中国血吸虫病控制策略的演变和管理变革的研究
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摘要
本研究采用文献查阅、典型调查、专家咨询、焦点访谈、血防老专家座谈等定性与定量研究结合的方法,重点分析、研究不同经济体制时期和不同历史条件下,中国血吸虫病防治策略的经验和不足以及血吸虫病控制效果;同时,分析不同防治阶段、不同经济体制和历史条件下血防政策和管理模式、经费投入和科技进步等支撑条件、血防机构、专业队伍的变化情况和对血吸虫病控制的作用:重点论述我国血吸虫病控制策略的演变过程和发展趋势,并试图通过对不同时期防治策略对机构和人员需求与效果的对比分析,研究在现行经济体制下我国血吸虫病控制中存在的机遇与挑战,并思考传染性非典型肺炎暴发给公共卫生的启示,抓住国家加大对公共卫生建设的良好契机,提出与经济体制转型时期相适应的控制策略、政策、支撑条件、机构变革和队伍建设以及完善管理模式的设想,为建立可持续发展的我国控制血吸虫病的运行机制,提供科学依据,有着积极的意义。
     在计划经济体制下,血防工作在党中央血防领导小组的领导下,以消灭血吸虫病为目的,采取了以“全党动员、全民动手,开展广泛的群众性防治运动”的防治政策,实施以灭螺为主导的综合防治措施。在长期的防治工作中,积累了一整套适合我国当时经济体制下的防治经验。如加强党和政府的领导,是消灭血吸虫病的保证,人民群众是消灭血吸虫病的主力军等。但是由于过分强调血防工作的政治意义,而对血防工作的艰巨复杂性和经济效益认识不足。
     1980年代中期开始,我国开始进入经济转型阶段。在世界卫生组织、世界银行贷款的帮助和寄生虫学诊断技术及化疗药物等科学进步的影响下,我国的血防工作引入了疾病控制的策略和概念,开展了以化疗为主导和有重点的消灭钉螺的防治措施,并逐步开展健康教育。但是血防工作仍沿用计划经济体制下的一套政策和管理模式,出现了许多资源不配套、措施不到位、管理上的错位缺位、任务得不到落实等现象。新的管理机制的建立和完善势在必行。
     在不同经济体制下,血防机构和队伍也发生了不少变化。首先在计划经济阶段,中央成立了防治血吸虫病领导小组及其办事机构,负责组织制定血防工作的方针、政策、措施。各流行省、地区均成立血吸虫病领导小组,并建有血吸虫病防治所(站),县级血吸虫病防治所(站),在相应的重疫区还建有血吸虫病防治站(组),负责当地血吸虫病防治工作的实施。另外还组建一支由当地群众组成的不脱产队伍。至1980年代中期,全国省、地(市)、县三级共有260多个血防专业机构,区、社共有1620多个血防专业机构,血防专业人员共16000多人,不脱产的血防人员则更多,基本上每个大队10人左右。
     随着改革的不断深入,血防机构从中央到地方都进行了重组。但在经济体制转型过程中,组织机构没有及时转变其职能,带来了管理上弊端较多,包括在血防一线人员向上一级单位聚集,形成管理人员增加,而第一线工作人员数下降;一方面增加了“内耗”,另一方面形成权职冲突,阻碍了科学而有效地发挥管理人员的才能,管理渠道不能畅通无阻。
     进入21世纪以后,由于疫区省份频繁发生洪涝灾害,人畜流动频繁,导致一些地区血吸虫病疫情反弹回升,钉螺扩散明显,人畜感染危险增加;病人数居高不下:新疫区不断增加;血吸虫病正在向城市蔓延,血防工作面临的形势十分严峻,控制血吸虫病仍将是一个长期而艰巨的任务。
     目前血吸虫病防治工作中存在的问题主要有:1)社会经济方面的问题:在重视经济发展时忽视了血吸虫病防治工作:血防经费投入严重不足;血防专业机构和队伍难以适应新形势下防治工作的需要;血防科学研究不能满足血防工作的需要;2)生物环境问题:血吸虫病宿主和传播环节多,单一的预防控制措施很难奏效;影响血吸虫病流行的自然环境因素复杂,防治难度大;大型水利建设项目的影响;退田还湖;南水北调;气候变暖;洪涝灾害等。
     对现有的血防卫生人力资源和血防机构方面存在的问题做了深入的调查后发现:
     在卫生人力资源方面存在的问题很多,主要表现在现有的血防专业人员的年龄偏大,平均年龄42.5岁;学历、职称偏低,大部分工作人员是初级职称;职工待遇低下,大部分人员的人均年收入在5000—10000元,按照国家基本工资的标准,尚有较大差距;血防人员接受过培训的太少,有一部分工作人员从来没有参加过培训:近5年来,血防调入人员的总数明显多于调出人员的数量,但是调入人员的职称较调出人员的质量低,无职称人员的比例占了53.60%,其学历也以中专学历最多,占了51.61%,高素质人才的大量流失,导致人才匮乏,难以适应新时期血防工作的需要。
     在血防机构方面,目前县级血防机构的规模大小不一,部分血防机构规模过大。虽然血防财政供养人员过多,但实际工作人员太少,血防人员的薪资低于国家基本工资的标准,导致高素质人才的大量流失;在市场经济的作用下,现在很多地方的血防工作人员不再注重预防,而把绝大部分精力都放在治病赚钱上。由于一些地方政府对血防工作重视不够,财政投入严重不足,以及世行贷款结束的落差,血防机构缺少收入来源,加上前几年非专业、低素质人员的大批涌入,加重了血防机构的经济负担,许多血防机构入不敷出,甚至不能保证职工的生计,血防机构为了寻求生存空间,希望在疾病的治疗上求得经济上的补偿。但是这种行为一方面受到农村“费改税”等政策的制约,另一方面也产生了很多负面效应。从血防机构满意度调查结果来看,现有血防机构中的机制效率,技术的创新以及血防系统的亲和力都已经达到了非常低的水平。
     血防机构的改革也迫在眉睫,面临着何去何从的问题,是并入疾病预防控制中心,还是继续保持原有的建制?建议借卫生机构改革的契机,“精兵简政”,提高疾病防治和监测的效率,改善职工待遇。加强工作人员的培训等。并建立与防病相适应的薪酬体系。目前比较得到血防管理人员赞同的是进行医防分离的改革,将血防医疗部分与医疗机构统一管理。将血防工作的预防控制职能归口国家公共卫生体系,并入疾病预防控制中心,进行机构的调整或优化,按全额的财政预算保证工资和工作经赞,保证一支精干的血防队伍。
     综上所述,本研究的主要结论有:1)控制血吸虫病传播的背景条件发生了巨大的变化;2)血吸虫病控制策略的出发点和落脚点在于——以人为本。3)全面规划血防工作,分阶段实现防治目标;4)完善突出重点、因地制宜、综合防治、联防联控、稳步推进的防治策略;5)协调联防,扩大防治效果和巩固血防成果;6)依法进行防治,明确目标责任制:7)加大各级财政的投入,统筹使用各种资源,增强控制能力:8)尊重控制疾病与社会经济和环保的协调发展;9)血防机构实现卫生资源整合和优化的综合管理;10)血防策略必须与经济体制变革相适应——建立可持续发展机制;11)控制和消除血吸虫病最终要依靠科技的进步和社会发展。
