规制对孕产保健服务公平性影响的案例研究

发布时间：2018-05-30 03:41

本文选题：孕产保健 + 规制　；参考：《复旦大学》2012年博士论文

【摘要】：一、研究背景健康公平是让所有社会成员均有机会达到尽可能高的健康水平,要实现这一目标,需要有良好的卫生服务系统,保证健康权作为人的一项基本权利,不受到经济水平、外部环境等的影响。2000年世界卫生组织将卫生服务公平性列为卫生系统绩效评价的重要指标,此后各国围绕健康和卫生服务公平性开展了广泛研究,来自妇幼保健服务领域的研究表明,经济发展水平所导致孕产保健服务利用不公平,是低收入、中等收入和高收入国家之间孕产妇死亡率形成巨大反差的原因之一。我国学者对孕产妇健康和服务利用公平性的研究虽有限,但结果均提示,我国城乡之间、东中西部地区之间孕产保健服务利用和孕产妇健康存有不公平,而城市流动人口与户籍人口在孕产保健服务利用和孕产妇死亡上所表现出来的明显差距,已成为城市孕产保健服务系统面临的挑战。经济因素和卫生服务系统是影响我国卫生服务公平性的两个主要因素。社会经济发展引起贫富差距增加,影响健康的决定因素变得愈加不公平；而卫生服务改革的市场化倾向,以及政府在矫正市场失灵、改善卫生服务尤其是公共卫生服务公平性上的职能缺位,使得卫生服务公平性进一步下降。规制的源起之一,是希望达到公平、实现权力等社会目标,世界卫生组织明确提出：规制是政府和卫生系统的责任,是促进卫生服务公平性的重要工具,通过政府制定各种规则对卫生服务市场进行适度规制,规制相关参与者的行为以确保其履行职责,以强化卫生服务的公平性,保障人人享有健康这项人类的基本权利。因此,寻找改善我国孕产保健服务公平性的途径,将不可避免的涉及我国的卫生服务体系和卫生服务规制体系。在缩小孕产保健服务利用的公平性上,我国政府已采取了一系列的措施,近十年来全国住院分娩服务利用公平性的显著改善,揭示了有效的政府规制对促使改善公平的政策达到预期目标的重要作用。目前,我国对卫生服务公平性的研究中,针对孕产保健服务公平性的研究相对较少,且尚未见到从政府规制的角度深入分析孕产保健服务规制对公平性影响的实证研究。本研究正是致力于填补这一空白,以促进孕产保健服务规制发挥更大的作用,推动孕产妇健康公平性的不断改善。二、研究目的本研究在描述与分析我国孕产保健服务的公平性现况的基础上,利用规制理论和规制效果评价框架,以上海某区紧急产科保健服务为实证案例,分析有效的政府规制如何影响健康公平性,探讨规制的要素对规制效果的影响,并以此为借鉴,在了解该区基本孕产保健服务利用公平性及其相关规制的基础上,以良好治理和有效政府规制为理论框架,提出进一步改善孕产保健公平性的政策建议。三、研究内容与研究方法 1、以中国卫生统计年鉴为二次数据来源,采用公平性的评价理论和分析方法,分析2000-2009全国孕产妇健康公平性以及2005-2009全国孕产保健服务利用和资源配置的公平性,以期对我国孕产保健服务的公平性现况做出较为全面的描述,并通过分析全国住院分娩服务利用公平性显著提高的原因,初步探讨有效的政府规制对落实公平性政策、改善孕产保健服务利用公平性的作用。 2、采用定性研究的方法,以上海市某中心城区为研究现场,选择与上海市紧急产科保健服务相关的4类参与者共22人进行关键知情人半结构式访谈,结合使用文献分析法,评价紧急产科保健服务规制对改善上海市户籍和非户籍孕产妇健康公平性的影响,并分析规制的环境、过程、参与者和机制对紧急产科保健规制效果的影响。 3、采用该区2004-2011年妇幼卫生报表作为二次数据来源,分析户籍和非户籍孕产妇对基本孕产保健服务利用的公平性,并通过现场调查的方法在全区13个社区卫生服务中心对436名产后6个月内的妇女进行问卷调查,进一步分析2011年该区户籍和非户籍孕产妇对保健服务利用的公平性和影响因素,通过定性研究的关键知情人半结构式访谈,了解通过规制进一步改善孕产保健服务公平性的方向和关键环节,并以良好治理和有效规制为理论框架,提出进一步改善公平性的政策建议。四、主要研究结果 1.2000-2009年的10年间,全国的MMR持续下降,并以西部地区下降趋势最显著,2003-2009年间,东部和中部地区的MMR分别下降了44%和52%,而西部地区的MMR下降了62%。以极差法衡量2000-2009年全国及不同地区孕产妇健康公平性,东部与中部地区的孕产妇死亡差距变化不大,10年间MMR的率差约维持在10-20/10万之间,虽然东部和西部地区的孕产妇死亡率差距最大,但这种差距缩小的趋势却最明显,由2003年的65.43/10万缩小至2009年的27.80/10万。以集中指数反应健康公平性,无论是省际还是地区间,2000-2009年的集中指数全为负值,表明孕产妇死亡集中于人均GDP较低的省份或地区；10年间,省际和地区间的集中指数均在-0.2～-0.3之间波动,与2000年相比,2009年的集中指数绝对值变化极小,提示10年里全国孕产妇的健康公平性未得到明显的改善。 2.2005-2009全国产前检查、住院分娩、产后访视和系统管理四类孕产保健服务的集中指数均大于零,表明服务利用存有不公平,按人均GDP衡量,经济水平越低的省市,孕产妇对保健服务利用越差。四类孕产保健服务中,系统管理的集中指数绝对值最大,表明公平性最低；产前检查的集中指数绝对值最小,公平性最好。2005-2009年,除住院分娩服务外,其他三类服务的集中指数变化很小,公平性未见明显改善,而住院分娩服务利用的集中指数由2005年的0.0593迅速下降至2009年的0.0177,表明公平性持续且明显改善,这离不开”降消”项目在这一地区所取得的成功,也表明了有力的政府规制对改善公平性的作用。 3.上海市孕产妇健康不公平,主要体现在流动和户籍孕产妇死亡的健康公平性上,10年间,非户籍孕产妇是全市孕产妇死亡的主流,加强危重孕产妇转诊、会诊抢救,是降低MMR尤其是非户籍孕产妇MMR的主要途径之一。