目的 通过描述性统计对嵊州市按人头付费与签约服务相结合试点改革的效果进行初步评估,为后续的改革推进提供指导和建议.方法 采用Excel2016对所有数据进行整理,对按人头付费改革的医院业务数据和医保基金运行情况进行表述性统计分析.结果 改革后,门急诊和住院业务数量增长显著,平均住院日延长.门急诊和住院收入均增加,但住院收入增加更为显著,但住院药品收入控制比门急诊药品收入控制效果更好.门诊和住院的年人次均费用的增长率为负增长,初步实现均次费用控费目标.居民医保支付总费用改革前为1167.77万元,改革后为1366.35万元,实际增长率为11.44％,医保支付费用仍在增长.医保基金结余改革前后均处于赤字状态,但改革后有所改善.结论 按人头付费效果初步显现,基本实现门急诊和住院次均费用控费目标,但医保基金仍处于赤字,仍需要改革的持续推进,逐步实现结余目标.

目的:调查浙江省社区康复现状,为我省社区康复的可持续发展战略提供依据.方法:选择全省11个地区64家社区卫生服务中心及农村乡镇卫生服务中心发放问卷,对社区康复服务部门人力资源状况 、开展的主要康复治疗项目 、康复站规模及设施等方面进行调查.结果:64家社区共回收有效问卷64份,从调查结果我们可以发现研究生 、本科生 、大专 、中专生分别占5.3％ 、23.0％ 、41.1％ 、30.6％.康复工作人员中康复医师 、康复治疗师 、全科医师 、康复护士分别占25.9％ 、38.5％ 、10.5％ 、27.1％.职称以高级 、中级 、初级分别占5.3％ 、34.3％ 、38.7％.以康复为全职的占36.2％,曾参加康复专科继续教育学习占43.2％.康复治疗(训练)方面主要以上下肢运动能力训练 、推拿按摩为主;针对 ≥65周岁老年人生活及运动方式指导,包括预防跌倒训练 、提高老年人心肺(有氧)能力的训练 、改善老年肌少症的训练等3个项目所占比例均偏低,分别为20.3％ 、18.7％ 、23.4％.社区卫生机构拥有较多的康复硬件是电针仪 、远红外治疗仪 、轮椅 、颈腰牵引床,分别为81.2％ 、76.5％ 、73.4％ 、60.9％.踝关节矫形器 、木丁板 、PT凳 、矫姿镜拥有率最低,分别是29.6％ 、29.6％ 、31.2％ 、32.8％.结论:社区康复在我省得到健康的发展,体系也逐渐完善,但目前仍面临着许多挑战.建议今后我省社区康复服务能力建设过程中将转变社区康复从业人员的服务理念及社区居民的康复意识作为努力方向,重点提高社区康复服务体系中针对老年人及慢病患者的相应服务能力;此外,政策进一步向社区康复倾斜,争取从技术上,资源配备上 、人才管理以及中远期规划上保证和提高社区康复应有的质和量,为我省社区康复事业提供一条可持续发展道路.

Based on an analysis of the compensation policy and its problems of the primary medical and health institutions, this paper put forward the corresponding reform framework in Zhejiang province. It proposed to change the compensation policy of " predefining revenue and expenditure, subsidizing its gap after performance appraisal" into " a mixed system of special subsidy and pay for performance". Related policies were also described including governmental functions, special subsidies for input-based payments, classified payments for output services, precautions against financial risks, etc. This paper also suggested that we focus on dealing with the six pairs of balance, such as that between subsidy for the supply and demand sides, and that between internal market and external market.

