【作者】 郭足平；

【导师】 严非；

【作者基本信息】 复旦大学 ， 社会医学与卫生事业管理， 2011， 硕士

【摘要】 研究背景：我国仍是全球22个结核病高负担国家之一,同时也是全球27个耐多药高负担国家之一。2001-2010年,我国肺结核报告发病人数始终位居全国甲乙类传染病报告发病数的前列,每年新发耐多药肺结核患者数约为12万。为了减少和防止慢性传染源和多种耐药病例发生,卫生部举办结核病归口管理会议,建立了从国家到省(自治区、直辖市)、地(市)、县(区)的结防机构,要求综合医院将结核病人转到当地结核病防治所。上海市结核病防治工作在历届政府的重视和领导下,疫情控制效果一直在国内处于前列。进入20世纪90年代,随着结核病在全球的“死灰复燃”,上海的防疫形势也极为严峻。随着外来人口增多,城市化进程加快,老龄化时代到来,给上海市结核病疫情控制带来了挑战。1998年,上海市按照预防归口、网络统一、机构整合、综合管理的原则,对结核病防治机构进行了改革,构建了市、区(县)、社区三级结核病预防控制网络,实施疾病预防控制中心、结核病定点医院、社区卫生服务中心“三位一体”的新的防病模式。人力资源的状况直接影响各地结核病防治工作的质量。人力资源与经费是结核病防治可持续发展的重要因素,但多数结防机构领导和卫生行政部门领导重于强调经费不足,忽略人力资源；重视人员数量,忽视人员质量。随着我国结核病防治工作向纵深发展,人力资源的制约作用愈加突出,加强结核病防治的人力资源发展迫在眉睫。研究目的：通过研究示范区“三位一体”结核病防治模式下人力资源现状,即从人员设置、数量、结构、培训、考核、激励、工作满意度、工作稳定性等方面进行分析,发现人力资源配置中存在的问题,探讨影响人力资源配置的因素,为完善结防人力资源配置提供参考依据。研究方法：1.文献收集及评阅：查阅中国期刊网、OVID等数据库,中国疾病预防控制中心网站以及google等搜索引擎,收集相关文献资料：对资料进行归纳总结分析；2.现有政策文件评阅：收集2005-2009年上海市社会经济状况、结核病防治网络(疾病预防控制中心、结核病定点医院和社区卫生服务中心)现有政策文件、常规报表资料、现有研究报告、工作总结等；主要使用Excel软件进行对结防人员基本情况描述性分析；3.定量研究：通过机构调查表、结防人员满意度调查表收集结防人员配备情况、工作满意度情况、结防工作开展情况；通过Excel对机构调查表中人员学历、职称结构及工作量情况等指标进行统计学分析；利用统计软件SPSS13.0的描述性统计部分的频率、交叉表等过程对结防人员的基本特征、结防人员的满意度情况进行描述,并进行非参数检验；4.定性研究：采用访谈提纲对知情人进行个别深入访谈,了解网络运行、机构设置、人员设置、工作开展及负担、培训、考核、激励、流动等情况；用框架分析(Framework Analysis)法进行分析,即列出分析框架,对所有访谈内容进行编码,再进行类属分析与归纳综合,进行深入分析。主要结果：“三位一体”防治模式不同于国家普遍实行的结防所模式,区级结核病工作由疾控中心和定点医院分担,通过对两者之问的功能分工,细化了各自的工作职责,实现了有效的医防合作。在该模式下,各机构根据具体承担的职能,对人力资源进行了合理配备,因岗设人,为结核病规范防治提供了有力的保障。近5年来,示范区结防人员总量稳中有增,人员数量从2005年的306人增长至2009年的637人,维持了结核病防治人力资源的稳定性,并保持了一定的可持续性,但参照《中国结核病防治规划实施工作指南》(2008年版),人员仍显不足。各区问人口特征、疫情不同,各级机构间人员实际工作效率、防治压力差别较大。结防人员以25～34岁年龄组人数最多,占34.3%；其次为35～44岁,占21.7%,人员相对年纪较轻。结防人员素质也不断提高,本科及以上学历占36.5%。结核病作为重大公共卫生疾病,但在多数定点医院领导对结防工作重视不够,未设置防保岗位,存在一定的安全隐患。定点医院结核门诊医生因病源少、执业范围狭窄及名额限制等原因导致晋升困难,影响个人发展,收入水平较低,该岗位缺乏吸引力,人员储备出现断层现象。社区防保岗位因工作负担重,收入水平低等原因也缺乏一定吸引力。示范区结防机构利用研讨会、培训班和讲座、工作现场督导、例会、专科进修等,开展了内容丰富、形式多样的培训。是否积极派遣人员参加培训纳入对各个机构的考核项目。通过各种培训,普及现代结核病控制新技术、新方法,提高结防人员素质,保证现代结核病控制策略的成功实施。但培训尚缺乏针对性。同时,社区卫生服务中心相关人员的培训一般由条线医生执行,其专业技能、领悟能力、表达能力影响到对全科团队的培训效果。为调动结防人员的工作积极性,各机构一般给予结防人员业务科室平均奖,发放额度高于行政部门,体现了一定的政策倾斜。但在定点医院及社区,结核病科室仍属于待遇偏低科室,定点门诊或防保科医生收入低于呼吸／内科医生或全科医生。同时,示范区参照国家对结核病工作的相关政策,给结防人员发放各类补贴,包括报病费、督导管理费、防疫津贴等,部分项目激励费发放额度高于全国水平,但仍与上海市经济水平不相称。目前绩效考核由卫生局组织,CDC牵头,逐步加大对各级医疗机构的考核力度。通过考核规范了部门的自我管理,确保了各项工作的有序开展,激发了员工的工作热情。但指标合理性存在一些问题。部分考核数量、考核指标设计漏洞致使难以达标,如治愈率、查痰率等,影响到指标落实。结防人员作为一线防治队伍,患肺结核的危险性明显高于其他卫生人员和普通人群。但定点医院门诊医生由于接触肺结核患者的频率较高,患病风险较大。同时由于公众意识较低,对肺结核患者仍有歧视现象,社区医生在访视患者过程中被要求脱掉隔离衣,不采取任何防护措施,给访视医生也带来安全隐患。结防医务人员的职业安全还没有引起足够重视。人员总体满意度较高；工作负担是影响结防人员满意度的首要因素,其次为薪酬。政策建议：1.优化人员配置标准,保证结防人员的适宜配置,减轻人员工作负担2.保证结核病防治队伍的可持续性,尤其是定点医院门诊及社区防保岗位3.开展培训需求和效果评估,提供更针对性的培训项目4.完善激励机制,提高报病督导等补助标准,注意发放频率和方式5.完善人员绩效评价指标体系,提高绩效考核在人员管理和服务质量方面的作用更多还原

