ITiHeOUIIKSllGHIENCIIUI
Cai each tai chinh y te d Dong Nam A NHLfNG THACH THlfC DE DAT DlT0C
BAO PHU TOAN DAN
Dr Viroj Tangcharoensathien PhD a, Walaipom Patcharanarumol PhD a, Por Ir MFH b. Prof Syed Mohamed Aljunid PhD c, Prof All Ghtifron Mukti PhD d, Kongsap Akkhavong MPH e, Eduardo Banzon MD f. Dang Boi Huong MSc
g. Prof Hasbullah Thabrany PhD h. Prof Anne Mills PhD i
Ngffdi dich: Nguyen Quynh Anh - Biii Ngpc Linh
Trong bii vifit nay. ehdng ldi xem xet cai eich lai chlnh y te tai 7 ntfde ihupc khu vtfc Dfing Nam A, nhflng ntfde dang cd gang han chd stf phu Ihudc vio khoin chi tra trffe liep (bang tiln tui) eua ngtfdi bfinh, ting tii chinh y le b^ng quy cbung, va md rpng sff dung dich vti y te de dan tifi'n tdi bao hiem y id toan dan. Lio va Campuchia li hai ntfde ngheo, ehu yeu dtfa vao quy cong bang y Ifi'cua cae nha tai trd dd lifip cin ngffdi ngheo vi trong vific md rpng chffdng Irinh ra pham vi qud'c gia dang cfi hai thich Ihffc ldn, dfi la dam bao stf dung quy ddng muc dich va xie dinh dd'i tffdng nghfio ddng lieu chuan. Dfi'i vdi Thii Lan, Phihppines, Indonesia va Viet Nam Ihi bao hidm y tfi' cd ngudn thu tff Itfdng va dffde stf dung chd yfi'u cho nhffng ngffdi lao dpng trong khu vffe ehinh thffc[ I ] (trff Malaysia), vdi cac ket qua dau ra khic nhau vl mat bao vfi tai cbinh[21 d mdi nffdc.
Cic phffdng thffc chi tra khac nhau co lic ddng khie
nbau ddn hanh vi cda ngffdi eung cap dich vu va kha ning bao ve tai ehinh. Hai phtfdng phap nhim bao vfi tii ehinh eho ngtfdi khfing nghfio nam ngoii khu vtfc lao dpng chinh thffc la md hinh dam bao tai chinh dffa vio ihufi' va ed ehd eung tham gia, vdi cac kha nang khac nhau de dat dtfdc dd bao phu loan din mpl cich nhanh ehdng. 'Khdng gian tai khda'^ va huy dpng ddng gdp tff Iffdng deu rat quan trpng trong vific ning cao linh bao vc tai chinh. Md rdng do bao phu cic dich vu cd chi'l Itfdng vi dam bao nguon nhan life phu hdp eung la dieu quan irpng de dat dtfdc bao phd loan dan. Vi cai cich Iii chinh y te rat phffe lap, ning Itfc cda id chffc trong viee hinh Ihinh bang chtfng va thong tm cho chinh sich la rat cia Ihiel vi can dffde day manh.
Day la bai vifi'l ihff 6 trong tuye'n tip 6 bii viel vl y tfi' lai Dong Nam A
Khu vifc chtnh ibiicho^c khu viic loading ctiinh th]2c(ho<Sc chlnh quy.. )cM nhdm dan cugSmngUdi iao ddng cho cdc eaquan, donvf duifc hudng ch^df luang vd bdo hiem xd h$i, bdo hiim y te.
, Bdo vf ldi chinh cd the duac hieu Id viet tat cho cifm lit bdo vf ngudi ddn khdi cdc riii ro do chi phi yte gdy ra
Khdng gian ldi khda Id thudt nga ndi vi ti if cda thu tU thue irong CDP (%), the hifn khd ndng thu thuevd ttnh chii d$ng trong dieu hdnh ngdn sack Clia Chinh phu de clu neu cfw cdc muc dtch mong muSn
Tap chi Y td Cdng cong, 4.2011, Sd 18+19 (18+19) 35
ITtfNGQUM&NGHl'ENCirUI
Gim thifu
Vific chi Ira lien tdi cda hg gia dinh cho y te d mffe cao cd the lam tan nai va ban cdng hda hp gia dinh. Dd la Ijf do chinh cho vific thong qua Nghi quyei cda Dai hpi ddng Y idThe gidi (World Health Assembly Resolution) nim 2005 ve bao ve tai chinh[l]. Cic nffdc Irong khu vffe Ddng Nam A, ed sd din chidm den 8,7% dan sd the' gidi, vdi ling trffdng kinh te nhanh vi tinh trang ngheo ddi d mtfc dp irung binh (I4,6%)[2], cd tilm ning day nhanh qui irinh bao vfi nhan din khoi rdi ro tai chinh va dat dffde bao phd y te' toan din.
Bao phu y te loin dan (ggi tat Ii 'bao phd loan dan') dffde hieu Ii bao dam li't ca dan ehdng diu dtfde liep cin vdi dich vu nang cao stfc khde. dtf phdng, dilu tri va phuc hdi chtfe ning vdi chi phi hdp 1^[3]. Trien vpng vl viee xdc tifi'n Iheo htfdng nay ed ve nhtf cdn ban chfi'[4], die bifit vdi nhflng ntfde ma kha ning Iai ehinh edng thi^p va bao hiem y Ifi' cho ngtfdi Iao ddng thugc khu vtfc chinh ihtfc hidn dang ihifi'u hoac rat nhd le, va vl vay han chd viec huy dpng Ihfim ngudn Itfc do ddng gdp Iff quy Itfdng. Tii chinh y te d nhflng ntfde dang phit Irien phu thufic Idn vio cbi tra ifl tien tdi (vien phi)[5], trong khi hau bet cac nhi tii trd va c&c sing kie'n y te toan eau, vi du nhtf Quy loan eau. deu lip trung vao giai quydl cic benh tit hay ean ihiep eu the hdn l i vio loan bp hp thd'ng y id rgng Ida.
Thong di$p chinh
• Viic xdy dtfng chinh sdeh bao phd ytitodn ddn dtfa trin mdi quan tdm Id ldm thi ndo de bao phu vd tdi trg cdc nhom ddn cukhdc nhau mdt cdch lot nhdt, dd Id nhom ngudi lao dgng chinh thde, nhdm ngUdi ngheo vd di bi ton thuong, nhdm ngUdi lao dgng thude khu vtfc khdng chinh thtfe (lao dgng ttf do) vd phdn cdn lgi cda ddn sd.
• Nhffng ngudi lao dgng cho cdc ca quan, dan vi chinh thdc co the duac bdo vi tdi chinh thdng qua bdo hiim y ti dtfa vdo luang ho$c Id ca ehi ddm bdo tdi chinh ttf thui'.
• Nhdm ngudi ngheo vd di bi tdn thuang cdn dugc trg cdp nhiiu td ngdn sdch chung. Bang chdng d Ldo vd Campuchia eho thdy phucmg phdp tiip edn dinh hUdng vdo phia "cdu", vi du nhu quy cdng bdng y li', to ra hi$u qud han ehinh sdch miin gidm phi.
* Bao phu edc nhom lao dgng ttf do vd phdn edn lgi cua ddn sd vdn cdn Id thdch thdc. Mgt sd nude nhu Philippin vd Viet Nam dang tim each md rgng dd bao phd thdng qua cd chi cdng dong gop, vd mdt sdnudc khdc nhu Thdi Lan la nudc dang thtfe hiin hd tra tdi ehinh dtfa vdo thui.
' Ngodi viic md rgng bao phu todn ddn, cdn tgo ra khd ndng thich hgp dibdo ve nhdn ddn trUdc rdi ro ldi chinh vd tgo ra phucmg thtfe ehi trd hdn hgp cho cde nhd eung cdp dich vu, qua do tde dgng din thtfe hdnh ldm sdng cua bdc sy theo hudng sd dung hgp /jJ cdng nghi y ti, hieu qud, vd ddm bdo khd ndng chi trd Idu ddi.
' Md rdng dich vu cd chdt lugng vd bdo ddm cd du ngudn nhdn lue Id nhtfng yiu td cd ldm quan trgng nhunhau didgt tdi bao phu y titodn ddn.
> Phdn tich mang tinh so sdnh nhu trong idi liiu ndy rdt htfu ich trong viic mang din kinh nghiem phong phd td nhtfng nUdc trong khu vue Dong Nam A di hgc hoi vd phdt triin vdn hoa ra quyit dinh dtfa tren bdng chdng.
Nhflng ntfde cd ty lfi chi tra Irtfc tie'p cda ngffdi bfinh cao cd thd cd ti Ifi ldn gia dinh rdi vao tham canh do cic khoan ehi tra khdng Id cho y lfi'. Tinh trang nay dffde hifi"u li chi eho y tfi' da vtfdt mtfc 40%
chi tifiu phi Iffdng ihtfc ihtfc pham cua hfi gia dinh (la khoan cdn lai sau khi trff di ehi phi cho Itfdng Ihtfc, thffc pham-goi l^l la ehi pbi LTTP), hay vtfdt mffe 25% chi lifiu phi LTTP cua hd gia dinh, hoac eao hdn 10% tong ehi tifiu hd gia dinh bay ehi phi tham hpa[6]. Ty lfi ehi tra trtfc tie'p eda ngffdi bfinh trong tdng chi lifiu cho y te'tang Ifin 1% sfi din de'n tang 2,2% Irong ty le hg gia dinh rdi vao tham eanh do chi phi y id gay ra. Tii chinh y tfi' cd ty lfi tra trtfdc cing nhilu ihi ty Ie hd gia dinh rdi vao tham canh do ehi Ira eho y tdeang it[7]. Tuy nhien, khfing ed bang chtfng nio cho tha'y nhffng qudc gia trien khai bao hiem y id thi cd kha nang bao ve tai ehinb tdt hdn hoac tdi hdn nhffng qud'c gia phu thude vio thud[8]. Vifie tdn tai ed che' ehi tra trtfdc khdng dam bao kha ning bao vfi iai ehinb bdi vi ed bao eao eho tha'y mpl vai ed ehe' iri trtfdc chtfa lao ra kha nang dam bao vl iii chinh. Vi du, 15% thanh vifin tham gia vao md hinb bao hifi'm cda Hiep hpi phu nfl lao dpng ttf do tai An Do da rdi vio trang Ihii tham hga ve tai chinh, Ihim chi sau khi nhan bdi hoin phi
36 Tap chi Y td Cfing cfing, 4.2011, Sd 18+19 (18+19)
i r a N G QUAN a NGHIEN ctfu I
nhip vifin[9] vi He thd'ng Y le Hdp lic xa d ndng thfin Trung Qudc (Chinese Rural Cooperative Medical System) chi Ira ehi 30% chi phi dilu Iri npi ltd [10].
