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Article(id=1240929924614255541, tenantId=1146029695717560320, journalId=1227665162245664772, issueId=1240929920461886112, articleNumber=null, orderNo=null, doi=10.20043/j.cnki.MPM.202312466, pmid=null, cstr=null, oa=null, hot=null, price=null, onlineType=0, articleFormat=0, articleType=null, articleTypeStr=null, receivedDate=1703433600000, receivedDateStr=2023-12-25, revisedDate=null, revisedDateStr=null, acceptedDate=null, acceptedDateStr=null, onlineDate=1773790349391, onlineDateStr=2026-03-18, pubDate=1717948800000, pubDateStr=2024-06-10, doiRegisterDate=null, doiRegisterDateStr=null, onlineIssueDate=1773790349391, onlineIssueDateStr=2026-03-18, onlineJustAcceptDate=null, onlineJustAcceptDateStr=null, onlineFirstDate=null, onlineFirstDateStr=null, sourceXml=null, magXml=null, createTime=1773790349391, creator=13701087609, updateTime=1773790349391, updator=13701087609, issue=Issue{id=1240929920461886112, tenantId=1146029695717560320, journalId=1227665162245664772, year='2024', volume='51', issue='11', pageStart='1921', pageEnd='2112', issueExtLink='null', onlineDate='null', pubDate='null', beforeIssueId=null, nextIssueId=null, price=null, status=1, issueComplete=1, articleOrder=1, issueType=-1, specialIssue=0, createTime=1773790348400, creator=13701087609, updateTime=1773827281389, updator=13701087609, preIssue=null, nextIssue=null, ext={EN=IssueExt(id=1241084828704109275, tenantId=1146029695717560320, journalId=1227665162245664772, issueId=1240929920461886112, language=EN, specialIssueTitle=, coverIllustrator=null, specialIssueEditor=, specialIssueAbout=), CN=IssueExt(id=1241084828704109276, tenantId=1146029695717560320, journalId=1227665162245664772, issueId=1240929920461886112, language=CN, specialIssueTitle=, coverIllustrator=null, specialIssueEditor=, specialIssueAbout=)}, issueFiles=null}, startPage=2008, endPage=2012, ext={EN=ArticleExt(id=1240929925042074580, articleId=1240929924614255541, tenantId=1146029695717560320, journalId=1227665162245664772, language=EN, title=A quantitative study on the policy of county medical community in China from the perspective of policy tools, columnId=1228016572892119056, journalTitle=Modern Preventive Medicine, columnName=Primary Health Services, runingTitle=null, highlight=null, articleAbstract=

Objective To analyze the the current status and deficiencies of the county medical community construction policy and proposes policy recommendations to optimize the construction of the county medical community. Methods Based on the perspective of policy tools, a three-dimensional analysis framework was constructed combining policy evolution and stakeholder dimensions, and content analysis was used to quantitatively analyze the policy text in three dimensions. Results A total of 29 policy documents were included after screening. The overall utilization of policy tools showed an imbalance, with the utilization of capacity-type policy tools as high as 35.38%, but sub-tools such as financial investment (3.07%) and technical support(2.83%) were less used. Incentive-type policy tools were the least used, accounting for only 8.96%, with sub-tools such as price adjustment and promotion further education accounting for only 0.71% and 0.47%, respectively. The distribution of stakeholders was uneven, with primary medical and health institutions and county hospitals being the main targets, accounting for 27.77% and 25.52%, respectively. With the evolution of policies, the number and variety of policy tools used showed a rapid increase, but capacity-type policy tools still dominated, and there was an imbalance in the internal structure of policy tools. Additionally, the involvement of two key stakeholders including medical personnel and the public, was relatively low. Conclusion There is significant differentiation in the utilization of policy tools, with insufficient use of symbolic, incentive-type policy tools.It is suggested to improve the internal structure of policy elements, enhance the balance of policy tool utilization, continuously optimize policy tools, increase the use of incentive-type and symbolic policy tools, and strengthen the participation of two key stakeholders: medical personnel and the public.

