我国疾病预防控制绩效考核的研究与实践
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摘要
一、研究目的与意义
(一)绩效考核是政府履行职能、完善疾病预防控制体系的需要
履行公共服务职能是现代政府的显著特征,提高公共服务绩效亦成为现代政府管理的核心。加快政府绩效考核,是保证政府公正、高效地履行职能的保障。疾病预防控制体系服务的对象是社会公众,提供的是纯公共服务或准公共服务。作为政府公共服务的重要内容之一,其绩效状况自然成为政府与社会关注的重点,也应体现在政府绩效考核的范围之中。然而,现阶段我国疾病预防控制机构公共产品的提供效率并不容乐观,“重有偿服务轻无偿服务”现象突出,公共职能缺位、工作效率低下问题严重。2009年,中共中央、国务院颁发的《关于深化医药卫生体制改革的意见》中明确指出,公共卫生体系需要“加强绩效考核,提高服务效率和质量”,促进公共卫生服务的均等化。如何科学进行疾病预防控制工作绩效考核与管理,切实提高体系提供优质和高效的公共服务能力,成为新时期继续完善疾病预防控制体系建设的需要。
(二)绩效考核在疾病预防控制领域的研究与实践需要突破
绩效考核是指在实现目标或完成职能的过程中,依据可量化的指标对工作过程、结果、效率等各方面进行的评价。它起源于20世纪初的企业管理；20世纪50年代开始,美国、英国等国家先后将绩效管理的理念运用到政府及其公共部门。在卫生领域,世界卫生组织2000年第一次提出了三项总体目标的绩效考核指标：健康状况的改进度、人群期望的反应性和卫生筹资的公平性；初级卫生保健、健康城市等概念、目标和指标的提出也在世界各国间产生了重大的影响,促进了卫生系统绩效的提高；而在我国,卫生系统开展的诸多绩效考核研究和实践主要集中于医疗领域,而对于公共卫生领域,尤其是疾病预防控制体系的绩效考核工作很少：仅卫生部颁布了《全国卫生防疫站等级评审管理办法》(试点方案)和《全国卫生防疫站评审标准》,并于1996年开始对全国卫生防疫站实行等级评审。20世纪90年代后期,伴随着卫生监督与疾病预防控制体制改革的推进,卫生防疫站更名为疾病预防控制中心(以下简称疾控中心),其职能也进行了较大调整,如何考核其工作绩效,尚缺乏深入而系统的研究。因此,如何集成国内外其他领域成熟的理论与方法,紧密结合我国疾病预防控制体系的特点,研制系统评价体系绩效的指标体系及综合评价模型,并将其付诸实践是一个科学难题。
(三)绩效考核是疾病预防控制体系建设研究的延续
2003年始,卫生部疾病控制局筹建了疾病预防控制体系建设研究课题组,以体系的长远发展为目标,针对疾病预防控制体系“应该做什么?做这些需要什么条件?怎么做?做得如何?”等问题开展了一系列系统研究。该系列研究获得了决策部门的高度重视与支持,目前已完成“做什么?”、“需要什么?”、“怎么做?”的研究工作。现阶段,如何客观、准确地评价与改进我国疾病预防控制工作的绩效,已成为体系建设研究的重要命题。因些，在进行疾病预防控制绩效考核研究与实践中：如何科学设计全面反映疾病预防控制体系工作的考核框架、如何系统收集与筛选考核指标并建立指标体系、如何实现绩效的综合评价、如何确保科学可操作的实施等一系列关键问题亟待解决。
本研究期望在系统了解国内外绩效考核的研究与实践现状,总结可供借鉴的成熟经验和技术的基础上,结合我国疾病预防控制工作的特点,建立疾病预防控制绩效考核指标体系和综合评价模型,并通过构建绩效考核实施的全流程、设计与开发绩效考核管理软件,确保实施的科学性和可操作性；在此基础上,在省级疾控中心全面推广绩效考核,综合评价其绩效状况,并提出改进策略与建议。即明确疾病预防控制体系绩效“应该考核什么”、“如何综合评价”、“如何科学、可操作地实施考核”、“全国省级机构实践检验后结果如何”等一系列问题。
二、材料与方法
本研究首先运用卫生系统宏观模型、系统论和层次结构分析理论等方法构建模块化、层次化、条理化的绩效考核框架；在此基础上,通过“系统收集指标-筛选指标-界定论证指标”等步骤,经过多重论证与分析、机构预试验、网上公开与测试单位意见征询等,建立疾病预防控制绩效考核指标体系；运用模糊综合评价法、层次分析法、专家咨询与论证等方法构建了综合评价模型。
其次,综合运用文献归纳分析和专家咨询法,遵循业务流程管理理念和信息系统设计的流程与步骤,研制了绩效考核的实施流程与方法,形成了管理软件的设计思路,并通过测试单位的现场测试确保其可操作性。
最后,通过全国省级疾控中心绩效考核获取基础数据,遵循“结构-过程-结果”原理,选用横向和纵向比较、规范差距分析、聚类分析、多维度组合评价等方法,明确了省级疾控中心的绩效状况、取得的成绩、存在的问题；通过敏感性分析、回归分析等方法,明确优先改进重点和关键点,并提出改进策略与建议。
主要的资料来源包括文献归纳分析、专家咨询论证、头脑风暴法、机构预试验、测试单位现场测试、全国32个省级疾控中心绩效考核基础数据等。参与咨询论证的专家包括卫生部疾病预防控制局相关处室专家、全国部分省(自治区、直辖市)的省级卫生厅(局)疾病控制处负责人、中国疾控中心和30个省(自治区、直辖市)的省级疾控中心的主任、分管主任、办公室主任和业务负责人等；参与预试验的包括北京、河北、山西、辽宁、吉林、江苏、浙江、山东、广西、四川、云南、陕西、青海等13个省级疾控中心；参与现场测试的包括北京、吉林、四川3个省级疾控中心和河北省邯郸市、吉林省延边朝鲜族自治州、四川省成都市、北京市昌平区4个市县级疾控中心。
三、主要研究结果
(一)构建了疾病预防控制绩效考核指标体系与综合评价模型
运用科学、公认的方法,形成了“思路符合逻辑、方法得到公认、过程可以操作、结果容易考核”的疾病预防控制绩效考核研究的思路、步骤和具体方法学,并形成了以下两方面研究成果：
1、建立了疾病预防控制绩效考核指标体系。(1)在系统论和卫生系统宏观模型原理的指引下,结合疾病预防控制工作的特性,运用专家头脑风暴法和焦点小组讨论等方式,构建了疾病预防控制绩效考核框架,包括社会环境、工作基础、工作过程、系统结果和健康结果等五个维度；在此基础上,借鉴层次结构分析理论和卫生系统宏观模型“子模—概念／维度—指标”的思路进行逐层分解,形成模块化、层次化、条理化的绩效考核框架；(2)围绕着上述框架,通过“系统收集指标-筛选指标-界定论证指标”等步骤,经过多轮次的专家咨询与论证分析、机构预试验、网上公开与测试单位意见征询,建立了疾病预防控制绩效考核指标体系,对每个指标的界定与解释、依据、计算方法、基本数据的定义与解释、资料收集来源与方法等进行了明确界定。机构绩效考核指标体系包括疾病预防与控制、突发公共卫生事件应急处置、信息管理、健康危害因素监测与控制、实验室检验、健康教育与健康促进、技术指导与应用研究、综合指标等8个类别,其中省级机构包括34个项目77个指标,市级机构包括35个项目104个指标,县级机构包括35个项目101个指标。
2、实现了疾病预防控制绩效的综合评价。根据模糊综合评价法：首先运用层次分析法,结合对全国30个省(自治区、直辖市)及新疆生产建设兵团卫生厅(局)业务专家的咨询与论证,确定了考核指标体系的组合权重；其次,通过焦点小组讨论和头脑风暴法等方法,结合各考核指标值的分布状况,明确了每个考核指标不同量级(极差、差、较差、中、较好和好)的评分标准；在获取考核指标原始数据后,进行模糊判断构建隶属函数和评判矩阵,通过权重与评判矩阵的运算获得绩效综合得分,最终构建了绩效综合评价模型。
(二)研制了疾病预防控制绩效考核的实施流程与方法
在总结国内外研究成果和实践经验基础上,明确了疾病预防控制绩效考核的实施流程应包括准备阶段(制定方案、落实组织、收集资料)、实施阶段(数据填报、质量控制、验证核实)、反馈阶段(综合评价、绩效诊断、持续改进)等环节。
为了确保绩效考核实施的科学性,针对上述流程中的关键环节和节点,重点明确了全面收集数据、有效控制数据质量、科学绩效诊断的操作思路、步骤和具体方法：(1)实现考核数据的全面收集：构建包括4个模块、26个类别、50个子类别、3000多个指标的绩效考核数据采集表,明确数据收集的范围与途径,并建立了规范的数据收集与填报流程；(2)实现数据质量的有效控制：首先从类型、格式、数据间逻辑、数据界限等4方面对填报数据进行错误校验；其次采用逻辑判断、极值判断、经济判断和纵向比较判断4种方法对指标自评值进行分析,筛选出现场考核需重点关注的指标和机构；最后明确了现场数据资料核实的方法与流程,确保能够准确收集考核数据；(3)实现工作绩效的科学诊断：在获取绩效评价结果的基础上,借鉴横向和纵向比较、规范差距分析等思路和方法,形成了从“总体—类别/维度—指标”、横向、纵向等多维度交叉组合分析的思路,诊断明确各层面(总体、类别、指标)工作开展中的不足之处、定量明确差距的大小,并设计了《疾病预防控制绩效考核诊断报告》模板。
(三)形成了疾病预防控制绩效考核管理软件的设计思路
首先是管理软件的框架设计和需求分析。根据疾病预防控制绩效考核的实施流程,结合专家焦点组访谈,明确了管理软件的总体框架应包括信息填报、审核判断、综合评价、信息查询和系统管理5个功能模块；借鉴业务流程管理理念,明确各环节之间的逻辑关系以及数据信息的流向；明确管理软件应设置的用户类型,包括填报用户约6800个、审核员约450个、管理员约450个；在此基础上,进一步将5个功能模块细化。
其次是管理软件的数据结构分析。以信息流程为导向,演化并明确管理软件主要涉及到的结果数据库及其结构与内容,并实现用户角色与不同数据库之间的动态分配。
第三是具体功能模块设计。重点明确前期研究中绩效考核数据采集、数据错误校验、重点关注指标和机构的筛选、绩效综合评价模型等过程的“软件化”思路,并解析为对应的运算数据库、设计相应的软件流程,实现信息填报、数据错误校验、重点关注指标和机构判断、绩效指标值运算、绩效指标得分运算等主要功能模块的设计。
最后是管理软件的开发与测试。依据形成的软件设计思路,由本研究的合作单位完成疾病预防控制绩效考核管理软件的开发；通过现场测试对软件的稳定性、各主要功能模块和操作流程进行不断的完善,确保软件设计的可操作性和可行性。
通过设计与开发疾病预防控制绩效考核管理软件,为绩效考核的推广提供了数据收集、数据分析、结果评价与利用的统一、便捷的操作平台,确保实施的可操作性。
(四)省级疾病预防控制中心的绩效评价与改进策略
1、总体绩效状况
2009年全国32个省级疾控中心平均绩效得分为83.2分,平均完成度为82.1%。
2、取得的成绩
(1)疾病预防控制工作筹资机制逐步完善。省级财政加大投入,2009年省级疾控中心职工人均财政投入34.50万元,比2005年增长199.7%,职工人均人员经费和人均公用经费分别为5.42万元和2.70万元,比2005年分别增长79.5%和78.4%,每服务人口人均防治专项经费2.23元,比2005年增长283.7%,呈现出对业务专项经费投入的侧重；技术服务收入比重不断下降,2009年省级疾控中心技术服务收入所占比重为27.4%,比2005年下降33.2%,财政拨款占机构总收入的比重为67.2%,比2005年增加23.3%。
(2)专业技术队伍建设得到加强。2009年省级疾控中心人力综合素质得分平均为7.50；本科以上学历比例占57.9%,高级职称比例占26.6%,与2005年相比人力结构明显优化。
(3)机构工作条件得到改善。2009年省级疾控中心职工人均建筑面积66.8平方米,实验室面积比例为41.8%,A类设备配置率为78.6%,分别较2005年增长5.0%、34.8%和31.4%。
(4)重大疾病防控成效显著。传染病防控能力明显提高,暴发疫情规范处置指数平均为0.932(满分为1),传染病监测完成率和病媒生物监测完成率分别达到91.3%和99.8%；免疫规划工作规范有序,全国规范接种单位覆盖率达到89.8%,冷链运转完好率94.4%,脊灰、乙肝、百白破、卡介苗、麻疹5种基础疫苗接种率基本达到国家免疫规划要求；乙肝预防控制工作成效显著,新生儿首剂乙肝疫苗及时接种率达标县(区)比例为91.3%,五岁以下儿童表面抗原携带率下降到0.7%；结核病预防控制策略广泛实施,各省以县(区)为单位均已实现了DOTS策略全覆盖,29省新涂阳病人发现率超过了70%；血吸虫病控制规划目标如期实现,疫区省份的人群感染率和钉螺感染率控制均达到了目标要求；地方病防治工作稳步推进,碘盐监测达标的县(区)比例达98.7%,氟、砷中毒病区改水工程监测覆盖达标的病区比例达96.6%。
