疾病预防控制系统改革与公共卫生医师制度改革比较研究

随着医药卫生体制改革的不断深入推进,在健康中国战略实施的大背景下,疾病预防控制体系和公共卫生医师制度改革也被提上议事日程。本研究拟对疾病预防控制体系和公共卫生医师制度改革的成因和改革逻辑进行分析,以期从学理角度厘清二者改革的脉络和逻辑。疾病预防控制体系改革着眼于其与公共卫生体系、国家卫生健康行政机构的关系与分工,关注该机构如何与各级各类政府行政机构更加协调高效解决社会主要健康问题;公共卫生医师制度改革不仅关注其在疾病预防控制体系内人员流失严重的问题,更关注其自身医师队伍在整个健康事业中的定位和人员稳定。     

国外公共卫生医师培养策略及启示

公共卫生医师的个人素养和技能水平对于促进和改善医疗服务、提高人民健康水平起着举足轻重的作用,我国的公共卫生医师培养路径与国外有些差别,如何提高我国公共卫生医师的素养、有效提升疾病预防和卫生应急的业务水平、满足社会对公共卫生的需求是一个亟待解决的问题。文章对美国、英国、古巴和印度的公共卫生医师的培养方法进行了剖析,综述了其培养目标、对象、培养周期及内容,对上海市开展公共卫生医师培训提出了相关建议。     

青州市实施基本公共卫生服务均等化存在问题及对策探讨

基本公共卫生服务均等化是我国基本公共服务均等化的重要组成部分.本文从基本公共卫生服务均等化的相关概念和内涵等方面,分析当前我市公共卫生服务存在的主要问题,并提出了实现均等化的相关政策建议,旨在促进我市基本公共卫生服务健康、持续发展.     

城市基本公共卫生服务项目实施过程情况分析

目的对基本公共卫生服务过程进行分析,获取其执行过程中存在的问题。方法对黑龙江、安徽和广东省29家社区卫生服务机构,采用深入访谈法和问卷调查进行数据收集。结果政府基本公共卫生服务经费拨款为15元/人的占51.72%;3个省社区平均每万人口数与公卫医师的配比为0.25、0.25、0.35,正式编制人员数仅占44.15%;在9项基本公共卫生服务中,建立居民健康档案、健康教育、老年人保健和慢性病管理的覆盖率达到了100%,慢性病患者的管理率仅约为40%及重性精神病管理率低于10%,新生儿访视率、孕产妇产前管理率和产后访视率均约为20%;居民对基本公共卫生服务项目的知晓率仅为42.62%。结论所调查社区卫生服务机构基本公共卫生服务项目开展不均衡,在"量"上取得显著成效,但在"质"上存在较多问题。     

中国公共卫生医师制度建设政策演变研究

随着"健康中国"战略的提出,国家对公共卫生事业的重视更进一步。然而,作为公共卫生事业发展的核心环节之一的公共卫生人才建设当前仍存在诸多问题。本研究通过建立涵盖培养制度、准入制度、使用制度、职称制度、薪酬激励制度的理论分析框架,以制度建设中重要法律法规的出台为线索,来研究公共卫生医师制度政策演变。中华人民共和国成立至今,我国公共卫生医师制度不断完善,逐渐步入法制化轨道。但是当前公共卫生医师功能定位不明确,职业发展规划不清晰、渠道不畅通的问题仍然存在,建议在下一步的制度设计中秉持系统思维,加强多部门合作,以保障制度的顺利建成。     

新形势下中国公共卫生医师职能定位探析

新形势对现有公共卫生医师职能提出了更高的要求和新的挑战,但公共卫生医师职能存在政策设计不明晰、人员实际作用有限、难以满足多元健康需求等问题。新形势下的公共卫生医师涉及疾病预防、健康维护、健康促进三大基本职能,具体包括疾病预防控制、健康促进、健康影响因素监测、全科公共卫生、预防医学科公共卫生五类,其应做到推动医防结合、提高技术应用能力、倡导关口前移、参与全球健康治理,并做到提供连续的、覆盖全生命周期的公共卫生服务。     

