新医改环境下乡镇卫生院的发展
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摘要
我国医药卫生体制改革提出了建立健全覆盖城乡居民的基本医疗卫生制度的改革总目标。“保基本、强基层、建机制”是实现医改目标的核心策略。乡镇卫生院是农村三级医疗卫生服务网络的骨干,是为广大农村居民提供基本卫生服务的主要力量。乡镇卫生院的功能是否完善和服务能力的高低,对“保基本、强基层”的医改策略能否实现和农村居民能否享有可及和有质量的基本卫生服务具有重要意义。
我国已有的对乡镇卫生院功能的研究和探讨,普遍认为乡镇卫生院存在功能弱化、功能错位、重医疗轻预防保健的问题。对乡镇卫生院功能缺少明确详细的界定,政府投入不足,卫生人员配置不合理、能力水平低,缺少有效监管和考核是影响乡镇卫生院功能完善的主要因素。但以往的研究仍有一些需要解决的问题：1)对乡镇卫生院功能多为观点性的探讨,实证研究多为对某部分功能或工作任务的研究,而缺乏全面综合的评价；2)多为横断面的现状描述,较少动态变化的研究:3)较少对筹资、人力资源的投入变化与乡镇卫生院功能变化的综合研究。
新医改出台了针对基层卫生机构的一系列政策,涉及乡镇卫生院的功能定位、筹资和人力资源建设。在此契机下,乡镇卫生院的资金筹集和人力资源配置发生哪些变化,这些变化如何影响乡镇卫生院的服务功能,服务功能的变化是否符合医改的目标,还存在哪些问题,都需要进一步的研究。
本研究的总体目标是：通过调查研究,分析新医改环境下,乡镇卫生院资源投入及服务功能变化,为完善乡镇卫生院功能、实现医改强基层目标提供政策建议。具体的研究目的包括：1)揭示新医改前后乡镇卫生院财力筹集和人力资源配置变化；2)分析新医改前后乡镇卫生院服务功能的变化；3)研究乡镇卫生院服务功能的主要影响因素；4)为完善新医改强基层政策和实施提供证据和政策建议。
研究方法：
本研究采用定量和定性研究方法。资料来源包括全国性抽样调查数据和典型调查数据两部分。全国性抽样调查数据来自全国31个省市288家乡镇卫生院2008和2011两年度的机构问卷调查,采用前后对照研究设计,数据主要用于分析新医改政策投入和实施情况,乡镇卫生院服务功能、筹资补偿、人力资源的数量和构成在医改前后变化情况。典型调查数据来自2011年对吉林、陕西、山东、重庆、安徽五省市的30家乡镇卫生院进行的机构问卷调查,以及这30家乡镇卫生院的403名医生、护士和防保人员的卫生人员问卷调查。典型调查数据主要用于补充人力资源的素质能力、人员培训、人员流失与补充等方面的内容。同时,在典型调查中,对106名县市卫生局的卫生行政管理人员、乡镇卫生院负责人、医生和防保人员进行了关键知情者访谈,以对医改以来乡镇卫生院在服务功能、筹资和卫生人力方面的变化进行深层次分析。
本研究对乡镇卫生院功能的界定主要以《中国基本卫生服务及国家基本卫生服务包研究》中基本卫生服务的内容为基础,同时参考其他研究以及世界银行和其他发展中国家的经验,通过课题组研究讨论和专家咨询确定了乡镇卫生院基本卫生服务功能和项目,包括了基本医疗服务和基本公共卫生服务两大类,共9大项、100小项服务项目。采用项目升展比例和机构开展比例两个指标评价乡镇卫生院服务功能开展情况。对卫生人员的素质能力,除采用学历水平指标外,还采用闭卷测试的方式,测试医生、护士和防保人员对基本医疗卫生知识的掌握程度。定量数据采用Microsoft access二次录入系统录入,使用stata12.0软件进行分析,主要采用描述性统计分析、单因素统计推断分析方法。定性资料采用主题分析方法。
主要研究结果：
(1)医改政策实施和对基层卫生机构投入：新医改在国家层面上出台了一系列政策,主要针对乡镇卫生院的功能、筹资和人员队伍建设。新医改强调加强乡镇卫生院公共卫生服务的功能、加大政府投入的力度、采取多种措施加强人员队伍建设。各个县(市)陆续出台了针对性的政策,但进度不一。对基层卫生机构的财政投入逐步加强。西部地区对基层卫生服务机构的投入主要来自中央财政投入。医改最初各个县(市)主要加强基层卫生机构基本建设的投入,在2009年达到最高,2010年略有下降。对基本公共卫生服务的投入增加,大部分县(市)将资金拨付与考核结果挂钩。大部分县(市)实施了基本药物制度。对基层卫生人员培训的投入增加迅速。
(2)乡镇卫生院筹资变化：医改后,乡镇卫生院筹资来源的结构发生变化。实施全额预算拨款的乡镇卫生院比例增长了15.2个百分点。与2007年相比,2010年财政和上级补助收入占总收入的比例提高,超过药品收入,成为乡镇卫生院最主要的收入来源。但地区问的表现不一样,2011年西部地区已有57.5%的乡镇卫生院实施了全额预算拨款；但在东、中部地区仍以差额预算拨款为主,实施全额预算拨款的乡镇卫生院不超过20%。东、中部地区财政和上级补助收入占总收入的比例仍略低于药品收入,而西部地区则高于药品收入。
财政投入对乡镇卫生院的总的支付力度提高,财政补助占总支出的比例由2007年的20.4%提高到2010年的34.9%。对人员经费支出的支付力度上,2010年,财政补助中48.9%是基本人员补助,基本人员补助占人员经费支出的比例为59.1%,不能完全覆盖人员经费支出；但总的财政补助与人员经费支出之比由2007年的0.62上升到2010年的1.12,己能够支付全部的人员经费。在基本建设支出支付力度上,63.4%的乡镇卫生院2010年末获得基本建设补助,67.3%的乡镇卫生院当年也没有基本建设支出,平均来说,获得的基本建设补助大于当年的基本建设支出。对基本公共卫生服务项目支付力度上,2010年基本公共卫生项目专项补助占财政补助的27.8%,79.2%的乡镇卫生院获得的基本公共卫生项目补助高于其当年的基本公共卫生项目支出。对基本药物零差率销售的补偿力度,尽管实施基本药物零差价销售的乡镇卫生院数量增加,但2010年实际获得财政专项补助的乡镇卫生院卫生院仅占42.4%。且补助的力度较低,仅占卫生院财政收入的10.8%,仅能支付药品支出的11.6%。
