【作者】 张海宏；

【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， 2010， 博士

【摘要】 目的：中国是世界生产大国,进出口总额世界第一,制造业产值世界第二,产品遍布世界各个角落,但是中国与生产向伴生的职业病危害却日趋严重,近十年来每年新发职业病1万多例,2009年更是高达1.8万例,每年因职业病和工伤引起的直接经济损失高达千亿,成为中国经济发展的沉重负担。本研究从系统的观点出发,从职业卫生服务相关三方——企业、职业卫生服务机构和政府的角度,分析职业卫生服务体系的结构和运行机制中存在的问题及其内在原因,以提出改善中国职业卫生服务体系运行效率的办法,为中国职业病防治工作改革提供政策建议。方法与数据来源：资料来源：国家有关卫生政策的文件,中国卫生事业发展年报、资料汇编以及国家统计局发布的一些相关统计报告、中国统计年鉴中相关的社会经济发展资料、中国卫生统计年鉴和广东省卫生统计年鉴、广东省职业卫生服务调查数据。研究方法：本研究运用文献研究和调查研究等方法,通过对中国宏观经济经济和卫生统计资料的历史回顾和分析和调查数据的分析,借鉴国内外相对成熟的政策分析理论和方法,包括博弈论、公平效率理论、公共产品理论、政策执行力理论,结合中国职业卫生工作的实际,采用定性、定量研究方法,对职业卫生相关统计指标的进行比较,分析中国职业卫生服务体系的运行状态,用图表的方式描述职业卫生体系各元素间的关系和在不同社会经济环境下企业职业卫生工作开展情况。结果：(1)职业卫生服务体系的结构和运行机制中国职业卫生服务体系是由企业、职业卫生服务机构、政府、劳动者和社会等职业卫生相关组织构成为的以各种职业卫生相关法律法规为规范的以保护劳动者在生产劳动中免受职业性危害因素的影响的有机整体,动态平衡的、开放的整体,其中前三者为核心元素；企业既是职业卫生服务的提供者又是职业卫生服务的需方,是职业病防治工作的责任者；体系中职业卫生服务机构为职业卫生服务提供者；政府是职业卫生工作的监督管理者,是职业卫生机构的举办者,政府在职业卫生工作中起到主导作用。职业卫生三方是相互依存、相互协作的动态关系。劳动者是企业的一部分,但又与企业相区别,是职业卫生服务最终的服务对象。职业卫生服务机构是由取得职业卫生服务资质的各级职业病防治院、疾病预防控制中心为主体,包括社会医疗卫生机构、健康教育所及企业内设的职业病防治机构、基本职业卫生服务试点中的各地乡镇卫生院和城市社区卫生服务中心组成。国家努力构建国家级→省(市)级→县级→基层乡镇街道级的四级职业卫生服务网络。(2)中国职业卫生体系各元素现状①中国职业危害企业众多,企业职业危害严重。每年新发职业病超过1万人,职业病危害因素接触率为35.7%,其中粉尘是最重要的职业危害因素,占总有害因素的45.78%.②企业职业卫生工作开展不力。劳动者全部建立健康档案的38.60%；仅有41.62%的企业法人代表、43.29%的劳动者接受过职业卫生培训；约50%的企业没有设立职业卫生管理机构没有管理计划；仅18%的劳动者接受职业健康检查,其中尤以离岗体检比例低。③有资质的职业卫生服务机构数量少,专业技术人员数量不足,服务提供能力不足,服务提供少。2007年在全国3665家职业卫生服务机构中,仅1076家获得职业卫生技术服务资质,1772家获得职业健康体检资质,全国有半数以上的区县没有获得服务资质的职业卫生服务机构；在作为服务主体的疾病预防控制中心,未将职业卫生服务作为工作重点,其职业卫生技术人员仅占总数的2%,2005年平均每个职业卫生技术服务机构开展建设项目职业危害评价仅7项,每天职业性体检13人次。④政府财政投入不足,职业卫生监督人员数量不足,监督力度不到位。2008年全国有卫生监督机构2675个,工作人员78892人；具有职业卫生和综合卫生执法证的监督员仅占监督员总数的3.4%和32.2%,平均每个区县0.3人和2.9人,平均每个人要管理440多家工业企业；2009年监督检查建设项目10704家,检查用人单位125231家,平均每个卫生监督机构仅完成监督4个建设项目和47个用人单位；违法单位被经济处罚金额不足2万元,广东省则平均为0.5万元左右。结论：中国职业卫生服务体系的缺陷在于：(1)政府特别是地方政府侧重发展经济、解决就业问题,对职业卫生工作支持力度不够,表现在职业卫生监督力量不足,监督工作开展力度不够；(2)职业卫生服务机构服务提供能力缺乏；(3)政府对职业卫生服务的补偿机制存在缺陷,缺乏绩效考核制度,机构开展服务意识不强或选择性支付能力强的企业提供服务,(3)企业缺乏行业职业卫生管理,职业卫生工作开展不利,(4)劳动者缺乏职业病防治知识,缺乏监督企业开展职业卫生服务的主动性；完善职业卫生服务体系的建议：(1)构建良好的社会经济环境,全社会重视职业卫生工作。(2)加强政府社会公共服务职能,加强职业卫生监管机构建设和监督力度,加大职业卫生财政投入。(3)鼓励社会力量举办职业卫生服务机构,加强职业卫生服务机构服务能力建设；加大基层医疗卫生机构承担职业卫生工作的力度。(4)加强绩效管理,优化职业卫生机构的运行机制。(5)改变政府补贴职业卫生服务的方式,通过补贴企业对职业卫生服务的购买,补贴职业卫生工作。(6)畅通职业卫生信息沟通渠道,建立国家层面的职业卫生信息管理平台。(7)完善职业卫生法律法规体系,细化相关条款,提高法规执行的科学性和可行性。(8)加大工伤保险、社会医疗保险的覆盖面,扩大职业卫生服务筹资来源。(9)加强国际合作,将职业卫生相关标准逐渐与国际标准衔接。创新：本论文的创新主要有：(1)提出了一个基于职业卫生税收为职业卫生筹资来源,以职业健康基金管理为核心,在政府职业卫生监督部门监管下,由职业卫生服务联合体一揽子提供职业卫生服务,采用总额预付制服务补偿方式的,覆盖全体劳动者的有中国特色的国家职业卫生服务体系构想。(2)从利益集团的角度对农民工职业病防治问题进了分析,提出农民工职业病问题突出主要原因在于农民工的弱势地位,提出提高农民工政治话语权、加强农村基础教育和职业培训等,提高农民工集团和个体的地位和能力等解决办法。更多还原

【Abstract】 Purpose:The our country is a large production country, the total amount of import and exports is the first, the production value of her industry is the second in the world. Her product spreads all the world. But the occupational disease harm in production is vary serious in China. More than 10,000 people got the occupational disease annually in the last 10 years, and the number was up to more 18,000 in 2009. the direct economic loss aroused by occupational disease and industrial injury is up to several ten billions annually and become the heavy burden to the economic developmentin China. This research basing the