【作者】 黄莉；

【导师】 张亮； 冯泽永；

【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】 人口老龄化是社会文明、国家工业化、国家现代化的重要标志,也是社会进步、人民健康水平、生活水平提高的表现；随年龄增长、健康状况逐渐下降、卫生服务需求逐渐增多是公认的普遍规律,加上“健康老年”的需要,努力解决好老年人的医疗卫生、经济供养、生活照料、精神慰籍等问题也是我们必须解决的重要问题。目的：社区卫生服务是实现人人享有初级卫生保健目标的基础环节,是落实科学发展观、坚持以人为本、促进社会公平、维护社会稳定、构建社会主义和谐社会的重要内容。社区卫生服务的重要服务对象是老年人,人口老龄化给社区卫生服务带来很大影响。伴随中国的不断强大,社区卫生服务必将形成健全的体系,政府也将作为老年人口的社区卫生服务主导力量,在制度、机制、体制上为老年人享受方便、经济、有效的卫生服务提供坚强保障,让每一个中国老年人病有所医。本研究希望能为重庆市构建老年人口社区卫生服务体系提出思路,促进重庆经济发展,为重庆市实现社会和谐作出贡献。方法：本研究是重庆市科委软科学课题《重庆市人口老龄化对社区卫生服务体系的需求研究》、重庆市教委课题《重庆市社区卫生服务体系与社区建设同步发展的机制研究》的核心,本研究还是重庆市发改委课题《重庆市公立医院改革试点研究》的一部分。研究方法主要包括文献研究、现场调查、规范分析、访谈法等。结果：本课题理论研究部分从管理学、社会学、人口学、经济学等不同学科出发,将制度和文化作为本研究的理论基础,以新公共服务理论(只有以人为本,充分重视民生,政府的管理才能取得成效；政府的职责就是最大限度地满足公民的一切合理需求；凸显政府的服务意识、强化政府的服务职能；强调公共管理的权力和合法性来源于公众,公众的满意度是评判政府公共管理活动的最终标准)、底线公平理论(对于老年人口而言,依靠基本生活保障加上医疗卫生保险,就可以获得最基本的社会保护,这是政府的责任；底线公平回答了民生建设的原则要求：确保民众享有与经济社会发展水平相适应的民生建设成果,是政府应当承担的首要责任,也是政府必须坚守的责任底线)、中国的孝文化(树立关心老人、关注老龄、关怀老人,有利于应对老龄化带来的挑战；提倡孝道、孝文化,是实现社会和谐稳定的最佳途径之一；弘扬中国传统孝文化对于缓解我国人口老龄化问题,促进和谐社会建设有着重要的现实意义)、民生理论(加快推进以改善民生为重点的社会建设,是党的十七大提出的重大战略任务；改善民生提高社会福利,让所有的老人都能得到物质上的照料和精神上的尊重是建立中国和谐社会的重要内容)、社区建设理论(社区建设和社区发展过程是社会各个部门合作、协商、融合的过程,也是共同精神和共同价值的培养过程,是社会融合的过程；社区建设是解决社会问题的手段和推动社会发展的重要的内容)作为重庆市人口老龄化对社区卫生服务体系的需求研究的基础理论,很好地从民生角度阐述人口老龄化对社区卫生服务的需求。课题实证研究部分,研究共抽取了重庆市1102名老年人,社会人口学特征：男女性别比为为1：0.78；平均年龄66.4岁；大部分老年人月收入在1000-5000之间；老年人总体文化程度水平低；基本医疗保险覆盖率高达92.82%。慢性病患病情况：慢性病患病率63.4%；慢病顺位前五位是：高血压、糖尿、冠心病、关节炎、慢性支气管炎；老年人慢性病危险因素logistic回归分析发现,年龄、婚姻、文化程度、居住状态、饮酒与老年人口患慢性病相关。择医行为：老年人最满意的医疗卫生服务机构是社区卫生服务站,患病后56.77%首选社区卫生服务机构；82.28%的老年人有患病未就诊的情况,患病而未就诊危险因素逐步logistic回归分析结果显示性别、工作情况、收入、医疗保障、吸烟、社会活动及自我保健方式对患病后是否就诊有影响。社区卫生服务知晓情况：在被调查的1102名老年人中,全部都知道自己家附近有社区卫生服务机构,知晓率100%；社区卫生服务机构提供的服务中,老年人最熟悉上门出诊(63.91%),最不了解慢性病管理(8.28%)；重庆市81.07%老年人对政府社区卫生服务政策不了解。社区卫生服务利用情况：过去一年中老年人最常去的是社区卫生服务站(46.35%)；45.05%老年人一年体检一次,29.3%的老年人从不体检；老人接受的社区预防保健服务主要是量血压。对社区卫生服务评价：大部分被调查者对社区卫生服务机构满意,社区卫生服务机构设施、环境差最容易使老年人产生不满意。社区卫生服务需求：重庆市老年人口希望社区卫生服务机构提供的服务主要是提供固定的全科医生、上门出诊、建立家庭病床等；绝大多数受访老人认为老年人口社区服务应当由政府负担费用。重庆市社区卫生服务机构对老年人口服务提供的现状：重庆市大多数社区卫生服务中心均提供双向转诊(94.24%)、法定节假日接诊(92.91%)等服务,而临终关怀(17.99%)、家庭病床(32.86%)、家庭康复(32.86%)等老年人喜闻乐见的服务提供者很少；社区卫生服务提供的服务内容与医院非常雷同。重庆市老年人口获取社区卫生服务的主要障碍是：被医疗保障制度所排斥、卫生资源对老年人口不公平的分配、老年人口社区卫生服务的高需求与低利用。在分析障碍的基础上,提出了重庆市老年人口社区卫生服务体系框架的构想：明确政府职责(政府主导、多部门联合参与、完善投资机制)；建设重庆市老年人口社区卫生服务体系(建立以社区为中心的老年服务体系,加快社区老年服务建设；建立健全重庆市老年人口社区卫生服务网络；强化老年人口社区卫生的全科医疗服务；建立老年人口社区卫生服务机构与医院、预防保健机构的分工合作机制,逐步建立双向转诊制度；培养老年人口社区卫生服务的队伍)。本研究探讨了重庆市老年人口医疗保障制度改革取向,本研究还提出建立和完善老年人口社区卫生服务的政策体系：制定社区老年卫生服务规划、加大社区老年卫生服务建设投入、老年人口社区卫生服务发展的动力是体制和机制创新(培育社会力量参与社区卫生服务、在社区率先推行基本药物制度等改革措施、推行“公共卫生服务包”制度、开展“创富老年”行动、增加社会保障支出预算、大力发展老龄产业)、老年人口社区卫生服务的基础是卫生服务队伍建设。结论：1.理论研究每个社会的政治制度、文化形态决定了政府的管理体系,以及与政府管理体系相适应的社会分工基本组织结构形式,塑造了在特定管理环境下的管理者和被管理者的思想及行为方式。本研究提出从制度与文化角度来审视和构建老年人口的社区卫生服务体系。2.实证研究①老年人口是重庆市社区卫生服务机构的服务重点。②需要应进一步提升老年人口对社区卫生服务利用率,老年人口对社区卫生服务功能认识不足。③老年人口社区卫生需求项目和实际利用项目存在较大差异。④老年人口对重庆市社区卫生服务机构较为满意,不满意之处主要是设备、环境及技术水平。⑤供需双方需进一步提高对社区卫生服务的认识程度,政府应加强对社区卫生机构的政策指导,加大资金投入力度,把老年人口的预防、保健真正提到议事日程。3.构建重庆市老年人口社区卫生服务体系在理论研究与实证研究的基础上,通过对老年人口获取基本卫生服务的主要障碍进行分析,研究提出构建重庆市老年人口社区卫生服务体系框架。明确提出完善老年健康服务的社会保障机制；构建完善的老年人口卫生服务体系；加大对老年卫生服务体系的公共财政投入；加强社区卫生服务体系的老年卫生人才队伍建设；实施与社区建设同步发展的重庆市社区卫生服务体系运行、管理机制等政策建议。本研究的创新之处1.本研究提出从制度与文化角度来审视和构建老年人口的社区卫生服务体系。2.本研究提出社区建设与社区卫生服务同步发展的理念。更多还原

【Abstract】 The aging of population is an important mark of social civilization, national industrialization and modernization, and also a manifestation of social progress, and improvement of people’s health and living standards. As the universal rule, the demand for medical care service increases with the rise in age and fall in health. To guarantee "a healthy old age", we must make great efforts to deal with the challenging issues such as medical care service, economic support, life care, and spiritual consolation.Objectives:The community health service is the basic link of primary health care for every person which is the significant implementation of the concept of social development in a scientific, humane, righteous, stable and harmonious way. The target of community health service is the aged people, so population aging affects