【Abstract】 Background:China is still one of the 22 countries with highest burden of TB diseases and one of the 27 countries with heavy burden of MDR as well. From 2001 to 2009, the number of tuberculosis (TB) cases in the whole country ranked first in infectious diseases, the number of MDR case in newly-infectious TB patients is about 120 thousands each year.In order to reduce and prevent chronic infectious and multiple drug-resistant TB cases, TB prevention organizations from the state to county were established and TB patients were requested to refer to local TB dispensary.TB control work in Shanghai was in the top in China, but in 1990’s, with TB resurged with a vengeance, Epidemic situation in Shanghai was also serious. For the population increaseing, urbanization, aging population, TB control in Shanghai faced challenges. In 1998, according to the principle of prevention centralizition, network unity, institution integration, comprehensive management, the TB dispensary in Shanghai was reformed and the new disease control model was implemented.Human resources may affect the quality of the TB control work directly. While it might not be paid more attention comparing the financing by government officers or institution administrators. As the further development of TB control, it is necessary and urgent to improve the human resources for TB control.Objectives:To describe the current situation of human resource for TB control, to analyze the problems of allocaton, to explore the factors affecting human resources, and to provide evidences to improve the allocation of human resources for TB control in seven project districts under the new TB control model in Shanghai. Methods:1. Literature Review:Relevant literatures were collected, reviewed and summarized.2. Policy documents Review: Relevant policy documents of 7 project districts were collected and reviewed. Using Excel software to describe personnel information.3. Quantitative study: Investigation TB Human Resources situation and job satisfaction of staff were carried out applying questionnaires. Using Excel to analyse personnel education background, professional and title structure; using SPSS 13.0 to describe and anylyse characteristics and satisfaction of staff.4. Qualitative study:In-depth interviews were organized with policy makers, administrators of related institutions and health providers. The Framework Analysis was used.Key findings:Treatment and prevention were both emphased in the new TB model in Shanghai, which is differed from the general model practising in China. Staff was allocated according to the organization’s function.The number of staff for TB control in Shanghai increased steadily, from 306 in 2005 to 637 in 2009, but with reference to the Chinese TB control planning and implementation guideline (Edition 2008), staff is still insufficient.The staff was relative younger, aged from 25-34 accounted for 34.3%; aged from 35-44 accounted for 21.7%; quality of the staff was constantly enhanced, bachelor degree and above, accounted for 36.5%.TB is a major public health disease, but there was no specific prevention position in most designated hospital because of ignorision by their leaders. In Designated hospital, doctor position in TB outpatient department was unattractive, because of fewer patients that may lead to less clinic practice and may result in promotion difficulty. In Community Health Service Centers(CHSC), the prevention posts also lack of attraction for heavy workload and lower income.Training projects, such as lectures, seminars, job site supervision, meeting, advanced study, were carried out, which were in various content and forms. Through various training, new technologies and new methods were popularized and the staff quality was improved, but focused training need to be emphasizeed. In the meanwhile, personnel training in CHSC generally were carried out by the staff who in charge of TB management in CHSC, but their professional skills, understanding ability might influence the training effect.To mobilize staff enthusiasm, organizations generally given the TB staff the average income of clinic departments, higher than the administrative departments, which reflected certain policy tilt. But in designated hospitals and CHSC, doctors in TB department still had less income than the physician working in the department of respiratory or internal medicine. Meanwhile, the TB projects increased all kinds of subsidies, which was above the national level, but still dit not match the Shanghai economic level.Staff performance appraisal had strengthened step by step and the staffs working enthusiasm was inspired. But there were some problems on the index in performance appraisal.TB staff had higher risk in infecting tuberculosis than other health staff. Staff in department of outpatient in designated hospital had higher risk because the higher frequencies contacts with TB patients. In CHSC, staff had higher risk because they did not take any protective measures. Generally, the job satisfaction was good. It is needed to consider the workload and payment.Recommendations:1. Optimalise allocation standards for TB staff under the new TB control network2. Ensure the sustainability of TB staff, particularly doctors in deparment of outpatient in designated hospitals and doctors working on TB prevention in CHSC.3. Evaluation of training demand and training effects should be launched, focus training should be strengthened.4. The incentive mechanism should be enhanced, the level of motivation should be improved;5. Staff performance appraisal system should be improved.更多还原