public health-上海市社区公共卫生服务财政投入机制研究

Y.Zhaoa,S.Cuia,J.Yangb,W.aSchoolofPublicHealthandFamilyMedicine,bNationalInstituteofHospitalAdministration,cOfficeofHealthEmergency(CentreforPublic2010TheRoyalSocietyforPublicHealth.PublishedbyElsevierLtd.Allrightsreserved.Supplyingfreebasicpublichealthservices(individual-basedclinicalpreventiveservicesandpopulation-basedpublichealthservices)incommunitysettingsisofgreatsignificanceinimprovingqualityoflifeandpromotingsocialharmony.Since2005,theChineseGovernmenthaspromulgatedaserieswouldbefundedatalllevelsofgovernmentsandbedeliveredbythenationwidecommunityhealthservices(CHS)organi-zations.4On10April2009,theChineseGovernmentreleasedapolicystatementwhichenhancedthereformsofthemedicalandhealthsystems,andwhichre-emphasizedthatgovernmentalbodieswillofferequitableaccesstobasicpublic*Correspondingauthor.Tel./fax:861083911500.Healthww.publichealth125(2011)37e45E-mailaddress:(W.Liang).Introductionofdocumentsfordevelopingbasicpublichealthservices.1e3ThesereportsmandatedthatbasicpublichealthservicesCommunitymedicineQualitativeresearchChinainhabitantssince2008,butdemandforfundingfarexceededmoniesavailable.Teamsconsistingofgeneralpractitioners,communitynursesandpublichealthspecialistsdeliveredtheseservices.Thenumberofpractitionersandtheirlowlevelsofskillwereinsufficienttoprovideadequateservicesforcommunityresidents.Respondentsgaverecommendationsofhowtoresolvetheaboveproblems.Conclusions:Inordertoimprovethedeliveryofbasicpublichealthservices,itisnecessaryforBeijingMunicipalGovernmenttosupplyclearanddetailedprotocols,increasefundingandincreasethenumberofskilledpractitionersinthecommunityhealthservices.NanRoad,Beijing100044,ChinaarticleinfoArticlehistory:Received6October2009Receivedinrevisedform4August2010Accepted21September2010Availableonline8December2010Keywords:Publichealth0033-3506/$eseefrontmatter2010TheRoydoi:10.1016/j.puhe.2010.09.003Wanga,A.Guoa,Y.Liua,W.Liangc,*CapitalMedicalUniversity,Beijing100069,ChinaMinistryofHealthofthePeoplesRepublicofChina,Beijing100083,ChinaHealthEmergency),MinistryofHealthofthePeoplesRepublicofChina,No.1,XiZhiMenWaisummaryObjectives:TounderstandtheadvancementsinandbarrierstotheimplementationofmeasurestoimprovebasicpublichealthservicesinanurbanChinesecommunity.Studydesign:Aqualitativestudybasedonsemi-structuredinterviews.Interviewswereaudio-taped,transcribedandanalysedusingthematiccontentanalysis.Methods:In-depthinterviewswereundertakenwiththedirectorsofthemanagementcentresforcommunityhealthservicesin15ofthe18districtsinBeijingfromDecember2008toFebruary2009.ContentanalysisofthedatawascompletedinMay2009.Results:FifteentypesoffreebasicpublichealthserviceshadbeendeliveredinBeijing.Someweresuppliedatalowlevel.Anaverageof2.38perpersonperyearwasprovidedforaqualitativestudyBasicpublichealthservicesdeliveredinanurbancommunity:OriginalResearchPublicjournalhomepage:walSocietyforPublicH/puheealth.PublishedbyElsevierLtd.Avidesandco-ordinatescomprehensivemedicalcareforpublichealth125(2011)37e4538healthservicesforbothurbanandruralresidents.3Asthecentreofpolitics,economyandcultureofChina,BeijingMunicipalGovernmentattachesextremeimportancetoandpromotesadvancesinthedevelopmentofbasicpublichealthservicesdeliveredinthecommunity.Overthepasttwodecades,Chinahasbeenundergoingaprocessofeconomicreformandhasbeenrelativelysuccessful.Thehealthcaresystem,whichhadbeenreformedtosuitthemarketeconomy,5facedmultiplechallenges:limitedfinancialsupportfromgovernments;highratesofcatastrophicout-of-pocketspendingandimpoverishmentthroughhealthexpenses;inequalitiesinhealthandhealth-careutilization;andlimitedfinancialprotectionevenamongthosewithinsurance(asmallminorityofthepopulation).6Duetotheabovechallenges,theoldthree-tieredhospitalsystem,whichinvolvedlocalneighbourhoodhospitals,district-widesecondaryhospitalsandcity-widetertiaryhospitals,wasforcedtorelyonthesalesofnewdrugsandtechnologiestoboostincome,whichresultedinexpensiveandinefficientcareandstrainedpatientedoctorrelationships.7Theoldpublichealthsystemwastheresponsibilityofdozensofdisparateinstitutes,centres,agencies,bureausanddepartments,whichresultedinoverlappingandsometimesconflictingmissionstatementsandagencymandates.8Withanincreaseinlifeexpectancy,increasedburdenduetochronicdiseases,andthechallengesofemerginginfectiousdiseases(e.g.severeacuterespiratorysyndromein2003),theChineseGovernmentre-examinedthepublichealthinfra-structureandsawtheneedforanewpublichealthsystemtoaddressthemanyhealthissuesassociatedwiththesechanges.5Tominimizeoverlappingoffunctionsandtoincreaseefficiency,theChineseGovernmentconsolidatedexistinginstitutionsintoanewagency:theCentresforDiseaseControlandPrevention(CDC).ThegoaloftheCDCistoprovideacentralpublichealthorganizationwithresponsibilityforbothcommunityandindividualhealthneeds.Thedevelop-mentoftheCDCstrengthenedtheGovernmentsroleinpublichealth.5Aspublichealthandprimarycaresharethecommongoalofimprovingtheoverallhealthofspecificpopulations,itwasdecidedtointegratethetwosystemsbystrengtheningpublichealthfunctionsinprimaryhealthcaresettings.Thisapproachcouldimprovelocalpublichealthsurveillanceandreinforcediseasepreventionandhealthpromotion.9Inordertoresolvetheproblemsoftheincreasingburdenofhealthcareexpensesandlimitedaccesstohealthservices,theChineseGovernmentinitiateditsCHSprogrammein1997.4Thethree-tieredhospitalsystemwasreplacedbythecurrenttwo-tieredCHScentresystem.ThenewsystemconsistsofambulatorycareinCHScentresandinpatientcareinreferralhospitals.7ThemainrolesoftheCHScentresaretoprovidehigh-quality,affordable,accessibleprimaryhealthcareandpublichealthservicestocommunityresidents.ThescopeofservicesoftheCHScentresisdescribedsymbolicallybytheChineseGovernmentasonebody,sixaspects.ThebodyistheCHScentre.Thesixaspectsconsistofbasicclinicalservices,prevention,healtheducation,womenandchildrenscare,elderlycare,immunizationsandphysicalrehabilitation.7ThecentresintegrateWesternandtraditionalChinesemedicine.Inthepopulation-basedpublichealthservices,thereiscollaborationbetweenthecommunityindividuals,familiesandcommunities.10,11TwomodelsarecurrentlybeingusedtotraingeneralpractitionersinChina.Thefirstmodelisa3-yeargeneralpracticepostgraduateresidencytrainingprogramme.Thesecondmodelofeduca-tioninvolvesretrainingthemajorityoftheless-educateddoctorscurrentlyworkinginlocalcommunityhealthcentres,andtransformingthemintogeneralpractitioners.Completioncertificatesareawardedbydifferentorganizations,includingtheCentralMinistryofHealth,provincialministriesofhealthandcity-levelhealthbureaus.10,11Generalpractitionerstypi-callyworkintheclinicsofCHSorganizations.Whendeliv-eringpopulation-basedpublichealthservices,generalpractitionersoftenworkinteamswithpublichealthspecial-ists,communitynursesandotherproviders.10,11In2007,inordertoimplementtheCHSmoreeffectively,BeijingManagementCentreforCommunityHealthServices(MCCHS)wasestablished.ItisaffiliatedadministrativelywithBeijingMunicipalHealthBureau.Similarly,adistrictofficeoftheMCCHSisattachedtoeachofthecitys18districthealthbureaus.12ThemainresponsibilitiesofBeijingMCCHSincludewritingregulations,establishingassessmentstandards,andorga-nizingpracticesfortheCHSwhile,atthesametime,super-visingtheworkofthedistrictMCCHSs.ThedistrictMCCHSsareresponsibleforplanning,managingandassessingtheworkperformedbyallCHSorganizationsintheirrespectivedistricts.EachdirectorofadistrictMCCHSmustbefamiliarwiththeactivitiesoftheCHSinhis/herdistrict.12FifteentypesoffreebasicpublichealthserviceshavebeendeliveredbytheCHSinBeijingsince200613(Appendix1).Todate,noresearchhasinvestigatedtheimplementationoftheseservicesinBeijing.DuetoaninterestinunderstandingthestatusofandbarrierstobasicpublichealthservicesintheBeijingcommunities,theauthorschosetodesignastudythatwouldinvestigatetheconceptualframeworksoftheseservices.Tothatend,all18MCCHSdistrictdirectorswereapproachedinordertoascertaintheiropinionsofthequalityofthedeliveryofbasicpublichealthservicesbyprovidersintheCHS.MethodsParticipantsandsettingSamplingconsistedofall18directorsfromthe18MCCHSdistributedinthe18districtsinBeijing.Afterobtainingtheirnumbersfromthetelephonebook,initialcontactwasmadewiththem.Onedirectorwasawayonbusiness,onewastoohealthcentresandthelocalCDC.7LocalgovernmentsarethemainsourcesoffundingforthelocalCDCandCHScentres.ThecoreprovidersintheCHScentresaregeneralpracti-tioners(familydoctors),10,11publichealthspecialistsandcommunitynurses.Thesepractitionersareresponsiblefortheprovisionofbasicclinicalservicesandformaintainingthewellnessoftheresidents,ofallages,intheircommunities.4InChina,ageneralpractitionerisamedicalpractitionerwithrecognizedgeneraltraining,experienceandskills,whobusyanddeclinedtobeinterviewed,andonewasunabletobereached,despitemultiplecalls.Semi-structured,in-depthconsentandanagreementfortheuseofanonymisedquotespublichealth125(2011)37e4539fromtheinterviewswereobtainedfromallparticipants.Semi-structuredinterviewsSemi-structured,face-to-face,tape-recorded,qualitativeinterviews,lasting60e90mins,wereconductedbytrainedprofessionalinterviewersfromDecember2008toFebruary2009.Interviewerstookextensivenotes,inadditiontotaperecordingandtranscribingtheinterviews.Thetranscriptswerereviewedbytheresearchteam.Analysisandinterpre-tationwerereachedbyconsensus,usinganiterativeprocessintheresearchteammeetings.Theresearchteamwasamultidisciplinarygroupincludingtwocommunity-basedmedicalresearcherswithqualitativeandsocialresearchexperience,onehealthadministratorfromahealthbureaufamiliarwithhealthpolicy,onefamilydoctorfamiliarwiththeCHS,twoepidemiologistsandoneMastersdegreecandi-datewithafamilymedicinedegree.Thevarietyofperspec-tivesoftheteamensuredadepthofunderstandingcriticaltothedesignofthestudyandthevalidityoftheresults.Aninterviewguidewasdevelopedonthebasisofrefer-encesandrelevantgovernmentdocuments.Theinterviewquestionswereopen-endedandcoveredissuesaboutbasicpublichealthservices,thecontentofspecificservicesbeingdelivered,funding,typesofproviders,andgeneralinsightsoftherespondents.AnalysisQualitativecontentanalysis14,15wasusedtoanalysethedatabetweenMarch2009andMay2009.Thedataconsistedofrichtextfilescontainingtranscriptsofthetape-recordedinterviews.Theteammembersreadallthematerialthroughseveraltimestoobtainasenseofthewhole,andthenindependentlycodedtranscriptstoidentifythemesbycondensingandsummarizingthecontents.Codingdifferenceswereresolvedafterthoroughdiscussioninordertoensurethatallperspectivesonthethemeswererepresentedinthewrittenresults.Thethemesthatemergedforthepurposesofthisreportincludedthecontentofbasicpublichealthservices,fundingsupport,providersandrecommendations.Alloftheinterviewswereincludedintheanalysis;therewerenodisconfirmingcases.ResultsThemesfrominterviewsThefindingsrelatetothreemainthemes:thecontentofbasicpublichealthservices,fundingsupportforbasicpublichealthinterviewswereconductedwiththeremaining15MCCHSdistrictdirectorswhowerefamiliarwiththeworkintheCHS.Interviewswereusuallycarriedoutintherespondentsworkoffices.Allparticipantswereinformedaboutthepurposeofthestudyandweremadeawarethattheycouldstoptheinterviewatanypointwithoutgivingareason.Writteninformedservices,andtheproviderswhodeliverbasicpublichealthservices.ContentofservicesFifteentypesofbasicpublichealthservices,including78specificservices(Appendix1),weredeliveredatdifferentlevelsinthevariousdistricts.Amongtheseservices,mostofthedirectorsconsideredtheestablishmentofhealthrecords,chronicdiseasemanagement,childhoodimmunizationsandcare,maternalcare,elderlycare,disabilityandrehabilitationservices,andhealtheducationtobesuppliedathighlevels.However,theprovisionofmentalhealth,ophthalmologic,oralhealth,pestcontrolandendemicdiseaseserviceswerelowandsporadicinsomecommunitiesduetothelowlevelofstaffcompetencyforthesetasks.Incommunityhealthinformationmanagement,communityneedsassessmentswereoneoftheimportantjobsinthecommunity.The15directorsagreedthatitwasoftennecessaryforcommunityneedsassessmentstobeundertakenwiththeassistanceofaspecialresearchgroupduetopractitionerslimitedresearchskillsinthisarea.Theratesofcreationofpaperhealthrecordsforallinhab-itantswereestimatedtobehigh.Atpresent,thegovern-mentshaveattachedimportancetothedevelopmentofelectronichealthrecords,andthetransformationfrompapertoelectronicrecordsisaslow,stepwiseprocessinthecommunities:“Paperhealthrecordshavebeenestablishedfor70%ofpeopleinourdistrict,andweplantocompletethisworkforallourresi-dentsby2010.”“TheMunicipalGovernmentrequiredCHSorganizationstoestablishpaperhealthrecordsforallresidentsinBeijing.Acentreprovidesservicestoabout30,000e100,000residentsaccordingtothesizeofaregion.Infact,duetohealthworkforceshortagesandasmallnumberofrevisitingpatients,only30%ofestablishedpaperrecordscanbefollowedupandusedcontinuously.”“Howtocontinuouslyanddynamicallyusethesehealthrecords,especiallythoseofhealthypeople,isaGordianknot.Afeasiblemethodtoresolvethisproblemmaybebyusinganelectronichealthrecordinformationsystemstoreducethetimespentonpaperwork.Thefirstthingthatthegovernmentsneedtodoistoestablishthestandardsofelectronicrecordsystemsandtomakeexperimentsinsomedistricts.”Regardingthemanagementofcommunicablediseases,mostoftheCHSorganizationsrolesarelimitedtoassistingthelocalCDCswiththecompletionoftaskssuchasfinding,reportingandfollow-upofcases:“However,forresponsestoemergentpublichealthhazards,CHSorganizationsareplayingmoreandmoreimportantroles.”Themanagementofchronic,non-communicablediseasesisanimportantjobforCHSorganizationsbecauseofthehighincidenceanddeleteriouseffectsoftheseillnesses.Providingoptimalhealthcareforpersonswithchronicconditionsisamajorconcerninthecommunity.BeijingMunicipalHealthBureauhasestablishedasetofguidelinesforthemanagementofchronicdiseasesincommunitythatcommunitymembersforwhomtheywereresponsibledidnottrustthemastheseclinicianshadlowerlevelsofknowledgemembersservices:publichealth125(2011)37e4540settingseincludinghypertension,diabetes,strokeandheartdiseaseeandrequiresgeneralpractitionerstousetheseguidelineswhenmanagingchronicdiseases.However,defi-cienciesincontinuousprofessionaldevelopmentandalackofevidence-basedguidelineshavecreatedfurtherproblemsindeliveringcost-effectiveinterventionsforchronicdiseaseprevention:“Therateofadherencetotheseguidelinesislowduetopoorunderstandingandco-operation.Itisnecessarytomakerecommendationsforthesediseasesbymeansofaprocessofcriticalappraisalandconsensusbuilding.”Regardingmaternalandchildcare,theintervieweessaidthatCHSorganizationsassistedlocalwomensandchildrenshealthorganizationsincarryingoutrelatedprogrammes,suchashealtheducationandcounselling,screening,follow-upandreferral:“Childhoodimmunizationswereimplementedatthehighestrate.Itisestimatedtobe98e100%.”