Objective To analyze the medical service capacity of primary healthcare in Zhejiang province since the ongoing healthcare reform and put forward suggestions. Methods Key indicators of healthcare resources and medical service utilization from 2009 to 2015 reflecting the primary healthcare were identified,for a quantitative analysis in terms of the structure-process-outcome dimensions. Results In terms of structural service capacity,the average headcount growth rate of primary healthcare′s technical personnel was 5. 7% per year; the personnel competence structure kept improving; the hospital beds at primary institutions and their ratio among all were slightly decreased,with better devices and informatization. In terms of procedural service capacity,the proportion of primary institutions with contract-based services amounted to 89. 9%,with the standard contract signing rate up to 18. 8%. In terms of consequential service capacity,the average growth rate of the number of outpatient visits at primary institutions was 6. 3%. The amount and proportion of inpatients were slightly decreased,while the hospital bed utilization ratio was increased slightly. Conclusions It is necessary to further strengthen the training and introduction of primary healthcare professionals. The functional orientation of hospitals at various levels should be clarified, encouraging contract-signing of general practitioners, promote the medical insurance payment reform featuring the capitation payment at primary level,and improve the income distribution and incentive mechanism.

The "control handles"( including financing, provider payment, organization, regulation and behavior) proposed by World Bank in health policy research as the basic framework,and the nature and positioning of family doctors′ contract-based service as the precondition, we recommended the system framework of such a mechanism, comprising one contract, three regulations, five control handles and seven supporting policies. Such a framework can serve as the cornerstone for family doctors′ contract-based service experiment in Zhejiang province for the sake of hierarchical medical system.

<span id="ChDivSummary" name="ChDivSummary" class="abstract-text">目的:分析浙江省农村定向培养医学生履约意向现状以及影响因素。方法:在浙江省医学院校内共抽取350名在校订单定向培养医学生开展专项调查,收集有关数据资料,进行统计学分析。结果:329份有效问卷中35.6%的学生表示"一定履约",63.5%的学生选择"可能履约"或"不清楚",2.7%的学生选择"一定不履约",学生整体履约意向较高,同时多数学生存在一定违约风险。家庭居住地、学历层次对履约意向存在影响,而户籍、经济状况、服务机构层次等因素对履约意向无显著影响。结论:结合职业承诺理论3大维度,提出营造良好校园氛围,适当调整相关政策,增强情感承诺;扩大宣传力度,增加福利待遇,增强居民认同感,加强规范承诺;建立多样有效的约束机制,加强代价承诺。</span>

This paper summarizes the main measures of contracting service with doctors in primary care institutions project in Zhejiang Province,including the situation of pilot areas,the construction of information system,and the implementation of supporting policies to strengthen the assessment and training of doctors in primary care institutions under the lead of government and the cooperation of relevant departments to improve the service quality of primary care institutions and promote the contracting service with doctors in primary care institutions project.Recent data from direct online reporting system of primary care institutions in Zhejiang Province showed that the number of contracted residents and the times of residents visiting doctors in primary care institutions increased steadily,which meant the management of basic public health services achieved a remarkable effect.But the contracting service with doctors in primary care institutions project in Zhejiang Province still needs further publicity,and high service quality of primary care institutions is expected,while health insurance and other supporting policies are on the process of implementation.The following work will focus on the above aspects to promote the development of contracting service with doctors in primary care institutions project.The analyses of this project in Zhejiang Province are supposed to provide a reference for other areas of our country to conduct contracting service with doctors in primary care institutions project.

浙江省近期完成的专题调研发现,签约服务在取得成效的同时也面临一些问题. 一是医保配套政策不到位.政府文件明确,要调整完善基本医疗保险报销制度,科学设置门诊、住院和重大疾病报销政策,差别化设置不同等级医疗卫生机构和跨统筹区域医疗卫生机构就诊的报销比例,引导签约服务对象到基层医疗卫生机构首诊.已有医保配套措施的地区,签约服务对象对签约内容的知晓率和参与签约的积极性均明显高于其他地区,这说明医保政策的引导作用还是很明显的.

