【作者】 钱东福；

【导师】 尹爱田； Raymond W.Pong；

【作者基本信息】 山东大学 ， 社会医学与卫生事业管理， 2008， 博士

【摘要】 在我国农村,特别是西部农村地区,卫生服务利用不足比较普遍,就医可及性较差是一个突出的问题。就医选择行为研究是卫生需求研究的重要内容,这种需求行为研究更适宜关注需方的就医可及性问题。根据文献综述,在国内,有关就医选择问题的研究,对居民的就诊距离均没分析其偏好性问题,而且研究均没有涉及关于供方一个比较重要的因素——服务价格,也没考虑农村居民对私立卫生室的选择情况。研究人群都是针对门诊病人,没有涉及住院病人就医选择行为的研究。另外,对居民患病后推迟看病行为的影响因素、慢性病患者在多类医疗机构的就诊情况、有关居民就医机构选择的长期变化趋势等,也缺乏相应的研究。本研究目的就是通过对上述问题的深入探讨,揭示影响居民卫生服务需求行为的主要因素和内在规律,为合理引导农村居民的就医选择行为,合理配置卫生资源,完善有关农村卫生政策,更好地满足农村居民的卫生服务需求提供科学依据。具体目的包括:(1)明确医疗机构的距离、服务价格等有关因素对农村居民门诊就医机构选择的影响,探索影响农村居民选择住院机构的主要因素,对农村居民关于门诊和住院机构的选择行为解释提供科学依据;(2)明确影响农村居民推迟看病行为的因素以及慢性病患者在多类医疗机构就诊情况,从多方面分析了解农村居民的卫生服务需求行为;(3)明确农村居民就医流向的变化趋势,了解和把握农村居民卫生服务需求行为的长期变化特征和规律,为完善农村卫生资源配置、加强就医行为引导提供决策依据。本研究资料来源主要是2004年ASEM(Asian European Meeting)关于“加强农村贫困地区的公共卫生规划”资助项目(经世界银行支付)的甘肃省家庭入户调查资料、2003年国家卫生服务调查项目中有关甘肃省农村地区的家庭入户调查资料以及国家的宏观卫生统计资料和国家卫生服务调查的有关数据。研究的理论基础是消费者选择理论和效用理论。研究方法主要包括采用描述性统计分析、单因素统计推断、多元线性回归、Mixed Logit模型以及二项式Logistic模型等对有关内容进行了分析研究,分析软件采用SPSS12.0、SAS9.1.3。有关农村居民对门诊就诊机构的选择研究表明,影响甘肃农村居民选择门诊卫生服务机构的统计显著因素主要有就诊者的年龄、疾病类型、疾病发生期间、就诊者的卧床天数、医疗机构的距离、就诊者的收入和医疗机构的价格。平均来说,在其他因素一定的条件下,相对于自我医疗,年龄大的农村居民更不可能去县级医院(系数为-0.0358)就诊,然后依次是乡镇卫生院、公立卫生室、私立卫生室。从疾病类型分析,在其他因素不变的情况下,与感冒患者相比,慢性病患者更有可能在县级医院就诊,其次选择到乡镇卫生院就诊,再次是选择到私立卫生室、公立卫生室就诊。如果就诊者的疾病是调查时一个月前发生的,与调查时一个月内发生的相比,总的来说,就诊者选择自我医疗的概率要大一些。研究也发现就诊者在选择机构时,对距离重要性的认识上存在差异,当距离医疗机构在3～10公里时,有28%的农村就诊者对其因存在某种偏好而忽略这一距离障碍。分析这部分就诊者可能是为了获得更好的医疗服务而忽略相应的距离问题。随着农村就诊者卧床天数的增加,平均来说,农村就诊者更有可能选择到县级医院就诊,然后依次是乡镇卫生院、私立卫生室、公立卫生室。价格是一个影响就诊者选择卫生服务机构的显著因素,而且低收入者的价格弹性比高收入者的价格弹性要大,如乡镇卫生院价格增加50元时,低收入组就诊者相应的价格弹性系数为-0.4535,而高收入组就诊者为-0.1357。在各类机构之间,总体上,县级医院的价格弹性系数最大(绝对值),如价格分别增加50元时,低收入组就诊者对县级医院的价格弹性系数可达到-0.9586。有关农村居民对住院医疗机构的选择研究表明,影响选择住院医疗机构的统计显著因素主要有收入、疾病类型、住院天数、职业、性别。相对于乡镇卫生院,农村患者收入每增加一个单位,选择县级医院的发生比是原有发生比的2.651倍;在本研究所选的病种中,呼吸系统类疾病患者与消化系统类疾病患者相比,选择县级医院的相对概率较小,前者的发生比是后者的0.101倍;住院天数每增加一个单位,选择县级医院的发生比是原有发生比的1.105倍;具有第二类职业(工人,包括有一定社会地位的农村工作者,如教师、村干部、医生等)的农村住院患者选择县级医院的发生比约为普通农民患者的3.439倍。有关农村居民推迟看病行为的影响因素分析表明,患者的疾病类型、年龄情况、医疗保障、家庭年人均纯收入对其推迟看病的天数是否达到3天及以上的影响有显著的统计意义。如果患者的疾病是慢性病持续到调查一月内,则该患者出现相应推迟看病行为的发生比是调查1月内发生的急性病患者的2.126倍。农村自费患者出现相应推迟看病行为的发生比是享有任何医疗保险患者的2.141倍。农村低收入组患者出现相应推迟看病行为的发生比是农村高收入组患者的2.452倍。农村慢性病患者在多类医疗机构就诊情况分析表明,在调查前一年接受正式医疗的农村慢性病患者比例中,有30.05%的患者仅在卫生室接受治疗,有23.48%的患者仅在县及县以上医院接受治疗,仅在乡镇卫生院接受治疗的比例最低,为12.48%。调查前一年农村慢性病患者中,仅采取到药店购药治疗的例数占所有自我购药接受治疗的比例为41.50%。另外,在利用多个机构的患者中,慢性病患者在卫生室、县及县以上医院都治疗过的病例数最多。除了根据横断面调查资料进行上述分析外,本研究还利用全国卫生统计数据对农村居民就医流向的变化趋势进行了分析,结果表明,全国范围内乡镇卫生院的诊疗人次和入院人数,在1995年-2006年,总体上呈现下降趋势。根据国家卫生服务调查数据,2003年与1998年调查结果相比,农村居民两周患病就诊者中选择村级医疗机构的比例下降6.67个百分点,而到县及县以上医院就诊的比例增加4.04个百分点。农村住院者在乡镇卫生院住院的比例平均减少了6.62个百分点,而在县及县以上医院治疗的比例平均增加8.71个百分点。根据研究结果分析和讨论,提出了以下相应的具体政策建议:1、完善农村卫生筹资与分配:(1)促进卫生筹资的公平性,完善新型合作医疗筹资机制等。(2)改善补助需方卫生资金的使用,如尽量增加农村新型合作医疗定点医疗机构数量,方便患者就医;完善对农村居民慢性病门诊费用的补偿政策;将实施农村新型合作医疗与改革农村医疗提供系统有机结合起来。(3)合理分配补助供方的卫生资金,对乡村卫生机构实行倾斜政策。2、加强对农村医疗机构的管理和规制:(1)控制医疗服务价格,规范农村医疗服务市场。(2)完善卫生服务提供行为的监督评价机制。(3)加强对农村公立卫生服务机构组织和管理方式的改革。(4)充分发挥私立卫生机构的作用。(5)提高农村基层卫生技术人员的业务素质。(6)促进基层卫生机构转变服务模式。3、加强对农村居民的就医引导和贫困就助:(1)加强对基层医疗机构的宣传,普及卫生知识,引导居民合理就医。(2)加大对农村贫困患者、低收入患者的医疗就助力度。本研究的创新之处主要是在国内首次研究了价格因素对农村居民门诊就医选择的影响,计算了相应的需求价格弹性;研究了居民在选择医疗机构时关于距离因素认识上的差异,测量了差异程度;在研究方法上,也是在国内首次使用Mixed Logit模型对卫生服务需求选择行为进行研究。同时,还在国内首次研究分析了农村住院患者选择住院医疗机构的影响因素。另外,还研究了农村居民的推迟看病行为、慢性病患者在多个医疗机构的治疗情况以及农村居民在各类医疗机构就医流向的变动趋势,从新的视角进一步分析了农村居民的卫生服务需求行为。其不足主要是资料等限制,在有关居民门诊就医选择行为的影响因素研究中,没有考虑居民感知的卫生服务质量因素,这在实践中也有较大的测量和调查难度。关于对住院医疗机构的需求选择研究没有考虑价格因素,因为推导缺失的住院医疗价格更为困难,目前还没有经验可以借鉴。这些都是未来进一步研究的重点。更多还原

【Abstract】 The low rate of health service utilization and the lack of access to health care are serious problems in the rural areas of China, especially in the west rural areas. Rural patients’ choice of health care providers is an important aspect of health demand which can contribute to the analysis of rural patients’ difficulties in accessing to health care.The literature review indicates that former studies have not examined a range of factors that can be important in influencing rural patients’ choice of health care providers in China. Specifically, there is no study investigating the impact of the price of health