基于政策工具视角基层医疗卫生机构应对突发公共卫生事件的政策研究

背景　基层医疗卫生机构是应对突发公共卫生事件的最基层医疗单位，面向基层医疗卫生机构的突发公共卫生事件应对政策体系是提升基层应急能力的重要保障。目的　从政策工具视角分析基层医疗卫生机构应对突发公共卫生事件政策的侧重点、变化趋势，发现诊断政策体系的不足，提出相应的优化建议。方法　选取2009-03-17至2020-08-30的35份国家层面颁布的有关基层医疗卫生机构应对突发公共卫生事件的政策文本，运用内容分析法从政策工具、政策客体、应急管理生命周期3个维度对政策文本进行量化分析。结果　35份政策文本经编码后共获得99个参考点。单维度分析结果显示，目前需求型政策工具、政府与政府部门、响应阶段分别在3个维度中占比最多（53.5%、44.4%、74.7%）。二维度交叉分析结果显示，目前对政府部门使用频率最高的为供给型政策工具，对于基层医疗卫生机构、社区街道或乡村使用较多的为需求型政策工具；预防及准备阶段人力、物资供给型政策较少，响应及恢复阶段需求型政策工具较多；政府部门及基层医疗卫生机构两个客体贯穿应急管理生命周期的各阶段，而医疗工作者、社区街道或乡村等客体存在某阶段未涉及的情况。三维度交叉分析结果显示，在预防阶段及恢复阶段，各类政策工具整体使用次数较少，仅对政府部门、疾病预防控制机构和基层医疗卫生机构使用了少量的需求型或环境型政策工具；准备阶段，对于不同政策客体均为供给型政策工具使用最多；响应阶段，对各客体使用的各类政策工具均显著增加，对基层医疗卫生机构使用需求型政策工具频率最高。结论　我国基层医疗卫生机构应对突发公共卫生事件的政策体系仍处于建设阶段，政策工具分布差异化显著，重需求型而轻供给型与环境型；政策客体分布不均衡，聚焦政府及基层医疗卫生机构而忽视协同机构的参与；政策未能全面覆盖应急管理生命周期，重事发响应而忽视事前预防及事后恢复。因此，在制定基层医疗卫生机构应对突发公共卫生事件的相关政策时，应当充分考虑不同应急管理生命周期的特点，优化政策工具配比，均衡政策客体分布，强化预防和恢复阶段建设。

Policy Responses of Primary Care to Public Health Emergencies：a Policy Tool-based Analysis

Background　The front line of the fight against public health emergencies is primary care，so the response policy system for the emergencies is a guarantee to enhance primary care response abilities. Objective　To perform a policy analysis of the priorities and trend of changes in policies regarding primary care response to public health emergencies，and to put forward recommendations for improving the insufficiencies. Methods　Thirty-five policy documents regarding primary care response to public health emergencies issued by China's central government between 2009-03-17 and 2020-08-30 were selected，and quantitatively analyzed using content analysis from aspects of policy tools，policy responsible parties and emergency management cycle. Results　A total of 99 reference points were obtained from 35 policy texts. Unidimensional analysis demonstrated that policy tools with the highest proportion in X，Y and Z dimensions were demand-side policy tools（53.5%），government and relevant departments（44.4%） and response policy tools（74.7%），respectively. In the two-dimensional analysis，the most frequently used policy tool for government departments was supply-side type. For primary medical institutions，community，subdistrict or rural areas，demand-side type was often used. There were fewer supply-side policies in terms of healthcare workforce and healthcare resources in mitigation and preparedness phases，and many demand-side policy tools in response and recovery phases. The government departments and the primary health institutions were involved in each phase of the emergency management cycle，while healthcare workers，community，subdistrict or rural areas were not covered at every phase. In the three-dimensional analysis，policy tools was less used in both preparedness and recovery phases in general，only a few demand-side and environmental-side policy tools were applied to government departments，institutions of disease prevention and control and the primary health institutes. In the preparedness phase，supply-side policy tools were used the most for each policy responsible party. When entering the response phase，the policy tools for each party significantly increased，and the use of demand-side policy tools tended to be higher in primary health institutions. Conclusion　The policy system of China's primary care response to public health emergencies is still under construction. The distribution of policy tools is significantly different，with a focus on demand-side rather than supply-side and environment-side. The distribution of policy responsible parties is unbalanced，mostly involving the government and primary medical institutions，but neglecting the participation of collaborative agencies. The policies fail to fully cover the emergency management cycle，focusing on response but neglecting prevention and recovery. Therefore，it is recommended that policies associated with public health emergency management should be developed with four aspects fully taken into consideration: features of each phase of emergency management cycle，appropriately optimizing the proportion of different types of policy tools，balancing the distribution of policy responsible parties，and strengthening the construction of preparedness and recovery phases of emergency management.