Through literature reviewing, typical survey, experts consulting, focused group discussion and symposiums, this project aims to review the experiences and lessons of schistosomiasis control in China in different economic systems and history stages. At the same time, to retrospect the function of different policies, administrative patterns, financial support and technological progresses under different background. Through describing the developing progress and trend of the schistosomiasis control policy, and by comparing the demand of the institutes and human resources in different stages, and the effect of schistosomiasis control with different strategies, we analyzed the chances and challenges in the present anti-schistosomiasis system, and being the alarm of SARS, the government try to rebuilt and perfect the public health system, we must grasp the opportunity to reform anti-schistosomiasis system and try to control schistosomiasis.
    Under the planned economic system, the target of anti-schistosomiasis is eliminating schistosomiasis. The prevention and cure policy is "motivate the whole party, everyone should take part in the widely preventive and curing action", the main purpose of the integrate measures was eliminating snail. Now, we accumulated lots of experiences that suitable to the planned economic system. Such as strengthen the governmental and CCP's leadership, which will ensure the project of eliminating schistosomiasis, and the people is the main force etc. But in this stage the political meaning had been overemphasized while the complication and long-term of schitosoniasis and ecological effect had been not paid more attention.
    In the middle of 1980, China began to reform the economical system. And within this phase, the concept and strategy of diseases control had been introduced to the schistosomiasis control projects, and the strategy turned to focus in curing patients, and try to eliminate snail in the important areas, health education was gradually carried out. Because the policy and administrative model held the line, however, the side effect emerged, such as the resources collocated unreasonable, measures can't be actualized, management default and the task unimplemented, etc. The new administrative system was called to be established and improved.
    With the development of economic system, the anti-schistosomiasis institutes and human resources changed. In the stage of planned economy, the integrated administrative model of anti-schistosomiasis had been founded. Until the middle of 1980, there were 260 anti-schistosomiasis
    institutes distributing in the counties and higher lever all around the country, and 1620 in the communities, the whole staff come up to 16000, unincluding the many amateurs, about 10 persons in each group.
