【作者】 高琦；

【导师】 姜宝法；

【作者基本信息】 山东大学 ， 流行病与卫生统计学， 2008， 硕士

【摘要】 研究背景社区卫生服务是以全科医学为指导,开展预防、保健、医疗、康复、计划生育技术指导和健康教育等“六位一体”的服务,为居民提供综合、经济、方便、可及的基层卫生服务,实现“小病在社区,大病进医院”,把群众的基本医疗卫生问题解决在基层。山东省开展社区卫生服务已有十多年的时间,社区卫生服务工作的各个方面都取得了快速的发展,取得了比较成熟的经验,但是在机构建设、政策支持、功能定位等诸多方面还存在许多问题,社区卫生服务机构的资金短缺问题仍十分普遍,还有大量的卫生决策需要做出。同时现阶段国内社区卫生服务的筹资机制还不够完善,筹资渠道也比较狭窄,现有的研究未对各筹资渠道进行明确分类、区别分析,而是将多种筹资渠道混合分析,这样不利于充分理解、应用各种渠道。因此有必要收集关于各种现有筹资渠道的研究证据,对现有社区卫生服务各种筹资渠道的优缺点及其发展趋势做出系统总结和综述,为决策者提供高质量的决策证据。完成关于社区卫生服务筹资渠道的系统综述之后,本研究又根据山东省的情况进行了“个人深入访谈”研究,对系统综述的结果加以验证和补充。本研究探讨了如何运用系统综述(systematic review)结合定性访谈的方法向决策者提供科学的证据,为开展“亚洲循证公共卫生决策网络(EvipNet Asia)”项目奠定了基础。研究目的1.收集我国关于社区卫生服务五种筹资渠道的研究证据并进行系统评价和综述;2.探讨各筹资渠道的应用证据、应用效果、运行机制,结合当地情况,分析其适用性和可行性;3.提出社区卫生服务多渠道筹资可持续发展的建议,为山东省决策机构制定关于社区卫生服务的政策提供循证依据;4.了解山东省社区卫生服务各筹资渠道的现状,为系统综述的结果提供验证和补充;5.探讨运用系统综述以及定性研究为循证卫生决策提供证据的方法。研究方法1.系统综述本研究的一系列方法步骤是参照Cochrane中心做系统综述的方法和标准。首先根据PICO原则制定检索策略和文献的纳入排除标准,然后根据检索策略检索文献,数据库主要包括CNKI、中文科技期刊数据库、中国生物医学文献数据库、Pubmed;将重复文献剔除,根据文献的纳入排除标准筛选文献,然后搜索文献全文;将纳入的文献逐一加以评价,并提取摘要和重要信息;最后对文献进行综合分析和整合,得出结论并提出建议。2.定性访谈本研究制定了个人深入访谈提纲,采用“滚雪球”抽样法,从山东省卫生厅,济南市、区两级卫生局,社区卫生服务机构以及相关研究机构等单位,选取了10名对社区卫生服务有较深刻了解的相关人员,采用采访的形式逐个进行了深入访谈,采用录音结合笔录的方式采集资料,随后建立数据库并进行分析。研究结果1.最终纳入文献59篇,其中有一篇文献设计类型属于前后对照(CBA),其余58篇文献为1999年至2007年间现况调查研究,其中有19篇主要研究了政府投入这种筹资渠道,包括全国15个省市,覆盖了我国的大部分地区;有16篇文献对社区医疗服务纳入社会医疗保险这一政策做出了分析;有22篇文献讨论了社区卫生服务机构收支状况、服务项目成本测算、收费比例等;有1篇文献讨论了社区筹资;没有发现关于基金或捐赠的文献。根据这些研究证据我们讨论了各种渠道的筹资方式、所占比例和公平性,筹资渠道以政府投入和使用者付费这两种为主,其中使用者付费占绝大部分比例。2.部分政府人员没有认识到医疗保险的作用,对社区卫生服务重视不够。目前社区卫生服务机构和政府主管部门在进行收入统计的时候,没有把社会医疗保险同普通的业务收入分开,而是简单的将社会医疗保险理解为业务收入。政府投入存在不公平问题,政府对政府开办的社区卫生服务机构实行差额或者全额补助,对非政府开办的社区卫生服务机构无补助。结论政府投入在社区卫生服务总筹资中所占比例太小,这个比例在大多数地区低于10%,远远满足不了社区卫生服务发展的需要;使用者缴费所占社区卫生服务总收入的比重过大,特别是药品收入,平均超过70%;国内大多数地区没有完善社区卫生服务纳入社会医疗保险政策措施,其在社区卫生服务总筹资的比例仅占1%左右;社区筹资在国外某些国家具有重要意义,但在国内开展还比较少;基金或捐赠渠道对于整体社区卫生服务筹资来说作用不大,但是对于个体机构具有重要意义。建议建立社区卫生服务专项基金,坚持政府财政对社区卫生服务的定额补助。筹资总额占当地财政支出的比例为0.2%以上可以作为各地各级政府在制定当地社区卫生服务筹资政策时的参考指标;将社区卫生服务中的基本医疗服务纳入医疗保险范围,适当拉开社区卫生服务机构和二、三级医疗机构的个人自付比例;应该制定和完善社区卫生服务收费标准和价格管理体制,规范社区卫生服务项目内容,根据社区卫生服务项目的特性以及成本核算的结果,制定合理的价格政策和收费标准,理顺补偿机制,促进社区卫生服务健康和可持续发展,并且每年要按物价指数进行调整;政府应该通过政策、法规、技术、经济等途径支持、鼓励社区卫生服务的社区筹资;引导社区卫生服务机构积极争取其他部门的专项资金投入,积极吸纳社区团体、慈善机构或个人捐助等。更多还原

