关于社区卫生服务的若干问题

《中共中央、国务院关于卫生改革与发展的决定》明确提出了改革城市卫生服务体系,积极发展社区卫生服务的任务, 这对于我国卫生事业,特别是城市卫生事业的未来走向极为重要。为了加强对这一问题的理解和贯彻执行,有必要在以下若干问题上展开研讨,取得共识。1 改革城市卫生服务体系,发展社区卫生服务的现实针对性与目标 城市现有的卫生服务体系存在严重缺陷,必须改革。最突出的方面是:(1)与市场经济体制不适应。人们对卫生服务的需要与需求80％是在社区,20％是在社区以上。而卫生服务供给在社区很少,绝大部分集中在社区以上,形象的说法是需要与需求的正三角与供给的倒三角。(2)与医学模     

对卫生改革与调整的宏观思考

问题改革开放以来 ,卫生改革成就巨大 ,但也存在突出的问题。从方法论角度进行反思 ,重要教训是 :卫生改革单项突进 ,孤军深入 ,没有能够协调配套地进行 ;人事制度改革滞后 ;没有处理好卫生改革与发展的关系。其结果是某些卫生要素状态得到一定改善 ,但相关体制失去约束 ,导致卫生经济运行机制的紊乱和卫生经济结构失衡。我国卫生结构不合理 ,首先 ,医疗与预防之间、城乡间发展失衡 ;其次 ,医疗事业内部 ,农村医疗事业的发展大大落后于城市 ,矛盾突出。这些具体体现在以下几个关系上 :医疗服务劳务生产与预防服务劳务之间比例失调 ;基本医疗…     

卫生人力与三个市场

卫生人力的产出和需求牵涉到三个市场、两个接口、两个过程。所谓的三个市场就是医学教育市场、卫生人力市场和卫生服务供给市场 ;两个接口就是医学教育出口和卫生人力市场入口间的接口以及卫生人力市场出口和卫生服务供给市场入口间的接口 ;两个过程就是医学教育过程和卫生人力的需求实现过程。如果它们间运转不畅 ,就会影响到卫生人力与三个市场的合理关系 ,并造成卫生资源的巨大浪费。一、卫生服务供给市场与卫生人力(一 )卫生服务供给者垄断卫生服务供给市场是一个特殊的市场 ,存在着垄断现象。一为进入障碍 :由于卫生服务需求的有限性…     

国际基本医疗服务购买模式现状及启示

从国际卫生服务领域改革与发展的趋势来看,卫生服务的供给已经开始从过去的等级性、综合性的集权供给方式向基于供需分离的购买服务模式转变[1].在这一模式中,购买什么样的卫生服务,从哪里和如何购买卫生服务等都在事先就已经决定[2].在欧洲一些国家,已经从卫生服务的集权管理模式转变成基于供需分离的购买模式,即政府与私立部门,以及保险机构(第三方支付者)在组织形式上与卫生服务提供者分离[1-3].卫生服务购买模式的出现不仅引起了国际社会的广泛关注,而且,在中国的卫生改革与发展过程中也开始实施并探索这一改革措施.     

农村公共卫生服务项目成果、成本和筹资政策研究之一:研究框架和服务项目的重要程度分析

1.1 主要问题 无论在发达国家还是发展中国家,任何卫生服务系统都存在着公共卫生资源短缺和配置使用不合理等问题。近几年来,各国、特别是发展中国家纷纷通过改革卫生筹资和服务系统,以期有效地解决卫生资源与社会卫生服务需求之间的矛盾。在我国,就卫生资源配置的结构而言,存在着以下主要问题。     

满足社会整体发展需要科学制定区域卫生规划

《中共中央、国务院关于卫生改革与发展的决定》中指出:区域卫生规划是政府对卫生事业发展实行宏观调控的重要手段,地(市)级政府根据中央和省级人民政府制定的区域卫生规则指导原则和卫生资源配置标准,制定当地区域卫生规划,并组织实施。区域卫生规划是指对在一定区域内的卫生服务活动所做的规划,包括双重含义:一是指对某一区域范围内卫生服务发展的整体规划,主要从区域卫生服务需求与供给平衡上来解决区域内卫生资源的合理配置;二是区域间卫生服务协调发展的规划,主要是从社会整体发展的角度来解决区域之间卫生服务非均衡发展等问题。     

