CHINH SACH
COCHETHITRirClNG
TRONG C H A M S O C S U C KHOE VA CHINH SACH Y TE
Le Qpang Cridng*
• GS.TS. BS. Nguyen Thd trUdno Bo Y te Thong tin bai viet:
Tic Ichda cham soc sijc khoe, djch vu y te, thi tniong y te, "that bai thi truong", tir chu ciia benh vien Lich sir bai viet.
Nhan hai Bien tap Duyet bai
: 20/04/2019 : 10/05/2019 : 16/05/2019
Article Infomation:
Keywords services.
health care, medical health medical maricet.
failure", hospital autonomy Article History.
Received Edited Approved
: 20 Apr. 2019 : 10 May 2019 : 16 May 2019
'market
Tom tat:
Bao ve siic khoe ngirai dan can tinh den chat lirong djch vu, kha nang chi tra va cong biing trong tiep can dich vu (mpi ngudi d^n d8u CO thg tiep can cac dich vu y te ca ban) la trung tam cua cac chinh sach y te va chinh sach cong. De co nhimg chinh sach tot, can xac dinh ro cac dac thu cua nganh djch vu y te, ciia thi trucmg y t l va vai tro chii dao cua Nha nuac, Luat Kham chita beiih - xucmg song cua he thong y te - dang dupe nghien cuu sira doi can chii trpng den cac dinh huang nay.
Abstract
it is required to take into account the quahly of services, afFordability and fairness in access to medical services (all residents are able to access to basic health services), which is as the fical point of the medical policies and the public ones. In order to develop good pohcies, it is necessary to clearly define the charactenstics ofthe health service sector, the health service market and the leading role of the governmental adminisn^tion. The Law on Medical Examination and Treatment, the backbone ofthe pulic health system - being reviewed, needs to receive attentions to the mentioned above matters.
I. Mot so dac thii cua nganh dich vu cham soc sue khoe va cac yeu to "that bai thi triTOTig" trong thj trutmg y te
Cham^ soc sue khoe la nganh dich vu trong do, ve ban chat, nguoi eung iing va nguai su dung quan he voi nhau thong qua gia dieh vu. Tuy nhien, khong giong cac loai dich vu khac, cham soc sue khoe co mot so dac diem rieng, do la:
; Moi nguoi c6 nguy co mac benh va nhu cau cham soc siic khoe a cae miic do khac nhau. Do khong du doan duac thai diem mac benh nen nguai benh thuang gap kho khan trong chi tra eac chi phi y te khong luong truae duac.
- Dich vu y te la loai hang hoa ma nguai su dung (nguai di kham sue khoe) khong the tir minh de dang lua ehpn loai dich vu theo y muon ma phu thuoe rat nhieu vao ben cung ung (ca so y te). Cu the, khi n^uai dan co nhu cau kham chira benh, viec dieu tri bang phuang phap nao, thai gian bao lau hoan toan do thay thuoe quyet dinh Nhu vay, nguai ta chi co the lua chpn nai dieu tn va a mpt ehung muc nao do, nguai chira ciiu khong chu dpng lira chpn duac phuang phap dilu tri cho minh. Mat khac, do dich vu y tl la loai hang hoa gin lign vai tinh mang con nguai nen mac du khong co lien nhung ngucri benh vSn phai kham chira benh (mua
, NGHIEN ClilU I J l l S6 9(385)T5/2019 V L A P PHAPl ^ '
CHINH SACH
dieh vu). Diem dac biet nay khong gifing cae loai hang hoa khac, do la d6i voi cac foai hang hoa khong phai la sue khoe, nguai mua CO the CO nhieu giai phap lua ehpn, tham ehi tam thai khong mua neu chua co kha nang tai ehinh.
Trong ca che thi tru&ng chudn, de eo lai nhuan toi da, nha san xuat se can eu vao nhu eau va gia tren thj truong d | quygt dinh san xuat cai gi, san xuat nhu the nao va san xuat eho ai. Thong qua c a che thi truang, eac nguon luc cua nen kinh te tu dpng phan bo mpt each toi uu. Tuy nhien, de eo che thi truang thuc hien tot dupe chiic nang cua minh, thi truang phai eo moi trucmg canh tranh hodn hao, thong tin cdn day du, cong khai vd khong bi dnh huang b&i cdc tdc dpng ben ngodi v.v..
Trong ITnh vuc y te, do dich vu cham soc sue khoe eo eac dae diem rieng biet neu tren, nen co che thi truong khong the van hanh mpt each hieu qua. Cac nha phan tich kinh te da thua nhan rang trpng thi truang y tg luon ton tai cac yeu to/'th^t bai thi truang"(market failure), cu the la:
- Thi truang y te khong phdi la thi truang tic do. Trong thi truang tu do, gia eua mpt mat hang dupe xac dinh dua tren sy thoa thuan tu nguyen gi&a nguai mua va nguai ban. Trong thi trudng dich vu y IS khong CO su thoa thuan nay, gia djch vu do nguai cung ung quyet dinh.