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目的 分析县域医共体建设政策的现状与不足，为优化县域医共体建设提出政策建议。方法 基于政策工具视角，结合政策演进、利益相关者维度构建三维分析框架，采用内容分析法对政策文本进行三维量化分析。结果 筛选后共纳入29份政策文件。政策工具利用总体呈现不平衡现象，能力型政策工具利用占比高达35.38%，但子工具中财政投入(3.07%)、技术支持(2.83%)使用较少；激励型政策工具使用最少，仅为8.96%，子工具中价格调整和晋升进修占比仅为0.71%和0.47%。利益相关者分布不均衡，作用对象主要是基层医疗卫生机构和县级医院，占比分别为27.77%和25.52%。随着政策演进，政策工具的使用数量与种类均呈现迅速上升的态势，但仍以能力型政策工具为主，政策工具内部要素结构失衡，而且医务人员与群众方两个利益相关者涉及较少。结论 政策工具利用差异化显著，象征与劝诫型、激励型政策工具应用不足，应完善政策要素内部结构，增强政策工具运用的均衡性，持续优化政策工具，增加激励型与象征与劝诫型政策工具的使用，增强医务人员与群众两个利益相关者的参与。

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马国芳，E-mail:
, copyrightStatement=本刊刊出的所有文章不代表中华预防医学会和本刊编委会的观点，除非特别声明。, copyrightOwner=中华预防医学会和四川大学华西公共卫生学院, extLink=null, articleAbsUrl=null, sourceXml=GPNi3WKhka3RxHZWrpPyWw==, magXml=h/zgihg6A7fwLmosqUh7XQ==, pdfUrl=null, pdf=qyA2URyikjHWpgRjkhZdgw==, pdfFileSize=706095, pdfExtLink=null, richHtmlUrl=null, mobilePdfUrl=null, reviewReport=null, pdfFirstPage=null, abstractGraph=ha6hE/4KktMaB88PHrcmog==, abstractGraphContent=null, abstractVideo=null, citation=null, cebUrl=null, magXmlContent=F0gSxQCkYq8m161/ITP+lg==, mapNumber=null, authorCompany=null, fund=null, authors=

吴瑶（1994—），女，硕士在读，研究方向：社会医学与卫生事业管理

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吴瑶（1994—），女，硕士在读，研究方向：社会医学与卫生事业管理

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吴瑶（1994—），女，硕士在读，研究方向：社会医学与卫生事业管理

