thi i mi

TP CH NGHIN CU & THO LUN

S 33
thng 7, 2015

Y t phng Ty: M hnh c, 40 nm

chuyn ho v i mi
Phm Duy Thoi
Berlin, c
Tm tt
S pht trin ca y t phng Ty t trn hai th k qua l do bit vn
dng khoa hc t nhin. Nh tnh hiu qu, Ty y thuyt phc, t
c tin tng trong chn on cng nh trong cha tr v ng vai tr
ch yu ca mi h thng y t quc gia. Cc h thng y t phng Ty
hot ng trn ba nguyn tc: Trong khi y t M ch yu qua cc bo
him y t t, Anh li do nh nc trc tip iu hnh. Ti c h
thng y t hot ng c lp vi nh nc v qu y t x hi nm vai tr
quyt nh ngn sch. Trong nhng thp k qua s khc bit v nguyn
tc trn cng lc cng c nhiu ch tip cn nhau. K t thi im khng
hong xng du vo nhng nm 70 v nht l sau khi thng nht t
nc nm 1989, nc c c hng lot chng trnh cng nh lut
l ci t v chuyn ho hai h thng y t ng-Ty vn khc nhau v c
bn. M hnh y t c hin nay c mt s c im c coi l mu mc
nh mc bo him cao, quyn t do chn la bc s, bnh vin v s
bnh ng trong vic khm, cha bnh. Mt khc trong m hnh ny
cng c mt s nhc im m th thch chnh l cha kim sot c
hiu qu chi ph y t ngy cng cao. Trong chin lc y t, y t d
phng v y t cng ng ng vai tr quan trng trong vic bo v sc
kho ngi dn, qua gim c chi ph y t v h tr cho nn kinh t
quc dn.

Y t phng Ty, thnh qu v tiu ch

Ty y t hn hai th k qua pht trin nh xy dng trn nn tng khoa
hc t nhin. c tnh ca n l chn on v cha tr c chng c nn
chinh phc lng tin ca con ngi. Nhng thnh tu ph bin thay
i cc din ca i sng m ai cng bit n nh: Chng u t cui
th k th 18, qua m nhng trn dch hng nm tng git hi

Phm Duy Thoi | Y t phng Ty M hnh c

109

nhiu trm ngn ngi c ngn chn mt cch hiu qu.1 Th d

khc l vic pht hin vi trng v s thnh hnh ca vi trng hc vi
Robert Koch v Loius Pasteur vo nhng nm cui th k 19. n gia
th k 20 Fleming tm ra tr sinh, m ra mt giai on mi trong vic
cha tr. Ty y tip tc ln su vo s sng con ngi vi thuc nga
thai (1965), th tinh trong ng nghim (1978) v kp vo u th k 21
vi nhng cng trnh gii m Genom.
S dng Ty y xy dng mt h thng y t tr thnh mt nhim v
nng ct ca mi quc gia. Mt h thng y t hiu qu cng gp phn an
dn, n nh x hi. Tu kh nng ca mi nc c khc, nhng tiu ch
ca y t l nhng mc ch ph qut m cn c vo ta c th nh gi
c mt h thng y t. Nhng tiu ch ch yu l:
1. S bnh ng trong vic chn on v cha tr, khng phn bit a
v, quyn hn, gii tnh, tn gio, chng tc v.v
2. Ngi bnh c tip cn vi nhng phng php khm cha hiu
qu.
3. Ngi bnh khng phi lo v chi ph y t.
Tiu ch s 1 gn lin vi h thng chnh tr. Trong cc h thng m
quyn bnh ng trong i sng x hi khng c tn trng v bo m
th cng kh c s bnh ng trong y t.
Sc khe l vn qu nht ca con ngi nn ngi bnh trng i c
chn on v cha tr bng nhng phng php hiu qu nht, hin i
nht. Nhng tiu ch th 2 cng l im c nhiu tranh ci. Trong cc h
thng y t thng c mt c quan c lp v c thm quyn, hiu bit v
chuyn mn c th xut ra nhng hng dn hp l.
im 3 xem ra l yu cu then cht. Gii quyt ngn sch cho y t
nhng nc ngho vn l mt vn nan gii. cc nc c mng li
y t hay i ng chuyn mn tt m ngn sch thiu thn th kh nng
cng b gii hn, c khi b t lit khng hot ng c. Ngay cc
nc cng nghip cao y cng l vn kinh nin, i hi nhng i
mi lin tc.
Ngn sch ca y t phng Ty theo 3 m hnh khc nhau v nguyn tc
(Hnh 1). Trong khi ti Anh quc -v mt s nc Bc u- bo him y t
l nhim v ca nh nc, c chi phi bi S y t quc gia (National
1