(3)乡镇卫生院人力资源：从人员数量和结构来看,乡镇卫生院卫生技术人员数量略有增加,护士所占比例有所提高,但医护比倒置的现象仍然严重。从人员质量来看,卫生技术人员总体学历水平有所提高,但仍有58.3%的卫生技术人员仅拥有中专及以下学历；卫生技术人员对基本医疗卫生知识的测试成绩不高。人员的流失现象有一定程度缓解,2008-2010年间,乡镇卫生院人员流动规模很小,平均每家机构的净流入人数由2008年的0.3人增加到2009年和2010年的0.8。乡镇卫生院卫生人员平均每日工作时间均在8小时以上,平均每周工作时间在6天左右,大部分卫生人员认为自己的工作量较大。
人员编制设置在不同地区变化不一致,但总体上编制数变化不大,无法满足人员变化的需要,编制不足的机构增加。订单培养、上级对口支援等吸引和补充人才的措施效果还不明显。乡镇卫生院65.1%的卫生技术人员在2010年参加过各类培训。总体上,卫生人员认为医改后的培训数量增加、培训质量提高,但对获得的培训机会的评价仍然较低。
(4)乡镇卫生院服务功能变化：总体上乡镇卫生院服务功能进一步完善,2010年服务功能开展项目比2007年有所提高,且基本公共卫生服务功能项目的提高程度高于基本医疗服务功能项目。基本公共卫生服务功能受到重视,乡镇卫生院从过去的重医轻防转向基本医疗服务和基本公共卫生服务并重的功能定位。政策的重视、政府投入的增加、考核和激励制度的实施是促进乡镇卫生院基本公共卫生服务迅速开展的主要原因。
分析2010年开展机构比例不足90%的服务项目的未开展原因,基本医疗服务功能项目未开展的最主要原因是缺设备、人员能力不够、人员数量不足；基本公共卫生服务功能项目未开展的最主要原因是上级无要求,其次是人员能力不够和人员数量不足。乡镇卫生院服务功能还存在一些问题。部分全额拨款、全面实施基本药物制度和药品零差率销售的乡镇卫生院出现了不愿意提供医疗服务,基本医疗服务功能萎缩的现象。基本公共卫生服务功能虽得到加强,但限于服务能力,部分项目的开展遇到困难,服务的整体质量和水平有待提高。
结论和政策建议：
乡镇卫生院的筹资结构发生转变。财政补助收入成为乡镇卫生院最主要的收入来源,药品收入所占比重下降。财政补助对基本公共卫生服务支付力度较强,提高了提供基本公共卫生服务的积极性；而对药品零差价销售的补助力度较弱,降低了提供基本医疗服务的积极性。
乡镇卫生院卫生人员的数量、结构和质量均有所改善,但改善幅度不大,人员结构不合理,人员素质的总体水平仍然不高。人员培训的数量增加、培训质量有所提高。人员流失的现象得到缓解。用人机制不活,编制仍是引进人才的障碍。所实施的各类人才吸引和补充政策作用有限。
乡镇卫生院功能定位转变,由重医轻防转向基本医疗服务与基本公共卫生服务并重。基本医疗服务功能和基本公共卫生服务功能开展的范围和力度均有所增强。基本公共卫生服务发展更快,服务的可获得性增强,但服务的质量有待提高。政策的重视和引导、投入增加、考核和激励制度是功能转变的促进因素。卫生人力能力不足和财政投入不到位是影响服务功能开展和质量提高的主要因素。
我们提出以下政策建议：1)出台相应的法律法规,明确政府的投入责任,确保政府对基本卫生服务投入的持续性,确保投入资金的到位；2)根据基本卫生服务提供的要求和卫生服务需求,对乡镇卫生院所需人员的数量、结构和质量进行合理规划；对现有的人员补充政策进行总结评价,采取激励措施吸引人才到乡镇卫生院工作；发展医学教育,增加培训机会,改善培训质量,提升乡镇卫生院的人力素质水平。3)放松编制的管制,采用更灵活的用人机制。根据实际工作需要设置工作岗位,政府根据工作岗位进行投入。依据工作岗位招聘人员,明确岗位的工作任务和薪酬待遇,废除编制身份的终身制；4)注重卫生服务质量的提高,应进一步根据基本卫生服务的要求,出台细化的操作指导手册,对卫生人员进行有针对性的培训,在考核中加重服务质量的比重。
The new health system reform set the overall goals of constructing a basic health care system covering urban and rural residents. Providing equal basic public health services and basic medical care services and strengthening the capacity of the primary health institutions is a core strategy to achieve the goals of the health system reform. Township health centers (THCs) are the backbone of the three tier rural health service network and the main force to provide essential health services to most of the rural residents. The improvement of the functions of THCs are very important to achieve the goals of health system reform and to ensure the rural residents to enjoy the essential health service.
