Phát triển Con người từ độ chăm sóc sức khỏe một số vấn đề thực tiễn ở Việt Nam hiện na.pdf

PHAT TRIEN CON NGUdl ^~ ^' TU" GOC DO CHAM SOC StfC KHOE: M O T S VAN DE THUC TifiN VIET NAM HIEN NAY DAO THI MINH HUONG' Chi so y te cua Viet Nam hien tot hem nhidu nu-dc cd cung trinh d9 phat trien thap ky qua, Nha nu-dc da tang chi tieu cdng cho y te thong qua tang chi ngan sach nha nirdc va tang ti trpng ciia bao hiem y te chi tieu cong cho y te, va la ket qua cua nhieu chinh sach va chu-ong trinh lien quan den cham soc sue khoe toan dan da du-pc ban hanh va thu-c hien Mac dfl Id qudc gia ed thu nhdp binh quan dau ngudi thudc nhdm trung binh thdp nhung theo ddnh gid ciia nhidu bdo edo thi cdc chi sd y td cua Viet Nam tdt hon nhidu nude ed cflng trinh dp phdt trign va thdm chi cdn tucmg duong vdi mdt sd nudc cd mue thu nhdp binh qudn ddu ngudi cao ban 3-4 lan (World Bank, 2009) Ngu so sdnh mflc chi y tg binh qudn ddu ngudi cfla Viet Nam (khodng 77 USD nam 2008, 83 USD ndm 2010 vd 95 USD nam 2011 (Bd Y tg va Nhdm ddi tae y tg, 2010, 2013) vdi cdc chi sd kgt qud vd sue khde thi hidu sudt cfla he thdng y td Viet Nam tuong ddi khd quan Cac chi sd y tg, dac biet chi sd tudi thp ddng gdp vi tri quan trpng viec cdi thien ehi sd phdt trign eon ngudi Viet Nam thdi gian qua Tudi thp trung binh tang 11% giai doan 1999 - 2012, tu 69,1 tudi nam 1999 Idn 72,8 tudi nam 2009; 72,9 tudi nam 2011; 73 tudi ndm 2011 vd 2012 Sau gdn 15 nam (tu 1999 - 2012), chi sd HDI tang 15,5%, tu 0,651 len 0,752, dd tdng trudng kinh td ddng gdp vdo sy thay ddi ndy Id 9,4% so vdi chi sd tudi thp Id 4,1% vd chi sd gido due la 2,0% Ndu chi xet ridng HDI nam 2012 thi chi sd kinh td ddng gdp 60,9%, chi sd tudi thp ddng gdp 26,3%, chi sd giao due ddng gdp 12,9% (bang 1) Bang Ddng gop tang trirdng tuoi tho vao thay ddi HDI Toan quoc 2008 2004 1999 Thay doi 1999-2012 0,801 0,794 0,782 0,721 11,1% 4,1% Bong gop cac chi s6 phan vao HDI (%) 26,3% 0,841 0,830 0,826 0,803 4,8% 2,0% 12,8% 2012 (%) Tuoi thp trung binh Chi so giao duc Chi so thu nhap Chiso H D I Dong gop cac chi so vao thay doi (%) 0,615 0,559 0,496 0,430 42,0% 9,4% 60,9% 0,752 0,728 0,701 0,651 15,5% 15,5% 100% Ngudn • Tinh todn cua Trung ldm phdn tich du bdo Vien Hdn ldm Khoa hoc Xd hgi Viet Nam (VASS) trmh bi^ tgi Hgi thdo "Tdng trudng kinh tevi tdng irudng bao irion", HdNoi, thdng5/20l4 • TS ; Vien Nghien cOru Con nguiri; Vi?n H^n lam Khoa hpc Xa hpi Vifit Nam NghiSn ciiu Con ngudl s6S(74) 2014 21 Phdt trien ngudi Cac chi so y te khac co lien quan ciing dugc cai thien dang ke nhu ti suat tii vong tre em, ti le suy dinh duong tre em giam, mac dii tinh trang suy dinh duong tre em vmi cao va tro thach thiic Ion voi chat lugng nguin nhan luc va phat trien' Cu the, tinh chung cho ca nuac, ti le suy dinh duong the nhe can duoi tuli giam ben vihig ke tir nam 2000, tit 41% nam 1990 xuIng 16,2% nam 2012 (Vien Dinh duOng, 2012) Tire la da giam 60% tre suy dinh duong thoi gian nay, vugt Mue tieu thien nien ky la giam 50% vao nam 2015 Ti suit tii vong tre em dual tuli da giam hon 70% giai doan 2000 2012, tir 44.4 tren 1000 he de sing nam 1990 xuIng 15,4% vao nam 2012 (T6ng cue Thing ke, 2013); Ti suit tit vong tre em duoi tuli da giam 60%, tir 58 tren 1000 tte de sing nam 1990 xuIng 27,5% vao nam 2008, 23,8% vao nam 2010 va 23,2% vao nam 2012 Ngugc lai voi chi sl tren, ti le tre em duoi tuoi thira can, beo phi tang 16n la quan ngai moi ttong cham soc siic khoe So vol nam 2000 thi ti le hien tang khoang 6,2 lln va tang a ca khu vuc nong thon va thi, dii mai chi xuat hien thai gian gan day nhimg nong thon lai co toe dp tang nhanh ban thi Ti le tre em dual tuoi dugc tiem phong soi da tang gan 80% giai doan 1990 2012, tir 55% nam 1990 len 95,6% nam 2008 va tri ti le 95% din nam 2012 Tuy nhien, theo so lieu tir dieu tta hp gia dinh nam 2011, ti le tre em duoi I tupi dugc tiem phcng sgi ma thong tin dugc nguai me biet mai chi dat 84% (Tang cue thpng ke, UNICEF, va UNFPA, 2011) Dieu ggi y rang can tang cuang cac hoat dgng ghi chep viec tiem chung ro rang va tang hieu biet cho ngucri me ve tiem chung Nhieu giai phap can thiep nhu dao tao co &a thon, ban nguai dan tpc thieu so, ho ttg cac nhom chuyen tuyen dua vao cpng dong, thiic day cham soc siic khoe sinh san (CSSKSS) da gop phan tang ti le phu nir sinh dugc can bp y tl tir 55% len 97% nam 2005, va tir nam 2010 din da tri g mirc tren 97% (Bg Y tl va Nhom dli tac y tl, 2013), va co tac dpng tich cyc din viec giam 75% ti sl tii vong me/IOO.OOO tte de song, tir 233 tre nam 1990 xuIng 80 tre vao nam 2005 va 69 tre vao nam 2009 (Ting cue Thing ke, Bp Kl hoach va Diu tu (Kl hoach va diu tu), 2011) Ti le dan sl sir dung nguin nuoc uIng hgp ve sinh tang tir 57% nam 1990 len 92% vao nam 2011, va ti le dan sl su dung hi xi hgp ve sinh tang tir 37% nam 2009 len 78% vao nam 2011 (WHOAJNICEF JMP, 2012) Thanh tyu an tugng ctia he thing y te Viet Nam dugc ghi nhan viec kilm soat nhilu benh lay nhilm nhu sai, bach hlu, uln van, lao, HIV, Din nam 2012, Viet Nam da khing chl ti le nhiem HIV a mirc dual 0,3% dan sl vcti ti le 241/100000 Nam 2010, mpi doi tugng co nhu clu diu dugc dilu tri HIV/AIDS Nhilu chi sl y tl da dat dugc Myc tieu thien nien ky (2015) truoc thai han (bang 2) Cac chi sl y tl dugc cai thien dang kl thoi gian qua la kit qua ciia cac chinh sach, chuong trinh da dugc ban hanh va triln khai thyc hien tai Viet Nam lien quan din cham soc stic khoe (CSSK) toan dan, nhu: cac chuang trinh hi trg toan bp hoac mpt ' Theo Bg Y t6 (2008), khoang 21,2% tre em duoi tu6i bi suy dinh du&n^ can nang/tu6i; 33,9% tre em suy dinh du&ngchi§ucao/tu6i; va 7,1% tre em suy dinh du&ng can nang/chifiu cao 22 "Sl'li" Cliu Con ngua sgsa4) 2014 Bdo Thi Minh Huang phdn mua the bdo hidm y td cho cdc ddi tugng theo Luat Bdo hidm y td, bao gdm ngudi ngheo, ngudi can ngheo, ngudi ddn tdc thidu sd, tre em dudi tudi, cdc ddi tugng chinh sach, hpc sinh, sinh vidn, dac bidt la vide tang chi tidu cdng cho y td tfl ngdn sach nha nudc (NSNN) Tang ehi tidu cdng cho y tg Id mot chign luge quan trpng duge Td chuc Y td Thg gidi (WHO) khuygn cdo cac nude thdnh vien thyc hidn nhdm myc tidu bao phfl CSSK todn dan (WHO, 2009) Cd nhihig bdng chung cho thdy Igi ich ro ret eua vide tang chi cdng cho y td ddi vdi cac kdt qud dau vd sflc khde Theo Ngan hang Thg gidi (World Bank), ti Id chi cdng cho y td so vdi GDP tdng thdm 10% se Iam giam 7% ti sd tfl vong me, gidm 0,69% ti Id tu vong trd em dudi tudi, vd gidm 4,41% ti le suy dinh duong thd nhe cdn Ngudn chi tu Cbinh phfl cho y td nhin chung thdp han so vdi cde nudc khdc khu vyc, song da tang mdt cdch ddu dan tfl 4,8% lgn 10,2% tdng ngdn sdch qudc gia giai doan 2002 - 2008 (UNDP, 2010) vd giai doan 2008 - 2012, chigm 8.28% vao nam 2012 (Bd Y td vd nhdm ddi tdc, 2013) Tdng chi NSNN cho y td giai doan 2008 - 2013 tdng qua cdc nam vdi tdc dp tang binh qudn 34,2%, cao hem tdc dp tang binh qudn tdng chi thudng xuydn NSNN cimg ky 20% (Bd Tdi ehinh, 2013) So vdi GDP, ti trpng chi NSNN cho y td tdng lign tuc tu nam 2008 ddn ndm 2011, dat mflc cao nhdt Id 1,97%, sau dd cd xu hudng gidm di Chi sd ndy phdn dnh mflc dp uu tidn cho y td phdn bd ngdn sdch chung Chi tfl NSNN cho y tg tang thi mue dp bao phu BHYT tdng, dat 66,8% nam 2012 da tang ehi tigu edng cho y te Vd phdn bd ngudn tdi chinh, Viet Nam da xac djnh ro uu tign cho cac ITnh vyc mang Iai hieu sudt cao CSSK bao gdm y tg dy phdng, y tg co sd, CSSK, CSSK ba me tre em, hd trg ngudi ngheo vd cac ddi tugng thiet thdi Bang Ti trpng chi thirdng xuyen cho y te tu- NSNN so vdi tdng chi thu-ong xuyen NSNN va so vdi GDP (2008 - 2013) Nam 2010 2011 2012 2013 2008 2009 5.9 8,1 % chi thuang xuyen 4,9 6,2 8,2 8,3 cho y te /tong chi thucmg xuySn NSNN ^ chi thuang xuyen I.O 2,0 1,8 1,2 1,3 1,7 ^ y tl /GDP Ngudn: Bg Tdi chinh, Sd li^u thdng ke ve chi ngdn sdch nhd nudc wr Bgn canh do, phan bd NSNN ciing dugc uu tien cho vflng sau, vung xa vdi dinh mflc cao hon 1,7 - 2,4 ldn vung thi Sd lieu chi sy nghiep y te nam 2012 cho 63 tinh, thdnh cho thay khu vuc mien nfli phia Bdc vd Tdy Nguyen cd mflc chi ngan sach y td binh qudn ddu ngudi cao nhdt cd nudc (bang 3) MIJC chi ngan sdch ndy bao gdm chi sy nghidp y td vd chi ho trg mua BHYT cho ngudi ngheo vd tre em dudi tudi (Bg Y td vd nhdm ddi tdc y td, 2013) Vi$c uu tien xuat phat tu thidu thdn ve tdng ca sd cho y td Cling nhu ngudn nhdn lyc y td d nhihig vflng vd nham mue dich tang ca hpi tiep Nghiin ciiu Con ngudl s6S(74) 2014 23 Phdt trien ngudi can y te cho ngudi ddn vung sdu vflng xa va ddng bdo ddn tdc thidu sd chidn luac CSSK todn ddn cfla Viet Nam Bang Chi NSNN cho v tg binh quan dau ngudi Chung toan qudc 474 Trung du vd midn nui phia Bac 751 Ddng bdng sdng Hdng 420 Bae Trung Bd va midn Duyen hdi 475 Tdy Nguyen 572 Ddng Nam Bd 368 Ddng bang sdng Cflu Long 406 Nguon: Bd Tdi chinh So lieu thong ke ve chi ngdn sdch nhd mfdc Mae du tang, nhung phan ldn ngdn sdch nhd nudc chi cho y td vdn ehi de ddm bdo tri dich vu vd trg cap cho bdn cung cap dieh vu, edn chi tidu cho BHYT gdm cd trg cdp cho ngudi ngheo va ngudi thidt thdi thi it ban nhigu (Giang Thanh Long, 2010) Tuy nhign, ti trpng cua bao BHYT ehi tidu cdng cho y te da lidn tuc tang, tu 7,9% nam 2005 len 17,6% nam 2008, dp bao phfl cua BHYT tang