【作者】 刘军安；

【导师】 卢祖洵； 李汉帆；

【作者基本信息】 华中科技大学 ， 社会医学与卫生事业管理， 2008， 博士

【摘要】 一、研究目的乡镇卫生院是我国农村三级卫生医疗网的枢纽,是目前新型农村合作医疗的重要组织者和服务提供者,对社会主义新农村建设和造就新型农民具有重要的促进作用。由于政府长期投入不足,一些乡镇卫生院一直处于“贫血”状态,特别是贫困农村乡镇卫生院建设已经不能满足当地村民的健康需要,已经不能适应当地社会经济的发展。为此,2005年,卫生部和嘉道理慈善基金会共同对新疆和安徽两地17个贫困乡镇进行卫生服务项目建设。项目运转两年时间,目前已经结束。本研究采取第三方评估和参与式评估的方式,对项目活动的投入、过程、产出和影响进行系统研究,评价项目实施对乡镇卫生院的房屋设备、业务水平和服务能力的改善程度,对村民健康知识和健康行为以及对卫生服务可及性的提升作用;通过剖析项目实施对农村社区和卫生机构发展的深层次影响和社会价值,总结项目所取的成功经验和存在问题,为后续项目和其他农村卫生项目提供政策依据和参考;同时,通过对项目评价理论和方法进行探讨,为我国项目评价工作提供可资借鉴的理论和方法学依据。二、研究方法本课题在实证研究的基础上,利用项目评价的基本理论和评价方法,立足于循证原则,将定量和定性分析有机结合起来,从需方、供方和管理方三个层面对卫生服务项目进行系统评价。在研究过程中,结合评价内容和资料特点力求做到方法的科学性和合理性,具体来说,采取多因素分析,如线性回归方法和logistic回归方法对职工工作满意度和稳定性进行研究,采取层次分析(AHP)测量院长胜任力,采取案例分析对参与式健康促进活动进行理论剖析,采取数据包络分析方法(DEA)方法对项目卫生院进行综合评价。三、研究结果通过上述评价研究,本次研究取得了如下发现:①项目对17家乡镇卫生院的业务用房进行了规划建设,新建房屋的总面积为12864.14平米,占卫生院总面积的57.72%,而且是高质量的砖混结构,危房清除率达25.00%。平均每所卫生院业务用房面积增加了472平方米。②项目为17家乡镇卫生院总共新添各类医疗设备170多件。目前,X光机、B超、心电图机、半自动生化仪等设备的拥有率超过了100%。卫生院“新五件”拥有率从项目前的5.88%上升到58.82%。③项目采取上级医院帮扶和专家蹲点指导等形式强化卫生院的业务能力建设,项目期间,卫生院的总共新设了27个科室,临床科室增加6个,医技科室增设了21个,各类医务人员培训率到达93%以上,到上级医院进修率达到了16.47%。④项目对卫生院服务效率起到了拉动作用,和2004年相比,剔除合作医疗的影响,项目卫生院的门诊人次和住院人次的增长率分别为19.81%和16.85%。病床使用率从48.59%上升到71.95%。经过DEA分析发现,项目使DEA有效的乡镇卫生院个数由10家上升到13家,增加了17.65个百分点。⑤财务分析表明,项目乡镇卫生院的业务总收入在增加,从2004年的1243.51万元,增加到2006年的1787.79万元,增长率为43.77%,虽然目前还有35%的卫生院处于亏损状态,但伴随服务效率和能力改善,项目卫生院的发展前景还是乐观的。⑥从卫生院院长胜任力分析结果来看,院长基准胜任力最高10分,最低7.970分,鉴别胜任力最高为10分,最低为7.758分。研究发现,职工工作满意度和院长鉴别胜任力成正相关(相关系数为0.532,P<0.05),而与基准胜任力无关。⑦项目卫生院都采取了参与式健康促进工作模式,村民的健康知识知晓和健康行为形成,如产前检查率、母乳喂养率、刷牙率等有明显的上升,一些不正确生活方式也逐步改变,村民逐渐认识到吃盐过重、喜吃腌制食品等给健康带来的危害。⑧项目卫生院都实行了惠民医疗政策,有91628人享受了医疗费用减免政策,其中,贫困人口28011人,占30.57%,人均减免10.57元。项目卫生院对特困户、五保户等病人的医疗费用基本上是全部免除,一定程度上减轻了当地贫困病人的经济负担。⑨目前,项目乡镇卫生院的满意度得分为83.3分,其中新疆卫生院为89.7分,安徽卫生院为75.5分,都属于较满意状态,但新疆卫生院满意度得分要高于安徽,有离职意向的职工也少于安徽。四、研究结论本研究通过第三方评估,发现项目取得了满意结果:①项目乡镇卫生院的外在形象得到了彻底改变,建筑设计和环境卫生符合卫生院建设的基本要求;②项目乡镇卫生院开展的参与式健康促进活动,较好地提高了村民的健康知识知晓和健康行为形成;③项目乡镇卫生院的基本医疗设备得到了补充,“新五件”拥有率和基本设备的利用率得到了很大的提高;④项目从硬件和软件两个方面对卫生院进行整体建设,较好地促进了卫生院的服务能力和服务效率的提升;⑤项目乡镇卫生院的整体经营状况得到好转,卫生院的整体管理水平也在逐步提高;⑥项目乡镇卫生院的惠民医疗政策,一定程度上帮助了困难群体和健康弱势群体对卫生保健服务的利用,体现了社会公正;⑦项目乡镇卫生院建设提高了职工工作满意度水平,有利于降低职工离职意向,为卫生院发展注入了活力。五、研究创新①本研究采取第三方独立评估方式进行,整个研究以投入、过程、产出及影响评估为主线,并关注影响和绩效评估,保证了评估系统的完整性、侧重性以及评价结论的客观公正性,为我国卫生项目评价工作提供了一个有参考价值的范例。②虽然目前有关农村卫生服务研究比较多,但本研究具有一定的新颖性,一些结论属首次发现。第一次对乡镇卫生院院长的胜任力进行了定量分析,并首次发现职工满意度与院长的鉴别胜任力之间存在正相关关系,为选拔院长提供了理论依据。另外,本研究对日趋流行的参与式健康促进给予了系统评价,这在国内卫生服务领域里尚不多见。③本研究对项目评价理论和方法进行了有益的探索,把目前一些比较新颖而且具有一定难度的统计方法应用到评价实践中,为同类评价研究提供了方法学上的参考。更多还原

【Abstract】 ObjectiveThe township health center, as the important organizer and service provider of new cooperative medical system (NCMS), is hinge of the three-level rural health network in our country, promoting the construction to new socialism countries and bringing up peasants of new type. Due to the shortage of government long-term inputs, some township health centers are always in poor conditions. Not adequate to local economic development, considerable rural poor township health centers even cannot satisfy local peasants’basic health needs. Therefore, the Rural Health Promotion Project funded by the Ministry of Health and Kadoorie Charitable Foundation was started in 17 poor townships in Xinjiang and Anhui province in 2005. So far, the project has finished after two-year running.A third-part and participatory evaluation was used to provide a systematic research on the input, process, outcome and impact of the project, in which improvings of the township health centers’building facility, operation level and service ability were assessed, as well as advances in peasants’health information and behaviors and available health services. The deep impacts on rural community and health agency developments and social values of the project were probed into, success experiences and problems existed in the project summarized, so as to provide