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tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1240929924614255541, language=EN, orderNo=2, keyword=County medical community), Keyword(id=1240929928670146857, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1240929924614255541, language=EN, orderNo=3, keyword=Quantitative research), Keyword(id=1240929928775004469, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1240929924614255541, language=CN, orderNo=1, keyword=政策工具), Keyword(id=1240929928896639294, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1240929924614255541, language=CN, orderNo=2, keyword=县域医共体), Keyword(id=1240929928997302596, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1240929924614255541, language=CN, orderNo=3, keyword=量化研究)], refs=[Reference(id=1240929930624692681, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1240929924614255541, doi=null, pmid=null, pmcid=null, year=null, 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Study on the path of Party building leading the development of medical consumption linkage cooperation[J]. 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Quantitative research on provincial policy for medical alliance construction in China ——Based on three-dimensional analysis framework of policy tools, stakeholders and policy effectiveness[J]. Soft Science of Health, 2022, 36(2): 6-13., articleTitle=Quantitative research on provincial policy for medical alliance construction in China ——Based on three-dimensional analysis framework of policy tools, stakeholders and policy effectiveness, refAbstract=null), Reference(id=1240929934001107590, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1240929924614255541, doi=null, pmid=null, pmcid=null, year=2018, volume=38, issue=9, pageStart=24, pageEnd=27, url=null, language=null, rfNumber=[14], rfOrder=26, authorNames=崔成森, 左旭, 孟开, journalName=中国医院管理, refType=null, unstructuredReference=崔成森， 左旭， 孟开.基于政策工具的我国分级诊疗政策内容分析[J].中国医院管理，2018，38（9）：24-27., articleTitle=基于政策工具的我国分级诊疗政策内容分析, refAbstract=null), Reference(id=1240929934143713933, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1240929924614255541, doi=null, pmid=null, pmcid=null, year=2018, volume=38, issue=9, pageStart=24, pageEnd=27, url=null, language=null, rfNumber=[14], rfOrder=27, authorNames=Cui CS, Zuo X, Meng K, journalName=Chinese Hospital Management, refType=null, unstructuredReference=Cui CS, Zuo X, Meng K. Analysis of policy content of the hierarchical diagnosis and treatment based on policy tools in China[J]. Chinese Hospital Management, 2018, 38(9): 24-27., articleTitle=Analysis of policy content of the hierarchical diagnosis and treatment based on policy tools in China, refAbstract=null), Reference(id=1240929934256960146, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1240929924614255541, doi=null, pmid=null, pmcid=null, year=2023, volume=30, issue=5, pageStart=99, pageEnd=104, url=null, language=null, rfNumber=[15], rfOrder=28, authorNames=徐萍萍, 赵静, 李春晓, journalName=中国卫生质量管理, refType=null, unstructuredReference=徐萍萍，赵静，李春晓，等.政策工具视角下我国县域医共体政策文本分析[J].中国卫生质量管理，2023，30（5）：99-104., articleTitle=政策工具视角下我国县域医共体政策文本分析, refAbstract=null), Reference(id=1240929934395372184, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1240929924614255541, doi=null, pmid=null, pmcid=null, year=2023, volume=30, issue=5, pageStart=99, pageEnd=104, url=null, language=null, rfNumber=[15], rfOrder=29, authorNames=Xu PP, Zhao J, Li CX, journalName=Chinese Health Quality Management, refType=null, unstructuredReference=Xu PP, Zhao J, Li CX, et al. Policy text analysis of county medical community in China from the perspective of policy tools[J]. Chinese Health Quality Management, 2023, 30(5): 99-104., articleTitle=Policy text analysis of county medical community in China from the perspective of policy tools, refAbstract=null)], funds=[Fund(id=1240929930498863553, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1240929924614255541, awardId=JZ202001045, language=CN, fundingSource=新疆农村基层公共卫生防控能力建设研究(JZ202001045), fundOrder=null, country=null)], companyList=[AuthorCompany(id=1240929927151808664, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1240929924614255541, xref=1., ext=[AuthorCompanyExt(id=1240929927160197274, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1240929924614255541, companyId=1240929927151808664, language=EN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=School of Public Health, Xinjiang Medical University, Urumqi, Xinjiang 830054, China), AuthorCompanyExt(id=1240929927176974492, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1240929924614255541, companyId=1240929927151808664, language=CN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=1.新疆医科大学公共卫生学院，新疆 乌鲁木齐 830054)]), AuthorCompany(id=1240929927265054889, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1240929924614255541, xref=2., ext=[AuthorCompanyExt(id=1240929927273443499, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1240929924614255541, companyId=1240929927265054889, language=CN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=2.新疆医科大学健康管理学院，新疆 乌鲁木齐 830054)])], figs=[ArticleFig(id=1240929929160880470, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1240929924614255541, language=EN, label=Figure 1, caption=The X-Y-Z three-dimensional analysis framework for county medical community building policy, figureFileSmall=4UqO2JMloyOaBw4A0SCsQQ==, figureFileBig=ha6hE/4KktMaB88PHrcmog==, tableContent=null), ArticleFig(id=1240929929286709599, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1240929924614255541, language=CN, label=图1, caption=县域医共体建设政策X-Y-Z三维分析框架, figureFileSmall=4UqO2JMloyOaBw4A0SCsQQ==, figureFileBig=ha6hE/4KktMaB88PHrcmog==, tableContent=null), ArticleFig(id=1240929929542562169, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1240929924614255541, language=EN, label=Figure 2, caption=Three-dimensional cross-tabulation analysis of policy instruments-policy evolution-stakeholders, figureFileSmall=w24eJYDzs+lhWfNd9391Sg==, figureFileBig=Lh1epX0sALw1y0bbGW7xag==, tableContent=null), ArticleFig(id=1240929929664196995, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1240929924614255541, language=CN, label=图2, caption=政策工具-政策演进-利益相关者三维交叉分析, figureFileSmall=w24eJYDzs+lhWfNd9391Sg==, figureFileBig=Lh1epX0sALw1y0bbGW7xag==, tableContent=null), ArticleFig(id=1240929930016518543, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1240929924614255541, language=EN, label=Table 1, caption=