围绕紧急产科保健上海市制定了一系列规制,并以2008年颁布的规制发挥了最为核心的作用,定性研究表明,该规制的出台和执行,有效提高了危重孕产妇抢救成功率并推动了全人群尤其是非户籍孕产妇MMR下降,达到了预期效果,孕产妇的健康不公平缩小,而规制的执行过程也很好的体现了服务提供的公平性。 4.规制产生效果的促成因素包括：规制的目标与内容契合国内外所倡导的母亲安全的政策环境；制定过程中以信息为基础的设计、自上而下行政和技术管理的密切结合、规制执行前必要恰当的解读；孕产妇死亡评审、问责制、考核、惩罚、激励等机制的综合运用,尤其是问责制对相关的参与者所形成的有效监督与约束；各级服务管理者和提供者作为规制主要参与者,其权利和能力保证了规制的有力执行和良好效果。研究同时也表明,规制效果及持续性的阻碍因素包括：财政部门这一关键参与者的缺位,紧急产科保健服务可持续受限；激励机制未能发挥更好的作用影响了执行层面参与者的积极性。 5.对紧急产科保健服务规制的研究所得的另一重要结果是,减少危重孕产妇的发生、进一步缩小健康不公平,仅对紧急产科保健服务进行规制还不够,必须关口前一,重点规制基本孕产保健尤其是产前保健。而目前上海市对基本孕产保健服务所进行的规制主要是2010年出台的围绕孕产妇全覆盖管理的规制,这一规制旨在发动社区支持组织的力量完善社区孕情监测网络,加强全人群尤其是非户籍孕产妇对孕早期建册和系统管理服务利用。 6.以率差和集中指数评价2004-2011年上海市某区户籍和非户籍对6类基本孕产保健服务利用的公平性,早孕建册、规范产检和系统管理三类服务利用不公平最为明显且2004-2009年有扩大趋势,但2010年该区全面推行全覆盖孕产保健服务管理后,早孕建册和系统管理服务利用公平性显著改善：早孕建册的集中指数由2004年的0.1308上升至2009年的0.1746后,于2010年下降0.1034,2011年继续降至0.0594；而系统管理的集中指数由2004年的0.1434逐步升至2009年的0.1804,于2010年开始迅速下降至0.1054,并于2011年继续下降至0.0652,这种明显改善部分反映了全覆盖规制的效果。 7.现场调查共纳入436名研究对象,其中户籍孕产妇238名,非户籍孕产妇168名。分析表明,该区户籍和非户籍孕产妇的学历、职业、家庭人均月收入、医疗保险和生育保险覆盖率具有显著性差异(P0.05),且两类人群对早孕检查、规范产检、产后访视三类基本孕产保健服务利用存在明显差异；以率差衡量,最不公平的是早孕建册服务利用,户籍和非户籍孕产妇早孕建册服务利用的率差为29.4%,率比为1.44,集中指数为0.0816；对8次以上产检服务利用的率差为26.3%,率比为1.41,集中指数为0.1104；产后访视服务利用不公平性最小,率差为22.6%,率比为1.34,集中指数为0.0798。户籍和非户籍孕产妇对其他保健服务如产前筛查、孕妇学校和导乐分娩服务利用也存在明显不公平,并以孕妇学校最为明显,率比为1.6。影响户籍和非户籍孕产妇保健服务利用的主要因素是孕产妇的户籍、学历和生育保险。上海户籍、有生育保险的妇女,更有可能在孕早期建小卡并完成规范(整个孕期≥8次)的产前检查。除户籍因素外,学历水平越高的孕产妇,更有可能寻求和利用产后访视服务。 8.定性研究进一步提示,全覆盖规制对改善该区户籍和非户籍孕产妇在早孕建册和管理服务利用公平性发挥了明显作用,但关键参与者的缺位(财政部门、社区支持组织等)影响了规制的效果及可持续性。五、基于良好治理和有效规制理论进一步改善上海市孕产保健公平性的政策建议 1、进一步改善我国及上海市孕产保健服务的公平性,应重点关注产前保健服务利用的公平性,以项目推动服务的改善并通过政府规制落实为常态,是可行的途径之一。 2、环境因素影响规制的效果。新医改推行的基本公共卫生均等化服务,是改善孕产保健服务公平性的契机,改善孕产保健服务公平性的规制,需要抓住这一良好的环境促成因素,以强化规制效果。 3、改善公平性的孕产保健服务规制,需要在良好治理的框架下,纳入更多参与者并实现以政府为主导的多元共治,推动规制持续发挥作用,对于全覆盖规制,财政和公民社会是两个重要的参与者,应当发挥更大作用。 (1)、财政部门是保障规制顺利执行和持续发挥效果的重要参与者,孕产保健服务的规制不论是设计、管理还是执行,都理应纳入该参与者。 (2)、发挥公民社会的重要力量,为孕产保健服务规制的可持续性提供支持和保障。 4、完善全覆盖孕产保健服务规制的内容,增加对孕妇学校、规范产检服务的规制内容,从多个环节推动上海市孕产保健服务利用的公平性。 5、改善全覆盖孕产保健服务规制的可持续性,需要加强规制制定过程的程序性和规范化,并通过对规制的解读增强规制的可行性和可操作性,以改善执行的效果。 6、发挥全覆盖规制改善基本孕产保健服务公平性的作用,需要综合运用激励、惩罚、考核等多种机制,保证相关参与者充分履行职责,在财政部门纳入规制过程的前提下,应更多的采用经济性激励机制以确保规制执行者更加主动积极的参与规制的过程,实现规制的目标。
[Abstract]:First, research background
Health equity is an opportunity for all members of society to achieve the highest possible level of health. In order to achieve this goal, a good health service system is needed to ensure the right to health as a basic human right, without the influence of the economic level, the external environment and so on. In.2000, the health service fairness is listed as the health department in the WHO. The important index of the performance evaluation has been carried out