(5)疾病预防控制体系能力建设得到加强。突发公共卫生事件应急处置及时规范,组织建设、制度建设、职能分工、技术方案制订等基本满足突发事件处置的要求,预案体系完整、原因查明和规范处置3类指标达标省个数分别为28个、31个、28个；信息管理得到加强,数据报告、疾病相关信息检索、数据分析、发病趋势预测4类指标的达标省个数分别为28个、25个、27个、22个,信息利用率高达97.6%；食品安全和饮用水监测工作逐步引起重视,食品污染监测率、生活饮用水监测率2项指标的达标省分别达到了31个、24个；实验室检验能力稳步提升,实验室A类检验项目开展率达到84.3%,实验室安全管理达标率100%,实验室质控覆盖率为85.6%；健康教育与健康促进工作得到加强,重点卫生宣传活动工作的平均完成度为97.8%,目标人群重点卫生防病知识知晓率平均为73.6%,行为干预指数平均为0.916(满分为1)；技术指导与培训得到加强,现场专业技术人员下基层指导天数平均为25.0天,对基层机构工作指导覆盖率平均达97.7%,“关口前移、重心下沉”的工作理念正在省级疾控中心形成。
(6)疾病预防控制工作得到普遍认可。单位职工、社会公众和相关部门对疾病预防控制工作的满意度分别为98.6%、98.6%、96.5%。
3、存在的问题
(1)疾病预防控制投入机制仍待健全。财政投入增长仍滞后于社会经济增长,省级疾病预防控制工作的财政投入占同级财政经常性支出比例为0.16%,仅有16个省财政投入的增长幅度要高于同级财政政经常性支出；经常性维持经费投入仍显不足,省级疾控中心职工人均人员费和公用经费分别增长79.5%和78.4%,低于同期地方财政支出增长(129.9%)和社会经济增长(80.2%)；机构自筹经费的比例仍然较高,机构总收入来源中平均仍有27.4%为技术服务收入,经常性维持经费拨款占机构基本支出的比例仅为59.3%。
(2)人力资源总量不足、结构不够合理。人员数量总体呈下降趋势,2009年省级疾控中心平均在岗人员数量为374人,比2005年下降了5.6%,且较平均编制数(418人)少44人,每10万服务人口配备的疾病预防控制人员为0.88人,比2005年减少3.13%；人员结构仍然不合理,省级疾控中心本科以上学历比例、高级职称比例达标的省仅分别仅为7个和11个；部分专业人员配置不合理,从事健康危害因素监测和慢性病防制的人员分别仅占10.6%和2.5%。
(3)房屋设施配置远不能适应工作需要。省级疾控中心人均建筑面积和实验室面积比例均达到《建设标准》要求的仅有13个,A类设备配置率达标的仅有10个；仅有19个省级疾控中心检测设备正常运行率在95%以上
(4)重大疾病和慢性病预防控制仍需加强。艾滋病自愿咨询检测点设置不足,全国县(区)艾滋病自愿咨询检测点覆盖达标的比例为72.6%；结核病人系统管理工作有待加强,登记结核病人中系统管理率为85.6%,距标准仍差10个百分点；寄生虫病预防控制工作仍有差距,钩、蛔、鞭、蛲等4种常见土源性线虫病监测和防制工作的平均完成度仅为55.2%；慢性病预防控制工作进展缓慢,县级以上医疗机构中开展死因报告的覆盖率平均仅为81.1%,居民建档达标县(区)的比例仅为30.6%,慢性病人规范管理达标县(区)的比例仅为41.7%。
(5)疾病预防控制能力建设尚不适应发展需求。应急物品储备尚不完备,省级疾控中心传染病控制、中毒处置、队伍保障3类应急物品储备齐全率平均为68.6%,仅有1个省达标；信息网络建设亟待完善,从系统配置、工作环境、管理规范、运行情况和指导下级等5个方面评价网络建设情况,只有15个省达标；健康危害因素监测工作薄弱,健康危害因素监测与干预工作的平均完成度仅为75.7%,人群膳食指导项目达标县(区)比例仅为35.8%；实验室检验能力仍需提高,仅有20个省级疾控中心达到A类检验项目开展率85%的绩效考核标准；人员培训、继续教育仍需加强,平均岗位技能培训率为84.6%,继续医学教育合格率平均为85.8%,均未达到考核要求；应用研究能力亟待提高,专业人员人均发表论文0.32篇/人,科研立项和科研成果获奖工作的平均完成度分别仅为67.7%和65.9%,远未得到绩效考核要求。
4、改进策略与建议
(1)建立健全适宜、稳定长效的投入机制。从根本上建立对疾病预防控制工作的稳定长效投入机制,确保经常性维持经费与财政支出增长水平或GDP增长同步。
(2)打造规模适度、结构优化、素质优良的人才队伍。加强人才队伍建设管理,尽快核定疾控中心人员编制,建立疾病预防控制机构人员准入制度,优化人员结构,合理配置人员,确保人才质量。
(3)进一步加强重大疾病和慢性病防制。健全艾滋病免费检测和咨询网络,规范结核病患者管理,加强寄生虫病防治和监测工作,提高居民健康档案覆盖率,加强对慢性病病人的规范管理。
(4)加强疾病预防控制能力建设。改善机构设施设备条件,构建疾病预防控制信息共享平台,提高信息资源的利用率,健全覆盖省、市、县三级的健康危害因素监测网络,完善岗位培训制度,提高科技创新能力。
四、研究中的主要探索和创新
1、运用系统论、卫生系统宏观模型、模糊综合评价法、业务流程管理理念、层次分析法、层次结构分析理论、规范差距分析、定性定量多重论证等方法,形成了一整套疾病预防控制绩效考核的思路、步骤和具体方法学,经预试验、测试单位现场测试表明科学、可行,具有可操作性,并被卫生部直接采纳运用,为疾病预防控制绩效考核的开展和推广提供科学基础和技术支撑。
2、基于系统论、卫生系统宏观模型和层次结构分析理论等方法,通过构建考核框架-系统收集指标-筛选指标-界定论证指标等步骤,经过“理论-预实验-理论-实践”反复论证的过程,构建了疾病预防控制绩效考核指标体系。被卫生部采纳,并在全国推广运用。
3、基于模糊综合评价法以及层次分析法,构建了疾病预防控制体系绩效的综合评价模型,解决了因为体系的复杂性如何准确把握信息多样性的问题。被卫生部采纳,运用于医改12大重点工作之一——疾病预防控制体系绩效考核的实践中。
4、为了解决绩效考核实施中操作的复杂性和考核结果欠公正等问题,遵循业务流程管理理念和信息系统设计的流程,研制了疾病预防控制绩效考核管理软件,为考核提供了统一、便捷的操作平台,被卫生部采纳并直接运用于全国疾病预防控制绩效考核的实践中。
5、借鉴横向和纵向比较、规范差距分析等思路和方法,本研究形成明确了从“总体—类别／维度—指标”、横向、纵向等多维度交叉组合分析的绩效诊断思路,并首次形成了《疾病预防控制绩效考核诊断报告》标准化模板,为科学诊断绩效并逐步走向绩效改进奠定了基础。
6、遵循“结构-过程-结果”原理,运用规范差距分析、横向与纵向比较、聚类分析等方法,首次全面评价了省级疾控中心的绩效状况、取得的成绩、存在的问题,评价内容涵盖了资源配置、能力建设、职责落实和外部评价等方面；通过敏感性分析、回归分析等方法,明确了体系建设的关键点和控制重点,提出了资源配置、能力建设、职责落实等方面的优化策略与建议。
Objectives and Significances
1. Performance evaluation is required for government to fulfill its duty in disease control and prevention system
Public service implementation is the symbol of a modern government, and how to increase its quality has now become the core of the governmental management. Performance evaluation can promote the government to take up its public service responsibilities fairly and efficiently.
Disease control and prevention system (DCPS) has provided the pure public service to the society, and it is one of the government's major public service tasks. Nevertheless, in China, public service providing in DCPS is still lack of efficiency. The new medical system reform plan (2009) clearly declared that it was important to strengthen performance evaluation and improve efficiency and quality in DCPS to promote equalization of public health service. Hence, it is urgent to establish the DCPS, in premium quality and high efficiency, with scientific performance evaluation and management in the new era.
2. DCPS's appraisal presentation needs a breakthrough in the field of research and practice
Performance evaluation is a quantified analysis of working process, results and efficiency heading to the completion. It was oriented in the beginning of the 20th century; in the fifties, the United States, United Kingdom, and some other countries were using working evaluation in the management of the governmental operations and public service departments. In the health field, World Health Organization (WHO), in year of 2000, first declared three standard appraisal targets:improvement of health conditions, people's responsiveness and fairness of health care financing. Also, the primary health care guideline and the concept of healthy city have been a great influence around the globe. Those ideas helped to stimulate the perfection of health scheme. However, in China, most of the researches were focused in the field of medical treatment, rather than in public health. Especially DCPS was lack of systematic studies, and few regulations were announced:Only the Ministry of Health promulgated the "National Health and Epidemic Prevention Station evaluation criteria" and implemented the grade assessment around the country in 1996. At the end of the 1990s, following by the health reform, many health and epidemic prevent stations were changed into centers for disease control and prevention (CDC), and their functions have gone through a major shift with greater responsibility; nonetheless, it still lacked of in-depth study of performance evaluation. Therefore, it is a scientific issue to create the evaluation indicators and models, which closely combined DCPS with Chinese characteristics and other countries'experiences and methods.
