疾病预防控制机构突发公共卫生事件应急能力理论与评价研究
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摘要
背景
随着工业化的推进、城市化的发展和全球化的加剧,人类已由传统社会步入风险社会乃至高风险社会。在当今的社会生活中,无论是对于一个国家还是地域来说,突发事件越来也越成为一种“常态”。2001年美国的“9.11”和随之而来的白色炭疽粉末事件把国际社会带入了应对突发公共事件的应急状态。2003年肆虐32个国家和地区的“SARS事件”,更是为全球突发公共危机应对进一步敲响了警钟,世界各国政府纷纷加大力度完善其突发事件应对体系和能力建设。
社会公平、社会善治和有效的应急管理是建设和谐社会的三大基石。落实科学发展观,创建和谐社会,必须以社会稳定和公共安全为前提和保障。灾害不断,事故频发,不仅严重影响社会的稳定,影响经济社会又好又快发展,而且也会导致已取得的社会发展成果丧失殆尽。
疾病预防控制机构(CDC)是构成我国公共卫生体系的主要组织机构,其应急能力的强弱直接影响到国家突发公共卫生事件应急处置效果的好坏。而且,从某种程度上说,虽然突发公共卫生事件的发生是不可避免的,甚至是不能完全准确预测的,但是还是可以预防的,至少能够从程度上减轻或者从速度上减缓其影响和损失的,因此,加强突发公共卫生事件的应急管理就显得尤为重要。而对突发公共卫生事件应急能力进行评价,检验各级CDC机构在应对突发事件时所拥有的人力、组织、机构、技术和资源等应急要素的完备性、协调性以及最大程度减轻事件损失和影响的综合能力,是加强应急能力建设的关键所在。
SARS后经过三年的公共卫生体系建设,各级CDC机构突发公共卫生事件应急能力得到了长足发展,并连续经受了一系列突发公共卫生事件的考验。县级CDC往往是突发公共卫生事件的“第一现场反应人”,直接面对救灾防病的主战场,其水平与能力如何,能否正确判断突发事件的性质与发展趋势进而采取及时和有效的预防控制措施,对于能否成功地应对和预防突发公共卫生应急事件具有十分重要的意义。
基于此,本研究的立论包括以下三个方面:
第一,处置突发公共卫生事件的现实要求:一是落实法律法规的要求,二是应急处置工作的现实证据要求;
第二,突发公共卫生事件理论研究的缺乏:定义的不统一、事件分类分级尺度混乱、评价指标基础研究的缺乏、评价标准基础研究的缺乏、评价方法基础研究的缺乏;
第三,突发公共卫生事件应急能力评价实务的挑战:目前,对应急能力评价研究的主体多为城市、政府的应急能力,或者某种灾害等应急能力的研究;而对CDC应急能力的研究也多集中于省地市,有限的县级CDC的应急能力研究侧重的维度、研究的深度不够,指标体系和评价方法不合实际。应急能力评价既不能够体现能力评价的导向和示范功能,也不能更好地促进县级CDC应急能力建设。
开展县级CDC的应急能力评价研究,既是县级CDC应急能力建设的基础之基础,又是检验其应对突发事件时所拥有的人力、组织、机构、手段和资源等应急要素的完备性、协调性,以及找出应急管理中的优势和差距从而强化应急能力建设的重要工作。并且,这种自下向上的决策更加实事求是,能够结合实际,更加符合现代管理学的要求。
研究目的
在突发公共卫生事件现状研究和问题分析的基础上,应用应急、应急管理等相关基础理论,研究突发公共卫生事件的特征、发生机理、分级分类和应对机制,以及应急能力构成要素和评价体系;通过现场调查和理论研究,充分借鉴国内外及相关领域的研究成果、成功经验和做法,探索建立县级CDC应急能力评价指标体系、评价标准和评价方法,为县级CDC应急能力建设起引导和示范作用;在对应急能力进行定量评价的基础上,对县级CDC应急能力进行缺陷诊断,识别出其应急管理工作中较为满意和需要改进之处,并提出规划和整改政策建议。
研究方法
本研究按照一般与特殊相结合,理论与实证相结合,系统与局部相结合,内在与外在相结合的方法论原则,采用理论方法与实证方法两大类手法,通过对县级CDC突发公共卫生事件应急能力进行评价研究,提出进一步完善发展我国基层公共卫生应急处置能力的政策建议,以供决策者参考。
本研究通过文献复习掌握国内外突发公共卫生事件应急反应体系建设和能力评估的现况、所用的评估体系和指标的优缺点等,构建本研究的基本思路,运用系统分析法进行突发公共卫生事件应急系统、应急能力分析以及应急能力评价构成的核心要素分析。根据所获得的资料、经验和事实,进行逻辑思辨,运用演绎、归纳与类比的方法,从理论和实践上分析突发公共卫生事件应急处理的活动。运用德尔菲(Delphi)专家咨询法,建立应急能力评价初评指标体系基本框架和指标的筛选,采用层次分析法(Analytic Hierarchy Process,AHP)进行评价指标权重的确定,并利用实证研究的方法,选择青岛作为样本调查城市,利用建立的指标体系进行评价。
研究结果
1.理论探讨突发公共卫生事件的发生机理与应对机制。明确了突发公共卫生事件的分级与分类标准,提出了突发公共卫生事件形成的“三要素”、“四要素”机制,将突发公共卫生事件的影响因素概括为人、物、环境和管理4种基本的因素。并从发生、发展、演化三个进程,将突发公共卫生事件的机理体系分成三个体系、八个类型。
2.概念构建突发公共卫生事件应急管理系统,包括时间维、知识维、逻辑维三个维度层面。明确了突发公共卫生事件发生的防范阶段、处置阶段与预后恢复阶段三阶段全过程的核心应急响应能力。并对应急能力评价指标集确立为技术要素指标集和管理要素指标集。
3.确立了CDC应急能力构成要素及评价指标体系。提出并构建了CDC应急能力评价指标体系的STORM框架,包括5个一级指标,24个二级指标。并提出了CDC应急能力评价标准,四个等级状态以及应急能力规划措施和优先建设领域。
4.利用建立的突发公共卫生事件应急能力评价模型进行实证研究。对样本城市12个区市CDC的应急能力现状进行了评价,应急能力等级状态为“应急能力弱”;模拟分析结果显示,提升运行管理能力和预测预警能力的权重,可分别提高疾病预防控制机构应急能力的综合得分;提升运行管理指标权重的同时,平均降低其余一级指标的权重,可提升12个区市综合应急能力得分。
