【作者】 刘岳；

【导师】 张亮；

【作者基本信息】 华中科技大学 ， 社会医学与卫生事业管理， 2009， 博士

【摘要】 研究目的探讨县域卫生系统的概念及绩效评价框架，构建中国中、西部县域卫生系统评价指标体系，探讨县域卫生系统绩效评价工具和机制，为县域卫生系统管理提供科学建议。研究方法研究主要采用了文献法、系统分析法、深度访谈、Delphi法、专家研讨法、现场实证法、以及变异系数、主成份分析、卡方检验等统计方法。指标筛选和确定权重系数及标准值是以Delphi法为主，并辅以专家研讨、主成份分析、变异系数法等进行综合筛选。研究共进行了两轮Delphi咨询，基于代表性与权威性、学术专家与管理专家相结合的原则，选择25名卫生管理、卫生经济、社会医学等方面的专家，就县域卫生系统绩效框架、评价原则和评价指标进行Delphi问卷咨询。分别作为第一轮指标筛选和第二轮指标筛选的重要参考。研究选择了位于中部的山西和位于西部的重庆的共四个样本县，采用“现场验证指标体系”对样本县／区的卫生系统绩效进行评价，结合专家评价结果，验证指标体系的合理性。通过现场调查数据的可得性、各项指标在实际统计报表中的上报形式、获得的数据的质量验证和县卫生局人员反映的指标填报的难易程度，结合专家建议进一步完善指标体系。研究结果1．中国中、系部县域卫生系统概念框架结合WHO卫生系统的概念和县域的内涵，研究提出县域卫生系统的概念是：在县辖行政区划范围内的，以维护和促进居民健康为首要目的和功能，与卫生服务供需双方和县域社会经济环境相互作用的整体，包括卫生服务管理子系统、卫生筹资与支付子系统和卫生服务提供子系统。我国中、西部县域卫生系统的总目标是：适应我国建设社会主义新农村和实现城乡卫生统筹的要求，建立与县域经济社会发展水平和人民健康需求相适应的卫生服务体系，使县域内居民享有公平、高效、高质量的医疗卫生服务，提高居民健康水平。研究得出的县域卫生系统绩效是指县域卫生系统总目标的完成情况。2．中、西部县域卫生系统绩效及其评价框架根据多维绩效理论，本研究以WHO和RifatAtun等人提出的卫生系统绩效概念为理论基础，结合我国农村卫生的特点和建设重点，提出了中国县域卫生系统绩效评价框架。研究结合县域卫生系统的功能、产出和结果，提出县域卫生系统的三个子系统在与卫生服务利用方的相互作用下，其绩效包含七个维度，即：卫生服务质量、卫生服务效率、卫生公平性、居民获得的健康风险保护、居民健康改善结果、居民获得的财务风险保护、居民和医务人员对卫生系统的满意度。3．中国中、西部县域卫生系统绩效评价指标体系研究以中、西部县域卫生系统整体为评价对象，以结果绩效为导向，构建了包含两项一级指标、七项二级指标的中、西部县域卫生系统绩效评价框架。在评价框架下，按照完备性、可获得性原则，筹集了72个初步三级指标。研究按照科学性、代表性、可操作性、导向性、动态性原则，通过Delphi法、专家咨询和40个卫八项目县的客观数据分析进行综合筛选，最终提出了包含26个三级指标的评价指标体系，并确定了指标体系权重分配和指标标准值。最终“中国中、西部县域卫生系统绩效评价指标体系”的评价指标包括“产出”和“结果”两项一级指标。“产出”下含“卫生服务质量”、“卫生服务效率”、“卫生公平性”、“健康风险保护”四个二级指标；“结果”下含“健康结果”、“财务风险保护”、“满意度”三个二级指标。三级指标为：全乡(镇)村使用基本药物目录的村卫生室比例(％)，乡镇卫生院一次性注射器毁型管理率(％)，乡镇卫生院住院治愈率(％)，合格的村卫生室覆盖率(％)，孕产妇住院分娩率(％)，0-1岁儿童国家免疫规划接种率(％)，乡镇卫生院病床使用率(％)，农村居民与城镇居民医疗保健支出占消费性支出百分比之比，每千农业人口乡村医生和卫生员数，每千农业人口乡镇卫生院人员数，每千农业人口乡镇卫生院床位数，每平方公里卫生技术人员数，参加合作医疗的居民的两周就诊率(‰)，农村卫生厕所普及率(％)，农村自来水普及率(％)，居民合格碘盐食用率(％)，15岁以上调查人口对艾滋病无认知及认知错误比例(％)，DOTS下结核病人治愈率(％)，婴儿死亡率(‰)，孕产妇死亡率(／10万)，5岁以下儿童死亡率(‰)，甲、乙类法定报告传染病总计发病率(／10万)，地方病现有病人数占病区人口比重(／10万)，新农合住院人均补偿比，新农合资金使用率(％)，居民对所获得的医疗卫生服务整体满意度，乡村两级机构卫生从业人员满意度。4．中国中、西部县域卫生系统绩效评价指标体系的应用指标体系中各客观数据资料均来源于国家规定的统计报表，收集便捷，数据的质量较好，可比性较强。对需要现场测评的指标，指标体系提出了统一、具体的评价指导方法，减少了主观偏移。指标体系可用于各县进行绩效变化的纵向比较，也可用于地区间横向比较，还能进行各维度间的进一步分析比较，为深入分析县域卫生系统绩效影响因素提供参考依据。该指标体系有助于各级卫生决策者和管理者了解被评价县在本省中所处的水平和在整个中部或西部县域卫生系统绩效中的水平，从而更好地引导资金流向，提高资金使用的成效，促进中国中、西部县域卫生系统建设成本-效果的改进。讨论及建议1．学术性框架与实用性框架的比较两种框架都是多维度的，学术性框架更为宏观，关注投入、产出、结果全过程，，各国投入实际使用的绩效框架在借鉴、参考各类学术性框架的基础上，基于各国卫生系统实际情况进行了改进，往往只关注产出和结果，较少关注管理路径。与学术性框架相比较，实用性框架的目标更为简明、直接，指标数据更易获取。2．国内外绩效评价指标体系的比较比较国外的指标体系，可以发现，国家政府在卫生系统绩效评价指标体系的制定中发挥了重要的作用，对指标体系的动态性，尤其是前瞻性提供了重要的政策参考和支持，并且使指标体系得以在全国实行。同时，由于我国卫生信息尚不完善，有部分指标的数据还不能保证能够连续追踪，因此动态性和实用性还需要进一步改进。我国卫生系统绩效评价工作中，尚缺乏如英国、澳大利亚一样，由国家研究、构建并应用较成熟的卫生系统绩效评价指标体系。我国的卫生信息系统建设也还需要进一步完善，提高数据搜集的及时性和数据质量，才能为构建更完善的卫生系统绩效指标体系、发挥卫生系统绩效评价的作用提供保障。3．指标评分方法的动态性根据专家建议和现场调研情况，对于部分敏感性较高或年度值波动较大的指标，可尝试采用综合计分模式。即：指标综合得分=权重系数×(“与参考标准值比较得分”+“与上年度数据值比较得分”)。可以使用此计分模式的指标有10个指标。4指标体系体现中、西部县域卫生系统特点指标体系综合考虑了县域卫生建设以农村卫生为重点，兼顾城乡统筹发展的特点，既评价了对农业人口的卫生资源配置情况，也评价了对县域全体常住人口的卫生资源配置情况。同时，根据中、西部地区地广人稀的特点，设置了反映卫生资源配置的覆盖面积的指标。研究还提出了“乡村两级卫生机构卫生从业人员满意度”指标，关注中、西部县域卫生系统持续发展的能力。研究以中部、西部地区指标数据的当年平均值和部分中、西部监测点的指标数据作为标准值，符合中、西部县域卫生系统的特点，并体现了鼓励县域卫生系统绩效改善的导向。5．指标体系对于促进县域卫生系统管理和提高整个卫生系统绩效具有导向作用、区分作用及管理作用。6．建立县域卫生系统绩效评价机制的建议。根据指标的可获得性，并结合专家建议和基层卫生管理人员意见，县域卫生系统绩效评价应该作为一项长期工作开展。研究建议，通过进一步研究和实践，进一步完善指标体系，探讨适宜的评价周期，并建立相对稳定的分析途径，形成科学、完善、在县一级政府能够实际应用的一套评价工具。并且，通过一定的政策或规定，将绩效评价与县域卫生系统的考评相结合，达到激励绩效改善、促进县域卫生管理水平不断提高的目的。研究创新本研究首次提出具有我国中、西部县域特色的卫生系统绩效评价指标体系。研究所构建的指标体系以结果绩效为导向，针对卫生系统运行的产出和结果进行评价，反映了一般的卫生系统建设中最为直观的结果，有利于卫生管理人员，尤其是县一级的卫生管理人员了解最终的绩效结果，有效利用指标体系的数据，分析卫生系统建设中的不足和问题，明确需要加强投入和管理的方向。研究着眼于中、西部县域卫生系统，考虑了中、西部县域卫生系统的特点，提出了能够切实地应用于中、西部县域的卫生系统绩效评价的指标体系，具有较好的科学性和实用性，能够为促进县一级卫生建设和提高卫生管理水平提供决策参考。更多还原

