农村卫生适宜技术项目实施评价研究
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摘要
我国医药卫生事业发展的重点是农村卫生工作。农村卫生工作的开展必须依靠科技进步。针对农村防病治病工作的实际需要，从现有科技成果中，选择成熟、适宜的卫生技术向农村医疗卫生机构转移，是推动我国农村卫生事业发展的新思路。“农村卫生适宜技术推广示范研究”项目就是这种思路下的一次探索实践。该项目于2004年底启动，并列入“十五”国家科技攻关计划，作为重点项目组织实施。
本研究是在复习项目评价相关文献的基础上，利用“十五”国家科技攻关计划“农村卫生适宜技术推广示范研究”项目的常规登记资料以及现场问卷调查与访谈资料，通过定量与定性两种方法，对该项目(主要是西医技术部分)的实施过程和实施结果进行评价，并分析项目实施和技术推广的影响因素。
本研究的主要结果：
(1)所调查10个项目省都成立了省、县两级项目管理体系，并建立健全了项目管理制度。项目共投入经费2603万元，其中国拨经费2000万元，地方配套经费603万元。个别地方配套经费较少，部分示范县和医疗机构反映其经费不足。
(2)有99.1％的医务人员认为其工作“很需要”或“需要”所培训的技术。县、乡、村三级医务人员平均每项技术的培训时间分别为3天、1天稍多和不足1天。有65.9％的受培训医务人员认为需要再次培训，其中村卫生室人员需要再次培训的比例高达75.4％。被调查医务人员中有65.7％的认为自己已经“熟练掌握”或“较熟练掌握”了所培训技术。所培训技术的77.9％已经应用。未应用原因以“时间太短还没有病人”为最多，占44.6％，其次是“没有配套的设备、器械或药品”，占32.3％。
(3)10个项目省共培训167项次西医技术，培训医务人员11887人次。截至调查时，适宜技术已服务68965人次。93.5％的受调查服务对象认为适宜技术与其所接受过的其他技术相比效果更好。适宜技术推广以后，大部分疾病的次均门诊或住院费用与2003年基线数据相比有所降低，个别疾病费用降低幅度较大。
(4)技术推广效果的影响因素包括：项目管理因素，如领导重视程度、工作积极性和主动性、管理力度等；项目经费因素，如经费总量和经费使用方式；技术本身的“适宜性”，如技术难易程度、服务价格、所针对疾病的患发病情况：技术持有方因素，如技术总量、推广意愿；技术服务提供方因素，如设备水平、人员素质、提供意愿：技术服务需求方因素，如收入水平、就医习惯、健康观念等。
结论：适宜技术推广受到了农村卫生机构和医务人员的普遍欢迎。各项目省对适宜技术推广工作比较重视，都建立了项目组织管理体系，大部分项目省还提供了经费支持。项目的实施提高了示范地区农村基层医务人员和医疗机构的适宜技术服务能力，改善了部分疾病的诊疗效果，所推广大部分技术都降低了相关疾病的诊疗费用，项目的开展也增加了一些新的卫生服务内容。
通过研究也发现了一些问题，如适宜技术推广经费不足，地方配套难以有效保证，部分示范县和医疗机构经费数量较少；适宜技术总量不足，难以满足不同地区、不同机构的技术需求；技术培训师资和教材缺乏，培训时间较短；基层机构尤其是乡镇卫生院设备水平较差，所培训部分技术难以开展等。
建议：(1)中央和地方各级政府加大适宜技术推广工作的经费投入，并向经济落后地区倾斜，在经费使用上重心下移。(2)重视科研成果转化与分享，加强适宜技术的评估筛选，扩大技术可选择范围。(3)提高培训效果和培训质量，延长培训时间，重视学员反馈。(4)为适宜技术推广创造条件，及时做好适宜技术相关药品和器械的供应，制定适宜技术服务收费标准，加大项目宣传。
Rural health care is the emphasis of the health sector in China. Transferring appropriate health technologies to hospitals and clinics in rural area is a strategical measure to develop rural health care. Appropriate Health Technology Program in Rural China, which covered 20 counties in 10 provinces, was implemented as a major project of the Ministry of Science and Technology and the Ministry of Health from 2004 to 2006. By now, the program has been carried out for more than two years. Most of the stakeholders want to know clearly about the process, lessons learned and outcome of the program. It is necessary and significant to develop scientific evaluation for the program.