结论和建议
1.县级CDC突发公共卫生事件应急能力评价应该突出县级CDC和突发公共卫生事件为主要内容的特殊性,并与突发事件的共性相结合。通过客体与主体、宏观与微观相结合的角度所体现出来的共同特征,围绕县级CDC应急能力评价这个中心确定了反映县级CDC应急能力的五个层面的内容。
2.县级CDC突发公共卫生事件应急能力评价综合指数必须反映预测预警、技术实施、资源储备、运行管理和获得外援五个各自的权重对指标体系的影响,这是评价CDC应急能力大小的主要指标。
3.在应对和处置突发公共卫生事件的过程中,县级CDC应急能力的提高是预测预警能力、技术实施能力、资源储备能力、运行管理能力和获得外援能力五个方面动态下相互协调的理想或完美状态及其实现过程。
4.提高县级CDC突发公共卫生事件应急能力过程中,五个维度的有机协调必须以科学的指标体系和评价方法为前提条件。因此,无论从突发公共卫生事件应急能力的内涵还是从其评价实践看,都应该以突发公共卫生事件应急能力的评价指标体系作为其应急能力评价的载体。完善该指标体系是突发公共卫生事件应急能力评价的理论基础。
5.按照《中华人民共和国突发事件应对法》,县级政府和部门是处置一般突发事件的责任主体。从12个区市实证结果看,各地政府在确保经济投入的前提下,还应该进一步加强运行管理能力和预测预警能力的建设和提升,以确保发生突发公共卫生事件后能够及时、科学、有效地处置和应对。
创新与不足
本研究的创新有以下几个方面:
第一,研究目标定位于有重要现实价值但缺乏理论关注的领域。
现有研究多以建立区域性突发公共卫生事件应急能力指标体系为主,本研究的研究目标定位于公共卫生机构的应急能力指标体系及其支持理论的探索。本研究从突发公共卫生事件的发生机理、特征入手、探讨其应对机制,分析突发公共卫生事件发生和应急响应能力这一对矛盾的规律,能促进我国加强应急管理理念,补充与完善突发公共卫生事件应急能力处置的相关理论体系。
第二,研究对象定位于处于应急处置一线负有重要防御责任的县级CDC。
县级CDC因为处于突发公共卫生事件应对的第一线,担负着大部分的防御处置任务,但目前对其研究所侧重的层面与研究的深度均不够。本研究通过对CDC突发公共卫生事件应急能力构成要素进行分析,立足县级CDC,通过重点分析其应急能力并构建其综合评价体系,对于我国实施应急战略,进行突发公共卫生事件应急能力评估工作,加强CDC重大灾害事故应急能力建设,具有重要的实践指导意义。
第三,研究方法与指标筛选上注重综合与全面,可有效实现机构自身纵向评价与机构间横向评价。
通过专家咨询与AHP层次分析法所构建的应急能力评价指标体系,不仅有利于对CDC自身应急综合能力进行清晰评价,而且能够为不同机构之间评价甚至第三方评价提供一个可行的标准与操作工具。这对查找应急能力的优势与不足,进而全面提升公共卫生危机管理和应对能力具有重要的现实意义。
研究的不足:
突发公共卫生事件应急能力评价是一个研究内容丰富、研究方法繁杂、支持理论多学科并存的复杂系统工程。在公共卫生具体实践中,各级政府和相关机构对突发公共卫生事件的应急能力建设和应急能力评价都非常重视。本研究虽然做了大量的工作,也建立了能力评价指标和模型的框架,但由于研究对象的复杂和自身研究能力有限,肯定还存在很多细节上的问题需要进一步探讨和研究:
第一,在研究样本上。本研究的样本为青岛市12个区市的CDC。虽然对全部样本都进行了调查,并且从研究目的上能够满足研究要求,但从研究样本上看,可能还存在一些问题。
第二,在各级指标选取方面。由于缺乏对县级CDC进行应急能力评价的深入研究和经验,可能会漏掉一些评价指标,或出现选取不合适的情形。因此,需要做进一步的研究,以使该指标体系更加完整且合理。
第三,在分级分类研究方面。本研究对突发公共卫生事件的分级分类,从理论上构建了以传染病为主的突发公共卫生事件的分级模型,由于时间和资金的原因,专家小组分级法的具体实现有一定困难,因而不能给出各个指标的权重,使得分级未能实现具体的量化操作。
研究展望
第一,完善县级CDC突发公共卫生事件应急能力评价指标体系的实证研究。本课题的区域性实证研究为评价县级CDC公共卫生事件应急能力提供了可参考的依据。在全国或全省范围内样本的调查或者在一个区域连续多年数据的收集,将为更加科学、合理地全面评价县级CDC突发公共卫生事件应急能力提供完善依据,这为课题的后续研究指明了方向。
第二,完善各级各类突发公共卫生事件的分级定量和定性相结合的理论和实证研究。本研究对突发公共卫生事件的分级分类,从理论上构建了以传染病为主的突发公共卫生事件的分级模型,但没有根据不同类型的传染病进行分级实证研究,更没有对各种类型突发公共卫生事件的分级进行理论和实证研究。本文结果可作为对突发公共卫生事件进行深入研究的起点,实现对突发公共卫生事件进行全面、科学分类分级的目标。
BACKGROUND
With promotion of industrialization, development of urbanization andglobalization, we have stepped into high risk society from traditional society. In current social life, emergent incident has increasingly became normality to whether a country or a region. American 9·11 in 2001 and subsequent white anthrax terrorism had brought international society into emergent status of public incidents response. SARS, which broke out in 32 countries and regions, knolled warning alarm for preparing the global unexpected public crisis.