“Now,cost-freescreeningsforbreastcancerandcervicalcancerforadultwomenaredeliveredinsomedistrictsaccordingtolocalgovernmentsregulations.”Whenaskedaboutgeriatriccareandcareofpersonswithdisabilities,all15directorsrepliedthattheinstructionofself-careandthemanagementofchronicdiseaseswereemphasizedfortheelderly,andthatexercisesiteshavebeengraduallyupgradedbysupplyingphysicalrehabilitationequipmentfordisabledpeople.Healtheducationisdeliveredregularlyinthecontextofsupplyingotherhealthservices.Mostoftherespondentsagreedthatillness-orientedvisitswerethemostimportantopportunitiestodeliverhealthhabitcounsellingandeduca-tiontopatients,butthatthiswasdonelessfrequentlyduringhealthmaintenancevisits.Thedirectorsagreedthattobaccocessationcounsellingandexerciseadvicewerethemostcommonhealtheducationtopicscoveredbydoctorsandpatientsduringillnessvisits.FundingsupportAnaverageof2.38(ataconversionrateof10.49RMBto1)perpersonperyearwasprovidedforbasicpublichealthservicesinBeijingsince2008,andeachdistrictgovernmentsupplieddifferentamountsofmoneyforbasicpublichealthservicesinitscommunitiesaccordingtoitseconomiclevelandpop-ulation.However,basicpublichealthserviceswereoftenperceivedasnotbeingreimbursedproportionatelytotheamountoftimeexpended,particularlywhentheywereopportunisticallyaddedtoillnessvisits.The15directorsconveyedtheopinionthatfundingforbasicpublichealthserviceswasinsufficient,andthatmostofthefundswerespentoncorrelativepublicequipmentandexpendableitems:“Fewfinancialincentivesarepaidtotheindividualhealthserv-ices.Thismaybeanimportantreasonwhywecantmotivateproviderstodelivermoreandhigher-qualitybasicpublichealthservices.”andskillthanspecialists.Asaresult,communityareoftenreluctanttoacceptbasicpublichealth“Youngpeopleespecially,whoseldomseegeneralpractitioners,donotknowclearlywhichbasicpublichealthservicesaresuppliedbyCHSorganizations.Asaresult,theyoftendonottrustandrefusethesecommunity-basedservices,sopatientnon-“ThereisahigherpercentageofmigrantsinsomedistrictssuchasChaoyang,FengtaiandHaidian,butnoexactbudgetsupportfromBeijingMunicipalGovernmentformigrantsexceptimmu-nizations.Partofpublichealthservices,suchashealtheducation,communicablediseasesmanagementaredeliveredformigrantsinsomedistricts,financedonlybylocalgovernment.TheMunicipalGovernmentneedstothinkovertheproblemsbroughtbymigrants.”ProviderswhodeliverbasicpublichealthservicesTeamsconsistingmainlyofgeneralpractitioners,communitynursesandpublichealthspecialistsdeliverbasicpublichealthservicesinthecommunity.Inadditiontosupplyingmedicalcare,generalpractitionersarerequiredtodeliverycost-freeclinicalpreventiveservicesforindividualsandfamilies,andpopulation-basedpublichealthservices(Appendix1).Theirrolesincludebeingexemplarsforhealth;providingassessments;servingaseducators,counsellorsandevaluators;andmakingreferralswhennecessary.Publichealthspecialists,whoserveasrecordersofhealthdataaswellashealtheducators,areresponsibleforpublichealthservicesforpopulationsintheircommunities.Communitynursesmainlyassistgeneralpractitionersandpublichealthspecialists.“Basicpublichealthservicesoftenwereactuallydeliveredbyalliedhealthprofessionalswhomaybemoreeffectivethanphysiciansininitiatingandcarryingoutmanypublicinterventions.”Duetothebroadscopeofbasicpublichealthservicesandlimitedfinancialincentives,providersfeltthattheywereundergreatstressandharriedbymanycompetingdemandsfortheirtime.Itisunrealistictoexp