农村地区培养卫生人才的国际经验与启示
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摘要
目的:描述国外为农村地区培养卫生人才的政策和项目,分析增加农村地区卫生人力的做法和措施,为我国订单定向免费医学生培养政策提供参考和依据。方法:采用文献综述方法,搜索国内外为农村地区培养卫生人才相关文献48篇,对上述文献进行逻辑分析归纳,系统回顾分析国内外相关策略和做法,总结经验启示。结果:为农村地区培养卫生人才的常见措施包括:招收农村背景学生、导师制医学培养、农村卫生机构实习、经济激励措施、毕业后强制农村服务。对我国的启示包括:充足的财政资金是保证项目顺利实施的先决条件;做好项目管理和评价工作可以提高项目实施效果;选择合适的做法组合实施此类项目可以提高其效果。结论:订单定向免费医学生培养政策适合当前我国国情,同时不少国外经验值得我们借鉴:加大资金投入,加强管理和评价,加强部门合作,进一步完善订单定向医学生培养。
Objectives:To describe and summarize international evidences on policies and programs for training health personnel in rural areas,to identify best practice to increase health manpower in rural areas,and to provide references for China's policy of targeted admission program.Methods:This is a literature review based research.48 literatures in Chinese and English were selected about the training of health professionals in rural areas at home and abroad.Thematic framework approach was applied to review and analyze the related strategies and practices,and lessons learned.Results:Common measures to train health personnel in rural areas included:enrollment of students with a rural background,tutoring system in medical training,internship in rural health institutions,financial incentives,and compulsory rural services after graduation.Lessons learnt:(1) adequate financial resources are a prerequisite for smooth program implementation;(2) Good project management and evaluation are critical aspects of effective project implementation;(3) choosing the right combination of various practices to implement such projects can improve effectiveness.Conclusions:The policy of targeted admission program is suitable for China's current situation.Meanwhile,international experiences can provide valuable lessons to improve China's program design and implementation and these include:increasing capital investment,strengthening management and evaluation,and strengthening sector cooperation to further improve targeted admission program.
Objectives:To describe and summarize international evidences on policies and programs for training health personnel in rural areas,to identify best practice to increase health manpower in rural areas,and to provide references for China's policy of targeted admission program.Methods:This is a literature review based research.48 literatures in Chinese and English were selected about the training of health professionals in rural areas at home and abroad.Thematic framework approach was applied to review and analyze the related strategies and practices,and lessons learned.Results:Common measures to train health personnel in rural areas included:enrollment of students with a rural background,tutoring system in medical training,internship in rural health institutions,financial incentives,and compulsory rural services after graduation.Lessons learnt:(1) adequate financial resources are a prerequisite for smooth program implementation;(2) Good project management and evaluation are critical aspects of effective project implementation;(3) choosing the right combination of various practices to implement such projects can improve effectiveness.Conclusions:The policy of targeted admission program is suitable for China's current situation.Meanwhile,international experiences can provide valuable lessons to improve China's program design and implementation and these include:increasing capital investment,strengthening management and evaluation,and strengthening sector cooperation to further improve targeted admission program.
引文
[1]王文广.西部某高校农村订单定向医学生职业认同现状调查分析[M].昆明:昆明医科大学,2015.
[2]Hou J,Ke Y.Addressing the shortage of health professionals in rural China:issues and progress Comment on“Have health human resources become more equal between rural and urban areas after the new reform?”[J].International journal of health policy and management,2015,4(5):327-328.
[3]黄星,左延莉,潘小炎,等.农村订单定向免费医学生现状调查研究[J].中国卫生事业管理,2015,32(6):456-457,462.
[4]胡丹,陈楚康,张超,等.农村订单定向医学生免费培养政策实施现状调查[J].中国卫生政策研究,2016,9(9):60-64.
[5]梁喜跃.订单定向委培模式的利弊得失[J].中国农村卫生,2016(5):14-15.
[6]Keane S,Lincoln M,Smith T.Retention of allied health professionals in rural New South Wales:a thematic analysis of focus group discussions[J].Bmc Health Serv Res,2012,12:175.