1796 chng u c BS ngi Anh Edward Jenner th nghim, cng b v

c p dng rng ri Anh. Sang th k 19 lut bt buc chng u c p
dng trong nhiu quc gia cho n nhng nm 60 ca th k 20. Cch nay 40
nm, em b Rahima Banu ngi Bangladesh c ghi nhn l ca cui cng b
bnh u ma. 1980 WHO, qua chng trnh xa b bnh u ma th gii
(Global Smallpox Eradication Program), chnh thc tuyn b bnh u ma
c dt im.

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Phm Duy Thoi | Y t phng Ty M hnh c

110

Health Service) l mt b phn trc thuc B y t. M bo him y t

thuc v t nhn. Cc c quan y t nh nc ch phi lo cho nhng ngi
trn 64 tui (Medicare). Nhng trng hp ngho tng hay tn tt th s
x hi c bin php tr cp (Medicaid). 15% tc l khong 45 triu
ngi dn M khng c bo him y t. Obamacare (Patient Protection
and Affordable Care Act, PPACA) l mt chnh sch ln ca tng thng
Obama nhm vo i tng ny.

Hnh 1: Cc m hnh v ngn sch ca y t phng Ty

M hnh y t c
c v mt s nc Trung u nh Php, o, Benelux chi ph cho y t
thng qua qu bo him y t c lp. c bit c, qu y t x hi
c th tng Bismarck thnh lp t 1883 nh mt th php chnh tr
nhm xoa du lc lng th thuyn cng nh chng li ch ngha
x hi ang tranh ginh nh hng trong gii ny. Mi ngi lao ng
u bt buc phi ng gp vo qu nhm bo him bnh tt v nhng
ri ro lao ng khc. Qu c qun l v hot ng c lp vi nh
nc. Vo thi im ny, m hnh Bismarck c mt khng hai trn th
gii!
Thi gian sau th chin th II, h thng bo him y t x hi tuy vn duy
tr nguyn tc Bismarck. Nhng v kinh t cha phc hi, h thng y t
c ci t v hnh chnh tho ng yu cu l ngha v ng gp
vo qu khng bp nght kh nng cnh tranh ca k ngh. Trong s
15% khu tr t lng ca ngi lao ng, c s k ngh phi gp mt

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111

na. Tng tin ng bo him dn n tng gi thnh sn phm, kh

nng cnh tranh s b tc ng tiu cc. Trong hon cnh th trng cnh
tranh m hnh Bismarck phi i u vi mu thun l: Mt mt nh
nc mun an dn, mun thc hin l tng cao p lo cho dn, nh
c ghi trong hin php ("Y t thuc v trch nhim nh nc v sc
khe ngi dn l ti sn ca x hi"). Hot ng ca b my y t li c
lp, khng thuc quynca gung my nh nc. Cui cng theo lut
nh, nh nc li phi chu gnh ly trch nhim cui cng!
Mu thun th hai chnh l nguyn tc on kt, ng gp. V theo
cng phn trm ng gp, nn lng nhiu s phi ng nhiu, lng t
th ng t, khng lng khng ng (trng hp ny qu tr cp x hi
s ng thay). Mc c bo him li ging nhau. Qua c s tri
u gi-tr, khe-m, giu-ngho. S ng gp nh vy c hm cha
tnh bt bnh ng. Trong hnh 2 ta khng thy nhng ngi khng lao
ng v tht nghip, nhng ngi lm ngh t do, nhng b ni tr, tr
em v ngi gi. l nhng ngi khng c lng nn khng th ng
phn "on kt" ca mnh vo qu bo him y t. H s c mt s bit l
di nhiu hnh thc khc nhau u c th hng bo him. T nm
2007 lut php bt buc mi ngi u phi c bo him. Nm 2011,
theo S thng k lin bang, mng li bo him ph kn 99,8% dn sng
trn nc c.

