【作者】 田淼淼；

【导师】 冯占春； 刘远立；

【作者基本信息】 华中科技大学 ， 社会医学与卫生事业管理， 2013， 博士

【摘要】 研究目的本研究以公共政策评估理论为指导，通过分析乡村卫生服务一体化管理政策的背景、发展历程，探寻政策问题，界定乡村卫生服务一体化管理内涵；通过分析西部地区农村卫生服务体系建设现状，确定乡村卫生服务一体化管理政策根本目标及目标体系；以目标为前提，提出乡村卫生服务一体化管理政策效果评估框架，并确定西部地区乡村卫生服务一体化管理政策效果评估指标体系，运用评估工具对西部地区乡村卫生服务一体化政策效果进行评估应用，为系统、客观评价乡村卫生服务一体化管理政策效果提供适宜工具，并为优化政策和实施方案提供理论指导。研究方法通过分析乡村卫生服务一体化管理政策的背景、发展历程，探寻政策问题，界定乡村卫生服务一体化管理内涵；以文献研究、规范分析为主，结合理论功能、实践导向及专家论证分析，在西部地区农村卫生服务体系建设现状基础下，运用树形图法，界定乡村卫生服务一体化管理政策根本目标及目标体系；从SPO模型出发，探讨乡村一体化政策价值导向，构建政策效果评估概念框架；运用专家咨询法、层次分析法，并结合实证研究，确定西部地区乡村卫生服务一体化管理政策评估评价指标体系及其权重。通过实证研究，分析一体化政策效果并探寻影响效果的关键因素。数据来源：一是专家咨询数据；二是实证研究现场调研数据；三是国家卫生统计年鉴数据。研究结果（1）乡村卫生服务一体化就是要形成和建立一个适宜于当地社会经济以及卫生服务网络的紧密性服务体，具有系统性、经济性和公益性的价值导向。（2）乡村卫生服务一体化管理目标体系包括6项直接子目标（优化卫生资源配置、规范化分工协作、卫生服务连续性提供、提高卫生服务能力、改善卫生服务质量和提高卫生人员满意度）和3项间接子目标（改善服务利用效率、改善居民健康状况以及提高居民满意度）。（3）乡村卫生服务一体化管理政策效果评价指标体系包括组织体系、资源配置和满意度三个方面内容，共有三级指标27个。（4）西部地区乡村卫生服务一体化管理多为松散型一体化模式，乡村医生薪酬、养老保险及对村卫生室统一财政管理的实施率分别为66.67%、16.67%和33.33%。（5）乡村两级卫生机构人员交流率从2008年的5.25%增至2010年的24.57%，从事防保工作的人员增加了7.75%，公共卫生人员密度指数从1.0206增长至1.0685。（6）乡镇卫生院公共卫生人员所占比例从2008年的12.96%提高至2010年的15.42%，从事防保工作的时间所占比例提高了5.61个百分点，村卫生人员从事公共卫生服务的时间则从22.25%提高至65%。（7）松散型一体化下，村卫生室基本公共卫生服务任务完成率均为48.84%，而相对紧密型一体化下的完成率平均为95.42%。（8）乡镇卫生院对村卫生室的业务督导频率从2008年的每季度一次提高至2010年的每月均为1.43次；每年参加过两次以上乡镇卫生院业务培训的村医比例也从2008年60.37%提高至90.21%。（9）村卫生室处方书写规范率从2008年的26.45%提高到2010年的85.13%。（10）松散型一体化下村卫生室处方两联抗生素使用率为11.52%，而相对紧密性一体化下的村卫生室为6.38%。（11）松散型一体化乡镇卫生院业务收入增长率比值比均值为0.77，村卫生室人均年收入增长率为11.3%；而相对密集型一体化中，乡镇卫生院业务收入增长率比值比均值为1.785，村卫生室人均年收入增长率为51.40%。（12）松散型一体化下，村卫生室对收入的满意度为8.9，对乡镇卫生院业务培训的满意度为6；相对紧密型下收入满意度为7.5，业务培训满意度为8.2。（13）影响乡村卫生服务一体化管理政策效果的关键因素分为政策自身因素，即政策内容的实施情况和政策外因素，包括同作用于乡村卫生服务机构的相关政策和乡镇卫生院管理效率。研究结论（1）同新医改中加强基层卫生服务体系建设的资源投入以及基本公共卫生服务项目的共同作用下，乡村一体化政策能够促进乡村卫生机构间的人员交流和资源配置、提高医疗机构对公共卫生工作的重视程度，紧密型一体化对于促进公共卫生服务项目的落实有着积极的推动作用。（2）乡村卫生服务一体化对加强机构间联系、恢复两级机构的相互协调有着一定的促进作用，同时，通过加强乡镇卫生院对村卫生室的管理，提高村卫生室的行医规范和服务质量。（3）相对密集型一体化下卫生人员交流程度较高，乡村一体化管理能够有助于村卫生室回归公益性，但村卫生室的积极性仍取决于村医经济收入及乡镇卫生院的管理效率。（4）推进西部地区乡村卫生服务一体化管理的策略：明确促进乡村两级卫生机构的协同合作、共同发展的管理目标，强化乡镇卫生院管理效率；稳定乡村医生合理收入，提高其积极性；推进紧密型一体化管理，解决好乡村医生执医稳定和安全问题；加强基层各项政策的组合运用和衔接。创新与不足本研究主要创新点：（1）在国内卫生政策研究中，首次将公共政策分析的理论框架应用于乡村卫生服务一体化管理的政策效果分析中。（2）从理论功能、实践导向的多重分析角度下，探讨乡村卫生服务一体化政策目标，将其分解为可量化、可考核的目标体系。（3）通过对目标体系的系统分析，构建乡村卫生服务一体化管理政策评估指标体系，为系统评估乡村一体化政策效果提供现实工具。本研究的局限：（1）因地区间卫生服务体系建设的差异，指标体系中中优指标的标准值采用了相对优选区域来代替标准值，未对标准值的界定进行严格探讨。（2）评价指标体系的实践应用所选择的样本地区存在一定的民族地域特殊性，样本乡镇数量偏少。（3）分析影响因素因政策作用的复杂性，采取了理论分析方法，而未能用数理统计方法对其他政策的实施对乡村卫生服务一体化管理的确切影响进行分析。更多还原

【Abstract】 ObjectiveGuided by the theory of public policy evaluation, this study defined the connotation ofthe Township and Village Health Services Integration Policy (TVI) by analyzing thebackground and development history of TVI and exploring the policy issues. Based on thestatus of rural health system construction of western China, the fundamental goal and targetsystem of TVI had been established and policy evaluation framework of TVI had beenstructured. Guided by policy evaluation framework of TVI, index system of the effectassessment of TVI in Western China had been developed and the tool used for evaluatingeffect of