Jahr 2014 VN Full PDF

B Y t Vit Nam
Nhm i tc y t
BO CO CHUNG
TNG QUAN NGNH Y T NM 2014
Tng cng d phng v kim sot
bnh khng ly nhim
Nh xut bn Y hc
H Ni, thng 3 nm 2015
Ban bin tp
PGS.TS. Nguyn Th Kim Tin - Trng Ban
PGS.TS. Phm L Tun
TS. Nguyn Hong Long
TS. Trn Vn Tin
ThS. Sarah Bales
Nhm iu phi
TS. Nguyn Hong Long - Trng Nhm
TS. Trn Vn Tin
ThS. Sarah Bales
TS. Trn Khnh Ton
ThS. Nguyn Th Thu Cc
CN. Ng Mnh V
Cc chuyn gia tham gia bin son

TS. Nguyn Hong Long
TS. Trn Vn Tin
ThS. Sarah Bales
PGS.TS. Phm Trng Thanh
TS. Trn Khnh Ton
TS. Nguyn ng Vng
ThS. Dng c Thin
TS. Phm Ngn Giang
TS. Nguyn Khnh Phng
ThS. Hong Thanh Hng
ThS. Nguyn Trng Khoa
PGS.TS. Nguyn Thanh Hng
TS. H Anh c
TS. Phm Thi Sn
PGS. TS. Trn Vn Thun
GS.TS. Ng Qu Chu
ThS. Phan Hng Dng
ThS. Trng L Vn Ngc
2
Li cm n
Bo co chung Tng quan ngnh y t 2014 (JAHR 2014) l bo co th 8 do B Y t cng
vi Nhm i tc y t (Health Partnership Group - HPG) phi hp thc hin hng nm. Bo co
JAHR nh gi tin thc hin cc nhim v ra trong K hoch 5 nm ngnh y t 20112015, kt qu thc hin cc Mc tiu Thin nin k v K hoch 5 nm, ng thi tp trung phn
tch su chuyn v Tng cng d phng v kim sot bnh khng ly nhim.
Qu trnh thc hin bo co JAHR 2014 nhn c s h tr nhit tnh ca cc bn
lin quan. Chng ti trn trng cm n nhng kin ng gp v t vn quy bau trong qu trnh
xy dng Bo co ny ca cc v, cc, vin, cc n v thuc B Y t, ca mt s b, ngnh.
Chng ti trn trng cm n v nh gi cao s h tr k thut v t vn ca Nhm i
tc y t v cc t chc, c nhn khac, cm n s h tr v ti chnh ca T chc Y t Th gii,
Lin minh ton cu v vc xin v tim chng (GAVI) v Rockefeller Foundation.
c bit, chng ti cm n cc chuyn gia t vn trong v ngoi nc trc tip tham
gia phn tch cc thng tin c sn, thu thp v x l kin ca cc bn lin quan bin son
cc chng ca bo co; cm n Nhm iu phi JAHR do TS. Nguyn Hong Long, Cc
trng Cc Phng, chng HIV/AIDS ch o, cng cc iu phi vin gm PGS.TS. Phm
Trng Thanh, TS. Trn Vn Tin, ThS. Sarah Bales, TS. Trn Khnh Ton, ThS. Nguyn Th
Thu Cc v CN. Ng Mnh V tch cc tham gia qu trnh t chc, xy dng v hon thin
bo co ny.