[7]Pfarrwaller E,Sommer J,Chung C,et al.Impact of Interventions to Increase the Proportion of Medical Students Choosing a Primary Care Career:A Systematic Review[J].J Gen Intern Med,2015,30(9):1349-1358.
[8]Pathman D E,Taylor D H Jr,Konrad T R,et al.State scholarship,loan forgiveness,and related programs:the unheralded safety net[J].JAMA,2000,284(16):2084-2092.
[9]Zink T,Center B,Finstad D,et al.Efforts to graduate more primary care physicians and physicians who will practice in rural areas:examining outcomes from the university of Minnesota-duluth and the rural physician associate program[J].Acad Med,2010,85(4):599-604.
[10]Pathman D E,Konrad T R,King T S,et al.Outcomes of States’Scholarship,Loan Repayment,and Related Programs for Physicians[J].Medical Care,2004,42(6):560-568.
[11]Rabinowitz H K,Diamond J J,Markham F W,et al.A program to increase the number of family physicians in rural and underserved areas:impact after 22 years[J].JAMA,1999,281(3):255-260.
[12]Rabinowitz H K.Recruitment,retention,and follow-up of graduates of a program to increase the number of family physicians in rural and underserved areas[J].N Engl J Med,1993,328(13):934-939.
[13]Rabinowitz H K,Diamond J J,Markham F W,et al.Long-term retention of graduates from a program to increase the supply of rural family physicians[J].Acad Med,2005,80(8):728-732.
[14]Rabinowitz H K,Diamond J J,Markham F W,et al.Retention of rural family physicians after 20-25 years:outcomes of a comprehensive medical school rural program[J].J Am Board Fam Med,2013,26(1):24-27.
[15]周海燕.美国乡村医学教育计划对我国医学教育的启示[J].中国高等医学教育,2011,170(2):114-115.
[16]Glasser M,Hunsaker M,Sweet K,et al.A comprehensive medical education program response to rural primary care needs[J].Acad Med,2008,83(10):952-961.
[17]Smucny J,Beatty P,Grant W,et al.An evaluation of the Rural Medical Education Program of the State University Of New York Upstate Medical University,1990-2003[J].Acad Med,2005,80(8):733-738.
[18]Zink T,Center B,Finstad D,et al.Efforts to graduate more primary care physicians and physicians who will practice in rural areas:examining outcomes from the university of Minnesota-duluth and the rural physician associate program[J].Acad med,2010,85(4):549-604.
[19]Halaas G W.The Rural Physician Associate Program:successful outcomes in primary care and rural practice[J].Rural and remote health,2005,5(2):453.
[20]Matsumoto M,Inoue K,Kajii E,et al.Retention of physicians in rural Japan:concerted efforts of the government,prefectures,municipalities and medical schools[J].Rural and remote health,2010,10(2):1432.
[21]Matsumoto M,Inoue K,Kajii E.A contract-based training system for rural physicians:follow-up of Jichi Medical University graduates(1978-2006)[J].The Journal of rural health,2008,24(4):360-368.
[22]Matsumoto M,Inoue K,Kajii E.Characteristics of medical students with rural origin:implications for selective admission policies[J].Health Policy,2008,87(2):194-202.
[23]Matsumoto M,Inoue K,Kajii E.Long-term effect of the home prefecture recruiting scheme of Jichi Medical University,Japan[J].Rural and remote health,2008,8(3):930.
[24]Matsumoto M,Inoue K,Kajii E.Policy implications of a financial incentive programme to retain a physician workforce in underserved Japanese rural areas[J].Soc Sci Med,2010,71(4):667-671.
[25]Matsumoto M,Kajii E.Medical education program with obligatory rural service:analysis of factors associated with obligation compliance[J].Health Policy,2009,90(2-3):125-132.
[26]Inoue K,Matsumoto M,Sawada T.Evaluation of a medical school for rural doctors[J].The Journal of rural health:official journal of the American Rural Health Association and the National Rural Health Care Association,2007,23(2):183-187.
[27]Dunbabin J S,Mc Ewin K,Cameron I.Postgraduate medical placements in rural areas:their impact on the rural medical workforce[J].Rural and remote health,2006,6(2):481.
[28]Sen Gupta T,Murray R,Hays R,et al.James Cook University MBBS graduate intentions and intern destinations:a comparative study with other Queensland and Australian medical schools[J].Rural and remote health,2013,13(2):2313.
