决策制定与项目纵向分析

决策制定与项目纵向分析Decisionmaking,有效性,研究层面和操作层面的优先性,可选择的干预措施:,效能效率负面效应可接受性,文化，社会-道德伦理-,优化实施方案,净效益,优化实施方案,项目的整合,资源的分配,+,质量管理,-资源产生分配，管理-针对目标人群接受（公平性）经济保护（保险）-合理,质量管理体现效能-,卫生政策,对良好的社会和生活的讨论,卫生系统的管理,Questions:Linearityinpractice?Interactionsandoverapsbetweenareas?Actors?Whichtypesofrationality?Whichlevelsofrationality?,建立优先准则的相互关系,MagnitudeoftheVulnerabilityproblemHealthseverityavailabilityservicesfrequencyapplicabilityPopulationperceptionacceptability,（二）流行病学模型,模型的基本要素Elementsofthemodel:根据疾病自然史，确定疾病发展的相关阶段Intheconstructionofsuchamodelwemakeuseofelementsofthenaturalhistoryofthedisease:therelevantstagesinsystemictermsand/orintermsofinterventions;确定各阶段的静态概率和动态概率Tothisareaddedthe“static”probabilities(intermsofprevalence)andthe“dynamic”ones(intermsofrisks,probabilitiestogofromonestageorstatustoanother);,描述疾病转归的相关因素describetheelementsthatarerelevantfortransmissionofthedisease,ifthisisnecessaryandrelevant;描述动态转变的影响因素describethefactorsthatcaninfluencethedynamicswithinthesystem(co-factors,risk-factors,risk-markers),结核病流行病学模型,Inf.Notres.Ill(1)Inf.Inf.Inf.NotInf.NotillResistIll(2)Notres.Notill“Resist”Thereappeartobe2differentdiseases:-type1isatypicalinfectious,transmittable,mono-factorial;-type2,thoughetiologicallyaninfectiousdisease,hasmoreofthecharacteristicsofachronicdisease,multi-factorial.,影响感染的因素,1年龄2性别3职业4HIV感染和艾滋病5其他因素,影响流行的因素,1自然因素2病原生物学因素3社会因素,（三）列出可能的干预措施并进行选择Inventoryofinterventions-selection,对每项干预措施进行分析1.干预措施的关联性分析（一般可分解为以下二个问题）:干预措施的有效性？Isthisinterventiondesirable?干预措施的可行性？Isthisinterventionfeasible?,2.对预措施进行系统分析技术层面效能Itstechnicalefficacy操作层面效能Itsoperationalefficacy(oreffectiveness)成本（效率）Itscost(efficiency)可行性Itsacceptability,（三）结核病可能的干预措施,检测和治疗肺结核检测和治疗原发或继发感染BCG接种化学预防提高社会-经济状况隔离病人重症患者的康复对动物传染源的措施,结核病可行的干预措施,选择三项措施检测和治疗肺结核检测和治疗原发或继发感染BCG接种,（四）实施机构,Choicestobemadeherearesituatedinthefollowingsetsofoppositions:综合性、专科性卫生服务机构或社区卫生服务机构Centralized-decentralized永久性或阶段性机构Permanent-periodic多功能或专业机构Multi-functional(versatile,polyvalent)-specialized,（五）实施人员personnel,专业技术人员或社区卫生服务人员Onecan,again,usetheoppositesspecializedmulti-functional,butalso,morespecifically,thenecessaryleveloftrainingorqualification.,操作性分析OperationalisationofselectedactivitiesAnswerstothequestions:whodoeswhat,where,how,when,forwhom,whatwith?,措施：检测和治疗肺结核患者,问题:主动或被动检测?主动检测目的:“todetectpeoplebeforetheyhavesymptoms,inordertoavoiddetectingthemwhentheyhavealreadycontaminatedtheirenvironment”,措施：肺结核患者被动检测,在普通就诊中发现肺结核的可疑患者对可疑患者进行对痰涂片检查痰涂片检查阳性中启动足够的治疗持续对已启动治疗的患者进行治疗,被动监测,(1)在一般就诊中发现肺结核可疑患者-Whatweneed,therefore,isadiscriminatingsignatanearlystageofillness,andmoreover,onethatcaneasilybeoperationalised.,(1)在一般就诊中发现肺结核可疑患者,Inthiscase,“cough2weeksappearstobethemostefficientscreeningsign.Othersign:-weightloss(well-nourishedpopulation)-nightsweat,（1）在一般就诊中发现肺结核可疑患者,Inconclusion,adecentralizedandversatileserviceisnecessary.Permanencewillbeanasset,butratherasecondaryone.Quality,(2)痰涂片检查-technicalcompetence:-trainingtoacquirethenecessaryskill-sufficientfrequencytomaintaintheskill-somekindofqualitycontrolsystem(supervision,qualitytesting)-decentralizedstructure,(3)痰涂片检查阳性者启动抗结核治疗commonsituation:patientsarediagnosedasPTBinthehospitalandthattreatmentisstartedinthehospital.After2or3monthsthesepatientsarereferredbacktotheHCforfurthercontinuationoftreatment.-theinitiationoftreatmentcanbestbeintegratedinthepackageofactivitiesofthesameservice(multipurposeanddecentralized).,（4）持续进行抗结核治疗-maintainingcontinuity:accessibility(decentralizedservice)-otherfactors(socialcontextandindividualtendency):sex,age,literacy,degreeofschooling.-identifyingindividualcauseswiththepatients,byaskinghimwhyheisirregular.-searchforsolutionswithpatients-acapacitytolistenandtohearthingsoutsideourownprofessionallogic-acapacitytoempathize,操作性分析（OA）(M.PiotsModel),1.定义通过对卫生服务功能进行综合分析，构造模型识别实施特定健康问题干预时可能存在的问题。以定量分析为主。,2.方法(1)选择某一健康问题，如结核病防治(2)描述已采用的策略（根据VA分析情况）ResultsoftheV.A.:Strategyofpassivedetection-treatmentatFLHSDiagnosis=findingAAFBinsputumTreatmentisstartedassoonasresultsareknow,(3)对各干预环节可能环节进行分析（从起点到终点）A:individualisstillfreeofPTBZ:individualiscuredofPTB=Attempttovisualisethepatientshealthseekingandcasemanagementcourse,3.构造分析模型3.1识别干预过程的主要环节（每一环节的概率）A:populationofindividualsstillfreeofproblemX=populationforwhichthehealthservicetakesresponsibility(1)PTB发病或患病情况:Incidenceorprevalence(2)对疾病的知晓率（根据症状）:Awareness,(3)知晓者接受卫生服务的频率:Motivation(4)就诊者中接受痰涂片检查的频率:Examination(5)PTB患者痰涂片检查阳性率:Sensitivity,(6)实验室检测的一致性:Reliability(7)持续接受规则治疗:Regularity(8)治疗的有效性:EfficacyZ:TotalNofindividuals(timely)curedofPTB=NxIncidence(prevalence)xAwarenessxMotivationxExaminationxSensitivityxReadingReliabilityxRegularityxEfficacy.,四方面参数:1.流行病学Epidemiology:Incidence(prevalence)2.参与性Participation:AwarenessxMotivationThesepatientswantaccesstoservice3.诊断Diagnosis:ExaminationxSensitivityxReliabilityTheirstatushastobecorrectlyassessed.4.治疗Treatment:RegularityxEfficacy,Table1:ModelofoperationalanalysisofPTBcasemanagement,评价:流行病学参数选择Prevalence=calculatingneedsintermsofplanning=atstartofanewprogrammeIncidence=on-goingprogramme“Z=5”Thismeansthatonly