Hnh 2: M hnh Ty c: Qu bo him y t

Trong khi ti Ty c, nng theo pht trin kinh t v s h tr c
bit t M, cng vi mt th h nhng bc s c tu nghip tr v, lc
lng bc s c nhanh chng bc li nhp cu vi cc nc Ty u
v M, thc y y khoa kp theo tin th gii. Nhiu trung tm gio
dc y khoa hin i cng c xy dng, tiu biu l bnh vin
Klinikum Steglitz thuc i hc T do (Ty) Berlin c khnh thnh

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112

nm 1969 sau 10 nm chun b, 4 nm xy dng vi tn ph l 304 triu

DM, trong c 58 triu do qu Benjamin-Franklin (M) ti tr. Cng
trnh ny c ngha tng trng cho quan h c-M. Cng v th i
s M ti c Henry Cabot Lodge,2 tham d bui l khnh thnh ti
Ty Berlin, tuyn b khng nh M bo m An ninh v T do cho Ty
Berlin.

Hnh 3: Klinikum Steglitz (Free University Berlin) ti Ty Berlin, l

trung tm gio dc y khoa hin i nht chu u trong thi im ny.
Xy dng vi s tr gip ca M v ta lc Ty Berlin nm gia ng
c, n cng l biu tng cho quan h cht ch gia c v M sau
chin tranh ( Ngun: Berliner Woche).
Trong 40 nm va qua, hai s kin quan trng l t khng hong xng
du vo nhng nm 70 v vic thng nht nc c nm 1989. Ti Ty
c khng hong xng du dn n tng tht nghip v tc dng trc
tip n qu y t. Cc bin php cm xe hi vo cui tun tit kim
2

Henry Cabot Lodge (1902-1985): Trc nhim k ti CHLB c Lodge

tng c Tng thng Kennedy c lm i s M ti Nam Vit Nam nhm
"un nn" Tng thng Ng nh Dim, khi phong tro u tranh Pht gio ln
cao . Lodge c xem l cng CIA nhng tay vo vic o chnh v git
Tng thng Dim.

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113

nhin liu khng mang li kt qu kinh t ng k. Trong tnh hnh ,

khi nim gim chi ph(Kostendmpfung) cho y t tr thnh mt yu
cu chnh tr. T 1975-1989 chi ph cho y t khong 6-7% GDP v
thng c gi trong gii hn ny. Chnh quyn v cc c cu lin h
a ra nhng bin php tit gim chi ph ch yu qua vic i mi t
chc truyn thng cng nh gin lc hnh chnh. Song song vo ,
tng bc cc bin php cnh tranh trong y t c a vo th nghim.
Tnh hnh ti ng c sau chin tranh t 1951-1989 c nhng thnh
cng ng k vi mc tng trng kinh t trung bnh hng nm l 4.5%.
Nhng tim lc kinh t ca ng c vi khong 16 triu dn v GDP
cao nht l 353 t DDR Mark (nu theo sc mua 1988, 1DM = 4.4 DDR
Mark, tnh ra l 45 t ) vn cn khim nhng bn cnh Ty c. 60%
bnh vin pha ng c xy dng vo u th k XX v ng c
cng khng thot khi nn chung ca cc nc XHCN l tnh trng thiu
thit b v thuc cao cp. Trong giai on t 1977-1989 c 316.000
ngi dn ng c xin xut cnh.3 Ch ring nm1987, trong s
112.000 ngi xin xut cnh, s ln c tay ngh cng nh nhiu chuyn
vin trong ngnh y t:4

52.000 Th chuyn mn
11.500 Trnh i hc
1142 Bc s
2675 Chuyn vin y t, iu dng
670
Gio vin

Trong h thng y t nh nc XHCN ca ng c c mt s mt tch

cc nn c ghi nhn nh l danh sch tp trung cc bnh ung th, cc
cng tc tim phng hay cc chng trnh d phng cho thiu nhi, cc
b m v.v Cc trm y t c s vi cc BS chuyn mn (Polikliniken) l
mt m hnh m sau khi thng nht cng c ng dng trn khp nc
c (Medizinische Versogungszentren, MVZ), d nhin vi nguyn tc
chi ph khc.

