【作者】 樊宏；

【导师】 卢祖洵；

【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

【副题名】基于中国社区卫生服务体系建设26个重点联系城市的实证研究

【摘要】 研究目的发展社区卫生服务是我国医疗卫生体制改革的重要突破口,也是体现政府维护人群健康责任的最佳切入点。我国的社区卫生服务自引入以来,服务功能不断完善、服务质量不断提高,呈现出良好的发展势头。但在客观上,由于各地经济水平的制约,导致我国的社区卫生服务发展极不均衡。总体来看,卫生资源较丰富的高收入城市对社区卫生服务的需求较少,但可利用的社区卫生资源却较多,而卫生资源较缺乏的中、低收入城市对社区卫生服务的需求较大,但可利用的社区卫生资源反而较少,这不利于我国社区卫生服务的健康可持续发展,也不利于人群健康公平性的实现,但纵观国内外文献,专门针对这一问题的研究非常匮乏。另外,从研究内容上来说,目前大多数研究均是关于居民对社区卫生服务需求与利用层面上的,对资源配置、供给效率、服务质量、居民满意度等方面的研究较少。从方法学上来说,也较多采用简单统计描述的形式进行比较分析,应用多种数理统计方法与综合评价方法相结合的研究少之又少,从而造成大多数研究浮于表面,流于形式,无法真正起到辅助社区卫生决策的作用。针对上述问题,一方面,本研究试图在对中国不同经济发展水平城市的社区卫生服务进行形势分析及综合评价的基础上,找出不同经济发展水平城市社区卫生服务发展过程中所存在的主要问题及原因,进而探讨适应不同经济发展水平城市的社区卫生服务机构可持续健康发展的管理机制和运行体制,以促进我国社区卫生服务的均衡发展。另一方面,本研究也旨在为社区卫生服务的深入研究提供可借鉴的方法学基础和建议,不断提升我国社区卫生服务研究的理论水平,夯实社区卫生服务体系建设的实践基础,并最终形成功能完善的社区卫生服务体系框架。研究方法本研究综合应用了多种分析方法对不同经济发展水平城市的社区卫生服务进行了科学全面的深入分析：①采用描述性研究与分析性研究相结合的方法对不同经济发展水平城市社区卫生服务的资源配置、服务质量、供给、利用与满意度情况进行了系统全面的形势分析；②采用洛伦茨曲线和基尼系数对不同经济发展水平城市社区卫生服务资源配置的公平程度进行评价；③采用文献研究、专家论证、变异系数、相关系数、聚类分析等方法筛选不同经济发展水平城市社区卫生服务质量的综合评价指标；④采用主成分分析法确定不同经济发展水平城市社区卫生服务质量以及社区卫生服务利用者满意度的评价指标权重；⑤采用数据包络分析法研究不同经济发展水平城市社区卫生服务的供给效率；⑥采用加权Topsis法、加权秩和比法以及二者的模糊联合法综合评价不同经济发展水平城市的社区卫生服务质量；⑦采用模糊综合评价法评价不同经济发展水平城市社区卫生服务利用者的满意度；⑧采用单因素分析与Logistic回归分析、最优尺度回归分析相结合的方法研究不同经济发展水平城市社区卫生服务利用与满意度情况的影响因素。研究内容为评价不同经济发展水平城市的社区卫生服务发展状况,本研究对26个重点联系城市的全部社区卫生服务机构进行了调查分析。其研究内容主要包括：①不同经济发展水平城市社区卫生服务机构的资源配置情况：包括社区卫生服务机构人、财、物等资源配置的平均水平以及按人口配置的公平程度；②不同经济发展水平城市社区卫生服务机构的服务质量情况：包括服务质量评价指标的筛选、指标权重的确定、服务质量的综合评价；③不同经济发展水平城市社区卫生服务的供给情况：包括社区卫生服务机构基本医疗服务供给情况、公共卫生服务供给情况、供给效率；④不同经济发展水平城市社区卫生服务的利用情况及其影响因素：包括社区卫生服务利用者的社会人口学特征、社区卫生服务利用者最近一年利用社区卫生服务机构的次数、在社区卫生服务机构接受卫生服务的类型、在社区卫生服务机构的就诊类型、以及利用情况的影响因素；⑤不同经济发展水平城市社区卫生服务利用者的满意度情况及其影响因素：包括社区卫生服务利用者对社区卫生服务机构各分项目的满意度、对社区卫生服务机构的总体满意度及其影响因素。