目的:评价浙江省经济欠发达地区基层医疗机构的影像设备:彩超、黑白B超、直接数字化X射线摄影系统(DR)、计算机X成像(CR)、X光机和CT的配置现状和公平性,指导浙江省“十三五”期间医疗设备合理配置.方法:以浙江省35个经济欠发达县(市、区)的所有基层医疗卫生机构为研究对象,资料来源于浙江省卫生和计划生育委员会2014年医疗设备配置现状和规划调查数据,采用SPSS17.0和Excel 2007对数据进行统计描述、Lorenz曲线和Gini系数分析.结果:在6种影像设备中,以彩超、黑白B超和X光机的配置最为齐全,以彩超、黑白B超和直接数字化X射线摄影系统(DR)的购置需求最为迫切.彩超、黑白B超和X光机按照服务人口分布的公平性较好,DR、CR和CT的公平性较差,处于警戒状态.结论:浙江省欠发达地区的基层医疗机构中影像设备配置受到经济、地理和政策等因素的影响.

Objectives: To evaluate the allocation present situation and the equity of the imaging equipments in primary medical establishments in Zhejiang Province and to provide evidences for medical equipment resource allocation standard in the 13th five years planning of health. The main imaging equipments include the Color Doppler Ultrasound, Black and White Ultrasound, Direct Digital radiography system (DR), computed radiography (CR), x-ray machine, and computer tomography (CT). Methods: The study undertakes the descriptive statistics and the Theil index analysis by SPSS 17.0 and Excel 2007. Results: The order of allocation of all selected equipment except the Black and White Ultrasound was the Central Town, Small City and Less Developed area. The result of the Theil Index shows that the inequity of imaging equipment resource was caused by both inter-regional and internal region differences, but the inter-regional difference was the main reason. Conclusion: The allocation of imaging equipment resource should be combined with the economy, geography and policy factors and use the classification management to reduce the inter-regional difference.

In 2012, the contracted service with the general practitioners ( rural doctors) was implemented in Zhejiang Province. This paper conducted an analysis on the existing problems in the contracted service from three as-pects of policy background, policy objective, main measures and the following suggestions have been put forward:Strengthening the whole family team of doctors and information construction, and improving the multi sectoral coopera-tion mechanism in order to establish the classified diagnosis and treatment system as targeted to lay a good foundation.

目的：了解浙江省居民健康电子档案的建设和应用情况以及存在的问题。方法应用分层随机抽样的方法，从杭州和宁波2个地区的10个县（市、区）抽取30家社区卫生服务中心进行问卷调查和专题访谈。结果作调查的25家单位，均建立了居民健康档案管理系统和医生工作站系统，重点人群建档率均在90.00％以上，91.70％是通过就诊时进行健康档案更新。从2010年到2012年建档率呈逐年增长趋势（P ＜0.05）。结论政府需加大政策支持，规范健康档案系统，推进信息互联互通，提高资源利用效率。

目的:了解浙江省乡镇卫生院(社区卫生服务中心)设备配置现状,提出科学配置医疗设备的对策建议;方法:对浙江省210个中心镇(含小城市培育试点镇)和35个经济欠发达县(市、区)的所有建制乡镇卫生院和社区卫生服务中心开展问卷调查,并选取不同经济发展水平的11个县(市、区),召开专题座谈会;结果:回收有效问卷640份,有效率为91.69％.根据卫生院的规模分为A、B、C三个类别,不同类别的卫生院主要设备配置存在明显差异;结论:要严格遵循医疗设备配置原则,制定不同类别乡镇卫生院(社区卫生服务中心)配置标准,完善设备配置方案,加大财政补助力度,提升设备配置水平;探索建立医疗设备县域维修维护中心.