the community health service substantially. As China grows stronger, the community health service system will be accomplished, and government will play a leading role for the establishment of a system with proper rules and mechanism to guarantee an effective, economic, and convenient medical care service for every single aged person in China.This research is aimed to provide ideas to build a blueprint of the community health service for the aged people in Chongqing so as to promote the local economic development for the contribution to a harmonious society. Methods:This research is the core of the soft science project of Chongqing Science and Technology Commission’s "A research of the Demand for the Community Health Service System by the Aging of Population in Chongqing" and the core of the project of Chongqing education commission "A Research of the Mechanism in the Synchronized Development of Both Community Construction and Community Health Service System in Chongqing City". It is also one part of the Chongqing Development and Reform Commission’s project "A research of the Experimental Reform of public Hospitals in Chongqing City". The research methods mainly include literature review, field investigation, normative analysis and interview.Result:The theoretical part of this research explores from diverse subjects such as management, sociology, demography, and economics. This research is theoretically based on the system and culture, and takes the new public service theory (the government management can get effect only if we stress the people-oriented theory and people’s livelihood; the responsibility of government meeting reasonable demand of citizens to the utmost extent; to stress the service awareness of government, to strengthen the service functions of government; to emphasize the power and legality of public administration is derived from public, public satisfaction is the final standard of judgment for public administration), the bottom-line equity theory(the aged people can get the most basic social protection by means of basic living allowance and health insurance which are the responsibilities of government. The bottom-line equity is a response to the principled request of livelihood construction, and ensures that the public get the profit of livelihood construction which is consistent with the development of economic and society. That’s the Primary responsibility of government, and the bottom-line of government’s responsibilities.), the filial piety of Chinese traditional culture (the caring and concern of aged people is helpful to overcome the challenge of aging population. Advocacy of filial duty and filial piety is one of the best ways to harmonious society. Carrying forward the filial piety of Chinese traditional culture can help us to face the challenge of the aging of population in our country and promote the construction of a harmonious society.), the people’s livelihood theory (speeding up socialist construction with the improvement of people’s livelihood as its focus is a major strategic task brought forward from the seventeenth national congress of the Communist Party of China. Improvement of people’s livelihood and social welfare, and all aged people getting physical care and respect are the important content of a harmonious society in China.) and the community development theory (The construction and development of community is a process of cooperation, negotiation and amalgamation of all social departments. The construction of community is a method of solving social problems, and it is an important element of promoting social development.) as theoretical basis for the research, this paper expatiates the demand for community health service system by the aging of population in Chongqing from the perspective of livelihood.In the empirical research,1102 aged people in Chongqing were sampled. The sex ratio of the sample is 1 male:0.78 female, and the average age is 66.4 years. Most of the aged people have a monthly income of 1000-5000 yuan. The educational level of the aged