基本公共卫生服务项目的实施效果评价研究—以孕产妇健康管理服务为例.docx

目录常用缩略词中英文对照表 VIII中文摘要 IIAbstract VI前言 1第一章 基本公共卫生服务项目政策进展的结构性评价 7一、对象与方法 71.基本公共卫生服务项目 71.1 项目的组织与实施 81.2 资料来源 81.3 研究方法 8二、结果 81.基本公共卫生服务体系不断完善，保障项目平稳实施 82.服务内容不断增多，服务规范化、精细化管理水平不断提高 133.筹资机制不断完善，人均服务费用不断提高 163.考核机制逐步建立，规范化、合理化水平不断提高 19三、讨论与建议 21第二章 基于供需双方视角的基本公共卫生服务项目中孕产妇健康管理服务实施效果的过程评价研究 26第一节 基于需方视角的基本公共卫生服务项目中孕产妇健康管理服务实施效果的过程评价研究 27一、对象与方法 271. 基本公共卫生服务项目的孕产妇健康管理服务 271.1 服务需方 271.2 服务内容 272. 研究对象与研究方法 282.1 研究对象 282.2 资料收集方法 312.3 资料分析 31二、结果 311.项目的宣传与知晓 321.1 宣传方式多样 321.2 服务带动宣传 321.3 宣传深度有待提高 322. 项目的服务与利用 332.1 多阶段多频次的产前检查 332.2 延续性的产后服务 332.3 全孕期的健康教育 333. 项目的获得感与满意度 343.1 保证服务质量 343.2 改善服务态度 343.3丰富服务内容 34三、讨论 35第二节 基于供方视角的基本公共卫生服务项目中孕产妇健康管理服务实施效果的过程评价研究 36一、对象与方法 371. 基本公共卫生服务项目的孕产妇健康管理服务 371.1 服务供方 371.2 服务流程 371.3 服务要求 382. 研究对象与研究方法 382.1 研究对象 382.2 资料收集方法 402.3 资料分析 40二、结果 411. 培训与服务 411.1 多样化的培训方式 411.2 规范化的服务内容 421.3普遍存在的服务瓶颈 422. 考核与薪酬 422.1 考核模式有待改进 422.2 薪酬待遇有待提高 433. 职业认同与期待 433.1 职业认同感较强 433.2 执业动力不足 43三、 讨论 44第三章 基本公共卫生服务项目中孕产妇健康管理服务实施效果的结果评价研究 47第一节 基本公共卫生服务项目对孕产妇健康服务利用及孕产妇死亡影响的趋势研究 47一、对象与方法 471. 基本公共卫生服务项目的孕产妇健康管理服务 471.1服务对象 471.2 服务内容 471.3 项目实施要求 481.4 评价指标 481.5 数据来源 491.6 统计学分析 49二、结果 501.基本情况描述 502. 间断时间序列回归分析结果 522.1. 孕产妇服务利用率的间断时间序列回归分析 522.2. 孕产妇死亡率的间断时间序列回归分析 553. 相关分析结果 57三、讨论 58第二节 基本公共卫生服务项目中孕产妇健康管理服务与孕产妇死亡的关联性研究 61一、材料与方法 611. 数据来源 612. 指标解释 613. 统计分析 62二、结果 641. 基本公共卫生服务项目实施后各省孕产妇服务及卫生资源的描述性分析 642. 基本公共卫生服务项目实施后各省孕产妇服务及卫生资源变化的趋势性分析 663. 基本公共卫生服务项目实施后孕产妇健康管理服务率与孕产妇死亡率关联性的面板数据分析 68三、讨论 71全文小结 74研究特色与创新之处 75参考文献 75基金资助 87综述 88攻读学位期间发表论文情况 107致谢 108个人简介 110图目录图2-1 孕产妇健康管理服务流程 32图3-1 基本公共卫生服务项目实施前后早孕建册率的趋势变化 46图3-2基本公共卫生服务项目实施前后系统管理率的趋势变化 47图3-3 基本公共卫生服务项目实施前后产前检查率的趋势变化 47图3-4 基本公共卫生服务项目实施前后产后访视率的趋势变化 47图3-5 基本公共卫生服务项目实施前后全国孕产妇死亡率趋势变化 50图3-6 基本公共卫生服务项目实施前后城市地区孕产妇死亡率趋势变化 51图3-7 基本公共卫生服务项目实施前后农村地区孕产妇死亡率趋势变化 51表目录表1-1 基本公共卫生服务综合规划相关政策及内容 11表1-2 基本公共卫生服务项目服务内容调整及服务指南相关政策文件 14表1-3 基本公共卫生服务项目中央财政与地方财政补助分配比例 17表1-4 基本公共卫生服务项目筹资与财政保障相关政策 18表1-5 国家基本公共卫生服务项目绩效考核相关政策 20表2-1 20例研究对象的一般资料 29表2-2 20例研究对象的一般资料 39表3-1 2000-2018年各孕产妇健康管理服务利用率（%） 50表3-2 1991-2018年国家、城市及农村的孕产妇死亡率（1/10万） 51表3-3 2009-2018年孕产妇死主要疾病死亡率（1/10万） 52表3-4基本公共卫生服务项目实施前后孕产妇服务利用率间断时间序列分析结果 55表3-5 孕产妇死亡率的间断时间序列分析结果 56表3-6 2009-2016年各省孕产妇服务及卫生资源的变化情况 65表3-7 2009-2016年各省孕产妇服务及卫生资源的广义估计方程结果 67表3-8 2009-2016年孕产妇健康管理服务率与孕产妇死亡率的面板数据分析 69常用缩略词中英文对照表缩写全称中文WHOWorld Health Organization世界卫生组织UNICEFUnited Nations Children's Fund联合国儿童基金会PHCPrimary Health Care初级卫生保健MDGsMillennium Development Goals千年发展目标SDGsSustainable Development Goals可持续发展目标UHCUniversal Health Coverage全民健康覆盖BPHSBasic Public Health Service基本公共卫生服务MMRMaternal Mortality Ratio孕产妇死亡率ITSInterrupted Time-series Study间断时间序列回归分析CIsConfidence Intervals可信区间GDPGross Domestic Product国内生产总值中文摘要目的：1、了解基本公共卫生服务项目的在项目保障、财政筹资、绩效考核等方面的政策进展并对现阶段的政策体系进行结构评价；2、 以基本公共卫生项目中孕产妇健康管理服务为案例，从供需双方视角对项目的执行流程及服务体验等进行过程评价；3、以基本公共卫生项目中孕产妇健康管理服务为案例，探讨基本公共卫生服务项目实施后各项服务利用率的变化情况及其与健康结局的关联性，对项目的实施效果进行结果评价。