【Abstract】 Purpose of the StudyThe study tried to explore and identify concept for county health system throughin-depth interview,system analysis,and Delphi method on the basis of literature review.Performance evaluation framework and indicator system were established,of whichindicator system was refined through field verification.On the basis of theoretical research,the study also discussed ways to develop performance evaluation tools,set up performancereview mechanism and enhance management over county health system,and offered policysuggestions on these areas.MethodologyThe methods used in this study include Literature review,System analysis,In-depthinterview,elphi method,Expert discussions Field verification and statisitics analysis,such as Chi-square test and principal component analysis.A number of specialists on health administration,health economics and social medicinewere consulted through Delphi questionnaire on performance framework,evaluationprinciples and evaluation indicators targeting county health system.2 rounds of Delphiconsultations were conducted,findings of which served as importance reference forindicator selection in the first and second round respectively.4 sample counties were chosen in the study to assess county/district health systemperformance with“field verification indicator system”.Comparison was made againstfindings of expert evaluation to verify validity of the indicator system.Indicator system was further refined upon availability of field investigation data,submission format of indicatorsin statistical report,quality verification of acquired data,feedback from county healthbureau staff in obtaining information against indicators and expert suggestions.Outcomes1.Definition and performance framework for county health system in central and westernChinaCounty health system is defined as an integral within county administrative jurisdiction,which serves to safeguard and promote health of local residents,and interacts with healthservice supply side and demand side,as well as social economic context in the county.Thecounty health system is composed of 3 subsystems-health service management,healthfinancing and disbursement,and health service delivery.A general goal of county healthsystem in central and western China is to establish health service system in line with socialeconomic development and health needs in the county,so as to deliver equitable,efficientand quality health services to residents in the county and improve health status of people.2.Performance and its evaluation of county health system in cetral and western ChinaPerformance evaluation framework proposed in the study works on county healthsystem as an integral,and conducts assessment through a third-party agency or supervisinggovernment agencies.Performance of county health system is measured against fulfillmentof this general goal.The study based itself on health system performance concepts initiatedby WHO and experts including Rifat Atun,and proposed performance framework forcounty health system upon characteristics and priorities of China’s rural health.Focusingon function,output and outcome of the county health system upon interaction between 3sub-systems and health service users,the study explored 7 dimensions of performance-health service quality,health service efficiency,health equity,health risk protection,healthstatus improvement,financial risk protection,and satisfaction on health system among localresidents and health workers.3.Performance review indicator system for county health system in central and westernChinaThe study launched a result-oriented evaluation targeting county health system in central and western region,and worked out a performance review framework consisting of1 primary indicator and 7 secondary indicators.By standard of completeness andavailability,72 preliminary tertiary indicators were proposed under the performance reviewframework.Consequently,26 tertiary indicators were chosen through Delphi method,expert consultation and analysis of objective date in 40 HealthⅤⅢcounties,to make theindicator system scientific,representative,workable,dynamic and with guidance functions.Weight distribution and reference value were then identified accordingly.Primary indicators in the indicator system consist of“output”and“outcome”.