Henke, Klaus Dietmar et al. (Hrsg.): Anatomie der Staatssicherheit.

Geschichte, Struktur und Methoden. MfS-Handbuch. Teil 3: Wichtige
Diensteinheiten Teil 17: Die zentrale Koordinierungsgruppe Bekmpfung von
Flucht und bersiedlung, Berlin 1995, S. 50
4
Wolfgang Mayer Flucht und Ausreise, Anita-Tykve-Verlag 2002, S. 113

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114

Hnh 4: Mt s c im trong thi gian i mi v chuyn ha h thng

y t c
Sau khi nc c thng nht, vic chuyn i h thng y t ti cc bang
pha ng c khn trng tin hnh. Mng li phng mch c
thnh lp. Thay i c cu trong cc bnh vin song song vi yu cu
xy dng v nng cp trang thit b y khoa mt cch lp lang. T nm
1991 cho n nm 2019 theo lut ph thu on kt
(Solidarittszuschlag) mt khon tin 3,75-7,5% tin lng (ty theo
nm) c thu h tr cc bang pha ng. n nay s tin chuyn t
Ty sang ng khong 1.500 t .5 Chi ph cho y t ca CHLB c
thng nht nm 2012 khong 300 t .6

G-DRG (German-Diagnosis Related Groups)

Giai on sau thng nht cng l giai on i mi su rng nht, khi h
thng tnh im chi tr cho cc dch v y t theo cng mt gi c p
dng cho khp nc c.
Trong mng li y t, bnh vin ng vai tr then cht. Chi ph cho bnh
vin chim khong 30% ton b chi ph cho y t. DRG l khi nim ch
mt gi bnhvi nhng vn v vic lm khc lin h vi cn bnh
chnh. Nm 1983 ngi M x dng DRG nh gi cht lng cha
tr ni b trong cc nh thng hoc phn phi ngn sch.Ti c,
sau nhiu nm chun b v th nghim tnh nguyn, t nm 2004 G-DRG
c chnh thc p dng mt cch bt buc cho ton nc c. V trong
thi im ny nc c l nc duy nht trn th gii dng DRG chi
tr ph tn y t cho nh thng. Nguyn tc c bn ca vic p dng
DRG l: Cng cng vic th c tr cng mt mt s tin.
5
6

Deutsches Institut fr Wirtschaftsforschung, FAZ 01.07.15

GDP ca CHLB c nm 2014 l 2.903 t

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115

Hng nm cc thng tin v ngh lin quan n qu trnh p dng DRG

c tp trung, phn tch v sa i hay b xung nhm cp nht .
Nm 2015 c tt c 664 Gi bnh
n nh cc Gi bnhbng Tr gi ca bnh (Case Mix Index,
CMI) cn c vo ngn sch v tr gi ca bnh vi CMI=1.0 bng bao
nhiu tin. Nm 2015 Gi bnhno c CMI bng 1.0 s c chi tr
s tin l 3.190
Cc Gi bnhs c m ha, th d: Rut tha. Cc khm nghim v
chi ph lin h n vim rut tha s c m ha l G23. V G23 c
CMI l 0,74. Vi biu gi nm 2015, ph tn cha tr gii phu rut tha
s c tr trn gi l 2.360 (0,74x3.190). Tng t nh th cho bnh
nhn b t qu l 3.068 (CMI=0,962x3.190). Hay trng hp au
tim nng phi phu thut ghp tim, vi CMI=34,594, nh thng s c
chi tr 110.354 .
Trong thi gian 10 nm qua DRG c ti u ha. H qu ca n
i vi nh thng l:
Rt ngn thi gian nm vin
Tng s ca bnh
20-30% thi gian lm vic ca bc s l gii quyt cc vn
hnh chnh
To ra cnh tranh gia cc nh thng
Vi vic chi tr theo gi bnh, c s y t hay nh thng no khng hot
ng hiu qu kinh t, ch y s l l. Trong thi gian t 2003-2012 theo
bo co ca c quan bo him y t c 74 nh thng vi 5200 ging
bnh phi ng ca.7 Kt qu ca bo co nm 2015 cng b v 1000
bnh vin vi 600 h s chi thu cho thy 33% nhng bnh vin ny lm
n l, 17% c nguy c ph sn.8
B phn th hai ca mng li y t l lc lng bc s phng mch t.
Trong tng s 365.200 bc s hnh ngh c 147.900 bc s lm vic ti
cc phng mch v 186.300 bc s ti bnh vin.9