方法： 本研究以Donabedian质量理论为框架，结合定量研究与定性研究，从结构、过程、结果三个维度对基本公共卫生服务项目的实施效果进行评价。1、基本公共卫生服务项目政策进展的结构评价通过在国家卫生健康委员会、财政部、国家中医药管理局等多个官方网络平台检索2009年基本公共卫生服务项目实施以来出台的纲领文件、资金筹备、绩效考核等相关政策，以及规范指南、公开发表的研究报告等。将检索到的政策文件、通知、法规及规范指南按照政策保障、资金筹备与使用、服务规范、绩效考核等多个方面进行归纳总结，并对每一个部分的政策进展和体系构建进行结构性评价。2、基于供需双方视角的基本公共卫生服务项目中孕产妇健康管理服务实施效果的过程评价采用目的抽样的方法，于2018年11月至2019年3月在长沙、重庆、贵阳、北京、哈尔滨5个地区12家社区卫生服务中心及乡镇卫生院对符合纳入排除标准的孕产妇及负责孕产妇健康管理服务的基层医务人员进行现场访谈。访谈依据研究设定的访谈提纲采取一对一的方式在单独空间进行，对访谈结果进行整理后，采用Colaizzi 7步分析法对访谈结果进行分析，对项目的执行流程及服务体验进行过程性评价。3、基本公共卫生服务项目中孕产妇健康管理服务实施效果的结果评价以2003-2019年中国卫生统计年鉴及国家卫生健康委基层卫生司的2009-2016年国家基本公共卫生服务项目自评报告为基础，对基本公共卫生服务项目中孕产妇健康管理服务的服务利用指标：早孕建册率、产前检查率、系统管理率、产后访视率及孕产妇健康结局指标：孕产妇死亡率进行趋势分析与关联性分析。孕产妇健康管理服务利用率及健康结局的趋势性分析采用间断时间序列回归分析，孕产妇健康管理服务利用率与健康结局的关联性分析采用面板回归分析，综合两种分析方法，对基本公共卫生服务项目中孕产妇健康管理服务的实施效果进行结果评价。结果：1、基本公共卫生服务项目政策进展的结构评价各项针对性政策及规范指南的出台保障了基本公共卫生服务的有效落实，人均服务费用逐年提高，服务内容不断丰富，均等化可持续的筹资模式逐步完善，绩效考核体系不断优化。但服务项目的动态调整机制缺乏，部分项目超出基层服务能力，基本医疗服务与基本公共卫生服务之间缺乏有效的衔接机制，绩效考核的结果导向性仍显不足。2、基于供需双方视角的基本公共卫生服务项目中孕产妇健康管理服务实施效果的过程评价多样化的宣传方式提高了孕产妇对基本公共卫生服务项目的知晓水平，全孕期多频次的连续性健康管理与健康教育提升了孕产妇的健康水平与健康素养，服务质量的提高与服务态度的改善提高了孕产妇对基本公共卫生服务项目的满意度与获得感。但现阶段项目涵盖的孕产妇健康服务尚不能满足不同孕产妇日益增长的健康需求，同时宣传的深度仍有待提高。规范化的培训与服务规范指南的出台保障了服务同质同量的实施，从事基本公共卫生项目的基层医务人员具有较高的职业认同感与满意度，但多数医务人员对长期从事基本公共卫生服务项目工作缺乏动力，主要原因包括：项目工作量大，考核压力大，薪酬待遇水平低及职称晋升空间小。3、基本公共卫生服务项目中孕产妇健康管理服务实施效果的结果评价2000-2008年基本公共卫生服务项目实施前，早孕建册率、产前检查率、产后访视率及系统管理率等孕产妇服务利用指标均处于缓慢上升或下降状态，2009-2018年，各项孕产妇服务利用率则处于明显上升状态。间断时间序列回归分析结果显示，基本公共卫生服务项目的实施对提升孕产妇的早孕建册率（=0.36，p=0.03）、产前检查率（=0.46，p0.01）、产后访视率（=0.56，p=0.02）及系统管理率（=0.99，p0.01)起到了促进作用。同时孕产妇死亡率在基本公共卫生服务项目实施前后均保持明显的下降趋势（项目实施前=-2.31，p0.01；项目实施后=-1.46，p0.01)。Pearson相关分析结果显示各项孕产妇健康管理服务利用率与孕产妇死亡率均呈现负相关。基本公共卫生服务项目实施后，2009-2016年孕产妇健康管理服务利用率与孕产妇死亡率的面板回归分析结果显示，在控制了住院分娩率、卫生人力资源、城乡医疗资源分配及财政相关因素后，孕产妇健康管理服务利用率与孕产妇死亡率存在负向关联(=-0.35，p<0.001)，其它影响孕产妇死亡率的因素包括：人均基本公共卫生服务费用(=-0.30，p<0.001)、每千人医生数(=-21.38，p<0.001)、城乡护士比（=9.78，p<0.001）、每千人床位数（=-2.77，p=0.02）、住院分娩率（=-3.53，p<0.001）及人均GDP（=-0.95，p<0.001）。结论:1、基本公共卫生服务项目的实施，推进了我国公共卫生服务体系建设，在人群覆盖性、服务内容优化、筹资的可持续性及绩效考核的合理性等方面都取得了重要进展。但服务内容动态调整机制，医防融合的效果及考核的结果导向性等方面仍有待提高。2、多元化的宣传模式提高了孕产妇对基本公共卫生服务的知晓水平，基本公共卫生服务目的实施对孕产妇的健康水平改善与健康素养的提升起到了促进作用。孕产妇对基本公共卫生服务具有较强的满意度与获得感。未来应有针对性的增加个性化服务内容，满足不同孕产妇的健康需求。3、科学的培训与规范指南的出台，保障基本公共卫生服务项目同质同量的实施。工作压力大、人员流失严重、信息化水平不足、考核效率低下、薪酬待遇较低是基本公共卫生服务项目可持续实施所面临的主要挑战。4、基本公共卫生服务项目的实施有效提升了早孕建册率、产前检查率、产后访视率、系统管理率等孕产妇健康管理服务利用率的水平，缩小了各地区间孕产妇服务能力的差距，对降低孕产妇死亡率起到了促进作用。关键词：基本公共卫生服务、效果评价、孕产妇服务利用率、孕产妇死亡率AbstractObjectives:1、To review the policy progress of Basic Public Health Service (BPHS) projects in terms of project guarantee, fiscal financing and performance appraisal, and to conduct structural evaluation on the current policy system;2、To conduct the process evaluation on implementation process and service experience from the perspective of supply and demand based on the example of maternal