【作者】 汲进梅；

【导师】 尹爱田；

【作者基本信息】 山东大学 ， 社会医学与卫生事业管理， 2009， 博士

【摘要】 研究背景我国农村地区慢性非传染性疾病发病率、患病率正在逐年升高,给农村居民带来严重健康损害的同时,也给慢病患者及其家人带来了沉重的经济负担,甚至使得许多慢病家庭生活陷于困境。在缺少有效控制措施的前提下,农村地区因为慢性非传染性疾病致贫、返贫的家庭也越来越多。为此,如何建立完善的农村地区慢病控制机制已成为亟需解决的问题。根据文献综述,在国外,尤其是老龄化越来越严重的西方发达国家基本上建立了相对完善的疾病预防控制制度,已形成了针对慢病的疾病控制体系,明确了政府、机构等方面组织的慢病控制职责。在国内,目前对慢性病控制的研究和措施主要集中在传染性疾病,对慢性非传染性疾病控制主要集中在临床防治方面,虽然在预防控制等方面也采取了一些措施,但不系统,特别是缺乏慢病控制机制的系统设计及其相关的研究内容。研究目的本研究的目的是在对我国目前慢病控制现状总结的基础上,发现问题,为合理分配利用资源、提高疾病预防控制人才素质,完善农村地区慢性非传染性疾病控制体系,提出建立适合我国农村地区慢性非传染性疾病控制机制的建议。具体目标包括:(1)分析农村地区居民主要慢病经济负担与家庭疾病风险,农村地区卫生服务机构提供慢病防治能力现状:(2)分析现有农村慢性非传染性疾病控制机制的现状,明确农村慢性非传染性疾病控制机制存在的问题;(3)在对我国农村慢病控制体系薄弱环节和问题进行研究的基础上,提出农村慢病控制需要加强的工作;(4)在分析现状的基础上,借鉴国内外慢病控制的成功经验,提出以慢病控制为目标导向的农村居民健康保障体系建设的建议。资料来源本研究的样本资料主要来源于卢森堡-WHO-山东省农村地区卫生人员培训与慢病控制项目基线调查的数据以及国家的宏观卫生统计资料和国家卫生服务调查的有关数据。研究方法包括系统分析法、文献综述法、专家咨询法等。分析方法有单因素分析,Logistic回归,分析采用SPSS统计软件进行分析。对乡村两级卫生机构的调查发现,乡镇卫生院和村卫生室普遍存在人员素质低,队伍不稳定,设备落后等问题。近几年随着乡村卫生院一体化管理,乡镇卫生院和村卫生室较以前规范了许多,但是仍然存在许多问题,尤其是农村医生应该承担相应的疾病预防控制职能的问题仍然没有得到很好的解决。县乡村三级医疗机构以及疾病预防控制机构开展慢病预防工作比较薄弱,没有形成机制。县级医院、县级疾病预防控制机构、乡镇卫生院慢病控制人员的比例分别为5.23%、6.91%、4.46%;开展健康教育的次数平均为6.7次、7次和5次,主要采取发放宣传单的形式;慢病管理只有少数乡镇卫生院和村卫生室开展,主要方式是通过接诊或者免费查体获取的信息建立健康档案,但是利用率比较低,未能有效开展随访及家庭康复与社区康复:基层医生在有限的康复治疗中过于注重临床治疗而忽视了心理、精神与功能的康复,这与他们的综合素质有密切的联系。通过调查,我们发现造成现存三级卫生机构开展慢病预防控制工作薄弱的主要原因是缺少资金、政策等的支持,机构以及人员没有开展慢病预防工作的积极性;对慢病工作缺少监督,为数不多慢病控制政策没有有效落实;农村合作医疗对慢病控制的投入不足,尤其是对预防环节投入薄弱,没有建立慢病控制预警机制;农村合作医疗对慢病患者门诊费用以及基层医疗机构就诊费用补偿力度偏弱,不利于引导慢病患者在基层卫生机构就诊,以降低慢病患者的经济负担。结果与发现对农村地区居民慢性非传染性疾病负担研究发现,本次调查的山东省样本地区农村地区32.92%的家庭目前处于负债的状态,这些家庭中人均负债2500元,其中有22.38%的家庭是因为看病而借钱。25岁以上人口的高血压和糖尿病患病率分别为37.19%和3.49%。高血压和糖尿病患者人均每年的花费为787.67元/年和1545.67元/年,分别占个人经济收入的19.06%和33.78%。24.34%的高血压患者、24.9%的糖尿病患者和26.0%的其他慢病患者在2006年得到农村合作医疗的补偿,补偿额度分别为40.00(中位数)、526.84(均数)和150.0元(中位数)。山东省农村居民整体的慢病知识水平低。慢病知识得分为0分的达到48.8%;仅有49.4%的被调查者想知道慢病相关知识。经常主动获取健康知识的比例低,仅为33.0%;最希望获取的慢病健康知识类型是预防知识;希望更多的通过医生、报刊书籍、广播及宣传手册等权威性较好的途径获取健康知识。分析我国慢病防制工作现状,可以发现:有项目支持的慢病防治地区的工作一般效果较好,没有项目支持地区的慢病防治工作一般效果较差,而将试点地区的经验向非项目地区推广存在很多问题:慢病防治的政策支持环境尚未形成,能切实解决问题的政策如防治经费的保障机制尚未建立;慢病防治人员的聘用、工资补偿、晋升、培训等政策还有待开发;慢病专业防治机构不健全,系统功能难以有效发挥;城乡社区卫生服务体系尚未形成规模,社区慢病防治服务中起关键作用的“守门人”制度和“双向转诊”制度尚未建立,使社区卫生服务功能在慢病防治中的功能难以充分发挥;慢病防治队伍的技术能力有待提高,防治规范和技术尚不能形成体系等。其中,医疗服务收费决定慢病防治人员的经济收入的机制,是系统的慢病防治计划难以实施,社区慢病防治人员缺乏主动提供慢病预防保健服务的原因之一。农村慢病防治所依托的医疗机构体系已经基本理顺,但是相应的政策支持还没有到位;农村卫生体系正在逐渐完善,但是相比城市、相对于慢病控制目标而言还有较大差距,主要是农村医生待遇问题、身份问题、能力问题以及职责界定等问题;慢病信息系统正在逐渐开发,但是还没有形成国家级别的统一规范,相应的技术支持、人员配备等问题尚待解决;慢病控制成本效果最优的健康教育工作仍然很薄弱,这与机构设置、农村居民健康意识以及农村医生水平有很大关系。建议针对发现的问题,我们提出了以下需要加强的工作:一是控制措施前移,通过公共卫生体系的建设,增加投入,强化健康教育和健康体检制度建设等,实现基本公共卫生服务均等化的目标;二是控制措施下沉,强化对基层医疗保健和康复体系的建设;三是提高农村慢病居民基层医疗保障水平,在新型农村合作医疗保障体系中设立门诊慢病报销基金,使患慢病的农村居民能够得到必要的诊治和康复治疗。在对我国目前农村地区慢病控制体系进行综合分析的基础上,结合我国实际,借鉴国外慢病控制经验,提出了农村地区以慢性非传染性疾病控制为导向的居民健康保障体系完善的建议:增加慢病控制协调职能,协调卫生系统内外的资源开展慢病控制工作;扭转政策制定“重医轻防”的倾向,明确卫生机构的慢病控制职责:完善现有疾病预防控制信息系统的慢病控制信息职能,建立慢病信息数据库,对人群采取分类管理政策;在新农合制度内成立慢病基金,对慢病预防控制和基层卫生机构就诊费用进行补偿,引导慢病控制关口前移和防治工作下沉。本论文在对农村慢病控制机制系统分析基础上,首先明确了目前农村地区慢病控制机制建设的差距与薄弱环节,并提出了农村地区慢病控制机制的建设需要加强的重点任务;第二,提出了从慢病的病因学到疾病的预防、保健、医疗、康复全程控制机制的无缝隙战略思想,为农村慢病控制建设提供了比较明确的建设任务和要求;第三,提出了通过医疗保障体系建设,即借助新型农村合作医疗制度的手段导向慢病控制机制完善的程序和方法。第四,提出了慢病控制机制建设应针对慢病病因学控制措施为重点,完善以慢病控制措施为导向的农村卫生体系建设,为强化预防控制措施和基层卫生体系明确了可持续性的制度建设目标。更多还原