in all countries. The research from the field of maternal and child health service shows that the economic development level leads to the unfair utilization of maternal and health services, which is the original difference between the low income, the middle income and the high income countries. One of the reasons is that the research on the fairness of maternal health and service utilization is limited, but the results indicate that the health service utilization of pregnant and maternity and the health of pregnant and lying in women between the urban and rural areas in China are not fair, and the urban floating population and the household registration population are shown in the use of pregnant and maternal health services and maternal death. The obvious gap has become a challenge for the urban maternity and health care service system.
Economic factors and health service systems are the two main factors that affect the fairness of health services in China. The social and economic development causes the gap between the rich and the poor, and the determinants of health have become more unfair; the market-oriented tendency of health service reform, and the government's correction of the market failure, and the improvement of health services, especially public health. The lack of function on the fairness of service makes the fairness of health service decline further. One of the origins of the regulation is to achieve fairness and realize the social goals of power. The WHO clearly suggests that regulation is the responsibility of the government and the health system and is an important tool to promote the fairness of health services, and the government has formulated various rules through the government. It is necessary to regulate the health service market moderately, to regulate the behavior of the participants to ensure the performance of their duties, to strengthen the fairness of health services and to ensure the basic human rights of everyone. Therefore, the ways to improve the fairness of the health service in China will inevitably involve the health service system in our country and the health service system in our country. The health service regulation system has taken a series of measures to reduce the fairness of the utilization of maternity care services. In the past ten years, a significant improvement in the fairness of hospital delivery service in the country has been improved, which reveals the important role of effective government regulation to the expected goal of improving the policy of improving equity.