The current researches found that the funcions of THCs are weakend and medical services are more valued than public health services. The lack of a clear and detailed definition of the functions, inadequate government investment, unreasonable staffing, low level of the service capacity and the lack of effective supervision and assessment are the main factors that against the improvement of the functions of THCs. The following questions are needed to be solved:1) most of the researches of the functions of THCs are just discussions of different views, and the empirical researches only covered part of the functions, there are few of comprehensive and integrated evaluations;2) most of the researches are cross-sectional researches and there are few researches on dynamic changes;3) there are few comprehensive studies on the changes of financing, human resources, and functions of township health centers. The new health system reform introduced a series of policies for the primary health institutions. Functions, financing and human resources of THCs were covered by these policies. Under this environment, further researches are needed on what changes has happened of the financing and human resources and how these changes affect the funcions of THCs, whether the changes are appropriate with the goals of health system reform, and what problems still exist.
The overall objective of this study is to analyse the changes of financing, human resources and functions of THCs under the new health system reform, and to propose strategies on the improvement of functions of THCs and achievement of goals of health system reform. The specific objectives of the study include:1) reveal the changes of financing and human resources of THCs before and after the new health system reform;2) analyse the changes of the functions of THCs before and after the new health system reform;3) explore the influencing factors of the functions of THCs;4) provide evidence and propose strategies to achive the goals of the new health system reform.
Date and Methods
Quantitative and qualitative methods are adopted in this study. There are two data sources, two national surveys and a special survey. The institutional data of288THCs in31provinces are from two national surveys conducted in2008and2011. Using before and after study design, the national data is used to analyse1) the input and implementation of the new policies of the new health system reform;2) the changes of functions, financing and compensation, and the quantity and composition of health human resources of THCs. The special survey was conducted in Jilin, Shanxi, Shandong, Chongqing and Anhui in2011. Institutional data of30township health centers and personnel data of403health workers including doctors, nurses and prevention and health care workers were collected. The data of the special survey is used to do supplementary analysis of the quality, training and mobility of human resources.106key informants are interviewed including officers of local health bureaus, deans of THCs, doctors and prevention and health care workers. The qualitative data are used to do deep analysis of changes of financing,human resources and funcions before and after the new health system reform.
The definition of THCs' service functions is primarily based on the contents of essential health services in "the study of essential health service and national essential health service package in China", while making reference to other studies and the experience of the World Bank and other developing countries. The functions of the THCs were defined through discussing in the research team and consulting some experts. The functions of the THCs in this study consist of basic medical services and basic public health services, including9categories and100items. Two indicators, the proportion of items carried out and the proportion of institutions carrying out the items, are calculated to evaluate the implementation of services in THCs. In addition to educational level, closed-book exam is taken to test the basic health knowledge's mastery of doctors, nurses and prevention and health care workers. The quantitative data were double entered into Microsoft Access, and then were analysed using Stata12.0. Qualitative data were analyzed using thematic analysis method.
Main results
(1) The implementation of health system reform policies and investment in primary health institutions The new health system reform, which includes a series of policies at the national level, focused on the functions, financing and staff team building of THCs. The new health system reform emphasize on strengthening the public health service functions in THCs, increasing the intensity of government investment and taking a variety of measures to strengthen the staff team building. Counties have promulgated specific policies, but the progress was different. The financial input in primary health institutions was gradually strengthened. In the western regions, fisical subsidies of primary health institutions mainly came from the central government. At first, counties focused on increasing the input into the infrastructures of primary health institutions, which peaked in2009and declined slightly in2010. In addition, the investment to primary public health services increased. Most of the counties linked up financial investment with performance. Most of the counties implemented essential drug policy, as well as the essential drug zero rate sales policy. The financial investment on training human resources for primary health institutions increased rapidly.
(2)The changes of financing of THCs before and after health system reform After the new health system reform, the proportion of the sources of financing of THCs has changed. The proportion of THCs which implemented whole-budget management has increased by15.2percentage points. Compared to2007, the ratio of fisical subsidy income to total income increased in2010, which exceeded income from drugs and became the main source of income in THCs. But different regions had different situations. In2011in the western region there were57.5percent of THCs implemented whole-budget management; while in the eastern and middle regions budget management by remainder was the main financing method for THCs, and the percent of THCs which implemented whole-budget management was less than20%. In the eastern and middle regions, fisical subsidy income to total income ratio was still slightly lower than the income from drugs, while in the western region was higher than the income from drugs.