3. Performance evaluation is an extension of the research of DCPS in China
Starting from 2003, Disease Control and Prevention Bureau of Ministry of Health has prepared a disease control and prevention research group, which focused on the long term development target in series of questions "What should be done? What does it require? How to proceed? And how was it done? ". These series of studies have obtained many supports and inquiries from several government ministries for further decision making. Currently, how to objectively and accurately evaluate the DCPS's performance has been the main topic of the system.
Hence, through the reviews of updated international researches and practices, this research was specifically designed for the needs of the performance evaluation of DCPS in China. It clarified a series of inquiries in performance evaluation:What should be evaluated? How to comprehensively evaluate? How to scientifically and operationally implement the evaluation? What is the result after the practice in provincial institutions?
Materials and Methods
First, the performance evaluation indicator system was established by applying system theory, Macro-Model of Health System, the hierarchical structure analytic theory, expert consulting and field reviewing; the comprehensive evaluation model is constructed, based on the principle of fuzzy comprehensive evaluation, analytic hierarchy process (AHP), focus group discussions and brainstorming. Second, combining inductive analysis of literatures and expert consultations, following the concept of business process management and information systems design process and steps, the implementation procedures and methods in the practice of performance evaluation were developed and the design idea of the management software was formed. Finally, based on the data from 32 provincial CDCs, by using the principle of "structure-process-outcome", crosswise and longitudinal comparison, gap analysis, cluster analysis, sensitivity analysis and regression analysis, the performance status quo of the provincial CDCs were evaluated and some suggestions and improvement strategies were made.
Data-collecting methods included inductive analysis of literatures, expert consultations, focus group discussions, brainstorming, pre-trial, field reviewing and evaluation data collected from 32 provincial CDCs across the country. The experts came from Disease Control and Prevention Bureau of Ministry of Health, the provincial health department (bureau) officers. Institutions involved in pre-trials included 13 provincial CDCs as Beijing, Hebei, Shanxi, Liaoning, Jilin, Jiangsu, Zhejiang, Shandong, Guangxi, Sichuan, Yunnan, Shaanxi, Qinghai. Institutions participating in field reviewing included 3 provincial CDCs(Beijing, Jilin, Sichuan) and 4 municipal/country CDCs(Handan, Hebei; Yanbian, Jilin; Chengdu, Sichuan; Changping, Beijing).
Main Results
1. Establish the performance evaluation indicator system and comprehensive evaluation model of DCPS
Using scientific and accepted methods, this research has developed the research thought, procedure and methodology on the performance evaluation of DCPS as "logical thoughts, acknowledged methodology, operable procedures and accessible results":
By applying system theory, Macro-Model of Health System and the hierarchical structure analytic theory, a evaluation framework has been constructed, including 5 aspects:social environments, working conditions, working processes, system results and health outcomes. On the basis of the framework, through three steps of "collecting indicators-screening indicators-defining indicators", with expert consulting and field reviewing, the performance evaluation indicator system was established. The definition and calculation of each indicator, interpretation of basic data, data collection sources and methods were clearly defined. The indicator system of disease control and prevention institution was made up of 8 categories including disease control and prevention, the disposal of public health emergencies, information management, health hazards monitoring and intervention, laboratory testing, health education and health promotion, technical guidance and applied research and integrated indicators, which included 34 projects and 77 indicators at provincial level,35 projects and 104 indicators at municipal level,35 projects and 101 indicators at county level.
And then, with the guidance of the Analytic Hierarchy Process (AHP), the indicator weights were determined by consulting experts from the provincial health department (bureau) officers across the country. Through focus group discussions and brainstorming, combined with the distribution of indicator values, the evaluation criteria of each indicator was identified. Finally, by obtaining the original data, constructing membership functions and evaluation matrix, calculating the weight with matrix, a comprehensive evaluation model was built to calculate the performance scores, based on the principle of fuzzy comprehensive evaluation.