standpoint of system analyzed the states of occupation health serves(OHS)he shortcoming of the function mechanism of it and the reason of the shottcoming, and make way to improve the efficiency of the system function,and make suggestion for the OHS.Method and data sourcese:Data source:The document concerning occupational health policy of China, the report of health business, the data of economic statisticses annals and health statisticses annals of the country, the health statisticses annals of Guangdong province, and the investigation data of the OHS in Guangdong province.Study a method:Using the way of literature reseach and investigation reseach, to analyze the history data of macroscopical economic and the investigation, and using the theory: Game theory, Equity and efficience theory, public good theory and policy execution ablity tyeroy, and consider the actual status of OHS,by the qualitative analysis and quantitative analysis, to contrast the stststics data to estimate the ststuse of the OHS system. Using the chart to describe the the rational of the elements of the system.Result:(1)Structure and function mechanism of the occupationhealth service systemThe OHS system of China is constituted by the occupation health related organizations such as enterprise, the OHS organization, government, worker and the society etc, basing various occupation health related laws to protect the health of worker to avoid the influence of the occupation harm factors is a organic whole, dynamic and, opening body. The enterprise is the the provider of occupatheion health service to the workers and the needer to the OHS organization, is duty body of the occupational disease prevention and streatment work. the occupationhealth service organization is the provider of the services.the government is the superviser and the shareholder of the OHS organization. the worker is the part of the enterprise,is the aim of service.The The OHS organization is mostly composed by occupational disease hospital and Center for Disease Control and Prevention that had got the qualification of service,also includes the other hospital and the OHS of the enterprise.the country is trying his best to bult up a OHS net with 4 ranks:the country rank→the provivine rank→county rank→the skeleton medical organizations.(2)the statue fo the elements in the occupationa; health service system in China①The our country amount of enterprises is numerous, the enterprise occupation endangers is severes, the contact rate of the occupational disease endangers factor is 35.7%. the dust is the most important occupational endanger factor, takinf up 45.78% of the all harmful factors.②The occupation health work of the enterprises was not well.38.60% enterprises had built up the healthy file for all workers; Only 41.62% enterprise’s legal persons representative and 43.29% workerses once accepted occupation health training; About 50% enterprises didn’t establish the occupation health management organization and don’t make a plan;Only 18% workers had accepted the occupation health inspection, the proportion is low, and especially the proportion of the health inspection leaving the job is low.