贫困地区医疗救助面临的问题与对策——基于四川秦巴卫生项目效果的实证分析

针对贫困者实施医疗救助是消除和减轻健康贫困的重要措施,当前中国正在逐步建立覆盖全果的贫困医疗救助制度。文章结合秦巴卫生扶贫项目在四川干预试点的调查结果．分析了贫困地区实施医疗救助所取得的极大成就和面临的实际困难,指出贫困地区需要更多的财政转移支付进行筹资,救助目的要建立在促进改善健康水平的基础上。作者认为促进救助资金的高效利用和改善管理与监督环节是贫困地区开展医疗救助制度的关键措施。     

改善生育卫生服务研究的背景、目的与方法

为探索在中国农村贫困地区改善生育卫生服务的有效途径,卫生部国外贷款办公室在福特基金会的资助下,结合世界银行贷款卫生Ⅷ项目,开展了“改善生育卫生服务项目”。这是一项运作式研究（Ｏｐｅｒａｔｉｏｎｓ ｒｅｓｅａｒｃｈ）,其第一阶段为在河南等４省组织生育卫生服务需求评估,目的在于（１）了解农村贫困地区生育卫生现状;（２）了解农村居民,尤其是妇女对生育卫生服务的需求;（３）分析生育卫生服务的提供能力与利用     

改善中国农村生育卫生服务的思考与切入点

世界卫生组织根据生育卫生的定义,全球生育卫生的现状及亟需进行研究的重大问题,筛选出１０个宜优先考虑的研究领域,其中首要的便是生育卫生规划与项目。生育卫生规划已逐渐成为各国卫生部门的一项重要工作。生育卫生项目对改善人群生育卫生同样具有重大意义。卫生部国外贷款办公室在福特基金会资助下,结合世界银行贷款卫生Ⅷ项目开展了“改善生育卫生服务项目”（ＲＨＩＰ项目）。作者结合ＲＨＩＰ项目探讨了改善中国农村生育卫     

Privatisation & marketisation of post-birth care: the hidden costs for new mothers

Introduction

Health care financing reforms in both China and Vietnam have resulted in greater financial difficulties in accessing health care, especially for the rural poor. Both countries have been developing rural health insurance for decades. This study aims to evaluate and compare equity in access to health care in rural health insurance system in the two countries.

Methods

Household survey and qualitative study were conducted in 6 counties in China and 4 districts in Vietnam. Health insurance policy and its impact on utilization of outpatient and inpatient service were analyzed and compared to measure equity in access to health care.

Results

In China, Health insurance membership had no significant impact on outpatient service utilization, while was associated with higher utilization of inpatient services, especially for the higher income group. Health insurance members in Vietnam had higher utilization rates of both outpatient and inpatient services than the non-members, with higher use among the lower than higher income groups. Qualitative results show that bureaucratic obstacles, low reimbursement rates, and poor service quality were the main barriers for members to use health insurance.

Conclusions

China has achieved high population coverage rate over a short time period, starting with a limited benefit package. However, poor people have less benefit from NCMS in terms of health service utilization. Compared to China, Vietnam health insurance system is doing better in equity in health service utilization within the health insurance members. However with low population coverage, a large proportion of population cannot enjoy the health insurance benefit. Mutual learning would help China and Vietnam address these challenges, and improve their policy design to promote equitable and sustainable health insurance.     

改善生育卫生服务研究的主要结果与讨论

由福特基金会资助的“改善生育卫生服务项目”,于１９９８年１２月至１９９９年４月组织河南省嵩县、山西省榆社、贵州省大方、青海省互助４县开展了关于生育卫生服务需求的定性和定量调研。根据调研结果研究者认为,在我国贫困农村虽然开展了多项生育卫生服务,但依然存在大量问题。目前服务能力明显不足,质量不高,农民缺乏保健意识和卫生信息来源,支付能力差,服务利用率低下,农民对生育卫生服务有很大的现实的与潜在的需求,     