2. Develop the implementation procedures and methods in the practice of performance evaluation of DCPS
Based on the broad research results and practical experiences, this research developed the implementation procedures in the practice of the evaluation. It should include the three following phases:Preparation (program developing, organization implementation, and data collection), Implementation (data reporting, quality control and validation check), Feedback (comprehensive evaluation, performance diagnosis and continuous improvement).
Moreover, to ensure the scientific implementation of performance evaluation, this research has focused on three key points in the procedures as below:
(1) Broad collections of evaluation data:build performance evaluation questionnaire which included 4 models,26 categories,50 subcategories and more than 3000 indexes; define the scope and route of data collection; establish a standardized data collection and reporting process.
(2) Data quality control:check the data reporting error with data type, format, logic and limit; pick out the key indicators and institutions by means of logic judgment, limitation judgment, economic judgment and longitudinal comparison judgment; clarify the verification methods and processes of the on-site data.
(3) Scientific diagnosis of the performance:based on the crosswise and longitudinal comparison, gap analysis, the multi-dimensional thinking was formed to diagnose the inadequacies in quantitative gaps from "overall-dimensions-indicator", and a standardized template formation of "Diagnostic Report of Disease control and Prevention performance evaluation" was created.
3. Form the design idea of the management software of performance evaluation of DCPS
The first is the framework design and requirements analysis of the management software. Based on the implementation process and focus group interviews, this research has defined the framework of the software which included information reporting, verification & judgments, comprehensive evaluation, information search and system management. With the concept of business process management, the logical relationships between the aspects and the flow of information were clarified. The user types of the software were defined, including 6800 information reporting users,450 assessor users and 450 administration users. And then, this research has formed the structures and contents of main results databases of the software and implemented dynamic allocation between different roles of users and databases. After that, this research focused on the specific function module design such as evaluation data collection, data error check, picking out the key indicators and institutions, computing the values and scores of the indicators. Finally, the management software was developed based on the ideas above and tested through the field testing to ensure its operability and feasibility. In a word, the software provided a unified and convenient operating platform for data collection, data analysis, result evaluation and utilization in the practice of performance evaluation.
4. Performance evaluation and improvement strategies of provincial CDCs
(1) Overall evaluation
In 2009, a grade point of 83.2 and accomplishment of 82.1% in average were obtained from 32 provincial CDCs across the country.
(2) Achievements
Financing mechanisms for CDC's work have gradually improved. In 2009, the average financial input of provincial CDCs was 345 thousand Yuan per capital, an increase of 199.7% over 2005. The personnel and public funding were 54.2 and 27.0 thousand Yuan per capital, increased by 79.5% and 78.4% compared to 2005.The special prevention and control funding for people served was 2.23 Yuan per capital, an increase of 283.7% over 2005.From 2005 to 2009, the proportion of profit-oriented service revenue of total institution revenue has declined to 27.4% by 33.2% and the proportion of financial input has increased to 67.2% by 23.3%.
Professional personnel teams have been strengthened. The average score of the overall human quality was 7.50, the proportion of bachelor degree or above was 57.9%, and the proportion of senior professional titles was 26.6%.
Working conditions have been improved. The floor areas per capita were 66.8 square meters, the proportion of laboratory area of the total institution was 41.8%, and the configuration ratio of Class A device was 78.6%, increased by 5.0%,34.8% and 31.4% respectively over 2005.
The control and prevention of major diseases has achieved remarkable results. The index of regulate disposal of epidemic outbreak was 0.932. The completing rate of communicable disease surveillance and vectors monitoring were respectively 91.3% and 99.8%.The coverage of standardized vaccination unit was 89.8%.The proportion of cold-chain in good operation was 94.4%.Immunization rates of five basic vaccines including polio, hepatitis B, diphtheria-peruses-tetanus (DPT), bacillus calmette-guerin (BCG) and measles have all reached the requirements of national immunization programs. The ratio of counties (districts) that the timely immunization rate of the first dose of hepatitis B vaccine reached the standard was 91.3% and the positive rate of HBsAg within children under 5 years old has decreased to 0.7%. The DOTS strategy has achieved full coverage in all countries and the detection rate of new smear positive case in 29 provinces has reached more than 70%.The Schistosomiasis infection rates of humans and snails in epidemic provinces have under control. The ratio of counties (districts) Iodized salt monitoring reaching the standard was 98.7%. The ratio of endemic fluorosis and arsenism regions that water improvement project monitoring has reached the standard was 96.6%.
The capacity of disease control and prevention has been reinforced. The disposal of public health emergencies was in time and specification. In data reporting, disease-related information retrieval, data analysis, the incidence trend forecasting, the number of provinces reaching the standards were 28,25,27 and 22 respectively. Information utilization ratio was up to 97.6%. The rates of food contamination monitoring and drinking water monitoring have reached the standards in 31 and 24 provinces respectively. The conducting rate of Class A laboratory testing projects was 84.3%, the rate of laboratory safety management was 100%, and the coverage of laboratory quality control was 85.6%. The accomplishment of health promotion activities was 97.8%, the knowledge awareness of key diseases control and prevention in target population was 73.6%, and the index of health behavior intervention was 0.916. The average time for on-site professional staffs guiding works in primary institutions was 25 days per capital, and the coverage was 97.7%.
Disease control and prevention works have been widely recognized. The satisfactions of employees, the public and the relevant departments were 98.6%,98.6% and 96.5%.
(3) Ongoing issues
Financing mechanisms for CDC's work remained undeveloped. The growth of financial investment input was still lagging behind that of socio-economic, maintenance funding was still insufficient and the proportion of self-financing of total institution revenue was still high.
Working forces were insufficient and human resource structure was unreasonable. In 2009, the average number of staffs in the post was 374, compared with a 5.6% decline over 2005. Only 7 provincial CDCs reached the standard in the proportion of bachelor degree or above and 9 reached that of senior professional titles. The proportions of staffs engaged in health risk factors monitoring and chronic disease control were only 10.6% and 2.5%.
Equipment and facilities couldn't meet the needs of working configuration. Only 13 provincial CDCs reached the basic construction standards,10 CDCs'configuration ratio of Class A device reached the requirements, and 19 CDCs'proportions of equipment in normal operation were over 95%.
The control and prevention of major diseases and chronic diseases needed to be strengthened. The ratio of counties (districts) that the coverage of HIV voluntary counseling and testing points reached the standard was 72.6%. Among the registered TB patients, the percentage of patients in system management was 85.6%. The accomplishment of parasitic diseases monitoring and control was only 55.2%. The coverage of medical institutions above the county level carrying out the cause of death reporting was only 81.1%. The ratio of counties (districts) that the work of setting up health records of residents reached the standard was just 30.6%. The ratio of counties (districts) that the management of chronic diseases patients reached the standard was just 41.7%.
The capacity of disease control and prevention was not adapted to the development's needs. Only 15 provincial CDCs reached the network construction standards, and 20 CDCs' conducting rate of Class A laboratory testing projects were over 85%.The average rate of emergency supplies reserves was 68.6%, only 1 provincial CDC reached the standard. The accomplishment of health hazards monitoring and intervention was 75.5%, and the ratio of counties (districts) carrying out the projects of dietary guidance was just 35.8%. The average rate of job skills training was 84.6%, and the passing rate of continuing medical education was 85.8%. The average papers published by professionals were 0.32 per capital, and the accomplishment of research applying and research award-winning were only 67.7% and 65.9% respectively.
(4) Strategies and recommendations
In the future, the provincial CDCs should pay more attention:1) To establish an appropriated, long-term and stable financing mechanism.2) To create a quality scaled, optimize structured and qualified personnel team.3) To increase the power of control and prevention in major and chronic diseases.4) To reinforce the capability of DCPS.
Explorations and Innovations
This research has developed the thought, procedure and methodology of the performance evaluation by applying system theory, Macro-Model of Health System, the hierarchical structure analytic theory, the principle of fuzzy comprehensive evaluation, AHP, focus group discussions and brainstorming. And by using the methodology, the research has explored the indicator system and comprehensive evaluation model of DCPS. All the above provided a scientific basis and technological support for the performance evaluation of DCPS, and were adopted by the Ministry of Health and put into practice across the country.
In order to solve the complexity and unfairness issues in the process of performance evaluation, this research has developed the management software by using the concept of business process management and information systems design process, which provided a unified and convenient operating platform to ensure the practice of performance evaluation. The software was also adopted by the Ministry of Health and widely used in all levels of CDC throughout the nation now.
Moreover, by using the principle of "structure-process-outcome", crosswise and longitudinal comparison, gap analysis, cluster analysis, sensitivity analysis and regression analysis, this research has created the idea of scientific diagnosis of the performance and a standardized template formation of "Diagnostic Report of Disease control and Prevention performance evaluation". Also, it was the first time to comprehensively evaluate the performance status quo of the provincial CDCs, find out the key control points to promote the performance and finally make some suggestions and improvement strategies in resource distribution, building capability and duty responsibility.