De bao pbd toin din, can lien hanh trfin 3 Hnh vtfc chung: (i) md rpng dfi bao phd cua bao hiem y tfi' hoic hinh ihrfc tra trtfdc khae, (ii) xae dinh ro nhflng loai hinh dich vu ein dtfdc cung ci'p va dam bao tinb san ed vi ehat Itfdng eua chdng, (iii) ting etfdng bao vfi nhin dan trtfdc nhflng rui ro tai chinh (phu lue trfin web trang 1).
Trong hinh Irfin, chieu rdng la dfi bao phu bdo hiem y lfi', chilu sau la dich vu dtfdc chi tra, vi du nhtf dilu tri ngoai ird, npi trd va eic dieh vu ehi phi eao khie, va ehilu cao Ii mtfc dp bao vfi lai chinb, nhtf ddng ehi tra. T^ Ifi ddng ehi tra eda ngffdi bfinh eang it va dich vg dtfdc chi tra cang nhieu thi kha nang bao ve khoi rdi ro lii chinh cang cao.
Chdng ta lip trung Ihao luin vl 3 Iinh vtfe niy. Tinh trang khd xff trong bdi eanh ngudn Iffc han chfi' ebinb la vifie ltfa ehpn gifla cung ci'p dich vu va bio ve tai ehinh d mtfc eao cho mpt nhdm nhd dan ehdng hay md rpng dd bao pbd nhtfng chi cd thd cung ci'p cic dich vu va bao ve lai ehinh mpt cich ban chd.
Trong bai viet nay, chung tdi xem xfit, dinh gii eae phtfdng phap eai cich lii chinh y td vi tifi'n trinh bao phd y td loin dan tai 7 qufi'c gia cd tbu nhap thi'p va trung blnb d khu vtfc Ddng Nam A.
Brunei va Singapore, 2 ntfde ed Ihu nhip cao, khdng dtfdc de cip dfi'n Irong phan tich niy, ttfdng ttf la Myanmar. qudc gia eo rat It thfing tin vl tai ehinb y tfi'. Dtfa tren phan tieh tai Iifiu, chdng tdi tdng kfi't Iai nhifng thanh ttfu dat dtfdc trong eai cich tii chinh y te eua nhffng ntfde nay vi xie dinh nhffng Ihach thffc lien quan den bao phd loin din, dich vu dffde ehi tra va bao ve lai chinh dfi ehia se bii hoc vi thdng tin ddn cic qud'c gia ngoii khu vtfc.
Bdi canh
Bay ntfde trong khu vtfe Ddng Nam A dtfdc Itfa ehon lam nghien cffu tnfdng hdp ed mffe dp phat
Irifi'n kinh td khac nhau va td'c dfi md rdng bao phd dich vu y tdcung nhff bao ve tai chinh khac nhau: 2 ntfde ed Ihu nhip tha'p va dp bao phd tha'p (Lio va Campuchia), va 5 ntfde thu nhip Irung binh, 3 ntfde trong sd niy cd dp bao phd hdn 50% vi cd chinh sich rd rang theo hffdng bao phd loan dan (Indonesia, Philippines, Vifit Nam) vi 2 nffdc edn Iai da hoin thanh bao phd toan dan (Malaysia va Thai Lan).
Bang I: the hifin bifi'n thifin ldn vl cic chi sd kinh te vi ngheo ddi d eae ntfde niy. Khdng gian tai khda irong khoang tff 8,2% d Campuchia den 16,8%
d Thii Lan (so sinh vdi ly Ie 22,5% d nhflng nffdc cd thu nhip cao trong nim 2007)[11].
Bdngl. Thong lin chung ve kinh tivd ngheo ddi d 7 qudc gia trong khu vtfc Bong Nam A.
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.i ma vl dil si iiUri'MflnronV. iiU[ip4,fMS "
oc JMni la wiNim ' KfiiSn si 14a ciwo niK
Chi sd ddi ngheo (ti lfi ngtfdi sdng dtfdi ehu^n ngheo trong ldng din sd) khdng chi ndi den sd Itfdng ngtfdi khdng dd kha nang chi tri chi phi y id khi bi dm, ma cdn cho bifi'l Itfdng ngSn sich y ideln thidt nfi'u chinh phu quyfi'l dinh trd cap cho ngffdi ngheo. Khoan trd cap nay tao ra i p Itfc Ien khdng gian tai khda, va d nhffng qudc gia vdi ngudn Iffc ban chevi du nhtf Lao, Campuchia thi ngudn liln Iff nhi tii ird trd thinh mpt khoan khdng the thidu dfi hd trd tiep can dich vu y td^cho ngtfdi ngheo, die bifit li cie dich vu lien quan ddn Muc lieu Phil trien Thifin nifin ky.
Tap chl Y td Cdng cfing, 4.2011, S^ 18+19 (18+19) 37
ITi'HGIHAN&NGHIEHCtfBI
Nhffng thach thtfe vi tai chinb y td*
Mtfc do v^ dac difi'm ciia chi tidu y td"
Chi ttf cho y te ddng vai tro ndi bat trong tai ehinh y id tai 5 trong 7 qudc gia ke Irfin, ddng gdp bdn 70% long ehi y id d Lio vi Campuchia (bang 2)[13,14], mic du mffe dp ehi phi cho y Ifi'din den tham boa Ii khie nhau gitfa eae ntfde, thi du 6 Campuchia la 5% hp gia dinh va d Viet Nam la 10,5%[15]. Dtfdi 9% ngan sich nha ntfde dtfde phan bo cho y td d 5 trong 7 ntfde, ngoai trff Campuchia (vi ngan sich nha ntfde bao gdm ca khoan tai trd thfing qua kenh ehinh phd) va Thii Lan (vi nhffng khoan vay ttf ngan hang phit trien va nhflng ngudn song phtfdng phdi hdp vdi ngan sach chinh phu, can dtfdc hoin lai). Ltfdng ldn ngudn Itfc ben ngoai tff cic nha tai trd d Campuchia (16,4% trong long chi y te) va Lao (14,5%) khdng chi dat ra eau hdi vl kha nang duy tri liu dii ma edn ve mtfc dfi phd hdp cda chffdng trinh tai trd vdi UU lifin cua qudc gia[16].
Bao hiem y te diJa trfin thue'Iffdng bien ddi tff 0% d Campuchia den 12,7% long chi y id^ d Viet Nam (Bang 2). Malaysia, da'l nffdc ed thu nhap tren Irung binh, ed nhieu lao ddng Iim vifie cbo eae
Bdng 2. Cdc chi so guan trgng vi tdi chinh y tid 7 qudc gia khu vtfc Dong Nam A ndm 2007
doanh nghifip, ddn vi ehinh thffc, vin chffa Ihtfc hien md hinh bao hiem y te' toin dan vi khoan nay chi chiem 0,4% trong tdng ehi y id. Mac dd cic Ioai binh bao hiem di dffde td ehffc khi lot tai Thai Lan, Phihppines va Vifil Nam, chi lieu tff quy BHYT vin cdn thap hdn mffe trung binh eua nhom qudc gia cd thu nhap dtfdi trung binh Ii 15,8% long chi y id', the hien quy mfi din sd la Iao dpng Irong eie ed quan, ddn vi chinh thffc vin cdn nhd va gdi Idi ich tff viec Iham gia bao hiem thap bdn so vdi cic qude gia cd mffe thu nhip drfdi trung binh khae. Tong chi y tfi' dau ngffdi d 3 qudc gia, Indonesia, Lao, va Campuchia thi'p hdn mffe ldi thidu 49-54 dd la My/dau ngffdi, 17 mffe chi lifiu dffde dinh gii la can thiel de cung cap nhflng can thifip va nin lang be thdng y te can thiet di dat dffde Mue tifiu Phit Irien Thifin nifin ky.
miirsia n d , L . . n i l i p p J m (nlinetli V«.™m Uo t - k a d i . NMc I t i nhM M p n u i h i p dMJ
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Bao phu bang ctf chfi'bao v6 tai chinh Udc Iffdng tdt nhat ve dp bao phu bao hidm y id tai eac ntfde dtfdc phan thanh 4 nhdm Irong nam 2009 (phu lue trfin web trang 2), dtfa tren dieu ira hay sdlieu hanh rhinh. Vi tdc dd md rpng bao phu bao hiem y te khie nhau. tdng sd' ngtfdi tham gia bao hiem y td da tbay doi ding ke, dd bao phd thap nhtf d Lao vi Campuchia, do bao phd tmng binh d Indonesia va Vifit Nam, va do bao phd cao d Thai Lan va Phihppin. Theo bao eao thi tai Malaysia, do bao phd la 100%
bdi ap dung bfi tbdng tai chinh dtfa vio thue (mac du ehi tra trtfc tifi'p cda ngtfdi bfinh eao the hifin dd bao pbu thffc id tha'p hdn mffe bio cao).
Ty le ldn ngffdi dan khdng cd bao hiem y td (phii Iuc tren web Irang 2), cung vdi mtfc chi tra trtfc tiep eda ngtfdi bfinh cao, day nhffng ngtfdi khdng cd bao hiem y le vao nguy cd ngheo hda vl tai chinh bay khfing dtfdc htfdng dich vu y te can thiet. din de'n tan tat hoac tff vong tai nha.
Do bao phd bao hiem y tfi' toin dan ia iha'p do sd Itfdng lao dpng khu vffe chinb thffc il.
38 Tap chi Y td Cfing cdng, 4.2011, Sd' 18+19 (18+19)
I TUNG QUAN & NGHIEN ctfu I
Dp bao phu va md rong bao v^ khoi rui ro tai chinh
Hai phffdng phip dam bao tai chinh chinh Ihdng hay dtfdc stf dung dd chinh la (i) bao hiem y td xa hdi cho ngtfdi Iao dpng trong khu vtfc ehinh thffc va (ii) eung cap tii chinh dffa vao thud cbo ddi Iffdng ngheo vi dfi bi ton thffdng bdi vi chinh phd thtfdng dtf(?c coi Ii phai cd trach nhifim vdi cie nhdm niy. Vdi bai phtfdng phip niy, dg bao phd trong khu vtfe phi chinh thffc li mpt thich thtfe chlnh, dtfdc mfi ta nhff la "nhom bi kei d gifla"
(nhdm gifla) tai hpi nghi nim 2006[ 18]. Nhdm gifla bao gdm ngffdi Iao dpng d khu vtfc phi chinb thffc va khfing thupc nhdm ngheo hay nhfim khdng qui ngheo, trong khi nhdm trfin edng bao gdm nhflng ngtfdi Iao dpng khu vffe chinh thffc vi nhdm dtfdi cdng bao gdm ngtfdi nghfio.
