【作者】 袁芳；

【导师】 冯占春；

【作者基本信息】 华中科技大学 ， 社会医学与卫生事业管理， 2015， 博士

【摘要】 [目的]本研究以机制设计理论及管理控制理论为指导,通过系统研究农村公共卫生体系绩效形成的内在规律,基于农村公共卫生体系的投入、运行和产出三个关键环节,对农村公共卫生体系运行流程进行分析；从绩效形成的能力、压力和动力三个角度寻找影响公共卫生绩效的关键因素；确定农村公共卫生体系绩效控制的主体、客体以及主要控制手段；并对我国公共卫生体系绩效控制相关政策进行分析；在此基础上,设计构建相应的公共卫生绩效控制机制,将为促进农村公共卫生绩效改善,加快农村卫生事业发展,实现全面建设小康社会和社会主义新农村的战略目标提供理论指导和技术支持。[方法]通过分析中国公共卫生体系绩效改革相关的政策发展进程,探寻中国农村公共卫生体系绩效改革的演变历程和关键内容；通过典型案例研究及现场调研对农村公共卫生体系运行流程进行分析以寻找公共卫生体系控制关键因素；运用专家咨询法、层次分析法,确定农村公共卫生体系绩效控制关键影响因素集合及其权重。通过词频分析法和专家咨询法确定农村公共卫生体系绩效控制主体、客体及主要控制手段。借鉴机制设计理论,对农村公共卫生体系绩效控制各元素的经济特征进行分析设定,通过运用管理控制理论,对公共卫生体系绩效控制基本过程进行分析；最后从SDG建模法出发,建立农村公共卫生体系绩效控制机制。数据来源：一是实证研究现场调研数据；二是专家咨询数据。[结果](1)2003年以来,国家颁布政策的时间相对连续,政策制定的部门主要包括国务院、原卫生部/卫计委、财政部等,其中以原卫生部/卫计委颁布的政策较多,其次是国务院。相关政策主要包括综合政策、人力政策、财力政策、物力政策、组织政策以及其他政策。(2)农村公共卫生体系运行流程分为“投入-产出-结果”三个维度,投入维度分人力、财力、物力、组织和外部环境,过程维度分为公共卫生服务效率、服务质量和服务可及性,结果维度分为健康改进结果、健康公平性和社会评价三方面。(3)农村公共卫生体系绩效控制关键影响因素包括人力资源、财力资源、物力资源、组织体系和体系外部环境五个一级因素,14个二级因素和30个三级因素。(4)公共卫生体系关键影响因素分为能力类因素,包括人力、物力、财力及技术等能力；动力类因素,包括物质动力、精神动力及信息动力；压力类因素,包括各控制主体(政府、公共卫生服务机构)、控制手段(政策、项目、规则)以及社会公众等的压力。(5)农村公共卫生体系绩效控制主体及其控制强度包括政府(0.6072)、卫生服务机构(0.1551)及卫生行政部门(0.2377)；控制客体及其可控程度包括乡级服务机构(0.6483)、村级服务机构(0.1220)、县级服务机构(0.2296)；控制手段包括政策、项目、规则。(6)农村公共卫生体系绩效控制机制设计的基本过程为控制主体通过控制管理目标对控制客体设定期望状态,控制客体根据个体目标既倾向制定个体期望回报,将期望状态与期望回报调整到相适宜的结构,控制客体即可向管理目标接近。(7)公共卫生服务机构的经济特征为非均等化概率、关键控制因素、可控性、自身效益损失和机构关键责任系数；政府的经济特征包括政府失灵概率和政府责任指数,居民的经济特征包括健康损失和可控性。(8)控制主体的经济特征包括责任指数a和责任主体在关键控制因素中承担的责任系数b；控制客体ek的经济特征是可控程度C和利益损失L。(9)农村公共卫生体系绩效控制目标为非均等化概率趋近于0,既关键控制点的选择以及控制力的大小趋近于最优化,从而使得系统的控制达到最优。[结论](1)国家在制定绩效改进政策的同时,要及时追踪其实施的结果,并在此基础上对政策内容不断调整,以适应不断变化和发展的实际情况。(2)农村公共卫生体系绩效管理的目标是以公平性和可及性作为前提的,最终目标是达到公共卫生服务均等化,所以在设计绩效控制机制时,应该将需方即居民的利益作为重要的考虑环节。(3)农村公共卫生体系绩效控制过程关键环节是将系统初始状态和控制后状态进入量化器对系统进行评估。(4)农村公共卫生体系绩效控制的关键因素的确定需要根据系统状态进行筛选,关键因素之间力的作用会发生相互转化,最终希望达到的稳态时压力和动力能够最大程度地转化为可作为稳定状态存在的能力。(5)建立农村公共卫生体系绩效控制机制,能够明确体系内各要素的成分及相互联系,可以更有效率地达到资源配置的最优化,提高公共卫生体系的运行绩效。[创新与不足]本研究主要创新点：(1)从理论功能和实践导向的多重分析角度下,探讨农村公共卫生体系绩效控制机制,并将其分解为可量化的控制要素。(2)本研究的机制并非单一从一个角度入手设计,而是分别从时间流程、理论流程以及作用力等多个角度去分析构建机制,对农村公共卫生体系的绩效控制做了较为全面和详细的剖析。(3)在对体系整体绩效控制机制的研究基础上,通过对控制要素的拆分,构建每个影响因素对农村公共卫生体系绩效的控制机制,提出相应的控制策略以及控制后对体系绩效的改善程度,为农村公共卫生绩效改进提供现实工具。本研究的不足：本研究最大的不足在于没有对模型进行实践性的检验,而只做了理论性的推导。由于检验控制成效需要一定的干预期,收集控制后的量化数据,在时间上未能实现。本研究作为农村公共卫生体系绩效控制机制研究的理论部分,是为后期研究实践提供理论支撑,在此基础上设计相应的干预方案,进行样本地区的干预,得到干预后数据,对机制加以验证和修改。更多还原