The power of financial investment to THCs has increased, and the fiscal subsidies accounted for total expenditure has increased from20.4%in2007to34.9%in2010. According to the power of financial investment on personnel expenditures,48.9%of the fiscal investment was to subsidize basic personnel expenses, which accounted for59.1%of the personnel expenditures in2010; and the total fiscal subsidies to personnel expenditure ratio rose from0.62in2007to1.12in2010, which has been able to pay all of the personnel expenses. According to the power of financial investment on the infrastructure expenditures,63.4percent of THCs in2010did not get basic subsidies for the infrastructure, and67.3percent of THCs had no infrastructure expenditures in the same year. On the average, the basic infrastructure subsidies were greater than the expenditures in the same year. According to power of financial investment on the public health service expenditures, special subsidies of basic public health programs in2010accounted for27.8%of the fisical subsidies, and79.2%of the THCs whose basic public health project grants was above its basic public health project expenditures. According to power of financial investment on essential drugs zero sales policy, despite the number of THCs that implemented essential drugs zero sales policy greatly increased, only42.4%of the THCs actually received special fisical subsidies in2010, and the intensity of the subsidies was relatively low, accounting for only10.8%of the fiscal revenue of the THCs and could only afforded11.6%of drug expenditures.
(3)Health human resources of THCs before and after health system reform In terms of the amount and composition of human resources, the amount of health technical personnel of THCs increased slightly, and the percentage which nurses accounting for also increased, but the invert of the ratio of doctors and nurses was still seriously. In terms of quality of human resources, health technical personnel'educational level grew though there were still58.3%of whom receiving secondary education level or lower; the score of exam on basic medical knowledge received by health technical personnel was not too high. The situation of personnel turnover has been eased to some extent. During2008to2010, the flow scale of THCs pesonnel was small with the average net inflow of each center rising from0.3person in2008to0.8person in2010. The average working time every day of THCs pesonnel was above8hours and the average working time every week was around6days. Most of health technical personnel thought themselves confronting heavy workload.
The settings of the size of staffing changed differently in different regions, but the overall number of the size of staffing didn't change obviously, which still couldn't meet the demand of staff change and the amount of THCs which didn't own enough size of staffing increased. Effects of inventions aiming for talent attracting such as special training and support from higher level hospitals were still not obvious.65.1%of health technical personnel in THCs has participated various types of training. In general, health workers thought that the quantity as well as the quality of training has been improved after the health system reform, however, their estimation to training opportunities were still at a low level.
(4) Changes on service functions of THCs before and after health system reform:In general, service functions of THCs has been further improved. The amount of items carried out by THCs in2010was enhanced compared with that in2007, and the increase of basic public health service items was higher than that of basic medical service items. Basic public health service functions has received much attention, and THCs changed their functions from "valuing medical, despising prevention" to "paying equal attention to both basic medical service and basic public health service". Emphasis of the policy, the increase of the government investment and the implementation of assessment and incentive system were the main reasons which promoted basic public health service developing rapidly.
In2010, the percentage of some service items accounted no more than90%. The main reason that these service items hasn't been carried out was related with facilities and staff. The main reasons why basic public health service items didn't carried out were "not required", followed with "limited capacity of personnel" and "lack of the amount of personnel". Some problems of THCs'service functions still existed. Some THCs which implemented essential medicine system and zero rate of medicine sale were not willing to provide medical service. Basic public health service function has been strengthened, however, due to the limited service capacity, some items facing difficulty in being carried out and the overall quality and level of service still need to be improved.
Conclusion and policy implication
After the implementation of the new health system reform, policies in local regions were put into effect successively and the financial investment to primary health institutions was increased. Financing of THCs has changed, and proportion of THCs which implemented whole-budget management increased. Currently, fisical subsidies has become the main source of revenue while the percentage of medicine income has decreased. The power of payment of fisical subsidies to personnel expenditures and primary public health service expenditure were relatively high while fisical subsidies to the drug expenditures was relatively low.
There were improvement in the quantity, composition and quality of personnel in THCs, however, the personnel quality was still at a low level. The quantity of training programs were increased and the quality of training was improved. The scale of personnel mobility of THCs was small and the attrition problem has been partly solved. However, the personnel mechanism is not flexible enough, for instance, the setting of size of staffing is still the obstacle of enrollment of the personnel. The effects of all the policy on attracting personnel were still not obvious.
Both the functions of basic medical service and basic public health service have been enhanced in THCs, and the basic public health service functions developed more quickly,however, the quality still need to be improved. Human resource was the main factor influencing the improvement of the functions of THCs. The influence of variation of finance to primary public health care service was positive, however, it is opposite to the functions of basic medical service.
The following policy suggestions are proposed:1) Related laws and regulations need to be formulated, and the responsibility of sustainability of government financial investment must be explicated;2) According to the request of primary health service, the quantity, composition and quality of the THCs human resources need to be reasonably planned;3) Loosen the setting of size of staffing and apply the flexible personnel mechanism; on the base of summary and evaluation of current policies and measures, the incentive measures to attract personnel to THCs should be taken to improve the quality of human resource t.4) The health care service quality should be given more attention to and detailed operation and guide book in the light of the request of primary health care service should be made up. Base on that, training program to the health care workers is to be conducted, meanwhile, put more rate on the service quality in assessment.