Vdi bio hiem y id, chdng Ifii mudn ndi ddn cd chd bao dam tii chinh thfing qua thue Itfdng danh cho ngtfdi Iao dpng thudc khu vtfe iff nhan hay nhi nffdc, trong dd se thu mdt ty le nhi't dinh ttf Itfdng ciia ngtfdi Iao ddng vi ihu ty lfi Itfdng itf hay eao bdn Itf td chtfc stf dung Iao dpng. Tai mpt so' ntfde thi ehinh pbd eung tham gia ddng gdp. Ngtfdc lai, ed chfi' bio dam tii chinh ihfing qua thud lai dtfa vio sd thu vl tff thud vi khfing tinh den phan dfing gdp tra tnfdc cua ca nhan bay hp gia dinh.
Cic nhdm din ehung dtfdc phin nhfim lai tai phu Iuc trfin web trang 3 de phan bifil gifla nhdm thuin ldi ve kinh td (khu vtfc chinh thffc vi khong chinh thffc) vdi ngffdi ngheo va phan cdn Iai trong dan chdng, eung nhff eho biet quy mfi cua mfii nhdm. Phan eon Iai Irong dan ehdng bao gdm Ire em khdng thupc dien ngheo, ngtfdi cao tudi sdng phu thupe vi nhffng nhdm khdng Iham gia boat dfing kinh td. Ngffdi ngheo bao gdm tre em, ngtfdi cao tuoi sdng phu thupc va ngtfdi ngheo trong khu vtfe khdng chinh thtfe. Bat chap nhffng phffe lap cda vifie chdng chIo cd the xay ra giffa cic nhfim din ehdng khi dffpc phan chia thinh 4 nhdm chinh, phin loai nhdm nhff viy van td rfi tinh hflff dung irong vific Ihong lin de'n nhi hoach dinh chinh sich ve cich thffc hfi trp tai ebi'nh de bao vfi tai chinh eho mfii nhdm va xue tidn viee giam sit md rfing dd bao phd.
Bao v^ ngtfdi ngheo va ngtfdi dfi hi tdn thi/dng
Campuchia gidi Ihieu chinh sich vifin phi vio nim 1996 vdi mue dich cai thien nang Itfc cua hfi
thdng cung cap dich vu cham sde stfc khde, sd tiln Ihu dtfdc se ehi tra eho viec khuyen khIch ein bp y td^, bd sung cho ngan saeh nhi ntfde edn ban hep, vi giai quyfi'l thanh loin cho eic trtfdng hdp ngoai lfi[19]. Tuy nhifin, vien phi Iai tao rao can cho ngffdi ngheo ndu nhff khfing cd hfi Ihdng mien giam hifiu qua[I9, 20]. Tff cufic Ihtf nghiem diu tifin nim 2000, quy edng bSng y te' chu ye'u dffde hd ird tii ehinh bdi eae nha tai trd de bdi hoin cho cic ed sd y te cho cic khoan chi tifiu y tfi' danh eho ngffdi nghfio va chi tra mfit sd ehi phi di lai, da d£n dan dffde md rgng, bao phu khoang 68% ngtfdi nghfio Itfdng dtfdng vdi 23% tdng din sd Campuchia vio nim 2008[2I]. Bing chrfog eho thay ngudn quy nay di gfip phan ning eao tidp e|n vdi dich vu y te'eho ngtfdi ngheo vi cd kha nang bao vfi tai chinh cho hp.
Mac dd chtfa ttfng cd nghifin cffu nio vdi phffdng phap chit che, ehinh xie dtfdc thtfe hifin nham dinh gia tinh hieu qua cda quy cfing bang y tfi' dfi'n tidp can cham sde stfc khde va kha ning bao vfi iai chinh, mpt vai nghifin ctfu trtfdng hdp di ehi ra rang ly lfi stf dung dieh vu tai bfinh vifin cda ngtfdi ngheo li thinh vifin cua quy cdng bling y id ting Ifin ding ke trong khi sdltfdng bfinh nhin ttf ehi tri khong he giam. Hau hfii eie tnfdng hdp, sd'ltfdng ngtfdi dtfdc htfdng ldi Iff quy chifi'm hdn mfil phin ba tdng sd bfinh nhin dilu Iri noi trd cua bfinh vifin[22-24].
Tuy nhien, tinh bin vffng tai ehinh eung nhtf nang life eua nha nffdc trong vific ting ctfdng stf dung ngudn npi life ludn la vi'n di cin ban[25].
Chinh sich ihu vifin phi cda ngtfdi benh nim 1995 tai Lio[26] da lao nfin ngudn dtf trff cho vific miln phi cho ngtfdi ngheo, nhffng phffdng phap nay khong hifiu qua vi nhffng ngtfdi dffng dau Iang xa xie dinh dd'i Itfdng ngheo mgt eieh tdy lien, khfing theo quy ehuan nao. Cham sde miln phi cho ngtfdi ngheo li nhiem vu bat bufie nhtfng ngudn quy Iai khdng du. Bfin canh vific phin bd thtfdng quy cho thuoe, Iffdng nhan vien, khong cd Ihfim ddng ngin sich nao dffde bd sung cho muc dich nay[27]. Trung tim y idva benh vifin id ra mien ctfdng khi phai ltd cap cbo ngtfdi ngheo tff nhflng khoan lien ma hp thu dffde tfl phi dich vu. Quy cong bang y te do cic nhi lii trd hd trp ve lai chinh, dffde thffc hifin thi diem nim 2003, da dtfdc md rdng quy md sau khi ed dinh gii cho thay vific sff dung dich vu y te eda ngtfdi nghfio tang Ifin vi ddi thoai vl chinh sich cda nhi ntfde gan day diu dng hp vific tang etfdng hd trd tii chinh cho ngffdi ngheo[28].
Tap chf Y td Cdng cfing, 4.2011, Sd 18+19 (18+19) 39
jTiNGHM&NGHIENCBIII
Ung phd vdi khung hoang kinh td Chiu A nam 1997, vdi anh hffdng nang n l den ngtfdi ngheo[29], Indonesia da thifc hifin cd chfi' dam bao tai chinh dffa vao thue danh cho ngtfdi ngheo vi ngtfdi can ngheo, bao gdm ca ngffdi vd gia ctf va tre md edi.
Nguon tai chinh cda cd che nay la Iff tnmg tfdng va chinh quyln dia phffdng (quin huyfin), va ngtfdi cung cap dieh vu dtfdc chi tra theo phtfdng ibtfc Ihanh toan Iheo gdi tiieh vu da dffpe dieu chinh ddi vdi ca dilu tii npi trd va ngoai (ru. Vific md rpng cd chd^nay tren toan pham vi qudc gia da bao phu dtfdc 33 - 34% tdng dan sdvao nam 2008, do vay ma hlu het ngffdi nghfio vi can ngheo diu dtfdc bao phu. Tff so sach ghi chep cda benh vien cho thay viec stf dung dich vu ngoai tni tang len[30], va khoang each trong vifie sff dung dieh vu giffa ngtfdi ngheo va ngtfdi giau giam d i Vi Iy do ban che iai ehinh. trd cap nha nffdc tinh theo dau ngffdi chi cd S6/nam cho ca gdi dich vu ngoai trd \a ndi trd (Irong khi (dng chi tifiu y id la 41,8 ddla My/dlu ngtfdi). vi vay cd the din ddn linh trang cung d^g tlicb vu cung nhtf (inh bao \ fi tai chinh d mffe dp tha'p. Mffe dp ngtfdi din phai ttf chi tra bang tien tdi vi vay van cdn cao.
Tff thing 10 nam 1997, Quy bao hidm y te Phihppines (PhilHealth) trien khai mpt chtfdng trinh (ai trd cbo hp gia dinh ngheo dtfdc xie dinh vi ding ky bdi chinh quyen dia phtfcJng. Phi ddng bao hiem cho chtftmg tiinh nay dtfdc trd cap bdi nha nffdc (mffe ddng gdp trung binh SOrr. nam trong khoang 50 - 90%) va chinh quyln dia phffdng (mffe ddng gdp trung binh 20%. nam trong khoang 10 - 50%). Viec ding ky tham gia hang nam phu thupc vao mong mudn/y chi chinh tri eua ehinh quyln dia pbtfdng \~a kha nang tai ehinh, vi du thtfdng vao cic nam cd bau ctf (hi so' Iffdng tham gia dat den mffe rat eao.
Giai doan iff 1975 dfi'n 2002. Thai Lan thffc hifin mp( cd chfi' de tidp can vdi ngffdi ngheo nham dat dtfdc dp bao phd toin dan. Ban dau, viec mien phi mpt phin hay mifin phi toin bp hoan loan do ein bd
>• lfi' ttf quydt dinh, sau dd. mdt cupc tha'm tra kha nang kinh te (nhim xae minh xem ca nhan hay gia dinh nao du tifiu chuan dffde nha ntfde hd trd) dtfdc thtfe hifin dd xac dinh ngtfdi ngheo, ban diu dtfdc thtfe hifin bdi eac can bd \' Ifi', sau do den uy ban nhin dan dia phtftmg. Mae dff cd stf tham gia cda cdng ddng, finh trang ne nang, tfu dai ba con than Ihudc van dien ra, din den bo sdt nhilu ngtfdi ngheo thtfe stf. cdn ngffdi khdng nghfio nhffng do ed quan he vdi quan ehffc dia phffdng Ihi thffdng dffde htfdng Idi(3 Ij.
Xu the chung xui't hifin lai nhieu qufi'c gia ehinh la dich vu y tfi^cho ngtfdi ngheo dtfdc hd trd lii chinh tff ngudn Ihu thufi'thfing qua phan bd ngan sich cho cd sd cung cap tlieh vu cda nhi nffdc, vdi phan hd ird bd sung Iai Lao va Campuchia Iff eae nha iai trd thdng qua quy eong bing y lfi'. Tff Irtfdc dfi'n nay.
tbam tra kha nang kinh tfi' nham xie dinh ngtfdi nghfio khdng phai hoin loan chinh xae[32,33] va stf thieu ehinh xie niy vin lufin Ii thich thffc vdi eic qudc gia sff dung bien phap niy. Ndi dung trong hdp 1 so sinh kinh nghifim tai Phihppines, Lao vi Campuchia vdi cic bai hoc dtfdc rut ra tff eae phtfdng phip xac dinh ngtfdi nghfio khae nhau tai 3 qudc gia niy.