List of policies for county medical communities in China

, figureFileSmall=null, figureFileBig=null, tableContent=
序号发布时间文件名称发布机构
120090317关于深化医药卫生体制改革意见（中发〔2009〕6号）中共中央国务院
220120314“十二五”期间深化医药卫生体制改革规划暨实施方案通知（国发〔2012〕11号）国务院
320150908关于推进分级诊疗建设指导意见(国办发〔2015〕70 号)国务院办公厅
............
2720221211关于印发依托县域医共体提升农村地区新冠肺炎医疗保障能力工作方案通知国务院应对新型冠状病毒肺炎疫情
（联防联控机制综发〔2022〕126号）联防联控机制综合组
2820230223关于进一步深化改革促进乡村医疗卫生体系健康发展的意见中共中央办公厅、国务院办公厅
2920230323关于进一步完善医疗卫生服务体系的意见中共中央办公厅、国务院办公厅
), ArticleFig(id=1240929930112987548, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1240929924614255541, language=CN, label=表1, caption=

我国县域医共体政策一览

, figureFileSmall=null, figureFileBig=null, tableContent=
序号发布时间文件名称发布机构
120090317关于深化医药卫生体制改革意见（中发〔2009〕6号）中共中央国务院
220120314“十二五”期间深化医药卫生体制改革规划暨实施方案通知（国发〔2012〕11号）国务院
320150908关于推进分级诊疗建设指导意见(国办发〔2015〕70 号)国务院办公厅
............
2720221211关于印发依托县域医共体提升农村地区新冠肺炎医疗保障能力工作方案通知国务院应对新型冠状病毒肺炎疫情
（联防联控机制综发〔2022〕126号）联防联控机制综合组
2820230223关于进一步深化改革促进乡村医疗卫生体系健康发展的意见中共中央办公厅、国务院办公厅
2920230323关于进一步完善医疗卫生服务体系的意见中共中央办公厅、国务院办公厅
), ArticleFig(id=1240929930209456553, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1240929924614255541, language=EN, label=Table 2, caption=

Frequency distribution of policy instruments and policy evolution dimensions, stakeholder dimensions

, figureFileSmall=null, figureFileBig=null, tableContent=
X维度子工具名称Y维度Z维度
雏形期探索期发展期合计(%)政府县级医院基层机构医务人员群众合计(%)
权威型目标规划7171943(6.90)1013112734(6.90)
命令规定1112032(5.14)26310229(5.14)
策略性措施14363888(14.13)11282831861(14.13)
激励型价格调整1203(0.48)100023(0.48)
医保支付79925(4.01)10370517(4.01)
薪酬待遇54918(2.89)11313016(2.89)
晋升进修0202(0.32)000202(0.32)
能力型人才培养1083856(8.99)391627132(8.99)
信息建设381223(3.69)19102113(3.69)
资源统筹6364688(14.13)436385545(14.13)
评估指导2152441(6.58)188103235(6.58)
技术支持131216(2.57)2770012(2.57)
财政投入44816(2.57)10240013(2.57)
系统变革型制度建设726942(6.74)1011107418(6.74)
管理改革333036(5.78)14893226(5.78)
职责划分911626(4.17)11740415(4.17)
象征与劝诫型政策宣传36716(2.57)602447(2.57)
价值传达09312(1.93)4110610(1.93)
鼓励号召392436(5.78)113129132(5.78)
经验推广0314(0.64)400004(0.64)
合计86(13.80)222(35.63)315(50.56)623(100)147(23.60)159(25.52)173(27.77)80(12.84)64(10.27)623(100)
), ArticleFig(id=1240929930360451509, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1240929924614255541, language=CN, label=表2, caption=