【Abstract】 BACKGROUNDThe prevalence rates of chronic non-communicable diseases are getting higher and higher year by year in rural areas in China,generating poor health to rural habitants as well as a heavy economic burden to NCD patients and their families.In addition,it seems that there are more and more poor families in rural areas caused by NCD.Even some families in rural areas are at the edge of bankrupt without efficient NCD control measures.So,it becomes more and more necessary to build control consummate mechanism of chronic non-communicable diseases in rural areas to reduce the prevalence rate of NCD.According to the literature review,the developed countries,especially the aging countries in western world have built relative consummate diseases control system covering NCD,which have put many emphasize on NCD cnontrol as well as studies in these fields with specific responsibilities of government and health organizations. However,there is few studies on NCD control in our country,especially in rural areas, while the present studies focus on communicable diseases.The current studies on NCD control often focus on clinical treatment,while some are involved NCD prevention without systematic analysis,especially are lack of systematic design of NCD control.AIMSThe objective is to find the problem of present mechanism of chronic non-communicable diseases control in rural areas in China,based on the systematic analyses of actuality of NCD control.Provide the suggestions on reasonable allocating resources and advancing qualities of NCD control people,in order to consummate the NCD control system in rural areas.The detailed purpose includes:1) calculate the economic burden of NCD and risk of families with NCD patients,and analyze the ability of providing NCD control services of health institutions in rural areas;2) analyze the present situation of NCD control in rural areas to definitude the problems in the mechanism;3) point out the works those need to be strengthened by analyzing the weak progress and problems;4) based on the analysis of present situation and reference to the successful experience of foreign countries,advance some proposals on improving the health security system for rural residents with chronic diseases control for goal-oriented.RESOURCESThe datum of the study roots in baseline investigation of Luxemburg-WHO-Shandong rural health workers training and chronic non-communicable diseases control program,and macroscopical health statistic database and health service investigation.The study methods include systematic analysis,literature review,and informational interview and so on.Univariate analysis and Logistic regression with SPSS software are used to address the data.RESULTS AND FINDINGSThe investigation on township hospitals and rural cliniques shows some problems, which are health workers with low quality,unstable health human resource team and out-dated equipments of the two level health service providing institutions.With the progress of integrated management of township and rural health,the township hospitals and rural cliniques have been standard constructed,but there are still many problems,especially with the duties of public health rural health workers should take. County,township and village health institutions are lack of works for chronic diseases control,with no mechanism.The proportion of chronic diseases control crew in county hospitals,county center for diseases