Idn cdc nam (Bp Y tg vd nhdm ddi tac y td, 2010) Bao hiem y te dang ddng vai trd tich cure gii^p tang kha nang tilp cdn cua ngudi dan vdi cac dich vu y te va giam chi tu- tien tui cua ngudl dan; su- tham gia ciia moi ngirdi dan vao tat ca cac loai bao hiem y tl co tu'oTig quan vdi sh l^n tham kham va didu tri; dp bao phtd bao hiem y tg tang dan theo cac nam, nhung khong dong deu giira cac nhdm ddi tupng, giua cac vung mien Viet Nam, he thdng BHYT duge bdt ddu thyc hidn ndm 1992 nhdm huy ddng cdc ngudn lyc va tao mdt co chg ehi trd thich hgp ban cho eae dich vu Cde ngudn lyc tai chinh eua he thdng BHYT thu dugc thdng qua thug hoac bdo higm x5 hpi tinh theo mflc thu nhdp, dugc coi la ngudn tdi chinh cdng vd cd vai trd hdt sflc quan trpng viec dam bdo sy cdng bang cae ddng gdp tdi chinh cung nhu hudng lgi y td theo nhu eau (khdng dya trdn mflc ddng gdp) thdng qua mpt he thdng ngan ngfla rfli ro Viet Nam hipn cd hai hinh thflc bdo hidm, dd la bdo hiim bdl buoc va bdo hiim tu nguyen He thdng BHYT bao phfl gan 44,4% vdo nam 2006; nam 2007 Id 43,5%; nam 2008 Id 46,8%; nam 2009 Id 58,2%; nam 2010 Id 60,3%; nam 2011 la 65,0%; nam 2012 la 66,8%; nam 2013 Id 69,1% (Sd lieu tu Vy BHYT, Bp Y td, cde nam), cd mpt ti Ie ddng ke ngudi ngheo va cdc doi tugng chinh sdeh, ydu thd dang tham gia^ Thdng kg 10 ndm trd Iai day cho thdy ngdy cang nhigu ngudi sfl dung dich vu y te, chfl ygu Id dudi eac hinh thflc kham chfl-a bdnh tai edc co sd eua nhd nude; dich vu y td tu nhan cung cdp chi chidm 38% ddi vdi dich vu ngoai tru va 2%i ddi vdi dich vu ndi trfl vdo nam 2008 Dp bao phu BHYT md rdng lam tdng co hdi tidp can dich vu y td ngudi ddn thd hidn qua vide tang tan suat khdm chfta bdnh cua tdt cd cdc nhdm kinh td xa hdi " Nam 2008, tflng dan sfl cfl bao hifim, % cfl BHYT mien phi 10% cfl bao hilm bat buflc I % c bao hifim hoc sinh, sinh vien va 6% cfl bao hifim ty nguyen Trong nSm 2008 co % ngu6i nghfio 76 % ngirdi dSn tpc thifiu s6 va % ngirai tren 60 tufli cfl BHYT 24 "(/'"en cUu Con ngudf so 5(74) 2014 Bdo Thi Minh Huang Kd tfl Ludt Bdo hidm y tg cfla Viet Nam duge ban hdnh vd cd hidu lyc vdo ndm 2010, tinh ddn nam 2012, khodng trgn 60% ngudi ed BHYT dugc NSNN hd trg todn bp hoac mdt phdn kinh phi C) mdt so tinh mign nui cd ddng ngudi ngheo, ngudi dan tdc thidu sd, ti Id dat tren 75% (Bp Y td va nhdm ddi tdc, 2013) Trong 27 trieu ddi tugng cbinh sach xa hdi dugc Nhd nude hd trg todn bd kinh phi dd mua BHYT, cd 100% ngudi ngheo da cd BHYT, khodng 50,4% hd gia dinh cd ngudi khuydt tat trgn cd nudc da dugc thu hudng chinh saeh hd trg vd y td (gdn 40% dugc kidm tra sue khoe midn phi vd 45,4% cd the BHYT), 25% hd can ngheo da cd BHYT Tuy vdy vdn cdn ti le ldn ngudi dan (khoang 30%) khdng thudc chuang trinh bdo hidm ndo"* Trong sd cd rdt nhidu ngudi hd gia dinb can ngheo vd hp gia dinb Iao ddng khu vue phi chinh thuc (Castel P., Trdn Thi Mai Oanh Trdn Ngd Minh Tdm, 2010) So vdi nam 2008, ti le bao phu BHYT da tang ldn gan 20% vdo nam 2012, vdy ti Ie tham gia cua nhdm BHYT tu nguyen (lao ddng khu vyc phi chinh thfle; hpc sinh, sinh vien; ngudi nhd cfla ngudi lao ddng ), nhdm Iao ddng cac doanh nghigp vdn cdn rat thdp vd thay ddi khdng nhigu qua cde nam Phdn tich eac nghign cuu cho thdy, Iy mue dp bao phfl BHYT cdn thdp tai cdc nhom ddi tugng khdng dugc NSNN hd trg 100% va nhdm ddi tugng mua bdo hidm ty nguygn la do: I) Mflc hd trp ddng BHYT tfl NSSN cho khu vye Iao dpng phi ehinh thflc thdp, thu nhdp cua cde hd can ngheo, eung nhu cdc hp gia dinh ndng thdn trgn can ngheo d nudc ta cdn thdp, chua du dd giup hp tham gia ddng BHYT; 2)Td chflc bao phu BHYT theo timg cd nhdn ma khdng theo hd gia dinh nhu hidn lam mat di sy chia se timg hp gia dinh, 3) Chdt lugng dieh vu khdm chfta bdnh (KCB) d y tg CO sd chua dap ung nhu cdu; vdn de chuygn tuydn ddi vdi ngudi bdnh, dae biet Id ngudi benh cd BHYT gap khd khan chua cd quy dinh ro rang; 4) Ngudi bdnh thidu tin tudng vdo trinh dp chuygn mdn cua tuygn dudi ngn vdn phdi trd tign tui KCB d tuygn tren, ngn BHYT khdng phdt huy vai trd phdng chdng rfli ro nhidu nai vdn cdn nhigu ngudi khdng su dung cac dich vu tai cdc ca sd y tg nhdt Id trung tdm y tg; 5) Quy dinh vg cimg chi trd khdng trdn gidi ban d mflc 5% hoac 20% vugt qua khd ndng chi trd cua hp gia dinh thu nhdp thap; 6) Mflc phi BHYT binh qudn ehi dat dudi 50% so vdi mue chi tigu y tg binh qudn ddu ngudi He qua ddn dgn vice ngudi tham gia BHYT hoac phai chi tra thdm sfl dyng dich vu y te, hoac chdt lugng y td bj giam sflt Ngudi cd BHYT vdn cd nguy co cbi trd tign tfli vugt qud khd nang chi tra dp bao phfl y td cdn thieu dp sdu can thidp Dieu ban