HQpl
Thdch thdc trong viic xde dinh ngudi ngheo - bdi hgc ttf Campuchia, Ldo vd Philippines.
Tgi Campuchia, ngudi dugc hudng lgi ttf quy cdng bang y li dugc xdc dinh dtfa trin cdc tiiu chudn du dieu kiin tgi cgng ddng (xdc dinh trUdc) hay tgi casdy ti thdng qua bg cdu hdi phdng van sU dting phuang phdp thdm tra khd ndng ldi chinh thdng qua biin trung gian (vi du nhu tdi sdn Idu ndm, nhd cda, quyin sd hffu ddt dai, sd luong thdnh viin gia dinh co tham gia lao dgng kiim tien. so lugng thdnh viin song phu thudc, vd sd luang thdnh viin bi tdn tdt) vd udc luang thu nhdp, chi liiu vd cdc khodn nd cua hd gia dinh. Viic xdc nhdn thtfe hien tgi diem eung cdp dich vu tiip luc xdc dinh nhtfng ngUdi ngheo bi bd sdt irong budc xdc dinh lgi cgng dong.
Tgi Ldo, hg gia dinh ngheo du diiu kiin nhgn hd tra iff quy cong bang y li duac xde dinh bdi dy ban xd. sd dung cdc lieu chudn nhdt dinh trong thdm tra khd ndng tdi chinh. Tgi cde khu vtfe khdng duac bao phu bdi quy cong bdng y li, ngUdi dtfng ddu ldng xd se viii gidy theo di nghi cua ngudi binh, xdc nhdn cd nhdn thudc dien ngheo cho ttfng trudng hap. Khong gidng nhungudi dugc hudng lai td quy, khodn chi phi cho cdc dich vu miin phi cho ngudi ngheo se duac hodn lgi cho binh viin. cdc ed nhdn thugc diin ngheo lgi cdc khu vtfc khdng dugc quy hd trg si phdi thUOng luang di duac hudng dieh vu miin phi vdi ngudi cung cdp dich vu (vi igi do khong cd kinh phi eho viec chdm sde y ti' miin phi ddnh cho ngUdi ngheo). Trong thtfe ti. mdt sd ngudi binh dd duac cho phep tri hodn chi trd[27].
40 Tap cM Y Id Cong cdng, 4.2011, Sd 18+19 (18+19)
I T6'NG QUAN & NGHiEN Cltu I
Tai Philippin, nhdng ngudi gap khd khdn trong giai dogn nhdt dinh se do chinh quyin dia phuang ddnh gid, sd dung phuang phdp thdm tra thu nhdp gia dinh. vd dugc ddng ky vdo chuang trinh cd quy trg cdp cho diiu tri ngi trd vd ngogi trd. Chinh phu duge bdu cd mdi nhdt ndm 2010 dd chl dinh cho Bg Phue lai xd hgi vd Phdt triin qudn ly viic thdm dinh, bdi vi cdc dan vi chinh quyin dia phuang thtfe hiin viic thdm tra thu nhdp mgt edeh khdng nhdt qudn.
Mdc du edn thiit phdi thtfe hiin cdc nghiin cdu sdu han, viic mgt so ddi tuang thugc diin khdng ngheo dd duge hudng lgi van cd khd ndng xdy ra tgi cd 3 qude gia, ddc biit Id Lao vd Campuchia. Tgi 2 qudc gia ndy, viic ho trg ehi phi di lgi cho nhffng ngUdi hudng lgi id quy cong bang ytibin cgnh chi phi thudc men dd trd thdnh thiit yi'u trong viic thuc ddy tiip can chdm sde y ticho ngUdi ngheo.
Bdihgc
• Viee xie nban mgt cdch tuy ttin tai khu vtfc khdng dugc hd trg tdi ehinh cdng nhu ngudn hd trg bi han child nhdng nguyin nhdn ehinh ddn din tinh trgng bd sdt ngudi thtfe stf ngheo tgi Ldo
• Quy cdng bdng y ti tgi Ldo vd Campuchia, vdi thd tgc xdc nhdn rd rdng vd ngudn quy chde ehdn, on dinh dd gdp phdn cdi thien ty li sddung dieh vu vd cd xu hudng bdo vi tdi chinh tdt han.
Tuang ttf. chuang trinh duac tdi trg cua PhilHealth, vdi ngudn quy co muc tieu rd rdng, dd cdi thiin viic tiip can vd sUdgng dich vu.
• Bin cgnh viic cung tfng dich vu chdm sde sde khde ca bdn cd chdt lugng. viec hd trg ehi phi di lgi vd thdc an eho ngudi binh thugc diin ngheo trong qud trinh nhdp viin id ra cdn thiel.
• Mdc du gap nhieu thdch thdc, cde liiu chudn khdch quan, minh bgch cung nhu cam kit tham gia cua dy ban nhdn ddn dia phuang trong viic xdc dinh ddi tugng nghio, nhu nhffng gi dd ihtfe hiin duge tgi cd 3 quoc gia. Id v6 cung cdn thiit di trdnh tinh trgng uu ddi vd hudng lgi cda mdt sd ddi tugng khdng ngheo.
Bao v§ ngtfdi thupc khu vtfc lao ddng chinh thtfe
Thii Lan, Philippines, Indonesia, Viet Nam va Lao diu ip dung md hinh bao hiem y le bat bupc
ddi vdi nhflng ngffdi lam trong khu vffe lao ddng chinh thtfe. Quy bao hiem niy thdng thffdng dffde quan ly bdi mdt ed quan phi Idi nhuan vdi md binh quan Iy ro ring vi cic dieh vu dvKJc mua vi quyen ldi eda ngtfdi tham gia bao hiem. Mfit phan phi ddng bao hiem dtfde trfl vao Itfdng eda ngtfdi iao ddng, mpt phin Itfdng dtfdng hoae eao hdn do ed quan siJ dung lao ddng ddng, va d mpl so'quo'e gia Ihi ehinh phd cung ddng mpt phin, nhtf d Thii Lan.
Cd ehd bao hiem y te xa hfii cd vai trd rat to ldn trong chien Itfdc mua dich vu de dilu tidi cic hinh vi eda cd sd cung tfng dieh vu y te nha ntfde vi ti/
nhan nham dat dffde cic muc lieu vl hifiu qua, chat Itfdng vi bao v^ lai chinh. Cic phtfdng ihffc chi tra khic nhau eho cd sd cung cap dich vu se ed nhCftig lic dpng khic nhau den viec ra quyet dinh ve chuyfin mdn eflng nhff hanh vi ve sff dung ngudn life cua bic sy[34]. Kinh nghifim trfin the gidi cho thay phffdng thtfe chi tra theo phi dich vu din den ting cie chan doin, kfi ddn thud'e cung nhff ehi dinh dieu tri khdng cin thidi giy ting cbi phi, trong khi do cic phffdng Ihtfc ehi tra cd gidi han nhff Ihanh loan theo dinh suat hay theo trtfdng h(?p bfinh cd chi phi thap hdn. Pbtfdng thffc thanh toin theo dinh sua't hay theo trffdng hdp bgnh se giup tang vific sff dung cac Ihudc gdc cfing nhtf chan doan vi dilu tri phu hdp, tff dd cd thd ban chd chi phi.
Cich thiet ke cda PhilHealth khdng cd dd tinli bao v$ vl Iii chinh cho nhffng thanh vifin tbam gia.
Cac dich vu ngoai trd khfing dffde ehi tra, cic dich vu ndi trd chl dtfdc chi tra dfi'n mdt mtfc nhat dinh vi viy ngtfdi bfinh phai chi tra phin cdn lai, khi dd ngtfdi benh phai ttf tra cic khoan vtfdt qua mtfc ehi tra cua BHYT. Ti Ie ddng gdp cua bao hiem y id loin dan trong tdng chi phi khim chfla bfinh Ii 11%
trong nam 2005 va giam xudng cdn 8,5% trong nam 2007[36-38] cho thay tinh bao vfi vl tii ehinh ddi vdi ngtfdi tham gia bao hiem ngay cang han che.
PhilHealth nhain thi'y tdng chi cda bao hiem ch! cao hdn chdt it so vdi 1/3 tdng ehi cho y tddo benh nhan chi tra trong nim 2008[39] va cd muc tifiu cai diien linh bao ve tii chinh cho nhffng ngtfdi iham gia bao hidm. Thtfe te cho thay t^ Ie eie hp gia dinh phai chi tifiu qua nhieu cho y td (chi lifiu Idn hdn 25%
tdng chi tifiu phi Itfdng ihtfe thtfe ph^m cua hfi gia dinh) ngay cing ting, tff 2,11% dan sd^ vao nam 2000 lang Ifin 2,21% vio nam 2003 va 2,97% vao nam 2006[40]. Trong khi md binh chi tra theo phi dich vu cda PhilHealth cho phep ngffdi bfinh dtfde
Tap chi Y td Cdng cong, 4.2011, Sd 18+19 (18+19) 41
I Tfl'NG QUAN & NGHIEN ctfu I
Itf do Itfa chgn cd sd cung ea'p dich vu, mo binh bao hidm y te toan din eua Thii Lan ip dung tff nim 1991 han ehe viec tff do Iffa chpn ed sd cung ca'p dich vu thdng qua vific i p dung md binh hdp ddng Ihanh loan iheo dinh sua't, Hang nim, ngtfdi iham gia bio hidm phai ding k^ kham ehffa benh Iai mdt cd sd khim chffa bfinh cdng hoic ttf nio dd. Ddi lai, ed sd khim ehfla benh do se ddtic tra mdt khoan theo dinh suat, hifin nay la 1900 Bath (Itfdng dtfdng 57 ddla My) eho mdt ngtfdi bfinh, dd cung ci'p tat ea eie dieh vu ndi tru cung nhtf ngoai Iru. Ngtfdi bfinh Itf chi Ira mot phan bi eoi la phi phip. Cd che tren chi ip dung cho nhflng ngtfdi Iim trong khu vffe Iff nhin - nhffng ngtfdi phu thuge cda hp dtfdc tham gia hinh thffc BHYT loin dan. Nhffng ngtfdi Iam trong khu vtfc nhi ntfde va nhflng ngtfdi phu thupc cua bp dtfdc bao hidm Iff quy rieng trich ttf ihufi' va khdng phai ddng gdp. Hop 2 mfi la nhffng rio can dfi'i vdi cai cich ve bio hiem y tdd Malaysia.