中国公共卫生执业医师岗位胜任力模型构建与应用探讨

近年,随着中国社会经济的快速发展,人们的健康观念和意识不断增强,大卫生大健康的理念受到关注。公共卫生医师是公共卫生工作的重要承担者,其知识、能力与素质对于"健康中国2030"的实现有着重要的作用。因此,对于公共卫生医师岗位胜任力模型的研究及其转化应用势在必行。此文旨在对已构建的中国公共卫生执业医师岗位胜任力模型进行全面的解释,阐述模型自身及构建过程中的特点。该模型可以明确公共卫生医师胜任岗位所必需的各项特质,对改进公共卫生医师资格考试大纲具有重要作用;可以为公共卫生人才招聘、员工招聘、人员晋升与绩效考核和薪酬设计等人力资源管理提供依据;可以为公共卫生医师确定合适的职业生涯目标和职业生涯发展路线;对公共卫生人才教育和继续教育的改革提供依据;为公共卫生医师规范化规培制度的建立提供理论支持。     

基于继承与发展的公共卫生概念界定研究

目的在前期研究基础上,遴选公共卫生经典内涵,纳入公众健康核心理念,提出新时代各方统一的公共卫生定义,指导我国公共卫生理论和实践。方法通过专题小组讨论,明确应纳入的经典内涵和增加的核心理念;遵循逻辑学中公认的常用下定义方法和步骤,形成公共卫生定义和内涵外延;开展多重定性定量论证和全国范围的各方专题意向论证,明确接受程度,收集意见建议进行完善。结果通过遴选与完善经典内涵的过程,最终共"保留"8类经典内涵,"增加"4类公众健康核心理念,补充"公共卫生本意为公众健康"的强调;通过6轮"论证–完善–再论证–再完善"循环和3轮德尔菲论证,收集专家意见并修改完善;在此基础上,形成本研究的公共卫生概念界定:公共卫生(public health)是以保障公众健康与健康公平为导向的公共事业。由政府主导、社会协同、全体社会成员参与共享,运用健康相关理论与方法,预防和控制疾病与伤残,降低和消除健康风险,改善和促进人的生理、心理健康及社会适应能力,以提高全民健康水平与生命质量、维护社会稳定与发展。公共卫生本意为公众健康,其内涵已成为健康国家(地区)的基础。通过开展意向论证,调查全国七省的3 291名组织者和提供者以及全国10所高校的136名研究者,论证结果显示,公共卫生界定获得组织者、提供者、研究者等各方高度认可,其中定义的整体认可率达到98.7%,各块内涵外延的认可程度在97.6%～99.2%。结论新时代明确"何为公共卫生"意义重大,可以指导公共卫生理论和实践,有利于统一各方行动。本研究界定的公共卫生定义具有明确政府责任、强调健康公平、强调社会协同、明确公民义务等鲜明特点。     

从公共卫生的内涵看设立公共卫生委员会的必要

公共卫生的内涵包括疾病控制、健康保护和健康促进三个方面,具有明显的正面外部效应,需要政府主导。与医疗服务、预防医学都有明显区别。通过分析其内涵和外延,针对我国目前公共卫生管理体系存在的缺陷,得出政府在公共卫生管理中要成立国家公共卫生委员会以统筹体制改革;实行垂直的一体化管理以有效配置资源。     

医师多点执业影响因素调查与研究

目的：通过对江苏省医师多点执业影响因素的调查与分析，提出进一步推进医师多点执业的建议。方法：选取南京市和泰州市共14所医疗机构作为抽样单位，从中随机选取552名已取得执业资格的医师为调查对象进行问卷调查，通过SPSS20.0软件对结果进行统计学分析。结果：（1）医师学历、年龄、职称、科室对医师多点执业意愿存在显著影响；医师性别、所在医疗机构等级、从业年限和月收入对医师多点执业意愿无显著影响。（2）政策因素、组织因素和个人因素都与医师多点执业意愿呈显著正相关，按照影响程度由高到低排序依次是政策因素、个人因素和组织因素。结论：为进一步推进医师多点执业，相关部门需要站在立法高度上完善医师多点执业激励、风险、准入、财政和监管等规定；二、三级公立医院和基层医疗机构管理者也要及时转变观念，积极鼓励、支持医师多点执业，完善人事制度；医师自身也要重新定位角色，以更好的状态积极参与多点执业。     

Are public health physicians fading out of management?