health management service in the BPHS project.3、 To conduct the outcome evaluation on the changes of the utilization rate of maternal health services after the implementation of BPHS project and its association with maternal outcomes based on the example of maternal health management service in the BPHS project.Methods:This study evaluated the implementation effect of BPHS project based on Donabedian quality theory from three dimensions: structure, process and result. Both quantitative research and qualitative research were involved in this study.1、Structural evaluation of policy progress in BPHS project.We researched the programmatic documents, financing preparation, performance appraisal, published research reports and other policy issues through online platforms from national health commission, ministry of finance and national administration of traditional Chinese medicine since the implementation of BPHS project in 2009. The retrieved policy documents, notices, regulations and normative guidelines were summarized in terms of policy guarantee, fiscal financing, service specification and performance appraisal. The policy progress and system construction of each part were structurally evaluated.2、Process evaluation of the implementation effect of maternal health management services in BPHS project from the perspective of supply and demand.Objective sampling methods was used to conduct on-site interviews with pregnant women and grass-roots medical personnel responsible for maternal health management services who met the inclusion and exclusion criteria in 12 community health service centers and township hospitals in 5 regions of Changsha, Chongqing, Guiyang, Beijing and Harbin from November 2018 to March 2019. The interview was conducted in a one-on-one manner in a separate space according to the interview outline set by the research. The interview results were with Colaizzi 7-step analysis method, and the project execution process and service experience of the project were evaluated.3、Results evaluation of the implementation effect of maternal health management services in BPHS project.We conducted the trend change analysis and association analysis of maternal health outcomes and utilization rates of maternal health service management in BPHS project such as: the establishment rate of maternal health record, antenatal visit examination rate, maternal system management rate and postpartum visit rate based on data from China health statistics yearbook 2003-2019 and the self-report of Basic Public Health Service implementation 2009-2016. Segmented linear regression was used to evaluate the trend changes of maternal health outcome and utilization rates of maternal health service management before and after the implementation of BPHS project. Panel data model was used to explain the association between