- Dich vu y te la mpt nganh dich vu cp dieu kien, tuc la eo su han che nhat dinh doi vai su gia nhap thi truang cua eae nha cung ung djch vu y te. Cu the, muon cung ung djch vu y tS c4n dupe cap giay phep hanh nghe va c4n dam bap nhirng dieu kien nhat dinh ve ca sa vat chat. Noi mpt each khac, trong thi truang y te khong co sy canh tranh hoan hao.
- Co hien tuang bdt doi ximg thong tin gi&a ben cung cap dich vu va ben su dung djeh vu. Tren thuc te, benh nhan hiSu biet rit it y^ benh tat va cac chi dinh dieu tri, do vay hiu nhu ngucri benh hoan loan phai dya
\ko cae quy^t djnh cua thay thuoe trong viec lua ehpn cac dich vu y 16 {cdu do cung quyet dinh). NSu vin d l nay khong dupe kiem soat t6t se dan tai tinh trang lam dung djch vu tir phia eung ung, day cao chi phi y te.
- Dac di8m cua dich vu y ^{f 'IJ^f^^J I ' . . „ . .fnh rhat Knac hoa cong cong va mang tinn t u L - . . . T^L" ••- . . ! , ' u-A."Arfavlaviectnu biet .Khai mem khac biet o a a y " • • huong loi ich cua dich vu y te khong cm gioi han o nhung nguoi tra tiJn de huong dich vu ma CO nhimg loai dich vu ke ca nhung nguoi khong tra tiln ciing co the duoc huong cac loi ich nay (vi du: cac djch vu y te dv phong, giao due siie khoe...). Chinh do tinh chat neu tren, hhiSu loai dich vu y te khong tgo ra duac dong ca lai nhugn cho nguoi cung ling se khong khuygn khich duge viec cung ling cac loai djch vu nay. Do v|y, de dam bao cung dap iing dii cho cdu, rat can co su can thiep h6 trg ciia Nha nude trong cung ling cac dich vu y t8 mang tinh cong cpng.
2. Tinh hai mat ciia viec ap dung ctf ch^
thi trirtmg trong cham soc sire khoe Hien nay. tai mot so nuoc dang phat trien co to chuc xa hoi tuong tu Viet Nam, viee ap dung co ehe thi truong trong cham soc siic khoe, dac biet trong he thong kham chiia benh da va dang dugc thu nghiem trien khai voi nhiing ket qua rat dang suy nghT.
Viec ap dung thue muon cac c a so tu nhan cung img cac dich vu phi y te (non-medical services) nhu ve sinh, giat la... da giiip tiet kiem dugc nhan luc ciia benh vien va tinh chuyen nghiep ciing mang lai hieu qua va chat lugng TO rang hon. Tuy nhien, khi ap dung CO ch6 thi trucmg trong cung ling cac dich vu y tS (medical services) nhu kham chua benh thi mgi viec tro nen phiic tap hon va kho kiem soat Nhu tren da trinh bay do bat can xiing thong tin nen viec quylt dinh dung dan mot phuong phap diSu tri, sir dung mgt xet nghiem hoac mgt loai thu6c phu hop vo> tmig nguo, benh chu ylu phu thuoe vao quyet dinh cua nguoi thay thu6c. Nhu vay neu khong c6 co chi kilm
soat, viec chi dinh qua mue cac djeh vu cin cho nguoi benh hoan toan co the xay ra.
Kinh nghiem 6 Trung Oi.A^
t h g . g i a n d a . a p d , n g e o c h 4 ^ ~ J ^ cung ung dich vu kham chiia benh benh vien cong theo hucmg chuvln^h^^h vien cong tii hinh thuc don so hihi Lu -
""u^nhanuoc
48
I NGHlfeN Cini , I L A P P H A P — ^ S69(385)T5/2019CHINH SACH la chii sa hiru duy nh^t) sang hinh thuc benh
vien da so hiJu (e6 phhn hoa) vai hy vpng giam mpt phhn six dyng ngan sach nha nuoc, da eho thay hieu qua tang tinh tu chu, chu d6ng cua cae benh vien c6ng. Tuy nhien, ben canh viec cac benh vien cong (dac biet a tuy§n tren), trang thiet bj dupe hien dai hoa nhanh chong (do tu nhan phoi hcrp dau tu), ngudn thu tang ro ret, thi mpt van de a cap dp he thong da xay ra. Cu the, khi cae dich vy kham chira benh theo yeu cau na r6, bao hiem chi chi tra m6t phSn do menh gia dong khong cao nen nguoi dan phai tang chi tra tir tien tui (dong them ngoai phan bao hiem chi tra) va dieu nay thuc sy anh huang den tiing lop eo thu nhap trung binh va thap (chiem ti le cao trong xa hpi). Hau qua la kha nang tiep can dieh vu y te cua nguoi dan bi giam siit, chi phi y te ngay cang tang, tang muc dp mat eong bang trong y te.