③There is not enough the OHS organization that has got the service qualification. The technical personnels and the providing ability of the OHS are shortage, The service provided was little.④The the public finance to the OHS isn’t enough. The supervising personnels of OHS is shortage, the supervision is not strict.⑤The principle of purchasing: "Who pay, who get the benefit", limited the workers to accept OHS.Conclusion:The limitation of the OHS in China lies in:(1) The governments,especially the local governments, emphasis on the development of the economy and employment problem. the support to OHS isn’t enough. It was embodied in the supervise to OHS was shortage;(2) The ablilty of the service provision of OHS organization is lack;(3)the compensating mechanism to OHS of the Government is disabled, it lack the performance evaluation to OHS organization, the OHS organization lack the will of providing OHS or choose the enterprises in strong financial situation to provide the OHS.(4) the management of the guild to the occupational health of enterprise is shortage. The enterprises emphasis the cost control and think little of their OHS.(5)the workers lack the knowlage that how to prevent the occupational disease, and lack the ablility and the willing to inspect the OHS of enterprise.The suggestion of inprovment OHS system:(1)Building up a good social economic environment, whole social attach importance to the occupation health work. (2)Strengthen the function of social public service of the government. Strengthen the builing of the OHS supervision organization, Strengthen the supervision to OHS, Enlarge the public finance devotion to the occupation health; (3) Strengthen the builing of the OHS organization, encourage that the social organization holds the OHS organization, Enlarge grass-roots medical and health organization to undertake the basic OHS. (4)Strength the performance management and improve the function mechanism of organization of the OHS and OHS supervision. (5)Change the way of the government subsidy OHS, by subsidizing the enterprise to buy the OHS to subsidize occupation health work. (6)building the OHS information system of the country to to make the OHS informationized. (7)Perfect occupation health law system, make its performance more scientific and exercisable. (8)Enlarge The coverage of the industrial injury insurance and social medical insurance, Enlarge the finance sourcese of OHSInnovation:(1) Put forward a mode of national occupational health services with the chinese characters,that its core is occupational health fund manage, under the surveillance of the occupational health surveillance orgnization, that combos of occupational health services organiztions provide the whole occupational health services and subside by the prepaying system of total amount,that cover all the employees. (2) Basing the interest group theory, analyze the problem of the occupational disease prevent and trentment of the farm worker., put forward the radical reason, farmer work is powerless. Put forward to raise political position of farmer work and strengthen the basic education and the skill education in village, raise the ability of the farmer work group and the ability of the individual.更多还原