Social justice, good governance and effective emergency management are three cornerstones of constructing harmonious society. Social stability and public security must be the prerequisite and guarantee for implementing Concept for Sustainable Development and constructing harmonious society. Continuous incidents could seriously damage social stability and economy, and even destroy achievements of social development.
Centers for Disease Control and Prevention (CDC) are a crucial institution comprising public health system in China. The competence of emergency preparedness is directly rested with the emergency response capability of CDC. Public health emergency to a large extent is inevitable, even can not be accurately predicted. However, it can be prevented; at least its affection and damage can be alleviated and decelerated. Consequently, it is more important to strengthen the emergency management of public health incidents. And the key point of strengthening the construction for emergency response capability is to evaluate it, and inspect the emergency response factors' completeness, coordination and comprehensive capability which can to a large extent of alleviate affection and damage of, such as manpower, organization, institution, technology and resources which are required in face of emergency for CDC at all levels.
By three years constructions for public health system after SARS, CDC at all levels had gotten considerable developments in emergency response capability, and constant withstood a serious of challenges of public health emergency. CDC at county level are always the first responders of the public health emergency, are direct main battlefield of disaster rescue and disease prevention. The level and capability of its emergency response, and whether it can estimate character and trend of the emergency correctly and take timely and effective control measures, has important significance for preparing and preventing public health emergency successfully.
Based on this, the rationale of the research included three aspects as follows:
First, practical requirements of public health emergency operation: a) it was implementing laws and regulations requirements; b) it was practical evidence requirement of emergency operation.
Second, lack of theory research of public health emergency: not unified in definition, confusion of incidents classification and grade scales, and lack of basic research of evaluation indicator, evaluation standard and evaluation method.
Third, evaluation practice challenges of emergency response capability: for the time being, evaluation research subject of response capability was more focusing on the research of city and government response capability or response capability to some disasters; the researches of CDC response capability were also focusing on the provincial and municipal levels. Finite researches on emergency response capability of CDC institutions at county level are insufficient in terms of research dimensions and depth, and indicators system and evaluation methods were unpractical. The evaluation of emergency response capability could neither reflect the guidance and orientation function of capability evaluation, nor promoted the emergency response capability construction for CDC at county level.
Developing evaluation research of emergency response capability for CDC at county level was either the basic of response capability construction, or an important work for inspecting completeness and coordination of the emergency response factors, including manpower, organization, institution, technology and resources which were required in face of emergency. And it was an important work of strengthening the construction of emergency response capability by searching out the advantage and shortage of emergency management. Furthermore, the top-down policymaking was more seeking truth from facts and combining with practical, then meeting the requirement of modern management.
OBJECTIVE
Based on current situation and problem-oriented research of public health emergency, and utilizing related basic theories of emergency response and management, the research studied the characteristics, occurrence mechanism, hierarchical classification and response mechanism of public health incidents, and studied component elements and evaluation system of emergency response capability; by using field investigation and theory research, and drawing lessons from literatures of research results and best practices at home and abroad, this research explored to establish evaluation indicators, standard and method of emergency response capability for CDC at county level in order to provide a guidance and orientation in capacity building practice; based on quantitative evaluation of emergency response capability, the research diagnosed the defects of emergency response capability for CDC at county level, and identified advantages and disadvantages of the emergency management, then providing suggestions of planning and reforming policy in emergency preparedness.
METHODOLOGY
According to methodological principle of combining common with specialty, theory with practice, system with part, internal aspects with external, and utilizing theoretical method and demonstrating methods, the research studied and evaluated the emergency response capability for public health incidents, then providing policy suggestions for further improvement of public health emergency response capability.
Through knowing present situation, evaluation system, advantages and disadvantages, and so on by literature review, the research constructed essential thoughts by utilizing system analysis method to study emergency response system and capability, and core elements of capability evaluation. In accordance with the data, experiences and facts acquired, and utilizing logic argument and deductive inductive analogical methods, this research analyzed the action of emergency response capability for public health incidents from both theory and practice. Using Delphi method, establishing basic framework and indicator screening of emergency response capability evaluation indicator system, this research determined evaluation indicator weight by Analytic Hierarchy Process, and chose Qingdao as a sample city.
