【作者】 周勇；

【导师】 张亮； 罗乐宣；

【作者基本信息】 华中科技大学 ， 社会医学与卫生事业管理， 2006， 硕士

【摘要】 社区卫生服务中包含有大量的纯公共产品和准公共产品,这些服务的提供对全社会具有较高的成本效益,但并不能为社区卫生服务机构带来相应收入,有些甚至是免费提供,尤其是社区公共卫生服务必须有政府政策与资金的支持才能得以开展和维持。坚持政府财政对社区卫生服务的定额补助是政府重视社区卫生服务的直接体现,但在社区卫生服务机构提供的卫生服务项目中,政府投入的范围是多大,哪些应该由政府全额补偿、哪些应该由政府和市场相结合补偿,必须在定量研究与分析的基础上,根据不同时期、不同地区的经济发展水平和财力可能,紧密结合社区人群的健康需要,明确社区卫生服务中的基本公共卫生服务项目,以确定社区公共卫生财政补助范围,同时通过测算社区卫生服务项目成本,为制定社区卫生服务收费价格、完善补偿机制提供量化依据。自1996年正式启动社区卫生服务以来,深圳市福田区社区卫生服务得到了政府的重视与群众的支持,网络基本形成,功能日趋完善。但政府财政投入与社康中心所承担的公共卫生服务功能、任务不相适应,总体上呈现不足,阻碍了社区公共卫生服务的落实与开展。与此同时,客观上又缺少核定投入所需要的量化依据和科学的投入测算方法,社区基本公共卫生服务的补偿机制有待进一步优化和完善。目的:本研究以解决福田区社区基本公共卫生服务政府投入的依据和测算问题为最终目的,主要通过借鉴国内外社区卫生服务项目成本测算方法,测算福田区现已开展的社区卫生服务项目的实际成本和标准成本,结合福田区经济发展水平、政府财力、居民公共卫生服务需求,明确现阶段社区基本公共卫生服务政府补偿范围,同时将成本测算结果作为社区卫生服务有偿服务项目定价的参考依据,为政府履行公共卫生服务职能、完善福田区社区基本公共卫生服务的补偿机制、保障社区基本公共卫生服务的开展与落实打下基础。方法:利用文献研究法确定社区卫生服务项目实际成本与标准成本测算的具体方法;根据数据主要来源和数据类型要求,在福田辖区内抽取31个社区健康服务中心,查阅财务记录和物资消耗记录,结合问卷调查法、半结构访谈法、回顾性调查及观察法,获得各社区卫生服务机构业务、人员等一般情况和各类成本、各服务项目实际投入人力与时间数量,通过专家咨询法获得各项目社会平均投入人力与时间数量,采用时间分配系数法进行实际成本与标准成本的测算;利用文献法、逻辑归纳法、专家咨询法、多输入优序图法确定社区基本公共卫生服务项目界定的原则方法、福田区10大类社区卫生服务优先等级序列,在此基础上进行福田区社区卫生服务项目分类,进而结合成本测算结果及社区公共卫生服务标准投入明确现阶段福田区社区基本公共卫生服务包所涵盖的具体项目。结果:(一)福田区社区卫生服务一般情况福田区近年社会经济发展良好,保持稳步增长,辖区内卫生资源丰富,社区卫生服务机构与市属大型医疗卫生机构及社会医疗卫生服务机构并存。2004年年末福田区社区卫生服务人员共计515名,平均9.4人/中心,医务比1.94:1,以中专以下、初中级职称人员为主,正式职工与聘用人员各占一半,2004年平均每位社区卫生服务人员接受1.4次各类形式的培训。目前福田区已开展的社区卫生服务项目共计10大类76项,各社区卫生服务机构业务齐全,“六位一体”功能日趋完善。2004年福田区社区卫生服务政府补助占社区卫生服务业务收入与补助合计的37.05%,2000年~2004年福田区政府对社区卫生服务投入呈逐年增加趋势。所调查的31所社康中心药品收入仍是主要的收入来源,福田区社区卫生服务机构2004年业务收入平均54.20%来自药品收入,45.80%来源于医疗服务收入。(二)福田区社区卫生服务成本测算本研究对福田区现已开展的10大类76项社区卫生服务项目进行了实际成本与标准成本的测算,59项社区卫生服务项目的标准成本要高于实际成本,占服务项目总数的75%,另19项实际成本高于标准成本。(三)福田区社区基本公共卫生服务项目界定本研究提出了社区基本公共卫生服务项目的特征与界定原则,并结合公共产品理论提出了社区卫生服务项目分类办法,据此并结合成本测算结果中的标准成本参考值及10大类优先等级排序专家咨询结果,对福田区社区卫生服务项目进行了分类排序,得出福田区社区卫生服务项目排序及全区总标准成本额度表。(四)福田区社区基本公共卫生服务包以福田区社区卫生服务项目排序及全区总标准成本额度表为基础,参照有关专家的相关研究结果,以福田区2004年GDP的0.1%,即6761.80万元作为该区社区基本公共卫生服务的标准财政投入,分别以常住人口数和户籍人口数为测算口径,确定了在该标准投入下现阶段福田区社区基本公共卫生服务包所涵盖的具体项目,同时明确了2004年福田2413.23万元实际投入下的社区公共卫生服务包具体项目,并对福田区社区纯公共卫生服务包财政缺口进行了测算,以不同的人口测算口径,财政缺口分别达7488.78万元、1785.36万元。结论:(1)本课题以2004年为样本年对福田区社区卫生服务项目实际成本和标准成本进行了测算,测算结果数据可应用于福田区社区卫生服务机构运作效率的评价,标准成本参考值对合理确定社区卫生服务财政补偿额度及制订社区卫生服务价格标准有重要参考价值。(2)本课题明确了现阶段福田区社区基本公共卫生服务包的具体项目,并在此基础上测算得出了福田区社区纯公共卫生服务包的财政补助缺口,对明确政府对社区公共卫生的补偿范围、落实政府对社区公共卫生服务的职责提供了量化促进工具。更多还原

