连续—碎片—整合——我国农村三级医疗卫生网络服务提供模式的历史演变及启示

Continuity—fragmentation—integration: Historical review of health service delivery modes from three-level health service networks in rural China

几十年来,经济社会的巨大变革所引起的政府卫生决策意识改变导致我国农村卫生服务网络提供连续性卫生服务呈现明显的波动性:计划经济时代,"分级分工,就近就医"的服务模式曾是我国连续性服务的理念萌芽和初始实践;改革开放以来则形成了"自由择医,碎片化提供"的非连续服务模式;2009年公共卫生服务均等化实施后则呈现"基层就医,连续综合"的整合服务模式的发展趋势。上述三个阶段服务提供模式的波动特征背后隐含着不同时期政府意识形态对卫生服务治理的深刻影响,充分证明了基本医疗保健服务具有明显的政治脆弱性。这种历史演化特征的政策动因为我国以及转型国家维持卫生服务网络延续连续性服务模式提供了诸多政策经验和启示:重视基本保健策略,建立完整的基层卫生体系框架和系统的、整合的运行机制以及重视以人为中心的服务提供理念等。

Over the last several decades,the government＇s health decision-making consciousness has change as result of huge economic and social changes thereby resulting in obvious volatility in the continuity of health service delivery from China＇s rural health service network： In the planned economy era.,the rural service mode of ＂classification and division of medical institutions and local doctors for local patients＂was a starting point for the initial practice of health services continuity; however,following market reforms,rural China has adopted a discrete service mode of＂patients freely choosing their doctors,and a fragmentation of provision＂; after 2009,with the implementation of the equalization of primary public health service,rural health services exhibited a development trend towards a service mode of ＂medical treatment at primary health institutions,continuity and comprehensiveness of service provisions＂.The volatility of service provision modes in the above three stages indicates a deep influence on the government＇s understanding of health service governance at different periods and fully demonstrates that primary care services have obvious political vulnerability. These policy motivations behind the characteristics of historical evolution provide many policy experiences of enlightenment for all countries,particularly for the health networks of transitioning nations. To maintain health service continuity,importance must be attached to basic health care strategies,a complete,integrated grassroots health system framework and systematic operation mechanisms must be established and attention must be given to the service concept of people-centered services.