新型农村合作医疗：主要挑战和政策建议

本文基于面板调查数据，描述了新型农村合作医疗在我国农村地区的实施进展，以及该政策在实施过程中取得的成就和面临的挑战。结果表明，新型农村合作医疗在覆盖面、参合率、政策设计、筹资水平等方面成绩显著，但是，2007年参合农民对新型农村合作医疗的补偿政策的认知水平还非常低；新型农村合作医疗对参合患者的补偿水平不高，对大病患者的财务风险保护能力非常弱。而同时，医疗服务机构的不当激励可能已经损害了参合农民的利益。基于以上研究结论，本文在最后提出了相关政策建议。     

新型农村合作医疗制度运行现状的调查与分析

本文利用全国范围的大样本数据，分析新型农村合作医疗制度的运行现状。分析表明，农户的参合率较高，对制度总体评价较高；但对新型农村合作医疗的药品价格、报销比例以及医院服务态度等方面的满意度较低。此外，分析结果表明，农民收入是影响农户参合的重要因素，而加强监管、规范参与主体行为以及拓展农村医疗保障渠道等，则是目前新型农村合作医疗亟待加强的方面。     

认同尴尬折射制度缺陷--漫谈新型农村合作医疗的制度缺陷及对策

目前，新型农村合作医疗还难以真正惠及百姓，为数不少的农民仍然在徘徊、观望，新型农村合作医疗为何遭遇认同尴尬?通过调研、分析，发现新型农村合作医疗存在一系列制度缺陷：新型农村合作医疗虽然有“新”的一面，但仍然给人以“修旧如旧，，的感觉；完全自愿参与的原则使得“富裕者看不上，贫困者参不起”；新型农村合作医疗还走人了以“低水平”筹资换取“广覆盖”的误区；巨大的管理成本也将是其持续发展的很大威胁。     

进一步完善新型农村合作医疗制度的着力点--兼及三种模式的分析

新型农村合作医疗制度凸显了我国社会政策从以城市为重逐步转向农村的历史性转变，具有重大的历史和现实意义。但这种利国利民的新型农村合作医疗制度在远行中还是遇到了很多困难。认真分析这些困难产生的原因，找出解决办法。是进一步完善和推广新型农村合作医疗制度的迫切需要。论文提出多管齐下。找准进一步完善新型农村合作医疗制度的着力点。这些着力点主要有：进一步统一思想，大力开展培训和宣传发动工作；针对农村实际，采取各种灵活方式筹措资金；大力加强对合作医疗的资金监管；规范舍作医疗机构服务行为。加强服务能力建设。     

新型农村合作医疗不同利益相关者分析及启示

新型农村合作医疗运行中涉及三方主体——定点医疗机构、农民、新型农村合作医疗管理及经办机构。笔者认为，新型农村合作医疗与定点医疗机构是一种共谋博弈关系；与参合农民是一种“假性”补偿关系，并存在不同程度的“道德损害”；而管理机构性质与职权还不太明晰。要搞好新型农村合作医疗，应综合权衡各个方面的关系。     

农村卫生院--新型农村合作医疗制度的重要支撑点

农村卫生院可以从“服务”和“管理”两方面支持和促进新型农村合作医疗制度；同时，新型农村合作医疗制度也可以’使农村卫生服务体系在更高的需求水平上得到发展，改善其补偿机制。因此，农村卫生服务体系和新型农村合作医疗制度具有相辅相成的关系。     

乡村卫生服务机构门诊用药与新型农村合作医疗

通过对新型农村合作医疗试点地区乡村卫生服务机构门诊处方费用、药品使用种类、激素和抗生素使用频率、给药方式等及农民对新型农村合作医疗的参与意愿和新型农村合作医疗主体行为的分析，结果显示：乡、村两级卫生服务机构门诊用药均存在严重的不合理性，这将成为影响新型农村合作医疗发展的重要障碍。提出在新型农村合作医疗的运行中，一方面需加强对医务人员合理用药的培训；另一方面需通过调整支付方式、制定并执行基本药物目录和诊疗规范等措施，促进乡村卫生服务机构合理提供药品服务，促进新型农村合作医疗的稳步发展     

