【作者】 蒋文俊；

【导师】 张亮；

【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

【摘要】 传统上,我国农村公共卫生服务的提供是采用政府直接生产提供的方式,但随着社会主义市场经济体制的逐步确立和不断发展,这种服务提供模式已不能完全满足农村居民对公共卫生服务的需求变化,越来越暴露出其本身所存在的缺陷与不足。本文通过对农村公共卫生服务包提供模式的理论和实证分析,探索政府和市场在农村公共卫生服务提供中的优势结合,构建农村公共卫生服务包提供的新型模式,以不断提高农村公共卫生服务提供的质量和效率。研究方法1、文献分析法主要选用pubmed、proquest、medline、cnki和重庆维普、万方数据库、人大复印报刊数据库等文献数据库,收集国内外相关文献(书籍、期刊文章、调查报告、政策报告、政府工作文件等),建立文献数据库。通过广泛阅读本研究领域相关文献,系统深入了解我国农村公共卫生服务制度的演变过程和发展趋势,归纳总结公共卫生服务包的相关研究成果和研究经验。重点研究社会制度与农村公共卫生制度、服务包提供模式中服务包项目的设计与确定、筹资、补偿与支付、监管等。2、专家咨询法按照专家遴选原则,从科研机构及政府部门选择公共管理、公共卫生等相关领域的专家学者,通过半结构式的问卷访谈方式,获取专家指导意见。主要是对通过文献回顾整理而得的农村公共卫生服务内容进行的判断与筛选。对提供模式试点运行遇到的问题给予政策建议的指导等。3、专题小组讨论在构建农村公共卫生服务包提供模式的过程中,针对其中成本核算及费用支付方式等技术问题、绩效管理和监管机制的建立等关键环节设立专题,组织相关专家学者进行小组讨论,以优化模式运作流程。研究内容1、从改革农村医疗卫生体制的宏观视野出发,结合农村经济发展和社会发展的趋势,在形成农村公共卫生服务包提供模式的设计框架的基础上,根据服务包提供模式的实际运作绩效,形成中国农村公共卫生服务包提供的理论框架。2、在对农村公共卫生服务包提供性质进行更加深入剖析的基础上,利用理论研究的方法,分析研究服务包提供的理论,包括服务购买,绩效管理等。并且进一步地明确服务包内项目确定的具体筛选方法、成本测算方式以及服务包的运作流程。3、在系统的理论分析和研究基础上,确定农村公共卫生服务包提供的适宜模式,分析服务包内具体项目设计筛选、服务包购买与支付、以及运作过程中的监管方式等整个服务包系统运作的流程、各阶段的运行方式和方法,针对各实施环节中出现的理论和现实问题,提出相应的改善措施和政策建议,从而不断改进和完善农村公共卫生服务提供体系。研究结果1、农村公共卫生服务包提供的概念框架及理论框架的建立。我国公共卫生服务包提供的理论研究过多地集中在总体框架的研究或者社区基本公共卫生服务包提供的研究,而对农村公共卫生服务包的提供模式研究相对比较匮乏。本研究在对相关概念的内涵界定和相关基础理论进行系统总结、归纳和分析的基础上,初步构建了我国农村公共卫生服务包提供的概念框架和理论框架。2、农村公共卫生服务包提供模式的选择及其运作流程的确立。基于前期相关理论的分析与研究,进一步明确了公共卫生服务的特殊属性和政府在公共卫生服务提供中的主导责任,结合对传统服务提供模式的诊断分析和农村公共卫生服务包提供模式的选择依据,提出了通过政府购买提供农村公共卫生服务包的适宜模式,以提高服务提供的质量和效率。在此基础上,对该提供模式的各个运行环节进行了分析和探索,形成了具体可操作的农村公共卫生服务包提供操作流程。3、依据农村公共卫生服务包的设计原则和步骤,以国家基本公共卫生服务项目为基础,结合区域社会经济发展情况和专家访谈意见,本研究初步确立了农村基本公共服务项目清单,其中包括14个基本公共卫生服务包及103个基本公共卫生服务项目,并明确了各服务项目的服务内容和实施要点。4、农村公共卫生服务包提供工具的研究。本研究制定开发了政府购买提供农村公共卫生服务包所涉及到的关键工具和技术办法,如服务包项目成本测算办法,合同管理的文本开发,项目服务规程及规范的研究以及监管办法、项目绩效标准及考核办法等。5、结合对农村公共卫生服务包提供模式的理论和实证分析,在对政府购买提供模式的实施条件和关键环节进行系统分析的基础上,提出了促进和完善该模式实施的措施和建议,主要包括：明确政府筹资责任,完善政府筹资结构；制定服务提供发展规划,界定购买服务的范围和内容；加强基层服务机构建设,培养服务生产的多元主体；加强政府自身能力建设,提高服务购买提供的管理水平。研究特色与创新1、理论上对农村公共卫生服务包的提供模式进行了系统分析和研究,确立了服务提供的概念及理论框架,及时地填充了目前理论界在该领域的空白；2、依托卫十一项目的实践支持,将农村公共卫生服务包提供模式的理论研究成果应用到实践之中,并在实践中不断得以改进和完善,使得理论研究更加具有指导实践工作的现实意义。研究局限与不足受到研究周期、资料收集等因素的影响,本研究尚缺乏对农村公共卫生服务包提供模式的理论研究成果的实际应用效果验证。本研究的实践验证主要依托于卫十一项目的实施,由于目前项目开展实施的周期还比较短,同时由于公共卫生服务的效果体现具有滞后性,对服务提供模式的实施效果进行验证和评估并不具备现实可行性。因此,本研究仅限于对服务提供模式的实际运行状况进行阐述说明和简要分析,政府购买公共卫生服务的实践效果还有待在后续研究中加以系统评估。更多还原

