive. Especially, the prevention of AIDS has been very urgent.2. At present, the medical service system of urban and rural, public health service system and medical security system have been established which are accordant with the development of social economy. However, to speak with the allocation and utilization of health resources, there are lots of problems such as the low total quantity and quality of health resources, the low equity and utility efficiency, the unreasonable structure of THE financing, the low level of the government investment, the imbalance of the development among health service institutions, the too fast growth of medical expenditure, the low coverage and level of medical security etc, which are seriously obstructing the development of health enterprise.3. In the study we established SD model which had 114 variables and equations, and the effect of it was passable. The results showed that the main cause of Chongqing health service system were the low government investment and the unreasonable allocation of it, which brought the imbalance of the development among health service institutions and aim dislocation. According to current status, the increasing tendency of the percentage of personal health expenditure to THE would be controlled, but still high. The problem of high medical expenditure paid by people would not be solved radically. The maternal and child health status would be better, but the infectious diseases status would still austere. The health human resources would be optimized but still far from the national criterion. The structural illogicality would be improved but still serious.4. In our study three policy intervention experiments were conducted under different government investment increase and different distribution projects. The results showed that with the precondition of THE’s benign increase, government health expenditure would increase 80%~100%, the priority would be given to health service system development, and the urban medical service system would be controlled properly. The distribution proportion of increased government investment to public service system, urban medical system and rural health service system might be 1.8:1.2:3:4. With the forgoing framework, the problem exposed during sustain development of health service system in Chongqing would be greatly improved.Policy suggestion: The target should be located on preferential guarantee of people’s basic medical need. The emphases of policy intervention should firstly be public health service. Secondly, the medical resources should be allocated on the basic clinical services with low cost and high efficiency. Thirdly, those clinical services with good treatment effect but high cost should be developed restrainedly. Fourthly, those clinical services with bad effect and thigh cost should be given up. Fifthly, more attention should be put into the improvement of medical technique. The government function should be strong in the sustainable development of health service system, which means to strong the ability of government financing and distribution and to make comprehensive intervention on the constructing and development of health service system. The policy framework in the future is to establish a medical service system covering all people with no limit between urban and rural, to increase the government investment on public health and basic medical institutions, to increase the coverage and level of medical security system and to separate pharmacy from medical service.更多还原