政策工具与政策演进维度、利益相关者维度频数分布表

, figureFileSmall=null, figureFileBig=null, tableContent=
X维度子工具名称Y维度Z维度
雏形期探索期发展期合计(%)政府县级医院基层机构医务人员群众合计(%)
权威型目标规划7171943(6.90)1013112734(6.90)
命令规定1112032(5.14)26310229(5.14)
策略性措施14363888(14.13)11282831861(14.13)
激励型价格调整1203(0.48)100023(0.48)
医保支付79925(4.01)10370517(4.01)
薪酬待遇54918(2.89)11313016(2.89)
晋升进修0202(0.32)000202(0.32)
能力型人才培养1083856(8.99)391627132(8.99)
信息建设381223(3.69)19102113(3.69)
资源统筹6364688(14.13)436385545(14.13)
评估指导2152441(6.58)188103235(6.58)
技术支持131216(2.57)2770012(2.57)
财政投入44816(2.57)10240013(2.57)
系统变革型制度建设726942(6.74)1011107418(6.74)
管理改革333036(5.78)14893226(5.78)
职责划分911626(4.17)11740415(4.17)
象征与劝诫型政策宣传36716(2.57)602447(2.57)
价值传达09312(1.93)4110610(1.93)
鼓励号召392436(5.78)113129132(5.78)
经验推广0314(0.64)400004(0.64)
合计86(13.80)222(35.63)315(50.56)623(100)147(23.60)159(25.52)173(27.77)80(12.84)64(10.27)623(100)
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政策工具视角下我国县域医共体政策量化研究
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吴瑶 1 , 罗香林 1 , 马国芳 2
现代预防医学 | 基层卫生服务 2024,51(11): 2008-2012
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现代预防医学 | 基层卫生服务 2024, 51(11): 2008-2012
政策工具视角下我国县域医共体政策量化研究
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吴瑶1, 罗香林1, 马国芳2
作者信息
  • 1.新疆医科大学公共卫生学院，新疆 乌鲁木齐 830054
  • 2.新疆医科大学健康管理学院，新疆 乌鲁木齐 830054

    • 吴瑶（1994—），女，硕士在读，研究方向：社会医学与卫生事业管理

通讯作者:

马国芳，E-mail:
A quantitative study on the policy of county medical community in China from the perspective of policy tools
Yao WU1, Xiang-lin LUO1, Guo-fang MA2
Affiliations
  • School of Public Health, Xinjiang Medical University, Urumqi, Xinjiang 830054, China
出版时间: 2024-06-10 doi: 10.20043/j.cnki.MPM.202312466
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摘要
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目的 分析县域医共体建设政策的现状与不足，为优化县域医共体建设提出政策建议。方法 基于政策工具视角，结合政策演进、利益相关者维度构建三维分析框架，采用内容分析法对政策文本进行三维量化分析。结果 筛选后共纳入29份政策文件。政策工具利用总体呈现不平衡现象，能力型政策工具利用占比高达35.38%，但子工具中财政投入(3.07%)、技术支持(2.83%)使用较少；激励型政策工具使用最少，仅为8.96%，子工具中价格调整和晋升进修占比仅为0.71%和0.47%。利益相关者分布不均衡，作用对象主要是基层医疗卫生机构和县级医院，占比分别为27.77%和25.52%。随着政策演进，政策工具的使用数量与种类均呈现迅速上升的态势，但仍以能力型政策工具为主，政策工具内部要素结构失衡，而且医务人员与群众方两个利益相关者涉及较少。结论 政策工具利用差异化显著，象征与劝诫型、激励型政策工具应用不足，应完善政策要素内部结构，增强政策工具运用的均衡性，持续优化政策工具，增加激励型与象征与劝诫型政策工具的使用，增强医务人员与群众两个利益相关者的参与。