people was generally low.92.82% of participants had basic medical insurance. The Situation of Suffering from Chronic Diseases:the prevalence rate was 63.4%, and the top five chronics were:hypertension, diabetes, coronary heart disease, arthritis and chronic bronchitis. The logistic regression analysis of risk factors of chronic diseases of aged people showed that the prevalence of chronic diseases was related to age, marital status, educational level, housing status and alcohol. The Selection of Medical Care Service:the most satisfactory health care institution was community health service station.56.77% of patients preferred community health service because the community health service was close to their home, the cost was lower than hospital, and the service is good.82.28% of the aged people avoided seeing a doctor when they were ill. The logistic regression analysis of risk factors of avoiding seeing a doctor showed that they were related to gender, job, income, medical assurance, smoking, social activity and individual health care method. The awareness of community health service:All of the 1102 aged people were aware of the community health service centers near their home. Visiting a patient at home was the most familiar community health service (63.91% of aged people were aware of visiting a patient at home). Chronic disease management was the most unfamiliar community health service (only 8.28% of aged people were aware of chronic disease management).81.07% of aged people in Chongqing were not familiar with the policy of community health services. The utilization of community health services:the number one medical institution used by the aged people last year was the community health service station (46.35).45.05% of aged people had physical examination once a year.29.3% of aged people never had a physical examination. The community preventive health care services received by the aged people were mainly blood pressure tests. The appraisal of community health service:most of the aged people were satisfactory with the community health service institution. The defect of facility and the dirty environment of community health service institution most likely made the aged people unsatisfied. The demand of community health service:Some of the aged people in Chongqing wanted the community health service institution provide aptotic general practitioner, some of them wanted the community health service institution visit a patient at home, some of them wanted the community health service institution to establish family sickbed. Most of the aged people thought that the cost of community services of aged people should be paid by the government. The current situation of community health service for the aged people in Chongqing:Most of the community health service centers (94.24%) provided the services of two-way transfer of patients and treated patients in statutory holidays. But few of the community health service centers provided the services demanded by the aged people such as terminal care (17.99%), home-ward (32.86%) and home rehabilitation care (32.86%). The services provided by community health service centers were similar to those by hospitals.The major obstacles for the aged people to obtain community health service:Aged people are excluded by medical insurance system. the distribution of health resources to aged people is unfair. The demand of community health services for aged people is high, and the utilization is low. Ideas of the framework of community health services for aged people in Chongqing are proposed based on the analysis of the obstacles. The responsibility of government must be clarified (Government should be the leader of community health services. Diverse departments should take part in the community health services system. The investment mechanism should be improved.) The community health service system for aged people in Chongqing should be built. (The service system centered on community for aged people should be built to accelerate the construction of community services