RESULTS
a. This research discussed occurrence and response mechanism of public health incident theoretically. It clarified the hierarchical classification standard, and proposed three elements and four elements occurrence mechanism of public health emergency, generalizing influencing factors of public health emergency to people, matters, environment and management, which comprised four basic factors. And it classified mechanism system of public health emergency into three systems and eight types from three processes of occurrence, development and evolution.
b. Established emergency management system from conception, including three dimensions of time dimension, knowledge dimension and logic dimension. Clarified core emergency response capability of prevention stage, operation stage and Post-Emergency Response Rehabilitation and Reconstruction stage in the whole process and established evaluation indicator sets of emergency response capability for technology element indicator set and management indicator set.
c. Clarified component elements and evaluation indicator system of emergency response capability for CDC. Proposed and established STORM framework (Surveillance & Warning Capacity, Technical implementation Capacity, Resources Store Capacity, Operation Management Capacity, Mobilization & Coordination Capacity), including 5 first grade indicators and 24 second grade indicators. The study also proposed emergency response capability evaluation standards, 4 level states as well as planning measures and priority of emergency capability building.
d. Made demonstration study by utilizing evaluation model of emergency response capability for public health incidents. Evaluating the present situation of emergency response capability in 12 sample cities, the level state of whole emergency response capability was weak; simulating result showed that improving the weight of operation management capability and Surveillance and Warning capability could improve comprehensive scores of CDC emergency response capability respectively; meanwhile averagely decreasing indicator weight of other one grade could improve comprehensive scores of 12 samples emergency response capability
CONCLUSIONS & SUGGESTIONS
a. The emergency response capability evaluation for CDC at county level should emphasize on the specialty as main content of public health emergency, and it should be combined with generality of public health emergency. According to common characteristics reflected by the perspective which was combined object with subject, macrocosm with microcosm, it clarified 5 levels contents which reflected the response capability based on the center of emergency response capability evaluation for CDC at county level.
b. The evaluation comprehensive indicators of emergency response capability for CDC at county level must reflect the influence for indicator system of 5 respective weights, including Surveillance & Warning, Technical implementation, Resources Store, Operation Management and Mobilization & Coordination. These were main indicators to evaluate emergency response capability for CDC.
c. In the process of preparing and operating public health emergency, the improvement of emergency response capability for CDC at county level was the realization process of dynamic mutual coordination and perfect states. It included 5 respects: Surveillance & Warning capacity, Technical implementation capacity, Resources Store capacity, Operation Management capacity and Mobilization & Coordination capacity.
d. In the process of improving emergency response capability for CDC, well coordination of the 5 dimensions must be based on the scientific indicator system and evaluation method. Consequently, according to either the connotation of emergency response capability or its evaluation practice, we should regard evaluation indicator system as a carrier of emergency response capability evaluation. Improving the indicator system was the theoretical foundation of emergency response capability evaluation.
e. According to The Emergency Response Law of the People's Republic of China, government and involved department at county level was the responsibility subject of ordinary (four levels: especially serious, serious, large and ordinary) emergency response. From practical results of 12 samples, government should further improve the construction and promotion of operation management capability, and surveillance and warning capability on the premise of guaranteeing economic investment, to prepare and operate public health emergency timely, properly and effectively.
INNOVATIONS & LIMITATIONS
The innovations of this research were as follows:
First, research oriented on field with important practice value but lack of theory.
The current research was mainly focused on the indicator system of establishing regional emergency response capability, while the research subject was focused on the indicator system of emergency response capability and exploration of its support theory. The research started with occurrence mechanism and characteristics of public health emergency, with investigated the response mechanism, then analyzing contradictive disciplinarian between occurrence and response of public health emergency, which could strengthen the conception of response management, supplement and improve related theory system of emergency response capability.
Second, research object was oriented on the CDC at county level, which had the significant responsibility of prevention in the frontline of response and operation.
Because of in the frontline of emergency response for public health incidents, CDC at county level took the most responsibility of prevention and operation, but the emphasized aspects and depth of current research were both inadequate. By analyzing component elements of emergency response capability for public health emergency, and mainly analyzing emergency response capability and constructing comprehensive evaluation system, this study focused on CDC at county level, had important significance for implementing emergency response strategy, evaluating emergency response capability and strengthening capability construction for CDC in face of serious disasters and emergencies.
Third, integration of research method and indicator screening could efficiently realize longitudinal and horizontal evaluation between institutions.
Indicator evaluation system of emergency response capability constructing by Delphi and AHP, was beneficial to evaluate comprehensive emergency response capability clearly, and could provide a feasible standard and operational instrument for evaluation among different institutions or even third party evaluation, which had important practical significance for searching advantage and shortage of emergency response capability and improving management and response capability for public health crisis.
Limitations:
The evaluation of emergency response capability was a complicated system project which had abundant contents, various methods and multi-disciplinary theory. In specific practice of public health, governments at all levels and involved institutions highly emphasized the construction and evaluation of emergency response capability for public health incidents. Although the research had done lots of studies, and constructed capability evaluation indicator and model framework, it still left many detail problems to be investigated and studied because of complex research object and limited research capability.
First, study samples. The study samples were 12 regional CDC institutions of Qingdao. Although all the samples were investigated and met the research requirement according to research purpose, there still existed some problems on it. If sample data from different economic status at provincial level or from other regions were acquired, it would greatly modified and improved the conclusion of the research.
Second, screening and selecting evaluation indicators. Owing to lack of further research and experience of emergency response capability for CDC at county level, some evaluation indicators may be overlooked or selected improperly. So we need further study to keep the indicator system improved and reasonable.
Third, research on classification and level of public health incidents. The research theoretically constructed a model of level and classification which was based on infectious disease of public health emergency. It was difficult to get a nice model by Delphi method because of limited time and finance. Consequently, it couldn't provide every indicator weight, which made grading method unsuccessful in aspect of quantitative analysis.
RESEARCH PROSPECTS
First, improving practice research of evaluation indicator system of CDC emergency response capability for public health incidents. The regional practice research provided evidence for evaluating emergency response capability for CDC at county level. It will provide perfect evidence on evaluating emergency response capability for county CDC properly and comprehensively if the survey carried out in nationwide and provincial level or continuous data collection in a region.
Second, improving research on theory and practice by combining quantitative and qualitative method at all levels and classifications of public health emergency. The research didn't do grading practical research according to different types of infectious disease and other kinds of public health emergencies. The study result could be regarded as the starting point for further studying public health emergency and probation on realizing the target of comprehensive and scientific classification and grading for public health emergencies.