我国已有的对乡镇卫生院功能的研究和探讨,普遍认为乡镇卫生院存在功能弱化、功能错位、重医疗轻预防保健的问题。对乡镇卫生院功能缺少明确详细的界定,政府投入不足,卫生人员配置不合理、能力水平低,缺少有效监管和考核是影响乡镇卫生院功能完善的主要因素。但以往的研究仍有一些需要解决的问题：1)对乡镇卫生院功能多为观点性的探讨,实证研究多为对某部分功能或工作任务的研究,而缺乏全面综合的评价；2)多为横断面的现状描述,较少动态变化的研究:3)较少对筹资、人力资源的投入变化与乡镇卫生院功能变化的综合研究。
新医改出台了针对基层卫生机构的一系列政策,涉及乡镇卫生院的功能定位、筹资和人力资源建设。在此契机下,乡镇卫生院的资金筹集和人力资源配置发生哪些变化,这些变化如何影响乡镇卫生院的服务功能,服务功能的变化是否符合医改的目标,还存在哪些问题,都需要进一步的研究。
本研究的总体目标是：通过调查研究,分析新医改环境下,乡镇卫生院资源投入及服务功能变化,为完善乡镇卫生院功能、实现医改强基层目标提供政策建议。具体的研究目的包括：1)揭示新医改前后乡镇卫生院财力筹集和人力资源配置变化；2)分析新医改前后乡镇卫生院服务功能的变化；3)研究乡镇卫生院服务功能的主要影响因素；4)为完善新医改强基层政策和实施提供证据和政策建议。
研究方法：
本研究采用定量和定性研究方法。资料来源包括全国性抽样调查数据和典型调查数据两部分。全国性抽样调查数据来自全国31个省市288家乡镇卫生院2008和2011两年度的机构问卷调查,采用前后对照研究设计,数据主要用于分析新医改政策投入和实施情况,乡镇卫生院服务功能、筹资补偿、人力资源的数量和构成在医改前后变化情况。典型调查数据来自2011年对吉林、陕西、山东、重庆、安徽五省市的30家乡镇卫生院进行的机构问卷调查,以及这30家乡镇卫生院的403名医生、护士和防保人员的卫生人员问卷调查。典型调查数据主要用于补充人力资源的素质能力、人员培训、人员流失与补充等方面的内容。同时,在典型调查中,对106名县市卫生局的卫生行政管理人员、乡镇卫生院负责人、医生和防保人员进行了关键知情者访谈,以对医改以来乡镇卫生院在服务功能、筹资和卫生人力方面的变化进行深层次分析。
本研究对乡镇卫生院功能的界定主要以《中国基本卫生服务及国家基本卫生服务包研究》中基本卫生服务的内容为基础,同时参考其他研究以及世界银行和其他发展中国家的经验,通过课题组研究讨论和专家咨询确定了乡镇卫生院基本卫生服务功能和项目,包括了基本医疗服务和基本公共卫生服务两大类,共9大项、100小项服务项目。采用项目升展比例和机构开展比例两个指标评价乡镇卫生院服务功能开展情况。对卫生人员的素质能力,除采用学历水平指标外,还采用闭卷测试的方式,测试医生、护士和防保人员对基本医疗卫生知识的掌握程度。定量数据采用Microsoft access二次录入系统录入,使用stata12.0软件进行分析,主要采用描述性统计分析、单因素统计推断分析方法。定性资料采用主题分析方法。
主要研究结果：
(1)医改政策实施和对基层卫生机构投入：新医改在国家层面上出台了一系列政策,主要针对乡镇卫生院的功能、筹资和人员队伍建设。新医改强调加强乡镇卫生院公共卫生服务的功能、加大政府投入的力度、采取多种措施加强人员队伍建设。各个县(市)陆续出台了针对性的政策,但进度不一。对基层卫生机构的财政投入逐步加强。西部地区对基层卫生服务机构的投入主要来自中央财政投入。医改最初各个县(市)主要加强基层卫生机构基本建设的投入,在2009年达到最高,2010年略有下降。对基本公共卫生服务的投入增加,大部分县(市)将资金拨付与考核结果挂钩。大部分县(市)实施了基本药物制度。对基层卫生人员培训的投入增加迅速。
(2)乡镇卫生院筹资变化：医改后,乡镇卫生院筹资来源的结构发生变化。实施全额预算拨款的乡镇卫生院比例增长了15.2个百分点。与2007年相比,2010年财政和上级补助收入占总收入的比例提高,超过药品收入,成为乡镇卫生院最主要的收入来源。但地区问的表现不一样,2011年西部地区已有57.5%的乡镇卫生院实施了全额预算拨款；但在东、中部地区仍以差额预算拨款为主,实施全额预算拨款的乡镇卫生院不超过20%。东、中部地区财政和上级补助收入占总收入的比例仍略低于药品收入,而西部地区则高于药品收入。
财政投入对乡镇卫生院的总的支付力度提高,财政补助占总支出的比例由2007年的20.4%提高到2010年的34.9%。对人员经费支出的支付力度上,2010年,财政补助中48.9%是基本人员补助,基本人员补助占人员经费支出的比例为59.1%,不能完全覆盖人员经费支出；但总的财政补助与人员经费支出之比由2007年的0.62上升到2010年的1.12,己能够支付全部的人员经费。在基本建设支出支付力度上,63.4%的乡镇卫生院2010年末获得基本建设补助,67.3%的乡镇卫生院当年也没有基本建设支出,平均来说,获得的基本建设补助大于当年的基本建设支出。对基本公共卫生服务项目支付力度上,2010年基本公共卫生项目专项补助占财政补助的27.8%,79.2%的乡镇卫生院获得的基本公共卫生项目补助高于其当年的基本公共卫生项目支出。对基本药物零差率销售的补偿力度,尽管实施基本药物零差价销售的乡镇卫生院数量增加,但2010年实际获得财政专项补助的乡镇卫生院卫生院仅占42.4%。且补助的力度较低,仅占卫生院财政收入的10.8%,仅能支付药品支出的11.6%。
