基层医疗卫生机构发展困境分析:基于桂林市的扎根理论研究

Development Dilemma of Primary Health Care Institutions:a Grounded Theory Study Based on Guilin City

背景新医改以来基层医疗卫生机构在诊疗人次数、基本公共卫生服务项目方面取得明显成效,但仍面临着人员素质不高且流动性强、服务能力弱且效率低等问题,因此破解基层医疗卫生机构的发展困境成为当务之急。目的对基层医疗卫生机构的发展困境进行分析,并提出相应对策。方法于2021年4—5月,采用多阶段抽样方法抽取桂林市6个县、2个区共计16家基层医疗卫生机构的负责人开展半结构化访谈,访谈内容主要包括资源配置、服务能力建设、医保政策执行及发展困境等。采用NVivo 11.0质性分析软件,通过扎根理论方法,对原始访谈资料逐级分类、归纳和提炼。结果本研究提炼出38个初始概念、9个初始范畴、4个主范畴及1个核心范畴,获得样本地区基层医疗卫生机构发展在“资源配置制约”“三医联动路径阻碍”“功能定位偏离”“医共体建设缺乏紧密性”4个维度的阻滞节点。结论基层医疗卫生机构的发展受多种因素的制约:均衡资源配置、完善补偿机制是核心问题,三医联动路径协同是外部条件,调整功能定位是关键环节,组建紧密型医共体是重要手段。

Background Since the new medical reform,primary health care institutions have made remarkable achievements in the number of consultations and basic public health service projects,however,the problems including low quality and high mobility of personnel,weakened capacity and low efficiency of service still remain.Therefore,it has become an urgent task to solve the development dilemma of primary health care institutions.Objective To analyze the development dilemma of primary health care institutions and propose corresponding countermeasures.Methods From April to May 2021,the heads of 16 primary health care institutions in 6 counties and 2 districts in Guilin were selected using multi-stage sampling method to conduct semi-structured interviews,which mainly included resource allocation,service capacity building,health insurance policy implementation,and development dilemmas.NVivo 11.0 qualitative analysis software and the research method of ground theory were used to classify,ummarize and refine the original interview data at each level.Results A total of 38 initial concepts,9 initial categories,4 main categories,and 1 core category were extracted,and nodes of stagnation in four dimensions including"resource allocation constraints""obstruction of the path of three medical linkage""deviation of functional positioning"and"accessibility lacking in medical community construction"were obtained.Conclusion The development of primary health care institutions is constrained by a variety of factors,with resource allocation balance and compensation mechanism improvement as core issue,synergy of the three medical linkage paths as external condition,adjustment of functional positioning as key link,and the construction of close medical community as important approach.