【作者】 吕军；

【导师】 郝模；

【作者基本信息】 复旦大学 ， 社会医学与卫生事业管理， 2005， 博士

【摘要】 本研究为政策理论完善型研究,属《我国卫生事业主要领域关键问题界定与策略研究》的系统研究,在立足国内,从卫生事业发展战略层面出发:旨在构建和明确“我国卫生事业主要领域关键问题界定与策略研究,包括思路、步骤及其常用方法等”,以弥补公共政策理论的空白、消除实践的瓶颈。 一、立题依据 本论文为《我国卫生事业主要领域关键问题界定与策略研究》研究项目的子课题之一。 总课题研究认为政策优劣决定事业兴衰,追求高价值是政策的理性目标。在现实中,制约政策价值的障碍很多,在我国研究者和制定者之间以及科研和政策之间存在的隔阂和差距似乎更为明显。政策研究者和制定者各自为政,理论停留在理论,不具备指导实践的作用,实践只能依据经验。科学制定政策不仅需要有效的政策方法论,也需要政策研究者和政策制定者间的优势互补和良性互动。但目前我国卫生领域还缺乏政策研究者和政策制定者进行良性互动的平台。 总课题《我国卫生事业主要领域关键问题界定与策略研究》,旨在以“政策制定科学程序”为指导,依据从发现问题到解决问题的过程和步骤,在明确界定特定领域存在的问题基础上,根据这些问题的严重程度和对全局的重要性综合确定问题的优先解决顺序,然后参照政策研究衡量标准和政策决策衡量标准针对需要优先解决的焦点问题进行研究现状和空白缺陷分析,结合焦点问题研究现状和空白缺陷的分析结果,选择几个潜在热点和具有影响力的关键问题,超前进行专题政策研究,对科学制定国家重大卫生政策提供信息。 本研究作为《我国卫生事业主要领域关键问题界定与策略研究》中的一部分,研究将在总课题的基本框架下,围绕“政策制定科学程序”的各个逻辑步骤展开。对国内文献的评阅显示针对妇幼卫生领域重大问题及相关政策的系统研究在这20多年里是一个绝对的空白,可见妇幼卫生领域的政策研究是非常薄弱的,而政策研究是进行宏观管理顶层设计的基础和依据,研究的空白使决策失去了理论支撑。目前妇幼卫生政策研究滞后于我国宏观经济改革的进程,滞后于我国卫生改革的进程。妇幼卫生政策与立法是保障妇女和儿童健康及开展妇幼卫生工作的重要手段和措施。从政策开发和制度建设的角度,为了促进我国妇幼卫生事业的健康和可持续性发展,进一步提高妇女、儿童的健康水平,需要对我国妇幼卫生领域存在的问题能有一个清晰地认识和了解,需要明确在妇幼卫生领域目前究竟存在多少问题?这些问题的重要性和严重性如何?研究者对这些问题的研究程度?各级决策者对这些问题的认识程度?等等。 本研究包括“理论论证”和“策略研究”两个部分。“理论论证”部分包括三个部分:首先通过对妇幼卫生领域基本职能、运作规律、发展过程、政策环境等的分析来精确界定更多还原

【Abstract】 1. Research Objectives and SignificanceThis study is a component of project "A policy study on the key issue and strategies of health care system in China". The research of the parent project considers: the quality of the policy can determine whether the cause will succeed or not, the rational objective of the policy is to seek higher value. There are many obstacles limiting the value of policy in the real society. In China there exist gap and disparity not only between the policy researchers and policy makers but also between the policy research and policy, therefore the policy researchers and policy makers work each for themselves, the theory remaining at the research level cannot guide the practice and the practice only rely on the experience. Formulating policy scientifically not only need the effective policy methodology but also need advantage complementarities and mutually promotive between policy researchers and policy makers.The parent project "A policy study on the key issue and strategies of health care system in China" aiming at the guidance of "the policy making scientific procedure", in accordance with the procedure and process from finding problem to settling problem, firstly definite the existing problems in special field and then determine the precedence order based on the ponderance and the importance of problem, after then choice several potential hot spots and key issues to study.This research as a component of project "A policy study on the key issue and strategies of health care system in China ". centre on the logical procedure of "the policy making scientific procedure" under the basic frame of the parent project. The domestic literature review manifests the systematic study on the key issues and related policy in maternal and child health care was in vacancy at past 20 years. The policy research is the foundation and the basis for macro-administration, the decision-making will lose the theory support because of the research vacancy. At present, the policy research of maternal and child health care lags behind the macro-economic innovation course as well as health innovation course. The law and policy of maternity and child hygiene is important means and measures in ensuring maternal and child’s health and developing maternal and child health care. Considering the policy development and system construct, in order to accelerate healthy and persistence development of maternal and child health care cause in China, enhance the health level of maternity and child, researchers should emphasize the following issues: recognize and understand the problems in maternal and child health care clearly, definitude the quantity of existing problems and the ponderance and the importance of problem, investigating level by the researcher , cognition level by decision-makers at all levels et al.This study consists of two parts, one is theory demonstration, the other one is strategy exploration. "The part of theory demonstration" involves three aspects: definitude the scope of maternal and child health care by analyzing the basic function, operation disciplinarian, development course, policy surroundings et al; determine the existing problem quantity and precedence order ;find out the research blank and the decision-making defect in existing research aiming at special issues. "The other