(一)绩效考核是政府履行职能、完善疾病预防控制体系的需要
履行公共服务职能是现代政府的显著特征,提高公共服务绩效亦成为现代政府管理的核心。加快政府绩效考核,是保证政府公正、高效地履行职能的保障。疾病预防控制体系服务的对象是社会公众,提供的是纯公共服务或准公共服务。作为政府公共服务的重要内容之一,其绩效状况自然成为政府与社会关注的重点,也应体现在政府绩效考核的范围之中。然而,现阶段我国疾病预防控制机构公共产品的提供效率并不容乐观,“重有偿服务轻无偿服务”现象突出,公共职能缺位、工作效率低下问题严重。2009年,中共中央、国务院颁发的《关于深化医药卫生体制改革的意见》中明确指出,公共卫生体系需要“加强绩效考核,提高服务效率和质量”,促进公共卫生服务的均等化。如何科学进行疾病预防控制工作绩效考核与管理,切实提高体系提供优质和高效的公共服务能力,成为新时期继续完善疾病预防控制体系建设的需要。
(二)绩效考核在疾病预防控制领域的研究与实践需要突破
绩效考核是指在实现目标或完成职能的过程中,依据可量化的指标对工作过程、结果、效率等各方面进行的评价。它起源于20世纪初的企业管理；20世纪50年代开始,美国、英国等国家先后将绩效管理的理念运用到政府及其公共部门。在卫生领域,世界卫生组织2000年第一次提出了三项总体目标的绩效考核指标：健康状况的改进度、人群期望的反应性和卫生筹资的公平性；初级卫生保健、健康城市等概念、目标和指标的提出也在世界各国间产生了重大的影响,促进了卫生系统绩效的提高；而在我国,卫生系统开展的诸多绩效考核研究和实践主要集中于医疗领域,而对于公共卫生领域,尤其是疾病预防控制体系的绩效考核工作很少：仅卫生部颁布了《全国卫生防疫站等级评审管理办法》(试点方案)和《全国卫生防疫站评审标准》,并于1996年开始对全国卫生防疫站实行等级评审。20世纪90年代后期,伴随着卫生监督与疾病预防控制体制改革的推进,卫生防疫站更名为疾病预防控制中心(以下简称疾控中心),其职能也进行了较大调整,如何考核其工作绩效,尚缺乏深入而系统的研究。因此,如何集成国内外其他领域成熟的理论与方法,紧密结合我国疾病预防控制体系的特点,研制系统评价体系绩效的指标体系及综合评价模型,并将其付诸实践是一个科学难题。
(三)绩效考核是疾病预防控制体系建设研究的延续
2003年始,卫生部疾病控制局筹建了疾病预防控制体系建设研究课题组,以体系的长远发展为目标,针对疾病预防控制体系“应该做什么?做这些需要什么条件?怎么做?做得如何?”等问题开展了一系列系统研究。该系列研究获得了决策部门的高度重视与支持,目前已完成“做什么?”、“需要什么?”、“怎么做?”的研究工作。现阶段,如何客观、准确地评价与改进我国疾病预防控制工作的绩效,已成为体系建设研究的重要命题。因些，在进行疾病预防控制绩效考核研究与实践中：如何科学设计全面反映疾病预防控制体系工作的考核框架、如何系统收集与筛选考核指标并建立指标体系、如何实现绩效的综合评价、如何确保科学可操作的实施等一系列关键问题亟待解决。
本研究期望在系统了解国内外绩效考核的研究与实践现状,总结可供借鉴的成熟经验和技术的基础上,结合我国疾病预防控制工作的特点,建立疾病预防控制绩效考核指标体系和综合评价模型,并通过构建绩效考核实施的全流程、设计与开发绩效考核管理软件,确保实施的科学性和可操作性；在此基础上,在省级疾控中心全面推广绩效考核,综合评价其绩效状况,并提出改进策略与建议。即明确疾病预防控制体系绩效“应该考核什么”、“如何综合评价”、“如何科学、可操作地实施考核”、“全国省级机构实践检验后结果如何”等一系列问题。
二、材料与方法
本研究首先运用卫生系统宏观模型、系统论和层次结构分析理论等方法构建模块化、层次化、条理化的绩效考核框架；在此基础上,通过“系统收集指标-筛选指标-界定论证指标”等步骤,经过多重论证与分析、机构预试验、网上公开与测试单位意见征询等,建立疾病预防控制绩效考核指标体系；运用模糊综合评价法、层次分析法、专家咨询与论证等方法构建了综合评价模型。
其次,综合运用文献归纳分析和专家咨询法,遵循业务流程管理理念和信息系统设计的流程与步骤,研制了绩效考核的实施流程与方法,形成了管理软件的设计思路,并通过测试单位的现场测试确保其可操作性。
最后,通过全国省级疾控中心绩效考核获取基础数据,遵循“结构-过程-结果”原理,选用横向和纵向比较、规范差距分析、聚类分析、多维度组合评价等方法,明确了省级疾控中心的绩效状况、取得的成绩、存在的问题；通过敏感性分析、回归分析等方法,明确优先改进重点和关键点,并提出改进策略与建议。
主要的资料来源包括文献归纳分析、专家咨询论证、头脑风暴法、机构预试验、测试单位现场测试、全国32个省级疾控中心绩效考核基础数据等。参与咨询论证的专家包括卫生部疾病预防控制局相关处室专家、全国部分省(自治区、直辖市)的省级卫生厅(局)疾病控制处负责人、中国疾控中心和30个省(自治区、直辖市)的省级疾控中心的主任、分管主任、办公室主任和业务负责人等；参与预试验的包括北京、河北、山西、辽宁、吉林、江苏、浙江、山东、广西、四川、云南、陕西、青海等13个省级疾控中心；参与现场测试的包括北京、吉林、四川3个省级疾控中心和河北省邯郸市、吉林省延边朝鲜族自治州、四川省成都市、北京市昌平区4个市县级疾控中心。
三、主要研究结果
(一)构建了疾病预防控制绩效考核指标体系与综合评价模型
运用科学、公认的方法,形成了“思路符合逻辑、方法得到公认、过程可以操作、结果容易考核”的疾病预防控制绩效考核研究的思路、步骤和具体方法学,并形成了以下两方面研究成果：
1、建立了疾病预防控制绩效考核指标体系。(1)在系统论和卫生系统宏观模型原理的指引下,结合疾病预防控制工作的特性,运用专家头脑风暴法和焦点小组讨论等方式,构建了疾病预防控制绩效考核框架,包括社会环境、工作基础、工作过程、系统结果和健康结果等五个维度；在此基础上,借鉴层次结构分析理论和卫生系统宏观模型“子模—概念／维度—指标”的思路进行逐层分解,形成模块化、层次化、条理化的绩效考核框架；(2)围绕着上述框架,通过“系统收集指标-筛选指标-界定论证指标”等步骤,经过多轮次的专家咨询与论证分析、机构预试验、网上公开与测试单位意见征询,建立了疾病预防控制绩效考核指标体系,对每个指标的界定与解释、依据、计算方法、基本数据的定义与解释、资料收集来源与方法等进行了明确界定。机构绩效考核指标体系包括疾病预防与控制、突发公共卫生事件应急处置、信息管理、健康危害因素监测与控制、实验室检验、健康教育与健康促进、技术指导与应用研究、综合指标等8个类别,其中省级机构包括34个项目77个指标,市级机构包括35个项目104个指标,县级机构包括35个项目101个指标。
2、实现了疾病预防控制绩效的综合评价。根据模糊综合评价法：首先运用层次分析法,结合对全国30个省(自治区、直辖市)及新疆生产建设兵团卫生厅(局)业务专家的咨询与论证,确定了考核指标体系的组合权重；其次,通过焦点小组讨论和头脑风暴法等方法,结合各考核指标值的分布状况,明确了每个考核指标不同量级(极差、差、较差、中、较好和好)的评分标准；在获取考核指标原始数据后,进行模糊判断构建隶属函数和评判矩阵,通过权重与评判矩阵的运算获得绩效综合得分,最终构建了绩效综合评价模型。
(二)研制了疾病预防控制绩效考核的实施流程与方法
在总结国内外研究成果和实践经验基础上,明确了疾病预防控制绩效考核的实施流程应包括准备阶段(制定方案、落实组织、收集资料)、实施阶段(数据填报、质量控制、验证核实)、反馈阶段(综合评价、绩效诊断、持续改进)等环节。
为了确保绩效考核实施的科学性,针对上述流程中的关键环节和节点,重点明确了全面收集数据、有效控制数据质量、科学绩效诊断的操作思路、步骤和具体方法：(1)实现考核数据的全面收集：构建包括4个模块、26个类别、50个子类别、3000多个指标的绩效考核数据采集表,明确数据收集的范围与途径,并建立了规范的数据收集与填报流程；(2)实现数据质量的有效控制：首先从类型、格式、数据间逻辑、数据界限等4方面对填报数据进行错误校验；其次采用逻辑判断、极值判断、经济判断和纵向比较判断4种方法对指标自评值进行分析,筛选出现场考核需重点关注的指标和机构；最后明确了现场数据资料核实的方法与流程,确保能够准确收集考核数据；(3)实现工作绩效的科学诊断：在获取绩效评价结果的基础上,借鉴横向和纵向比较、规范差距分析等思路和方法,形成了从“总体—类别/维度—指标”、横向、纵向等多维度交叉组合分析的思路,诊断明确各层面(总体、类别、指标)工作开展中的不足之处、定量明确差距的大小,并设计了《疾病预防控制绩效考核诊断报告》模板。
(三)形成了疾病预防控制绩效考核管理软件的设计思路
首先是管理软件的框架设计和需求分析。根据疾病预防控制绩效考核的实施流程,结合专家焦点组访谈,明确了管理软件的总体框架应包括信息填报、审核判断、综合评价、信息查询和系统管理5个功能模块；借鉴业务流程管理理念,明确各环节之间的逻辑关系以及数据信息的流向；明确管理软件应设置的用户类型,包括填报用户约6800个、审核员约450个、管理员约450个；在此基础上,进一步将5个功能模块细化。
其次是管理软件的数据结构分析。以信息流程为导向,演化并明确管理软件主要涉及到的结果数据库及其结构与内容,并实现用户角色与不同数据库之间的动态分配。
第三是具体功能模块设计。重点明确前期研究中绩效考核数据采集、数据错误校验、重点关注指标和机构的筛选、绩效综合评价模型等过程的“软件化”思路,并解析为对应的运算数据库、设计相应的软件流程,实现信息填报、数据错误校验、重点关注指标和机构判断、绩效指标值运算、绩效指标得分运算等主要功能模块的设计。
最后是管理软件的开发与测试。依据形成的软件设计思路,由本研究的合作单位完成疾病预防控制绩效考核管理软件的开发；通过现场测试对软件的稳定性、各主要功能模块和操作流程进行不断的完善,确保软件设计的可操作性和可行性。
通过设计与开发疾病预防控制绩效考核管理软件,为绩效考核的推广提供了数据收集、数据分析、结果评价与利用的统一、便捷的操作平台,确保实施的可操作性。
(四)省级疾病预防控制中心的绩效评价与改进策略
1、总体绩效状况
2009年全国32个省级疾控中心平均绩效得分为83.2分,平均完成度为82.1%。
2、取得的成绩
(1)疾病预防控制工作筹资机制逐步完善。省级财政加大投入,2009年省级疾控中心职工人均财政投入34.50万元,比2005年增长199.7%,职工人均人员经费和人均公用经费分别为5.42万元和2.70万元,比2005年分别增长79.5%和78.4%,每服务人口人均防治专项经费2.23元,比2005年增长283.7%,呈现出对业务专项经费投入的侧重；技术服务收入比重不断下降,2009年省级疾控中心技术服务收入所占比重为27.4%,比2005年下降33.2%,财政拨款占机构总收入的比重为67.2%,比2005年增加23.3%。
(2)专业技术队伍建设得到加强。2009年省级疾控中心人力综合素质得分平均为7.50；本科以上学历比例占57.9%,高级职称比例占26.6%,与2005年相比人力结构明显优化。
(3)机构工作条件得到改善。2009年省级疾控中心职工人均建筑面积66.8平方米,实验室面积比例为41.8%,A类设备配置率为78.6%,分别较2005年增长5.0%、34.8%和31.4%。
(4)重大疾病防控成效显著。传染病防控能力明显提高,暴发疫情规范处置指数平均为0.932(满分为1),传染病监测完成率和病媒生物监测完成率分别达到91.3%和99.8%；免疫规划工作规范有序,全国规范接种单位覆盖率达到89.8%,冷链运转完好率94.4%,脊灰、乙肝、百白破、卡介苗、麻疹5种基础疫苗接种率基本达到国家免疫规划要求；乙肝预防控制工作成效显著,新生儿首剂乙肝疫苗及时接种率达标县(区)比例为91.3%,五岁以下儿童表面抗原携带率下降到0.7%；结核病预防控制策略广泛实施,各省以县(区)为单位均已实现了DOTS策略全覆盖,29省新涂阳病人发现率超过了70%；血吸虫病控制规划目标如期实现,疫区省份的人群感染率和钉螺感染率控制均达到了目标要求；地方病防治工作稳步推进,碘盐监测达标的县(区)比例达98.7%,氟、砷中毒病区改水工程监测覆盖达标的病区比例达96.6%。