“Output”can break down into 4 secondary indicators-health service quality,health serviceefficiency,health equity and health risk protection;“outcome”can be reduced to healthoutcome,financial risk protection and satisfaction.Tertiary indicators include:share ofvillage clinics using essential drug list in the township(town)(%);compliance of disposalinjector disposal in township health centers(%);coverage of cure among inpatients intownship health center(%);coverage of qualified village clinics(%),share of institutionaldelivery(%);coverage of national planned immunization program among 0-1 children(%),bed utilization rate in township health centers(%),ratio of medical expenditure out ofconsumption expenditure between rural residents and urban residents,availability of villagedoctors and health workers per 1000 rural population;availability of township healthtechnicians per 1000 rural population;availability of beds per 1000 population;number ofhealth technicians per square kilometer,two-week visit rate by NCMS insurees(‰),coverage of sanitary toilet in the countryside(%),coverage of tapping water in thecountryside(%),iodine salt intake compliance among local residents(%),share ofinterviewees with no or false knowledge on AIDS among above-15 residents(%),recoveryrate under DOTS program(%),infant mortality rate(‰),maternal mortality rate(/100,000),under-5 mortality rate(‰),aggregate incidence of Class A and Class B communicablediseases subject to mandatory reporting(/100,000),share of endemic patients among totalpopulation in the jurisdiction(/100,000),actual share of reimbursement by NCMS,comparison on actual reimbursement rate between MFA-aided NCMS insurees andnon-aided insurees,overall satisfaction rate on acquired health services by patients,andsatisfaction rate by health practitioners at township and village level. 4.Application of the evaluation indications systemObjective data information in the indicator system was collected from nationalstatistical reports with good quality and high comparability.For indicators subject to fieldmeasurement,consistent and concrete assessment guidance was developed to minimizesubjective deviation.The indicator system can be used to conduct vertical comparison toshow changes of performance in counties,horizontal comparison among different regions,as well as in-depth analysis and comparison on specific dimension,thus generatingevidence for intensive analysis of performance determinants of county health system.Theindicator system will help decision makers and health managers to understand the positionof a specific county in the whole province,and even in central or western region in terms ofhealth system performance,so that they can better allocate financial resources,enhanceeffectiveness of resource use,and contribute to higher cost-effectiveness for county healthsystem setup in central and western China.2.2 Verification of the indicator systemThe study chose 2 counties each from a central province(Shanxi) and a westemmunicipality(Chongqing) as samples for field investigation.“Questionnaires for countyhealth system performance review indicator system for central and western China”wasissued to the sample counties to collect information on health system performance in 2006and 2007.In the meanwhile,experts were recruited to conduct comprehensive evaluationon the sample counties from 5 aspects-function delivery,service quality,service efficiency,impact on medical burdens and service utilization,as well as assessment by local residentsand health practitioners.It was found that findings generated by the indicator system areconsistent with those by expert evaluation,showing that the indicator system is reliable inshowcasing county health system performance in central and western China,and can serveas a“ruler”for evaluation by competent health authorities.Conclusions and Recommendations1.Comparison between therotical framework and practical frameworkBoth of the frameworks are multi-dimensions.The therotical ones are more macroscopicand it pays attention to the whole process including the inputs,outputs and outcomes.The pratical framework of each coutry is based on different kinds of therotical framework andmodified according to the real situation of the country.The practical ones usually onlyconcentrate on the outputs and outcomes and less on the routes of performancemanagement.Compared to the