TVI in the empirical study, which provided a scientific and systematic tool for TVIaffection evaluation and a theoretical guidance for optimization of policy implementationand local direction.MethodsFirst, through analyzing the background and development history of TVI, the policyquestions were explored and then the connotation of TVI had been defined. Second,directed by the methods of document research, normative analysis and combining withtheory analysis, practice guidance and expert consultation, the fundamental goal and targetsystem of TVI had been established. Third, based on the SPO model and value orientationanalysis of TVI, policy evaluation framework of TVI had been established. Fourth, by usingthe Delphi method, analytic hierarchy process (AHP), combined with empirical research,index system and weight of each index of the effect assessment of TVI in Western China had been developed. By the empirical study in Western China, the effect and infect factorswere analyzed. Data source is from expert consulting data, empirical research field surveydata and national health statistics yearbook data.Results(1) TVI policy is to form and establish a regional health service consortium whichshould suit for local economy and health service system development and with valueorientation of systematic, economic and commonweal.(2) The target system of TVI includes six directly sub goals (i.e. optimize the allocationof health resources, standardized collaboration, providing health services continuity,improve the ability of healthcare capacity and health service quality and improve healthworkers’ satisfaction), and three indirect sub goals (i.e. improve the services’ efficiency,improve residents’health status and their satisfaction).(3) On the basis of the conceptual model, the policy evaluation index system includesthe organization system, resource allocation and satisfaction with27indexes.(4) In the western region, more of the TVI mode was the loose integration mode. Therate of implement payment, pension insurance and unified financial management were66.67%,16.67%and33.33%, respectively.(5) From2008to2010, the rate of personnel exchange rate increased from5.25%to24.57%, public health workers had a7.75%increase and public health personnel densityindex rose to1.0685from1.0206.(6) In township hospitals, the proportion of public health workers was increased from12.96%in2008to15.42%and the proportion of working hours in public health serviceswas increased by5.61%. While the rate in village clinics was raised from22.25%to65%.(7) In the loose integration mode, task completion rate of basic public health services invillage clinics was48.84%, as the same time the rate in close integration was95.42%.(8) The supervision frequency between township hospitals and village clinics wasraised from once a quarter in2008to1.43times a month in2010. The rate of village doctors attended more than twice doctor training was increased from60.37%to90.21%.(9) The writing standard rate of village clinics’ prescription was increased from26.45%in2008to85.13%in2010.