for aged people. the network of community health service for aged people should be built and improved. The general medical services for aged people in community health service should be strengthened. The mechanism of cooperation and division of health care between community health service centers and hospitals or disease prevention institutions should be built. The two-way transfer system should be established progressively. Community health service medical workers for aged people should be trained.) This research explored the reform orientation of medical security system for aged people in Chongqing. This research also proposes the policy system to establish and improve community health service for aged people and plans the community health service for aged people to increase investment in construction of community health service for aged people. The propulsion of development of community health service for aged people is innovation of system and mechanism. (Social sectors should be mobilized to take part in community health service. Community should take the lead in implementing reform measures such as essential drugs system. The Public health service package should be introduced. The action of creating wealth in old age should be advocated. The budget of social security expenditure should be increased. The industry for the elderly should be developed vigorously.) The basis of community health service for aged people is the construction of the health service team workers.Conclusion:1. Theoretical researchThe political system and cultural type of every society determine the management system of government and the basic organizational structure of social division of labor which is compatible with the system. And the political system and cultural type of the society shape the mode of thinking and behavior of supervisor and supervisee in the specific management environment.This research introduces a way to survey and build the system of community health service for aged people from the institutional and cultural perspective.2. Empirical Study①The aged people are the focus of community health service in Chongqing.②It is necessary to help the aged people to understand the function of community health service so as to increase the utilization of the facilities.③The health projects in use are quite different from what are demanded by the aged people.④The aged people are comparatively satisfied with the community health service institutions in Chongqing. Dissatisfaction lies mainly in the equipment, environment, and professional skill level.⑤Both sides of supply and demand should deepen the understanding of community health service. Government should reinforce the policy guidance of community health service institutions, and increase the investment, and put the prevention and health care of aged people on the agenda.3. Establishment of community health service system for aged people in ChongqingThis research introduces the way to build the framework of community health service system for aged people in Chongqing through the analysis of the major obstacles of aged people in getting basic health services on the basis of theoretical and empirical study. This research put forward suggestions as follows:The health service for aged people in social security system should be improved. A complete health service system for aged people should be established. The public financial investment in health service system for aged people should be increased. The medical workforce in the community health service system for aged people should be strengthened. The mechanism of synchronized development of community health service system with community construction should be implemented in Chongqing.Innovations in the research1. This research introduces a way to survey and build the system of community health service for aged people from the perspective of political system and historical culture.2. This research advocates the concept of synchronized development of community construction with community health care services.更多还原