Nam 2005, B6 truong Bp Y 16 Trung Qu6c da danh gia cong cupc cai each he thong y te ciia Trung Quoc theo hucmg co phan hoa da khong thanh cong. Mat khac, do ty chii nen benh vien eong dupe ty xac dinh gia dich vy va viee ehi dinh dich vy "qua mue can thiet"
cho nguoi benh la khong the tranh khoi va rat kho kiem soat. Dieu nay cang lam cho chi phi y te ciia nguai thu nhap thap tro nen nang ne hon do ben canh phan chi phi duoc bao hiem chi tra, nguoi benh phai bo them tien tui cho cac dich vu y te khong dupe thanh loan.
O Viet Nam, ly ehu cua benh vien cong ciing dang dupe trien khai tir nhieu nam nay. Hien dai hoa nhanh cac trang thiet hi 6 cae benh vien lan thong qua nhieu co che tai chinh khac nhau da lam "thay da doi Ihit" cac benh vien nay trong mpt thoi gian ngan, thu nhap tang them ciia can bp, nhan vien benh vien duoc cai thien dang ke, benh nhan co dieu kien tiep can voi trang thiet bj
hien dai de dang hon, dae biet o cac benh vien tuyen tren. Dieu nay thye su cung giup cho Nha nuoc mpl nguon ngan sach dang ke trong khi chi tieu cong co qua nhi^u ITnh vuc phai dau tu. Tuy nhien, nghien eim tai Viet Nam eiing da chi ra, tren thye te, cung da xay ra hien tuang chi dinh qua muc c4n thiet cac xet nghiem trong cac benh vien cong. Mat khac, do can nguon benh nhan de tang thu. Cling voi viee dau tu trang thik bi chu yeu tap trung a cac benh vien luyen tren - nai CO nhieu chuyen gia gioi (chir khong phan bo deu tren toan he thong y te) dan den viec benh nhan bi "hiit" len tuyen tren la tat nhien va kho co the giai quyet dupe van de
"qua tai benh vien'". Trong thoi gian qua, Bp Y te Cling Bao hiem Xa hpi Viet Nam ciing da va dang phoi hop de dua ra nhung quy djnh vai mong muon phat huy uu diem, han che nhupc diem eua ca che tu chii hien nay trong cac benh vien cong. Su thanh cong hay khong hay khong ciia cac quy dinh nay trong tuong lai hoan loan phy thupc vao viec phal hien va dua ra dupe cae chinh sach phii hap, trong do co cac giai phap cho cac hoat dpng tu chu hien nay trong benh vien cong.
3. Khuyen cao chinh sach cua WHO khu vuc TSy Thai Binh Duong
Tren co so tim hieu hoat dpng ciia ty chu benh vien cong tren the gioi, noi chung va 6 Viet Nam noi rieng, nham tu van giiip he th6ng y t§ Viet Nam tranh dugc nhirng sai l4m khong mong muon ciia nhirng nuoe c6 t6 chuc xa hpi tuong dong voi Viet Nam da di truae, WHO khu vye Tay Thai Binh Duang (2017) da dua ra Khuyen cao chinh sach (Policy Brief) ve tu ehii benh vien a Viet Nam duoi lieu de "Cai each cac benh vien cong thi nao de cai thien chat luong, kha nang chi tra va tiep can cong bang dich vy y t^ 6 Viet Nam"^. Xin neu duoi day npi dung chinh cac khuyen cao cho Viet Nam:
1 Vien Chien luge va Chinh sach Y ti, Bao can Khao sat tinh hinh thirc hien Nghi dinh 43/2006/ND-CP trong he thong benh vien cong lap, 2010.
2 WHOAVestem Pacific Region, How to reform public hospitals lo improve quality, affordability, and equitable access to health services in Viet Nam, 2017
- , NGHIEN CtfU I ilQ S6 9(385) T5/2019 V^LAP PHAPl ^ * '
CHINH SACH
1) Cdn CO mpt he thdng chinh sdch dii mgnh di kiim tra, gidm sdt cd benh vien cong lap vd ngodi cong lap
- Phap luat cku xac dinh ro trach nhiem ciia Chinh phii va lanh dao dia phuang trong quy hoach va phat Irian he thdng benh vien.