BACKGROUND: Recent developments in health services in the local arena in Norway have challenged the theoretical and applied scientific basis for both public health medicine and management. During the 1990s although public health physicians in Norway increased in number, they worked less with public health, as well as public health management. The effects of these developments on public health management are largely unknown. We studied public health physicians' involvement in management and their self-reported managerial competence. METHODS: Cross-sectional study of physicians working in local public health medicine in all Norwegian municipalities, using a mail-back questionnaire. RESULTS: Public health physicians reduced their administrative tasks and evaluated their own managerial competence rather conservatively and somewhat lower in 1999 than in 1994. Many had supplementary training in management in addition to their medical education and specialty training. CONCLUSIONS: Public health physicians may be fading out of management. To address this there is a need for development of both public health management training programmes and provision of adequate resources for managerial activities.     

Development of an interactive bioterrorism and emerging infections curriculum for medical students and internal medicine residents

While awareness of bioterrorism threats and emerging infectious diseases has resulted in an increased sense of urgency to improve the knowledge base and response capability of physicians, few medical schools and residency programs have curricula in place to teach these concepts. Public health agencies are an essential component of a response to these types of emergencies. Public health education during medical school is usually limited to the non-clinical years. With collaboration from our local public health agency, the Emory University School of Medicine developed a curriculum in bioterrorism and emerging infections. By implementing this curriculum in the clinical years of medical school and residency programs, we seek to foster improved interactions between clinicians and their local public health agencies.     

Higher fees paid to US physicians drive higher spending for physician services compared to other countries

Higher health care prices in the United States are a key reason that the nation's health spending is so much higher than that of other countries. Our study compared physicians' fees paid by public and private payers for primary care office visits and hip replacements in Australia, Canada, France, Germany, the United Kingdom, and the United States. We also compared physicians' incomes net of practice expenses, differences in financing the cost of medical education, and the relative contribution of payments per physician and of physician supply in the countries' national spending on physician services. Public and private payers paid somewhat higher fees to US primary care physicians for office visits (27 percent more for public, 70 percent more for private) and much higher fees to orthopedic physicians for hip replacements (70 percent more for public, 120 percent more for private) than public and private payers paid these physicians' counterparts in other countries. US primary care and orthopedic physicians also earned higher incomes ($186,582 and $442,450, respectively) than their foreign counterparts. We conclude that the higher fees, rather than factors such as higher practice costs, volume of services, or tuition expenses, were the main drivers of higher US spending, particularly in orthopedics.     

Insured without moral hazard in the health care reform of china

Public insurance possibly increases the use of health care because of the insured person's interest in maximizing benefits without incurring out-of-pocket costs. A newly reformed public insurance scheme in China that builds on personal responsibility is thus likely to provide insurance without causing moral hazard. This possibility is the focus of this study, which surveyed 303 employees in a large city in China. The results show that the coverage and use of the public insurance scheme did not show a significant positive effect on the average employee's frequency of physician consultation. In contrast, the employee who endorsed public responsibility for health care visited physicians more frequently in response to some insurance factors. On balance, public insurance did not tempt the average employee to consult physicians frequently, presumably due to personal responsibility requirements in the insurance scheme.     

National Health Service Corps Staffing and the Growth of the Local Rural Non-NHSC Primary Care Physician Workforce

CONTEXT: Beyond providing temporary staffing, National Health Service Corps (NHSC) clinicians are believed by some observers to contribute to the long-term growth of the non-NHSC physician workforce of the communities where they serve; others worry that NHSC clinicians compete with and impede the supply of other local physicians. PURPOSE: To assess long-term changes in the non-NHSC primary care physician workforce of rural underserved counties that have received NHSC staffing support relative to workforce changes in underserved counties without NHSC support. METHODS: Using data from the American Medical Association and NHSC, we compared changes from 1981 to 2001 in non-NHSC primary care physician to population ratios in 2 subsets of rural whole-county health professional shortage areas: (1) 141 counties staffed by NHSC physicians, nurse practitioners, and/or physician assistants during the early 1980s and for many of the years since and (2) all 142 rural health professional shortage area counties that had no NHSC clinicians from 1979 through 2001. FINDINGS: From 1981 to 2001, counties staffed by NHSC clinicians experienced a mean increase of 1.4 non-NHSC primary care physicians per 10,000 population, compared to a smaller, 0.57 mean increase in counties without NHSC clinicians. The finding of greater non-NHSC primary care physician to population mean ratio increase in NHSC-supported counties remained significant after adjusting for baseline county demographics and health care resources (P < .001). The estimated number of "extra" non-NHSC physicians in NHSC-supported counties in 2001 attributable to the NHSC was 294 additional physicians for the 141 supported counties, or 2 extra physicians, on average, for each NHSC-supported county. Over the 20 years, more NHSC-supported counties saw their non-NHSC primary care workforces grow to more than 1 physician per 3,500 persons, but no more NHSC-supported than nonsupported counties lost their health professional shortage area designations. CONCLUSIONS: These data suggest that the NHSC contributed positively to the non-NHSC primary care physician workforce in the rural underserved counties where its clinicians worked during the 1980s and 1990s.     