随着工业化的推进、城市化的发展和全球化的加剧,人类已由传统社会步入风险社会乃至高风险社会。在当今的社会生活中,无论是对于一个国家还是地域来说,突发事件越来也越成为一种“常态”。2001年美国的“9.11”和随之而来的白色炭疽粉末事件把国际社会带入了应对突发公共事件的应急状态。2003年肆虐32个国家和地区的“SARS事件”,更是为全球突发公共危机应对进一步敲响了警钟,世界各国政府纷纷加大力度完善其突发事件应对体系和能力建设。
社会公平、社会善治和有效的应急管理是建设和谐社会的三大基石。落实科学发展观,创建和谐社会,必须以社会稳定和公共安全为前提和保障。灾害不断,事故频发,不仅严重影响社会的稳定,影响经济社会又好又快发展,而且也会导致已取得的社会发展成果丧失殆尽。
疾病预防控制机构(CDC)是构成我国公共卫生体系的主要组织机构,其应急能力的强弱直接影响到国家突发公共卫生事件应急处置效果的好坏。而且,从某种程度上说,虽然突发公共卫生事件的发生是不可避免的,甚至是不能完全准确预测的,但是还是可以预防的,至少能够从程度上减轻或者从速度上减缓其影响和损失的,因此,加强突发公共卫生事件的应急管理就显得尤为重要。而对突发公共卫生事件应急能力进行评价,检验各级CDC机构在应对突发事件时所拥有的人力、组织、机构、技术和资源等应急要素的完备性、协调性以及最大程度减轻事件损失和影响的综合能力,是加强应急能力建设的关键所在。
SARS后经过三年的公共卫生体系建设,各级CDC机构突发公共卫生事件应急能力得到了长足发展,并连续经受了一系列突发公共卫生事件的考验。县级CDC往往是突发公共卫生事件的“第一现场反应人”,直接面对救灾防病的主战场,其水平与能力如何,能否正确判断突发事件的性质与发展趋势进而采取及时和有效的预防控制措施,对于能否成功地应对和预防突发公共卫生应急事件具有十分重要的意义。
基于此,本研究的立论包括以下三个方面:
第一,处置突发公共卫生事件的现实要求:一是落实法律法规的要求,二是应急处置工作的现实证据要求;
第二,突发公共卫生事件理论研究的缺乏:定义的不统一、事件分类分级尺度混乱、评价指标基础研究的缺乏、评价标准基础研究的缺乏、评价方法基础研究的缺乏;
第三,突发公共卫生事件应急能力评价实务的挑战:目前,对应急能力评价研究的主体多为城市、政府的应急能力,或者某种灾害等应急能力的研究;而对CDC应急能力的研究也多集中于省地市,有限的县级CDC的应急能力研究侧重的维度、研究的深度不够,指标体系和评价方法不合实际。应急能力评价既不能够体现能力评价的导向和示范功能,也不能更好地促进县级CDC应急能力建设。
开展县级CDC的应急能力评价研究,既是县级CDC应急能力建设的基础之基础,又是检验其应对突发事件时所拥有的人力、组织、机构、手段和资源等应急要素的完备性、协调性,以及找出应急管理中的优势和差距从而强化应急能力建设的重要工作。并且,这种自下向上的决策更加实事求是,能够结合实际,更加符合现代管理学的要求。
研究目的
在突发公共卫生事件现状研究和问题分析的基础上,应用应急、应急管理等相关基础理论,研究突发公共卫生事件的特征、发生机理、分级分类和应对机制,以及应急能力构成要素和评价体系;通过现场调查和理论研究,充分借鉴国内外及相关领域的研究成果、成功经验和做法,探索建立县级CDC应急能力评价指标体系、评价标准和评价方法,为县级CDC应急能力建设起引导和示范作用;在对应急能力进行定量评价的基础上,对县级CDC应急能力进行缺陷诊断,识别出其应急管理工作中较为满意和需要改进之处,并提出规划和整改政策建议。
研究方法
本研究按照一般与特殊相结合,理论与实证相结合,系统与局部相结合,内在与外在相结合的方法论原则,采用理论方法与实证方法两大类手法,通过对县级CDC突发公共卫生事件应急能力进行评价研究,提出进一步完善发展我国基层公共卫生应急处置能力的政策建议,以供决策者参考。
本研究通过文献复习掌握国内外突发公共卫生事件应急反应体系建设和能力评估的现况、所用的评估体系和指标的优缺点等,构建本研究的基本思路,运用系统分析法进行突发公共卫生事件应急系统、应急能力分析以及应急能力评价构成的核心要素分析。根据所获得的资料、经验和事实,进行逻辑思辨,运用演绎、归纳与类比的方法,从理论和实践上分析突发公共卫生事件应急处理的活动。运用德尔菲(Delphi)专家咨询法,建立应急能力评价初评指标体系基本框架和指标的筛选,采用层次分析法(Analytic Hierarchy Process,AHP)进行评价指标权重的确定,并利用实证研究的方法,选择青岛作为样本调查城市,利用建立的指标体系进行评价。
研究结果
1.理论探讨突发公共卫生事件的发生机理与应对机制。明确了突发公共卫生事件的分级与分类标准,提出了突发公共卫生事件形成的“三要素”、“四要素”机制,将突发公共卫生事件的影响因素概括为人、物、环境和管理4种基本的因素。并从发生、发展、演化三个进程,将突发公共卫生事件的机理体系分成三个体系、八个类型。
2.概念构建突发公共卫生事件应急管理系统,包括时间维、知识维、逻辑维三个维度层面。明确了突发公共卫生事件发生的防范阶段、处置阶段与预后恢复阶段三阶段全过程的核心应急响应能力。并对应急能力评价指标集确立为技术要素指标集和管理要素指标集。
3.确立了CDC应急能力构成要素及评价指标体系。提出并构建了CDC应急能力评价指标体系的STORM框架,包括5个一级指标,24个二级指标。并提出了CDC应急能力评价标准,四个等级状态以及应急能力规划措施和优先建设领域。
4.利用建立的突发公共卫生事件应急能力评价模型进行实证研究。对样本城市12个区市CDC的应急能力现状进行了评价,应急能力等级状态为“应急能力弱”;模拟分析结果显示,提升运行管理能力和预测预警能力的权重,可分别提高疾病预防控制机构应急能力的综合得分;提升运行管理指标权重的同时,平均降低其余一级指标的权重,可提升12个区市综合应急能力得分。
结论和建议