Ban bin tp
H tr ti chnh
WHO
T chc Y t
Th gii
Mc lc
Li cm n...............................................................................................................................3
Ch vit tt............................................................................................................................10
Gii thiu................................................................................................................................12
Mc ch ca Bo co JAHR ........................................................................................ 12
Ni dung v cu trc ca Bo co JAHR 2014 . ........................................................... 12
Phng php thc hin ............................................................................................... 14
T chc thc hin ......................................................................................................... 15
PHN MT: CP NHT THC TRNG H THNG Y T................................................... 16
Chng I: Tnh trng sc khe v cc yu t nh hng ............................................... 17
1. Tnh trng sc khe nhn dn........................................................................................ 17
2. Cc yu t nh hng ti sc khe .............................................................................. 43
3. Cc vn u tin......................................................................................................... 57
4. Khuyn ngh.................................................................................................................... 58
Chng II: Cp nht thc trng h thng y t .................................................................. 60
1. Nhng nhim v trng tm ca ngnh y t nm 2014 .................................................. 60
2. Tnh hnh thc hin K hoch bo v, chm sc v nng cao sc khe nhn dn
giai on 2011-2015....................................................................................................... 63
3. Tnh hnh thc hin cc ch tiu y t c bn trong K hoch 5 nm, 2011-2015
v Mc tiu Thin nin k ........................................................................................... 119
4. Tnh hnh thc hin cc Mc tiu Pht trin Thin nin k trong lnh vc y t............. 121
PHN HAI: TNG CNG D PHNG V KIM SOT BNH KHNG LY NHIM.... 136
Gii thiu..............................................................................................................................137
Chng III: Tng quan v phng, chng BKLN trn th gii v Vit Nam................... 138
1. Phng chng BKLN trn th gii v khu vc Ty Thi Bnh Dng........................ 138
2. Din bin dch t hc v gnh nng bnh khng ly nhim Vit Nam...................... 157
Chng IV: Kim sot cc yu t nguy c chung ca cc bnh khng ly nhim...... 175
1. Phng chng tc hi ca thuc l................................................................................. 175
2. Kim sot tc hi ca s dng ru, bia..................................................................... 185
3. Khuyn khch ch dinh dng hp l...................................................................... 192
4. Tng cng hot ng th lc.....................................................................................197
5. Khuyn ngh chung v gii php kim sot cc yu t nguy c chung ca BKLN....... 202
Chng V: Tnh hnh thc hin cc chng trnh, d n phng chng BKLN............ 205
1. D n phng, chng tng huyt p.............................................................................. 207
2. D n phng chng ung th......................................................................................... 211
3. D n phng chng bnh i tho ng................................................................... 215
4. D n phng chng bnh phi tc nghn mn tnh v hen ph qun ........................ 219
5. D n Bo v sc khe tm thn cng ng v tr em............................................... 222
Chng VI: Tng cng p ng ca h thng y t trong phng chng BKLN......... 227
1. Qun l, iu hnh........................................................................................................ 227
2. Nhn lc y t................................................................................................................ 233
3. Ti chnh trong phng chng BKLN.............................................................................. 240
4. Dc v trang thit b y t ........................................................................................... 248
5. H thng thng tin y t v gim st BKLN . ................................................................. 254

6. Cung ng dch v y t................................................................................................... 257
PHN BA: KT LUN V KHUYN NGH..........................................................................264