构建新农合市级信息平台实现经办业务全过程管理

随着新型农村合作医疗工作的不断发展和完善，特别是在一个地区实现全覆盖的情况下，管理手段的现代化已成为必然趋势和最基本要求。根据现行行政管理体制，建立市级新型农村合作医疗计算机信息系统已成为地市级管理组织和业务主管部门运用现代化管理手段加强地区新型农村合作医疗管理、保证基金安全、规范补偿行为的迫切需要。市级新型农村合作医疗信息系统对上可以衔接省及国家相关管理部门，实现信息自动搜集上报；对下可以衔接各县经办机构，实现全过程管理；居中可以衔接市属医疗机构，为各县提供参合人员在市级医疗机构的诊疗信息。文章主要从构建市级新型农村合作医疗信息系统的目的意义、信息系统的内涵两个方面对所构建的信息系统进行较深入的说明。     

可持续发展视角下新型农村合作医疗制度建设的思考

新型农村合作医疗自2003年试点以来，取得了举世瞩目的成绩。但在推进过程中，制度内外也出现了一些新的问题和矛盾，影响了新型农村合作医疗制度的可持续发展。因而，需要采取增加政策支持、建立法律保障、强化监管、优化农村卫生服务体系等来改善新型农村合作医疗制度的运行环境；建立稳定的筹资与增长机制、科学的补偿机制、有效的费用控制机制和严格的管理机制来优化新型农村合作医疗制度建设。     

新型农村合作医疗病人医药费用补偿数据的管理方法

新型农村合作医疗的实施给医院管理提出了新的问题,如何高效地开展新型农村合作医疗病人医药费用补偿工作和补偿数据的管理工作,随时掌握新型农村合作医疗病人的医药费用补偿数据,做到心中有数是医院管理工作者的任务.本文利用Excel强大的数据管理功能,对新型农村合作医疗病人门诊费用补偿的数据管理方法进行了探索,它提高了结算工作的速度和准确性;便于集中统一管理病人结算数据和快速查询统计,有利于加强病人费用的监督管理.     

The human drama of genetics: 'hard' and 'soft' media representations of inherited breast cancer

This paper examines media coverage of 'breast cancer genetics', and explores its implications for public understanding. We present a content analysis of coverage in British newspapers and look at a variety of popular forms, including women's magazines, television soap opera and radio drama. Genetic/inherited risk receives a great deal of coverage across a wide range of media formats and outlets. Much of this attention has focused on individuals from 'high risk families' and dilemmas around prophylactic mastectomies. Through examining media coverage, combined with interviews with media personnel and their sources, we show why this story proved so attractive to the media and highlight the different production values which influence coverage. Finally, we introduce preliminary findings from focus group discussions to demonstrate how such 'human interest' framing has engaged audience attention and influenced public understandings. The paper concludes by highlighting the implications for analysing, predicting, and engaging with, media representations of science.     

Worker education in the primary prevention of occupational dermatoses

This paper reports the evaluation of a skin care education programmeconducted on a fine chemicals manufacturing site where over1,000 employees are located. Approximately 60% are involvedin chemical manufacture. Over a 12 month period production staffreceived training in prevention of occupational dermatoses linkedto a site-wide poster initiative. The incidence of new casesof occupational dermatoses fell from 0.055 (70 cases in 1,277employees) to 0.021 (27 cases in 1,277 employees) before andafter the intervention respectively (p<0.0001). After otherfactors such as chemicals handled, observer bias and changesin reporting related to socioeconomic climate were taken intoaccount it is concluded that this study demonstrates the importanceof worker education as a tool for primary prevention of disease.Training materials such as video and poster presentations maybe effectively used in the chemical manufacturing industry asan adjunct to prevention and control of exposure to substanceshazardous to the skin. Such methods may also be used in otherindustries where there are significant risks of dermatoses.     

Regional Variation in Travel-related Illness acquired in Africa,March 1997–May 2011

To understand geographic variation in travel-related illness acquired in distinct African regions, we used the GeoSentinel Surveillance Network database to analyze records for 16,893 ill travelers returning from Africa over a 14-year period. Travelers to northern Africa most commonly reported gastrointestinal illnesses and dog bites. Febrile illnesses were more common in travelers returning from sub-Saharan countries. Eleven travelers died, 9 of malaria; these deaths occurred mainly among male business travelers to sub-Saharan Africa. The profile of illness varied substantially by region: malaria predominated in travelers returning from Central and Western Africa; schistosomiasis, strongyloidiasis, and dengue from Eastern and Western Africa; and loaisis from Central Africa. There were few reports of vaccine-preventable infections, HIV infection, and tuberculosis. Geographic profiling of illness acquired during travel to Africa guides targeted pretravel advice, expedites diagnosis in ill returning travelers, and may influence destination choices in tourism.     