HOP 2
Tinh phtfc lgp cua viic dp dung bdo hiem y ti xd hdi todn ddn d Malaysia
O Malaysia, mgt qudc gia cd thu nhgp trin trung binh, cdc dich vu chdm sde stfe khde Id miin phi cho todn ddn ttf luyin ca sd, tuyi'n 2 vd tuyin 3, vdi mdc ddng chi trd rdi thdp dao d^ng trong khodng 1,00 RM (tuang duang 0,31 ddla My) cho khdm chda binh ngogi tru din 3,00 RM (tuang duang 0,94 ddla My) cho mdt ngdy ndm viin.
Malaysia ehi 307,2 ddla My/ngUdi cho chdm soc sde khoe vdo ndm 2007 vdi phucmg thdc chi trd cho bin eung dng dich vu bang cdch phdn bdkinh phi hdng ndm cho cdc ea sd khdm chtfa binh cong.
Mac du ehi niu cho chdm soc sde khoe khd cao nhung Malaysia vdn gdp phdi nhiiu vdn di nhu: ty li ehi trd bdng lien tui eua ngudi binh cao, chiim 40,7% ldng ehi tiiu cho chdm soe sde khde (chu yi'u Id chi tieu eho cdc dich vu chdm soc sde khde tu nhdn d cdc cd sd y ti luyin 2 vd 3); thdi gian ehd dgi dedugc sd dung cdc dich vu phdu thugt tgi cdc binh viin cdng rdt Idu (vi du nhuphdi chd 23 tudn di duac phdu thugt chinh hinh[4I}): ldng chi phi chdm sde siic khde do chuyin dich md hinh dfch ti cda binh tdt trong bdi cdnh hgn ehi ve ngdn sdch; hay quy dinh khong chdt che dd'i vdi phi dich vu y titu nhdn.
Trong khodng thdi gian ttf ndm 1985 din 1996.
Chinh phd dd 5 ldn xem xet lgi hi thdng tdi chinh y tivd dua ra khuyi'n cdo Id Chinh phu edn thiit ldp Ca chi Tdi chinh Y ti qudc gia nham tgp trung edc ngudn Itfc cong vd tu de bdo vi ngUdi ddn trudc nhffng nguy ca vi tdi ehinh dtfa trin nhtfng nguyen tac cda hdo hiim y li todn ddn Cdc thdo ludn xung quanh nhffng cdi edeh vi tdi ehinh y ti mgt ldn nda lgi diin ra vdo ndm 2000. Ttf ndm 2000 din 2006, cdc eudc hgp gitfa cdc bin liin quan dugc to chdc dibdn thdo vi Cachi'Tdi chinh y tiqudc gia. Tuy nhiin, khdng cd quyi't dinh ndo dugc dim ra, nhiiu rdo edn duge xde dinh cung nhu thiiu y ehi chinh tri:
• Stf khde biit gida ngudi "dugc"vd "mdt": viic dp dung bdo hiem y titodn ddn doi hdi stf tham gia bdt budc cda lao ddng thudc khu vtfc ehinh thtfe nhu viin chdc vd ngudi ldm cdng d khu vtfc tu nhdn, hg Id nhdng ngUdi e de ve viic phdi trd mgt khodn tiin ngodi thui thu nhdp cd nhdn. Nhdng ngudi ldm trong khu vtfc lao ddng khdng chinh thdc vd ngudi ngheo, ddi lUgng cd khd ndng
"dugc" nhiiu ttf mo hlnh bdo hiim y titodn ddn, lai khdng eo tii'ng ndi. Ca chi dodn kit xd hgi dudng nhukhdng dd divugt qua nhffng rdo edn.
• Mdi quan ldm cda bdo hiim y li IU nhdn: Cdc cdng ly bdo hiim y li tu nhdn v4n dgng hdnh lang rdt mgnh bdi hg sg rang mo hinh bdo hiim y titodn ddn si ldm gidm lgi nhudn cua hg.
• Nhdng mdu thudn lgi ieh noi bg: Ca guan qudn ly tdi chinh y tiqudc gia, si dieu hdnh md hinh ndy, de doa lgi ich cda B6 Y tibdi Bd y tied nguy ca mdt quyen luc vi mdt tdi chinh vdo lay Ca quan quan ly tdi ehinh y tiqudc gia ndy..
Cdc rdo cdn vi ky thudl: kho thu phi bdo hiem ttf ngudi lao dgng trong khu vtfc lao ddng khdng chinh thdc
Thdng tin ttf Yon vd cgng sU 42. 43 RM= Ringgit (dan vi tiin ti cua Malaysia).
Md hinh Ihanh toin Iheo dinh sua't cda Thii Lan dam bao ban chfi'chi phi va chuyen cic rdi ro tii chinh ve phia cd sd eung ea'p dieh vu, irong khi do mfi hinh thanh loan theo phi dieh vu lai chuyen cac nguy cd tai chinh vl phia nhflng Ihinh vifin eua PhilHealth qua viec yfiu clu bfinh nhan ehi tra mfil phan. Do thanh loin theo dinh sui^t cd the dan den 42 Tap chi Y te Cfing cdng, 4.2011, Sd 18+19 (18+19)
ITtfNGQIAN&NGHIlNCUUI
vific cung cap khong dd dieh vu ufin chi phi ddn vi va ty le sff dung dich vu phai dtfdc iheo dfii chat ehe, ddng thdi ngffdi din cd the ihay ddi cd sd ding ky kham ehfla benh hing nam neu hp khdng hai long vdi dieh vu cda cd sd di dang ky tnfdc dd, Nhilu ket qua nghifin ctfu eho thay khi ap diing mfi hinh nay d Thii Lan, vifie sff dung dieh vu dat yfiu elu vl ca ty lfi stf dung (trfin hai Ian khim chffa bfinh/ngtfdi/nara) cung nhtf chi'l Iffdng dich vu cung cS^p eho nhffng ngffdi cd bao hiem[44-46].
Vifit Nam cung da nhan thay nhffng ban che eda phffdng thffc thanh toin theo phi dich vu, nhff chi dinh chan doin va dilu tri qui mffe cin thifi't vi mffe ddng ehi tra ldi da la 30% eda long ehi pbi dieu Iri.
Chmh vi viy, nam 2008, Luat bao biem y te ra ddi vdi quy dinh ip dung phtfdng Ihffc thanh loan theo dinh suSi cho cie dich vu chim sde stfe khde ban dau vi thanh toin theo trtfdng bdp bfinh ddi vdi eac dieh vu y te npi trd. Phffdng thffc niy dtf dinh se dtfdc thifc hifin tnfit dd trfin loan qudc vao nim 2014.
Vific mua dich vu cd ehien Itfdc, die bifit viee thidt ke gdi ldi ich vi phtfdng thffc ehi tra cho ed sd eung cap dich vu, sfi quyei dinh hifiu qua boat dfing cua hfi thdng, cung nhtf mffe dg ehi tra iff tiln ldi va chi tra 'tham hpa" cho y id. Trong ihi trffdng chim sde sffc khde ma eic nhi cung cl^p dich vu Iff nban vi Idi nhuin chifi'm da sd thi nhflng eai cich triet de chuydn tff phffdng ibtfc thanh toin Iheo phi dich vii sang thanh loan Iheo dinh suat bay theo trffdng hdp bfinh se va'p phai stf phan ddi quyet lifit iff bac sy, vi du nhtf trffdng hdp cda Hin Qude[47]. Viee ip dung sdm phffdng thtfe ehi tra pbu hdp li nin tang thiet ye'u eho thanh cfing cda bao hiem y id toin dan. Hpp 2 chl ra stf phtfc tap eua vific Ihdng nhat ap dung vi thidt kdbao hiem y tdxa hpi dMalaysia.
Bao v§ khu vtfc lao ddng khdng chinh thtfe va bO ph^n dSn sd'cdn lai O nhffng qudc gia niy, khu vtfc Iao dfing khfing ehinb thffc vi bp phan edn Iai eda din sd chidm iJ lfi ldn trong long dan sd, vi du nhtf chiem 49% d Campuchia. 64% d Indonesia va 73% d Vifit Nam.
Do sd Itfdng ldn vi ban che vl kha nang ddng phi bao hidm, vific bai bupc cic do'i ttfdng nay ddng bao hiem va md rpng dien bao phu ddi vdi nhdm nay li Ihich ibffe rat Idn. 7 qud'e gia niy diu phai dffng trtfdc Itfa chpn quan irpng - md hmh ddng bao hiem y le hay md hinh tii chinh dtfa vio thud.
L Md hinh PhilHealth \ a mo hinh bio hiem xa bo,
^ a \'ici \:im deu ap dung phtfdng thtfejharngi;
BHYT cd ddng°gop de md rgng bao phu doi vditbi vtfc Iao ddng^ong chinh thtfe (nhff lai xe taxi ha;
nhffng ngtfdi ban hang rong) PhilHealth dtfa ra mft ddngcddinhcho 1 nam la 1200 Peso (tffdng dirtft.
25,8 ddla My)^ho moi ngffdi. nhtfng viec bat buoc mgi ngffdi M g khong thanh cong mac du dacorai nhilu nd Itfcw^ang kie'n. Hdn nfla. quan ly viecUiii phi bao hidm cfing ton nhieu chi phi va viec thu phi eung phffe tap dp nguon thu bang lien mat Iuon tha) ddi, ed khi^M doan va co tinh thdi vu. Ben cant do cdn xay ra hien itfdng Itfa chgn ngtfdc do nhffng ngtfdi ddng bao hiem la nhffng ngtfdi mac cac bfinh man linh va c6 tan sua't stf dung dich vu cao PhilHealth can dtfdc ird ca'p tff thue' de bao phu bao hidm e h o ^ ^ ^ ddi ttfdng nay.
d Viel Nam. 50% mtfc dong bao hie'm cua khu vtfc lao dpng khdng chinh thffc dffde tip cap iff thue.
Khi bp phin dan sd dl tiep can da tham gia bao hiem, bao phu toin dien cd nguy cd khong datdilclc bdi ehi phi quan Iy cho vific thu phi bao hiem se rai eao d nhffng vdng sau vung xa khd tiep can Thera nffa. ket qua ciia cac nghien ctfu dinh gia tac dong chi ra rangm^e dd quy bao hiem y te loan dan lam tangdingke^ng sdltfdng dich vu stf dung va giam nguy cd chi tra qua nhieu cho y te cda hp gia dinh.
nd khfing lam giam mtfc chi tra trung binh tfl tieti tiii cda ngtfdi benh \a co tac dgng khfing dang ke de'n stf dung dich vu cua bp phan ngheo nha'i(48].