maternal health services utilization and maternal health outcomes. Based on the two analytical methods, the result evaluation of the implementation of maternal health management services in BPHS project was conducted.Results:1、Structural evaluation of policy progress in BPHS project.The introduction of various targeted policies and service standard guidelines ensured the effective implementation of BPHS project. The main performance was that the per capita fee of BPHS project increased year by year, the service content enriched continuously, the equalization and sustainable financing model gradually was improved, and the performance appraisal system was continuously optimized. However, the health services system also had limitations, such as there was a lack of dynamic adjustment mechanism for service content, some services were beyond the capacity of primary care, there was no effective connection mechanism between basic medical care and basic public health services, and the result guidance of performance appraisal was still insufficient.2. Process evaluation of the implementation effect of maternal health management services in BPHS project from the perspective of supply and demand.Diversify publicity methods improved the knowledge level of BPHS project in pregnant women. The continuous and frequency health management and health education during the whole pregnancy improved the health level and health literacy of the pregnant women effectively. The improved service quality and service attitude increased the satisfaction and sense of gain among of the pregnant women. However, the maternal health services covered by the current project were not yet able to meet the growing health needs of different pregnant women, and the depth of publicity still needed to be improved.The standardized training and service guidance ensured the implementation of the BPHS project in same quality and quantity. The professional identity and satisfaction of grassroots health workers were improved with the implementation of BPHS project, but most of the medical personnel lacked the motivation to engage in BPHS project for a long time, and the main causes included: the heavy workload, low level of salary and the small space of professional promotion space.3. Results evaluation of the implementation effect of maternal health management services in BPHS project.Before the implementation of BPHS project from 2000 to 2008, the utilization rates of maternal health services such as the establishment rate of maternal health record, antenatal visit examination rate, maternal system management rate and postpartum visit rate were all in a state of slow rise or decline, while all the utilization rates changed into increasing trend from 2009 to 2018. The results of segmented linear regression showed that the implementation of BPHS