chg vai trd bdo ve tdi chi'nh cua chinh sdch BHYT d Viet Nam vd gidm sflt nhu cau ed BHYT ' Nghien ciru cua Liberman Set al cho thay: nSm 2006 khoang trieu n%uij\ lao dflng chinh thirc, khoan tri?u tre em du'fli tufli, gan trifiu nguai ngheo, gan trieu hpc sinh, sinh vifin {khoang 1/4 tflng sfl), tri^u vifin gia dinh ciia nguoi lao dpng chinh thiJc va 24 trifiu dfli tuang khdc khflng thuflc chuang trinh bao hifim nao (Samuel s Lieberman & Adam Wagstaff 2008) •* Co toi 4,7% tflng sfl nguoi tham gia BHYT dupc NSSN dong phi BHYT mtic th5p (4,5% ciia mirc lucmg tfli thifiu) Nam 2011 mirc chi phi BHYT binh quan diu ngufli la 514.000 dflng (27USD 2.2% GDP binh quan diu ngudi), uflc chi tieu y te blnh quan diu ngufli nSm 2010 va 2011 tSng Ifin lin lupt 1^ 83 va 95USD, chi phi difiu trj binh quan diiu nguoi 1^ khoang 55USD Mue chi kham chua benh binh quan diu ngufli tir quy BHYT chi d?t mirc 24USD dufli 50% (Bp Y ti va nhflm dfll tac y tfi 2013), NghiSn cUU Con ngudf s6S(74) 2014 25 Phdi trien nguai Ti le bao phu y tg cd khac bidt giua cdc vflng midn, cu thd, ti Id chua cd BHYT tai mdt sd vflng ngheo cfla Viet Nam dang d mflc cao: 34% ngudi ddn tai vflng Ddng Bae Bd, 39% tai vflng Duygn hdi Bdc Trung Bd vd 38,5% tai Tdy Nguydn; ehi ed khodng 25% ngudi can ngheo cd BHYT (UNDP, 2011); ddn ndm 2011 vdn cdn khodng 19,7% tre em dudi tudi chua cd the BHYT, nhat Id d nhdm tre em ngudi dan tpc thieu sd va tre em gia dinh di cu; khodng 50% ngudi khuyet tat gap khd khan tidp can dieh vu y td chi phi y td cao khd khan dia Iy, phucmg tien di Iai, phdn bidt ddi xu Mac du cd tien bo viec lam giam bdt khoang each ve y te giua cac vung mien, nhdm kinh te - xa hoi, giira cac dan tpc, nhimg b^t binh dang co* hoi tiep c^n dich vu y te vSn tiep tuc va d^n den bat binh dang ket qua y td the hien qua cac tieu chi: 1) Phan bo nguon luc va tai chinh cho y te; 2) Bat bmh dang co" hpi tiep cSn va su- dung dich vu y te; 3) Khac biet chat luong dich vu va cham sdc y te giira cac vung; 4) Ti le chi tien tui hp gia dinh cho y te van cao, mac du da giam; 5) Si^ khac biet tinh trang sue khoe Bat binh dang eo hdi tidp can dich vu y td va bdt binh dang kdt qud y td dugc hidu nhu khdng cdng bang hudng lgi y td vd khdng cdng bang sflc khde Cdng bing hudng lgi y td hay cdng bang y tg duge higu nhu Id cdng bang CSSK (equty in health care) dya trdn quan didm cdng bang phan phdi ngudn lyc (Resource based Principles); cdng bang sue khde dugc hidu Id cdng bing vg tinh trang sflc khde (equal health equality- WHO) dya trdn quan didm trudng phdi phue lgi (Welfare based Pjineiples) Do vdy, sy cdng bang y td ehi cd gia tri thyc su mang Iai sy cdng bing vg sflc khde^ Cdng bdng y td cd nghta Id nhftng ddi tugng dupc tbu hudng cdc dich vy chdm sdc y td theo nhu cau thyc sy cfla bp ma khdng dya trdn mflc ddng gdp Cdc quygn Igi dugc thy hudng bao gdm cd viec tidp can cung nhu chdt lugng dich vy y td (trgn phuang dien ky thudt)^ Cdng bdng sue khde dugc higu Id tinh trang khdng cdn sy khdc bi?t (ehi bao gdm sy khdc bidt cd thd phdng trdnh dugc hoac chiu sy tac dpng cua chinh sdch) vg sflc khde va cae ygu td dnh hudng dgn sflc khde gifta cac nhdm ed hodn cdnh xa hdi, kinh td, dia ly, nhdn khdu khdc xa hdi' Tfl cdc quan didm trdn, cd nhdm chi sd dd ludng bdt binh ddng CSSK vd bdt binh ding sue khde: 1) Phdn bd ngudn lyc va tdi chinh cho y td; 2) Khd ndng tidp can vd su dung dich vu y td; 3) Chdt lugng dich vu vd chdm sdc y td; 4) Ydu td ca bdn dnh hudng ddn sue khde, va 5) Tinh trang sflc khde Dp bao phfl BHYT md rdng Iam tang co hdi tigp can dich vu y tg ngudi ddn thg hi?n qua viec tang tdn sudt khdm chua bdnh cua tdt ca cac nhdm kinh td xd hdi Tuy nhign, cdc nhdm ddn sd thdnh thi - ndng thdn, gidu - ngheo, ddn tdc Kinh - dan tdc thigu sd cd mflc dp tidp cdn cdc dich vu y tg thdng qua BHYT rdt khdc nhau, dd cdc nhdm sau Tran Hiing Minh (2011), "Quan difim quflc tfi vi thirc Ir^ng c4c chi so vfi cflng bang sire khoe t^i VietNam", in Cong bdng siic khoe a Vi?i Nam- Cdi nliin ddn su, PAHE - Partnership for Action Health Equityi Nxb Lao dflng, Ha Nfli Hoing van Minh, Nguyin Thj Mai Huong, "Cflng bang tii chinh y te fl Vi^t Nam", in Cdng b&ng sue khde a Vi4i Nam- Cdi ntiin ddn su, PAHE - Partnership for Action Health Equity, Nxb Laodpng, Hi Nfli ^ Braveman (2006), Trfch theo TrSn Himg Minh, Sdd 26 NghiSn eiiu Con ngudl si 5(74) 2014 Bdo Thi Minh Huang thudng cd tdn sudt tidp can thdp hon nhidu so vdi nhdm trudc Nhung ngudi tham gia BHYT ty nguyen vd BHYT hd ngheo it su dung the BHYT didu tri ndi trfl ban so vdi nhimg ngudi cd BHYT bat budc (Nguyen, H and Wang W., 2013), cd thd