Tuy Thii Lan c(j mo hinh bao hie'm y le Hi nguyfin dtfa vio cgng d6ng[49] va sau do la mo hinh baohidmy tetrfnguyfin dtfdc trd cap mot phan[501.
30% tong din sd van khdng cd bao hiem vao nam 2001 va da sd' la nhflng ngffdi trong khu vifc lao dgng khfing chinh thtfe. Ben canh cac kho khan nhi/
Iffa chpn ngffdc va o'n dinh tai chinhI51]. viec bai huge nhffng ngtfdi trong khu vu'c Iao dfing khong chinh ihtfc ddng bao hiem da khong kha thi (ve mai ky thuit). Trong chie'n dich bau cff vao thing 01 nim 2001, doyeu cau vfi mat chinh tn dai ra la phai dat dffde bao phu loan dan trong 1 nam. mfi hinh ddng bao hiem bl bac bd do khong the dam bao lien dp va cung de ctf tri cha'p nhan iing ho chinh phu mdi. Bd'i canh chinh tri luc ba'y gid khie'n mo hinh bao phu loan dan ttf thud la mfi hinh duy nhat co the ip dung, tuy nhien cac danh gia ve tai chinh da chi ra md hinhtfiy ehi cd finh kha thi irong ihdi gian ngan han (nhff rnam)va trung han (nhtf 5 nam)[ 52]
Tap cM Y td Cdng cong, 4 2012, 56' 18^19 (18.19) 43
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V a n d e chae c h i n p h a i lioh dfi'n la tinh kha thi v l tai chinh trong d a i b a n , khi i l i n s d g i i hda va nhu cau c h a m sde sffc k h d e tang Ien. Tfl ehd chi bao phu cho ngtfdi n g h e o , T h i i Lan da m d rpng md hinh tai chinh tOf t h u d dd'i vdi khu vtfc Iao dfing khdng ehinh thffc va bd p h a n d a n sd'cdn Iai (cd nghia la n h d m bi ket tinh tff dtfdi Ifin-squeezed bottom-up), trong khi PhiUppines v i Vifit N a m lai m d rpng md binh ddng b a o h i e m tff khu vtfe Iao dpng chinh thtfe sang khu vifc lao d p n g khdng chinh thffc (cd nghia la n h d m bi k e i linh tfl trfin xud'ng-squeezed top-down).
Bieu d o I t d m tat nhflng k e l qua d a i dffde trong vific m d rpng difin bao phd cua bao hidm ddn n a m 2009 cho 3 n h d m d i n tai 6 qudc gia (trong dd khu vtfc Iao ddng khdng chinh thtfe va bg p h a n dan so' cdn Iai dtfdc xe'p cbung v i o mdt n h d m ) . L a o p h a i
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Bieu dd J. Bao phd y ticho 3 nhdm ddn sdvdo ndm 2009.
Khdng ttnh den Malaysia dodad^i dupc bao phd todn difn cho 100% ddn sS. T^i Philippines, lao dfng trong khu vf/c chinh thitc duac bao phu bdi PkilHeatdi <S5%) giSm c6 tao dfng cda cdc ca guan nhd nude vd lUnhdn cUng v^ckSng vd nhiing ngudi ph# thufc cua hf, tuy nhifn so lifu th^ng ki cda Co guait lao dfng qu£c tibdo cdo nhdm dich cda PhilHealth (22%) chi gom tao dfng d nhOng ca quan nhd mldc vd tU nhdn. Sg lifu lit phi/ luc trang 2-3.
ROP=l'fph4n ddn s^cdn lai-
ddi m i l vdi t h i c h thtfe v e m d rdng difin bao phu d cd 3 n h d m d a n sd', trong khi Vifit N a m da b a o phd dffde toan bp khu vffe lao ddng chinh thffc v i ngtfdi nghfio nhimg cdn g a p phai thach ihtfc rl^t Idn d e b a o pbu dtfdc khu vtfc lao dpng khdng chinh thffc va b p p h i n dan so' edn lai vdi m d binh bao h i e m y te ed ddng gdp. Campuchia da cd btfdc tifi'n ldn trong vific sff dung quy edng b a n g trong c h a m sde sffc k h d e d e bao phu ngtfdi nghfio, luy nhifin ihanh qua n i y c a n dtfdc duy tri v i vific i p d u n g b a o hidm y lfi'toin d i n dd'i vdi khu vtfc lao ddng chlnh Ihtfc eung nhtf tim each bao phd khu vtfe lao dpng khdng ehinh thffc edn la t h i c h ihtfc ra'l Idn dd'i vdi qud'c gia nay ea v l kha n i n g tai chinh cung nhtf q u a n \^. Hai i h i c h thflc ldn dd'i vdi Philippines l i m d rfing difin bao phu dfi'i vdi ngtfdi n g h e o bang e i c h dgng vien chinh q u y l n dia phffdng cam ke't v l m a t tai ehinh va lam sao d e thu but sff tbam gia ddng b a o h i e m y tfi' cua nhffng do'i tffdng khd tidp can Irong khu vtfe lao dpng khdng ehinh ihtfc. Dd'i vdi Indonesia, vi'n d l cflng n a m d chfi l a m sao md rfing difin bao phd dd'i vdi khu vtfc Iao d d n g k h d n g chinh thffc v i bd p h i n d i n sd cdn lai vdi chinh sach ro r i n g v l ngudn I i i ehinh, ddng thdi tifi'p tuc duy t n bao phd ddi vdi ngtfdi nghfio v i c i n nghfio Irong mpt he thd'ng h o i n loan phan c a p . Ngtfdc lai. Thai Lan va Malaysia d i dat dtfdc bao phd cho loan bg dan sd.
Nhi&ig qudc gia d Ddng Nam A nay v i n dang g i p n h i l u khd k h i n d d bao phd bao hifi'm y tfi'loin dan, dieu n i y dat ra rat n h i l u t h i c h Ihtfc d i n g quan ngai trong giai doan nd Itfc doi mdi tifi'p theo.
B a n l u ^ n va khuyfi'n n g h i B a n g 3 Idm tat nhflng kdt qua d a i dtfdc trong 3 linh vtfc: bao phd ve d a a sd, bao phd v l dieh vu va b a o v& v e tai ebinb. B a o phd v l d i n s d dtfde xay difng dtfa trfin stf s i n s i n g va kha nang bao ci'p cho ngtfdi n g h e o , bil bupc khu vtfc lao dgng chlnh thffc tham gia b a o h i e m y t f i ' v a bao vfi bp phan d a n s d edn lai b a n g phtfdng Ihtfc tra Irtfdc thfing qua ihufi'hoae md binh ddng b a o hieuL B a o phu v l dich vu cd nghia l i d i u ttf trtfde day va hifin nay eho ed sd ha tang
44 T a p chi Y te C d n g edng, 4.20II, Sd 18+19 (18+19)
I TtiHG INAN & NGHliN ctfu j
dich vu y te vi dtfa ra quye't dinh vl gdi Idi ich cbo cac hinh thtfe bao hiem khac nhau. Mffe do bao v$
ve lii chinh dffde xie dinh dtfa trfin stf sin sang va kha nang ehi tra cho gdi ldi ich Idn hay nhd va chinb sich ddng chi tra.
Lfdc tinh, 76% dan sd Phihppin ed bao hiem y te Iff PhilHealth , my nhifin dilu tra hd gia dinh gan diy eda Cue Tbdng kfi qudc gia [53} ffdc tinh difin bao phd ehi la 38% cho tha'y can phai cai ihien he thd'ng dff iifiu difin iff cua PhilHealth. Ca 3 md binh bao hidm d Thii Lan (bao phd khu vtfc Iao ddng chinh thtfe, cdng chtfc vi bp phan dan sd' cdn Iai) cung cap gdi ldi ich toin dien vdi ehinh sach gin nhtf khdng cd ddng ehi tra. Ty lfi chi tra tff tiln tfli cda ngtfdi benh da giam tfl 33% long chi cho cham sde sflc khde vio nam 2001 trtfdc khi bao phu bao hiem loan din xud'ng cdn 17,7% vio nam 2008(54], ddng thdi vific giam ty le eung nhtf mtfc dfi hfi gia dinh chi tra qui nhilu cho y te da mang Iai ldi ich die bifit cbo nhdm ngtfdi ngbeo[55,56]. Vdi vific bao phd bao hiem toin dan, Thii Lan taeh rifing bfin mua dich vu va bfin cung ci'p dich vu va cho phep ngtfdi dan ltfa chpn ed sd chim sde sffc khde ban
Bang 3. Tdm tdt dg bao phu ve dan sd, ve dich vti vd bdo vf vStdi chinh Igi 7 qudc gia d Dong Nam A ndm 2009
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D1c^ (^ aiK\ sic sd: Hoe u n tin H B tmng vJn HK t U t U m e v l B i t n i n c t w d f e i n i n f l n p M c h ) noi nguM. [ l f t f i m H h « i ) t : f ^ b i i i U l o l i n c A a d 0 v J sA tdc sf ^ A m Dmg nung Um y tf. M r t i i M n U Chg* c h (T) d o djckup f tf Hf > M B , C & trg Clio U f i 6 Z % c ! i ) n E 6 c i i g o j l i n J i l D f t f a i c u i | i c f [ i Ga IH kft M n tien mJn : h l tfidi m iIS ¥ * 3 rrC hWi t>iD hifm rtne
GA ku ck CD' tao plii cN iihr ilitu Iq nb Ml, Iril (nftig i K i p d i i l n g l r a i t t l a D l i j l l i i t B O c h u d d i c l i
• * ogoii 3 u . d 6 n g m t i i c a D d S l i d l l B 0 l i i i n >
n « « t l i - 1 } It bSi t n i n a~jig binti IS 54% ubg chi
«hl, phjn cin m du H i bing tilii t H i i H nguBi btnh Tl* mjc dfch d a cnmti Mcti Mo Hfm \i cimg cSp ditf- w loan dito. mft: i-ij d p rtiS ruec cho mM n ; ^ nghto aid W p (G fib Mf mOl lUm doi vdi gAi Och vv ngo^ m. rt nJHiOl cd tnf dJn Un cum) cip ivt n Ui6ng 4 i . l » c h l i i < a o r i m f t ; d O [ B o v e t i i cfirl- - d p
G6i ^ U nan difn i i u i g > n L : « diSng c h i b i kid car 5^0%
Nnii d u i g , bio l»f m f tf ban din ra mS ftiWi bao I H ^ d S l « O n bd nhl luOc iH b u pU b i n dien.
nhi»i9 do « kinh ol» nJ- g i i deh w nhi
• g A ogMo ft«c n » pt> bli v $ d n g U n g y tf 1*1 a w e l i f t i a g6. * ! , « K n * a . taj g l t i ch l « <B W » i £n ( A g M m g pham vi va d d t u n q
* * » K « g e f t b a i n u f t y tf eftig cfti lull c h l i t * e l l . , a . l w . t f ^ r t i l i l i . t t . y r f
Bio vf U l chiDh an t d i t ( i | i f l n s i r | l i l i M B g biD( 1} tf % chr phi til ttfo nil trong ttfig chl IWa cho y i£, iHOT)
4 0 J *
19,2%
5 4 , 7 *
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54.8%
61,7%
GO.1%
dIu de dang k}? kham chffa bfinh va cAc chi phi dffflc thanh toan theo dinh sua't hole theo tnfdng h^
benh[57]. Malaysia tifi'p tuc gifl vai trd truyen thdag cua Bd Y te ve tai chinh va cung ci'p dich vu. VSj de lo ngai Idn Ii tinh thifi'u s^n sang dap rfng eua cac cd sd cung ci'p dich vu edng di dan de'n ty Ifi chi tra iff tien tdi cda ngtfdi benh cho cic cd sd iff nhin ting cao[58-60].