part of strategy exploration" emphasizes the remedy strategy exploration in view of key issues on "maternal and child health care institutions’ orientation misplacement, imperfect health care management".2. Research MethodologiesThe research design emphasizes "four combination principle" meaning "combine research with the situation of our country, mix together multi-subject, integrate both quantity and quality, combine research and decision-making" and embodies "six characteristics " meaning "systematic, scientific, initiative, logicality, rational, feasible".This study applies "the policy making scientific procedure" as a direction research method and research technique course, applies "the macro modular of health system" providing system ideas, selects "multi-dimensions construction evaluation" guiding crossrange research content.Under the direction of the above research method, the theory demonstration accomplishes the recognition of key issues in maternal and child health care , key issues research present situation and vacancy and defect research through the literature review, narrative review, AHP, cluster analysis. The strategy exploration, aiming at "maternal and child health care institutions’ orientation misplacement, imperfect health care management", instructed by the principle of the macro modular of health system , analyzes the influencing factors leading to key issues, applies cause and effect analysis, will demonstration to definitude the main influencing factors leading to key issues, proves these influencing factors through on-the-spot investigation data, formulates the policy strategy resolving key issues.Data-collecting method includes literature review analysis, group discussion, insider interview, intention survey, on-the-spot representative investigation, will survey and reasoning, second data picking-up and questionnaire survey.3. Main Research Results3.1 The definition of maternal and child health care field in ChinaThe maternal and child health care field consists of administrative system and service providing system, provides the following 5 functions: policy development, construction of service providing system, technique planning and direction implement, information monitor and administration, international cooperation and exchange.3.2 key issues in maternal and child health care fieldThere are 28 main problems in maternal and child health care field by analysis and demonstration. According to the importance and ponderance of the problem, via comprehensive evaluation and many argumentations, three key issues in maternal and child health care field were confirmed:Issue 14: maternal and child health care institutions’ orientation misplacement, imperfect health care managementIssue 1: low-educated maternal and child health care provider, personnel being lack of special training, being not competent to the taskIssue 8: maternal and child health care service system being organizationally imperfect 3.3 Research situation on the key issues of maternal and child health care in China By analysis of the following key issues of maternal and child health care field, Issue 14: maternal and child health care institutions’ orientation misplacement, imperfect health care management; Issue 1: low-educated maternal and child health care service provider, personnel being lack of special training, being not competent to the task; Issue8: maternal and child health care service system being organizationally imperfect; Issue2: maternal and child health care service provider being shorthanded, instability, health care task being unable implement, main present research situation and defect or vacancy represents as follows:3.3.1 Research situation on the root and function mechanism of key issuesPrevious domestic studies on the root and function mechanism of key issues in maternal and child health care were scattered, on the one hand, these studies given priority to intuitive exploration about influencing factors, on the other hand, they lacked systematic and special focusing, research and decision-making were lack of coordination. Though previous researchers summarized and induced the influencing factors and function mechanism of key issues preliminarily, more attention should be paid to probe into the root and function mechanism, enhance research logicality, scientificity and maneuverability.3.3.2 Research situation on the policy idea of solving key issuesMany of the policy ideas of solving key issues in the maternity and child health care