政策工具  /  县域医共体  /  量化研究

Objective To analyze the the current status and deficiencies of the county medical community construction policy and proposes policy recommendations to optimize the construction of the county medical community. Methods Based on the perspective of policy tools, a three-dimensional analysis framework was constructed combining policy evolution and stakeholder dimensions, and content analysis was used to quantitatively analyze the policy text in three dimensions. Results A total of 29 policy documents were included after screening. The overall utilization of policy tools showed an imbalance, with the utilization of capacity-type policy tools as high as 35.38%, but sub-tools such as financial investment (3.07%) and technical support(2.83%) were less used. Incentive-type policy tools were the least used, accounting for only 8.96%, with sub-tools such as price adjustment and promotion further education accounting for only 0.71% and 0.47%, respectively. The distribution of stakeholders was uneven, with primary medical and health institutions and county hospitals being the main targets, accounting for 27.77% and 25.52%, respectively. With the evolution of policies, the number and variety of policy tools used showed a rapid increase, but capacity-type policy tools still dominated, and there was an imbalance in the internal structure of policy tools. Additionally, the involvement of two key stakeholders including medical personnel and the public, was relatively low. Conclusion There is significant differentiation in the utilization of policy tools, with insufficient use of symbolic, incentive-type policy tools.It is suggested to improve the internal structure of policy elements, enhance the balance of policy tool utilization, continuously optimize policy tools, increase the use of incentive-type and symbolic policy tools, and strengthen the participation of two key stakeholders: medical personnel and the public.