Chng VII: Kt lun..........................................................................................................265
1. Tnh trng sc khe v cc yu t nh hng ti sc khe........................................ 265
2. Cp nht tnh hnh h thng y t ................................................................................. 267
3. Kim sot cc yu t nguy c chung ca cc BKLN.................................................... 273
4. Tnh hnh thc hin cc chng trnh, d n phng chng bnh khng ly nhim..... 275
5. Tng cng h thng y t trong phng chng BKLN................................................... 277
Chng VIII: Khuyn ngh..................................................................................................280
1. nh hng h thng y t p ng vi tnh hnh bnh tt,
yu t nguy c hin nay ca Vit Nam........................................................................ 280
2. Thc hin nhim v ca K hoch 5 nm v Mc tiu Thin nin k v y t............... 281
3. Tng cng kim sot cc yu t nguy c chung........................................................ 283
4. Thc hin cc chng trnh mc tiu quc gia phng chng bnh khng ly nhim.. 283
5. Tng cng h thng y t trong d phng v kim sot BKLN................................... 286
Ph lc: Cc ch s gim st v nh gi.........................................................................289
Ti liu tham kho...............................................................................................................299
Danh mc bng
Bng 1: Mi bnh c gnh nng bnh tt cao nht trong nhm bnh truyn nhim, vn
lin quan sc khe b m, giai on chu sinh v ri lon dinh dng, 2010......... 26
Bng 2: Mi nguyn nhn gy gnh nng bnh tt ln nht trong nhm BKLN, 2010...... 28
Bng 3: Mi loi tai nn, thng tch gy gnh nng bnh tt cao nht, 2010.................. 30
Bng 4: 10 nguyn nhn gy gnh nng bnh tt ln nht theo gii, 2010......................... 31
Bng 5: Xu hng 20 nguyn nhn gy gnh nng bnh tt ln nht, 1990-2010.............. 32
Bng 6: Tnh hnh dch cm, 2007-2014...............................................................................33
Bng 7: Cc ch s c bn v dn s trong K hoch 5 nm ngnh y t, 2010-2015.......... 44
Bng 8: Cc nguyn nhn gy gnh nng t vong v gy nm sng tn tt
ngi cao tui (70 tui tr ln), 2010................................................................... 46
Bng 9: C cu cc yu t nguy c tnh theo t l t vong v t l DALY, 2010.................. 49
Bng 10: T l ngi v gia nh luyn tp th dc th thao, 2010-2013............................... 54
Bng 11: S lng cc c s t tiu chun thc hnh tt qua cc nm.............................. 93
Bng 12: Tnh hnh thc hin cc ch tiu y t c bn trong K hoch 5 nm, 2011-2015 . 120
Bng 13: Chnh lch vng i vi cc ch s sc khe c bn .......................................... 121
Bng 14: Ch s nh gi tin t cc Mc tiu Pht trin Thin nin k........................ 122
Bng 15: Tnh hnh gim suy dinh dng tr em trong thi gian t 1990 n 2015............ 124
Bng 16: Cc yu t nguy c chung ca bn BKLN............................................................. 140
Bng 17: Cc yu t nh hng n sc khe tm thn..................................................... 141
Bng 18: nh hng ca BKLN n cc mc tiu thin nin k.......................................... 143
Bng 19: Nguyn tc thc hin k hoch hnh ng phng, chng cc BKLN
va bnh tm thn................................................................................................... 146
Bng 20: So snh mc ch phng, chng BKLN giai on 2008-2013
v giai on 2013-2020 ........................................................................................ 147
Bng 21: Cc mc tiu v ch s gim st BKLN ton cu .................................................. 151
Bng 22: Cc mc tiu v ch s gim st hnh ng phng, chng bnh tm thn .......... 153
Bng 23: Cc can thip kim sot yu t nguy c lin quan n hnh vi, li sng.............. 154
Bng 24: T vong v YLL do bnh khng ly nhim theo gii
v tnh trng c hay cha c chng trnh can thip, 2010 . ............................... 160
Bng 25: Gnh nng bnh tt tnh theo DALY do BKLN theo gii, 2010.............................. 161
Bng 26: T l hin ht thuc l theo tui v gii Vit Nam, 1992-2010........................... 164
Bng 27: T l s dng ru, bia (%) c trng theo tui - gii, 2008................................ 166
Bng 28: T l hot ng th lc c trng theo tui - gii theo 3 mc (%)................... 168
Bng 29: Bin ng khu phn n ca ngi Vit Nam 2000-2010
(n v gam/ngi/ngy)....................................................................................... 170
Bng 30: T l hin mc i tho ng (%) theo tui v gii, 2008................................... 172
Bng 31: Cc giai on thc hin nm d n phng chng BKLN, 1998-2015 .................. 205
Bng 32: Tm tt mt s ni dung hot ng chnh ca cc d n phng chng BKLN
theo Q 1208/2012/Q-TTg................................................................................. 206