control and township hospitals are 5.23%, 6.91%and 4.46%respectively;carried out health education 6.7,7 and 5 times with leaflets as the main method in county,township and village clinical organizations; chronic diseases managements are carried out only in several township hospitals and village cliniques,which establish health files with information from health physical examination,but that the files are not used enough results in weak works of home visits and community healing;grass-rooted doctors over emphasize clinical measures in healing with neglect of psychological and functional healing,which due to their qualities.By investigation,we found the main reasons why three level health institutions weakly carry out chronic diseases control are short of financial and policy supports,which result in the institutions and people being lack of incentives to develop NCD prevention jobs.There are less supervision on chronic diseases control and some NCD control policies does not work;new rural corporative systemedical scheme has little investment in chronic diseases control,especially the prevention with no warning mechanism for chronic diseases control;rural chronic diseases patients get less compensations from new rural corporative health system for clinical and grass-rooted organization expenditure,which are not good for leading they to see grass rooted doctors.Based on the studies chronic diseases burden of rural residents,we find that 32.9% of rural families in Shandong province have run into debt with 2500 Yuan per capita, 22.38%of who get into debt because of chronic diseases treatment.The diabetes and hypertension prevalence rates of older than 25 years old people are 37.19%and 3.49%respectively,with spending 787.67Yuan and 1545.67 Yuan per year,accounts for 19.06%and 33.78%of their yearly family economic income.24.34%of hypertension patients,24.9%diabetes sufferers and 26.0%other chronic diseases sufferers got compensations from NCMS in 2006,and the amounts are 40.00yuan(M), 526.84yuan(mean) and 150.0yuan(M) respectively.Rural residents in Shandong province,48.8%of who get 0 points in knowledge test,acquire less knowledge on chronic diseases.There are only 33.0%of inhabitants to aquire health knowledges actively,and they most want to know prevention knowledge by reliable ways,such as consulting doctors,reading books and newspaper,and listening radio.The analysis of status of NCD control in rural areas of our country demonstrates that:the districts with NCD control program supporting performance better than no program supporting districts,and there are many problems to extend the experiences to other regions without programs:1) no policy environmental,no health financial mechanism;2) the policies of employment,promotion,training of rural NCD control workers needed to be deeply explored;3) professional institutions for controlling NCD are not well equipped,and their functions are not very efficiency;4) the health service providing system covering rural and urban’areas is not perfect enough to build "gate keeper" and "two-way referrable system",the community functions of NCD control cannot play well;5) the professional teams’ abilities of controlling NCD need to be improved,preventive and therapeutical criterions and technologies are not integrated.That