care services on patients’ demands, nor is there research on the determinants of choosing private health care providers, or how distance to health institutions influences rural patients’ preferences. Furthermore, previous researches on rural patients’ choice of health care providers included only outpatients and did not involve inpatients, nor did they take into consideration the factors that result in rural patients’ postponement on a visit to doctors. The literature review also showed that both the determinants of rural patients’ visits of different types of health institutions and the trends in rural patients’ choice of health care providers have not been studied in China.The aim of this study is to identify the main factors that affect rural patients’ health care demand behavior and to use these results to suggest policy changes that would result in better meeting rural patients’ demands for health care. More specific objectives of the study are: (1) to elucidate the effects of the factors of distance to health institutions, health care services price, and availability of private health care providers on rural patients’ choice of health care providers; (2) to identify the factors that influence postponing a visit to a doctor by rural patients, and to analyze the status of rural patients’ visits to different health institutions in order to elucidate rural patients’ health care demand behavior from different angles; and, (3) to analyze the trend of rural patients’ choice of health care providers in order to elucidate long-term change characteristic of rural patients’ demand behaviour for health care, and to provide empirical evidence for the possibilities of improving health care services in rural areas and guiding reasonably rural patients’ health care provider choice behaviour.This study is based mainly on data from a household survey in rural areas of Gansu province, China that was completed for the project "To Strengthen Public Health Planning in Poor Rural Areas" in 2004. It was funded by the ASEM (Asian European Meeting). This study also employs data from a household survey in rural areas of Gansu province, China, that were collected for the project "National Health Household Interview Surveys in 2003" and which was supported by the Ministry of Health. In addition, some data come from Chinese Health Statistical Yearbook or Digest 2005-2007. The theoretical framework of this study is based on consumer choice theory and utility theory. Research methods that have been used in different parts of this study include descriptive statistical analysis, bivariate inferential statistics, Multivariate Linear Regression, Mixed Logit Model, and Binary Logistic Regression Model. The data were analyzed in SPSS 12.0 and SAS 9.1.3.The results of Mixed Logit Model analysis on rural outpatients’ choice of health care providers indicate that the following determinants were statistically significant: age, the type of disease, whether illness started before the reference period, number of total days when an individual was confined to bed due to illness, distance to health care institutions, patients’ income and health care services price. Relative to self-treatment for rural outpatients, an individual, on average, has a lower probability of visiting a county hospital as his/her age increases (the estimated coefficient is -0.0358, holding all other factors constant). Further, on average, the order of probability of an individual choosing a provider, from high to low, is (a) Township Health Center (THC), (b) public village clinic (PUBVC), and (c) private village clinic (PRIVC). Compared to fever patients, chronic patients have higher probability of visiting any of the formal health care providers rather than confining themselves to self-treatment. According to the absolute value of coefficients of chronic illness variables, on average, the order of probability of an individual choosing a provider, from high to low, is (a) county hospital, (b) Township Health