1.县级CDC突发公共卫生事件应急能力评价应该突出县级CDC和突发公共卫生事件为主要内容的特殊性,并与突发事件的共性相结合。通过客体与主体、宏观与微观相结合的角度所体现出来的共同特征,围绕县级CDC应急能力评价这个中心确定了反映县级CDC应急能力的五个层面的内容。
2.县级CDC突发公共卫生事件应急能力评价综合指数必须反映预测预警、技术实施、资源储备、运行管理和获得外援五个各自的权重对指标体系的影响,这是评价CDC应急能力大小的主要指标。
3.在应对和处置突发公共卫生事件的过程中,县级CDC应急能力的提高是预测预警能力、技术实施能力、资源储备能力、运行管理能力和获得外援能力五个方面动态下相互协调的理想或完美状态及其实现过程。
4.提高县级CDC突发公共卫生事件应急能力过程中,五个维度的有机协调必须以科学的指标体系和评价方法为前提条件。因此,无论从突发公共卫生事件应急能力的内涵还是从其评价实践看,都应该以突发公共卫生事件应急能力的评价指标体系作为其应急能力评价的载体。完善该指标体系是突发公共卫生事件应急能力评价的理论基础。
5.按照《中华人民共和国突发事件应对法》,县级政府和部门是处置一般突发事件的责任主体。从12个区市实证结果看,各地政府在确保经济投入的前提下,还应该进一步加强运行管理能力和预测预警能力的建设和提升,以确保发生突发公共卫生事件后能够及时、科学、有效地处置和应对。
创新与不足
本研究的创新有以下几个方面:
第一,研究目标定位于有重要现实价值但缺乏理论关注的领域。
现有研究多以建立区域性突发公共卫生事件应急能力指标体系为主,本研究的研究目标定位于公共卫生机构的应急能力指标体系及其支持理论的探索。本研究从突发公共卫生事件的发生机理、特征入手、探讨其应对机制,分析突发公共卫生事件发生和应急响应能力这一对矛盾的规律,能促进我国加强应急管理理念,补充与完善突发公共卫生事件应急能力处置的相关理论体系。
第二,研究对象定位于处于应急处置一线负有重要防御责任的县级CDC。
县级CDC因为处于突发公共卫生事件应对的第一线,担负着大部分的防御处置任务,但目前对其研究所侧重的层面与研究的深度均不够。本研究通过对CDC突发公共卫生事件应急能力构成要素进行分析,立足县级CDC,通过重点分析其应急能力并构建其综合评价体系,对于我国实施应急战略,进行突发公共卫生事件应急能力评估工作,加强CDC重大灾害事故应急能力建设,具有重要的实践指导意义。
第三,研究方法与指标筛选上注重综合与全面,可有效实现机构自身纵向评价与机构间横向评价。
通过专家咨询与AHP层次分析法所构建的应急能力评价指标体系,不仅有利于对CDC自身应急综合能力进行清晰评价,而且能够为不同机构之间评价甚至第三方评价提供一个可行的标准与操作工具。这对查找应急能力的优势与不足,进而全面提升公共卫生危机管理和应对能力具有重要的现实意义。
研究的不足:
突发公共卫生事件应急能力评价是一个研究内容丰富、研究方法繁杂、支持理论多学科并存的复杂系统工程。在公共卫生具体实践中,各级政府和相关机构对突发公共卫生事件的应急能力建设和应急能力评价都非常重视。本研究虽然做了大量的工作,也建立了能力评价指标和模型的框架,但由于研究对象的复杂和自身研究能力有限,肯定还存在很多细节上的问题需要进一步探讨和研究:
第一,在研究样本上。本研究的样本为青岛市12个区市的CDC。虽然对全部样本都进行了调查,并且从研究目的上能够满足研究要求,但从研究样本上看,可能还存在一些问题。
第二,在各级指标选取方面。由于缺乏对县级CDC进行应急能力评价的深入研究和经验,可能会漏掉一些评价指标,或出现选取不合适的情形。因此,需要做进一步的研究,以使该指标体系更加完整且合理。
第三,在分级分类研究方面。本研究对突发公共卫生事件的分级分类,从理论上构建了以传染病为主的突发公共卫生事件的分级模型,由于时间和资金的原因,专家小组分级法的具体实现有一定困难,因而不能给出各个指标的权重,使得分级未能实现具体的量化操作。
研究展望
第一,完善县级CDC突发公共卫生事件应急能力评价指标体系的实证研究。本课题的区域性实证研究为评价县级CDC公共卫生事件应急能力提供了可参考的依据。在全国或全省范围内样本的调查或者在一个区域连续多年数据的收集,将为更加科学、合理地全面评价县级CDC突发公共卫生事件应急能力提供完善依据,这为课题的后续研究指明了方向。
第二,完善各级各类突发公共卫生事件的分级定量和定性相结合的理论和实证研究。本研究对突发公共卫生事件的分级分类,从理论上构建了以传染病为主的突发公共卫生事件的分级模型,但没有根据不同类型的传染病进行分级实证研究,更没有对各种类型突发公共卫生事件的分级进行理论和实证研究。本文结果可作为对突发公共卫生事件进行深入研究的起点,实现对突发公共卫生事件进行全面、科学分类分级的目标。
BACKGROUND
With promotion of industrialization, development of urbanization andglobalization, we have stepped into high risk society from traditional society. In current social life, emergent incident has increasingly became normality to whether a country or a region. American 9·11 in 2001 and subsequent white anthrax terrorism had brought international society into emergent status of public incidents response. SARS, which broke out in 32 countries and regions, knolled warning alarm for preparing the global unexpected public crisis.
