【作者】 徐欣；

【导师】 高红霞；

【作者基本信息】 华中科技大学 ， 社会医学与卫生事业管理， 2023， 硕士

【摘要】 【目的】当前村级卫生服务供给依然存在人力不足、服务能力低、村卫生室医疗功能弱化的问题,无法有效满足村民多层次卫生需求,这都影响着村民享受便捷可及、优质高效的卫生服务。因此不论是国家政策还是地方实践,都在强调乡镇卫生院参与村级卫生服务供给,寻找当前困境的解决方法。本研究基于整合卫生服务理念,提出乡镇卫生院延伸村级卫生服务,并探索影响该服务实施的因素及优化策略,以期为提高农村卫生资源配置效率、更好维护人群健康提供新思路。【方法】基于文献研究初步梳理出乡镇卫生院延伸村级卫生服务的影响因素。在此基础上,采用典型抽样与方便抽样相结合的方式,在3个省3个县共抽取了11个乡镇卫生院、18个行政村进行现场调查。主要包括问卷调查以及关键知情人物访谈。对45名卫健局、医保局、县乡医疗机构领导、乡镇卫生院医务人员进行半结构式访谈,调查31名参与乡镇卫生院延伸村级卫生服务的卫生院医务人员以及525名村民。了解该服务的具体开展情况,并调查村民对乡镇卫生院延伸村级卫生服务的认可度。通过45名相关人员的访谈以定性方法分析影响乡镇卫生院延伸村级卫生服务的因素,对文献梳理出的影响因素进行验证补充并确定纳入DEMATEL-ISM模型的因素,基于模型分析各因素的重要性以及因素间的相互关系。【结果】(1)界定乡镇卫生院延伸村级卫生服务内涵,并提出核心特征。本研究所指的乡镇卫生院延伸村级卫生服务主要包含两种形式:(1)乡镇卫生院巡诊;(2)乡镇卫生院派驻。乡镇卫生院延伸村级卫生服务是以系统连续、协同高效、以人为本为核心理念,以县域内多元相关主体互动协作为基础的整合型村级卫生服务形式。(2)提出乡镇卫生院延伸村级卫生服务影响因素的四个核心维度,即社会环境要素、政策环境要素、资源环境要素和机制环境要素。社会环境要素包括地形地貌、人口数量、人口健康状况、时间范围等;政策环境要素包括县域医共体;资源环境要素包括医务人员数量、服务能力、便携式医疗设备、信息化建设等;机制环境要素包括激励与绩效考核。(3)乡镇卫生院延伸村级卫生服务的实践发现。乡镇卫生院巡诊在实际中运用广泛,而乡镇卫生院派驻运用较少、多出现于山区。相较于派驻,乡镇卫生院巡诊的服务范围广、资源投入大、对县域医共体的帮扶需求高。(4)与未开展巡诊服务的行政村相比,乡镇卫生院巡诊可提高村民健康需求满足程度(t=-6.27,P<0.001)。乡镇卫生院派驻的“中心村卫生室”可便捷村民就医、获得村民认可。(5)乡镇卫生院延伸村级卫生服务影响因素重要性分析。根据DEMATEL模型结果,最重要的影响因素是该服务可以使用的人力资源即乡镇卫生院的卫生人员数量。相比较而言,重要性小的影响因素是药品种类、使用智能辅助设备和乡镇卫生院服务的可及性。(6)乡镇卫生院延伸村级卫生服务影响因素多层递阶结构模型结果。将影响因素划分为五层,第Ⅴ层的因素是社会环境要素,第Ⅳ层和第Ⅲ层是政策环境要素,第Ⅱ层是资源环境要素中的物质资源,第Ⅰ层中包括资源环境要素中的人力资源和机制环境要素。影响因素从底层开始依次对相邻的上一层产生直接影响。【结论】(1)社会环境要素形成乡镇卫生院延伸村卫生服务开展的现实需求。需继续加强农村基础设施建设,缩小城乡发展差距。(2)县域医共体是乡镇卫生院延伸村级卫生服务发展的强助力。需做好政策体系顶层设计,形成村级卫生服务改革的外部推力;发挥县域医共体对乡镇卫生院延伸村级卫生服务在人、财、物等方面的支撑作用。(3)干预资源要素可直接改善乡镇卫生院延伸村级卫生服务开展。以信息化手段,提高现有卫生人力服务效能;以人群健康需求为导向,逐步提高卫生服务质量。(4)激励机制可快速影响乡镇卫生院人力资源。建立并完善绩效考核体系,促进乡镇卫生院延伸村级卫生服务持续改进;建立多种方式并举的激励措施,提高乡镇卫生院及其人员积极性。更多还原