At present, in the study of health service fairness in China, the research on the fairness of maternal health service is relatively small, and the empirical study on the effect of maternal health care regulation on fairness has not yet been seen from the point of view of government regulation. This study is devoted to filling this gap in order to promote the regulation of maternal health service. Great role in promoting the continuous improvement of maternal health equity.
Two, the purpose of the study
On the basis of describing and analyzing the current status of the fairness of health care service in China, this paper uses the regulation theory and the framework of regulation effect evaluation, taking emergency obstetric care service in a district of Shanghai as an empirical case, and analyzes how effective government regulation affects health equity, and discusses the influence of regulatory factors on the effect of regulation. On the basis of understanding the equity and related regulations of the use of basic maternity care services in the area, the policy suggestions for further improvement of the health equity of pregnant women are put forward with the theoretical framework of good governance and effective government regulation.
Three, research content and research methods
1, based on the two data sources of China's Health Statistics Yearbook, the fairness of the health of pregnant women in 2000-2009 countries and the fairness of the utilization of 2005-2009 national maternity care services and the allocation of resources were analyzed by the equity evaluation theory and analysis method, so as to make a more comprehensive description of the fairness of the health service in China. The effect of effective government regulation on the implementation of fair policy and improving the fairness of maternal health care services are preliminarily discussed by analyzing the reasons for the significant improvement in the use of equity in hospital delivery services in China.
2, using the qualitative research method, taking a central city in Shanghai as the research site, 22 people of 4 types of participants related to emergency obstetric care service in Shanghai were selected to conduct the semi structural interview with the key lovers, and the emergency obstetric care service regulation was evaluated to improve the household registration and non domicile maternal health in Shanghai. It also analyzes the impact of regulatory environment, process, participants and mechanisms on the effectiveness of emergency obstetric health regulation.
3, using the 2004-2011 year maternal and child health report of the area as the two data source, this paper analyzes the fairness of the household registration and non domicile pregnant and parturient women's utilization of basic maternity care service, and through the field survey method, a questionnaire survey was conducted in 13 community health service centers in the whole region for the women within 6 months after 436 labor, and further analyzed the area in 2011. The fairness and influence factors of household registration and non domicile pregnant and parturient on the utilization of health care services, through the qualitative research on the semi structural interview with the key lovers, understand the direction and key links to further improve the fairness of the health service of pregnant women, and take good governance and effective regulation as the theoretical framework to further improve the fairness. Policy recommendations.
Four, the main research results
In the 10 years of 1.2000-2009, the national MMR continued to decline and the most significant decline in the western region. In the 2003-2009 years, the MMR in the eastern and central regions decreased by 44% and 52% respectively, while MMR in the western region declined by 62%. to measure the health equity of pregnant and lying in women in the eastern and central regions by the extreme difference method for 2000-2009 years in the whole country and in different regions. The difference in the gap between women's death is not significant. The difference between the MMR rate in 10 years is about 10-20/10 million, although the maternal mortality gap between the eastern and western regions is the largest, but the narrowing trend is most obvious, from 65.43/10 million in 2003 to 27.80/10 million in 2009. In the interval, the concentration index of 2000-2009 years was all negative, indicating that maternal mortality was concentrated in the provinces or regions with lower GDP per capita. In 10 years, the inter provincial and inter regional concentration index fluctuated between -0.2 and -0.3, compared with 2000, the absolute value of the concentration index changed little in 2009, suggesting that the health fairness of the pregnant and lying in women in the 10 years did not have to be obtained. To the obvious improvement.
2.2005-2009 national prenatal examination, hospitalization delivery, postpartum visit and system management were all more than zero, indicating that the service utilization was not fair, according to the per capita GDP, the lower the economic level, the worse the pregnant and parturient women were using the health service. The concentration index of the system management in the four kinds of maternity care services was the absolute index. The value of the maximum value is the lowest. The absolute value of the concentration index of the antenatal examination is the smallest, the fairness is best.2005-2009 years. In addition to the delivery service in the hospital, the concentration index of the other three kinds of services is very small, and the fairness is not obviously improved, but the index of the use of the hospital delivery service declined from 0.0593 in 2005 to 0.017 in 2009. 7, the persistence and obvious improvement of fairness, which is inseparable from the success of the "reduction" project in the region, also shows the effect of strong government regulation on improving fairness.
