【作者】 诸爱囡；

【导师】 李俊伟；

【作者基本信息】 浙江大学 ， 社会医学与卫生事业管理， 2004， 硕士

【摘要】 研究背景 随着社会经济的发展，医学模式的转变，导致卫生服务发生了人口结构与疾病谱及健康需求的转变，社区卫生服务正是适应这一变化而产生的一种以满足基本卫生服务需求为目的，融预防、医疗、保健、康复、健康教育和计划生育指导等服务为一体的，有效、经济、方便、综合、连续的基层卫生服务。然而社区卫生服务在我国刚刚起步，特别是农村社区卫生服务更是在初步探索中，社区卫生服务运行过程中有待于解决和研究的问题还很多。至今，对农村社区卫生服务的研究仍停留在对现状的描述性研究，尚缺乏综合系统的评价。丁桥镇于2001年开展了农村社区卫生服务试点，采取了三个互相结合的改革措施：与乡村卫生组织一体化管理相结合、与农村合作医疗相结合、与乡镇卫生院功能转型相结合。至今已积累了比较丰富的实践经验，为系统评价改革的成效提供了丰富的材料。研究目的 本研究阐述了丁桥镇社区卫生服务改革的主要措施，总结了丁桥镇农村居民对社区卫生服务的需求特征，通过对需求与利用的拟合分析和卫生服务的现状研究，评价丁桥镇社区卫生服务改革的实际成效，并针对社区卫生服务开展以来的成功经验和暴露的问题，提出进一步的改革措施。浙江大学硕士学位论文丁桥镇农村社区卫生服务改革研究研究方法 采用问卷调查法，社区居民采取抽样法，职工采取普查法，患者采用偶遇调查法。改革的具体方案、当地社会经济发展状况、丁桥镇卫生资源等情况，依据区卫生局、镇政府和乡镇卫生院的存档资料完成。调查内容主要包括:居民的一般情况、健康状况和卫生需求及利用的情况、丁桥镇社区卫生服务改革的具体操作方案、村卫生室和社区卫生服务中心及站点从2000一2002年的卫生资源和利用效益、职工民意和患者满意度。 通过居民对社区卫生服务的需求与利用的拟合分析及社区卫生服务改革前后在基础建设、服务能力、经济状况和社会效益等方面的纵向比较和尚存的村卫生室与已建的社区卫生服务站之间的横向比较来评价社区卫生服务改革的实际成效。调查数据资料使用SPSsl 1.0统计包进行分析，采用t检验、方差分析、卡方检验等统计方法处理。研究结果 共1134名居民完成了健康调查，6家村卫生室和2家社区卫生服务站及1个社区卫生服务中心全部完成调查，30名职工完成民意调查，70名就医患者完成满意度调查。 改革的主要内容:①社区卫生服务与乡村一体化管理相结合②社区卫生服务与合作医疗相结合③社区卫生服务与镇卫生院功能转型相结合 改革后居民对社区卫生服务的需求与利用情况:①需要与需求:居民两周患病率略高于全国农村平均水平;愿意到市级医院以上就诊的为25.4%，选择在社区卫生服务机构就诊比例为63.9%;在服务功能选择上，44.1%的居民要求以诊疗为主;选择门诊的占93.2%;有21%的居民选择需要全科医生。②利用与供给:两周就诊率略低于全国农村平均水平;医疗服务占64.24%，其次是预防接种占15.98%，再次是老年保健和健康教育分别占7.67%和6.93%;门诊服务占84.81%，上门服务只占2.90%，而家庭病床尚未开展;尚无正规的全科医生，其中参加全科医生岗位培训的有4人。 改革后社区卫生服务机构的改善程度及尚存在的问题:①基础设施增加:社区卫生服务站建筑面积扩大到3倍，医疗设备投资增加了9倍:社区卫生服务中浙江大学硕十学位论文丁桥镇农村社区卫生服务改革研究心用于医疗设备的投资也增加了1.57倍:在患者满意度的调查中，87.4%认为社区卫生服务站的就医环境较好。②服务能力提高:改革前后社区卫生服务中心的年门诊人次增加0.77倍;社区卫生服务站的年门诊人次增加2.03倍;服务内容增加，服务形式多样化;大多数职工认为社区卫生服务改革后总体服务能力明显提高。③经济效益增加:业务结余逐年增加，特别是社区卫生服务站的业务结余实现了从零到5万的大幅增长;社区卫生服务中心职工的经济收入由原来的年收入2.66万元提高到4.35万元，增长63.2ry0;④社会效益扩大:在改革期间三年中，次均门诊费用及其药费保持稳定，在一定程度上相对减轻了患者的医疗负担;80.5%的门诊病人在社区卫生服务机构就诊，只用去了近1/2的门诊费用;87.4%认为社区卫生服务站的就医环境较好，79.2%表示对社区卫生服务站就医方便比较满意，72.7%表示对社区卫生服务站的服务态度比较满意。⑤医生水平较低:丁桥镇卫生人员的学历比较低，本科及以上学历的比例极低，而中专和无学历的人数分别占36%，39%;整个一厂桥镇卫生机构医务人员中副高及以上职称人数为零，中级比例也是极少数，初级比例却接近80%，村卫生室卫生人员全部无职称。结论 本课题研究的结果证明丁桥镇社区卫生服务改革在总体上是成功的。其中社区卫生服务与乡村一体化相结合、与合作医疗相结合、卫生服务功能调整方面所采取的方法是适宜的，值得在今后的社区卫生服务改革实践中运用和推广。调查也显示改革后社区卫生服务的开展与居民的卫生服务需求有较高的吻合度，但在卫生服务质量方面更多还原