The design of hazard risk assessment matrices for ranking occupational health risks and their application in mining and minerals processing

Two hazard risk assessment matrices for the ranking of occupational health risks are described. The qualitative matrix uses qualitative measures of probability and consequence to determine risk assessment codes for hazard-disease combinations. A walk-through survey of an underground metalliferous mine and concentrator is used to demonstrate how the qualitative matrix can be applied to determine priorities for the control of occupational health hazards. The semi-quantitative matrix uses attributable risk as a quantitative measure of probability and uses qualitative measures of consequence. A practical application of this matrix is the determination of occupational health priorities using existing epidemiological studies. Calculated attributable risks from epidemiological studies of hazard-disease combinations in mining and minerals processing are used as examples. These historic response data do not reflect the risks associated with current exposures. A method using current exposure data, known exposure-response relationships and the semi-quantitative matrix is proposed for more accurate and current risk rankings.     

Psychopathological features of a patient population of targets of workplace bullying

BACKGROUND: A strong association between workplace bullying and subsequent anxiety and depression, indicated by empirical research, suggests that bullying is an aetiological factor for mental health problems. AIMS: To evaluate levels of stress and anxiety-depression disorder developed by targets of workplace bullying together with outcome at 12 months and to characterize this population in terms of psychopathology and sociodemographic features. METHODS: Forty-eight patients (36 women and 12 men) meeting Leymann Inventory of Psychological Terror criteria for bullying were included in a prospective study. Evaluations were performed at first consultation and at 12 months using a standard clinical interview, a visual analogue scale of stress, the Hospital Anxiety and Depression (HAD) scale, the Beech scale of stress in the workplace and a projective test (Picture-Frustration Study). RESULTS: At first consultation, 81% of patients showed high levels of perceived stress at work and 83 and 52% presented with anxiety or depression, respectively. At 12 months, only 19% of working patients expressed a feeling of stress at work. There was a significant change in symptoms of anxiety while there was no change in symptoms of depression. Stress at work and depression influenced significatively capacity to go back to work. At 12-month assessments, workers showed a significantly better score on the HAD scale than non-workers. Over half the targets presented a neuroticism-related predominant personality trait. CONCLUSION: Workplace bullying can have severe mental health repercussions, triggering serious and persistent underlying disorders.     

The rise and fall in incidence of malignant mesothelioma from a British Naval Dockyard, 1979-1999

BACKGROUND: The incidence of malignant mesothelioma in Britain is predicted to rise over the next 15-25 years because of past failure to protect the workforce against inhalation of asbestos. In British Naval dockyards, alternative insulation materials and respiratory protection were introduced from the mid-1960s. Aims This study was carried out to investigate the effects of these control measures on mesothelioma deaths in dockyard workers. METHODS: Cases of mesothelioma of the pleura and peritoneum between 1979 and 1999 in workers from the Devonport Naval Dockyard, south-west England, were sought from coroners' and medico-legal records. RESULTS: Three hundred and one cases were identified, 7% peritoneal. The peak incidence occurred in 1991 with 25 cases per annum (quadratic model fit R(2) = 74.2%, P < 0.001) and we predict that by 2003 the incidence will fall to fewer than five cases per annum. The mean time between first exposure and presentation was 48.5 years [95% confidence interval (CI) = 47.3-49.8], but this was significantly shorter in the more heavily exposed trades, when compared with the less heavily exposed (42 years, 95% CI = 39.0-45.0, versus 49.5 years, 95% CI = 48.2-50.9). Those with higher exposure were also at significantly greater risk of peritoneal disease (P < 0.023, Fisher's exact test). CONCLUSION: The reduction in incidence of mesothelioma is greater than can be accounted for by reduction in numbers of dockyard workers over the last 50 years. Changes in insulation materials and improved industrial hygiene measures introduced into the Devonport Dockyard from the mid-1960s have resulted in an earlier decline in the incidence of malignant mesothelioma than that predicted for the British workforce as a whole.     