Policy tools  /  County medical community  /  Quantitative research
吴瑶, 罗香林, 马国芳. 政策工具视角下我国县域医共体政策量化研究. 现代预防医学, 2024 , 51 (11) : 2008 -2012 . DOI: 10.20043/j.cnki.MPM.202312466
Yao WU, Xiang-lin LUO, Guo-fang MA. A quantitative study on the policy of county medical community in China from the perspective of policy tools[J]. Modern Preventive Medicine, 2024 , 51 (11) : 2008 -2012 . DOI: 10.20043/j.cnki.MPM.202312466
正文
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国家在《十四五规划》中要求以县医院为重点，推进分级诊疗建设，积极发展医疗联合体[1]。县域医共体是医疗联合体在县域探索的一种发展模式，通过整合县域内所有医疗资源，促使优质资源有效下沉到基层，提高县域医疗卫生服务能力[2]，是我国为实现有序就医新格局、打造优质高效医疗卫生服务体系的重大举措[3]。自新医改以来，中央政府出台一系列县域医共体建设的政策文件，政策发文量逐年上升，县域医共体逐步引来政府和各类学者的关注，随着政策措施和相关研究的推进，使得县域医共体整体建设持续推进[4]。基于此，本文利用县域医共体领域现有政策，以政策工具、政策演进和利益相关者角度构建三维分析框架，深入探讨政策工具在不同时间阶段与不同利益相关者使用上的差异，旨在发现我国现有县域医共体政策的不足之处，为健全我国县域医共体政策提供一定借鉴或参考。
1　资料与方法
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1.1　数据来源
根据中国人民政府网、国家卫生健康委等官方网站，以及北大法宝、CNKI、万方等数据库，将“县域医共体”“县域医疗共同体”“医联体”“医疗联合体”等作为关键词进行全文检索，为确保研究结果的可靠性和代表性，由两名研究人员对政策文件进行检索，并按照纳入和排除相关标准进行筛选，两人共同讨论解决分歧之处。最终遴选出2009-2023年（截至2023年3月底）国家层面的县域医共体政策文本共计29份。见表1。
1.2　纳入与排除标准
纳入标准：（1）文本内容与县域医共体建设密切相关，可体现政府对县域医共体建设的明确态度；（2）发文机关为国家层面；（3）政策文件均公开颁布；（4）政策类型为法律法规、规划、办法、意见、通知、公告等。
排除标准：将与县域医共体建设发展相关性与针对性不强的政策文件排除。
1.3　研究方法
本研究以最终筛选的29份县域医共体政策文本作为研究对象，首先把政策文本按照时间顺序进行编号，再按照“政策文本编号-分级标题-具体条款”进行编码，如“13-3-2-6”则表示第13份政策文件中“三、工作内容”中的“（二）深化体制机制改革”中的“6.推进人事制度改革”。最后将形成的编码表通过Excel 2021录入数据，利用X-Y-Z三维分析框架对数据进行量化分析。
政策工具是研究公共政策的有效手段[5]，本研究参照周立芳[6]以及石敏[7]的政策工具模型，同时与县域医共体建设的实际工作相结合，将县域医共体政策工具划分为权威、激励、能力建设、系统变革、象征与劝诫五种类型。根据政策文本的发文时间、数量以及政府机关级别，并参考刘宝琴[8]学者的研究成果，将县域医共体建划分为政策雏形(2009—2015年)、探索(2016—2018年)和发展(2019年至今)三阶段。利益相关者[9]是指能影响企业目标实现或实现过程中的任何个人或组织群体[10]，县域医共体建设的核心利益相关者可分为政府部门、县级医院、基层医疗卫生机构、医务人员和群众五类。本文综合政策工具（X维度）、政策演进（Y维度）、利益相关者（Z维度）构建县域医共体建设政策X-Y-Z三维分析框架，量化分析医共体政策文本的科学性与不足。见图1。
2　结果
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2.1　县域医共体政策内部结构特征及其均衡性分析
政策工具方面，共编码424条，其中能力型工具最多，占比35.38%；激励型工具最少，占比8.96%。在二级指标中，比如在象征与劝诫型工具中，鼓励号召应用最多，占比7.55%，政策宣传和经验推广使用偏少，分别为1.65%、0.94%；激励型工具中医保支付运用最多，为4.01%，晋升进修使用相对不足，为0.47%。县域医共体建设政策工具除系统变革型工具内部分布较均衡外，其他类型工具的内部结构尚存在一定失衡现象。
政策演进方面，在雏形期，国家仅出台了3项关于县域医共体建设的政策，2015年“医疗联合体”[6]首次以文件的形式出现。在探索期，国家陆续出台了7项关于县域医共体的政策，内容涵盖了县域医共体的组织形式、发展目标等，为医共体的进一步发展奠定了基础。在发展期，国家出台了19项促进县域医共体建设的政策，全国范围展开试点，发布紧密型县域医共体的评判标准和监测指标，为县域医共体的规范化发展提供了参考依据。
利益相关者方面，共编码623条，分别从五个层面对县域医共体建设政策进行评估，其中，对基层医疗机构作出相关规定的次数最多，占比27.77%；对群众作出的相关规定次数最少，占比10.27%，具体领域的分布也呈现出明显的不均衡。补充说明，不是每一条政策都对利益相关者作出了规定，反之，有的政策缺反复提及，因此利益相关者方面的总数与编码总数不一致，需要加以区别。
2.2　县域医共体政策二维交叉维度匹配性分析
2.2.1　政策工具与政策演进阶段量化分析