试析卫生经济改革活动中三项基础性工作

卫生经济改革是卫生改革的重要组成部分。在当前及今后所要解决的卫生问题中,其中加强农村卫生和预防保健工作、完善医疗保障制度、解决卫生资源投入不足和浪费并存、医药费呈不合理增长等问题,与卫生经济改革有直接和密切的关系。为解决这些问题,中央提出今后卫生经济改革的方针和政策,明确了卫生经济改革的方向,确定了卫生经济改革的重点。通过学习《中共中央、国务院关于卫生改革和发展的决定》(以下简称《决定》),笔者认为,在卫生经济改革中,有三项基础性工作,即区域卫生规划、基本卫生服务的界定和卫生服务成本核算,将贯穿于卫生经济改…     

中南6省（区）卫生经济研讨会综述

中南6省（区）第12次卫生经济研讨会，于1998年11月5－7日在广东省珠海市举行。卫生部卫生经济研究所所长蔡仁华、广东省卫生厅厅长黄庆道等领导亲临会议并讲话。会议共收到论文120多篇，出席会议的代表65人。研讨会上，蔡仁华所长作了学术报告，就当前卫生改革与发展的几个重大问题表达了他的见解，包括公立卫生机构转换经营机制的问题，积极推进区域规划的问题，大力发展社区卫生服务的问题，以及建立医疗保障制度的问题。黄庆道厅长就贯彻落实《中共中央、国务院关于卫生改革与发展的决定》，增创广东卫生发展新优势，在补偿机制、服务体…     

关于第三产业的兴起与卫生服务业发展问题的设想

所谓第三产业,一般是指除了第一产业(农业),第二产业(工业和建筑业等)以外的其他各业。它包括两个大的部门和四个具体层次。两大部门是流通部门和服务部门。四个层次是,第一层次为流通部门,包括交通运输、邮电通讯、商业、物资供销和仓储等;第二层次为生产和生活服务的部门,它包括金融保险,饮食、旅游和居民服务业;第三层次为提高科学文化水平和居民素质服务的部门,包括文化教育、体育卫生、科学研究和社会其他福利事业;第四层次为社会公共需要服务的部门,包括国家机关、社会团体和军队、警察等等。     

发展社区卫生服务 推进城市卫生服务体系改革：济南市开展社区卫生服务情况

1993年济南市曾在全市范围内开展了社区服务工作。经过几年的实践,我们感到开展社区服务,卫生服务应是其中不可缺少的重要内容。特别是全国卫生工作会议之后,《中共中央国务院关于卫生改革与发展的决定》中明确提出“改革城市卫生服务体系,积极发展社区卫生服务”我们把开展社区卫生服务作为城市卫生服体系改革的切入点和突破口。在市委、市政府的领导下,从1996年起,在试点的基础上,积极开展了社区卫生服务工作,这种服务是面向社区家庭,集临床医学、预防医学、康复医学以及相关人文社会科学于一体,政府领导,卫生行政部门管理,有关部门支持,     