C k thanh lap phap^ nhan quan !y cac benh vien tuyen 2 va tuyen 3.
- Phat lri§n benh vien phai tuan theo nguyen tSc minh bach trong xay dyng, nang cap va mo rpng tren ca so dya tren nhu cau ciia cpng ddng. Cac nguyen lac nay gom c4p phep, chiing nhan, kigm dinh mua trang thi^t bi ky thuat cao de dam bao hai hoa chat luang va an toan cho ngudi benh.
- can thanh lap va giao eho mot phap nhan a tirng viing de giam sat hoat dpng hang ngay cac benh vien trong viing.
+ Chuc nang cua phap nhan nay la hudng dan phat trien he thdng benh vien, quyet dinh dau tu trang thiet bi, md rpng quy md benh vien dya tren nhu cau kham chira benh ciia nhan dan trong viing ciing nhu giam sat van hanh cua cac benh vien.
+ Thanh phan cua phap nhan nay bao gdm cac chuyen gia ve phat trien benh vien, dai dien quan ly nha nudc trong ITnh vye y tS, tai chinh, bao hiem va dai dien ciia nguai dan 2) Chien luoc tim nguon tdi chinh thay the ddu tu cong cho cdc benh vien cong.
- Can su dung von dau tu, vay ngan hang CO Nha nudc dam bao thay cho viec huy dpng lien tir nhan vien benh vien hoac eac nha dau tu lu nhan (loai d^u tu nay cSn phai huy bd bang quy dinh cua Luat).
- Chi phi thudng xuyen va gia dich vu can duoc tinh toan dya tren gia hgp ly d^
benh vien cd the thu hdi dupe chi phi thuang xuyen khi cung irng djch vu. Bao hilm y te can dupe sir dung nhu ddn bay d§ kk ndi sy phat trien benh vien vdi cac ehinh sach ciia Chinh phii thdng qua viec xay dyng gia djch vu, CO ehe chi tra va Ipi ich cho ngudi cung img dich vy.
- Dau tu cua Chinh phu ddi vdi cham sdc siic khde ban dSu ("ngudi gac cdng")
thong qua bao hiem can dii dk co th6 dam bao dugc can ddi tai chinh va phat tri^n linh vuc sue khoe.
3) Chudn hoa hi thong ki todn vd bdo edo cong
- He thdng ke toan benh vien cSn chuan hoa cung voi trien khai tren toan qudc cac phuong phap kiem toan hieu qua.
- Thong tin tai chinh phai dugc bao cao minh bach cho cac ben lien quan, kh ca cho ngucri dan.
Nhu vay, bao ve sue khde ngudi dan can tinh den chat lugng dich vu, kha nang chi tra va cdng bang trong tiep can dieh vu (mpi nguoi dan deu eo the tiep can eac dich vu y te cpf ban) la trung tam ciia cac ehinh sach y te va chinh sach cdng. Hien nay, chung ta dang soan thao nhieu ehinh sach quan trpng lien quan den nang eao sue khoe ngudi dan theo tinh than cua Nghi quyet 20/NQ-TW cua Ban Chap hanh trung uong nam 2017. Dac biet, mdt van ban quan trpng, Luat Kham ehira benh - xuong sdng ciia he thdng y te dang dugc nghien cuu sira ddi se la mpt hanh lang phap ly quan trpng trong tuang lai. Nghien euu than trpng, hpc tap kinh nghiem cac nudc di trudc va dac biet tranh het sue nhiing quy dinh gay mat cdng bang trong y te la dieu can dugc uu tien. Mat khac, can phai lam rd vai trd ciia Nha nudc trong viee dam bao ngudn tai chinh, tao eq ehe thuan Igi de mpi ngudi dan deu cd the de dang tiep can cac dich vu y te co ban.
Dau tu cho y te eo sd va cd ngudn ngan sach dn dinh cho viec cung img cae dich vy y te cdng cpng, de tu nhan cung iing eac dieh vu y te tu la xu huong chung ciia cac nude co nen y te phat triln. Ddng thdi vdi sy tao dieu kien thuan Ipi phat trien cae loai hinh dich vu y te lu, vai trd quan ly,cua Nha nudc la rat can thiet trong viec kiem soat gid cd va chat luang dich vu, tang cuong thdng tin, tham djnh dieu kien hanh nghe nhu da neu d tren. Cong cy huu hieu nhat trong kilm soat gia ca va cung iing dich vu chinh Xk phuang thiec chi trd phii hap.
An sinh xa hpi chinh la an ninh xa hdi!
Mpt chinh sach tdt cho y ll se gop phdn quan trpng cho xa hpi dugc dn djnh va phat trienB