结果如表2所示，由于第一阶段只包含3项政策文本，其中能力型工具占比4.17%，但象征和劝诫型工具占比0.96%；在第二阶段中，能力型工具出现次数最多，占比11.88%，但激励型工具使用最少，占比2.73%；在第三阶段中，依然是能力型工具出现次数最多，占比22.47%，激励型工具使用最少，占比2.89%。在子工具种类方面，第三阶段使用的种类最多，使用全部政策工具，且主要集中在能力型。比较发现，三阶段以来，政策工具的数量与种类迅速上升。说明国家一直在重视能力型政策工具，通过人才培养、资源下沉、信息建设等方式，不断提升县域基层医疗卫生服务能力。
2.2.2　政策工具与利益相关者量化分析
结果显示，权威型工具中政府出现次数最多，占比7.54%；激励型工具中医务人员占比最多，占比2.41%；能力型工具中基层医疗机构出现次数最多，占比13.64%，县级医院次之，占比11.40%；系统变革型工具中政府出现次数最多，占比5.62%；象征与劝诫工具各利益相关者的出现次数较为均衡。在政策子工具方面，对政府使用较多的为命令规定，占比4.17%；对县级医院和基层医疗卫生机构使用较多的均为资源统筹；对医务人员使用最多的为人才培养，占比2.73%；其中对群众使用的政策子工具均较少。
2.3　县域医共体政策工具三维交叉分析
图2显示，我国县域医共体建设政策中不同政策利益相关者，在政策演进的三个阶段所使用的政策工具情况。从增长趋势来看，其中增速最快的是能力型政策工具，增速最慢的是激励型政策工具。第一阶段，各类政策工具整体使用次数都相对较少，与该阶段政策发文数量较少有关。第二阶段，政策发文数量突飞猛进，政策工具已经逐步涉及到所有的利益相关者。第三阶段，对各利益相关者使用的五类政策工具均显著增加。
3　讨论
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3.1　完善政策要素内部结构，增强政策工具运用的均衡性
政策工具的种类和属性各不相同，如何搭配使用完成互补耦合，对于推进县域医共体建设至关重要[11]，但县域医共体建设政策工具的内部结构尚存在一定失衡现象，需要完善政策要素的内部结构，增强政策工具运用的均衡性。第一，在县级医共体的建设进程中，打造信息化的统一平台、培养高水平的卫生人才以及及时的评估指导运行效果，资金保障必不可少，需要政府持续增加财政投入，不断完善投入方式，激发县域医共体各层医疗机构的参与热情，从而促进县域医共体的共同建设。第二，象征及劝诫工具是政策实施的指引与保证，通过电视、网络等大众媒体，加大对医共体政策宣传的力度，在县域营造良好的舆论氛围，引导群众有序就医。第三，激励型工具能够增强政策对象的积极性，如果不注重激励手段，牵头医院对基层的帮扶也是有限的，县域医共体建设很难达到真正意义上的紧密。因此，应加大对激励型工具中各个细分目标的支持力度，通过“通报表扬、惩戒批评”等辅助手段，强化县域医共体建设的激励约束机制。
3.2　兼顾各方利益，重视医务人员和群众相关政策工具的带动性与辐射性
现有的政策工具中，涉及医务人员和群众两利益方较少，需要调整优化。县域医共体建设政策涉及基层医疗卫生机构、县级医院与政府的条目相对较多，从而忽视了医务人员和群众。因此，在医务人员方面，要将薪酬待遇[12]、晋升进修等措施与绩效考核挂钩，不断优化收入分配机制，提高医务人员的积极性和主动性[10]。鼓励医共体内资深专家与骨干到基层坐诊或担任管理负责人，提供技术指导与帮扶，实现优质医疗卫生资源有效下沉[13]。在患者方面，推动有序就医的各项政策落地实施；对于辖区常见病或高血压、糖尿病等慢性病患者，可以搭建线上药品配送的信息化平台；进一步扩充基本药物目录，实现医共体内部机构药品处方互认，方便患者就医与用药[14]。通过这些举措不断增强利益相关方的凝聚力，以便更好地为医共体建设服务。
3.3　不同政策演进阶段特点有所差异，从根本上推动县域医共体建设发展
政策演进的三个阶段中增速最快的是能力型工具，在第三阶段对各利益相关者使用的三类政策工具相比第一阶段和第二阶段均有所增加，但当前第三阶段发布的县域医共体建设政策的重点仍是能力型政策工具，且涉及最多的利益相关者主要是县级医院和基层医疗卫生机构。近年来，我国医疗卫生事业将进入高质量发展阶段，分级诊疗制度也日渐成熟，县域医共体建设也迎来新的挑战和需求，但现有的政策组合性不强，政策工具使用趋向僵化，对现阶段的适用性不强[15]。一方面要通过完善医共体建设参与主体的多元化，调整优化政策运用的动态性，优化配置医疗卫生资源。另一方面要注重县域医共体政策工具运用的内部结构，不断增强政策工具的均衡性，推进县域医共体建设等政策的发展迈向新阶段。
基金
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  • 新疆农村基层公共卫生防控能力建设研究(JZ202001045)
文献
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2024年第51卷第11期
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doi: 10.20043/j.cnki.MPM.202312466
  • 接收时间：2023-12-25
  • 首发时间：2026-03-18
  • 出版时间：2024-06-10
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  • 收稿日期：2023-12-25
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新疆农村基层公共卫生防控能力建设研究(JZ202001045)
作者信息
    1.新疆医科大学公共卫生学院，新疆 乌鲁木齐 830054
    2.新疆医科大学健康管理学院，新疆 乌鲁木齐 830054

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红菇科 Russulaceae 3 23 11.00 小皮伞属 Marasmius 6 2.87
小菇属 Mycena 11 5.26
光柄菇属 Pluteus 5 2.39
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