【作者】 吴森林；

【导师】 卢祖洵； 程锦泉；

【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】 深圳市劳务工医疗保险卫生服务研究研究目的全面系统地了解深圳市劳务工卫生服务需要、需求和利用、卫生服务供给、劳务工医疗保险运行等情况，总结经验，发现问题，为进一步完善相关医疗保险政策和卫生服务制度设计提供依据。研究方法本课题主要采用文献研究、现场调查、深入访谈、案例研究、比较研究方法对深圳市劳务工医疗保险卫生服务进行了调查分析。将定量分析和定性分析结合起来，从需方、供方和管理方三个层面试图对卫生服务项目进行系统评价。具体来说，采用描述性分析和卡方检验分析卫生服务供给、需要、利用情况及其影响因素，采用广义线性回归模型分析参保劳务工对社区卫生服务的反应性和满意度的影响因素。研究结果研究表明，1．劳务工卫生服务供给情况：①定点社区健康服务中心共有337家，平均服务半径为1.59公里，平均服务人口为4.86万人，其总体状况经营状况较差，45.45％处于亏损状态。②受调查的参保劳务工中，到最近医疗点用时10～19分钟占30.28％，用时30分钟及以上占37.32％。⑧专业人员构成不合理，尤其缺乏公共卫生医师；平均每所社区健康服务中心有工作人员14人，医护比为1：0.76(高于全国1：0.61)；职称构成多以初级职称为主：学历以中专学历为主。2．劳务工卫生服务需要情况：参保人员与未参保人员两周患病率分别为22.24％、25.52％，慢性病患病率分别为21.06％、16.68％，均高于第三次国家卫生服务调查报告的城市人口两周患病率、慢性病患病率(15.23％、17.73％)。3．劳务工卫生服务利用情况：①参保人员与未参保人员两周就诊率分别为20.10％、15.47％，两周患病未就诊率分别为57.63％和64.61％；参保患者和未参保患者自我医疗的者比例分别为：34.09％、46.13％，未采取任何措施的比例分别为23.54％、20.07％。未治疗的主要原因中，超过50％的患者自感病情较轻，而由于经济困难而没有治疗仍有25％。参保患者在社区健康服务中心就诊的比例为42.44％，未参保患者为23.4％。②参保人员住院率为3.56％，未参保人员为3.05％，均低于第三次国家卫生服务调查分析报告城市人口住院率4.2％；参保人员和未参保人员在镇级医院住院的比例在各级别医疗机构中最高，分别为：42.86％、36.67％。参保人员与未参保人员应住院而未住院率分别为50.67％、46.58％。参保患者和未参保患者应住院而未住院的主要原因都是由于经济困难，比例分别为74.36％、58.82％。参保与未参保人员的住院率间差异无统计学意义(P＞0.05)，未住院率间亦差异无统计学意义(P＞0.05)。4．劳务工医疗保险卫生服务反应性：反应性各要素评分中保密性平均分最高(3.65)，环境和可及性得分最低(3.07)。对劳务工医疗保险卫生服务反应性的总体评价中，12.31％的就诊者认为“很差”或“差”，53.08％认为“好”或“很好”。广义线性模型分析结果表明，职业性质和卫生机构硕士以上学历人员比例对反应性的影响均有统计学意义(P＜0.05)。5．劳务工医疗保险卫生服务满意度：各要素评分中服务态度平均分最高(3.49)，费用平均分最低(3.06)。399名就诊者对医疗机构满意度的总体评价中，13.07％的就诊者表示“很不满意”或“不太满意”。广义线性模型分析结果表明，每年支出的医疗费用、卫生机构硕士以上学历人员比例对满意度的影响均有统计学意义。研究结论劳务工医疗保险及其卫生服务工作取得了一些成效：人力资源已经基本到位；引导劳务工就医的合理流向；参保劳务工的医疗费用有所控制；提高了门诊卫生服务利用水平；拓展社区卫生服务的发展空间，提高了卫生服务可及性：卫生服务反应性和满意度较好。但是存在一些问题，主要是：供方定点医疗机构和服务人员数量严重不足，人员结构和机构布局不合理，服务水平和质量有待改善，诱导需求现象仍然存在；劳务工门诊和住院服务需要量较大，而住院服务利用较少；劳务工医疗保险政策本身有待进一步完善；社区卫生服务机构亏损约占到一半；劳务工医疗保险政策宣传力度不够，影响参保企业和个人的积极性。政策建议正确认识劳务工医疗保险，明确政府在劳务工医疗保险中的主导作用和功能；通过提高卫生服务供给能力提高劳务工卫生服务利用水平；提高办卡效率和质量，简化报销、转诊手续，提高定点医疗机构管理水平，加强医疗保险基金管理，从而提高劳务工医疗保险机构的服务水平和质量；注重劳务工医疗保险与新农合工作的衔接；建立农民工大病医疗救助制度、贫困医疗救助制度。以上政策建议可以保障深圳市劳务工医疗保险制度持续、稳定、健康的发展。研究创新①深圳市率先进行大范围劳务工医疗保障研究与实践。②在适合农民工特点的筹资水平下，重点探索了劳务工卫生服务提供、需要、利用，并对卫生服务提供质量进行了评估。③社区卫生服务的提供与劳务工医疗保险结合，为解决农民工医疗保障的公平性问题提供了一个很好的思路。更多还原