(3)乡镇卫生院人力资源：从人员数量和结构来看,乡镇卫生院卫生技术人员数量略有增加,护士所占比例有所提高,但医护比倒置的现象仍然严重。从人员质量来看,卫生技术人员总体学历水平有所提高,但仍有58.3%的卫生技术人员仅拥有中专及以下学历；卫生技术人员对基本医疗卫生知识的测试成绩不高。人员的流失现象有一定程度缓解,2008-2010年间,乡镇卫生院人员流动规模很小,平均每家机构的净流入人数由2008年的0.3人增加到2009年和2010年的0.8。乡镇卫生院卫生人员平均每日工作时间均在8小时以上,平均每周工作时间在6天左右,大部分卫生人员认为自己的工作量较大。
人员编制设置在不同地区变化不一致,但总体上编制数变化不大,无法满足人员变化的需要,编制不足的机构增加。订单培养、上级对口支援等吸引和补充人才的措施效果还不明显。乡镇卫生院65.1%的卫生技术人员在2010年参加过各类培训。总体上,卫生人员认为医改后的培训数量增加、培训质量提高,但对获得的培训机会的评价仍然较低。
(4)乡镇卫生院服务功能变化：总体上乡镇卫生院服务功能进一步完善,2010年服务功能开展项目比2007年有所提高,且基本公共卫生服务功能项目的提高程度高于基本医疗服务功能项目。基本公共卫生服务功能受到重视,乡镇卫生院从过去的重医轻防转向基本医疗服务和基本公共卫生服务并重的功能定位。政策的重视、政府投入的增加、考核和激励制度的实施是促进乡镇卫生院基本公共卫生服务迅速开展的主要原因。
分析2010年开展机构比例不足90%的服务项目的未开展原因,基本医疗服务功能项目未开展的最主要原因是缺设备、人员能力不够、人员数量不足；基本公共卫生服务功能项目未开展的最主要原因是上级无要求,其次是人员能力不够和人员数量不足。乡镇卫生院服务功能还存在一些问题。部分全额拨款、全面实施基本药物制度和药品零差率销售的乡镇卫生院出现了不愿意提供医疗服务,基本医疗服务功能萎缩的现象。基本公共卫生服务功能虽得到加强,但限于服务能力,部分项目的开展遇到困难,服务的整体质量和水平有待提高。
结论和政策建议：
乡镇卫生院的筹资结构发生转变。财政补助收入成为乡镇卫生院最主要的收入来源,药品收入所占比重下降。财政补助对基本公共卫生服务支付力度较强,提高了提供基本公共卫生服务的积极性；而对药品零差价销售的补助力度较弱,降低了提供基本医疗服务的积极性。
乡镇卫生院卫生人员的数量、结构和质量均有所改善,但改善幅度不大,人员结构不合理,人员素质的总体水平仍然不高。人员培训的数量增加、培训质量有所提高。人员流失的现象得到缓解。用人机制不活,编制仍是引进人才的障碍。所实施的各类人才吸引和补充政策作用有限。
乡镇卫生院功能定位转变,由重医轻防转向基本医疗服务与基本公共卫生服务并重。基本医疗服务功能和基本公共卫生服务功能开展的范围和力度均有所增强。基本公共卫生服务发展更快,服务的可获得性增强,但服务的质量有待提高。政策的重视和引导、投入增加、考核和激励制度是功能转变的促进因素。卫生人力能力不足和财政投入不到位是影响服务功能开展和质量提高的主要因素。
我们提出以下政策建议：1)出台相应的法律法规,明确政府的投入责任,确保政府对基本卫生服务投入的持续性,确保投入资金的到位；2)根据基本卫生服务提供的要求和卫生服务需求,对乡镇卫生院所需人员的数量、结构和质量进行合理规划；对现有的人员补充政策进行总结评价,采取激励措施吸引人才到乡镇卫生院工作；发展医学教育,增加培训机会,改善培训质量,提升乡镇卫生院的人力素质水平。3)放松编制的管制,采用更灵活的用人机制。根据实际工作需要设置工作岗位,政府根据工作岗位进行投入。依据工作岗位招聘人员,明确岗位的工作任务和薪酬待遇,废除编制身份的终身制；4)注重卫生服务质量的提高,应进一步根据基本卫生服务的要求,出台细化的操作指导手册,对卫生人员进行有针对性的培训,在考核中加重服务质量的比重。
The new health system reform set the overall goals of constructing a basic health care system covering urban and rural residents. Providing equal basic public health services and basic medical care services and strengthening the capacity of the primary health institutions is a core strategy to achieve the goals of the health system reform. Township health centers (THCs) are the backbone of the three tier rural health service network and the main force to provide essential health services to most of the rural residents. The improvement of the functions of THCs are very important to achieve the goals of health system reform and to ensure the rural residents to enjoy the essential health service.