Bng 33: Danh mc thuc h huyt p c BHYT thanh ton tuyn y t x.................. 209
Bng 34: Bng phn tng nguy c tim mch tng th xc nh nhm c nguy c cao
b cc bin c tim mch trong 10 nm ti.............................................................. 210
Bng 35: Kt qu thc hin D n phng chng ung th giai on 2006-2010,
nh gi theo mc tiu.......................................................................................... 212
Bng 36: nh gi kt qu thc hin d n theo mc tiu
ca D n phng chng bnh i tho ng giai on 2006-2010.................... 217
Bng 37: Kt qu thc hin D n Bo v sc khe tm thn cng ng

v tr em theo mc tiu ........................................................................................ 224
Bng 38: Chi ph iu tr ung th v thc hin can thip tim mch ti Vit Nam.................. 246
Bng 39: So snh danh mc thuc ti thiu phng chng BKLN trong CSSKB
ca WHO v Danh mc thuc thit yu theo thng t s 31/2011/TT-BYT.......... 250
Bng 40: So snh danh mc thit b y t ti thiu phng chng BKLN trong CSSKB
theo khuyn co ca WHO [236]........................................................................... 252
Bng 41: Kh nng cung ng gi can thip thit yu phng chng BKLN
trong mng li y t c s Vit Nam ................................................................ 260
Danh mc hnh
Hnh 1: Tui th trung bnh cc nc ang pht trin chu , 2005-2010........................ 18
Hnh 2: T s t vong m cc nc ang pht trin chu , 2013................................... 18
Hnh 3: T sut t vong tr em di 1 tui v di 5 tui
cc nc ang pht trin chu , 2005-2010....................................................... 19
Hnh 4: T l suy dinh dng th thiu cn v thp ci tr em di 5 tui
cc nc ang pht trin ca chu nhng nm gn y.................................. 20
Hnh 5: T l nhim HIV nhm 15-49 tui, 15-24 tui
cc nc ang pht trin chu , 2012................................................................ 21
Hnh 6: T l mc st rt cc nc ang pht trin chu , 2012 ................................... 21
Hnh 7: T l hin mc lao cc nc ang pht trin chu , 2012.................................. 22
Hnh 8: Tui th trung bnh theo vng, c tnh nm 2013.................................................. 23
Hnh 9: T sut t vong tr em di 5 tui theo tui v vng, 2013..................................... 23
Hnh 10: T l suy dinh dng tr em di 5 tui theo vng, 2013........................................ 24
Hnh 11: Xu hng m hnh bnh tt o lng bng DALY, 1990-2010................................. 25
Hnh 12: C cu nguyn nhn t vong theo tui v gii, 2010............................................... 25
Hnh 13: Cc nguyn nhn gy gnh nng bnh tt trong nhm bnh truyn nhim, vn
lin quan sc khe b m, cc vn chu sinh v ri lon dinh dng, 2010....... 26
Hnh 14: S nm sng mt i do t vong sm v s nm sng tn tt ca 10 bnh
gy gnh nng bnh tt ln trong nhm 1 (2010).................................................... 27
Hnh 15: Gnh nng bnh tt ca cc nhm BKLN, 2010...................................................... 28
Hnh 16: S nm sng mt i do t vong sm v s nm sng tn tt ca 10 nguyn nhn
gy gnh nng bnh tt ln nht trong nhm BKLN, 2010...................................... 29
Hnh 17: Cc nhm nguyn nhn gy gnh nng bnh tt nhm tai nn,
chn thng, ng c, 2010.................................................................................... 29
Hnh 18: S nm sng mt i do t vong sm v s nm sng tn tt ca 10 loi tai nn,
chn thng gy gnh nng bnh tt ln nht, 2010.............................................. 30
Hnh 19: Gnh nng bnh tt tr em di 5 tui do cc bnh phng c
bng vc xin, 1990-2010 ......................................................................................... 35
Hnh 20: Xu hng t l mi mc lao theo c tnh v t l c pht hin, 1990-2012...... 40
Hnh 21: C cu tui t vong theo vng quc t, 2010.......................................................... 45
Hnh 22: Quy m cc nhm tui ph n v tr em, 2013....................................................... 47
Hnh 23: Cc mc chi NSNN cho y t, c thc hin nm 2012 . ......................................... 79
Hnh 24: Xu hng chi NSNN theo mc ch s dng t 2010-2014, theo gi nm 2014..... 79
Hnh 25: T l gia tng thc t chi NSNN chung v cho y t hng nm, 2010-2014.............. 80
Hnh 26: T l chi tiu tin ti h gia nh trong tng chi tiu cho y t, 1998-2012................. 81
Hnh 27: T l NSNN chi cho YTDP v nng cao sc khe, 2009-2011................................. 81
Hnh 28: Kinh ph t NSNN h tr mua BHYT cho cc i tng
theo Lut BHYT (triu ng)..................................................................................... 82
Hnh 29: C cu cc nhm i tng tham gia BHYT, 2013.................................................. 84
Hnh 30: S lng bo co phn ng c hi ca thuc gi v Trung tm Thng tin thuc
v theo di phn ng c hi ca thuc, 2010-2013................................................. 94
Hnh 31: Xu hng gim t l thp ci theo vng, 2010-2013.............................................. 124