project increased the establishment rate of maternal health record（=0.36，p=0.03）, antenatal visit examination rate（=0.46，p0.01）, maternal system management rate（=0.99，p0.01) and postpartum visit rate(=0.56，p=0.02）effectively. The maternal mortality ratio kept decreasing continuously before and after the implementation of BPHS project (before the project: =-2.31，p0.01；after the project: =-1.46，p0.01). The Pearson correlation results showed significant negative correlations between maternal health service utilization rates and maternal mortality ratio.The panel data analysis results showed that after controlling the covariates such as hospital delivery rate, health human resources, urban and rural resources distribution, and some financial factors, the maternal health service utilization rate was associated with maternal mortality ratio (=-0.35，p<0.001) after the implementation of BPHS project, other factors that influenced maternal mortality included: the fee of BPHS project per capita(=-0.30，p<0.001), doctors per thousand(=-21.38，p<0.001), urban rural nurse ratio（=9.78，p<0.001）, sickbeds per thousand（=-2.77，p=0.02）, hospital delivery rate（=-3.53，p<0.001）and GDP per capita（=-0.95，p<0.001）.Conclusions:1、The implementation of BPHS project had promoted the construction of China's public health service system, and made important progress in the aspects of population coverage, service content optimization, financing sustainability and performance appraisal. However, the dynamic adjustment mechanism of service contents, the combination of medical and prevention and the results guidance of performance appraisal were still need to be improved.2、Diversify publicity methods improved the knowledge level of BPHS project in pregnant women. The implementation of BPHS project had increased the health level and health literacy of the pregnant women effectively. The pregnant women was satisfied with the BPHS project. Personalized maternal health services should be added to meet the health needs of different pregnant women in the future.3、The standardized training and service guidance ensured the implementation of the BPHS project in same quality and quantity. High work pressure, severe staff turnover, insufficient informatization level, low performance appraisal efficiency and low salary were the major challenges to the sustainable implementation of BPHS project.4、The implementation of BPHS project has effectively improved the utilization rate of maternal health services, such as the establishment rate of maternal health record, antenatal visit examination rate, maternal system management rate and postpartum visit rate, narrowed the gap in service capacity between regions and played an important role in reducing maternal mortality.Key words:Basic Public Health Service, Implementation Effect, Maternal Health Service Ut