nguydn nhan lidn quan dgn mflc ddng BHYT cua cac ddi tugng ndy thdp hem, dan dgn ca sd y td it quan tam den cac ddi tugng va thdi gian ehd dgi ldu han Tan sudt sfl dung dich vu KCB thdng qua BHYT cua ngudi ngheo, can ngheo edn thap ddn ddn ti Id sfl dung quy BHYT cfla nhdm ddi tugng chi khodng 75% thdm chi cd noi cbi khodng 40 60% Didu ndy cho thdy nghich ly la nhihig ngudi gidu van Id nhung ngudi hudng Ipi nhigu hon ngudi ngheo tfl quy BHYT tdn suat kham chfta benh eua nhdm sau thdng qua BHYT cao hon Viee ngudi ddn hay bd tuydn ca sd dg khdm chua benh vupt tuydn cd Iy chinh la su thieu hut vg sd lugng vd kem vd chdt lugng dich vu y td ca sd tai vung ndng thdn, vung sdu, vung xa, lidn quan dgn bat binh ddng phan bd ngudn lyc y tg Dde bidt Id sy khdc biet ndng lue cfla y td tuygn dudi va vflng sdu, vflng xa so vdi tuygn tinh vd trung uang Theo ddnh gid cfla Bd Y tg vd nhdm ddi tae, nhidu benh vidn d tuydn huyen chua cd du khd nang thyc hidn cdc ky thuat theo phdn tuygn, chfl ygu thidu cdn bd cd trinh dp chuydn mdn tuang flng Didu phdn dnh su bdt binh ddng ea hdi tigp can dich vu y tg cd chat lugng hay su bat cdng bang hudng lgi y tg va Id mdt nguygn nhdn quan trpng dan ddn bdt cdng bdng vg sfle khde Day Id ly chinh, ben canh Iy mflc phflc Igi tfl bao hiem thudng Id thap, dac bidt Id ddi vdi bdo hidm thudc dang gidm ngheo vd an sinh xa hdi, dan dgn viec ngudi ddn thudng bd tuygn ca sd dg khdm chua benh tuygn trgn bang tign tfli Trong sy khae bidt vd mflc dp sfl dung cdc dich vy y tg giua ndng thdn va thi Id khdng ddng kd, thi su khdc biet gifta edc vflng Id rat Idn, vdi mflc dp sfl dung dich vu y te cao nhdt d ddng bang sdng Cflu Long va thap nhdt d Tdy Bac Dich vu y td cd sin va dg tigp can hon d khu vyc thdnh thi, khu vue mign Nam hon Id khu vyc Tay Bac Id mdt nhung ly giai thieh sy khde bidt (UNDP, 2011) Di sau vao phan tich cho thdy, di cung vdi viec sfl dung dich vu y td thdp Id ti Id sfl dung dich vu ngoai tru thdp, d vung Tdy Bdc lai phdn dnh nguydn nhdn tfl phia ngudi ddn dd Id ngudi ngheo va ngudi sdng d viing sau, vung xa thudng cd xu hudng tri hoan viee tham khdm, chfta tri cho tdi van dg sue khde trd ndn that sy trdm trpng Day Id each hp tdi thigu hda chi phi eham sdc y td ngan han nhung tao cu sdc ddi han (Uy ban ddn tdc va UNDP, 2008) Didu gdp phdn khang dinh thdm rang, bdn canh ygu td tinh san cd vd chdt lugng dich vu y td, chi phi dich vu y td md ngudi ddn phdi ty trd tfl tidn tfli anh hudng ddn sy khac bidt su dung dich vu y te Ndi each khdc, chi tidu cho y tg tu tidn tui cao nhu hidn d Viet Nam ciing Id ygu td ca ban lao ngn bdt binh ddng tidp can y tg vd bdt binh ddng tinh trang sflc khde Ti Ie chi phi tu tidn tui hp gia dinh so vdi tdng chi cho y tg cang Idn thi khd nang chia se nii ro vd tdi chinh cdng it va ngudi ngheo cdng khd tidp can vdi cac dich vu y tg, hoac chi tiep can dugc nhihig dich vu cd chdt lugng thap, do tinh cdng bang cfla he thdng y te cdng thdp Chi phi tfl tidn tfli Idm cho hd gia dinh phai cat gidm cdc khodn chi can thiet khac nhu chi cho luong thuc, thyc phdm, qudn do, nhu yeu phdm, chi eho viec hpc NghiSn Cliu Con ngudf s^5(74) 2014 27 Phdt trien ngudi hdnh cfla cdi, Vide cdc ngudn ehi trd tu hd gia dinh chidm ti trpng cao se ddn ddn viec cae gia dinh se phdi thudng xuydn ddi mdt vdi chi phi y td qua khd nang chi trd Hp ed nguy ca bi ngheo hda phdi trd cdc chi phi y td trudng hgp khdng nhdn dugc hd trp tu phia Nhd nudc hoac cdc cd nhdn vd td chfle khdc Thdng kd cho thdy, cbi tu tidn tui hd gia dinh cho y td - Out of pocket health payments giai doan 2002 - 2008 gia tang ed vd gia tri tuyet ddi vd ti Id tdng chi tidu hp gia dinh, ti Id so vdi kha nang chi tra, cung nhu ti Id gifta chi tidu tfl hd gia dinh va tfl ngan sach nhd nudc^ Chi tu tidn tiii eua hp gia dinh cho y tg - chigm khodng 8,3 - 11% kha nang chi trd cfla hd gia dinh (OOP/ khd ndng ehi tra) vd khodng 4,6 - 6,0% tdng chi tidu cua ho gia dinh (OOP/tdng ehi tidu) (bdng 4) Nhung nam gdn day, mac dfl gid tri tuyet ddi vdn tigp tuc gia tdng nhung ti Ie chi tigu cho y tg tfl hp gia dinh vd NSNN da gidra di (cao nhdt vao khodng 66 - 67% vdo nam 2005) ddu tu NSNN cho y tg tang cao Cho dfl CO gidm di nhung ti le khodng 56% vao nam 2008 vd khoang trgn 50%» vao nam 2012 chi cho y tg tu hd gia dinh van Id rdt eao ddi vdi cdc nudc thu nhap thap va trung binh Ti trpng ndy tuang ddi cao so vdi mdt sd qudc gia khae khu vuc vd trdn thd gidi vd cao hon nhidu so vdi mue 30%, vdn duge eoi Id Iy tudng dd dat dugc myc tidu CSSK todn ddn (WHO, 2009, Bd Y tg vd Nhdm ddi tae, 2013) Nhu hien nay, chi tigu hd gia dinh cho y td dang Id