Hnh 32: T sut t vong tr em di 5 tui theo vng, 2010-2013..................................... 125
Hnh 33: Nguyn nhn chnh gy t vong tr em Vit Nam, 2010.................................... 126
Hnh 34: Mt s ch s lin quan tip cn dch v KHHG theo vng, 2011......................... 128
Hnh 35: T l ph n sinh con cha c p ng nhu cu khm thai,

theo vng, 2011............................................................................................ 128
Hnh 36: T l dng bao cao su trong ln quan h tnh dc nguy c cao
gn y nht, 2009-2013........................................................................................ 130
Hnh 37: Xu hng mc v t vong do st rt, 2000-2012................................................... 131
Hnh 38: C cu cc loi bnh nhn lao c pht hin, 2005-2013................................... 133
Hnh 39: C cu loi h x khu vc nng thn, 2000-2012................................................... 134
Hnh 40: Khung phn tch chuyn bnh khng ly nhim trong bo co JAHR 2014..... 137
Hnh 41: Mi quan h gia i ngho, BKLN v cc mc tiu pht trin.............................. 142
Hnh 42: T l chi ph ca cc bnh trong tng chi ph cho 5 BKLN
ca Trung Quc v n ...................................................................................... 144
Hnh 43: Mt s chnh sch ton cu v cc BKLN t nm 2000 n nay . ........................ 145
Hnh 44: Khung can thip Khu vc Ty Thi Bnh Dng da trn khuyn co ca WHO .149
Hnh 45: Bnh khng ly nhim v cc yu t nguy c........................................................ 163
Hnh 46: Ht thuc l hin ti cc nc ang pht trin chu nhng nm gn y...... 165
Hnh 47: Tiu th ung c cn bnh qun u ngi cc nc ang pht trin chu ,
trung bnh trong giai on 2008-2010.................................................................... 166
Hnh 48: Cc ch s hot ng th lc i vi thiu nin cc nc ang pht trin chu ,
nm gn y nht................................................................................................... 169
Hnh 49: C cu BMI ngi trng thnh theo gii
v khu vc thnh th/nng thn, 2009.................................................................... 172
Hnh 50: T chc mng li qun l tng huyt p ti Vit Nam......................................... 207
Hnh 51: S t chc Chng trnh Phng chng cc BKLNM........................................ 230
Hnh 52: NSNN phn b cho chng trnh phng chng BKLN 2012-2013......................... 241
Hnh 53: Kinh ph cp cho cc CTMTQG phng chng BKLN 2012-2014........................... 242
Hnh 54: Thit b n gin o dung tch th ra ti a (Peak flow meter)............................... 253
Ch vit tt
ADR
Phn ng c hi ca thuc
ARV
Thuc khng vi rt
BHXH
Bo him x hi
BHYT
Bo him y t
BKLN
BMI
Bnh khng ly nhim

Ch s khi c th
CPI
Ch s gi tiu dng
CSSK
Chm sc sc khe
CSSKB
Chm sc sc khe ban u
CSSKSS
Chm sc sc khe sinh sn
CTMTQG
Chng trnh mc tiu quc gia
DALY
Nm sng hiu chnh theo mc tn tt
DPT
Vc xin chng bch hu, ho g, un vn
EC
Phi on Lin minh chu u ti Vit Nam
GAVI
Lin minh ton cu v vc xin v tim chng
GDP
Tng sn phm trong nc (Gross Domestic Production)
GDP
Thc hnh tt phn phi thuc (Good Distribution Practice)
GLP
Thc hnh tt kim nghim thuc
GMP
Thc hnh tt sn xut thuc
GPP
Thc hnh tt nh thuc
GSP
Thc hnh tt bo qun thuc
HIV/AIDS
Vi rt suy gim min dch ngi/hi chng suy gim min dch mc phi
HPG
Nhm i tc y t
HPV
Vi rt Papilloma ngi
IHME
Vin nh gi v o lng sc khe
IMR
T sut t vong tr em di 1 tui
JAHR
Bo co chung tng quan ngnh y t
KCB
Khm cha bnh
KHHG
K hoch ha gia nh
MDG
Mc tiu Pht trin Thin nin k
NSNN
Ngn sch nh nc
ODA
PCTHTL
H tr pht trin chnh thc

Phng chng tc hi ca thuc l
PPP
Sc mua tng ng ( la quc t)
SXH
St xut huyt
TCMR
TDTT
Tim chng m rng

Th dc th thao
TFR
TPP
Tng t sut sinh

Hip nh i tc xuyn Thi Bnh Dng
10
U5MR
T vong tr em di 5 tui
UBND
y ban nhn dn
UNAIDS
Chng trnh phng, chng AIDS ca Lin Hp Quc
UNFPA
Qu Dn s Lin Hp Quc
UNICEF
Qu Nhi ng Lin Hp Quc
USD
la M
VGB
Vim gan B
WHO
T chc Y t Th gii
YDCT
Y dc c truyn
YHCT
Y hc c truyn
YLD
S nm sng tn tt
YLL
S nm sng mt i do t vong sm
YTDP
Y t d phng
11
Bo co chung tng quan ngnh y t nm 2014
Gii thiu
Mc ch ca Bo co JAHR
Theo tha thun ca Nhm i tc y t, t nm 2007, Bo co chung Tng quan ngnh
y t hng nm (Joint Annual Health Review - JAHR) c mc ch chung l nh gi thc trng
v xc nh cc vn u tin ca ngnh y t, nhm h tr cho vic lp k hoch hng nm ca
B Y t, ng thi lm c s cho vic la chn cc vn trng tm trong hp tc v i thoi
gia ngnh y t Vit Nam v cc i tc nc ngoi. Cc mc tiu c th ca bo co JAHR
bao gm: (i) Cp nht thc trng ngnh y t, bao gm cp nht cc chnh sch mi v tnh hnh
thc hin cc mc tiu, nhim v ra trong cc k hoch ca ngnh y t, cc khuyn ngh
ca JAHR, tin thc hin cc Mc tiu Pht trin Thin nin k lin quan n y t v mc
tiu sc khe ca Vit Nam v (ii) Phn tch nh gi su hn v mt lnh vc ca h thng y t,
hoc mt s ch quan trng ang c cc nh hoch nh chnh sch y t quan tm (phn
chuyn ).
