基于离散选择实验研究吸引和稳定农村基层卫生人员的最优策略

Rural primary care providers are essential components of health service system. Attraction and retention of rural primary care providers is the dire demand of China’s health reform aimed at strengthening primary health care, also the vital access to achieve universal health coverage. However, the difficulty in recruiting and retaining rural primary care providers has made China’s rural primary care providers less competent, and greatly restricted the quality of rural primary health care. In order to solve the recruiting and retaining problem, policy makers must first understand the factors that influence the decision or choice of primary care providers to relocate to, stay in or leave rural areas, and then formulate interventions that respond to these factors. In consideration of the scarcity of health care resources, there is also a need to estimate and forecast the cost and effect of the interventions in order to find the most cost-effective one. This study will analyze rural primary care providers’ job preference by discrete choice experiment, which could overcome the defect of traditional methods and could elicit the most realistic factors that influence primary care providers’ job decisions. This study will also use cost-effectiveness analysis to analyze the interventions that formulated by discrete choice experiment, and provide policy suggestions on the most cost-effective intervention to attract and retain rural primary care providers.

农村基层卫生人员是卫生服务体系的重要组成部分，加强农村基层卫生人员的吸引和稳定既是新医改“强基层”的迫切要求，也是实现全民健康覆盖的必经之路。然而当前我国农村基层卫生机构面临着突出的招募难、留用难的困境，造成农村基层卫生人员整体素质较低的局面，限制了农村基层卫生服务的质量。为了缓解农村基层卫生人员招募难、留用难的困境，决策者必须首先从农村基层卫生人员的需求出发了解其选择或离开农村基层工作的因素，进而采取相应的政策措施。同时考虑到卫生资源的稀缺性，需要对可能采取的干预策略进行前期的效果预测和成本估算，以选择最经济有效的策略。本研究拟基于离散选择实验首先研究农村基层卫生人员的工作意愿，能克服传统方法在意愿研究中的不足，最为真实地反映影响基层卫生人员做出工作选择的因素；进而对经离散选择实验识别的干预策略进行成本效果分析，提出吸引和稳定农村基层卫生人员的最优干预策略，为相关政策制定提供依据。

提高我国农村基层卫生服务机构的吸引力，为农村基层卫生服务机构招募足够数量的、具备较高业务能力的卫生服务人员，是改善农村基层卫生服务质量的重要途径，也是实现基层首诊的分级诊疗制度的重要前提。为了探讨并制定切实有效的农村卫生人力资源的吸引和稳定策略，必须从农村基层卫生服务人员的需求角度出发真正了解影响农村基层卫生服务人员做出工作选择的因素。同时考虑到卫生资源的稀缺性，需要对可能采取的吸引和稳定策略开展前期的效果预测和成本估算，以选择具有最优成本效果的策略。本研究以离散选择实验设计为基础，通过对农村基层卫生服务人员工作意愿的研究，以及对吸引和稳定农村基层卫生服务人员干预策略的成本效果分析，寻求吸引和稳定农村基层卫生服务人员的最优策略。对农村基层卫生服务人员工作意愿的研究发现，纳入研究的收入、福利、工作条件等六项工作属性对其工作意愿均具有显著性影响。从单一干预策略的效果预测来看，提高收入效果最明显，其次为改善福利状况，此外为农村基层卫生服务人员提供较好的职业发展机会对于稳定农村基层卫生人员也具有较好的效果。从混合干预策略的效果预测来看，将当前农村基层卫生服务人员的平均月收入提高20%同时提供基本的福利待遇，效果最为明显。对主要干预策略的成本效果分析发现，当前最优的吸引和稳定农村基层卫生服务人员的干预策略为“收入提高10%”。考虑到成本因素后，虽然“收入提高20%”的干预效果更好，但是却不是最具成本效果的。研究还发现，从加强农村基层卫生工作的吸引力的角度来看，为基层卫生机构完善设备配备并不具有足够的成本效果。提示我们应重视基层卫生的“软件”建设，选择更直接、更有成本效果的举措，切实提高农村基层卫生服务人员的收入、福利待遇和职业发展机会，使农村基层卫生服务机构能够“引得来”、“留得住”优秀的卫生服务人员。