Policy relevant determinants of health: an international perspective

BACKGROUND: International comparisons can provide clues to understanding some of the important policy-related determinants of health, including those related to the provision of health care services. An earlier study indicated that the strength of the primary care infrastructure of a health services system might be related to overall costs of health services. The purpose of the current research was to determine the robustness of the findings in the light of the passage of 5-10 years, the addition of two more countries, and the findings of other research on the possible importance of other determinants of country health levels. METHODS: Thirteen industrialized countries, all with populations of at least 5 million, were characterized by the relative strength of their primary care infrastructure, the degree of national income inequality, and a major manifestation of a behavioral determinant of health that is amenable to policy intervention (smoking), using international data sets and national informants. Health system and primary care practice characteristics were judged according to pre-set criteria. Major indicators of health were used as dependent variables, as were health care costs. FINDINGS: The stronger the primary care, the lower the costs. Countries with very weak primary care infrastructures have poorer performance on major aspects of health. Although countries that are intermediate in the strength of their primary care generally have levels of health at least as good as those with high levels of primary care, this is not the case in early life, when the impact of strong primary care is greatest. A subset of characteristics (equitable distribution of resources, publicly accountable universal financial coverage, low cost sharing, comprehensive services, and family-oriented services) distinguishes countries with overall good health from those with poor health at all ages. Neither income inequality nor smoking status accurately identified those countries with either consistently high or consistently poor performance on the health indicators. Interpretation: A certain level of health care expenditures may be required to achieve overall good health levels, even in the presence of strong primary care infrastructures. Very low costs may interfere with achievement of good health, particularly at older ages, although very high levels of costs may signal excessive and potentially health-compromising care. Five policy-relevant characteristics appear to be related to better population health levels. There is no consistent relationship between income inequality, smoking, and health levels as measured by various indicators of health in different age groups.     

Barriers and Facilitators to Providing Common Preventive Screening Services in Managed Care Settings

Despite increasing emphasis on disease prevention and health promotion, and ample evidence demonstrating the effectiveness of preventive services, such services are underutilized in the United States. The current trend of health care toward health maintenance organizations and other managed care systems opens the door, perhaps to more effective control of heart disease, cancers and other chronic diseases through preventive care. This warrants attention to the barriers/facilitators to the provision/utilization of preventive screening services in such settings. Overall goal of this study was to assess barriers/facilitators to the provision/utilization of preventive services in managed care organizations (MCOs). This was accomplished by a) identifying barriers/facilitators to the provision/utilization of three common preventive screening services (cholesterol screenings, mammograms, and Pap smears); and b) profiling typical MCO recipients of these three preventive screening services. A self-administered, mail questionnaire was used to obtain information from a national sample of 1,200 Directors of MCOs associated with preventive care. A total of 175 usable responses were received resulting in a 17.3 percent net response rate. The strongest barrier to the provision of all three screening services is the inability of them to generate short term savings for the MCO. Other barriers include high disenrollment rates, conflicting recommendations about effectiveness (for mammograms and cholesterol screenings), and patients' fears of getting a positive result (for mammograms and Pap smears). The improved health status as a result of early intervention, high consumer awareness (for mammograms and Pap smears), and long term savings are important facilitators to the provision/utilization of these screening services. Comparing barriers and facilitators across the three services shows the stronger barriers affecting the provision/utilization of mammograms. For all three screening services, typical managed care recipients are those in the high income groups with greater education levels. However, with the increasing enrollment of Medicaid beneficiaries into managed care, MCOs may find themselves selectively targeting these high risk low income and less educated individuals to receive the preventive screening services. Study findings should be useful to health planners, policymakers and researchers at all levels in their efforts to encourage and promote healthier lifestyle choices among U.S. residents. Future studies should address receipt of preventive services by Medicaid and Medicare beneficiaries in managed care settings.     

An approach to effective health care delivery in a developing nation: A case for Nigeria

Delivery of health care services in the developing countries is at present, yielding little or no results to the people being served due to programme structurelessness and lack of goal orientation. Those charged with programmes relating to health services have failed to identify the health problems in their communities. Even when these problems are identified, lack of planning, effective programme execution and evaluation has often brought failures. The result has been poor health for the people.If health services programmes are to be considered successful there must be guarantees that such services are at the disposal of the people wherever they are. In order to achieve complete geographical and population coverage of health services, a state should be organized into provinces, divisions, districts and sectors with the health services also organized according to levels of care (i.e. primary, secondary and tertiary levels). Thus, in any given province, we shall have a number of divisions, districts and sectors, each determined to serve a certain size of population. Also, the size of the population required for effective provision of different levels of care will increase with the complexity of the medical condition involved. Connecting these levels of care, must be referral system whereby complex cases at lower levels can be spent to the level immediately above.Since many health problems are preventable, particular attention must be paid to this area in the overall health services programme. Notably among measures to be taken are effective immunization programmes and environmental health services, both to be strongly sipported with health education.Immunization of the whole population must be the first task in the field of public health. In addition to coverage of all ages in mass immunization at the onset, a further campaign for routine childhood immunization should be essentially carried out.Another important area is environmental health. At present, a considerable number of the health problems in our society are the consequences of wide range of environmental factors. Most health hazards from the environment are those resulting from water supply, food sanitation, waste disposal, housing, inadequate rodent and insect control, pets and domestic animals, occupational source, air pollution and accidents.     