【Abstract】 [Objective]The current supply of village health services still suffers from a lack of manpower,low service capacity and weakened medical functions in village health offices,which cannot effectively meet the villagers’ multi-level health needs.All these affect the villagers’ access to convenient and accessible,quality and efficient health services.Therefore both national policy and local practice are emphasising the participation of township health centres in the provision of village health services and finding solutions to the current dilemma.Based on the concept of integrated health services,this study proposes the extension of village health services by township health centres,and explores the factors affecting the implementation of this service and strategies for optimisation,with a view to providing new ideas for improving the efficiency of rural health resource allocation and better maintaining the health of the population.[Methods]Based on the literature study,the factors influencing the extension of village health services by township health centres have been initially sorted out.On this basis,a combination of typical sampling and convenience sampling was used,and a total of 11 township health centers and 18 administrative villages were selected for on-site investigation in three provinces and three counties.It mainly included questionnaires and key informant interviews.Semi-structured interviews were conducted with 45 health care bureaux,health insurance bureaus,leaders of county and rural medical institutions,and medical staff of township health centers,and questionnaires were administered to 32 medical staff of health centers involved in the extension of village health services at township health centers and 525 villagers.To understand the specific implementation of this service,analyze the problems of village health service integration in practice,and investigate the villagers’ recognition of the extension of village health services by township health centers.Based on the influencing factors initially proposed theoretically,an interview outline was developed,and the influencing factors of extending village health services in township health centers were analyzed by qualitative methods through interviews with 45 relevant personnel to verify and supplement the influencing factors proposed theoretically.By constructing the DEMATEL-ISM model,the importance of each factor and the interrelationships between the factors were analysed.[Results](1)Defined what it means to extend village health services at the township health centre level and proposed core features..The extension of village health services at the township health centre level referred to in this study consisted of two main forms:township health centre rounds and township health centre postings.The extension of village health services by township health centres was an integrated form of village health services based on the core concept of systemic continuity,synergy and efficiency,and people orientation,and the interaction and collaboration of multiple related subjects within the county.(2)Four core dimensions of the factors influencing the extension of village health services by township health centres were proposed,namely elements of social environment,elements of policy environment,elements of resource environment and elements of mechanism environment.Social environment elements included topography and landscape,population size,population health status,and time frame.Policy environment elements included county medical communities.Resource environment elements included the number of medical personnel,service capacity,portable medical equipment,and information technology construction.The mechanism environment element included incentives and performance assessment.(3)Practical findings on the extension of village health services at the township health centre level.Township health centre rounds were widely used in practice,while township health centre deployments were less commonly used and were mostly found in mountainous areas.Compared to posting,township health centre rounds had a wider range of services,greater resource input and a higher need for support from the county health community.(4)Compared to villages without visiting clinics,visiting clinics at township health centres improved the satisfaction of villagers’ health needs(t=-6.27,P<0.001).The "central village health centre" in the township health centre was convenient and well-recognised by villagers.(5)The importance of analysing the factors influencing the extension of village health services at the township health centre level..According to the results of the DEMATEL model centrality calculations,the most important influencing factor is the human resources available for this service,i.e.the number of health personnel involved in the township health centre.In comparison,the less important influencing factors are the type of medicine,the use of smart aids and the accessibility of the services in the township health centre.(6)The results of the multi-layer recursive structure model of the influencing factors for the extension of village health services in township health centres.The influencing factors were divided into five layers.The factors in layer V were the social environment factors,layers IV and III were the policy environment factors,layer II was the physical resources of the resource environment factors,and layer I included the human resources and mechanism environment factors of the resource environment factors.The influencing factors had a direct impact on the upper layers in turn,starting from the bottom layer.[Conclusion](1)Elements of the social environment form a realistic demand for the development of extended village health services in township health centres..Need to continue to strengthen rural infrastructure construction and narrow the development gap between urban and rural areas.(2)The county medical community is a strong aid to the development of village health services by extending the rural health centre.Need to do a good job of top-level design of the policy system to form the external thrust of the reform of the village-level service model.Play the role of county medical community to support the township health center to extend the village health services in terms of human,financial and material.(3)The intervention resource element can directly improve the delivery of extended village health services at the township health centre level.Increase the use of information technology to improve the effectiveness of existing health manpower services.To gradually improve the quality of health services,oriented to the health needs of the population.(4)Incentives can quickly influence the human resources of a township health centre.Establish and improve the performance appraisal system to promote continuous improvement of rural health centers to extend village health services.Establish incentives in multiple ways to improve the motivation of township health centers and their personnel.更多还原