【Abstract】 The community health service contains massive pure public products (health education, community health information management and so on) and the public product, such as the prevention health care, the planned immunization program, the infectious disease management and so on, these services have the higher cost benefit to the entire society, but certainly cannot bring the corresponding income for the community health service organization, some even is free provided. The community public health service must have the government policy and the fund support in particular that can be able to develop and to maintain. The persisting governmental finance input to the community health service is the embodiment of the governmental recognition on CHS.But, in so many public health service items that is provided by the community health service organization, what is the government investing scope, which should compensate by the government sum total, which should compensate by unifying the government and the market, these questions must be solved by in the foundation of quantitative investigation and analysis, according to the different time, the different local economy level of development and the financial resource possibility, in close integration with community crowd’s health need, identificating the community public health service items, to determine the scope of the community public health finance input. At the same time, through the cost accounting of the community health service items, provide the basis for formulation the community health service charge price and consummation of the CHS compensating mechanism.Since 1996 official start community health service, the CHS in Futian ditrict Shenzhen city obtained the support from government and populace, the network and function of the CHS organizations is perfected and enhanced. But compare with the governmental financial input on the medical orgnizations, the governmental financial input on the CHS is insufficient in a mass, the disconformity between the input and the public health service function and the duty blocked the sustaining development of CHS, but meanwhile the quantity basis and scientific accounting method of the governmental financial input is not provided ,and the compensating mechanism of community public health service must be further optimized and perfected.Objective: This research take to provide the basis of the governmental financial input on CHS in Futian distric as the final goal, mainly through profits from the domestic and foreign communities health service project cost survey method, surveys community health service project actual cost and standard cost which the Futian area already developed, unifies the Futian area economy level of development, the government financial resource, the inhabitant public health service demand, initially ascertain the present scope of community basic public health service that the government compensates, simultaneously take the cost surveys result as the reference of the community health service compensated service project fixed price, builds the foundation that fulfills the public health service function of the government, consummates the compensating mechanism of Futian area community basic public health service, safeguard community basic public health service development and realization.Method: Using the literature methodology determined the method of the basic public health service project actual cost and the standard cost survey; according to the data main origin and the data type request, extracts 31 community health service centers in the Futian area, consult the finance record and the commodity expenditure record, union questionnaire survey , half structure interview, the review investigation and the observation methodology, obtains various communities health service organization service, the personnel and so on, and each kind of cost, each service project actual investment manpower and the time, uses the time distribution system method to carry on the cost to survey; Using the literature methodology, the logical induction, the expert consult methodology, inputs the superior foreword chart method to determine the principle and the method of community basic public health service project limits, and according to the above ascertain the project of Futian area community basic public health service in the present stage.Result:(1) The ordinary circumstances of community health service in Futian areaIn recent years the social economy development in Futian area is good, the growth is maintaining with steady steps, the resources in the area is rich, the community health service organization, the city large-scale medical and health organization and the social medical service health service organization coexists. At present the Futian area has developed the community health service project total 10 big kinds of 76 items, the health service organization service is complete in various communities, "a six body" consummates day by day. The end of 2004 Futian area community health service personnel total 515, average 9.4 person of/centers.In 2000 ~2004 the investment of Fukuda area government to the community health service increases year by year. The drugs income is the main source of income in the Investigated 31 society health centers, the drugs income accounts for the service income proportion to surpass 80% in the individual society health center. The service income average of community health service organization in Futian area in 2004, 54.2% comes from the drugs income, 45.8% of income comes from medical service income.(2) The community health service cost surveys in Fukuda areaThis research carry on the actual cost and standard cost surveying to 10 big kinds of 76 items of communities health service project which already developed in Futian area, 59 items of community health service projects’standard cost had to be higher than the actual cost, accounted for the service project total 75%, another 19 actual cost was higher than the standard cost. The concrete result sees the main text.(3) The limit of community basic public health service project in Fukuda areaThis research proposed the characteristic and the limits principle of community basic public health service project, and proposed the community health service project classification means union public product theory, according to the above connection gathered the standard cost reference value of the cost to survey in the result and 10 big kind of prioritys-rating arrangements expert consults, has carried on the classified arrangement to the Futian area community health service project, then obtained.(4) The community basic public health service package in Futian areaTaking the Futian area community health service project arrangement and an entire area total standard cost volume table as the foundation, the reference concerned expert’s correlation findings, by taking 0.1% of GDP in the Fukuda area in 2004 as the standard financial investment of community basic public health service, respectively is the resident population number and the household register population number for surveys caliber, had determined the concrete project in Futian area community basic public health service package under this standard investment.Conclusion:(1) this topic has surveyed the Futian area community health service project actual cost and the standard cost taken 2004 as the type, the result of surveys data can be applied to the Futian area community health service organization operation efficiency appraisal, the standard cost reference has the important reference value to reasonable determination compensation to the community health service finance and make community health service price standard.(2) This topic had determined the concrete projects of community basic public health service package at present in Futian area, and in this foundation has obtained the finance subsidy gap in community pure public health service package in Fukuda area, has provided the quantification promotion tool to ascertain the compensating scope of the community public health and realize government responsibility to the community public health service.更多还原