Healthcare Reform and Disease Management in Italy

The 1999 reform of the Italian healthcare system has softened the effects of the 1992 shift to market mechanisms and competition within healthcare by promoting cooperation and partnerships among providers and Local Health Units (LHUs). In addition, it has facilitated the completion of transfering organizational and financial responsibility to the regional governments.Such health policy developments require both the introduction of administrative tools, which stimulates integration, and the design of a coherent policy for quality of care. A 3-fold integration between healthcare and social services has been promoted to tackle the introduction of administrative tools: institutional integration between municipalities and LHUs, managerial integration at the district level for the provision of primary care and non-hospital care, and professional integration between healthcare professionals. A similar approach has characterized the policy for quality of care: an essential benefit package is to be identified as a guarantee to all citizens, practice guidelines will be developed and implemented and an accreditation process is underway.Implementation issues aside, effective introduction of the suggested tools requires careful planning and organization of the system and, above all, coordinated interventions at the 3 levels of healthcare provision (i.e. the macro, intermediary and micro levels).     

Guthrie house: a rural community organizing for wellness

This paper is interested in the issue of community participation and empowerment in health care provision and decision-making. In Canada, the present scope for public involvement in planning or managing the state's health and social services system is limited. This poses a particular problem for rural communities--places where the provision of health care services has historically been limited when compared to urban locations. These rural communities are now facing a double burden as public policy moves increasingly towards a retrenchment of the welfare state. This paper examines one rural community's response to this double burden. The village of Elgin in rural Ontario recently established Guthrie House, a community-based resource center for health and wellness services. Community participation in this case involved a level of control whereby local citizens together defined the health and social care services that they saw as best meeting the needs of their community. This form of community participation is considerably different from the forms of public involvement in the established medical system and represents a critical link to 'empowering' the local community as partners in health care. Through an examination of Guthrie House, the paper presents a review of some critical 'characteristics' which mark successful community self-help organizations and concludes with a discussion of the policy implications for greater community participation. It is argued that such community participation in health care is a policy option which government should be paying particular attention to in these times of fiscal constraint, increasing health care needs and increasing consumer dissatisfaction with government service provision mechanisms.     

Patterns of health service utilization and perceptions of needs and services in rural Orissa

Despite emphasis on strengthening local health care provision, concern remains regarding the rates of utilization of state-provided services within Orissa. The reported study examined patterns of service utilization across the rural population of four districts of Orissa, with special reference to perceptions of the availability and quality of state services at the primary care level. Within the selected districts, 219 interviews were conducted across 66 villages. Households reported utilizing a wide range of health care providers, although hospitals constituted the most frequently--and primary health care centres (PHCs) the least frequently--accessed services. Private practitioners (qualified and unqualified) represented a major sector of provision. This included high rates of access by scheduled tribes and castes (running at approximately twice the rate of access to both local and PHC provision). Key factors guiding patterns of utilization were reputation of the provider, cost and physical accessibility. Local health provision through assistant nurse midwives and male health workers was generally perceived of poor quality, with the lowest rates of resolution of health problems of all service providers. The location of a sub-centre base for assistant nurse midwives within a village had no demonstrable impact on access to services. Acknowledging constraints on broader generalization, the implications of the findings for informing health policy and programming within Orissa are noted. This includes support for current efforts to strengthen the capacity of PHC and sub-centre level provision within the state, and acknowledgement of the potentially growing role of effectively regulated private provision in meeting the needs of the rural poor.     

