【作者】 任鹏；

【导师】 李士雪；

【作者基本信息】 山东大学 ， 社会医学与卫生事业管理， 2020， 硕士

【摘要】 研究背景国家基本公共卫生服务项目作为我国公共卫生领域的一项基础性的、长期性的制度,是党中央、国务院做出的一项关注民生、造福百姓的重大决定,是新医改“保基本”的重要内容,也是通过“建机制”推动“强基层”的重要举措。我国自2009年开始实施国家基本公共卫生服务项目。自国家基本公共卫生服务项目实施以来,山东省非常重视该项工作,充分发挥政府保障民生、促进公平的兜底线作用,促进了城乡居民健康水平和健康素养的不断提升,体现了我国医疗卫生事业的公益性质。2009年项目实施初期,国家基本公共卫生服务项目的人均补助经费标准为15元,近年来不断提高,到2017年人均补助标准达到50元;项目服务内容也不断扩展,由原来的9大类22项到扩展为2017年的12大类49项。基本公共卫生服务项目的补偿方式主要是通过政府进行财政补助经费,项目工作量是确定财政经费补助额度的首要依据。对项目进行科学合理的成本测算是政府完善基本公共卫生服务补偿的重要依据,对于保障项目的稳定实施具有重要意义。在导师李士雪教授的指导下,作者本人自主设计调查问卷和培训调查员,组织调查人员前往基层医疗卫生机构现场调查获得调查数据。本人还对山东省社区卫生服务机构和乡镇卫生院基本公共卫生服务项目进行成本测算,为进一步规范项目的经费投入提供政策依据。此外,山东省探索以基本公共卫生服务为主要内容开展农村地区乡村医生签约服务和城市地区家庭医生式签约服务,截至到2016年底,签约人口达4000余万,实现了签约服务以县(市、区)为单位的全覆盖。对基本公共卫生服务进行成本测算,不仅可以有利的推动项目实施,还可为下一步全面推动和升级家庭医生签约服务进行成本测算及规范相关标准的制定奠定基础。研究目的为了促进山东省基本公共卫生服务项目更好的发展,在省内选择6个地级市进行专项调查,旨在对山东省2016年度基本公共卫生服务项目完成情况、资金到位和使用情况、基本公共卫生服务项目成本进行测算,为政府合理制定基本公共卫生服务项目补助标准提供依据,也为下一步制定家庭医生服务项目补助标准提供参考。此外,通过比较两种不同测算方法,探索更有效的基本公共卫生服务成本测算方法。研究方法采用分层抽样的方法,从山东省东、中、西部地区分别抽取2个地级市,最终抽取东部地区青岛市、潍坊市,中部地区淄博市、泰安市,西部地区聊城市、菏泽市6个地级市。在每个地级市抽取2016年基本公共卫生服务项目排名靠前的2个县(区),各含一个城市县(区)和一个农村县(区)。每个县区抽取2016年山东省基本公共卫生服务项目绩效考核成绩名次靠前的6家基层医疗卫生机构(包括乡镇卫生院和社区卫生服务中心)作为样本机构,共抽取72家基层医疗卫生服务机构。参考国家基本公共卫生服务规范(第三版),确定2016年山东省开展基本公共卫生服务项目的具体工作内容。对72家基层医疗卫生机构采用问卷调查、现场调查、重点访谈的方式收集相关数据,以标准门诊服务(标准服务当量)作为参考,确定山东省不同地区医疗卫生服务机构基本公共卫生服务项目的人时数和当量值,采用国家基本公共卫生服务项目的成本测量方法(即当量法)进行成本测算。同时采用标准成本法对基本公共卫生服务项目进行成本测算,采用Pearson相关分析比较分析当量法和标准成本法这两种测算方法结果的相关性。研究结果1.本研究参考2016年国家基本公共卫生服务项目规范,共涉及13大类48小项服务项目。共调查了 6个地区,每个地区调查12家机构,共72家机构,其中社区卫生服务中心32家,乡镇卫生院40家。平均服务区域面积47.62km,平均机构建筑面积5598.61 m2,公共卫生业务用房面积平均718.63 m2;共有编制人员3996人,实际在岗人员5184人;共有户籍人口 3463232人,常住人口 3722027人。2016年度72家机构医疗支出共507931126元,其中,72家机构公共卫生支出共 270059224 元。2.以一个标准服务当量所需要的人时数作为参考标准,确定调查机构基本公共卫生服务项目的当量值。结果显示,72家机构国家基本公共卫生服务总当量值为16404123.37个标准服务当量,其中,东部地区总服务当量值为5875210.01个标准服务当量,中部地区总服务当量值为2683156.24个标准服务当量,西部地区总服务当量值最多,为7845757.12个标准服务当量。农村地区总服务当量值为8869184.53个标准服务当量,城市地区总服务当量值为7534938.84个标准服务当量,农村多于城市;从机构平均来看,城市地区机构平均总服务量为235466.84个标准服务当量,多于农村地区221729.61个标准服务当量;13个服务项目中,高血压患者健康管理服务总当量值最多,肺结核患者健康管理服务总当量值最少。3.根据调查机构的公共卫生服务支出和国家基本公共卫生服务项目的总当量值,国家基本公共卫生服务项目一个当量值的成本为16.46元。根据各个项目的当量值和一个当量值的成本,计算各个项目的成本,结果显示,开展健康教育服务的成本最高,居民健康档案管理服务成本最低;城市(社区卫生服务中心)标准服务当量成本高于农村(乡镇卫生院);中部地区标准服务当量成本最高,西部地区最低。4.当量法研究结果显示,山东省人均国家基本公共卫生服务项目成本为72.56元。其中农村成本为79.22元,城市为67.02元;东部地区成本为73.92元,中部为83.74元,西部最低,为65.97元。5.利用标准成本法进行成本测算,结果显示人均项目成本为66.44元。其中,农村地区人均项目成本为77.61元,高于城市地区的57.56元;东部地区人均项目成本最高,为65.67元,中部地区为67.75元,西部地区最低,为62.07元。6.研究结果显示,利用当量法测算的总体人均项目成本为72.56元,高于标准成本法测算的66.44元,农村东中部地区标准成本测算的结果低于当量法,城市当量法测算的结果均高于标准成本法;将两种方法的测算结果采用Pearson相关分析,结果显示相关系数为0.706,说明两种方法的测算结果比较接近。政策建议:根据本次研究的主要研究结果,本文主要提出以下几条政策建议:1.科学测算成本,政府适当提高服务项目的补偿标准。2.政府建立科学的基本公共卫生服务考核制度3.基层医疗卫生机构加强医院信息系统建设4.基层医务人员增强成本管理技能和意识更多还原

【Abstract】 BackgroundAs a basic and long-lasting policy of public health,establishing the national basic public health service program is a big decision of the Central Committee and the State Department to care for and benefit people.It’s an important part of the new healthcare reform to ensure basic services,and also a key move to strengthen the grass-roots through constructing mechanism.Shandong provincial government has attached great importance to the work to bear its responsibility of ensuring livelihood and promoting fairness after the national basic public health service program was put into practice in 2009,which has been continuously promoting the health level and health literacy status of the urban and rural population.This program also embodied