the professional people’s incomes depend on charges for services which leads they negative in providing preventive and health care services,is the key reason why NCD prevention and therapeuty plans can not be well played.The corresponding institutions have been almost rationalized,but there is lack of supportive policies;there are also a long distance between rural and urban NCD control systems,of which the treatment,identity,ability and duty of clinical doctors are the points;information systems are been exploring while be lack of criterions and technologies,human resources supports;health education,the best cost-benefit way of controlling NCD,is still very weak,lack of emphasize,which have strong relationship with institutions setup,rural residents’ health consciousness and rural health workers’ abilities.SUGGESTIONSContraposing the problems we found,the study gives the following areas need to be strengthened:1) forward control measures:by constructing the public health system, increasing investment,consolidate the health education and health physical examination systematic construction and so on,to implement the equalization of basic public health services;2) subsidence control measures to grass-rooted organizations, intensify the grass-rooted health and healing organizations construction;3) advance the basic health security for rural residents,set up chronic diseases control foundation in new rural corporative health system to compensate the expenditure at grass-rooted cliniques.From our analysis,in accordance with the current realities in our country and with referring from developed countries’ experiences,the study proposes the concepts of improving the health security system for rural habitants with chronic diseases control goal-oriented.Adding harmonize functions for chronic diseases control,coordinating both within and outside the health system resources to carry out chronic diseases control;turn the incline of "attention to medical care,neglect of prevention", definitude the duties of organizations involved in chronic diseases control; consummate the function of chronic diseases control information system,setting up chronic diseases databases,taking classified management strategies;establish chronic diseases fund within new rural corporative health system to compensate the expenditure occurring in grass-rooted cliniques with leading forwarding and subsidizing control measures.Based on the systematic analysis of NCD control systems in rural areas,firstly,the thesis definitude the weak links of current NCD control measures and the distance between situition and goal,while bringing forward the measures need to be strengthed. Secondly,the thesis definitude the integrated procedures of chronic diseases control from prevention,clinical care and healing,giving a specific goal for NCD control mechanism building in rural areas.Thirdly,the procedures and methods of leading chronic diseases control in virtue of NCMS are advanced for the first time.Fourthly, the thesis foucus on the etiology control as the key points of NCD control system building,and propose consummating the health systems in rural areas with improving NCD control measures as goal oriented,giving an specific goal for intensify NCD prevention and grass-rooted health system.更多还原