(10) The two couplet prescription antibiotics usage in village clinics in looseintegration is11.52%and6.38%in the intensive integration.(11) In loose integration, the ratio of business income growth rate of township hospitalswas0.77, and the ratio in the intensive integration was1.785. The average per capitaincome growth rate of village clinics was51.40%.(12) In loose integration, income satisfaction of village clinics was8.9; in townships’business training satisfaction was6. The income satisfaction relatively close integration is7.5, training satisfaction was8.2.(13) The influence factors of effect of TVI policy can be divided into two parts, one isthe content of policy itself and the other is the other policies which had the same scopedobjects with TVI and township hospitals’ management efficiency.Conclusion(1) With the combined action of strengthen the construction of basic public healthservices of New Health System Reform, TVI could promote personnel exchanges, resourceallocation and improve public health services providing. Meanwhile, the intensiveintegration could promote the implementation of public health services.(2) TVI could strengthen links between institutions and have the certain role inpromoting the mutual coordination. What’s more, by strengthening townships hospitalsmanagement, the quality of medical practice standard and service of village clinics could beimproved.(3) In the management of intensive integration, health personnel exchanges rate washigher and could promote the village clinics to return to commonweal. But the enthusiasmof the village doctors still depends on their income and the efficiency of township hospitals’management. (4) The strategies for promoting TVI policy in western China:1) Clear and definitegoals and strengthen the management efficiency of township hospitals.2) Make sure thereasonable income stable for village doctors and keep their enthusiasm.3) To carry out theintensive integration management in western China.4) Strengthen the combination ofpolicies and cohesion.Innovation and LimitationMajor innovations:1) this is the first time to apply the theoretical framework of publicpolicy on TVI in domestic health policy research.2) From the multiple perspectives oftheory analysis and practice guidance, the goal of TVI has been defined and divided intoquantifiable and verifiable sub goal system.3) Based on the guidance of conceptualframework and systematic analysis on the target system, the policy evaluation index systemof TVI has been established, which provide a systematic tool for TVI affection evaluation.Major limitations:1) Cause of the difference among regional health service systemconstruction, the optimal value of interval index use the value interval instead of standardvalues.2) Sample region of empirical research field survey exist certain nationalparticularity and the sample number of villages and towns is insufficient.3) Due to thecomplexity of policy effect, this study used the theoretical analysis on influence factorsinstead of statistics methods.更多还原