目的:分析浙江省参合农民健康体检存在问题及原因,并提出政策建议;方法:每个地市各随机抽取1个县(市、区),每个县(市、区)按比例抽取1/3的乡镇卫生院和社区卫生服务中心,开展问卷调查.结果:共收回有效问卷70份,“基层卫生人员不足”、“体检经费标准太低”、“参合农民自己体检意识不强”、“体检对象在外打工不能回来”、“体检经费纳入绩效总量”是当前制约农民健康体检工作主要困难和障碍.结论:提高经费标准,保障财政投入;加强能力建设,规范质量控制;转变农民意识,重视健康管理.

Objective To put forward a reasonable proposal based on the research on operation effects of health resources integration in Yuyao,Zhejiang.Methods A survey was conducted in Center for Clinical Laboratory,16township hospitals,and among 80residents,and we had discussion with relevant personnel.Results The number of outpatient,inpatients and surgery patients had a certain increase compared with pre-pilot in township hospitals,and the proportions of growth were 12%,6%and 20%respectively.From 2009to 2011,the revenue of Center for Clinical Laboratory increased significantly,and the proportion of personnel expenses and material costs to revenue decreased from 90.3%to62.7%.The survey showed that 97.5%of the residents trusted in present results of clinical tests,and 96.3%felt costs lower than before.Conclusions The health resource integration reform enhanced the capacity and quality of primary health care services,reduced the medical costs,improved the resource efficiency,and promoted the complementary functions of hospitals and primary health care institutions,which can be promoted in those areas with developed economies and convenient transportation.At the same time we should increase the financial transfer payments to help less developed areas.

目的了解浙江省在职社区护士培训实施情况和需求,为规范开展在岗社区护士的分层次培训提供依据.方法以方便采样的方法抽取浙江省杭州市、宁波市和舟山市三地10家社区卫生服务中心102名在岗社区护士进行问卷调查,内容包括社区护士的一般情况、培训现状、培训需求等方面.对中心主任和社区护理科长开展访谈.结果社区护士目前参加培训的形式以中心内集中培训为主,培训需求强烈,73.5%护士希望按岗位培训,培训内容需求侧重于对基本公共卫生服务(89.2%)和基础知识和技能培训(87.2%),培训周期以80~120学时为主(43.1%),教学方式以课堂直接讲授(62.7%)和教室操作示范(69.6%)为主,培训的方式以理论和实践并重(55.9%).结论社区护士目前的培训形式单一,过于理论化,培训内容缺乏针对性,培训机会不足,不能满足社区卫生服务发展的实际的需要.提高对社区护理培训工作重要性的认识,提高基层培训能力和培训效果,建立完善社区护理培训体系,提高培训的针对性和实用性,落实培训保障,提高社区护士的参训率.

Objective To understand the main problems and residents' cognition and utilization condition of national essential drugs in Zhejiang province.Methods On-the-spot questionnaire survey was conducted among doctors working in community health service institutions or township hospitals of 3 counties(cities,regions) selected according to their economic development levels.Results There were 32.9% patients who held that the efficacy of national essential drugs were lower than that of other drugs;37.8% patients believed that essential drugs were cheap drugs;62.3% patients said that they had to visit higher medical institutions if they could not buy the drugs they needed in community health service institutions or township hospitals after the implementation of essential drug system.Conclusion Residents have cognition prejudice of essential drugs,so the work of propaganda and popularization should be strengthened.Lack of essential drugs will lead to the loss of patients,which will restrict the development of basic medical institutions.

Objective To explore the difficulties and problems in compensation mechanism of basic medical institutions,and to put forward suggestions for establishing reasonable compensation mechanism.Methods The financial revenues and expenditures before and after the implementation of essential drug system were analyzed and specific interview was made.Results The fiscal compensation amount and ratio were improved greatly.The ratio of drug income to business income was reduced,and drug add rate was reduced greatly.The compensation approaches lacked variety and rigidity.Conclusion Measures,such as strengthening government ' s responsibility,improving checking methods of frequent payment balance,establishing various channels of compensation mechanism and incentive distribution system,should be implemented to set up a scientific and rational compensation mechanism.