清华团队柳叶刀发文：《中国公共卫生体系：提高正当时》,千万公共卫生事业从业者迎来重大利好！

2021年11月26日，清华大学万科公共卫生与健康学院常务副院长、健康中国研究院院长梁万年教授团队在国际权威期刊《柳叶刀·公共卫生》（The Lancet Public Health）发表题为“ China’s public health system: time for improvement（中国公共卫生体系：提高正当时）”的评论文章。

摘要

新冠肺炎疫情的爆发再次突显出构建强大的公共卫生体系对于维护人民健康的重要性。在疫情防控的常态化时期，如何放眼长远，总结经验和教训，找堵点、补短板、强弱项，建设有韧性的公共卫生体系，成为全球关注的热点议题。在此背景下， 文章着重介绍了在疫情影响之下全球公共卫生与健康事业的当下，我国如何进一步强化公共卫生体系建设，并从健康理念的变革、公共卫生投入机制的完善、人才培养和能力建设、疾病控制系统的核心功能定位以及医防融合等方面提出了进一步完善我国公共卫生体系的建议。该文章在公共卫生体系建设的关键时期，为进一步完善我国重大疫情防控体制机制、健全公共卫生与健康的管理体系做出了有益探索，并与国际社会分享宝贵经验，对完善全球公共卫生体系，推动构建人类健康共同体起到了积极的促进作用。

原文阅读

The SARS-CoV pandemic in 2003 prompted the first substantial improvement of the public health system in China since the reform and opening up, and these improvements have greatly helped the country to contain the COVID-19 pandemic through effective resource sharing and the tracking of close contacts.

Although important advancements have been made to the Chinese public health system, we have to ensure it is robust enough to respond appropriately to emerging and traditional health challenges.

The COVID-19 pandemic has made it clear that governance needs to address gaps in the public health system in order to provide resilience. First, the concept of health needs to be revised: although a prevention-oriented health policy has been promoted in China since the 1950s, the overall health system still remains heavily focused on disease treatment, therefore the concept of health needs substantial change at the institutional level and in the construction of an integrated health service system. Second, the undervalued and underemphasised status of public health needs to change: the growth rate of health expenditures for public health institutions is much lower (from ¥48·8 billion [6·5%] of total government health spending in 2011 to ¥135·3 billion [7·5%] in 2019) than for clinical institutions (from ¥101·2 billion [13·6%] of total government health spending in 2011 to ¥673·5 [37·4%] in 2019).

The number of health personnel in the Chinese Center for Disease Control and Prevention (CDC) (the principal sector of public health in China), as a percentage of the total number of health staff, was 3·3% in 2004 after the SARS pandemic but by 2019 was only 1·45%.

Increasing government investment in public health together with improving mechanisms for subsidising public health institutions and linking salaries to performance rather than fixed remuneration directed from government is essential. Additionally, to attract and retain qualified personnel, discrimination against people in the public health sector must be eliminated, the role of public health professionals who work behind the scenes to provide evidence for policy makers must be recognised, and the salary of people working in public health should be aligned with their social value and consistent with that of clinical personnel at the same level. Third, the skills of professionals must be improved: to address complex public health issues, extending public health education beyond medical knowledge and integrating content from related disciplines (eg, law, political, social sciences and humanities) is indispensable. Moreover, retraining of personnel is vital to ensure there are enough trained personnel to respond to crises such as pandemics. Fourth, the core capabilities of the Chinese CDC must be refined: on May 14, 2021, the National Bureau of Disease Control and Prevention was established to promote public health in a comprehensive manner, marking a major step forward in enhancing the nation's post-epidemic public health governance.

However, it is not clear how the Chinese CDC operates, especially at the grassroots level. Therefore, core capabilities should be refined to ensure more efficient cooperation at all levels, including national (eg, global public health governance, personnel education, and advanced laboratories for precision diagnosis), provincial (eg, professional training and precision diagnosis at the local level), municipal (eg, identifying health issues and intervention), and county level (eg, developing skillsets for epidemiological investigation and meaningful health education). Additionally, building regional public health centres and public health information platforms based on health informatisation technologies will help to develop material reserves and organisational channels needed to address public health issues. Fifth, clinical treatment and prevention needs to be better integrated: in order to improve the response of public health systems to substantial infectious disease threats and growing non-infectious disease challenges (eg, diabetes, hypertension, stroke, cancer and tobacco use), it is imperative that the insufficient integration of medical treatment and public health is addressed.

Treatment and prevention currently fall into two isolated sectors. Hospitals need to promote public health by encouraging clinicians to prescribe health education as well as traditional prescriptions for drugs. Additionally, clinical and public health institutions (such as the fever clinic and infection department) can share personnel and data, and this will be conducive to the decision-making involved in population health and crisis prevention. Importantly, the establishment of an effective incentive mechanism (eg, making professional experience in public health a prerequisite for the promotion of clinicians) is important for integrating medical treatment and public health. Sixth, collaboration needs to happen across sectors: the widespread effect of public health issues highlights the need for actions taken at multisectoral level beyond the public health field, such as the public, private, and grassroots sectors including village and neighbourhood committees.