Caring for children with specialized health care needs in the community: the challenges for primary care

People needing intensive and specialized health care are being cared for now in community settings; this has implications for both primary health care professionals and family carers. This paper draws on research investigating how services can be developed to support families caring for children with complex health care needs, to consider the challenges facing professionals working in the primary health care sector. Interviews conducted with parents, professionals and those who fund and commission specialized health services reveal particular problems in relation to the purchasing and provision of short-term care and specialist equipment/therapies in the community. These problems need to be addressed if people with specialized needs are to be cared for outside hospitals. The new Primary Care Groups (PCGs) will have the opportunity to enhance the provision of these services. Primary care professionals will also need to work in partnership with other sectors of the health service and with local authority services, at both strategic and operational levels, to develop integrated and coordinated services for this growing group of people.     

Organization of ambulatory care provision: a critical determinant of health system performance in developing countries

Success in the provision of ambulatory personal health services, i.e. providing individuals with treatment for acute illness and preventive health care on an ambulatory basis, is the most significant contributor to the health care system's performance in most developing countries. Ambulatory personal health care has the potential to contribute the largest immediate gains in health status in populations, especially for the poor. At present, such health care accounts for the largest share of the total health expenditure in most lower income countries. It frequently comprises the largest share of the financial burden on households associated with health care consumption, which is typically regressively distributed. The "organization" of ambulatory personal health services is a critical determinant of the health system's performance which, at present, is poorly understood and insufficiently considered in policies and programmes for reforming health care systems. This article begins with a brief analysis of the importance of ambulatory care in the overall health system performance and this is followed by a summary of the inadequate global data on ambulatory care organization. It then defines the concept of "macro organization of health care" at a system level. Outlined also is a framework for analysing the organization of health care services and the major pathways through which the organization of ambulatory personal health care services can affect system performance. Examples of recent policy interventions to influence primary care organization--both government and nongovernmental providers and market structure--are reviewed. It is argued that the characteristics of health care markets in developing countries and of most primary care goods result in relatively diverse and competitive environments for ambulatory care services, compared with other types of health care. Therefore, governments will be required to use a variety of approaches beyond direct public provision of services to improve performance. To do this wisely, much better information on ambulatory care organization is needed, as well as more experience with diverse approaches to improve performance.     

Observations and impressions of the Canadian health care system.

The United States government, in its desire to deliver broad health care coverage to its citizens, has looked to several of the established socialized health care systems for direction. There are definitely good points in each system, and the Canadian system, in particular, has done quite well in providing services within a limited federal budget. On the other hand, the unlimited access to care has led to increased demands for health care services, overperformance of services, and excessive utilization of facilities. There are major technological constraints now emerging and the fiscal integrity of the system is shaky. There is a notable decrease in research and voluntary faculty participation at university levels. Financial constraints are becoming more severe and it appears that demand vis-a-vis the resources available will soon force stringent readjustments in Canadian health care delivery and funding. Health care plan administrators concede that unless more dollars are invested in the system, the current level of health care delivery cannot be maintained.     

Independent hospice care in the community: two case studies

Following its remarkable success over the past 25 years the hospice movement is now at a watershed in its development. The growing legitimacy of palliative care as a health care specialty has coincided with the development of the internal market within public sector services, and the promotion of community care. The impact of these changes is now being felt by the hospice movement and may well result in radically new forms of service provision. The focus of this paper is on the future direction of the hospices. We argue, that in the present policy context the main priority must be palliative care in the community, using two case studies of innovative services to illustrate how this might be achieved. We also explore a variety of factors which may constrain the development of community care for dying people. These include the diminishing experience of families and primary health care workers in managing death and dying and the often strongly held belief that hospice care must be in-patient care. New community services may also face difficulties both in finding a market niche which complements rather than supersedes existing provision, and in securing service contracts where provision cuts across the health and social care divide. These issues are explored through an examination of the models of care developed by the two hospice groups, their integration within existing networks of provision, and their relationship with purchasing authorities.