Organophosphate toxicity and occupational exposure

The ubiquitous organophosphates present a continuing health hazard in agriculture, public health eradication programmes and as chemical warfare agents. Despite significant progress in understanding the potential mechanisms of toxicity far beyond the commonly accepted mechanism of cholinesterase inhibition in intentional exposures, the precise health effects following occupational exposures are yet to be completely defined. A much greater understanding exists of the clinical features of organophosphate poisoning. These are characterized by a triphasic response involving an initial acute cholinergic phase, an intermediate syndrome (both associated with high mortality) and a disabling but non-lethal delayed polyneuropathy. The delayed polyneuropathy may occur in the absence of the cholinergic or intermediate phases. However, progress is still required in order to improve the quantification and assessment of occupational exposures and the implementation of appropriate preventive measures. Finally, evidence-based guidelines for appropriate or optimal therapeutic interventions following poisoning are required urgently and collaborative work with colleagues in developing countries, where the occurrence of organophosphate exposures is more frequent, may provide the answers.     

Miliaria rubra of the lower limbs in underground miners

This report documents a case series of miliaria rubra of the lower limbs in miners at a deep underground metalliferous mine in tropical arid Australia. During the summer months of February and March 1999, all cases of miliaria rubra of the lower limbs in underground miners seen at the mine's medical centre were clinically examined and administered a questionnaire. Twenty-five patients were seen, an incidence of 56.4 cases per million man-hours. Miliaria rubra was most often located between the ankle and knee (88% of cases). Twenty-four percent had concurrent folliculitis and 20% had concurrent tinea. Thirty-two percent had a personal history of asthma. Walking through ground-water and splashing of the legs was common. Three to 4 weeks of sedentary duties in air conditioning was generally required to achieve resolution of miliaria rubra. The incidence of miliaria rubra of the lower limbs is 38% of the incidence of heat exhaustion at the same mine. The length of disablement is greater, however. Atopics may be at increased risk of miliaria rubra. Control measures are discussed.     

Die sogenannte Vinylchlorid-Krankheit—eine berufsbedingte Systemsklerose?

Zusammenfassung Es wurden 13 Arbeiter untersucht, die zwischen 1 3/4 und 18 Jahren in einem PVC-herstellenden Betrieb beschäftigt waren. 8 von ihnen wiesen sklerodermieartige Hautveränderungen (Abb. 2) auf, die histologisch charakterisiert sind durch Verbreiterung und Homogenisierung der kollagenen Faserbündel (Abb. 3 u. 4) sowie Fragmentation und Rarefizierung der elastischen Fasern (Abb. 5). Bei 7 Patienten bestanden trommelschlegelartige Auftreibungen einzelner Fingerendphalangen (Abb. 1). 11 Patienten zeigten Durchblutungsstörungen der Extremitäten (4 von diesen ein Raynaud-Syndrom) und 6 Patienten Acroosteolysen einzelner Fingerendphalangen (Abb. 6, Tabellen 1–3).Darüber hinaus bestand bei allen Patienten eine Thrombocytopenie, bei 12 Patienten eine Splenomegalie, bei 11 Patienten eine Einschränkung der Leberfunktion (erhöhte BSP-Retention). An der Leber ließ sich histologisch bei den 5 laparoskopierten Patienten eine deutliche Fibrosierung der Portalfelder nachweisen. Bei 4 Patienten bestanden Oesophagusvaricen (Tabellen 4 u. 5). 8 Patienten zeigten eine Partialinsuffizienz mit Hinweisen für vorwiegend restriktive Veränderungen.Die hier beschriebenen Veränderungen gehen weit über das bisher bekannte Acroosteolysesyndrom hinaus. Es wird der dringende Verdacht geäußert, daß langfristige Vinylchlorid-Exposition dieses komplexe Krankheitsbild verursacht. Daher wird für diese systemische Krankheit die Bezeichnung Vinylchlorid-Krankheit vorgeschlagen.Wir danken Frau E. Voigtländer für die Herstellung der klinischen und histologischen Abbildungen.     

Planning research

The starting point for any research project should be a question.Once this has been defined and the relevant scientific literaturereviewed, a protocol should be drawn up. This will be used notonly as a guide to the conduct of the study and in the preparationof the final report, but also in seeking any financial supportand approvals that are required for the investigation. A protocolis normally arranged in sections covering the background tothe study, the question(s) that it will address, the methodsthat will be used for the collection and analysis of data, thestatistical power of the investigation (where relevant), anyethical considerations, and the financial input that will beneeded. A pilot study is often helpful where aspects of thestudy method are untried or of uncertainvalidity.