Finally, the legal framework for public health development should be improved (eg, responsibility rules, regulation on production and sales of emergency materials, information management, and security supervision) to ensure the health of the population. If these public health principles can be implemented in China, a country of more than 1·4 billion people, they will also be of use for other countries that are in the process of developing a resilient public health system.

We declare no competing interests.

全文翻译

2003 年的 SARS-CoV 大流行推动了改革开放以来中国公共卫生体系的首次实质性改善，这些改善通过有效的资源共享和密切跟踪，极大地帮助了国家遏制了 COVID-19 大流行。

尽管中国公共卫生系统取得了重大进步，但我们必须确保它足够强大，以适当应对新出现的和传统的卫生挑战。

COVID-19 大流行清楚地表明，公共卫生治理需要解决公共卫生系统中的不足，以提供足够的风险抵御水平。第一，健康观念需要修正：虽然中国自1950年代以来推行以预防为主的卫生政策，但整体卫生系统仍以疾病治疗为重心，因此健康观念需要在制度层面发生实质性转变。加强疾病预防水平和综合卫生服务体系建设。二是公共卫生被低估、不重视的状况需要改变：公共卫生机构的卫生支出相比临床机构卫生支出的增长率要低得多（从2011年政府卫生总支出的488亿元[6·5%]上升到2019年的1353亿元）[7·5%]）比临床机构（从2011年政府卫生总支出的1012亿元[13·6%]到2019年的6735亿元[37·4%]）。

中国疾病预防控制中心（CDC）（中国公共卫生的主要部门）的卫生人员数量占卫生人员总数的百分比在 2004 年SARS 大流行期间为 3·3% ，但到 2019 年仅为 1·45%。

增加政府对公共卫生的投资，同时改进对公共卫生机构的补贴机制以及将工资与绩效挂钩而不是由政府指导的固定薪酬至关重要。此外，为了吸引和留住合格人员，必须消除对公共卫生部门人员的歧视，必须承认在幕后为决策者提供证据的公共卫生专业人员的作用，必须承认在公共部门工作的人员的工资。健康应与其社会价值相一致，并与同级临床人员的社会价值相一致。第三，专业人员的技能必须提高：解决复杂的公共卫生问题，将公共卫生教育延伸到医学知识之外，整合相关学科（如法律、政治、社会科学和人文科学）的内容是必不可少的。此外，人员再培训对于确保有足够的训练有素的人员来应对流行病等危机至关重要。四是要提炼中国疾控中心核心能力：2021年5月14日，国家疾控局成立，全面推进公共卫生事业，标志着我国抗疫工作迈出重要一步。公共卫生治理。

然而，中国疾控中心的运作方式尚不清楚，尤其是在基层。因此，应该提炼核心能力，以确保在包括国家（例如全球公共卫生治理、人才教育和精准诊断先进实验室）、省级（例如地方层面的专业培训和精准诊断）在内的各级合作更高效。 )、市级（例如，确定健康问题和干预措施）和县级（例如，为流行病学调查和有意义的健康教育开发技能组合）。此外，建立基于卫生信息化技术的区域公共卫生中心和公共卫生信息平台，将有助于发展解决公共卫生问题所需的物质储备和组织渠道。第五，临床治疗和预防需要更好地结合起来：为了改善公共卫生系统对重大传染病威胁和日益增长的非传染病挑战（例如糖尿病、高血压、中风、癌症和烟草使用）的反应，它必须解决医疗和公共卫生结合不充分的问题。

目前治疗和预防分为两个孤立的部门。医院需要通过鼓励临床医生开具健康教育和传统药物处方来促进公共卫生。此外，临床和公共卫生机构（如发热门诊、感染科）可以共享人员和数据，这将有利于涉及人口健康和危机预防的决策。重要的是，建立有效的激励机制（例如，将公共卫生专业经验作为晋升临床医生的前提）对于医疗与公共卫生的融合具有重要意义。第六，需要跨部门合作：公共卫生问题的广泛影响凸显了在公共卫生领域之外的多部门层面采取行动的必要性，例如公共、私营和基层部门，包括村委会和居委会。

最后，完善公共卫生发展的法律框架（如责任制、应急物资生产销售监管、信息管理、安全监管等），保障人民群众健康。 如果这些公共卫生原则能够在中国这个拥有超过 14 亿人口的国家得到实施，它们也将对其他正在发展具有弹性的公共卫生系统的国家有用。

我们声明没有竞争利益。

转自公众号 医健趋势：原文链接