ganh nang ddi vdi cde hp gia dinh, tham chf cdn cd thd vupt qua khd nang ehi trd cfla nhigu hp vd ddn den viec bdn eung hda chi phi y td Bang Mue chi cho y te tu tien tui cua ho gia dinh trung binh/hp/thang (theo gia hien hanh va gia so sanh nam 2010), nam 2002 - 2010 va ti le so vdi kha nang chi tra va chi tieu Nam 2002 2004 2006 2008 2010 Chi cho y te theo Chi cho y te theo gia hien hanh (1000 gia hien hanh (1000 d/thang) d/thang) 119,7 67,3 175,4 126,4 140,0 175,9 201,3 220,8 243,0 243,0 OOP/kha nang chi tra OOP/chi tieu 10.2 11,1 9,9 10,5 8,3 5,1 6,0 5,5 5,6 4,6 Ngudn: Hoang Van Minh, Nguyen Thi Kim Phuong and Priyanka Saksena, Research report: Assessment of financial protection in the Vietnam Health System: Analyses of Vietnam Living Standards Survey Data 2002-2010 2012: Hanoi Kha nang chi tra Ik sfl thu nhap cua hp gia dinh sau da trir di cac chi phi cho luong thuc vk thyc ph^m Theo so lieu cua Bao cio tong quan chung vfi y tfi Vifit Nam Bo y tfi vk cac nhflm dfli tdc th\rc hifin cdc nam 2008, 2010, 2013, nam 2008, Vifit Nam da chi 7,3% GDP hay 77 USD theo sire mua tuong duong eho y tfi Trong ehi tir ngan saeh nhd nuflc chifim 38,5% va tir khu vuc tu nhdn chiem 61,5%, md phSn Ion Id chi tir tifin tiii ngucti ddn Chi tir tifin tiii chifim 90% ngufln chi tu nhdn, vdo khoang 56% t6ng chi cho y tfi (BO y tfi va Nhom dfli tae 2008) Chi tieu tiJ tui cua nguoi dan dait mirc eao nhdt a ndm 2005 vfli ti I? 66 - 67%, nhung sau dfl da giam xuflng, phan Ifln Chinh phii tang chi tifiu cho y tfi vd mfl rpng BHYT (Bp Y te vd nhflm dfli tdc y tfi, 2010) Ndm 2012, ehi tir tifin^tui hp gia dinh cho y te chifim gan % ngufln chi tu nhan va khoang trfin 50% tflng chi cho y tfi (Bp Y te vd nhflm dfli tdc y te, 2013) 28 NghiSn cuu Con ngudl s6S(74) 2014 Bdo Thi Minh Huang Ti Id vd sd Iupng cdc hd gia dinh tai Viet Nam phdi chiu chi phi y td tham hpa khodng dgn gdn 6% vd ngheo hda ehi phi y tg"^ vao khoang 2,5 den hem 4% cae nam 2002 - 2010 (bang 5) Day Id ti Id tuong ddi cao so vdi cdc nudc khu (WHO, 2011) Ddng luu y Id ti Id gidm ban vdo nam 2010 cd thg ed tae dpng Ludt Bdo higm y tg vd cdc ehinh saeh, ehuong trinh dgn CSSK todn dan vao qua vue cfla Bang Thuc trang chi phi y te tham hpa va ngheo hda chi phi y te tai Viet Nam (2002 - 2010) Nam 2002 2004 2006 2008 2010 Chi phi y te tham hpa Ngheo hoa chi phi y te So hp gia dinh Ti le phan So hp gia dinh Ti le phan tram tram 811499 4,7 590446 3.4 1055910 5,7 769505 4,1 1096177 667863 5,1 3,1 1151500 5,5 742587 3,5 862661 3,9 563785 2,5 Nguon: Hoang Van Minh, Nguyen Thi Kim Phuong, and Priyanka Saksena Research report: Assessment of financial protection in the Vietnam Health System: Analyses of Vietnam Living Standards Survey Data 2002-2010 2012: Hanoi Mac du ti trpng chi phi tfl tidn tfli cua hd gia dinh tdng chi cho y tg, ti I? hp gia dinh chiu "chi phi y td thdm hpa" vd "ngheo hda chi phi y td" sau nam 2010 cd xu hudng gidm so vdi cae nam trude dd ti trpng chi phi tfl ngudn BHYT cd xu hudng tang theo thdi gian, nhung vd gia tri tuyet ddi chi phi y tg ddi vdi hd gia dinh d Viet Nam dang gia tdng, va cd su khdc biet ddng kg gifta cac nhdm dan eu khac theo vimg, dieu kien kinb td xd hpi vd ddn tpc Vg gid tri tuyet ddi chi tu tign tui binh quan ddu ngudi da tdng 20% (bdng 4) Ngudi dan tpc thigu sd va ngudi ngheo chi cho y te it nhat, tuang ung vdi 4,7% vd 5,6% ehi tigu ho gia dinh, nhung ho gidu nhdt vd ngudi Kinh/Hoa chi gdp Ian so vdi ngudi ngheo vd ngudi dan tpe thigu so; ngudi thj ehi gdp 1,7 Ian ngudi ndng thdn Digu ndy khdng ed nghTa la ngudi gidu va ngudi Kinh/ Hoa dm nhigu ban ngudi ngheo vd ngudi dan tpc thieu sd ma Id hp ed didu "Chi phi y tfi tham hpa" (catastrophic healt payment) - mirc chi phi true tiep cho y te (out of pocket payment) bang hoac cao hon 40% so voi kha ndng chi trd eiia ho gia dinh (capacity to pay hay cfln gpi la Non-subsistence expenditures) Khd ndng chi trd td so thu nhap ciia ho gia dinh sau dd trir di cac chi phi cho luong thyc vd thuc pham, "Nghfio hfla chi phi y tfi" (Impoverishment); Miic chi phi ciia hp gia dinh bdng hodc cao hon mirc chi phi CO bdn toi thifiu nhung lpi tra nfin thdp hon sau trir di cac chi phi tryc tifip cho y tfi) WHO (2005), Distribution of heahh payments and catastrophic expenditures methodology Discussion Paper Number Department "Health System Financing" (HSF) and Cluster "Evidence and information for Policy" (EIP), Geneva, 2005) Nghien ciiu Con ngudf so 5(74) 2014 29 Phdt trien ngudi kien quan tam ddn viec cham sdc sflc khde cfla minh nhigu ban vd cd lign quan dgn cac ygu td xa hdi md trude hdt Id thu nhdp va sau dd la nhan