Basing on experience gained from literature review and information from program stakeholders, the author designed evaluating indicators. Most of the indicators were collected through questionnaire and interview during field work in August 2006. Others were acquired through recorded database of the program.
The major findings of the research are as follows:
(1) Organizations were established in 10 provinces and 10 counties to manage the program. The total outlay of the program was 26.03 millions yuan, 20 millions from cental government, 6.03 millions from local governments. Some local program managers and hospital functionaries reported that the outlay they got was scarce.
(2) 99.1% of the medical staffs thought they had "urgent demand" or "demand" for technologies they had been trained, 65.9% of them wanted to be trained again. 65.7% of the medical staffs been investigated showed that they knew much about technologies they had been trained, and 77.9% of the technologies had been utilized in clinical practice.
(3) 167 health technologies and 11,887 medical staffs had been trained in 10 provinces during the program period. 68,965 patients had benefited from the program by August 2006. 93.5% of the interviewed patients prefered the new technology to others they had utilized before for better efficiency. Expenditure of numerous diseases was reduced in contrast with that in 2003.
(4) Factors that influence the effect of appropriate health technology transfer include: positivity and capability of the program managers; total amount and allocation of program outlay; propriety of technologies, such as conveniency, price of service, prevalence of target disease, etc; willingness of patent holders to transfer or share their technologies; hospital facility and staff ability; income level and health care utilization of rural residents, etc.
Conclusions: The program received a warm welcome from hospitals and medical staffs in rural areas. Local governments of the 10 provinces attached much importance to the program. Most of them invested in the program in proportion to central government' outlay. Organizations at two levels—province and county were established to manage the program. Thanks to the program, capabilities of rural hosipitals and rural doctors to diagnose and treat diseases have been improved significantly. In addition, expenditures of several diseases have been reduced. Otherwise, several problems were discovered to be resolved. For example, the outlay for appropriate health technology transfer is limited, especially in western provinces; There are few appropriate technologies that can be selected to meet demands of rural hospitals; The training was in such a hurry that quite a lot medical staffs could not master the technology. Lack of necessary facilities was reported by several hospitalsas an obstacle to technology utilization.
Suggestions: (1) Both central government and local governments should increase budget for appropriate health technology transfer, and western depressed areas have the priority to obtain invest from central government. (2) Facilitate a faster transition from research to clinical practice. More attention should be payed to Health Technology Assessment and the selection of appropriate health technology, so that rural hosipitals and clinics will have more choices. Evidence shows that technology demands of different hospitals are diverse. They prefer techonologies that adapt to their own situation. (3) Enhance the quality of technology training. Time of learning should be prolonged, especially for doctors from township hospitals and village clinics. Envidence also shows that retraining is necessary for the majority of doctors. Besides, quite a few doctors expressed that they need multimedia teaching material to learn the technology by themselves after training. (4) Appropriate health technology transfer needs policy supports such as market admittance of new technologies, setting up the price of technology service, etc. Hospitals and doctors that provide appropriate health service to rural residents should be encouraged and granted with bonus.