public welfare nature of the medical and health services.Per allowance of the basic public health service program increased from 15 RMB in early 2009 to 50 RMB in 2017,and service contents also expanded from 9 categories 22 items to 12 categories 49 items.The government supported the basic public health service program mainly by financial assistance which largely depended on the workload of the program.Scientific and reasonable estimation on the cost of the program is the basis of performing public health service and perfecting compensation mechanism,it also has great significance for stable development of the program.This research used the survey data of Shandong Health Care Commission in 2017 to estimate cost of basic public health service program in community health center and township health center to provide policy basis for further standardizing fund investment of the program.Furthermore,Shandong province explored country doctor contracting service in rural areas and family doctor contracting service in urban areas.By the end of 2016,contracted physician engaged in basic public health services aggregated more than 40 million,contracted service completely covered all the county(municipal or district)units.Cost estimation of basic public health service will not only promote and implement the program but also lay foundation to fully promote and upgrade cost estimation and standards establishment of family physician contracted servicesObjectTo better promote the implementation of the program.6 administrative cities in Shandong province were investigated for a comprehensive and in-depth understanding of the completion,allocation and usage of fund and cost of basic public health service in 2016.Results of the investigation could provide reasonable subsidy standard for service and family doctor program.In addition,more effective estimation methods for basic public health service cost were explored by comparing results of two different estimation methodsData and MethodsStratified sampling was used to select 6 prefecture-level cities in the eastern,central and western regions,including Qingdao and Weifang from the eastern region.Zibo and Tai’an from the central region,Liaocheng and Heze from the western region.In each prefecture-level city,1 county and 1 municipal district which ranked well on the 2016 basic public health service program list were selected.A total of 72 primary health institutions were collected,including 6 township health centers from each county and 6 community health centers from each municipal district.Basic contents of the public health service program in 2016 was ascertained by referring to the national basic public health service specification(third edition).Data of the 72 selected primary health institutions were collected by questionnaire survey based on interviews.Person hour and equivalent value of the basic public health service program in different regions of Shandong were ascertained on the basis of standard outpatient service(standard service equivalent).Standard cost method and equivalence method which was also adopted by the national basic public health service program were both used to estimate the cost.Besides,correlation of the results were analyzed by Pearson correlation method.Results1.There were 13 categories and 48 items of services involved in this study.The study selected 12 institutions in each city,with a total of 72 primary health institutions in 6 regions investigated,including 32 