研究结果研究表明,不同经济发展水平城市的社区卫生服务机构在完善城市卫生服务体系、弥补卫生资源不足、方便群众就医等方面均发挥着适宜的补充作用,但同时也存在诸多问题。本研究的主要结果包括：①不同经济发展水平城市社区卫生服务机构的人、财、物等资源的平均水平存在显著差异(P<0.05),且医护比倒置、学历和职称结构不合理以及收支状况不理想等现象普遍存在；但不同经济发展水平城市社区卫生服务机构的人、财、物等资源按人口配置的公平程度均处于较好水平,除社区卫生服务中心固定资产总额的基尼系数超过0.30以外,其余各项社区卫生服务资源的基尼系数均在0.30以下,处于最佳的公平状态。②不同经济发展水平城市的社区卫生服务中心服务质量由优到劣依次为：高收入城市、中等收入城市、低收入城市,社区卫生服务站服务质量由优到劣依次为：高收入城市、低收入城市、中等收入城市。③总体来说,高收入城市在提供基本医疗和公共卫生服务方面的服务理念及服务方式更加科学合理,服务功能定位也较为准确。而中、低收入城市仍延续着外延式发展的模式,过多地将注意力集中在追求直接的经济利益上,违背了社区卫生服务最初的功能定位；在供给效率方面,5个高收入城市的社区卫生服务中心相对服务效率全部为1,11个中等收入城市中只有南昌、武汉、天津、银川的社区卫生服务中心相对服务效率为1,10个低收入城市中只有兰州、西宁、阳泉的社区卫生服务中心相对服务效率为1；不同经济发展水平城市中各有1个城市(杭州、南昌、焦作)的社区卫生服务站的相对服务效率为1。④不同经济发展水平城市社区卫生服务机构的利用与满意度状况各不相同(P<0.05),影响因素也存在差异。其中高、中、低收入城市的社区卫生服务利用者满意度得分分别为75.38分、73.93分、76.01分,均处于“满意”与“一般”之间。政策建议社区卫生服务是一项比较复杂的社会工程。只有在政府大力扶持和各个相关部门之间协调配合的基础上,大力促进社区卫生服务的资源建设和内涵建设,不断提高其服务质量,社区卫生服务才能惠泽于民,为解决老百姓“看病难、看病贵”问题做出应有的贡献。针对不同经济发展水平城市社区卫生服务的研究结果,本研究提出了以下几点政策建议：①不同经济发展水平城市的政府均要为社区卫生服务的发展提供良好的政策环境,同时也要针对其出现的负面因素加强监管；②不同经济发展水平城市社区卫生服务机构的规划设置应结合当地的实际情况,因地制宜,合理配置,避免盲目扩张现象的出现；③不同经济发展水平城市的社区卫生服务机构均需注重内涵建设,全面提升服务质量,同时也应加强与其他各级医疗卫生服务机构的协作,提高其作为医疗卫生服务供给方的运作活力。研究的创新点1.在研究视角和研究思路上,首次将中国社区卫生服务体系建设26个重点联系城市按照经济发展水平划分为不同类别的城市,并对其社区卫生服务机构的资源配置、服务质量、供给状况以及利用和满意度状况逐一进行了全面、系统、客观的形势分析与综合评价,特别是在社区卫生服务质量的分析中,较为全面地透视了反映社区卫生服务质量的各个维度。2.在研究方法上,将多种数理统计和综合评价方法应用于社区卫生服务的研究中,对不断提升我国社区卫生服务的理论水平有着重要的借鉴意义。不足之处与需要继续开展的研究由于纳入本研究的对象均是国务院确立的社区卫生服务体系建设的重点联系城市,其工作基础好,创新意识强,社区卫生服务建设的总体水平领先于全国的平均水平,虽然这部分城市的研究结果和结论对我国目前社区卫生服务网络体系的不断完善有重要的借鉴意义,但为了提高研究结果的普及性及国际视角的可比性,尚应进一步将工作基础薄弱、社区卫生服务开展情况不理想的城市纳入研究,这也是我们下一步研究工作的重点。更多还原