The current researches found that the funcions of THCs are weakend and medical services are more valued than public health services. The lack of a clear and detailed definition of the functions, inadequate government investment, unreasonable staffing, low level of the service capacity and the lack of effective supervision and assessment are the main factors that against the improvement of the functions of THCs. The following questions are needed to be solved:1) most of the researches of the functions of THCs are just discussions of different views, and the empirical researches only covered part of the functions, there are few of comprehensive and integrated evaluations;2) most of the researches are cross-sectional researches and there are few researches on dynamic changes;3) there are few comprehensive studies on the changes of financing, human resources, and functions of township health centers. The new health system reform introduced a series of policies for the primary health institutions. Functions, financing and human resources of THCs were covered by these policies. Under this environment, further researches are needed on what changes has happened of the financing and human resources and how these changes affect the funcions of THCs, whether the changes are appropriate with the goals of health system reform, and what problems still exist.
The overall objective of this study is to analyse the changes of financing, human resources and functions of THCs under the new health system reform, and to propose strategies on the improvement of functions of THCs and achievement of goals of health system reform. The specific objectives of the study include:1) reveal the changes of financing and human resources of THCs before and after the new health system reform;2) analyse the changes of the functions of THCs before and after the new health system reform;3) explore the influencing factors of the functions of THCs;4) provide evidence and propose strategies to achive the goals of the new health system reform.
Date and Methods
Quantitative and qualitative methods are adopted in this study. There are two data sources, two national surveys and a special survey. The institutional data of288THCs in31provinces are from two national surveys conducted in2008and2011. Using before and after study design, the national data is used to analyse1) the input and implementation of the new policies of the new health system reform;2) the changes of functions, financing and compensation, and the quantity and composition of health human resources of THCs. The special survey was conducted in Jilin, Shanxi, Shandong, Chongqing and Anhui in2011. Institutional data of30township health centers and personnel data of403health workers including doctors, nurses and prevention and health care workers were collected. The data of the special survey is used to do supplementary analysis of the quality, training and mobility of human resources.106key informants are interviewed including officers of local health bureaus, deans of THCs, doctors and prevention and health care workers. The qualitative data are used to do deep analysis of changes of financing,human resources and funcions before and after the new health system reform.
The definition of THCs' service functions is primarily based on the contents of essential health services in "the study of essential health service and national essential health service package in China", while making reference to other studies and the experience of the World Bank and other developing countries. The functions of the THCs were defined through discussing in the research team and consulting some experts. The functions of the THCs in this study consist of basic medical services and basic public health services, including9categories and100items. Two indicators, the proportion of items carried out and the proportion of institutions carrying out the items, are calculated to evaluate the implementation of services in THCs. In addition to educational level, closed-book exam is taken to test the basic health knowledge's mastery of doctors, nurses and prevention and health care workers. The quantitative data were double entered into Microsoft Access, and then were analysed using Stata12.0. Qualitative data were analyzed using thematic analysis method.
Main results
(1) The implementation of health system reform policies and investment in primary health institutions The new health system reform, which includes a series of policies at the national level, focused on the functions, financing and staff team building of THCs. The new health system reform emphasize on strengthening the public health service functions in THCs, increasing the intensity of government investment and taking a variety of measures to strengthen the staff team building. Counties have promulgated specific policies, but the progress was different. The financial input in primary health institutions was gradually strengthened. In the western regions, fisical subsidies of primary health institutions mainly came from the central government. At first, counties focused on increasing the input into the infrastructures of primary health institutions, which peaked in2009and declined slightly in2010. In addition, the investment to primary public health services increased. Most of the counties linked up financial investment with performance. Most of the counties implemented essential drug policy, as well as the essential drug zero rate sales policy. The financial investment on training human resources for primary health institutions increased rapidly.
(2)The changes of financing of THCs before and after health system reform After the new health system reform, the proportion of the sources of financing of THCs has changed. The proportion of THCs which implemented whole-budget management has increased by15.2percentage points. Compared to2007, the ratio of fisical subsidy income to total income increased in2010, which exceeded income from drugs and became the main source of income in THCs. But different regions had different situations. In2011in the western region there were57.5percent of THCs implemented whole-budget management; while in the eastern and middle regions budget management by remainder was the main financing method for THCs, and the percent of THCs which implemented whole-budget management was less than20%. In the eastern and middle regions, fisical subsidy income to total income ratio was still slightly lower than the income from drugs, while in the western region was higher than the income from drugs.