Center, (c) private village clinic, and, (d) public village clinic. An individual with ailment which started before the reference period has a lower probability of visiting public village clinic, private village clinic, or township health center in place of self-treatment compared to an individual with ailment started within the reference period.Distance to a health care provider plays a significant role in the patients’ choice. About 28% of the rural outpatients prefer a provider who is within of 3 ~ 10 km distance of their home. An individual’s likelihood of visiting county hospital increases as his / her bed-days increase. According to the absolute value of the coefficients of bed-days, individuals are most likely to choose a Township Health Center (THC), followed by a private village clinic (PRIVC), and lastly a public village clinic (PUBVC). Price is a significant determinant of health care demand in poor rural areas. Price elasticity of health care is higher for the low-income groups than for the high-income ones. For example, when the price of THC goes up to 50 yuan, the price elasticity of THC in low income group is -0.4535, and that in high group is -0.1357. Between the different provider types, the price elasticity for county hospital is the highest.The results of Binary Logistic Model analysis of the choice of health care providers by rural inpatients indicate that, income, the type of disease, hospital days, occupation, and gender are statistically significant determinants. One unit increase in rural inpatients’ income results in a 2.651 times change in the odds of visiting county hospital relative to choosing Township Health Center (THC). Among the sample’s types of disease, the odds of inpatients with respiratory system diseases visiting county hospital is 0.101 times that of inpatients with diseases of digestive system relative to choosing THC. One unit increase in hospital days of rural inpatients results in a 1.105 times change in the odds of visiting county hospital relative to choosing THC. The odds of the second occupational group inpatients (including workers in sample rural areas, village teachers, village cadres, village doctors, etc.) visiting a county hospital is 3.439 times that of ordinary rural inpatients.The results of Binary Logistic Model analysis on the determinants of postponing a visit to a doctor indicate that the type of disease, age, income, and lack of medical insurance are statistically significant determinants of rural patients’ postponing a visit. to a doctor. The odds of a chronic patient whose disease started before the reference period and lasted into the reference period postponing a visit to a doctor is 2.126 times that of an acute patient whose disease started within the reference period. The odds of postponing a visit to a doctor by patients having no any medical insurance coverage is 2.141 times that of patients having medical insurance coverage. The odds of postponing a visit to a doctor by low-income groups is 2.452 times that of high-income groups.According to the descriptive statistical analysis of the status of rural chronic patients’ visits to different types of health institutions, rural chronic patients who had received formal treatment during the year previous to the study, 30.05% of them sought treatment only at village clinics, and 23.48% of them sought treatment only at county-level and above hospitals. The lowest proportion, 12.48%, sought treatment only at a Township Health Center. Among rural chronic patients who had sought self-medication as a way of treatment, 41.50% did not seek any other formal treatment during the previous year. In addition, among rural chronic patients who had visited more than one type of health care institution, the number of cases who had sought treatment at both village clinics and county-level and above hospitals is the largest.In this study, trends in rural patients’ choice of health care providers have been analyzed using national health statistical