[29]Veitch C,Underhill A,Hays R B.The career aspirations and location intentions of James Cook University’s first cohort of medical students:a longitudinal study at course entry and graduation[J].Rural and remote health,2006,6(1):537.
[30]Lee Y H,Barnard A,Owen C.Initial evaluation of rural programs at the Australian National University:understanding the effects of rural programs on intentions for rural and remote medical practice[J].Rural and remote health,2011,11(2):1602.
[31]Wiwanitkit V.Mandatory rural service for health care workers in Thailand[J].Rural and remote health,2011,11(1):1583.
[32]Pagaiya N,Kongkam L,Sriratana S.Rural retention of doctors graduating from the rural medical education project to increase rural doctors in Thailand:a cohort study[J].Hum Resour Health,2015,13(1):10.
[33]Wibulpolprasert S,Pengpaibon P.Integrated strategies to tackle the inequitable distribution of doctors in Thailand:four decades of experience[J].Hum Resour Health,2003,1(1):12.
[34]Tangcharoensathien V,Limwattananon S,Suphanchaimat R,et al.Health workforce contributions to health system development:a platform for universal health coverage[J].Bull World Health Organ,2013,91(11):874-880.
[35]Putthasri W,Suphanchaimat R,Topothai T,et al.Thailand special recruitment track of medical students:a series of annual cross-sectional surveys on the new graduates between 2010 and 2012[J].Hum Resour Health,2013,11:47.
[36]Yi Y,Chongsuvivatwong V,Sriplung H,et al.CPIRD:A successful Thai programme to produce clinically competent medical graduates[J].F1000Research,2015,4:158.
[37]Ross A J.Success of a scholarship scheme for rural students[J].S Afr Med J,2007,97(11):1087-1090.
[38]Thaker S I,Pathman D E,Mark B A,et al.Service-linked scholarships,loans,and loan repayment programs for nurses in the southeast[J].J Prof Nurs,2008,24(2):122-130.
[39]Liu X,Dou L,Zhang H,et al.Analysis of context factors in compulsory and incentive strategies for improving attraction and retention of health workers in rural and remote areas:a systematic review[J].Hum Resour Health,2015,13(1):61.
[40]Barnighausen T,Bloom D E.Designing financial-incentive programmes for return of medical service in underserved areas:seven management functions[J].Hum Resour Health,2009,7:52.
[41]Barnighausen T,Bloom D E.Financial incentives for return of service in underserved areas:a systematic review[J].Bmc Health Serv Res,2009,9:86.
[42]Sempowski I P.Effectiveness of financial incentives in exchange for rural and underserviced area return-of-service commitments:systematic review of the literature[J].Canadian journal of rural medicine,2004,9(2):82-88.
[43]袁蓓蓓,孟庆跃.农村基层卫生服务人员工作行为决定机制:基于工作动机理论的分析[J].中国卫生经济,2012,31(7):50-52.
[44]侯志远,孟庆跃,袁蓓蓓,等.农村基层卫生人员激励偏好研究[J].中国卫生政策研究,2010,3(10):18-22.
[45]刘晓云.农村地区吸引和稳定卫生人员研究的理论框架[J].中国卫生政策研究,2011,4(5):11-15.
[46]李强.农村订单定向医学生学习倦怠状况及其影响因素分析[J].新乡医学院学报,2016(3):208-211.
[47]刘洋,李杰,贾怡.农村订单定向医学生学习动机的研究[J].现代预防医学,2015(9):1653-1655.
[48]张海英,韦波,赵永祥,等.农村订单定向医学生培养模式的探索与实践[J].中国高等医学教育,2012(8):1-2,4.
[2]Hou J,Ke Y.Addressing the shortage of health professionals in rural China:issues and progress Comment on“Have health human resources become more equal between rural and urban areas after the new reform?”[J].International journal of health policy and management,2015,4(5):327-328.
[3]黄星,左延莉,潘小炎,等.农村订单定向免费医学生现状调查研究[J].中国卫生事业管理,2015,32(6):456-457,462.
[4]胡丹,陈楚康,张超,等.农村订单定向医学生免费培养政策实施现状调查[J].中国卫生政策研究,2016,9(9):60-64.
