县域农村公共卫生服务多元主体协同供给机制研究

To gradually promote the equalization of basic public health services among the urban and rural residents is one of the key tasks of China's new round of medical and health system reform. However, the current three-tier rural health service system is in disorder and absent from the overall collaborative service efficacy. Even if the government has been increasing investment in rural public health year by year, it is difficult to obtain the desired standardized and homogenized public health services that can be enjoyed by all in the rural area, as well as to secure and protect the human health. With the order parameters in the control system, the principle of synergetics can transform the whole system from disorderliness into orderliness so as to achieve synergetic effects, and to ultimately bring about the overall effectiveness of the whole system that is greater than the total effectiveness of various subsystems. This study intends to draw on the principle of synergetics to build a theory model of multi-provider rural public health services supply mechanism in county region. It also intends to identify the supply forming mechanism based on analysis of the evolution of the multi-provider development and also identification of the synergistic effects of internal and external factors and powers by using the social network analysis methods. It will analyze the expectations and aspirations of multi-provider synergetic supply so as to identify the realization mechanism of the synergetic supply. From the multi-provider perspective, it will build performance evaluation index system and mechanism for multi-provider rural public health services synergistic supply in county region. It will propose the feasible recommendation for realization of multi-provider supply mechanism and contribute to theoretical and practical guidance for the management of the rural public health service supply system in China.

促进城乡居民逐步享有均等化的基本公共卫生服务是我国新一轮的医药卫生体制改革的重点任务之一。然而，当前农村公共卫生服务供给体系的无序和整体协同服务功效的缺失，即使政府逐年增加农村公共卫生投入，也难以获得所期望的让农村居民人人享有规范化和同质化的公共卫生服务以及保障维护健康的效果。协同学原理具有通过控制系统中的序参数，使整个系统从无序转换为有序达到协同状态，实现系统的整体效益大于各子系统效益之和。本研究拟借鉴协同学原理构建县域农村公共卫生服务多元主体供给机制理论模型。在分析多元主体协同发展演化和利用社会网络分析法确定影响协同的内外部因素和动力的基础上确定供给形成机制，分析多元主体协同供给的期望和诉求形成协同供给的实现机制，从多元主体视角，构建县域农村公共卫生服务协同供给绩效评价指标体系和机制。提出多元主体供给机制实现的可行性的对策建议，为我国农村公共卫生服务供给体系的管理提供理论和实践的指导。

目的：基于协同理论构建县域农村公共卫生服务复杂系统协同度模型。利用社会网络分析法评价我国农村慢性病管理机构协同服务的现状等。方法：分别抽取浙江省的象山县、河南省的武陟县和陕西省的彬县作为样本县，对其卫生行政部门进行问卷调查，测算其县域农村公共卫生服务复杂系统的协同度。利用文献研究法和专家咨询法确定县域公共卫生服务多元主体协同供给网络维度、核心利益相关者和协同绩效评价概念框架和指标体系。对样本县共计99家农村慢性病管理机构进行问卷调查，运用UCINET软件进行相关的社会网络指标的测量及分析。采用问卷调查确定核心利益相关者的利益诉求。采用模糊评价法确定农村公共卫生服务多元主体的协同绩效的评价指标的权重。结果：象山县、武陟县和彬县农村公共卫生服务复杂系统协同度的最高值分别为0.33337、0.18068和0.21312。息县项店镇的网络密度为信息交流网络0.1050，资源共享网络0.1686，项目合作网络0.0833，社会扶持网络0.1436；息县包信镇的网络密度为信息交流网络0.0569，资源共享网络0.0952，项目合作网络0.0542，社会扶持网络0.1402；武陟县谢旗营镇的网络密度为信息交流网络0.1022，资源共享网络0.1844，项目合作网络0.0803，社会扶持网络0.1403。QAP相关分析显示三个样本乡的四大网络之间都存在相关性，且具有统计学意义（P<0.05）。核心利益相关者为县卫计委、医疗卫生服务机构、医务人员和农村居民，且利益诉求呈现多样性。协同供给绩效评价概念框架和指标体系包括3个一级指标、8个二级指标和18个三级指标，一级指标权重系数分别为0.3239、0.3303、0.3459。结论：供方和需方系统一致性不高、财政支持可持续性不强导致县域农村公共卫生服务复杂系统协同水平较低。慢性病管理的县、乡、村三级医疗卫生服务网络机构合作、互动不足，制约了农村地区慢性病管理工作的整体效率和效果。县域公共卫生服务多元主体协同供给需要以政府为主导，平衡各利益相关者的利益诉求，增强医疗卫生服务机构间的协同能力。指标体系构建的方法切实可靠，结构科学合理，具有一定的实用性和创新性。