data. The results indicate that from 1999 to 2006, both the number of outpatients visits and the number of inpatients in Township Health Centers decreased across the entire country. Data from the National Health Household Interview Surveys showed that, among two-week visit outpatients, the proportion visiting village clinics decreased by 6.67 percentage points from 1998 to 2003. At the same time, the proportion of visiting county-level and above hospitals rose 4.04 percentage points. As for rural inpatients, the proportion choosing Township Health Centers dropped by 6.62 percentage points, while the proportion of choosing county-level and above hospitals rose by 8.71 percentage points.According to the analysis and discussion of the research results, the following suggestions on relevant policy improvements are brought forward. Firstly, in the area of health care financing and allocation it is suggested: (1) to improve the equity in health care financing and the financing mechanism of new rural cooperative medical insurance system; (2) to perfect the policy of health funding utilization to support health care demand. Namely, to add a number of new rural cooperative medical insurance system fixed-point medical institutions, to perfect the outpatient expenses’ reimbursement policy for rural chronic patients, and to combine implementing of a new rural cooperative medical insurance system with the reforming of the rural medical provider system; (3) to allocate more the goverment fund for village and town health institutions. Secondly, in order to strengthen the administration and regulation of rural health institutions it is suggested: (1) to control the health care services prices and regulate rural health care market; (2) to perfect the mechanism for supervising and evaluating the delivery of health care services; (3) to strengthen the reform of organization and administration of rural health institutions; (4) to make the best use of rural private health institutions’ positive actions; (5) to enhance the professional qualities of health professionals at rural and grass-root levels; (6) to accelerate the change of the model of health service delivery in rural health institutions. Finally, in order to strengthen the health seeking guidance and poverty aid for rural patients it is suggested: (1) to strengthen the propaganda on rural health institutions, popularize basic health knowledge in order to guide rural patients’ health care seeking behavior; (2) to increase the extent of medical aid for rural needy patients.This study makes an original contribution to the field of rural patients’ health care demand by using new perspectives to analyze rural patients’ choice of providers. To our knowledge, it is the first study to examine the impact of health care services price on rural patients’ choice of providers in China and to obtain the corresponding price elasticities. This study provides insight into the effect of distance on rural patients’ choice of health care. Furthermore, this study is the first to examine the determinants of inpatients’ choice of health care providers in China. In addition, this study is the first study that examines the factors that affect postponing a visit to a doctor by rural patients, the status of rural chronic patients’ visits of different types of health care institutions, and the long-term trend of rural patients’ choice of health care providers. In addition, this study adds to the area of research that employs the Mixed Logit Model following Boarh (2006) and Jose (2007). The main limitations of the study are that, due to the lack of relevant data, the indirect cost of medical care and the impact of health care quality were not included into analysis of rural patients’ health care provider choice behaviour. Another limitation is related to a fact that the analysis on inpatients’ choice of health care providers in this study does not refer to the price variable. These limitations are worthy of further investigation.更多还原