community health centers and 40 township health centers.The average service area of the institutions was 47.62 square kilometers,with an average construction area of 5598.61 square meters and anaverage house area of 718.63 square meters.There were a total of 3996 enlisted personnel and the actual number of persons on duty was.The total household registered population was 3463232 and resident population was 3722027.In 2016,total expenditure of the 72 health institutions was 507931126 RMB,including 270059224 RMB for public health service.2.Equivalent value of basic public health services of the investigated institutions were ascertained on basis of human hours per standard service equivalent.Results showed that total basic public service equivalent value of the 72 institutions was 16404123.37,including 8869184.53 in the rural regions and 7534938.84 in the urban regions.Average service quantity in urban regions was 235466.84 compared to 221729.61 in rural regions,among the 13 service items,patients with high blood pressure enjoyed the biggest service equivalent values,and patients with tuberculosis enjoyed the smallest service equivalent values.In this study,total standard service equivalent value was 5875210.01 for the eastern regions,2683156.24 for the central regions and 7845757.12 for the western regions of Shandong province.3.Cost for one equivalent value of the basic public health service was 16.46 which was calculated according to expenditure and total equivalent values of the basic public service.Cost of each item was based on equivalent values and cost of one equivalent value.Cost of health education was the highest,while cost of health records management was the lowest.Cost of standard service equivalent in community health centers was higher than township health center,with the highest cost of standard service equivalent in central regions and the lowest in western regions.4.According to the equivalent method,cost of basic public health service per person in Shandong was 72.56 RMB.The number was 72.56 RMB in rural areas and 67.02 RMB in urban areas.Cost of basic public health service per person was 73.92 RMB in the eastern regions,83.74 RMB in the central regions and 65.97 in the western regions.5.Cost evaluation using the standard costing method showed that project cost per person was 66.44 RMB,77.61 RMB in rural areas which was a little higher than the urban areas(57.56 RMB).Project cost per person was 65.67 RMB in eastern regions,67.75 RMB in the central regions and 62.07 RMB in the western regions.6.According to the results,project cost per person of the equivalent method was higher than the result of the standard costing method.Results of equivalent method of the rural areas in the central and eastern part was higher than results of standard costing method,results of equivalent method of urban areas were higher than standard method in all parts.Correlation of the results was analyzed with Pearson correlation analysis,which showed a correlation coefficient of 0.706,indicating good correlation between results of the two methods.SuggestionsOur findings may have translational implication for the following:1.To evaluate the cost scientifically and raise the compensation standard properly.2.To establish an assessment mechanism for basic public health service.3.To strengthen the establishment of information systems for medical and health institutions4.To strengthen the technical ability for basic public health service.更多还原