【Abstract】 ObjectiveTo know health service need, demand and utilization of migrant workers and thehealth service supply, and the performance of the Migrant Worker’s Medical InsuranceSystem (MWMIS) in Shenzhen, and to provide basis for related departments to perfectthe policy of medical insurance and design health service system for migrant workersby summarizing the experience and discovering problems.MethodsIn this study, document analysis, the field observation, depth interview, caseexample research, and comparison research were performed to investigate and analyzehealth service of MWMIS in Shenzhen. By combining quantity and quality analyses,efforts were afford to give a systematic review on the project from health servicedemander, provider and manager sides. In details, the health service supply, need,utilization rate and the influencing factors in migrant workers were analyzed by thedescriptive method and chi-square test. Multiple factor analysis such as linearregression was adopted to study satisfaction and the response of the migrant workers tothe community health service.ResultsThe study demonstrated that: (1) Health service supply of the migrant workers’medical insurance. There were 337 Community Health Centers (CHCs) totally.Average service radius and average service coverage of each CHC was 1.59 kilometersand 48.6 thousands people respectively. Totally the running condition of CHCs was bad,and 45.45％of them had a deficit; Among the migrant workers investigated, thosespending 10-19 min to walk to the nearest CHC accounted for 30.28％, and those spending 30 min or above for 37.32％; The constitution of the health human resourceswas not reasonable, and particularly there was a lack of the public health doctors. Thehealth human resources quantity of each CHC was 14. The ratio of doctors to nurseswas 1:0.76, which was higher than the whole nation’s (1:0.61). Most professional titleswere junior, and the education background of the most migrant workers waspolytechnic.(2) Statue of migrant workers’ health service need. The tow-week prevalence ratesof the insured and the un-insured were 22.24％and 25.52％, respectively, the chronicdisease prevalence rates of the insured and the un-insured were 21.06％and 16.68％,respectively, which were higher than the average levels in city areas in China in 2003(15.23％, and 17.73％, respectively).(3) Health service utilization of migrant workers. The two-week clinic rate of thesick insured and un-insured was 20.10％and 15.47％, respectively, and the two-weekno-clinic rate was 57.63％and 64.61％, respectively; The self-treatment percentage ofthe insured and the un-insured was 34.09％and 46.13％, respectively, and thepercentage of the insured and the un-insured who did not adopt any measure was23.54％and 20.07％, respectively. The major reasons of un-treatments included mildillness (more than 50.00％of patients) and economy difficulty (25.00％of patients).The clinic rate of the insured and the un-insured in CHCs was 42.44％, and 23.40％,respectively; The hospitalization rate of the insured and the un-insured was 3.56％and3.05％, which was both lower than that of the city population issued by the ThirdNational Health Service Investigation Report (4.2％); The hospitalization rate of theinsured and the un-insured in the township health centers was highest among the allmedical levels (42.86％, and 36.67％). The percentage of the insured and the un-insuredwho should stay in the hospital but did not stay in the hospital was 50.67％and 46.58％,respectively, and the major reason was economy difficulty, accounting for 74.36％and58.82％, respectively. There was no significant difference in the hospitalization rate andnot-hospitalization rate between the the insured and the un-insured (both P＞0.05). (4) Health service response of MWMI. Among the elements of the response, theaverage score of keeping secret was the highest (3.65), and those of environment andthe accessibility were the lowest (3.07). 12.31％of the patients believed the healthservice of MWMI was "very bad" or "bad", and 53.08％"good" or "very good". Broadlinear regression model indicated that professions and the proportion of the healthhuman resource with master degree and above could significantly influence theresponse (P＜0.05).(5) Health service satisfaction of MWMI. Among the factors, the average score ofthe satisfaction of service attitude was the highest (3.49), and that of the averageexpenses was the lowest (3.06). In overall evaluation of the satisfaction to medicalorganizations, 13.07％of the 399 patients were "very dissatisfied" or "not too satisfied".Broad linear regression model indicated that the medical expense every year, and theproportion of the health human resource with master degree and above couldsignificantly influence the health service satisfaction (P＜0.05).ConclusionsThere are some achievements in health service of MWMIS: The health humanresource has already been put in place; Reasonable allocation of seeking medical adviseof migrant workers has been taken shape; The medical expenses of the insured migrantworkers have been controlled certainly; The level of health service utilization has beenraising; The space of the CHCs was broaden, such as the service quantity and itemshave been increasing and the level of the health service accessibility has been improved;The response and satisfaction of migrant workers to health service were good.There are some problems: The quantity of health provider including theinstitutions and the staff were inadequate. The personnel components and the allocationof institution were not reasonable. The service level and quality should be improved.Induced medical service still existed; The health service needs of in-patient andout-patient were much, while the health service utilization of hospital was little; Policyshould be adopted to the health service of MWMIS; About half of the CHCs were deficit; (5) The dynamics of broadcasting medical insurance policy publicly was notenough to influence the migrant workers to attend in health service of MWMIS.Policy Suggestions(1) We should recognize MWMIS rightly and definite that the dominant functionof government in MWMIS clearly; (2) We should increase the ability of the healthservice supply to increase the utilization level of health service continuously; (3) Weshould increase the service level and quality of health insurance institution byincreasing the efficacy of the health insurance cards dealing, simplifying the procedureof submitting the expense account and turning to next health institution, increasing themanagement level of the medical institution, and enhancing the management level ofmigrant workers’ medical insurance fund; (5) We should make a joint between thehealth service of MWMI and the New Cooperative Medical Insurance System(NCMIS); (6) The big disease medical relief system should be established to poormigrant workers. All of above will guarantee MWMI to develop continuously, stablyand healthily.Innovation(1) The research about MWMI system and its practice were first done by a widemargin in Shenzhen.(2) Under the proper level of raising insurance premium, we explore the supply,need and utilization of the health service of MWMI, and evaluate the quality of thehealth service.(3) The idea of combining MWMI system and community health service offered agood solution to guarantee the fairness among migrant workers.更多还原