[5]梁喜跃.订单定向委培模式的利弊得失[J].中国农村卫生,2016(5):14-15.
[6]Keane S,Lincoln M,Smith T.Retention of allied health professionals in rural New South Wales:a thematic analysis of focus group discussions[J].Bmc Health Serv Res,2012,12:175.
[7]Pfarrwaller E,Sommer J,Chung C,et al.Impact of Interventions to Increase the Proportion of Medical Students Choosing a Primary Care Career:A Systematic Review[J].J Gen Intern Med,2015,30(9):1349-1358.
[8]Pathman D E,Taylor D H Jr,Konrad T R,et al.State scholarship,loan forgiveness,and related programs:the unheralded safety net[J].JAMA,2000,284(16):2084-2092.
[9]Zink T,Center B,Finstad D,et al.Efforts to graduate more primary care physicians and physicians who will practice in rural areas:examining outcomes from the university of Minnesota-duluth and the rural physician associate program[J].Acad Med,2010,85(4):599-604.
[10]Pathman D E,Konrad T R,King T S,et al.Outcomes of States’Scholarship,Loan Repayment,and Related Programs for Physicians[J].Medical Care,2004,42(6):560-568.
[11]Rabinowitz H K,Diamond J J,Markham F W,et al.A program to increase the number of family physicians in rural and underserved areas:impact after 22 years[J].JAMA,1999,281(3):255-260.
[12]Rabinowitz H K.Recruitment,retention,and follow-up of graduates of a program to increase the number of family physicians in rural and underserved areas[J].N Engl J Med,1993,328(13):934-939.
[13]Rabinowitz H K,Diamond J J,Markham F W,et al.Long-term retention of graduates from a program to increase the supply of rural family physicians[J].Acad Med,2005,80(8):728-732.
[14]Rabinowitz H K,Diamond J J,Markham F W,et al.Retention of rural family physicians after 20-25 years:outcomes of a comprehensive medical school rural program[J].J Am Board Fam Med,2013,26(1):24-27.
[15]周海燕.美国乡村医学教育计划对我国医学教育的启示[J].中国高等医学教育,2011,170(2):114-115.
[16]Glasser M,Hunsaker M,Sweet K,et al.A comprehensive medical education program response to rural primary care needs[J].Acad Med,2008,83(10):952-961.
[17]Smucny J,Beatty P,Grant W,et al.An evaluation of the Rural Medical Education Program of the State University Of New York Upstate Medical University,1990-2003[J].Acad Med,2005,80(8):733-738.
[18]Zink T,Center B,Finstad D,et al.Efforts to graduate more primary care physicians and physicians who will practice in rural areas:examining outcomes from the university of Minnesota-duluth and the rural physician associate program[J].Acad med,2010,85(4):549-604.
[19]Halaas G W.The Rural Physician Associate Program:successful outcomes in primary care and rural practice[J].Rural and remote health,2005,5(2):453.
[20]Matsumoto M,Inoue K,Kajii E,et al.Retention of physicians in rural Japan:concerted efforts of the government,prefectures,municipalities and medical schools[J].Rural and remote health,2010,10(2):1432.
[21]Matsumoto M,Inoue K,Kajii E.A contract-based training system for rural physicians:follow-up of Jichi Medical University graduates(1978-2006)[J].The Journal of rural health,2008,24(4):360-368.
[22]Matsumoto M,Inoue K,Kajii E.Characteristics of medical students with rural origin:implications for selective admission policies[J].Health Policy,2008,87(2):194-202.
[23]Matsumoto M,Inoue K,Kajii E.Long-term effect of the home prefecture recruiting scheme of Jichi Medical University,Japan[J].Rural and remote health,2008,8(3):930.
[24]Matsumoto M,Inoue K,Kajii E.Policy implications of a financial incentive programme to retain a physician workforce in underserved Japanese rural areas[J].Soc Sci Med,2010,71(4):667-671.
[25]Matsumoto M,Kajii E.Medical education program with obligatory rural service:analysis of factors associated with obligation compliance[J].Health Policy,2009,90(2-3):125-132.