(5)疾病预防控制体系能力建设得到加强。突发公共卫生事件应急处置及时规范,组织建设、制度建设、职能分工、技术方案制订等基本满足突发事件处置的要求,预案体系完整、原因查明和规范处置3类指标达标省个数分别为28个、31个、28个；信息管理得到加强,数据报告、疾病相关信息检索、数据分析、发病趋势预测4类指标的达标省个数分别为28个、25个、27个、22个,信息利用率高达97.6%；食品安全和饮用水监测工作逐步引起重视,食品污染监测率、生活饮用水监测率2项指标的达标省分别达到了31个、24个；实验室检验能力稳步提升,实验室A类检验项目开展率达到84.3%,实验室安全管理达标率100%,实验室质控覆盖率为85.6%；健康教育与健康促进工作得到加强,重点卫生宣传活动工作的平均完成度为97.8%,目标人群重点卫生防病知识知晓率平均为73.6%,行为干预指数平均为0.916(满分为1)；技术指导与培训得到加强,现场专业技术人员下基层指导天数平均为25.0天,对基层机构工作指导覆盖率平均达97.7%,“关口前移、重心下沉”的工作理念正在省级疾控中心形成。
(6)疾病预防控制工作得到普遍认可。单位职工、社会公众和相关部门对疾病预防控制工作的满意度分别为98.6%、98.6%、96.5%。
3、存在的问题
(1)疾病预防控制投入机制仍待健全。财政投入增长仍滞后于社会经济增长,省级疾病预防控制工作的财政投入占同级财政经常性支出比例为0.16%,仅有16个省财政投入的增长幅度要高于同级财政政经常性支出；经常性维持经费投入仍显不足,省级疾控中心职工人均人员费和公用经费分别增长79.5%和78.4%,低于同期地方财政支出增长(129.9%)和社会经济增长(80.2%)；机构自筹经费的比例仍然较高,机构总收入来源中平均仍有27.4%为技术服务收入,经常性维持经费拨款占机构基本支出的比例仅为59.3%。
(2)人力资源总量不足、结构不够合理。人员数量总体呈下降趋势,2009年省级疾控中心平均在岗人员数量为374人,比2005年下降了5.6%,且较平均编制数(418人)少44人,每10万服务人口配备的疾病预防控制人员为0.88人,比2005年减少3.13%；人员结构仍然不合理,省级疾控中心本科以上学历比例、高级职称比例达标的省仅分别仅为7个和11个；部分专业人员配置不合理,从事健康危害因素监测和慢性病防制的人员分别仅占10.6%和2.5%。
(3)房屋设施配置远不能适应工作需要。省级疾控中心人均建筑面积和实验室面积比例均达到《建设标准》要求的仅有13个,A类设备配置率达标的仅有10个；仅有19个省级疾控中心检测设备正常运行率在95%以上
(4)重大疾病和慢性病预防控制仍需加强。艾滋病自愿咨询检测点设置不足,全国县(区)艾滋病自愿咨询检测点覆盖达标的比例为72.6%；结核病人系统管理工作有待加强,登记结核病人中系统管理率为85.6%,距标准仍差10个百分点；寄生虫病预防控制工作仍有差距,钩、蛔、鞭、蛲等4种常见土源性线虫病监测和防制工作的平均完成度仅为55.2%；慢性病预防控制工作进展缓慢,县级以上医疗机构中开展死因报告的覆盖率平均仅为81.1%,居民建档达标县(区)的比例仅为30.6%,慢性病人规范管理达标县(区)的比例仅为41.7%。
(5)疾病预防控制能力建设尚不适应发展需求。应急物品储备尚不完备,省级疾控中心传染病控制、中毒处置、队伍保障3类应急物品储备齐全率平均为68.6%,仅有1个省达标；信息网络建设亟待完善,从系统配置、工作环境、管理规范、运行情况和指导下级等5个方面评价网络建设情况,只有15个省达标；健康危害因素监测工作薄弱,健康危害因素监测与干预工作的平均完成度仅为75.7%,人群膳食指导项目达标县(区)比例仅为35.8%；实验室检验能力仍需提高,仅有20个省级疾控中心达到A类检验项目开展率85%的绩效考核标准；人员培训、继续教育仍需加强,平均岗位技能培训率为84.6%,继续医学教育合格率平均为85.8%,均未达到考核要求；应用研究能力亟待提高,专业人员人均发表论文0.32篇/人,科研立项和科研成果获奖工作的平均完成度分别仅为67.7%和65.9%,远未得到绩效考核要求。
4、改进策略与建议
(1)建立健全适宜、稳定长效的投入机制。从根本上建立对疾病预防控制工作的稳定长效投入机制,确保经常性维持经费与财政支出增长水平或GDP增长同步。
(2)打造规模适度、结构优化、素质优良的人才队伍。加强人才队伍建设管理,尽快核定疾控中心人员编制,建立疾病预防控制机构人员准入制度,优化人员结构,合理配置人员,确保人才质量。
(3)进一步加强重大疾病和慢性病防制。健全艾滋病免费检测和咨询网络,规范结核病患者管理,加强寄生虫病防治和监测工作,提高居民健康档案覆盖率,加强对慢性病病人的规范管理。
(4)加强疾病预防控制能力建设。改善机构设施设备条件,构建疾病预防控制信息共享平台,提高信息资源的利用率,健全覆盖省、市、县三级的健康危害因素监测网络,完善岗位培训制度,提高科技创新能力。
四、研究中的主要探索和创新
1、运用系统论、卫生系统宏观模型、模糊综合评价法、业务流程管理理念、层次分析法、层次结构分析理论、规范差距分析、定性定量多重论证等方法,形成了一整套疾病预防控制绩效考核的思路、步骤和具体方法学,经预试验、测试单位现场测试表明科学、可行,具有可操作性,并被卫生部直接采纳运用,为疾病预防控制绩效考核的开展和推广提供科学基础和技术支撑。
2、基于系统论、卫生系统宏观模型和层次结构分析理论等方法,通过构建考核框架-系统收集指标-筛选指标-界定论证指标等步骤,经过“理论-预实验-理论-实践”反复论证的过程,构建了疾病预防控制绩效考核指标体系。被卫生部采纳,并在全国推广运用。
3、基于模糊综合评价法以及层次分析法,构建了疾病预防控制体系绩效的综合评价模型,解决了因为体系的复杂性如何准确把握信息多样性的问题。被卫生部采纳,运用于医改12大重点工作之一——疾病预防控制体系绩效考核的实践中。
4、为了解决绩效考核实施中操作的复杂性和考核结果欠公正等问题,遵循业务流程管理理念和信息系统设计的流程,研制了疾病预防控制绩效考核管理软件,为考核提供了统一、便捷的操作平台,被卫生部采纳并直接运用于全国疾病预防控制绩效考核的实践中。
5、借鉴横向和纵向比较、规范差距分析等思路和方法,本研究形成明确了从“总体—类别／维度—指标”、横向、纵向等多维度交叉组合分析的绩效诊断思路,并首次形成了《疾病预防控制绩效考核诊断报告》标准化模板,为科学诊断绩效并逐步走向绩效改进奠定了基础。
6、遵循“结构-过程-结果”原理,运用规范差距分析、横向与纵向比较、聚类分析等方法,首次全面评价了省级疾控中心的绩效状况、取得的成绩、存在的问题,评价内容涵盖了资源配置、能力建设、职责落实和外部评价等方面；通过敏感性分析、回归分析等方法,明确了体系建设的关键点和控制重点,提出了资源配置、能力建设、职责落实等方面的优化策略与建议。
Objectives and Significances
1. Performance evaluation is required for government to fulfill its duty in disease control and prevention system
Public service implementation is the symbol of a modern government, and how to increase its quality has now become the core of the governmental management. Performance evaluation can promote the government to take up its public service responsibilities fairly and efficiently.
Disease control and prevention system (DCPS) has provided the pure public service to the society, and it is one of the government's major public service tasks. Nevertheless, in China, public service providing in DCPS is still lack of efficiency. The new medical system reform plan (2009) clearly declared that it was important to strengthen performance evaluation and improve efficiency and quality in DCPS to promote equalization of public health service. Hence, it is urgent to establish the DCPS, in premium quality and high efficiency, with scientific performance evaluation and management in the new era.
2. DCPS's appraisal presentation needs a breakthrough in the field of research and practice
Performance evaluation is a quantified analysis of working process, results and efficiency heading to the completion. It was oriented in the beginning of the 20th century; in the fifties, the United States, United Kingdom, and some other countries were using working evaluation in the management of the governmental operations and public service departments. In the health field, World Health Organization (WHO), in year of 2000, first declared three standard appraisal targets:improvement of health conditions, people's responsiveness and fairness of health care financing. Also, the primary health care guideline and the concept of healthy city have been a great influence around the globe. Those ideas helped to stimulate the perfection of health scheme. However, in China, most of the researches were focused in the field of medical treatment, rather than in public health. Especially DCPS was lack of systematic studies, and few regulations were announced:Only the Ministry of Health promulgated the "National Health and Epidemic Prevention Station evaluation criteria" and implemented the grade assessment around the country in 1996. At the end of the 1990s, following by the health reform, many health and epidemic prevent stations were changed into centers for disease control and prevention (CDC), and their functions have gone through a major shift with greater responsibility; nonetheless, it still lacked of in-depth study of performance evaluation. Therefore, it is a scientific issue to create the evaluation indicators and models, which closely combined DCPS with Chinese characteristics and other countries'experiences and methods.