【Abstract】 Background:In China, there are still many problems in the health service, especially the inequity of health resources utilization. As we know, the large scale economic reform in China has brought a lot of laid-off workers in urban areas, and they are lowest-income population in cities. On the other hand, because of the unsuccessful health reform, the health resources are centralized to the large hospitals, the medical expense of patients has gone up too fast to burden by the common citizens. If those unemployed people are suffering from diseases, it may lead to extreme poverty in those families due to the growing of medical expenditure. As a result, the medical expenditure becomes one of the heaviest burdens and the main cause of poverty among citizens.Chinese government has taken a lot of effective measures to solve the inequity of health resources utilization, one of the solutions is community health service (CHS). The organizations of the CHS spread rapidly in Shandong province in the past decade. However, the development of the CHS is very unbalanced in various areas of the whole province, there are still many problems need to be solved in the implementation process. For example, the population coverage rate is very low in some cities; the financing mechanism is not appropriate; the lag of general practitioner’s training. Consequently, citizens can not benefit from some of the CHS items, and some service functions fail to bring effectively into play. After consulting the senior policy makers, according to our survey results we identified that lack of the ineffective financing mechanism of the CHS is the key factor which blocked the implement of community health service. We need the correct decisions and policies to promote the fundraising so that the community health service can play its functions. Therefore the financing mechanism of the CHS is selected as a priority issue of systematic review for EvipNet-Shandong.According to the criteria set by the Cochrane center, we have conducted this systematic review for more than six months, and we have completed it now. The systematic review can explore the best financing mechanism of the community health service, make full use of the role of the experts, and provide evidence for the policy decision makers. It is conducive to the development of effective policies of the CHS. With our efforts facilitating evidence-informed policy making step by step, we believe that the inequity of health resource allocation will be reduced in Shandong province. At last, to understand the situation of the financing mechanism of the CHS in Shandong province and to provide supplement for the Systematic Review, several experts or officers, who have engaged in studying or managing CHS, were selected and interviewed.Objectives:1. To gather evidences on financing mechanism of the CHS, and conduct systematic reviews;2. To explore the evidences, the proportions, the effects and the advantages or disadvantages of various financing mechanisms of the CHS;3. To put forward suggestions for sustainable development of the Community health services to fill the decision-makers’ requirements;4. To understand the situation of the financing mechanism of the Community Health Services in Shandong province and to provide supplement for the Systematic Review;5. To discuss the ways of using Systematic Review and qualitative study to provide evidence for policy makers.Methods:1. Systematic ReviewWe perform this Systematic Review according to the Cochrane’s criteria. Search strategy: A comprehensive search was performed to avoid both bias in the selection of published articles and bias in the language of publications. We used five various databases. Relevant websites and the online resources of relevant international organizations, consultancy firms and academic and research centers were also searched. Selection of studies: The criteria for considering studies in the reviews were applied in two stages. At the primary stage, titles and abstracts of studies were included on the basis of the type of intervention investigated. The second stage inclusion criterion was based on geography: this review included only those studies undertaken in China. Quality assessment: The conclusions of a systematic review depend primarily on the quality of the studies included. Therefore, an assessment of such quality is an integral part of the analytical process. Each study was independently assessed by two reviewers, who would mark the selected literatures. Synthesis: All studies included in this report were categorized into three groups according to their scores: high quality, moderate quality and low quality.2. In-depth InterviewsTo understand the situation of the financing mechanism of the CHS in Shandong province and to provide supplement for the Systematic Review, 10 experts or officers, who have engaged in studying or managing CHS, were selected and interviewed. The outline of the interviews was developed, and the "snowball" sampling method was used in the interviews, and recordings and transcripts were used to collect the data.Results:1. Finally we include 59 literatures, 58 of which are cross-sectional studies, and one of them is narrative review of experts’ advice. Government financing: Including 19 literatures, 5 of them are high quality. Based on these evidences, we talked about the financing modes and the mechanism of the government financing. User fee: Including 16 literatures, 7 of them were high quality. Based on these evidences, we talked about the financing modes and the charging criteria. Community financing: Including 22 literatures, 11 of them were high quality. Based on these evidences, we talked about the financing modes and the tendency of Community financing. Social medical insurance: We only found only one narrative review. Project funds or donation: Mentioned in seven literatures.2. Some government officials have not recognized the role of medical insurance, and paid insufficient attention to community health services. Currently, when community health service institutions and government departments take in charge of income statistics, they don’t depart social health insurance from ordinary business’s incomes, but simply view the social medical insurance as business income. There are some unfair issues in government financing.Conclusions:1. Government financing: Its proportion in the total income of the CHS is too small, and the proportions in most provinces of China are below 10%, which can hardly satisfy the needs of the development of the CHS.2. User fee: Its proportion in the total income of the CHS is too large, especially the drugs income (one of the fees), which is over 70% on an average.3. Community financing: We have ignored this role, and we can hardly find cases about it.4. Social medical insurance: Most of the provinces of China have not perfect this financing mechanism in the CHS, and its proportion in the total income of the CHS is below 1%. But it is surely an important financing mechanism.5. Project funds or donation: For the whole CHS organizations, it is nearly useless; but for a single one, it is very helpful.Suggestions1. Government financing: The government’s role is the key of the development of the CHS. The government should better use more modes to invest funds for the CHS.2. User fee: According to the current situations, it is particularly urgent to set criteria of the fees for the CHS, and meanwhile administer incomes and expenditures of the CHS in two lines.3. Community financing: Increase the percentage of the community financing part in the whole financing mechanism. Reform the financing modes.4. Social medical insurance: Mobilize and encourage various departments to invest the CHS.5. Project funds or donation: Positively establish various foundations. Conduct the organizations of the CHS to apply for funds from domestic or international research institutions.更多还原