Leaving the stethoscope behind: public health doctors and identity work

Public health medicine is distinct in two ways from most other forms of medical specialisation; firstly, it is predominantly non-clinical and secondly, its concern is with populations, rather than the more common individual physician–patient encounter. In spite of recent attempts to ‘mainstream’ public health approaches into medical training and practice, it remains a relatively low prestige medical specialty. In the face of the centrality of all things clinical in medical training, the identity work needed to think beyond this and into population health approaches is significant. In the face of public health physicians’ subaltern position within medicine, this research investigates the identity work doctors did as they made the transition into public health medicine and how they understood their positioning once they were within the specialty. The inductive thematic analysis conducted on the qualitative interview data generated for this research elicited three key themes of relevance for the 19 public health physicians in New Zealand who were interviewed. The calling into question of biomedical identities was evident and concomitant with this was a sense of loss of the satisfactions of clinical medicine including contact with patients and the ability to solve discrete clinical problems. The final theme revolved around how public health physician identities were felt by the participants to be discredited. Lack of attention to the identity work required to think beyond the individual in health terms may contribute to a slow pace of change.     

我国公共卫生医师培养现状及影响因素研究

目的:通过分析当前公共卫生医师培养现状及其影响因素,探究制度根源并提出相应建议以完善公共卫生医师培养制度。方法:通过文献法及专家咨询法,厘清当前我国公共卫生医师培养现状,并运用解释结构模型对影响公共卫生医师培养的因素进行分区和分层,追溯问题根源。结果:当前我国公共卫生医师培养模式包含院校教育、毕业后教育、继续医学教育三部分,解释结构模型将影响公共卫生医师培养的13个因素划分为7个层级。结论:当前我国公共卫生医师培养由于底层因素政府投入的不足,导致激励机制不健全以及指导性标准制定滞后,三阶段制度待完善;继而影响到各阶段教育任务的落实,以及与之相随的师资结构、教学设计及生源质量问题。     

A systems model of clinical preventive care: the case of breast cancer screening among older women. For the NCI Breast Cancer Screening Consortium

BACKGROUND: In older women covered by Medicare, relationships among physician recommendation, mammography in the past 2 years, and clinical breast examination (CBE) in the past year were systematically explored with a variety of predisposing, enabling, and situational factors identified in the Systems Model of Clinical Preventive Care. METHODS: A population-based survey of women age 65 years and older was conducted in five National Cancer Institute's Breast Cancer Screening Consortium geographic areas. Analyses focused on women with a regular physician and site of care (n = 5318). RESULTS: Physician recommendation and mammography use declined with women's increasing age and increased with income, education, and insurance. CBE and mammography increased with number of physicians and breast cancer family history; mammography use decreased with worsening health status. Recommendations were higher among physicians who were younger, female, and internists. Family practitioners were older and male; women who saw family practitioners reported characteristics associated with decreased screening-lower income, education, and insurance-and seeing only one physician. CONCLUSIONS: Public policy and health system changes that create a uniform system of finance and service performance expectations may reduce the persistent discrepancy in physician recommendation and mammography use due to sociodemographics and physician specialty.     

北京市公共卫生医师培训制度建立与执行情况调查

目的调查北京市市、区两级疾病预防控制中心(CDC)公共卫生医师相关培训制度,为进一步完善北京市公共卫生医师规范化培训试点工作提供依据。方法采用问卷调查方法,对北京市市、区两级19家CDC,以及2004～2010年期间预防医学专业不同学历毕业入职的327名公共卫生医师进行调查。结果 19家单位,公共卫生医师相关培训制度多由单位自行制定;各项制度的建立与执行存在不同程度的缺失与不足。结论北京市需要建立覆盖预防医学专业不同学历毕业的公共卫生医师规范化培训制度,并进行统一有效的组织管理。