Social justice, good governance and effective emergency management are three cornerstones of constructing harmonious society. Social stability and public security must be the prerequisite and guarantee for implementing Concept for Sustainable Development and constructing harmonious society. Continuous incidents could seriously damage social stability and economy, and even destroy achievements of social development.
Centers for Disease Control and Prevention (CDC) are a crucial institution comprising public health system in China. The competence of emergency preparedness is directly rested with the emergency response capability of CDC. Public health emergency to a large extent is inevitable, even can not be accurately predicted. However, it can be prevented; at least its affection and damage can be alleviated and decelerated. Consequently, it is more important to strengthen the emergency management of public health incidents. And the key point of strengthening the construction for emergency response capability is to evaluate it, and inspect the emergency response factors' completeness, coordination and comprehensive capability which can to a large extent of alleviate affection and damage of, such as manpower, organization, institution, technology and resources which are required in face of emergency for CDC at all levels.
By three years constructions for public health system after SARS, CDC at all levels had gotten considerable developments in emergency response capability, and constant withstood a serious of challenges of public health emergency. CDC at county level are always the first responders of the public health emergency, are direct main battlefield of disaster rescue and disease prevention. The level and capability of its emergency response, and whether it can estimate character and trend of the emergency correctly and take timely and effective control measures, has important significance for preparing and preventing public health emergency successfully.
Based on this, the rationale of the research included three aspects as follows:
First, practical requirements of public health emergency operation: a) it was implementing laws and regulations requirements; b) it was practical evidence requirement of emergency operation.
Second, lack of theory research of public health emergency: not unified in definition, confusion of incidents classification and grade scales, and lack of basic research of evaluation indicator, evaluation standard and evaluation method.
Third, evaluation practice challenges of emergency response capability: for the time being, evaluation research subject of response capability was more focusing on the research of city and government response capability or response capability to some disasters; the researches of CDC response capability were also focusing on the provincial and municipal levels. Finite researches on emergency response capability of CDC institutions at county level are insufficient in terms of research dimensions and depth, and indicators system and evaluation methods were unpractical. The evaluation of emergency response capability could neither reflect the guidance and orientation function of capability evaluation, nor promoted the emergency response capability construction for CDC at county level.
Developing evaluation research of emergency response capability for CDC at county level was either the basic of response capability construction, or an important work for inspecting completeness and coordination of the emergency response factors, including manpower, organization, institution, technology and resources which were required in face of emergency. And it was an important work of strengthening the construction of emergency response capability by searching out the advantage and shortage of emergency management. Furthermore, the top-down policymaking was more seeking truth from facts and combining with practical, then meeting the requirement of modern management.
OBJECTIVE
Based on current situation and problem-oriented research of public health emergency, and utilizing related basic theories of emergency response and management, the research studied the characteristics, occurrence mechanism, hierarchical classification and response mechanism of public health incidents, and studied component elements and evaluation system of emergency response capability; by using field investigation and theory research, and drawing lessons from literatures of research results and best practices at home and abroad, this research explored to establish evaluation indicators, standard and method of emergency response capability for CDC at county level in order to provide a guidance and orientation in capacity building practice; based on quantitative evaluation of emergency response capability, the research diagnosed the defects of emergency response capability for CDC at county level, and identified advantages and disadvantages of the emergency management, then providing suggestions of planning and reforming policy in emergency preparedness.
METHODOLOGY
According to methodological principle of combining common with specialty, theory with practice, system with part, internal aspects with external, and utilizing theoretical method and demonstrating methods, the research studied and evaluated the emergency response capability for public health incidents, then providing policy suggestions for further improvement of public health emergency response capability.
Through knowing present situation, evaluation system, advantages and disadvantages, and so on by literature review, the research constructed essential thoughts by utilizing system analysis method to study emergency response system and capability, and core elements of capability evaluation. In accordance with the data, experiences and facts acquired, and utilizing logic argument and deductive inductive analogical methods, this research analyzed the action of emergency response capability for public health incidents from both theory and practice. Using Delphi method, establishing basic framework and indicator screening of emergency response capability evaluation indicator system, this research determined evaluation indicator weight by Analytic Hierarchy Process, and chose Qingdao as a sample city.