thfle vd kha nang san cd cua dieh vu (PAHE, 2011) Digu nhdn manh ring bdt binh ding vg thu nhap, khdc biet vg noi cu trfl cd rdt nhidu khd ndng ddn dgn bdt binh ddng ve sue khde Nghign ciru ndm 2007 cho thdy, khae biet rd rdng eua sfle khde tre em theo thdnh phdn ddn tpe, tinh trang ngheo khd cua hd gia dinh, mflc sdng, trinh dp hpc vdn cua cha me (ddc biet la ngudi me), su tham gia Iao dpng cua tre em vd khd nang tiep can cac dich vy cdng (Jones, Nicola, Nguyen Ngpc Anh va Nguydn Thu Hang, 2007) Nghien ciiu eua Dai hpe Y Ha Npi cho thay, mac du cd mflc chi phi tu tidn tfli cho y td thdp hon nhung cac hp khdng cd BHYT, cac hp gia dinh thudc khu vyc ndng thdn va cac hp gia dinh ngheo Iai cd ti le chi phi y td thdm hpa vd ngheo hda chi phi y td cao hon, mat khde chi phi y td thdm hpa vdn xay d cdc hd gia dinh cd cac vidn cd BHYT (PAHE, 2011) Ti le ehi phi y tg tham hpa eao nhat d nhdm ngheo nhdt, ti Ie ngheo hda chi phi y tg cao nhat d nhdm can ngheo Chi phi y td tham hpa va ngheo hda chi phi y td van xdy d nhom CO thu nhap trung binh vd d cdc hp gia dinh co cdc vidn cd BHYT, va chi mdi co tdc dung giam 16 - 18% chi phi tu tign tui cua hp gia dinh Didu cho thay tdc dpng tdi ehinh cua BHYT cdn thdp Ti Ie chi phi y tg thdm hpa vd ngheo hda chi phi y tg cao hon d hd gia dinh ndng thdn vd gia dinh can ngheo chijng td rang cac nhdm ddn eu cdn it dugc hudng lgi tfl eae chinh sach tai chinh y td Nhiing sy khac bidt phdn bd ngudn lyc va tdi chinh cho y te; ca hdi tigp can va su dung dich vy y tg; khdc biet vg chdt lugng dich vu va cham sde y td giua cde vflng; ti le chi tign tfli hd gia dinh cho y tg van eao da ddn dgn su khac bidt tinh trang sfle khde ngudi dan gifta cae nhdm kinh tg, xa hdi, vflng midn, dan toe d Viet Nam hidn Cham sdc sue khde sinh sdn va sfle khde nhung nam dau ddi la ehi sd quan trpng Ken quan den cdng bang CSSK, cdng bdng tinh trang sue khde vd phdn ndo thd hidn ca hpi tidp can dieh vu y td Trong cac nam tfl 2005 - 2009, ti le phu nft sinh dugc kham thai Idn trd ldn tang ddu qua cac nam, tu 84,6% nam 2005 tang Idn 87% nam 2009 vd udc dat 89,4% nam 2012 (tham kham thai trdn ldn thdi ky) Tuy nhidn, ti Id sfl dung dich vu cham sdc trude sinh dat thdp d cac khu vyc mien nui va ndng thdn, chi dudi 50% d cdc huydn ngheo nhdt Su bit binh ddng vd kinh td xa hpi the hidn rd rang vdi ti Ie tfl vong me cao nhdt sd phy nft mfl chft ddng bao dan tde thidu sd, ndng ddn vd d cac dia ban khd khan Kdt qua ndy cd lien quan tryc tidp ddn ti Id phu nft sinh dugc cdn bp y td dd thap nhdt la d cdc khu vuc ndng thdn, midn nfli, ddng bdo dan tdc, phu nft thupc cdc hp ngheo (Tdng cue Thdng kg, UNICEF, UNFPA, 2011) Ti Id phu nu cd nhu cdu kd hoach hda gia dinh chua dugc dapflngcao hon d nhiing phu nft ngheo, phu nft dan tdc thidu sd, dde bidt la phu nft chua lap gia dinh cd quan he tinh due Ti Id sinh d tudi vi thdnh nidn eung cao hon dang kd d khu vyc ndng thdn, midn nui; cao gdp 10 Idn d phu nu dan tdc thidu sd, vd eao ban Ian d phu nft cd trinh dp hpe van thdp Bdt binh ddng vd 30 NghiSn cuu Con ngudf s6S(74) 2014 Ddo Thi Minh Huang thu nhap vdn tidp tyc Id ydu td quan trpng dnh hudng tdi viec tigp can cdc dich vu CSSK tidn sinh sdn vd SKSS Thu nhdp, yeu td dan tpc vd tinh san cd cua cac dich vy y td quygt dinh vide tre cd dugc tidm phdng hay khdng (Knowles, J vd cpng sy, 2010) Tuy cd tidn bd vd y td tang ddu tu cdng vd cam kdt Chinh phfl vd thue hidn chidn lugc bao phfl y te todn dan, chdnh leeh dai dang ve kdt qua y td van edn tdn tai gifta cde vung mign, ddn tpc, nhdm kinh td xa hdi, the hidn qua ti Id tre em tidm chflng ti Id tre em coi xuong, suy dinh dudng, ti Id tfl vong d tre em, Cd sy khdc gifta eac vflng mign, ddn tdc vg ti le tre em dp tudi tfl - tudi khdng dupc tiem phdng cde benh eua trd nhd Ti le ndy cao nhdt d vimg Tdy Bde vd Ddng Bic chigm 59% vd 53%, thdp nhdt d vimg Ddng bang sdng Hdng la 17%, d tre em Kinh/Hoa Id 25% vd ddn tpe thigu sd Id 58,5%; d khu vyc dd thi Id 20% vd nong thdn Id 35%, ti Ie todn qude Id 31,5% vdo nam 2006 (Chinh phfl Viet Nam, 2010) Cu the: ti le tre em cdi xuong vd suy dinh dudng, ti ie tu vong tre em so sinh d khu vye ndng thdn vd vflng sau, vung xa, mign nui cao gdp - Ian so vdi khu vye ddng bang vd thdnh thi Tinh trang suy dinh duang tre em cdn cd sy khdc biet ldn theo vflng Tay Bdc vd Tdy Nguygn cd ti Id tre em suy dinh dudng cao nhat Xet theo nhdm thu nhdp, nghign cuu cfla UNICEF (2008) cho thay nhdm cang ngheo thi ti le tre em dudi tudi bi suy dinh dudng edng cao vd mflc dp cdi thidn tinh hinh cung chdm han nhdm cd thu nhdp cao hon; dac biet, gifta nhdm ngheo nhat vd giau