3. Performance evaluation is an extension of the research of DCPS in China
Starting from 2003, Disease Control and Prevention Bureau of Ministry of Health has prepared a disease control and prevention research group, which focused on the long term development target in series of questions "What should be done? What does it require? How to proceed? And how was it done? ". These series of studies have obtained many supports and inquiries from several government ministries for further decision making. Currently, how to objectively and accurately evaluate the DCPS's performance has been the main topic of the system.
Hence, through the reviews of updated international researches and practices, this research was specifically designed for the needs of the performance evaluation of DCPS in China. It clarified a series of inquiries in performance evaluation:What should be evaluated? How to comprehensively evaluate? How to scientifically and operationally implement the evaluation? What is the result after the practice in provincial institutions?
Materials and Methods
First, the performance evaluation indicator system was established by applying system theory, Macro-Model of Health System, the hierarchical structure analytic theory, expert consulting and field reviewing; the comprehensive evaluation model is constructed, based on the principle of fuzzy comprehensive evaluation, analytic hierarchy process (AHP), focus group discussions and brainstorming. Second, combining inductive analysis of literatures and expert consultations, following the concept of business process management and information systems design process and steps, the implementation procedures and methods in the practice of performance evaluation were developed and the design idea of the management software was formed. Finally, based on the data from 32 provincial CDCs, by using the principle of "structure-process-outcome", crosswise and longitudinal comparison, gap analysis, cluster analysis, sensitivity analysis and regression analysis, the performance status quo of the provincial CDCs were evaluated and some suggestions and improvement strategies were made.
Data-collecting methods included inductive analysis of literatures, expert consultations, focus group discussions, brainstorming, pre-trial, field reviewing and evaluation data collected from 32 provincial CDCs across the country. The experts came from Disease Control and Prevention Bureau of Ministry of Health, the provincial health department (bureau) officers. Institutions involved in pre-trials included 13 provincial CDCs as Beijing, Hebei, Shanxi, Liaoning, Jilin, Jiangsu, Zhejiang, Shandong, Guangxi, Sichuan, Yunnan, Shaanxi, Qinghai. Institutions participating in field reviewing included 3 provincial CDCs(Beijing, Jilin, Sichuan) and 4 municipal/country CDCs(Handan, Hebei; Yanbian, Jilin; Chengdu, Sichuan; Changping, Beijing).
Main Results
1. Establish the performance evaluation indicator system and comprehensive evaluation model of DCPS
Using scientific and accepted methods, this research has developed the research thought, procedure and methodology on the performance evaluation of DCPS as "logical thoughts, acknowledged methodology, operable procedures and accessible results":
By applying system theory, Macro-Model of Health System and the hierarchical structure analytic theory, a evaluation framework has been constructed, including 5 aspects:social environments, working conditions, working processes, system results and health outcomes. On the basis of the framework, through three steps of "collecting indicators-screening indicators-defining indicators", with expert consulting and field reviewing, the performance evaluation indicator system was established. The definition and calculation of each indicator, interpretation of basic data, data collection sources and methods were clearly defined. The indicator system of disease control and prevention institution was made up of 8 categories including disease control and prevention, the disposal of public health emergencies, information management, health hazards monitoring and intervention, laboratory testing, health education and health promotion, technical guidance and applied research and integrated indicators, which included 34 projects and 77 indicators at provincial level,35 projects and 104 indicators at municipal level,35 projects and 101 indicators at county level.
And then, with the guidance of the Analytic Hierarchy Process (AHP), the indicator weights were determined by consulting experts from the provincial health department (bureau) officers across the country. Through focus group discussions and brainstorming, combined with the distribution of indicator values, the evaluation criteria of each indicator was identified. Finally, by obtaining the original data, constructing membership functions and evaluation matrix, calculating the weight with matrix, a comprehensive evaluation model was built to calculate the performance scores, based on the principle of fuzzy comprehensive evaluation.