RESULTS
a. This research discussed occurrence and response mechanism of public health incident theoretically. It clarified the hierarchical classification standard, and proposed three elements and four elements occurrence mechanism of public health emergency, generalizing influencing factors of public health emergency to people, matters, environment and management, which comprised four basic factors. And it classified mechanism system of public health emergency into three systems and eight types from three processes of occurrence, development and evolution.
b. Established emergency management system from conception, including three dimensions of time dimension, knowledge dimension and logic dimension. Clarified core emergency response capability of prevention stage, operation stage and Post-Emergency Response Rehabilitation and Reconstruction stage in the whole process and established evaluation indicator sets of emergency response capability for technology element indicator set and management indicator set.
c. Clarified component elements and evaluation indicator system of emergency response capability for CDC. Proposed and established STORM framework (Surveillance & Warning Capacity, Technical implementation Capacity, Resources Store Capacity, Operation Management Capacity, Mobilization & Coordination Capacity), including 5 first grade indicators and 24 second grade indicators. The study also proposed emergency response capability evaluation standards, 4 level states as well as planning measures and priority of emergency capability building.
d. Made demonstration study by utilizing evaluation model of emergency response capability for public health incidents. Evaluating the present situation of emergency response capability in 12 sample cities, the level state of whole emergency response capability was weak; simulating result showed that improving the weight of operation management capability and Surveillance and Warning capability could improve comprehensive scores of CDC emergency response capability respectively; meanwhile averagely decreasing indicator weight of other one grade could improve comprehensive scores of 12 samples emergency response capability
CONCLUSIONS & SUGGESTIONS
a. The emergency response capability evaluation for CDC at county level should emphasize on the specialty as main content of public health emergency, and it should be combined with generality of public health emergency. According to common characteristics reflected by the perspective which was combined object with subject, macrocosm with microcosm, it clarified 5 levels contents which reflected the response capability based on the center of emergency response capability evaluation for CDC at county level.
b. The evaluation comprehensive indicators of emergency response capability for CDC at county level must reflect the influence for indicator system of 5 respective weights, including Surveillance & Warning, Technical implementation, Resources Store, Operation Management and Mobilization & Coordination. These were main indicators to evaluate emergency response capability for CDC.
c. In the process of preparing and operating public health emergency, the improvement of emergency response capability for CDC at county level was the realization process of dynamic mutual coordination and perfect states. It included 5 respects: Surveillance & Warning capacity, Technical implementation capacity, Resources Store capacity, Operation Management capacity and Mobilization & Coordination capacity.
d. In the process of improving emergency response capability for CDC, well coordination of the 5 dimensions must be based on the scientific indicator system and evaluation method. Consequently, according to either the connotation of emergency response capability or its evaluation practice, we should regard evaluation indicator system as a carrier of emergency response capability evaluation. Improving the indicator system was the theoretical foundation of emergency response capability evaluation.
e. According to The Emergency Response Law of the People's Republic of China, government and involved department at county level was the responsibility subject of ordinary (four levels: especially serious, serious, large and ordinary) emergency response. From practical results of 12 samples, government should further improve the construction and promotion of operation management capability, and surveillance and warning capability on the premise of guaranteeing economic investment, to prepare and operate public health emergency timely, properly and effectively.
INNOVATIONS & LIMITATIONS
The innovations of this research were as follows:
First, research oriented on field with important practice value but lack of theory.
The current research was mainly focused on the indicator system of establishing regional emergency response capability, while the research subject was focused on the indicator system of emergency response capability and exploration of its support theory. The research started with occurrence mechanism and characteristics of public health emergency, with investigated the response mechanism, then analyzing contradictive disciplinarian between occurrence and response of public health emergency, which could strengthen the conception of response management, supplement and improve related theory system of emergency response capability.
Second, research object was oriented on the CDC at county level, which had the significant responsibility of prevention in the frontline of response and operation.
Because of in the frontline of emergency response for public health incidents, CDC at county level took the most responsibility of prevention and operation, but the emphasized aspects and depth of current research were both inadequate. By analyzing component elements of emergency response capability for public health emergency, and mainly analyzing emergency response capability and constructing comprehensive evaluation system, this study focused on CDC at county level, had important significance for implementing emergency response strategy, evaluating emergency response capability and strengthening capability construction for CDC in face of serious disasters and emergencies.
Third, integration of research method and indicator screening could efficiently realize longitudinal and horizontal evaluation between institutions.
Indicator evaluation system of emergency response capability constructing by Delphi and AHP, was beneficial to evaluate comprehensive emergency response capability clearly, and could provide a feasible standard and operational instrument for evaluation among different institutions or even third party evaluation, which had important practical significance for searching advantage and shortage of emergency response capability and improving management and response capability for public health crisis.
Limitations:
The evaluation of emergency response capability was a complicated system project which had abundant contents, various methods and multi-disciplinary theory. In specific practice of public health, governments at all levels and involved institutions highly emphasized the construction and evaluation of emergency response capability for public health incidents. Although the research had done lots of studies, and constructed capability evaluation indicator and model framework, it still left many detail problems to be investigated and studied because of complex research object and limited research capability.
First, study samples. The study samples were 12 regional CDC institutions of Qingdao. Although all the samples were investigated and met the research requirement according to research purpose, there still existed some problems on it. If sample data from different economic status at provincial level or from other regions were acquired, it would greatly modified and improved the conclusion of the research.
Second, screening and selecting evaluation indicators. Owing to lack of further research and experience of emergency response capability for CDC at county level, some evaluation indicators may be overlooked or selected improperly. So we need further study to keep the indicator system improved and reasonable.
Third, research on classification and level of public health incidents. The research theoretically constructed a model of level and classification which was based on infectious disease of public health emergency. It was difficult to get a nice model by Delphi method because of limited time and finance. Consequently, it couldn't provide every indicator weight, which made grading method unsuccessful in aspect of quantitative analysis.
RESEARCH PROSPECTS
First, improving practice research of evaluation indicator system of CDC emergency response capability for public health incidents. The regional practice research provided evidence for evaluating emergency response capability for CDC at county level. It will provide perfect evidence on evaluating emergency response capability for county CDC properly and comprehensively if the survey carried out in nationwide and provincial level or continuous data collection in a region.
Second, improving research on theory and practice by combining quantitative and qualitative method at all levels and classifications of public health emergency. The research didn't do grading practical research according to different types of infectious disease and other kinds of public health emergencies. The study result could be regarded as the starting point for further studying public health emergency and probation on realizing the target of comprehensive and scientific classification and grading for public health emergencies.
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