nhdt, mflc dp chdnh lech ngdy cang ldn, tfl ldn vao ndm 1992/1993 (40,2% so vdi 20,1%) len hem 3,5 ldn vdo ndm 2005 (28,6% so vdi 6,3%) Tuang ty, ngudi ngheo cd ti le benh tdt thdp hon ngudi gidu, nhung hp Iai mac phdi nhihig can benh nghidm trpng han ngudi gidu (Evans vd cdng sy, 2007) Cdc can bdnh Idy nhidm van gdy 40% sd chet d tre em tfl - tudi vd 20% sd chdt d nhom cd thu nhap thdp nhdt (cao gap hai Ian so vdi eac nhom khae) Tai mpt sd khu vyc nhu Tdy Nguydn, ti Ie tre suy dinh duong cdn d mue 25% vdo cudi nam 2012 so vdi mue tigu cua vflng la 23,5% vdo nam 2014 (Vien Dinh dudng Qudc gia, 2013) Mac dfl ehua cd nghidn eflu ridng biet ndo eua Viet Nam vg sflc khde cfla ngudi Iao dpng ndi chung va ngudi lao dpng tai khu cdng nghidp, hay ngudi lao ddng khu vyc phi chinh thuc ndi ridng, nhung cde kdt qua cfla mpt sd nghien cuu vd ddi sdng cua cae ddi tugng ndy cho thdy nhftng khd khan hanh chinh vd tdi chinh vide tigp can dich vu y tg, mdi trudng Idm viec khdng an todn cfla hp da dan ddn tac ddng bat Igi ddi vdi sflc khde thd chat, sfle khde tinh thdn va thdm chi Id tinh mang cfla hp Con cdi cua nhiing ngudi di cu cung rdt khd khan vide tidp can cdc co sd y te cdng dd kham chfta benh theo he thdng BHYT Nhung bat binh dang ca hpi tigp can dich vu y tg vd bdt binh dang ket qua y tg vdn edn tdn tai dai dang d Viet Nam Id thach thflc rat Idn ddi vdi viec phat tridn ngudn nhdn lyc cho edc vung Viet Nam dang no lue gidm bdt khodng cdch gifta cdc vung vd cdc nhdm thu nhdp Nghien ciiu Con ngui4 s65(74) 2014 31 Phdt trien eon ngudi Tai lieu tham khao Bp Y te Viet Nam va nhom ddi tac y tfi (2010), Bdo cdo chung tdng quan ngdnhy te ndm 2010, "He thong y tg Viet Nam trudc thgm kfi hoach nam 2011 - 2015", Nxb V hpc, Ha Npi, Bp Y te va nhom ddi tac y tg (201 ]), Bdo cdo chung tdng quan ngdnh y te ndm 2011, "Nang cac nang lyc quan ly, ddi mdi tdi chinh y ti", Nxb Y hpc Ha Npi Eg Y te va nhom ddi tac y te (2012), Bdo cdo chung long quan ngdnh y te nam 2012, "Nang cao chat lupng dich vy kham chua benh", Nxb Y hoc Ha Npi Bp Y te va nhom ddi tac y tfi (2013), Bdo cdo chung tdng quan ngdnh y te nam 201, "Hudng tdi bao phii chdm sdc sue khde todn ddn ", Nxb Y hoc, Ha Npi Bp Y te, WHO (2011), Tai khoan y tg qudc gia thyc hien tai Viet Nam 1998 - 2010, Ha Noi Bo Tai chinh, Sd lieu vg ngan sach nha nudc, 2012 Castel P., Trdn Thi Mai Oanh, Trdn Ngo Minh Tam (2010), "Bao hiem y tg d Viet Nam: tien tdi cap: Trudng hpp ciia cdng nhan khu vyc khong chi'nh thflc", HdNpi, Chinh phit Viet Nam (2010), Bdo cdo qudc gia ve cdc Mue tieu phdt trien thien nien ky 2010, "Vi?t Nam 2/3 chang dudng thyc hien cac Mue tieu phat frign thien nign ky hudng tdi nam 2015", Bp Kg hoach va Ddu tu Ha Npi Evans, M Cough, S Harkness, A McKay, T H Dao, and L T N Do (2007), "The Relationship between Old Age and Poverty in Viet Nam", United Nations Development Program (UNDP) VieUiam Policy Dialogue Paper, No 2007-08, Hanoi: UNDP Vietnam 10 Jones, Nicola, Nguyen Ngpc Anh va Nguygn Thu Hdng (2007), "Ty hoa thirang mai va ngheo doi hp gia dinh d Viet Nam: Danh gia tac dong xa hpi" 11 Giang Tiianh Lxing (2010), "Trudc mpt dan sd gia di: tdng hpp nhimg cai each eac djch vu bao trp xa hpi d Viet Nam", Tai lieu phye vu Bao eao quoc gia vg phat trien ngudi 12 Knowles, J va cpng sy (2010), "Can bdng vg sue khde d Viet Nam: Phan tich tinh hinh tap trung vao tu vong ba me tre em va so sinh", Ha Ndi, UNICEF 13 Hoang Van Minh, Nguydn Thi Kim Phuong and Priyanka Saskena (2012), "Reseach report: Assesment of finacial protection in the Vietnam Health System", Hanoi 14 Minh HV & Phuong, N,K (2010), "Burden of household out-of pocket health xpendituie in Vietnam: findings from analyses of Vietnam living standard survey data 2002 - 2008 (draft report) Hanoi", Hanoi Medical University 15 Nguyen, H and Wang W (2013), "The effects free govemmem health insurance among small childrent evidence from the 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Sanitation Nghien ciiu Con ngudf s6'5(74) 2014 ^ -5 ... Viet Nam hipn cd hai hinh thflc bdo hidm, dd la bdo hiim bdl buoc va bdo hiim tu nguyen He thdng BHYT bao phfl gan 44,4% vdo nam 2006; nam 2007 Id 43,5%; nam 2008 Id 46,8%; nam 2009 Id 58,2%; nam. .. sing nam 1990 xuIng 15,4% vao nam 2012 (T6ng cue Thing ke, 2013); Ti suit tit vong tre em duoi tuli da giam 60%, tir 58 tren 1000 tte de sing nam 1990 xuIng 27,5% vao nam 2008, 23,8% vao nam 2010... dieh vu y td Trong cac nam tfl 2005 - 2009, ti le phu nft sinh dugc kham thai Idn trd ldn tang ddu qua cac nam, tu 84,6% nam 2005 tang Idn 87% nam 2009 vd udc dat 89,4% nam 2012 (tham kham thai