Bieu do 2 md ta mdi hfin quan gifla dien bao phd cua bio hiem va ti Ifi chi tieu cho cham sde siJc khde Iff ngan sich nha ntfde Irong tong ehi tifiu cho cham soc sffc khde cua loan xi hdi, kich thtfdc cua mdi khd'i elu bieu thi dp ldn cda 'khdng giao tij khda' eda mdi qudc gia. Cd thd thay rd 3 nhdm qudc gia; ngudn thu tff thufi' chilm khoang hdn 15% tdng san pham qudc ndi (Malaysia va Tbii Lan), 10-15%
(Philippines, Indonesia, Vifii Nam vi Lao) va it hcfn 10% (Campuchia). Kha ning dii ban vl tai chinh de duy tri bao phu bao hifim toan dan d Thii Lan la mdt thicb thffc ldn, nhat la khi bao hiem cung cap gdi ldi ieh ldn. Dd'i vdi Malaysia, can tang effdng linh san sang dap flng cua cic ed sd cung ci'p dich vu cdng va tang ty lfi phin bd tii chinh bang cic phffdng thflc tra trffdc[61,62] La mpt ntfde ed thu nh^p trfin trung binh, Malaysia ed tilm ning ting chi tifiu cho cham sde sffc khde ttf mffe 44% tdng ehi lifiu cho chim sde sffc khde la tfl Ngan sich NhS nffdc (Bang 2) Ifin mffe cao hdn hoac i p dung md hinh bao hiem y td^ tfl thud thu nhip trong bdi canh da cd mpt ty Ifi ldn lao dpng trong khu vtfc chinh thffc.
De giam chi tifiu eho ehim sde sffc khde tfl tiln tdi cda hp gia dinh, se rat khd khan cho chinh phu cae nffdc hien dang ip dung he Ihdng phan cap nhff Philippin vi Indonesia trong vipe van dfing sff ung hp vl chinh iri vi tang effdng stf cam kfi't vl tai ehinh dl bao phu bao hidm cho ngtfdi ngheo vi nhffng dd'i Iffdng dfi bi ldn thffdng. Gdi ldi ieh 6 ddla MJ mdt nim ebo eae dich vu khim chfla henh ngoai tru va npi trd dinh cho ngtfdi nghfio d Indonesia chl cd thd eung ca'p mdt nhdm dich
Tap chi Y td Cdng cdng, 4.2011, Sd 18+19 (18+19) 45
ITfi'NGIIUAN&NGHIlNCliDI
vu rat gidi ban, do dd ehi tieu tff tiln tdi cua ngtfdi bfinh d mffe ra^t cao. Ttfdng ttf, mffe ddng 25,8 ddla My cho ihe bao hiem cua lao ddng Irong khu vtfe khfing chinh thffc d Phihppin cflng chi cung ci'p mdt gdi dieh vu ban chd va dan den ly lfi ehi tifiu tfl tien Idi cua ngudi benh eao. Cic thanh vifin cda PhilHealth cd the dtfdc bao hiem Iff thud my nhien vific niy ii mpt quydl dinh Idn vl ehinh tri bdi hien
X) o-
80 100 ft chi c i n g y t e t h e o t i n g c t i T y t i
Biiu dd 2. "Khdng gian tdi khoa" trong bdi cdnh diin bao phu cua bdo hiim vd chi tieu cua chinh phu cho chdm s6c stfc khoe.
Kich thudc cda WiiJi cdu biiu th cho khd ndng vi tii chlnh (khdng gian tdi Uida) do tudng btng nguSn thu tit thui theo t^ If phdn trdm trong tdng sdn phdm quSc nfi GGHE = Chi tliu cho chdm sde Siic khde cda chinh phd. THE= ldng chi tiiu cho chdm s6c s^c khde.
tai chtfa cd quy dinh nay trong lugt. CMnh phd can md rdng ngudn ihu tfl thufi' vi da dang hda eac ngudn thu ngoai ihue^. Tuy nhifin, tang ctfdng stf ddng gdp cda nhflng ngtfdi trong khu vtfc Iao dpng khdng chinh Ihtfc cung la dinh htfdng vl chinh sich cda PhilHealth.
Mdt khuydn cio khi nhin vio irtfdng hdp eda Vifit Nam la chinh phd cin tang chi cho cham sde sffc khde (tfl 'khdng gian tii khda') ttfdng flng vdi tinb hinh phit Irifi'n kinh td hifin nay de dam bao cam ket bao phd bio hidm loan dan vio nam 2014 nhtf dtf dinh. Vdi mo hinh ddng bao hiem irong khu vtfc lao ddng khdng chinh ihffc, stf trd cap cua chinh phu se cd the gidp lang ctfdng si^ tham gia cua ngtfdi din nhffng n h ^ g ngtfdi khd tiep can van khd dtfde bao phd. Vi v^y,Vifit Nam eung nfin cin nhae vi xem xfil i p dung mfi binh tii ehinh tff thue' de bao phu bao hiem cho nhdm dan eff nay. Vific niy chac chin se ddi hdi quyfi'l tam cua chinh phd va can dtfde hd trd bdi kha ning tai chinh.
Khdng gian tii khda edn khifim ton da han chfi'
vific md rdng dien bao phu bao hiem ddi vdi ngtfdi nghfio d Lao vi Campuchia, do do 2 qudc gia niy thtfdng phai dtfa vao eae ngudn tii trd. Hai qud'c gia niy se cd cd hdi de cin ddi cung nhtf dinh htfdng Iai va'n de tii chinh vdi nhffng kfi' hoach vl cham sde sffc khde loan eau nham cdng edhe thdng y te Ibeo Tuyfin bd'Paris vl hifiu qua cda vien trd[63], dae biet la tang etfdng he Ihdng cham sde stfc khde ban diu. Tuyfin bd' keu gpi stf phdi hdp gifla cic chtfdng trinh tii trd phd hdp vdi cie tfu tifin quoe gia va lao cd hdi ting ctfdng he thd'ng cham sde stfe khde ban dau ma nhflng ngtfdi ngheo d ndng thdn ed the tiep can dtfdc. Tiep can lot bdn vdi cic dieh vu chim sde sffc khde cd cha't Itfdng cung Ii mot khia canh cda bao phu cham sde stfe khde loan dan vi cic dich vu chim sde stfc khoe ban dau cd chat Iffdng cao va de tidp cin se gidp eai thifin cic dich vu sff dung bdi ngffdi nghfio[46].
Vific tang ctfdng hifiu qua da dtfdc ehffng minh la kha tbi ndu cd stf Iham gia tich etfc eda ngtfdi dan trong edng ddng de xae dinh ngtfdi ngheo bang nhieu each khac nhau nhtf dinh gii dinh Itfdng vl mtfc dfi tifiu dung hay dinh gii dinh tinh de xdp hd gia dinh theo eie mffe dp giau/ngbeo[64]. Kinh nghifim d Campuchia Ii mdt vi du cho nhffng tfu diem cua md hinh phin bd tai chinh cho bfin clu qua quy cdng bing trong ehim sde sffc khde da gidp tang effdng dang ke trich nhifim giai trinh cua cae ddn vi cung ci'p dich vu cho ngffdi ngheo. Vific bii bd thu vien phi mi khdng ed ngudn thu bd sung de bao ea'p cho chim sde stfc khde cua ngffdi ngheo cung khdng phai la Iffa chpn ed ldi[65].
Nhffng qudc gia mdi bat diu xiy dffng mo binb bao hidm y tfi' toan din cin xem xet nhflng diem manh va yeu eda eic phffdng thffc chi tra khic nhau cho cd sd cung cap dieh vu. PhilHealth khdng chi bao ve vl tai chinh d mffe han chd cho nhffng ngffdi cd bao hiem ma cdn khdng phat huy dtfdc kha nang dpe quyln vl mua dieh vu de lic ddng tdi vifie eai thien tinh hieu qua cda cic cd sd y te. Vdi vai trd la ben mua dieh vu ehim sde sffc khde ldn nha't hoic
46 Tap chi Y td Cdng cdng, 4.2011, Sd 18+19 (18+19)
ITfi'NGIUAN&NefllENCUBI
duy nhi't trong ntfde, PhilHealth cd cd hdi sff dung dae quyln eua minh de dat dffde hifiu qua trong eung cap dieh vu, ching ban nhff ap dung phffdng thtfe thanh toan theo dinh suit hoie theo trtfdng hdp bfinh. Bio cio thtfdng nifin cda PhilHealth 2008 ghi rd: "PhilHealth can thay the phtfdng ihtfc thanh toin theo phi dich vu bang phffdng thffc thanb loan khae cho ngtfdi cung cap de ed the dfi ding tang mffe mua dich vu Ifin 18,5 ly Peso vao nam 2008"[66].
Bao biem y td toin dan d Lao my la bat budc nhtfng khdng bao phu toan bp dan sdvi can phai cd' gang ri't nhilu dd md rpng difin bao phu.
Campuchia chtfa xiy dtfng dtfdc md hinb bao hidm y tfi' loan dan de bao phd khu vtfc lao ddng chinb Ihtfe dang ling Ifin ra^t nhanh ve sdltfdng. Tuy vific md rpng md hinb bao hiem dtfa vao cpng ddng ed the din den bifin ttfdng lufa chpn ngtfdc, md hinh nay cd the tam thdi sff dung de' bao phd khu vtfe lao ddng khdng chinh thtfe, nhtf da thtfe hifin lai Thii Lan. Ndi ehung, md rdng pham vi bao pbd ddi vdi nhdm pbi ehinh thffc va dan cff cdn lai ngoai nhdm chinh thffc dffde chia ra thanh 2 hinh thffc: mdt la ddng phi va hai li bao cip bang thud. Vific ltfa ebon md hinh nio cdn tdy thupc vao bdi eanh chinh tri cung nhff hfi ihdng y id. Demo hinh ddng bao hidm boat dpng hifiu qua can cd ehinh phd vi ddi ngu quan ly hifiu qua. u nhihig qude gia ed kha ning td'i vl tii chinh nhtf Thai Lan thi md hinh tii chinh dtfa trfin thufi'la kha Ihi.