3. the health impartiality of pregnant and lying in women in Shanghai is not fair, mainly reflected in the health equity of migrant and maternal death. In the 10 years, non domicile pregnant and lying in women are the main stream of maternal death in the city. It is one of the main ways to reduce the MMR especially the non domicile pregnant women MMR. The city has formulated a series of regulations and played the most important role in the regulation issued in 2008. Qualitative research shows that the introduction and implementation of the regulation have effectively improved the success rate of critical pregnant and lying in pregnant women and promoted the decrease of MMR in the whole population, especially the non domicile pregnant and lying in women, which had achieved the expected effect, and the health of pregnant and lying in women was unfairly reduced. The execution of the system also reflects the fairness of service delivery.
4. the factors contributing to the effect of regulation include: the objectives and contents of the regulation are compatible with the policy environment of mother's safety advocated at home and abroad; the information based design, the close combination of top-down administrative and technical management in the process of formulation, the necessary and appropriate interpretation before the implementation of the regulation, the review of maternal mortality, accountability, assessment, and punishment. The comprehensive use of mechanisms such as punishment and incentive, especially the effective supervision and restraint formed by the accountability system for the related participants; service managers and providers at all levels as the main participants, their rights and abilities guarantee the powerful enforcement and good effects of regulation. The absence of this key participant in the financial sector, the sustainability of emergency obstetric care services, and the failure to play a better role in the incentive mechanism have affected the enthusiasm of the participants at the executive level.
5. another important result of the study on the regulation of emergency obstetric care service is to reduce the occurrence of critical pregnant women and to reduce the health inequity further. It is not enough to regulate the emergency obstetric care service only. It is necessary to close the mouth of the first place, especially the basic maternity care, especially the antenatal health care. At present, the basic maternity health care is in Shanghai. The main regulation of the service is to regulate the full coverage management of pregnant and parturient women in 2010. This regulation aims to mobilize the strength of community support organizations to improve the community pregnancy monitoring network, and to strengthen the full population, especially the non domicile pregnant and lying in pregnant women in the early pregnancy and system management service.
6. to evaluate the fairness of the household registration and non domicile of 2004-2011 years for the utilization of 6 kinds of basic maternity care services in a district of Shanghai for 2004-2011 years, the establishment of early pregnancy, the standard production inspection and the system management of the three types of service utilization is the most obvious and 2004-2009 year expansion trend, but in 2010, the full coverage of the full coverage of maternal health service management in the district After that, the use of equity in early pregnancy and system management services improved significantly: the concentration index of the early pregnancy volume rose from 0.1308 in 2004 to 0.1746 in 2009, and continued to fall to 0.0594 in 2010, and the centralized index of system management rose from 0.1434 in 2004 to 0.1804 in 2009, and it began to decline rapidly in 2010. To 0.1054, and continued to decline to 0.0652 in 2011, this marked improvement partly reflects the effect of full coverage regulation.
7. the field survey included 436 subjects, including 238 pregnant and lying in women and 168 non domicile pregnant and lying in women. The analysis showed that there were significant differences in the educational background, occupation, family per capita income, medical insurance and birth insurance coverage (P0.05) for the household registration and non domicile pregnant and lying in women in the district (P0.05), and the two groups were examined for early pregnancy, standardized production and postpartum visits. There were obvious differences in the utilization of the three kinds of basic maternity care services; the most unfair was the utilization of early pregnancy volume, with the rate difference of 29.4%, the rate ratio of 1.44, the concentration index of 0.0816, the rate difference of 26.3% and 1.41, the ratio of 1.41, and the ratio of 1.41 to the rate of 1.41. The number was 0.1104; the postpartum visit service was the least fair, the rate difference was 22.6%, the rate was 1.34. The concentration index was 0.0798. and non domicile pregnant and parturient for other health care services such as prenatal screening, pregnant women's schools and the use of guidance delivery service. The main factors for the use of maternal health care service are the domicile household registration, educational background and birth insurance. The Shanghai domicile and childbearing insurance women are more likely to build a small card in the early pregnancy and complete the prenatal examination (the whole pregnancy more than 8 times). Besides the household registration factors, the higher and higher education women are more likely to seek and use postpartum. Visit service.
8. qualitative research into one
【学位授予单位】：复旦大学
【学位级别】：博士
【学位授予年份】：2012
【分类号】：R172

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