[26]Inoue K,Matsumoto M,Sawada T.Evaluation of a medical school for rural doctors[J].The Journal of rural health:official journal of the American Rural Health Association and the National Rural Health Care Association,2007,23(2):183-187.
[27]Dunbabin J S,Mc Ewin K,Cameron I.Postgraduate medical placements in rural areas:their impact on the rural medical workforce[J].Rural and remote health,2006,6(2):481.
[28]Sen Gupta T,Murray R,Hays R,et al.James Cook University MBBS graduate intentions and intern destinations:a comparative study with other Queensland and Australian medical schools[J].Rural and remote health,2013,13(2):2313.
[29]Veitch C,Underhill A,Hays R B.The career aspirations and location intentions of James Cook University’s first cohort of medical students:a longitudinal study at course entry and graduation[J].Rural and remote health,2006,6(1):537.
[30]Lee Y H,Barnard A,Owen C.Initial evaluation of rural programs at the Australian National University:understanding the effects of rural programs on intentions for rural and remote medical practice[J].Rural and remote health,2011,11(2):1602.
[31]Wiwanitkit V.Mandatory rural service for health care workers in Thailand[J].Rural and remote health,2011,11(1):1583.
[32]Pagaiya N,Kongkam L,Sriratana S.Rural retention of doctors graduating from the rural medical education project to increase rural doctors in Thailand:a cohort study[J].Hum Resour Health,2015,13(1):10.
[33]Wibulpolprasert S,Pengpaibon P.Integrated strategies to tackle the inequitable distribution of doctors in Thailand:four decades of experience[J].Hum Resour Health,2003,1(1):12.
[34]Tangcharoensathien V,Limwattananon S,Suphanchaimat R,et al.Health workforce contributions to health system development:a platform for universal health coverage[J].Bull World Health Organ,2013,91(11):874-880.
[35]Putthasri W,Suphanchaimat R,Topothai T,et al.Thailand special recruitment track of medical students:a series of annual cross-sectional surveys on the new graduates between 2010 and 2012[J].Hum Resour Health,2013,11:47.
[36]Yi Y,Chongsuvivatwong V,Sriplung H,et al.CPIRD:A successful Thai programme to produce clinically competent medical graduates[J].F1000Research,2015,4:158.
[37]Ross A J.Success of a scholarship scheme for rural students[J].S Afr Med J,2007,97(11):1087-1090.
[38]Thaker S I,Pathman D E,Mark B A,et al.Service-linked scholarships,loans,and loan repayment programs for nurses in the southeast[J].J Prof Nurs,2008,24(2):122-130.
[39]Liu X,Dou L,Zhang H,et al.Analysis of context factors in compulsory and incentive strategies for improving attraction and retention of health workers in rural and remote areas:a systematic review[J].Hum Resour Health,2015,13(1):61.
[40]Barnighausen T,Bloom D E.Designing financial-incentive programmes for return of medical service in underserved areas:seven management functions[J].Hum Resour Health,2009,7:52.
[41]Barnighausen T,Bloom D E.Financial incentives for return of service in underserved areas:a systematic review[J].Bmc Health Serv Res,2009,9:86.
[42]Sempowski I P.Effectiveness of financial incentives in exchange for rural and underserviced area return-of-service commitments:systematic review of the literature[J].Canadian journal of rural medicine,2004,9(2):82-88.
[43]袁蓓蓓,孟庆跃.农村基层卫生服务人员工作行为决定机制:基于工作动机理论的分析[J].中国卫生经济,2012,31(7):50-52.
[44]侯志远,孟庆跃,袁蓓蓓,等.农村基层卫生人员激励偏好研究[J].中国卫生政策研究,2010,3(10):18-22.
[45]刘晓云.农村地区吸引和稳定卫生人员研究的理论框架[J].中国卫生政策研究,2011,4(5):11-15.
[46]李强.农村订单定向医学生学习倦怠状况及其影响因素分析[J].新乡医学院学报,2016(3):208-211.
[47]刘洋,李杰,贾怡.农村订单定向医学生学习动机的研究[J].现代预防医学,2015(9):1653-1655.
[48]张海英,韦波,赵永祥,等.农村订单定向医学生培养模式的探索与实践[J].中国高等医学教育,2012(8):1-2,4.