policy evidences and references for implementing succedent project and other rural health programs. In the meanwhile, additional researches on theories and methods of the program evaluations offered reference theoretic and methodological evidences on program assessments in our country. MethodsFounded on evidence-based principles, essential theories and methods of program evaluations were introduced on the basis of positive research, to give a systematic review on the project from health services demander, provider and manager sides, by combining quantity and quality analysis. In the study, efforts were afforded to pursue scientific and reasonable methods according to the evaluation contents and data characteristics. In details, multiple factor analysis such as linear regression and logistic regression were adopted to study staff satisfaction and stability at work, analytic hierarchy process (AHP) to determine the deans’competency, case study to investigate the participatory health promotion theoretically, data envelop analysis (DEA) to evaluate the township health centers comprehensively.ResultsFindings as below were obtained from the program evaluations above.①In the project, the buildings of the 17 township health centers received programming constructions, with the total area of newly constructed buildings 12864.14 square meter, accounting for 57.72% of the total health center area. All the new buildings were of high-quality brick concrete structure. The rate of dangerous building clearance reached 25.00%. The mean area of buildings increased per health center was 472 square meter.②More than 170 pieces of medical equipment of various kinds were supplied to the 17 township health centers in the project. So far, each of township health centers owned more than one piece of medical equipment such as X-ray machine, ultrasonic scan machine, electrocardiogram machine, semi-automatic biochemical analyzer and so on. The percent of township health centers that owned the new five pieces of medical equipment increased from 5.88% to 58.82%.③Superior hospital helping, experts coaching on spot and so on were adopted to emphasize the operation ability construction of health centers in the project. During the project, 27 new departments came into being at the health centers, including 6 clinical departments and 21 medico-technical departments. More than 93% diverse medical staff received trainings. The percent of doctors attended in advanced studies in superior hospitals was account for 16.47%.④The service efficiency of health centers was elevated in the project, which compared with those of year 2004, the prevalence of outpatients and inpatients at health centers increased by 19.81% and 16.85% respectively, controlling for confusions of NCMS. The bed occupancy rate increased from 48.59% to 71.95%. After the project’s implementation, number of“the DEA is effectual”township health centers increased from 10 to 13, with the proportion increased by 17.65%.⑤Findings from financial analysis suggested that all of the 17 township health centers were run with an increased services earnings at present, which changed from 1243.51 million yuan in 2004 to 1787.79 million yuan in 2006 (by 43.77%). Thanks to the improved service efficiency and ability, the perspectives of township health centers are optimistic, although there are 35% of township health centers run to the bad for the moment.⑥As a result, the maximum threshold competency score of township health center deans was 10, while the minimum was 7.970; the maximum differentiating competency score of the targeting health center deans was 10, while the minimum was 7.758. The staff satisfaction at work was found to associate with differentiating competency of the health center deans positively (r=0.532, P<0.05), but have no association with threshold competency of the deans in the meanwhile.