本研究是在复习项目评价相关文献的基础上，利用“十五”国家科技攻关计划“农村卫生适宜技术推广示范研究”项目的常规登记资料以及现场问卷调查与访谈资料，通过定量与定性两种方法，对该项目(主要是西医技术部分)的实施过程和实施结果进行评价，并分析项目实施和技术推广的影响因素。
本研究的主要结果：
(1)所调查10个项目省都成立了省、县两级项目管理体系，并建立健全了项目管理制度。项目共投入经费2603万元，其中国拨经费2000万元，地方配套经费603万元。个别地方配套经费较少，部分示范县和医疗机构反映其经费不足。
(2)有99.1％的医务人员认为其工作“很需要”或“需要”所培训的技术。县、乡、村三级医务人员平均每项技术的培训时间分别为3天、1天稍多和不足1天。有65.9％的受培训医务人员认为需要再次培训，其中村卫生室人员需要再次培训的比例高达75.4％。被调查医务人员中有65.7％的认为自己已经“熟练掌握”或“较熟练掌握”了所培训技术。所培训技术的77.9％已经应用。未应用原因以“时间太短还没有病人”为最多，占44.6％，其次是“没有配套的设备、器械或药品”，占32.3％。
(3)10个项目省共培训167项次西医技术，培训医务人员11887人次。截至调查时，适宜技术已服务68965人次。93.5％的受调查服务对象认为适宜技术与其所接受过的其他技术相比效果更好。适宜技术推广以后，大部分疾病的次均门诊或住院费用与2003年基线数据相比有所降低，个别疾病费用降低幅度较大。
(4)技术推广效果的影响因素包括：项目管理因素，如领导重视程度、工作积极性和主动性、管理力度等；项目经费因素，如经费总量和经费使用方式；技术本身的“适宜性”，如技术难易程度、服务价格、所针对疾病的患发病情况：技术持有方因素，如技术总量、推广意愿；技术服务提供方因素，如设备水平、人员素质、提供意愿：技术服务需求方因素，如收入水平、就医习惯、健康观念等。
结论：适宜技术推广受到了农村卫生机构和医务人员的普遍欢迎。各项目省对适宜技术推广工作比较重视，都建立了项目组织管理体系，大部分项目省还提供了经费支持。项目的实施提高了示范地区农村基层医务人员和医疗机构的适宜技术服务能力，改善了部分疾病的诊疗效果，所推广大部分技术都降低了相关疾病的诊疗费用，项目的开展也增加了一些新的卫生服务内容。
通过研究也发现了一些问题，如适宜技术推广经费不足，地方配套难以有效保证，部分示范县和医疗机构经费数量较少；适宜技术总量不足，难以满足不同地区、不同机构的技术需求；技术培训师资和教材缺乏，培训时间较短；基层机构尤其是乡镇卫生院设备水平较差，所培训部分技术难以开展等。
建议：(1)中央和地方各级政府加大适宜技术推广工作的经费投入，并向经济落后地区倾斜，在经费使用上重心下移。(2)重视科研成果转化与分享，加强适宜技术的评估筛选，扩大技术可选择范围。(3)提高培训效果和培训质量，延长培训时间，重视学员反馈。(4)为适宜技术推广创造条件，及时做好适宜技术相关药品和器械的供应，制定适宜技术服务收费标准，加大项目宣传。
Rural health care is the emphasis of the health sector in China. Transferring appropriate health technologies to hospitals and clinics in rural area is a strategical measure to develop rural health care. Appropriate Health Technology Program in Rural China, which covered 20 counties in 10 provinces, was implemented as a major project of the Ministry of Science and Technology and the Ministry of Health from 2004 to 2006. By now, the program has been carried out for more than two years. Most of the stakeholders want to know clearly about the process, lessons learned and outcome of the program. It is necessary and significant to develop scientific evaluation for the program.
Basing on experience gained from literature review and information from program stakeholders, the author designed evaluating indicators. Most of the indicators were collected through questionnaire and interview during field work in August 2006. Others were acquired through recorded database of the program.
The major findings of the research are as follows:
(1) Organizations were established in 10 provinces and 10 counties to manage the program. The total outlay of the program was 26.03 millions yuan, 20 millions from cental government, 6.03 millions from local governments. Some local program managers and hospital functionaries reported that the outlay they got was scarce.
(2) 99.1% of the medical staffs thought they had "urgent demand" or "demand" for technologies they had been trained, 65.9% of them wanted to be trained again. 65.7% of the medical staffs been investigated showed that they knew much about technologies they had been trained, and 77.9% of the technologies had been utilized in clinical practice.
(3) 167 health technologies and 11,887 medical staffs had been trained in 10 provinces during the program period. 68,965 patients had benefited from the program by August 2006. 93.5% of the interviewed patients prefered the new technology to others they had utilized before for better efficiency. Expenditure of numerous diseases was reduced in contrast with that in 2003.