提高卫生院管理水平改善卫生院服务质量--陕西省项目区卫生服务管理水平分析

目的对陕西省世界银行贷款卫生Ⅷ项目利用日本赠款改善乡镇卫生院基本卫生服务情况进行分析。方法采用访谈、参与性评估以及资料复习等。结果项目县的卫生院服务供给状况得到了改善．提高了卫生院管理水平．增强了卫生服务能力，提高了服务效率，特困人口医疗救助(MFA)实施效果得到提高。但是存在配套资金不到位的问题，应加大特困人口医疗救助工作的宣传力度。建议加大项目管理力度，完善项目监督机制，推广示范点经验。     

Utilization of delivery care among rural women in china: does the health insurance make a difference? a cross-sectional study

Background  

Since 2003, the New Cooperative Medical Scheme (NCMS) has been implemented throughout rural China, usually covering delivery services in its benefit package. The objective of this study was to compare the difference of utilization of delivery services, expenditures, and local women's perceived affordability between women with and without reimbursement from NCMS.     

参与式方法在改善生育卫生服务项目中的应用

探讨在中国农村贫困地区改善生育卫生服务的有效途径,卫生部国外贷款办公室在福特基金会的资助下,开展了“改善生育卫生服务项目”[1],过去,基层医疗服务人员做这种“上面的（国家级”项目一般是按部就班地等着上面安排相应的工作,现在,贵州省妇幼保健所和大方县政府,县卫生局项目办和县妇幼保健院积极配合,在“恳谈会”上运用参与方法讨论开展项目活动,把“上面的”项目当作“自己的（基层级）”项目。这种方法为基层开展“上面的”项目架起了一座桥梁,使项目活动内容深入到千家万户,并使村民确实感受到了项目的实在意义,从而大大地改善了村民的生育卫生服务利用状况,这种方法为改善中国贫困农村生育卫生服务提供了思路与借鉴。     

宁夏同心县实施特困医疗救助的实践与思考

宁夏同心县是秦巴卫生项目县之一，该县医疗救助的实施已形成了一套较为完善、行之有效的监督管理办法及制度。其主要做法为：(1)强化组织领导，加强宣传力度；(2)严格把关，选准、选好救助对象；(3)严格监管，确保救助效果。特困医疗救助的实施，为老百姓就医减轻了负担，提高了卫生院的服务能力。为探讨农村实施合作医疗、贫困医疗救助提供了宝贵的经验。     

农村公共卫生服务体系绩效评价指标在农村卫生改革中的实践

目的:评价中国农村卫生发展项目(简称"卫十一项目")实施期间,项目地区公共卫生服务体系的绩效。方法:采用项目开发的农村公共卫生服务绩效评价指标体系,连续收集40个项目县2008—2013年的投入、产出指标,进行综合分析与评价。结果:项目地区2008—2013年间公共卫生的投入和产出均逐年提高,分别由项目初期的22.73分和39.05分增加到32.62分和57.60分,增幅达43.15%和47.50%,部分项目省份投入增幅较产出明显。项目地区投入产出比从1.72增加到1.77,年间略有波动。结论:采用公共卫生服务体系绩效考核指标监测项目实施进程,有利于及时发现农村公共卫生服务体系建设中存在的薄弱环节,从而针对性地采取有效措施促进体系的完善。在加大公共卫生投入的时候,如何高效利用资源,提高服务效果依然是亟需解决的问题。     

农村贫困地区女性生殖道感染现状及对策研究

为了解农村贫困地区女性生殖道感染现状,对世界银行贷款“加强中国农村贫困地区基本卫生服务项目”（简称卫生Ⅷ项目）贵州省大方县、山西省榆社县、河南省嵩县、青海省互助县的１２个乡镇３６个村的７２２名已婚育龄妇女进行问卷调查,并在１２个村开展了参与式农村评估（ＰＲＡ）调研。调研发现：在被调查妇女中最近半年内有各种生殖道感染症状者占３６．３％,就诊率仅为２６．３％,就诊地点乡卫生院为５７．４％,村卫生室为２     