【Abstract】 Traditionally, the provision model of rural public health services was directly produced and provided by government. However, with the establishment and development of the socialist market economy, this service provision model had not fully satisfy the change in demand for public health services of rural residents, and revealed its own existence of deficiencies and inadequate. Through the theoretical and empirical analysis on the provision model of rural public health service packages, this dissertation had explored the combination of government and marketing advantages in the provision of rural public health service and built a new provision model of rural public health service packages, thus constantly improving the quality and efficiency in providing the rural public health services.Methods1. Literature reviewMainly selecting databases such as the Pubmed, Proquest, Medline, CNKI and Chongqing VIP, Wanfang database, newspapers and periodicals copying database of RUC, collected the relevant literatures at home and abroad (books, periodical articles, investigating reports, government reports and documents) and built literature database. Through review these relevant literatures, systematically looked into the evolution and development trend of rural public health services system, summarized relevant studies and research experience on public health service packages. Selectively studying the social system and rural public health system, the designing and establishing of service package items, financing, compensation and paying, regulation in the provision of public health service packages.2. Delphi techniqueAccording the chosen principles, chose experts and scholars from the public administration and public health and other related areas in research institutions and government departments and obtained the specialist guidance through semi-structured interviews. Particularly obtained guidance on the selection of rural public health service items that systemized from literatures and suggestions on the problems faced in the pilot running of provision model.3. Focus group discussionIn process of building the provision model of rural public health care packages, setting topics to technology problems such as costs calculation and payment and key links such as performance management and establishing monitoring mechanism, organizing relevant experts and scholars to discuss to optimize the operational process.Contents1. From the macro view of reform rural medical and health care system, combined the rural economic and social development trend, constructed theoretical framework of rural public health service packaged provision in China according practical operational performance of the service provision model based on the design framework of provision model of rural public health service packages.2. Analyzed relevant theories about service package providing including service purchasing and performance management using theoretical research method based on the deep-analysis on provision nature of the rural public health service packages. And further defined the specific screening method of service items, the costs measuring ways and the operational process of service packages.3. Based on the systematic theoretical analysis and research, indentified the proper provision model of rural public health service packages, analyzed the operational process of service packages including screening service items, service packages purchasing and paying and supervision and proposed the corresponding improvement measures and policies to enhance and improve the rural public health services providing system. Results1. Establishment of conceptual and theoretical framework of rural public health service packages. Theoretical research on the provision of rural public health service packages in China had over centered on the research of the overall framework or the provision of basic community public health service packages and study on the provision model of rural public health service packages was relative scarce. This research had preliminarily established the conceptual and theoretical framework of rural public health service packages based on the definition of relevant connotation and systematical summary and analysis of relevant basic theory.2. Selection of the provide mode and establishment of operational process of the rural public health service packages. Based on the analysis and research of the relevant theory, and further define the special properties of public health service and the leadership responsibility of government in public health services provide, combination of diagnostic analysis of provider mode of traditional service and the basis of provide model of rural public health services package, propose the appropriate mode to provide the rural public health services packages by government purchasing, in order to improve quality and efficiency of service. On this basis, analysis and discovery the operation process of provide mode, and form the operational process of provide of the rural public health care packages.3. Based on the principles and procedures of rural public health service, based the state’s basic sanitation services, combined regional social and economic development and expert opinions interviews, the study preliminary established the list of rural basic public services, including 14 basic public health services packages and 103 basic public health services, and define the content of service and implementation.4. Study on the provision instruments of rural public health service packages. This study had formulated and developed the key instruments and techniques involved in purchasing and providing rural public health service packages by government, such as the cost estimation method of service package items, the development of contract management text, research on service procedures and specifications and supervision, performance standards and evaluation methods.5. Combination of the theories of provide of the rural public health services packages and empirical analyses, on the basis of the conditions of implementation of provided models for government purchasing and systematic analysis of critical link, propose the measures and proposals to promote and improve the implementation of the mode, including that specific the funding responsibility of government, improve the financing structure of government; making planning for services provided and development, define the scope and content of services purchasing; strengthen the construction of primary service institution and developing plural subject to produce services; strengthen the government’s capacity building and improving the management level in service purchasing and providing.Innovations1. Systematic theoretical analysis and study on the provision model of rural public health service packages had conducted, the establishment of conceptual and theoretical framework of service providing had filled the theoretical space in this field.2. Rely on the practical support of health XI project, the theoretical research achievement had applied to the practice and continued to improved and perfected in practice, the theoretical research thereby of more practical significance in guiding practical work.DeficienciesConfined by research period, information collection and other factors, this study was lack of practical applications to verify actual effect of theoretical research achievement on the provision model of rural public health care packages. The practical verify of this study mainly rely on the implementation of health XI project. Owing to the implementation of project implementation period was relatively short and the effects of public health services was hysteretic, the verifying and assessing of practical effects was not feasible. Therefore, this study was only available in brief description and analysis of the actual operating conditions. The practical effect of the government purchasing model was subject to evaluate systematically in the subsequent studies.更多还原