A Study on the Health Management Mechanism for Diabetes Patients Based on the ICCC Framework

在慢性病已成国家健康战略核心议题的背景下，糖尿病作为典型慢病，对我国基层照护体系的整合能力提出严峻挑战。尽管“健康中国2030”提出构建多层次慢病管理机制，现实中糖尿病管理仍面临制度协同弱化与患者赋能不足等结构性难题。本文基于世界卫生组织提出的“慢性病创新照护框架”(ICCC)，聚焦河南省某地实践，通过18名政策制定者、服务人员与患者的半结构式访谈，采用NVivo进行质性编码，构建“地方照护嵌套模型”，识别出财政支持碎片化、信息系统割裂、签约服务虚化、患者行为参与薄弱等典型问题。研究发现，ICCC在地方层面的落地面临政策动能衰减、组织协同失效与行为激活乏力等多重张力。本文从“制度–组织–个体”三维结构出发，提出优化路径：健全财政与支付激励机制、强化基层组织协同能力、提升患者与家庭赋能水平。研究为理解资源有限地区慢病管理的协同困境提供了理论支撑与实践借鉴。Against the backdrop of chronic diseases emerging as a core agenda in national health strategies, diabetes—representing a paradigmatic chronic illness—poses significant challenges to the integration capabilities of China’s primary care infrastructure. While the “Healthy China 2030” initiative advocates for a multi-tiered mechanism for chronic disease management, the practical realities of diabetes care still confront structural obstacles including weakened policy synergy and limited patient empowerment. Based on the WHO’s Innovative Care for Chronic Conditions (ICCC)framework, this paper investigates practices in a specific area of Henan Province through semi-structured interviews with 18 stakeholders—including policymakers, practitioners, and patients. Qualitative coding with NVivo was used to develop a “locally nested care model,” which revealed key challenges such as fragmented fiscal support, siloed information systems, nominal contracting of services, and insufficient patient participation. The study reveals that operationalizing the ICCC at the local level is subject to various tensions, such as waning policy impetus, ineffective organizational collaboration, and a lack of behavioral activation among key actors. Adopting the tripartite analytical structure of “institution-organization-individual”, this study suggests pathways for optimization: improving fiscal and payment incentive systems, reinforcing organizational coordination at the primary level, and advancing the empowerment of patients and families. The study offers both conceptual underpinnings and empirical references for grasping the coordination challenges inherent in chronic disease management within resource-limited regions.