对宁夏开展人人享有基本医疗卫生服务的探索和思考

根据宁夏开展人人享有基本医疗卫生服务实施情况,采用现场调研的方法,从构建和谐社会、公共医疗卫生服务均等化、与合作医疗嵌入式关系等方面分析了政策意义。认为存在的主要问题有:基本卫生服务包没有结合贫困地区情况区别对待目标人群;服务包设计内容太多太广,实际难以操作;四级服务包不符合村卫生室和居民卫生服务需求等。建议考虑均等化问题,根据筹资情况,完善方案设计。     

Social health assistance schemes: the case of Medical Financial Assistance for the rural poor in four counties of China

Background  

Economic transition which took place in China over the last three decades, has led to a rapid marketization of the health care sector. Today inequity in health and poverty resulting from major illness has become a serious problem in rural areas of China. Medical Financial Assistance (MFA) is a health assistance scheme that helps rural poor people cope with major illness and alleviate their financial burden from major illness, which will definitely play a significant role in the process of rebuilding Chinese new rural health system. It mainly provides assistance to cover medical expenditure for inpatient services or the treatment of major illnesses, with joint funding from the central and local government. The purpose of this paper is to review the design, funding, implementation and to explore the preliminary effects of four counties' MFA in Hubei and Sichuan province of China.     

农村公共卫生服务包的构建研究

目的:探讨农村公共卫生服务包的构建,为各地区选择与自身社会经济条件相适应的农村公共卫生服务内容提供科学依据。方法:采用经济学分摊的方法对农村县、乡、村三级公共卫生机构进行成本测算,并运用D e lph i专家咨询法,对92项农村公共卫生服务项目进行属性、重要性和必需性的鉴定,构建公共卫生服务包。结果:构建了三个层次的农村公共卫生服务包:基本公共卫生服务包、扩大公共卫生服务包和全面公共卫生服务包,人均成本依次为27.57、52.52和66.21元,项目数分别为30、66、92项。结论:三类农村公共卫生服务包适合不同的经济发展水平的各地区:经济发达地区应充分开展全面公共卫生服务包中的项目;经济较发达地区应选择扩大公共卫生服务包,即在保证基本公共服务的同时,结合地方特点适当选择其他一些公共卫生服务内容;贫困地区应保证基本公共卫生服务包的开展。     

Developing sustainable models of rural health care: a community development approach

Globally, small rural communities frequently are demographically similar to their neighbours and are consistently found to have a number of problems linked to the international phenomenon of rural decline and urban drift. For example, it is widely noted that rural populations have poor health status and aging populations. In Australia, multiple state and national policies and programs have been instigated to redress this situation. Yet few rural residents would agree that their town is the same as an apparently similar sized one nearby or across the country. This article reports a project that investigated the way government policies, health and community services, population characteristics and local peculiarities combined for residents in two small rural towns in New South Wales. Interviews and focus groups with policy makers, health and community service workers and community members identified the felt, expressed, normative and comparative needs of residents in the case-study towns. Key findings include substantial variation in service provision between towns because of historical funding allocations, workforce composition, natural disasters and distance from the nearest regional centre. Health and community services were more likely to be provided because of available funding, rather than identified community needs. While some services, such as mental illness intervention and GPs, are clearly in demand in rural areas, in these examples, more health services were not needed. Rather, flexibility in the services provided and work practices, role diversity for health and community workers and community profiling would be more effective to target services. The impact of industry, employment and recreation on health status cannot be ignored in local development.     

卫生Ⅷ项目对妇女孕产期保健知识、就医态度和行为的影响

目的探讨卫生Ⅷ项目对于提高贫困地区妇女的孕产期保健知识、改善就医态度和行为的作用。方法利用"卫生Ⅷ项目/卫生Ⅷ支持性项目对母婴保健与健康的影响"专项评估中的孕产妇入户调查数据库,分析比较项目县和非项目县妇女的孕产期保健知识来源和掌握程度,产前检查和住院分娩的就医/不就医原因。以及所选择的医疗机构级别。结果"乡镇卫生院医生"和"村医或村妇幼专干"为项目地区孕产妇传播了较多的孕产期保健信息。费用不再是影响项目地区孕产妇去医院进行产前检查和分娩的主要原因。在曾进行过产前检查和住院分娩的被调查对象中,项目县的大多选择的是乡镇卫生院,而对照县的大多选择的是县级及以上医疗机构。结论卫生Ⅷ项目的实施使贫困地区孕产妇在乡镇卫生院获得了更多的孕产期保健知识和服务,就医态度和行为趋向合理,有利于各级卫生资源效率的最大发挥。     