(4) Factors that influence the effect of appropriate health technology transfer include: positivity and capability of the program managers; total amount and allocation of program outlay; propriety of technologies, such as conveniency, price of service, prevalence of target disease, etc; willingness of patent holders to transfer or share their technologies; hospital facility and staff ability; income level and health care utilization of rural residents, etc.
Conclusions: The program received a warm welcome from hospitals and medical staffs in rural areas. Local governments of the 10 provinces attached much importance to the program. Most of them invested in the program in proportion to central government' outlay. Organizations at two levels—province and county were established to manage the program. Thanks to the program, capabilities of rural hosipitals and rural doctors to diagnose and treat diseases have been improved significantly. In addition, expenditures of several diseases have been reduced. Otherwise, several problems were discovered to be resolved. For example, the outlay for appropriate health technology transfer is limited, especially in western provinces; There are few appropriate technologies that can be selected to meet demands of rural hospitals; The training was in such a hurry that quite a lot medical staffs could not master the technology. Lack of necessary facilities was reported by several hospitalsas an obstacle to technology utilization.
Suggestions: (1) Both central government and local governments should increase budget for appropriate health technology transfer, and western depressed areas have the priority to obtain invest from central government. (2) Facilitate a faster transition from research to clinical practice. More attention should be payed to Health Technology Assessment and the selection of appropriate health technology, so that rural hosipitals and clinics will have more choices. Evidence shows that technology demands of different hospitals are diverse. They prefer techonologies that adapt to their own situation. (3) Enhance the quality of technology training. Time of learning should be prolonged, especially for doctors from township hospitals and village clinics. Envidence also shows that retraining is necessary for the majority of doctors. Besides, quite a few doctors expressed that they need multimedia teaching material to learn the technology by themselves after training. (4) Appropriate health technology transfer needs policy supports such as market admittance of new technologies, setting up the price of technology service, etc. Hospitals and doctors that provide appropriate health service to rural residents should be encouraged and granted with bonus.
引文
1．刘晓波，刘雁飞，祁国明．推广卫生适宜技术 促进农村卫生事业发展[J]．中华医学科研管理杂志，2004，17(3)：131-162
2．科技部．关于“十五”国家科技攻关计划“农村卫生适宜技术推广示范研究”项目的批复．国科发计字[2004]328号
3．龚幼龙主编．卫生服务研究．上海：复旦大学出版社，2002
4. Freeman HE. The Present Status of Evaluation Research. In M. A. Guttentag S. Saar(eds), Evaluation Studies Review Annual, 1997, 2:17-51
5. Madaus GF, Stufflebeam D. Education Evaluation: The Class Works of Ralph W. Tyler. Boston: Kluwer Academic Publishers, 1989
6．彼得·罗希，霍华德·弗里曼，马克·李普希．项目评估：方法与技术．邱泽奇等译．第6版．北京：华夏出版社，2002
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11．梁万年，周纪安，段明月，等．综合性区域卫生发展项目(卫Ⅲ项目)的效果评价．中国卫生经济，1999，18(6)：19-21
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2．科技部．关于“十五”国家科技攻关计划“农村卫生适宜技术推广示范研究”项目的批复．国科发计字[2004]328号
3．龚幼龙主编．卫生服务研究．上海：复旦大学出版社，2002
4. Freeman HE. The Present Status of Evaluation Research. In M. A. Guttentag S. Saar(eds), Evaluation Studies Review Annual, 1997, 2:17-51
5. Madaus GF, Stufflebeam D. Education Evaluation: The Class Works of Ralph W. Tyler. Boston: Kluwer Academic Publishers, 1989
6．彼得·罗希，霍华德·弗里曼，马克·李普希．项目评估：方法与技术．邱泽奇等译．第6版．北京：华夏出版社，2002
7. American Evaluation Association. http://www.eval.org
8. Canadian Evaluation Society. http://www.evaluationcanada.ca
9. American CDC. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr4811al.htm
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