【Abstract】 BackgroundsWith economic development and transformation of medical model, come the transit of population structure, disease spectrum and health demand. People need prevention, health care, recovery, etc, other than treatment. To adapt to these changes, the community health service (CHS) is developing. It intents to resolve the main health problem and meets the essential sanitary needs. CHS has six functions: prevention, health care, medical treatment, recovery, health education and family planning. It is effective, economical, convenient, integrated and continuous. However CHS is at it’ s infant phase, especially in Chinese countries. There are still many problems in CHS need to be resolved.Till now, a study on rural CHS is still on the status of description, lacking of general assessment. In 2001 CHS was put into practice in Dingqiao town. Four main measures are taken: associating with the cooperative management system of health organization in town and country, with the medical insurance system, with the reform of township hospital and the training of general practitioner. Thus many valuable original data and experience were accumulated, and were used in this studyObjectivesThe aim of the study was to summarize the method of Dingqiao CHSreform and residents demands for health service, to evaluate the anastomosed degree between demand and utilization, to assess the achievement of CHS reform by compare the result after and before reform. Finally, some suggestions were bring forward for implementing CHS better.MethodsParts of residents in five countries, all staffs of CHS organizations and some occasional patients were investigated. Five questionnaires were designed. The residents completed the health questionnaire which including residents general characters, health problems, demand for health service and utilization of health service. The CHS organizations managers completed the CHS reform questionnaires including the medical resources, health service, it’ s economic and social benefits of utilization from 2000 to 2002 and so on. The medical staff completed the opinion questionnaires and the patients completed the satisfaction questionnaires. The reform methods, the socioeconomic condition of the town and the medical resources of the town were gotten from Sanitary Bureau of JiangGan Section, town government and township hospital.By analysis on the anastomosed degree between demand for CHS and CHS utilization or by longitudinal and transverse contrast in basic construction, health service ability, economic running and social benefit, the achievement of the reform was evaluated.In the data analysis, T-test, variance analysis and chi-square test were used in SPSS 11.0 for Windows.ResultsTotally 1134 residents, 6 village clinic, 2 CHS station, 1 CHS center, 40 staffs, 70 patient were interviewed.Reform content: (1) integration of CHS and Town-village integrative management, (2) integration of CHS and cooperative medical care system, (3) Adjustment of CHS functions.The residents Demands and utilization of CHS after the reform: 漏 Demands: Biweekly sicken ratio of the residents is slightly higher than the countrywide average level. 25. 4% of patients are willing to go to city-class hospitals, 63. 9% are willing to go to CHS organizations; 44.1% of the residents have their medical demands as diagnosis and treat; 93. 2% of the patients choose outpatient service; 21% need general practitioner (2) Utilization: Biweekly treat ratio is slightly lower than the countrywide average level; medical treatment account for 64. 24%, vaccination account for 15.98%, the aged health care account for 7.67%, health education account for 6. 93%; clinic service account for 84. 81%, visiting service account for 2.90%, no family sickhed exists; no formal general practitioner enrolled there, only 4 doctors attended the family medicine training.Improvement of the CHS organization after reform: 漏increase of the basic establishment building: the acreage of CHS station doubled, the medical equipment更多还原