    Along with the political reform, the anti-schistosomiasis model changed too. But the function of the institutes didn't change with it. So lots of problems came forth. Such as the workers aggregating from the basic line to the upper ones, and the number of administrators increased, while the operating workers decreased. On one hand, the burden of anti-schistosomiasis system was going up, and on the other hand, the conflict between the powers increased, hindering the further schistosomiasis control.
    After entering 21 century, because the frequent floods in the endemic regions and the quick transmigration among people and livestock within counties, the prevalence increases again; the snail area enlarges, and the risk of people and livestock infection increases, the number of cases keeps high, the new infected regions increase, and the schistosomiasis is spreading from the rural to the urban, the task of schistosomiasis control is still arduous in china.
    Now the problems of the schistosomiasis control in China are: 1) social and economical problems: the importance of schistosomiasis control had not been recognized by some local governments. Short of financial support to anti-schistosomiasis, the anti-schistosomiasis institute and the staff do not adapt to the new demand of schistosomiasis control, and the researches can't meet the anti-schistosomiasis work, too. 2) biologic and environmental problems: there are too many hosts of schistosome and many transmission ways of schistosomiasis, so it is very difficult to control schistosomiasis with single measure. The natural and environmental factors relevant to schistosomiasis are complicated, which will enhance the difficulty of controlling. And the other risk factors are: the large irrigation program; return the plowland to lake; South-to-North Water Transfer; the warmer climate; and the floods etc.
    After surveying on the administrative model and human resources in anti-schistosomiasis facility, we found that:
    There are many problems of human resource existing in the schistosomiasis control system. Such as too many older workers, the present staff's average age is 42.5, the lower educational level and title of technical post of the workers, most of them is the primary technician; lower income, which lower than the standard of the national basic salary level, most of the workers' income is about 5000 to 10000 yuan per year. Too few chances of training, some of the workers never obtain any
    training. In the recently five years, the number of the workers joined in the anti-schistosomiasis system larger than that of removing from the system. But the title of technical post of the new workers lower than the removers, 53.60 percent of the new workers without any technical title, and 51.61 percent of them just graduated from the technical secondary schools. Because lots of the high quality workers remove from the anti-schistosomiasis system, the whole anti-schistosomiasis system do not adapt to the new demand of schistosomiasis control.
    The sizes of some anti-schistosomiasis institutes in counties are too large. Although there are many workers financed by the institutes, few workers take part in the anti-schistosomiasis program. At the same time, being the lower income, lots of high quality workers remove from the institutes. Effected by the market economy, many anti-schistosomiasis workers do not pay attention to the prevention anymore, while focus on how to make money by treating patients and so on. Because some local governments neglected the importance of anti-schistosomiasis work, and short of the financial support, and the World Bank providing loan project ended, the institutes lacks for resources to make money, in addition, the unprofessional and low quality worker swarmed into the institutes several years ago, the financial burden of the anti-schistosomiasis institute become heavier and heavier. The income of many anti-schistosomiasis institutes fewer than payout, some of them even can't sustain the workers daily life. So the anti-schistosomiasis institutes try to compensate the money shortage from curing. But it was restricted by the rural policy such as "fee become tax", and gave birth to many side effects. In addition, the working efficiency, technological innovation and the attraction of the anti-schistosomiasis system became lower and lower.
    The reform of anti-schistosomiasis system is urgently now. should it join in the CDC system or retain the present framework? Someone suggested that the anti-schistosomiasis system should, along with the chance of health system reforming, "better troops and simpler administration", enhance the efficiency of prevention, cure and inspection, increase the income of the workers, and strengthen to train the employee, etc. The anti-schistosomiasis institutes should try to obtain the reasonable financial support and establish the proper salary system. At present, the acceptable model is that split the schistosomiasis control into prevention and cure, the schistosomiasis cure administrated by the hospital system, while the prevention belong to the public health system, financing by the government it totally. Anti-schistosomiasis institutes should unite with the CDC.
    As a word, the main conclusions of this project including: 1) the situation of the schistosomiasis control changed; 2) the start and end point of the schistosomiasis control strategy lies in human, which is the first of all; 3) planning the anti-schistosomiasis comprehensively, and divide the task into different parts for different stages and then accomplish it; 4) emphasizing the importance, adjusting measures to local conditions, integrating prevention and cure and making progress steadily; 5) enlarging and consolidate the effect of the schistosomiasis control; 6) preventing and curing according to the law; 7) increasing the financial support; 8) harmonizing diseases controlling, social economic development and environment protection; 9) optimizing the health resources allocation; 10) establishing the sustainable development mechanism of the anti-schistosomiasis; 11) schistosomiasis control must depend on the science and technical progress and social development
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