⑦Participatory health promotion was adopted in all the 17 township health centers, so that more community residents knew health information and formed healthy behaviors. The prevalence of diverse health behaviors, such as antenatal examination, breastfeeding, and teeth brushing increased significantly. Part of unhealthy life style was changed. The residents gradually realized that eating too much salt and pickled food were harmful to health.⑧In the project, 91628 people were involved in derating medical cost strategy, including 28011 (30.57%) poverty-stricken population, with average derating of 10.57 yuan each person. The health centers released almost all medical cost of patients from especially poor families and households enjoying the five guarantees, alleviating economic burden of the local poor population to some extent.⑨The present score of the township health center staff satisfaction was 83.3. The score of health centers’staff satisfaction was 89.7 in Xinjiang province, while it was 75.5 in Anhui province. They were both at a moderate level, but the score of staff satisfaction at health centers in Xinjiang province was higher than that in Anhui province, and less health center employees in Xinjiang province tended to resign compared with those in Anhui province.ConclusionsModerate satisfying results were observed after the third-part evaluation.①The external images of township health centers were totally changed, whose construction designs and environmental sanitations matched the requests of township health centers.②The Participatory health promotion held by township health centers enhanced more residents knowing health information and forming healthy behaviors.③The foundational medical equipment of township health centers was supplied, with a great increase to the owning of“new five pieces”and usage of basic equipment.④The constructions of township health centers from both hardware and software dimensions boosted moderately the advances in township health centers’service ability and efficiency.⑤The integral development status of township health centers turned better, and the whole level of management was elevated step by step.⑥Low price shared medical service provided by township health centers helped the poor population and weak population in health to ues health services to some extent, which improved the social equity.⑦C onstructions of township health centers increased the staff satisfaction at work, and decreased staff resignation intentions, which redound to accelerate developments of township health centers.Innovation①The third-part independent evaluation was used in the study. Focusion on the evaluations about input, process, outcome and impact as baseline in the research, adding the impact and performance assessments, ensured the integrality and emphasis of assessment system and impersonality of evaluation conclusions, which is a valuable reference example of health program evaluations in our country.②Although there are so many researchs on rural health services, some contents in our evaluation research are novel, with some conclusions obtained firstly. Quantity analysis of township health center deans’competency was performed for the first time. And positive association between the staff satisfaction and deans’differentiating competency was observed firstly, which provides evidences for selecting deans. As an addition, a systematic review on the popular participatory health promotion was performed in this study, which is infrequent in domestic health service fields.③The theories and methods of program evaluations were explored in this research, with novel and partly difficult statistical methods applied to the assessments, providing methodological references for kindred evaluation investigations.更多还原