【Abstract】 Research PurposesTo develop community health services is important to Chinese health care system reform, and is also the best starting point for China’s government to maintain the population health. Since the introduction of community health services in China, the services functions and qualities have been improved continually and taken on a good prospect. However, objectively speaking, due to the constraints of economic levels, the development of community health services is uneven in different regions. Overall, the community health resources are more in the high-income cities with abundant health resources, but the situation in low-income cities is opposite, although less health resources for the low-income cities. The infernal circle is neither conducive to the sustainable development of community health services in china nor conducive to the whole population to achieve health equity. But to date such evidence from large samples has remained scarce on this issue.In addition, as for the research contents, the majority of studies were currently on needs and utilization of the community residents, but there was a lack of studies on the resource allocation, supply efficiency, service quality, satisfaction of community health services. As for the research methodologies, the results were most described with simple comparative methods, but the combination of various mathematical statistics and comprehensive evaluation methods were little used. Therefore, most studies were superficial and could not play a supporting role for decision-making departments of community health services.To aim at above-mentioned problems, on the one hand, based on the results of situation analysis and comprehensive evaluation on community health services in different cities, this study was intended to search for the main problems and further to explore the management and operation mechanism of community health services adapted for different cities with different economic levels. On the other hand, this study also aimed to provide the reference and recommended methodological basis for further research on community health services, in order to continuously improve theoretical level of community health services research and to reinforce the practice basis of the construction of community health services system. Ultimately, it is to formulate the functional framework of community health services system in China and to promote the balance of community health service development.Research MethodsA variety of methods were used in this study:①the descriptive and analytical methods were used for situation analysis of community health services in different cities with different economic levels, mainly on the resource allocation, service quality, supply, utilization and satisfaction;②Lorenz curve and Gini coefficient were used to evaluate the fairness of community health resources allocation in different cities with different economic levels;③literature study, expert evaluation, coefficient of variation, correlation coefficient, and cluster analysis methods were used to screen the indicators of comprehensive evaluation on quality of community health service;④principal component analysis was used to determine the weights of indicators;⑤data envelopment analysis was used to study the supply efficiency;⑥the weighted topsis method, the weighted RSR method, and the two combined fuzzy methods were used to comprehensively evaluate the quality of community health services in different cities with different economic levels;⑦fuzzy comprehensive evaluation method was used to evaluate the community residents’satisfaction;⑧the combination methods of single factor analysis, Logistic regression analysis and optimal scaling regression analysis were used to indentify the influencing factors of utilization and satisfaction of community residents.Research ContentsTo evaluate the development status of community health services in different cities with different economic levels, we conducted the survey on the community health facilities of 26 key contact cities. The research contents included:①status of resource allocation:including the average level and the fairness of the allocation of community health resources, such as human, financial, and material resources;②quality of community health services:including screening of indicators, determination of weights and comprehensive evaluation of services quality;③the supply situation:including the supply situation of the basic medical and public health services in community health facilities, and the supply efficiency;④the utilization and the influencing factors:including the social-demographic characteristics of community resident, and as for the community residents, the times to go to the community health facilities last year, the type of services in community health facilities, the attendance type in the community health facilities, and the influencing factors of utilization status;⑤the satisfaction status and the influencing factors:including the satisfaction on sub-item services, the overall satisfaction of community residents and the influencing factors of satisfaction status.Research ResultsThe study results showed that the community health facilities of different cities with different economic level played the complementary role to improve the urban health system, to make up for the deficiency of health resources and to improve the community residents’access to medical services. The main results of this study included:①there were no significant differences in the average level of community health services resources (P<0.05). The doctor-nurse ratio was opposite to the ideal ratio; the structure of educational levels and professional title was irrational; and revenue and expenditure situation was also not ideal; but the allocating fairness of community health resources by population was in good situation.Except the Gini coefficient of total fixed assets in community health centers was above 0.30, the rest Gini coefficient of the community health resources were below 0.30 which indicated in the best condition.②the services of quality in community health centers from superior to inferior as follows:high-income cities, middle-income cities, low-income cities; the services of quality in community health stations from superior to inferior as follows:high-income cities, low-income cities, middle-income cities.③overall, it is more scientific and reasonable of services concepts and services manners of community health facilities in high-income cities in providing basic medical and public health services with more accurate positioning of service functions, while the community health facilities in middle and low-income cities were still focus on economic benefits and still insisted on the scale model that violated the nature functions of community health services; the relative supply efficiency of community health centers in all five high-income cities were 1; among 11 middle-income cities, relative supply efficiency of community health centers in Nanchang, Wuhan, Tianjin, Yinchuan were 1; among the 10 low-income cities, relative supply efficiency of community health centers in Lanzhou, Xining, Yangquan were 1; in every type of city, relative supply efficiency of community health stations in only one city (Hangzhou, Nanchang, Jiaozuo) were 1, respectively.④utilization and satisfaction of residents in different cities with different economic levels were different (P<0.05), and the influencing factors were also different. The community residents’satisfaction score in high, middle, low-income cities were 75.38 points,73.93 points, and 76.01 points, respectively, all between in the "satisfactory" and "general" situation.Policy suggestionsCommunity health services, as a complicated social project, must base on the government’s support and co-ordination of various sectors, and must enhance the resources and connotation construction and improve the quality of services. Only in this way, can community health services benefit the public and address the problem of "to access medical treatment is difficult and expensive".From the research findings, this study proposed the following policy recommendations:①the local government must provide a good policy environment for community health facilities, meanwhile should pay much more attention on strengthening the regulation targeting to negative factors;②community health facilities should be organized and established according to local conditions, avoiding blind expansion phenomenon;③community health facilities should be focus on quality improvement, as well as collaboration with other medical and health facilities.The innovation of the study1. As for the research perspective and ideas,26 key contact cities were divided into three different categories in accordance with the economic level in this study for the first time, and we conducted a comprehensive, systematic, objective and in-depth research on the resource allocation, quality of services, supply, utilization and satisfaction condition of the community health facilities. Particularly in the quality analysis, this study reflected the various dimensions of the quality of community health service.2. As for the research methods, we compared the community health services in different cities with a variety of mathematical statistics and evaluation methods with aim at providing the methodological basis for the future in-depth research on community health services.The limitations and the further study suggestionsAs a result of restrictions on raw data, the research subjects were all the key contact cities with good work basis and strong sense of innovation, so the overall level of development status of community health services was ahead of the national average level. Although the findings of these cities could provide the references for the present system construction of community health services network, in order to enhance the popularity of the findings and the comparability with the international perspective, there should be further studies on the community health services in cities with weak work basis and poor development situation, which would be the subject of research focus of the next step.更多还原