Mac dd nhffng quyfi't dinh lien quan den md rdng difin bao phd ddi vdi cic nhdm dan so'khic nhau phai dtfa Irfin tinh hinh thtfe te, chinb phu cic ntfde eung nfin xem xfil de lam sao can ddi gifla gdi lpi ieh. mtfc dd vi phtfdng phip cbi ira cho cd sd eung ea'p dich vu gifla eie md hinh bao hiem khic nhau, bdi ngtfdi din cd the chuyfi'n tff md binh bao hie'm nay sang md binb khac. Sff khae bifil giffa cie md hinh bao hifim trong mdt qude gia cung la mpt nguyfin nbin khdng dam bao dtfdc tinh cdng bang.
Trong bd'i canh cda hfi thd'ng phin ca'p, die hifit nhtf d Indonesia va PhiUppines, thtfe tfi' cho thi'y can phai cd stf can dd'i giffa ngudn ngin sach trung ffdng vi dia phffdng cdng nhff vai ird eua cua chinh quyln trung tfdng va dia phtfdng trong viec md rdng difin bao phd. Cic cai each vl lii chinh rat phtfc lap vi cin dtfa trfin bang chtfng cu the cho bdi canh cua tifng qud'e gia, do dd vific tdi quan trpng li kha ning dtfa ra bang chtfng va sff dung bang ehffng do de xiy dtfng chinh sich[67, 68]. Danh gii thtfdng xuyfin
cac yeu id phit sinh ehi phi, dtf bao tii chinh dai ban cung nhtf kha nang dffa ra va sff dung bang chihig vl ehi phi hieu qua cda cac giai phip la vd cdng dn thifi't. Tuy nhien cic qud'c gia can phai hoc hdi kuih nghifim iln nhau vi stf hdp tic giffa cic nha nghien ctfu trong khu vffe Ddng Nam A la nin tang quan trpng cho sff hdp tic khu vtfe trong no Itfe dam bao tinh bao \$ ve tai chinh vi bao phd bao hifi'm toin din trong khu vtfc.
Vdi nhffng kinh nghifim thffc te'da trai qua dffHc phan tich vi bin luan, cae qud'c gia trong khu vifc cd nhilu ed hpi de chia se kinh nghifim trong nfi lUc dat bao phu bao hiem loan dan nham nang cao sde khoe cdng ddng. Khdng chi viy, nhflng thach Ihiic ma eic qudc gia niy dang gip phai, bao gdm Iim the nio dd ling tinh san sing dap tfng eua eic c(J sd cung ea'p dieh vu cdng. md rpng bao hidm toin dan, xae dinh va bao vfi ngffdi nghfio, ddng thfii Iam thfi' nao de bao phu lot bdn dd'i vdi khu vffe Iao dpng khong chinh thffc vdi md hinh ddng bao hilm hay be thdng tii chinh dtfa vio thud la nhffng thach thffc ma lat ea cic nffdc dang phai Iridn dang phai dd'i mat.
Bii bio nay kip Ihdi ddng gdp eho nhflng cu$c tranh luin hifin nay Irfin toin eau vl viec lim Ihd nao bao vfi ngtfdi ngheo va nhflng dd'i ttfdng dl bi tdn ihtfdng Irtfdc cic nguy ed vl tai ehinh vi mS rfing bao phd bao hidm dd'i vdi khu vffe Iao ddng chinh Ihffc vi khdng ehinh Ihtfc, eung nhff lam sao dat dffde bao phu loan dan dtfa irfin nhffng kinh nghifim va bai hoc cda 7 qud'c gia trong khu vifc Ddng Nam A d nhtfng mffe dp phit tridn khie nhau.
Chdng tdi da bin luin ve didm manh va didm ydu eda eic mfi hinh bao biem vi nhffng ngudn tii chinh cho khu vffe Iao ddng khdng chinh Ihtfc. Kinh nghifim cda cae ntfde cho tha'y mdi qudc gia cd lit nhilu stf Itfa chpn khac nhau phu thupe vao cSc quyet dinh vl ehinh tri, bdi eanh lieh stf va gii tfi xa hdi. Tuy nhifin, sff ehu trong cua chdng ldi ve doi mdi phffdng thffc tii chinh khdng nen dtfdc hilu rang nhffng yfi'u to ling ctfdng vl phia eung (nhif chat itfdng dich vu vi ngudn nhin Itfc) la cac thinh td khdng quan trpng cho vific dat dtfde bao phu y td cho loin dan.
Tdm lai, chinb phd cic ntfde phii cd trich nhifim bao ve ngffdi dan cua minh trinh khdi vide chi nfiu qui nhieu cho cham sde sffc khde dan ddn ddi ngheo hay nhffng thifit hai ve stfc khde vi ho khdng dtfdc sff dung dich vu cham sde sffc khde khi
Tap chi Y td Cdng cdng, 4.2011, Sd 18+19 (18+19) 47
I TING Q I M & NGHIEN COS I
ean. Cic thdng difip quan trpng dffde dffa ra d day ddi vdi cic qudc gia cd ngudn Itfc ban che la (1) Md rdng vific eung cap dich vu chim soc sffc khde ban diu vdi chi phi hdp IJ (ngtfdi dan ed the chi Ira dtfdc) nfin la ifu tien hang diu cua cic chinh phu vi cho den nay nhffng khd khin trong tiep cin cd sd y te ve mat dia if van cdn ldn. Viee md rpng nay can phai di ddi vdi tinh bao ve ve tai ehinh ddi vdi ngtfdi nghfio bang cich xie dinh ehinh xie cac ddi Itfdng ngheo, miln giam vifin phi vi trd cap d mffe phd hdp: (2) Tuy khu vtfc Iao ddng ehinh thffc cd the chidm ty lfi nhd, bao hidm y te xa bpi cd the cd stf ddng gdp quan trong trong vifie bao phd bao hiem- mic du cd che tai chinh dtfa vao thud vin cd Ihd Ii phtfdng thffc nen lam ve mat dai han[69]. (3) Cud'i edng, khi ngffdi nghdo dffde bao phd bdi cic ed ehd dtfa vio thud, trong khi nang ebo phdp ve tai ehinb, vific Ird cap mpt phin eho eie ddi iffdng d khu vtfc lao dpng khdng chinh ihtfc li mpl ltfa chpn nfin Iim.
Nhflng btfdc di thffc tien nhff vay trong cai each se gidp dai dffde muc tieu liu dii la hii hda dtfdc cic md hinh ehi tra tnfdc hay cie hinb thffc bao hiem y tdvdi sff bao phd toan dan va edng bang.
Chifi'n Itftfc tim kifi'm v^ tifiu chi lijTa chpn tai li^u
VT vd WP dd xdy dtfng quy trinh phdn tich vd xin y kiin ddng thudn eda edc tdc gid d cdc quoc gia. Cde ngi dung phdn tich bao gdm bdi cdnh ve tdi chinh y tid mdi qudc gia, nhdng phdn tich ve nS Itfc cua chinh phu trong viee md rdng dtin bao phu bdo hiim ddi vdi ngudi ngheo. nhtfng ngudi ldm trong khu vtfe lao ddng chinh thdc vd khdng chinh thtfe. Cdc ngi dung cg thi gdm eo ngudn thu, tap trung quy, bao phd vi dieh vu, mdc do bdo vi trudc nhtfng rdi ro vi tdi chinh vd cde chinh sdch cda chinh phu detiin tdi bao phd todn ddn. Died bdo edo eho tffng qudc gia, cde tdc gid phdi tiin hdnh long quan cdc ldi liiu da xudt bdn cung nhu cdc vdn bdn chua cdng bd' ehinh thde cua chinh
phd, vi du nhu bdo cdo thudng niin cua quy bdo hiim y li Philippines, niin gidm thd'ng ki cua Viit Nam, sdliiu thd'ng ki cua Cd quan Lao ddng qude tivd Chiin luac Tdi chinh Ytieua Ldo 2011-15.
Sau do VTvd WP dd long hap lgi cde bdo edo cua edc tdc gid d cde qudc gia.
Vai trd cua cac tac gia
VT la tic gia chinh cd trich nhifim xay dffng khung l;y thuyfi't cho bii bio, tim kifi'm iai lieu, kiem tra va phifin giai sdlieu. ddng thdi viet ban thao eda bai bao vi dam bao sff iham gia va ddng gdp eua cic tie gia d eae qudc gia. WP hd trd trong vific xay dtfng khung ly thuyfi't vi cung ci'p sd hfiu cua Thai Lan, so sanh va phan tich sd Iifiu cbo 7 qud'e gia, xay dtfng eae bang bieu va gdp y cho npi dung ban thao.
PI (Campuchia), SMA (Malaysia), AGM (Indonesia), KA (Lao), EB (Philippines) va DBH (Vifil Nam) eung cap va kiem tra cic sd lieu cda mdi qud'c gia. HT (Indonesia) cung cap cic sd lifiu cua Indonesia. PI, SMA va AGM gdp y cho khung phan tich va ndi dung ehung eua ban thao. PI, SMA, KA, va EB hd Ird vie't Iai phin vidt irong bio eao lien quan dfi'n so'lifiu hp eung ea'p. DBH gdp y eho phin vifi'l vl Vifit Nam. AM dim bao v l tinh khoa hpe, chiu trich nhifim xay dtfng khung Iy thuyet cung VT, gdp y eho ban thao va chinh sffa ban thao ebo den khi dtfdc ban cudi cung.
M3u thudn 1^ ich
Chung tdi tuyfin bd i^ng chdng tdi khdng cd miu thuin ldi ich nio.
Ldi cam dn
Bii bio niy Ii mdt phan eda mpt loat bai do To chtfc China Medical Board, Td chtfe Rockefeller vi Atlantic Philanthropies. Chdng tdi xin chin thanh cam dn To chtfc China Medical Board vi Uy ban khu vtfc di to chtfc cae cudc hpp.
Cae npi dung bd sung cd thd tim irfin internet.
48 Tap chi Y te Cdng cdng, 4.2011, Sd 18+19 (18+19)