两层级公共医疗资源空间均衡性及其影响机制——以分级诊疗改革为背景

中国公共医疗资源在层级间和地区间配置不合理的问题较为突出。分级诊疗改革对优化医疗资源配置、实现供需均衡具有重要意义。运用探索性空间分析法和地理探测器分别从全国地级市域和四川县域两个尺度分析了2015年两层级医疗资源的空间配置特征与影响机制。结果表明：基层和上层医疗资源均呈显著空间聚集特征,而层级间空间配置格局具有差异性。不同尺度和区域两层级医疗资源配置的决定力及其影响强度不同,上层医疗资源对外部影响因素响应强度大于基层。对上层级医疗资源配置而言,城镇化率、人口密度、经济发展水平是全局性因素,老龄化、地形条件和发病率为地方性因素;对基层医疗资源配置而言,人口密度是较为显著的全局性影响因素,城镇化率是重要的地方性影响因素,地形、经济发展水平、人口老龄化和发病率在部分尺度和区域有局部影响。为实现分级诊疗改革的目标,各级决策部门需以“全局性和地域性因素相结合,统一性和地方性政策相结合,自上而下与自下而上决策机制相结合”为思路,统筹不同区域和层级医疗资源配置,以提高医疗卫生服务体系的整体功能,促进其均衡、协同发展。

Spatial equity and influences of two-level public healthcare resources:A background to hierarchical diagnosis and treatment reform in China

In present-day China, the unequal distribution of public healthcare resources across different levels and regions is problematic. Hierarchical diagnosis and treatment (HDT) reform is of great significance for optimising the distribution of healthcare resources and promoting fairness across health services. In this study, exploratory spatial data analysis (ESDA) was applied to evaluate spatial patterns at the lower and upper levels of healthcare resources. The Geodetector model was used to analyse the influences of the healthcare system at the municipal and county levels during 2015. The results show that there is significant spatial clustering in the distribution of the two-level healthcare resources. Influences on upper-level healthcare resources are more significant than those on lower levels. The dominant influencing factors of the two-level healthcare resources differ across spatial scales and regions. In terms of upper-level healthcare resources, urbanisation, population density and the level of economic development are the dominant global factors, in addition to the regional factors of population aging, topography and the morbidity of epidemic and endemic diseases. In the case of lower-level healthcare resources, urbanisation is an important influencing factor, while economic development, population aging and morbidity have local effects. Ultimately, population density was the dominant factor. Finally, this paper suggests that, aiming for HDT reform, decision makers should allocate healthcare resources among different regions and levels in consideration of relevant global and local factors, united and targeted policies, and top-down and bottom-up decision-making mechanisms. This could promote the overall function of the healthcare system and enhance the equity and coordination of multi-level healthcare resources.