were the commenting suggestions, most of them were experienced summary. On the one hand, the policy ideas were not analyzed through "determining the root and function mechanism", on the other hand, even if the analysis w as scattered. The policy ideas submitted by researchers were lack of logicality, scientificity and maneuverability, the researchers themselves were still suspicious of their policy suggestions. The systematic study on the constraint condition, motive power and obstruction, essential key technique and referrer’ responsibilities of implementation of policy idea were almost in vacancy.3.3.3 Research situation on the practice scheme of solving key issuesAlthough there are 47 literatures concerned the practice scheme of solving key issues, the practice scheme was based on the following studies with the shortage of the cognition of the influencing factors especially the root and function mechanism, without the fully demonstration of the policy idea in view of the solving key issues’ root and function mechanism, the study on the constraint condition, motive power andobstruction, essential key technique and referrer’ responsibilities of implementation of policy idea were almost in vacancy. Thereby the present researches aiming at key issues are limited by experience and intuition, theory divorced from practice.3.4 Strategy research on the key issues in maternal and child health care3.4.1 Influencing factors leading to "maternal and child health care institutions’ orientation misplacement, imperfect health care management"According to the "concept—index—factor" sequence ascertained by the health system macro model and relationship of different submodule, researchers hunt for the influencing factors aiming to"maternal and child health care institutions’ orientation misplacement, imperfect health care management", 14 main influencing factors leading to key issues are confirmed. There are 4 factors sitting in outer submodule and 1 factor sitting in inner submodule, this factor sitting in inner submodule is the issue of normal expenditure compensated channel being obstacle. It is obvious that maternal and child health care is as the systems engineering with strong sociality, outer factors such as politics, economy, culture, human demand surroundings have stronger influence to it . Four main influencing factors, namely normal expenditure compensated channel being obstacle, clinic service item becoming the placement of expenditure compensated; limitation of health care service content and pattern; imperfect maternal and child health care; lower-educated and lower-level maternal and child health care personnel; appear in most of maternal and child care institutions by quantitative demonstration using the spot investigation data.3.4.2 The function mechanism model for "maternal and child health care institutions’ orientation misplacement, imperfect health care management"On the base of influencing factors leading to key issues analysis, through the analysis of the behavior agent, behavior characteristic and social function of the maternal and child health care institutions, the function mechanism model directing against "maternity and child health care institutions’ orientation misplacement, imperfect health care administration" is built. The model connotation are as follow: maternity and child health care institutions have to pay more attention to service charge because of the shortage of finance input, compensate mechanism and social security policy; since the government and health administrative institutions cannot definitude the development pattern and development orientation of the maternal and child health care institutions, health care institutions are incapable of holding the consumer demand actively and neglect potential market in health care, therefore their behavior on "focus on clinic, belittle health care, focus on revenue, belittle service" become ever more violent, leading to health care function increasingly contraction; the maternal and child health care institutions lose the public function and the maternal and child cannot gain basic health care services, the other medical institutions set foot in the market of the maternal and child health care, the government oppugn the difference between the maternal and child health care institutions and the other medical institutions, there out forming a vicious circle. Those will bring about the following sequence: policy anticipation cannot achieve and the maternal and child health更多还原