therotical frameworks,the practical one’s aims are moresimple and straighe and its indicators are more available.2.Comparision of indicators between China and other countriesWhen we look at the indicators systems of other countries,we find that nationalgovernments play very important roles on making the indicators and provide importantpolicy reference and supports for the dynamicity of the indicators.This makes theindicators being adopted thoughtout the countries.Since the health information system inChina is still need to be perfect and the data of some indicators cannot be gotten continuely,the dynamicity and the practicality of the indicator in China still need improvement.3.dynamic counting method of the indicatorsFor those indicators that are more sensitive and fluctuated frequently between years,we may try to use an synthetic counting method as:the score of one indicator= weighingcoeffientx(“score compared with the standard values”+“score compared with the value oflast year”)。There are in total 10 indicators out of the indicators systems can use suchmethods.4.The indicators illustrates the characteristics of county health systems in central andwestern China.Unique position of county health system was considered by the indicator system-having rural health as the focus and serving to promote balanced urban-rural development.Health resources allocation was assessed for both rural population,and all permanentresidents in the county.In the meanwhile,indicator on health resources coverage wasdeveloped to reflect less-dense demographical picture in central and western regions.Thestudy also worked out an indicator on“satisfaction among township and village level healthworkers”,to shed light on sustainability on county health system.Mean value of indicatordata in central and western regions as well as indicator data on some surveillance sites incentral and western regions were used as reference value.Such arrangement not onlyreflected specific features of county health system in central and western regions,but also mirrored the policy incentive for performance improvement of county health system.5.Those indicators can contribute to scientific management and better performance in thefollowing ways:(1) Navigation.(2) Differentiation.Performance review will highlightvertical and horizontal gap.By understanding the gap and challenges,the counties can workout targeted measures,to upgrade operating mechanism and management system,and driveforth sustainable development of the whole health system.(3)Management.6.Establish performance evaluation mechanism for county health system.Performance evaluation shall be a consistent item in the agenda,built upon availableindicators and suggestions from experts and grassroots health managers.The studyrecommended that further study and experiment be conducted to fine-tune indicator system,explore appropriate evaluation cycle,develop relatively stable analytical pathways,andwork out a set of scientific and sound evaluation tools which can be applied by the countygovernment.Furthermore,through some policies or regulations,performance review can bemainstreamed into the evaluation of county health system,to create incentive for enhancinghealth administration in the county.Research innovationThis study invented county-specific health system performance review indicatorsystem targeting central and western China.The result-oriented indicator system helps toassess output and outcome of health system operation,and reveal the most direct outcomesin health system.Health administrators,at county level in particular,can make effective useof data generated through the system,to analyze weak links and problems in health systemsetup,and identify areas in need of more attention and better management.Laying eyes on specific characteristics of county health systems in central and westernChina,the study worked out a scientific yet practical indicator system on health systemperformance review,which can generate evidence for health system building and healthmanagement decision-making at county level.更多还原