The power of financial investment to THCs has increased, and the fiscal subsidies accounted for total expenditure has increased from20.4%in2007to34.9%in2010. According to the power of financial investment on personnel expenditures,48.9%of the fiscal investment was to subsidize basic personnel expenses, which accounted for59.1%of the personnel expenditures in2010; and the total fiscal subsidies to personnel expenditure ratio rose from0.62in2007to1.12in2010, which has been able to pay all of the personnel expenses. According to the power of financial investment on the infrastructure expenditures,63.4percent of THCs in2010did not get basic subsidies for the infrastructure, and67.3percent of THCs had no infrastructure expenditures in the same year. On the average, the basic infrastructure subsidies were greater than the expenditures in the same year. According to power of financial investment on the public health service expenditures, special subsidies of basic public health programs in2010accounted for27.8%of the fisical subsidies, and79.2%of the THCs whose basic public health project grants was above its basic public health project expenditures. According to power of financial investment on essential drugs zero sales policy, despite the number of THCs that implemented essential drugs zero sales policy greatly increased, only42.4%of the THCs actually received special fisical subsidies in2010, and the intensity of the subsidies was relatively low, accounting for only10.8%of the fiscal revenue of the THCs and could only afforded11.6%of drug expenditures.
(3)Health human resources of THCs before and after health system reform In terms of the amount and composition of human resources, the amount of health technical personnel of THCs increased slightly, and the percentage which nurses accounting for also increased, but the invert of the ratio of doctors and nurses was still seriously. In terms of quality of human resources, health technical personnel'educational level grew though there were still58.3%of whom receiving secondary education level or lower; the score of exam on basic medical knowledge received by health technical personnel was not too high. The situation of personnel turnover has been eased to some extent. During2008to2010, the flow scale of THCs pesonnel was small with the average net inflow of each center rising from0.3person in2008to0.8person in2010. The average working time every day of THCs pesonnel was above8hours and the average working time every week was around6days. Most of health technical personnel thought themselves confronting heavy workload.
The settings of the size of staffing changed differently in different regions, but the overall number of the size of staffing didn't change obviously, which still couldn't meet the demand of staff change and the amount of THCs which didn't own enough size of staffing increased. Effects of inventions aiming for talent attracting such as special training and support from higher level hospitals were still not obvious.65.1%of health technical personnel in THCs has participated various types of training. In general, health workers thought that the quantity as well as the quality of training has been improved after the health system reform, however, their estimation to training opportunities were still at a low level.
(4) Changes on service functions of THCs before and after health system reform:In general, service functions of THCs has been further improved. The amount of items carried out by THCs in2010was enhanced compared with that in2007, and the increase of basic public health service items was higher than that of basic medical service items. Basic public health service functions has received much attention, and THCs changed their functions from "valuing medical, despising prevention" to "paying equal attention to both basic medical service and basic public health service". Emphasis of the policy, the increase of the government investment and the implementation of assessment and incentive system were the main reasons which promoted basic public health service developing rapidly.
In2010, the percentage of some service items accounted no more than90%. The main reason that these service items hasn't been carried out was related with facilities and staff. The main reasons why basic public health service items didn't carried out were "not required", followed with "limited capacity of personnel" and "lack of the amount of personnel". Some problems of THCs'service functions still existed. Some THCs which implemented essential medicine system and zero rate of medicine sale were not willing to provide medical service. Basic public health service function has been strengthened, however, due to the limited service capacity, some items facing difficulty in being carried out and the overall quality and level of service still need to be improved.
Conclusion and policy implication
After the implementation of the new health system reform, policies in local regions were put into effect successively and the financial investment to primary health institutions was increased. Financing of THCs has changed, and proportion of THCs which implemented whole-budget management increased. Currently, fisical subsidies has become the main source of revenue while the percentage of medicine income has decreased. The power of payment of fisical subsidies to personnel expenditures and primary public health service expenditure were relatively high while fisical subsidies to the drug expenditures was relatively low.
There were improvement in the quantity, composition and quality of personnel in THCs, however, the personnel quality was still at a low level. The quantity of training programs were increased and the quality of training was improved. The scale of personnel mobility of THCs was small and the attrition problem has been partly solved. However, the personnel mechanism is not flexible enough, for instance, the setting of size of staffing is still the obstacle of enrollment of the personnel. The effects of all the policy on attracting personnel were still not obvious.
Both the functions of basic medical service and basic public health service have been enhanced in THCs, and the basic public health service functions developed more quickly,however, the quality still need to be improved. Human resource was the main factor influencing the improvement of the functions of THCs. The influence of variation of finance to primary public health care service was positive, however, it is opposite to the functions of basic medical service.
The following policy suggestions are proposed:1) Related laws and regulations need to be formulated, and the responsibility of sustainability of government financial investment must be explicated;2) According to the request of primary health service, the quantity, composition and quality of the THCs human resources need to be reasonably planned;3) Loosen the setting of size of staffing and apply the flexible personnel mechanism; on the base of summary and evaluation of current policies and measures, the incentive measures to attract personnel to THCs should be taken to improve the quality of human resource t.4) The health care service quality should be given more attention to and detailed operation and guide book in the light of the request of primary health care service should be made up. Base on that, training program to the health care workers is to be conducted, meanwhile, put more rate on the service quality in assessment.
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