Osterloh, Falk Krankenhausreform: Welche Huser mssen schlieen? Dtsch

Arztebl 2015; 112(24): A-1071 / B-895 / C-867
8
Krankenhaus-Rating-Reports 2015. Rheinisch-Westflisches Institut fr
Wirtschaftsforschung (RWI), Institute for Health Care Business (hcb), Stiftung
Mnch
und
Philips
Healthcare.
http://www.medhochzweiverlag.de/fileadmin/medhochzwei/Pressemeldungen/FlyerKrankenhaus_Rating_Report_2015_A4-Format.pdf
9
Ngun: Thng k 2014 ca Deutsche Bundesrztekammer

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116

Ph tn chi tr cho cc phng mch da vo h thng tnh im EBM

(Einheitlicher Bewertungsmastab) c gi tr t nm 2009. Khm tng
qut c nh l 202 im. Cn c vo ngn sch v tng s im c
ghi nhn mi nm, t chc thanh ton trung gian s tnh ra mt nh gi
bng tin. Nm 2015 mi im c tnh l 10 Cent. Vi 202 im cho
khm tng qut, BS s nhn c th lao l 20,2 . Ngoi ra mi phng
mch cn c ngn sch gii hn tng qu. y l mt bin php nhm
trnh tng s lng bnh nhn v l do kinh t. Hu qu l nu khng
bit t chc, cha ht k hn m vt ngn sch, phng mch phi
ng ca cho ht qu. Tuy nhin gii hn ny c th thay i cho nm
sau, nu c l do chnh ng. Cc phng mch BS t v th cng lc cht
vt vi gnh nng hnh chnh.
Nh th cc BS trong bnh vin hay ti cc phng mch cng nh nhn
vin iu dng thuc vo bn thua cuctrong qu trnh chuyn ho
v thay i t bn thp nin qua. H phi tn thi gi nhiu hn cho
cng vic hnh chnh, v v th t thi gi hn cho bnh nhn.
Chi ph cho y t trong nm 2011 l 293,8 t Euro, l 11,3% ca GDP.
Nu tnh t nhng nm sau thng nht t 1999 n 2011 chi ph y t tng
hng nm, tng cng tng 85%, tc l gp i tng trng GDP. Tnh
theo u ngi chi ph y t ca c ng th 3 sau M v Na Uy.

US $

cng

Hnh 5: Chi ph cho y t trn u ngi (2011), Ngun: T chc cng

tc v pht trin kinh t chu u (OECD).

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117

Vi mc ch gim chi, cc bin php gii hn ngn sch nhm vo

nhiu mt. Trong vic chi tiu ca bnh vin, hn 50% l tin tr cho
nhn vin ni chung (Hnh 6). Nn gim chi, cng vic u tin cho
nhng chuyn gia kinh t thng lm l gim s bc s, y t.
Bc s, iu dng
Thuc men, vt dng y t
n
Hnh chnh
D phng, chuyn ch v.v...

51,1%
26,9%
24%
5,3%
9,1%

Hnh 6: Chi ph cho y t 2006. (Ngun: S thng k lin bang)

c bit trong hai thp nin qua c th m t tnh hnh ni b trong cc
bnh vin nh l nhng chin trng khng ting sng. Nhng "chin
dch" thu gn nhn s, ti u t chc v hot ng thng nht, ci t b
my hnh chnh v.v l nhng yu cu phi lm thng xuyn . Nhng
ch s kinh t c p dng vo bnh vin v c kim sot cht ch.
Quan h bc s/bnh nhn v th khng trnh khi b sc p kinh t tc
ng.