【Abstract】 [Purpose]Based on the theories of mechanism designing and management mechanism systematically, this research investigated the innate law of rural public health system forming. In the meanwhile, the running process of rural public health system was analyzed based on the three key links (input, operation, and output) of rural public health system. Second, the key factors that effect public health performance were obtained from three different angels which are capacity, pressure and motivation of performance forming. Furthermore, this research also included the confirmation of control subjects, control objects, and main means of rural public health performance control. These findings will lead to control mechanisms of public health performance, which will improve the performance of rural public health, accelerate the pace of rural health service, and technically support the realizing of a well-off society in an all-around way and new socialist countryside.[Methods]The evolution and key points of public health system reformation in rural China were investigated with the analysis of the evolving process of related policy, and the key factors of public health control were obtained from the study of typical cases and the site investigation of rural public health system. Besides the collection and the weight of key factors that affect rural public health performance control were clarified with the use of expert consultation method and analytic hierarchy process. Moreover, the subjects, objects and main means of rural public health control were confirmed by the means of word frequency analysis, while the economic characteristics and basic process of rural public health performance control were respectively analyzed by the use of mechanism designing theories and management controlling theories. Finally, the mechanism of rural public health system performance control was constructed based on SDG modeling. All the data come from the study of site investigation and expert consultation.[Results](1) Since2003, the related policies were consecutively introduced by the State C ouncil, ministry of finance, ministry of health/National Health and Family Planning C ommission, etc. In terms of the amounts, Ministry of health/National Health and Fam ily Planning Commission rank the first, the State Council comes the second. These po licies covered the comprehensiveness, manpower, financial supports, material resourc es, organization and so on.(2) The running process of rural public health system contained three dimensiona lities: input, operation, and output. Input included manpower, financial supports, mate rial resources and externalities. While operation related to effectiveness, quality and a ccessibility of public health service. Output could be divided into3different aspects r esults of health improvement, equity in health care and social assessments.(3) The primary factors that affect the rural public health performance control we re manpower resources, financial resources, material resources, organizational system and externalities. While the secondary and tertiary factors respectively conclude14an d30items.(4) The key factors that effect public health system were capacities, motivations, and pressures. Manpower, material resources, financial resources and techniques were classified into capacities. And the motivations included the material, the immaterial a nd the informational. While the pressure factors include the controlling subjects (government and public health service institution), the controlling means (policies, projects and rules), and pressure comes from the public.(5) The control subjects of rural public health system performance were the government, health service institutions, and health administrative departments. And the control objectives consisted of town, village and country service institutions. Besides, the control means included policies, projects and rules.(6) The basic process of rural public health performance control system included the expecting state setting by control subjects, the individual expecting rewards design ing by control objects, the matching of expecting state and rewards and the leading for objects to aims of control.(7) The economic characteristics of public health service institutions included un equalised probabilities, key controlling factors, controllability, self benefit losing, cruc ially liability coefficient of institution. And those of the governments were failure pro babilities and liability indexes of government. Besides those of the residents consisted health loss and controllability.(8) Liability index and liability index b burdened by liability objects in primary c ontrolling effectors were included in economic characteristics of controlling objects. And the economic characteristics of controlling objects ek were controllability C and benefit loss L.(9) The unequalized probability of the rural pulic health system controlling aims approached0which means the selection of critical control point and the controlling fo rce drew near to the optimization leading to the optimal control of the system.[Conclusions](1)When the country is making a policy, the effectiveness result should be tracked in time, and the policy should be adjusted which based on the effectiveness results.(2)The objective of performance management of rural public health system is fairness and accessibility, and the final target of it is equity of public health services.(3)The key link of performance control of rural public health system is that evaluating the original state and the final state of the system.(4)Establishing performance control mechanism of rural public health system, which could definite the constituent and interrelation of the system factors. It wouldoptimize the allocation of resources efficiently and improve the performance of public health system.(5)When confirming the key effectors of rural public health performance control, it’s the system state should be considered for screen as the interaction of these key factors were mutually transformational. Only reaching the steady state, the transformation between the pressures and the motivations realized the maximum of the existing capacity of this steady state.[Innovation and Limitation]The innovations of this study:(1)For the multiple analysis angles of theory function and practice orientation, we explored the performance control mechanisms in rural public health system, which were decomposed into quantifiable control factors.(2)The mechanism of our study was not singly started with one angle, but was analyzed from multiple angles of the time process, the theory workflow, and acting force, etc., which comprehensively and detailed dissected the performance control mechanisms in rural public health system.(3) After splitting the control factors, we established the performance control mechanisms in rural public health system, which provided a practical tool for the improvement of rural public health performance.(4) We discussed the corresponding performance control mechanisms for each key control point respectively, put forward the control countermeasures, and quantized the strength of its effect on system performance, which showed a strong operability and practicability.The limitations of this study:The most inadequacy of this study was the deficiency for practical examination of the model, but only completed a theoretical derivation. Because a certain intervention period was needed in testing the control result, it was failed to collect the quantitative data after the control. As a theoretical part of the research for performance control mechanisms in rural public health system, this study provided a theoretical support for the later practice research. An intervention project was designed based on this theory, which was used to conduct an intervention in sample area, and the relevant data was received, thus, the mechanism was verified and modified ultimately.更多还原