2. Develop the implementation procedures and methods in the practice of performance evaluation of DCPS
Based on the broad research results and practical experiences, this research developed the implementation procedures in the practice of the evaluation. It should include the three following phases:Preparation (program developing, organization implementation, and data collection), Implementation (data reporting, quality control and validation check), Feedback (comprehensive evaluation, performance diagnosis and continuous improvement).
Moreover, to ensure the scientific implementation of performance evaluation, this research has focused on three key points in the procedures as below:
(1) Broad collections of evaluation data:build performance evaluation questionnaire which included 4 models,26 categories,50 subcategories and more than 3000 indexes; define the scope and route of data collection; establish a standardized data collection and reporting process.
(2) Data quality control:check the data reporting error with data type, format, logic and limit; pick out the key indicators and institutions by means of logic judgment, limitation judgment, economic judgment and longitudinal comparison judgment; clarify the verification methods and processes of the on-site data.
(3) Scientific diagnosis of the performance:based on the crosswise and longitudinal comparison, gap analysis, the multi-dimensional thinking was formed to diagnose the inadequacies in quantitative gaps from "overall-dimensions-indicator", and a standardized template formation of "Diagnostic Report of Disease control and Prevention performance evaluation" was created.
3. Form the design idea of the management software of performance evaluation of DCPS
The first is the framework design and requirements analysis of the management software. Based on the implementation process and focus group interviews, this research has defined the framework of the software which included information reporting, verification & judgments, comprehensive evaluation, information search and system management. With the concept of business process management, the logical relationships between the aspects and the flow of information were clarified. The user types of the software were defined, including 6800 information reporting users,450 assessor users and 450 administration users. And then, this research has formed the structures and contents of main results databases of the software and implemented dynamic allocation between different roles of users and databases. After that, this research focused on the specific function module design such as evaluation data collection, data error check, picking out the key indicators and institutions, computing the values and scores of the indicators. Finally, the management software was developed based on the ideas above and tested through the field testing to ensure its operability and feasibility. In a word, the software provided a unified and convenient operating platform for data collection, data analysis, result evaluation and utilization in the practice of performance evaluation.
4. Performance evaluation and improvement strategies of provincial CDCs
(1) Overall evaluation
In 2009, a grade point of 83.2 and accomplishment of 82.1% in average were obtained from 32 provincial CDCs across the country.
(2) Achievements
Financing mechanisms for CDC's work have gradually improved. In 2009, the average financial input of provincial CDCs was 345 thousand Yuan per capital, an increase of 199.7% over 2005. The personnel and public funding were 54.2 and 27.0 thousand Yuan per capital, increased by 79.5% and 78.4% compared to 2005.The special prevention and control funding for people served was 2.23 Yuan per capital, an increase of 283.7% over 2005.From 2005 to 2009, the proportion of profit-oriented service revenue of total institution revenue has declined to 27.4% by 33.2% and the proportion of financial input has increased to 67.2% by 23.3%.
Professional personnel teams have been strengthened. The average score of the overall human quality was 7.50, the proportion of bachelor degree or above was 57.9%, and the proportion of senior professional titles was 26.6%.
Working conditions have been improved. The floor areas per capita were 66.8 square meters, the proportion of laboratory area of the total institution was 41.8%, and the configuration ratio of Class A device was 78.6%, increased by 5.0%,34.8% and 31.4% respectively over 2005.
The control and prevention of major diseases has achieved remarkable results. The index of regulate disposal of epidemic outbreak was 0.932. The completing rate of communicable disease surveillance and vectors monitoring were respectively 91.3% and 99.8%.The coverage of standardized vaccination unit was 89.8%.The proportion of cold-chain in good operation was 94.4%.Immunization rates of five basic vaccines including polio, hepatitis B, diphtheria-peruses-tetanus (DPT), bacillus calmette-guerin (BCG) and measles have all reached the requirements of national immunization programs. The ratio of counties (districts) that the timely immunization rate of the first dose of hepatitis B vaccine reached the standard was 91.3% and the positive rate of HBsAg within children under 5 years old has decreased to 0.7%. The DOTS strategy has achieved full coverage in all countries and the detection rate of new smear positive case in 29 provinces has reached more than 70%.The Schistosomiasis infection rates of humans and snails in epidemic provinces have under control. The ratio of counties (districts) Iodized salt monitoring reaching the standard was 98.7%. The ratio of endemic fluorosis and arsenism regions that water improvement project monitoring has reached the standard was 96.6%.
The capacity of disease control and prevention has been reinforced. The disposal of public health emergencies was in time and specification. In data reporting, disease-related information retrieval, data analysis, the incidence trend forecasting, the number of provinces reaching the standards were 28,25,27 and 22 respectively. Information utilization ratio was up to 97.6%. The rates of food contamination monitoring and drinking water monitoring have reached the standards in 31 and 24 provinces respectively. The conducting rate of Class A laboratory testing projects was 84.3%, the rate of laboratory safety management was 100%, and the coverage of laboratory quality control was 85.6%. The accomplishment of health promotion activities was 97.8%, the knowledge awareness of key diseases control and prevention in target population was 73.6%, and the index of health behavior intervention was 0.916. The average time for on-site professional staffs guiding works in primary institutions was 25 days per capital, and the coverage was 97.7%.
Disease control and prevention works have been widely recognized. The satisfactions of employees, the public and the relevant departments were 98.6%,98.6% and 96.5%.
(3) Ongoing issues
Financing mechanisms for CDC's work remained undeveloped. The growth of financial investment input was still lagging behind that of socio-economic, maintenance funding was still insufficient and the proportion of self-financing of total institution revenue was still high.
Working forces were insufficient and human resource structure was unreasonable. In 2009, the average number of staffs in the post was 374, compared with a 5.6% decline over 2005. Only 7 provincial CDCs reached the standard in the proportion of bachelor degree or above and 9 reached that of senior professional titles. The proportions of staffs engaged in health risk factors monitoring and chronic disease control were only 10.6% and 2.5%.
Equipment and facilities couldn't meet the needs of working configuration. Only 13 provincial CDCs reached the basic construction standards,10 CDCs'configuration ratio of Class A device reached the requirements, and 19 CDCs'proportions of equipment in normal operation were over 95%.
The control and prevention of major diseases and chronic diseases needed to be strengthened. The ratio of counties (districts) that the coverage of HIV voluntary counseling and testing points reached the standard was 72.6%. Among the registered TB patients, the percentage of patients in system management was 85.6%. The accomplishment of parasitic diseases monitoring and control was only 55.2%. The coverage of medical institutions above the county level carrying out the cause of death reporting was only 81.1%. The ratio of counties (districts) that the work of setting up health records of residents reached the standard was just 30.6%. The ratio of counties (districts) that the management of chronic diseases patients reached the standard was just 41.7%.
The capacity of disease control and prevention was not adapted to the development's needs. Only 15 provincial CDCs reached the network construction standards, and 20 CDCs' conducting rate of Class A laboratory testing projects were over 85%.The average rate of emergency supplies reserves was 68.6%, only 1 provincial CDC reached the standard. The accomplishment of health hazards monitoring and intervention was 75.5%, and the ratio of counties (districts) carrying out the projects of dietary guidance was just 35.8%. The average rate of job skills training was 84.6%, and the passing rate of continuing medical education was 85.8%. The average papers published by professionals were 0.32 per capital, and the accomplishment of research applying and research award-winning were only 67.7% and 65.9% respectively.
(4) Strategies and recommendations
In the future, the provincial CDCs should pay more attention:1) To establish an appropriated, long-term and stable financing mechanism.2) To create a quality scaled, optimize structured and qualified personnel team.3) To increase the power of control and prevention in major and chronic diseases.4) To reinforce the capability of DCPS.
Explorations and Innovations
This research has developed the thought, procedure and methodology of the performance evaluation by applying system theory, Macro-Model of Health System, the hierarchical structure analytic theory, the principle of fuzzy comprehensive evaluation, AHP, focus group discussions and brainstorming. And by using the methodology, the research has explored the indicator system and comprehensive evaluation model of DCPS. All the above provided a scientific basis and technological support for the performance evaluation of DCPS, and were adopted by the Ministry of Health and put into practice across the country.
In order to solve the complexity and unfairness issues in the process of performance evaluation, this research has developed the management software by using the concept of business process management and information systems design process, which provided a unified and convenient operating platform to ensure the practice of performance evaluation. The software was also adopted by the Ministry of Health and widely used in all levels of CDC throughout the nation now.
Moreover, by using the principle of "structure-process-outcome", crosswise and longitudinal comparison, gap analysis, cluster analysis, sensitivity analysis and regression analysis, this research has created the idea of scientific diagnosis of the performance and a standardized template formation of "Diagnostic Report of Disease control and Prevention performance evaluation". Also, it was the first time to comprehensively evaluate the performance status quo of the provincial CDCs, find out the key control points to promote the performance and finally make some suggestions and improvement strategies in resource distribution, building capability and duty responsibility.
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