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重大慢性病多病共防的实践演进与策略构建

Integrated prevention and control of multiple major noncommunicable diseases: evolution of practice and strategy development

  • 摘要: 多病共存对传统单病种防控模式提出挑战。本文聚焦心脑血管疾病、癌症、糖尿病和慢性呼吸系统疾病,梳理多病共存的流行病学特征与多病共防的科学基础,归纳国内政策演进及国内外实践经验,提出“五同四共”整合策略框架。通过同防、同筛、同诊、同治、同康贯通全周期服务,以共管、共通、共担、共育完善治理、运行、筹资与能力保障,形成纵向服务协同与横向体系支撑相结合的多病共防路径,为我国慢性病综合防控和全生命周期健康管理提供参考。

     

    Abstract: Multimorbidity poses challenges to conventional disease-specific prevention and control. Focusing on cardiovascular and cerebrovascular diseases, cancers, diabetes, and chronic respiratory diseases, this article reviews the epidemiological characteristics of multimorbidity and the scientific basis for integrated prevention and control of multiple diseases, summarizes policy evolution in China and practical experience both in China and abroad, and proposes an integrated framework of "five coordinated services and four collaborative support mechanisms". The five coordinated services—prevention, screening, diagnosis, treatment, and rehabilitation—span the continuum of care. The four collaborative support mechanisms—collaborative governance, operational alignment, shared responsibilities, and joint capacity building—strengthen governance, operations, financing, and capacity. Together, they establish an integrated pathway combining vertical coordination across the continuum of care with horizontal system mechanism support, providing a reference for comprehensive noncommunicable disease prevention and control and health management across the life course in China.

     

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