Tho lun
Trong nhiu nc, Y t phng Ty vi ba tiu ch nu trn- bnh ng,
hiu qu v ngi bnh khng phi lo v ph tn y t- tuy c t nhiu
khc nhau, nhng tr thnh hin thc trong cuc sng hng ngy. Tri
qua nhng thay i trong vi chc nm va qua ta thy nhng nguyn tc
phn chia gia cc h thng y t khng cn r rt. Tiu biu cho y t t
nhn M c nhng b xung y t "cng" nh mng li nhng
ngi gi v nhng ngi khng c bo him. Y t Anh vi nguyn tc
Beveridge t thi th chin th II, vn k vng bo him cho mi
ngi: Ngi bnh, bc s hay bnh vin khng cn phi quan tm n
ph tn m ch cn tp trung n vic cha bnh. Vi nhng bin php
gim chi, y t cng Anh quc ngy nay ch cn chi cho nhng yu
cu c bn. n nm 2015 NHS phi tit kim khong 20 t Bng Anh
(khong 27 t ). Ngi dn phi mua thm nhng bo him t ph hp
vi yu cu ring ca mnh.
M hnh Bismarck ca c m c im l c mc bo him gn nh
v hn, v li cho php ngi bnh c t do la chn bc s hay bnh
vin m mnh tin tng. l nhng kha cnh c th c coi l mu
mc cho cc nc khc. Vi tnh trng tui th cng ngy cng cao v
tin b y khoa cn nhiu t ph mi tn km hn, chi ph cho y t c
nguy c cn tng tip tc. Cc yu t ang l mt th thch nghim

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118

trng lm h thng y t tr nn bp bnh. Bn thn m hnh c cha

ng 3 nhc im l: 1. Khng km hm ni chi ph ngy cng cao. 2.
Hiu qu v cht lng y t cn nhiu khc bit khi so snh vi nhau. 3.
Thiu iu phi trong dy chuyn cha tr. Qua 15 chnh sch i mi t
hn 30 nm nay cc vn then cht ny vn cha c gii quyt.10
Trong k hoch y t quc gia, bo m sc kho ngi dn cn bao gm
c chnh sch h tr sc kho v d phng bnh tt. Cng vic ny bao
trm vic vn ng c nhn, cc t chc x hi v thc v hiu bit
nhng vn lin quan n sc kho. Nguyn nhn gy ra nhng loi
bnh ph bin u c th gim thiu, nu c nhn v x hi c kh nng
c tc ng tch cc hn trong i sng nh n ung, cch t chc
sinh hot v lm vic, thi quen vn ng, th dc v th thao. Hn 50%
ca ton b chi ph cho y t l do 4 nhm bnh: Tim mch, ng rut,
tm thn v chnh hnh.11 Cc nc chu u b ra trung bnh 2.5% GDP
cho cng tc D phng v Y t cng ng. c b ra 3.3%, tuy trn
mc trung bnh, nhng km xa cc nc nh Tn Ty Lan hay Gia N
i khong 6%.12 Trong nm nay (2015) B y t c a ra chin
lc y t d phng cp quc gia. Qu x hi s chi thm 500 triu /
hng nm nhm h tr cc c s cng cng trong nhng bin php y t
d phng.13 Y t d phng v th l mt chin lc quan trng khng
nhng gim chi y t, m cn tc ng tch cc cho nn kinh t quc
dn.

Thi i Mi

10

Chancen fr das deutsche Gesundheitssystem, ISBN 978-3-642-25682-0

Springer Berlin (Redefining German Health Care, ISBN 978-3-642-10825-9
Springer, Berlin Heidelberg) 2012. Trong Porter M.E., Teisberg E.O.:
Redefining Health Care. Harvard Business School Press 2006
11
S thng k lin bang : Chi ph cho y t ( www.gbe-bund.de; Statistisches
Bundesamt: Gesundheitsausgaben)
12
Bo co ca T chc cng tc v pht trin kinh t chu u (OECD)2007
13
Lut tng cng h tr sc kho v y t d phng (Das Gesetz zur Strkung
der Gesundheitsfrderung und der Prvention, Prventionsgesetz PrvG).
http://bmg.bund.de/themen/praevention/praeventionsgesetz.html

Thi i Mi | Thng 7, 2015