农村卫生人力吸引和保留政策的经济学评价系统综述

Economic evaluation of policies to attract and retain health workforce in rural and remote areas: a systematic review

目的系统回顾国内外卫生人力吸引和保留政策的经济学评价方法和结果,成本测算角度主要是政府角度,包括工资、政府补贴、外出培训等成本.方法用增量成本效果比(incremental cost effectiveness ratio,ICER)表示成本效果指标,包括每增加一个农村地区服务人年所需要的成本以及每增加一个质量调整生命年所需要的成本.结果对于中国乡镇卫生院卫生工作人员,提高工资水平可有效改善人员流失情况,研究结果表明,将薪资水平提高至4000元人民币比将薪资水平提高至8000元人民币更为成本有效;对于南非国家,招收农村背景学生的干预措施与其他干预措施如提高薪资水平、外出培训机会等相比具有更好的成本效果;对于埃塞俄比亚、印度尼西亚、肯尼亚等国家的社区卫生服务工作者项目而言,尽管实施成本各不相同,但以国内生产总值的3倍作为比较阈值标准的话,3个国家的干预项目均显示为成本有效;对于马拉维国家的医师培训干预措施而言,将医师留在国内接受专科培训比在国外接受培训更为成本有效.结论目前对于卫生人力干预措施的评价证据比较少,仅有的研究证据均局限在中低收入国家内,因此对于卫生人力干预措施的实施效果评价研究仍需要进一步加强;其次,综述中纳入的文献研究结果表明,招收具有农村背景的学生,提高工作人员工资水平,将医师留在国内接受培训等卫生人力干预措施具有成本效果,但这些干预措施在其他国家的实施环境下是否依然保持成本有效则需要进一步的研究证据加以支持.

Objective To perform a systematic review to evaluate policies that attract and retain health workforce in rural and remote areas,and to adopt the government view to gain cost data,including salary,government subsidies and training cost,etc. Methods Incremental cost effectiveness ratio(ICER) was used,including the cost of each additional rural service person year and the cost of each additional quality adjusted life year(QALY). Results For staff in township health centers in China,raising wages can effectively improve staff retention. The results show that increasing salary level to 4 000 Yuan per month was more cost effective than increasing salary to 8 000 Yuan per month. For South African countries,interventions that recruiting students from rural areas were more cost effective than other interventions,such as raising salary level and providing training opportunities. For community health service workers in countries such as Ethiopia,Indonesia,and Kenya,although the implementation costs varied,if taking three times the gross domestic product as the comparative threshold,interventions in all three countries were shown to be cost effective. For physician training interventions in Malawi countries,the study showed that it was more cost effective to conduct domestic specialist training. Conclusion At present,there is little evidence for the evaluation of health manpower interventions. The only evidence is limited to low and middle income countries. Therefore,research on the evaluation of health manpower interventions needs to be further strengthened. Secondly,literature review shows that health manpower interventions such as enrolling students with rural backgrounds,raising salary level and carrying out domestic training are cost effective. However,whether these interventions remain cost effective in other countries requires further study.