农村地区中医药适宜技术推广路径探索——甘肃省甘谷、静宁县卫生XI项目经验总结与启示

农村卫生工作是我国卫生工作的重点,提高农村基层卫生技术能力和服务水平,是推动农村卫生事业发展的战略举措与现实需要。中医药作为我国传统医学,在农村具有广泛而深厚的群众基础,着力推广应用中医药适宜技术,是农村卫生事业发展的重要途径。甘肃省甘谷县和静宁县充分利用卫生XI项目平台,推广并探索中医药适宜技术应用与服务模式,有效推动了中医药服务的开展,并取得了良好的成效。     

安徽省三县农村居民卫生服务需求研究

对安徽省三个世行贷款卫Ⅷ项目县 1 80 0户 71 75名农村居民卫生服务需求进行了调查分析。结果显示 :两周就诊率为 2 1 .76 % ,平均就诊次数 2 .2 3 ,未就诊率 1 2 .50 % ;两周患病首次就诊单位分布村级卫生机构占 77.80 % ,乡镇卫生院占 1 4 .90 % ;年住院率为 3 .2 8% ,因经费困难延迟入院或提前出院者占全部住院者的 60 .60 % ,应住院未住院率为 53 .91 % ;居民对卫生服务利用的主要障碍是住院服务得不到经济保障。建议贫困地区卫生机构的布局与调整应以保障居民获得就近、低廉、方便的卫生服务为目标 ;改善卫生服务质量应以加强村级卫生机构管理为重点 ;实施合作医疗保险及医疗救助应以住院补偿为主。     

Evaluation of a routine telepsychiatry service

An assessment was undertaken of a routine telepsychiatry service in rural areas of a Canadian province as a follow-up to a pilot telepsychiatry project. Over two years, there were 546 consultations at the five participating general hospitals, although the level of use varied considerably between them. Health professionals expressed high satisfaction with the service. While there were equipment problems in 17% of all consultations in the second year, they did not seem to affect acceptance of the technique. A cost analysis comparing consultations provided by a visiting psychiatrist and telepsychiatry found a break-even point of 348 consultations a year. However, when use of the videoconferencing network for administrative meetings was considered, the break-even point was 224 consultations a year, substantially below the actual utilization of telepsychiatry. Telepsychiatry appeared to result in increased access to community mental health services, suggesting future increased demand for these. From the perspective of health authorities and health professionals, telepsychiatry proved to be a useful and sustainable addition to existing mental health services.     

中国农村地区高血压和糖尿病管理和控制模式的探索——基于中国农村卫生发展项目的实践分析

卫十一项目的 8个项目省、40个项目县,以社区诊断和健康档案的建立为切入点,以高血压、糖尿病等主要慢性病为抓手,针对健康人群、高危人群和患者等三类人群的需求,采取健康教育与促进、健康管理和疾病管理等措施,探索建立农村慢性病管理新模式。项目地区慢性病监测数据分析发现,登记和管理的高血压和糖尿病患者显著增加,其管理率从2009年的60.8%和32.2%分别上升到2013年的92.2%和88.8%;全国第五次卫生服务调查结果显示,项目地区调查人口自报高血压和糖尿病的控制率(63.8%,50.2%)显著高于全国农村地区平均水平(54.9%,38.3%)。结果提示,以培训、健康教育、健康管理和疾病管理为核心的农村慢性病管理模式有效改善了农村慢性病服务能力,项目地区所实施的慢性病综合干预措施切实可行,有借鉴和推广价值。