Ni dung v cu trc ca bo co JAHR 2014

Ty theo c im ca tng nm, bo co JAHR cn c ni dung v cu trc c th p
ng cc mc ch, yu cu c th ca cng tc xy dng k hoch ca ngnh y t v la chn cc
vn trng tm trong hp tc v i thoi gia ngnh y t Vit Nam v cc i tc pht trin.
Nm 2007, Bo co JAHR u tin c xy dng, cp nht ton din cc lnh vc
ch yu ca h thng y t Vit Nam, gm: (i) Tnh trng sc khe v cc yu t tc ng; (ii)
T chc v qun l h thng y t; (iii) Nhn lc y t; (iv) Ti chnh y t v (v) Cung ng dch
v y t.
Bo co JAHR 2008 v 2009, ngoi phn cp nht h thng y t, ln lt phn tch
su ch Ti chnh y t v Nhn lc y t Vit Nam.
Bo co JAHR 2010, c xy dng vo thi im sp kt thc K hoch pht trin y t
5 nm 2006-2010, t trng tm vo vic cp nht ton din cc cu phn ca h thng y t,
nhm h tr cho vic xy dng k hoch 5 nm ngnh y t 2011-2015.
Bo co JAHR 2011, c xy dng vo nm u tin ca K hoch 5 nm 2011-2015,
c nhim v cp nht nhng nh hng mi c xc nh ti i hi ng ton quc ln th
XI, v K hoch 5 nm pht trin kinh t-x hi, nhm thc y vic trin khai thc hin k
hoch 5 nm v h tr cho vic xy dng k hoch y t nm 2012
Bo co JAHR 2012, c xy dng vo nm th hai ca chu k k hoch 5 nm, c
nhim v h tr xy dng k hoch ca nm tip theo, bng cch cp nht nhng chnh sch
mi v nh gi tin thc hin cc nhim v ra theo c 6 cu phn ca h thng y t; phn
tch su chuyn v cht lng khm bnh, cha bnh v xut cc gii php tng ng.
Bo co JAHR 2013, c xy dng vo nm th 3 ca chu k k hoch 5 nm, c
nhim v tng t nh bo co nm 2012, la chn phn tch su ch Bao ph chm
sc sc khe ton dn.
12
Gii thiu
Bo co JAHR 2014, c xy dng vo nm th 4 ca chu k k hoch 5 nm, v l
nm cui cng cc quc gia tin ti cc Mc tiu Pht trin Thin nin k (MDGs), trong
c 5 nhm mc tiu lin quan ti y t, c cc nc thnh vin Lin Hp Quc cam kt hon
thnh n nm 2015. Bo co c nhim v: (i) H tr cho vic xy dng k hoch 2015, cung
cp sm nhng thng tin h tr xy dng k hoch 5 nm 2016-2020 v (ii) H tr cho vic xy
dng chin lc d phng v kim sot bnh khng ly nhim (BKLN) giai on 2015-2020.
PHN MT ca Bo co phn tch nh gi tnh trng sc kho, cc yu t nh hng
ti sc kho v cp nht, nh gi thc trng h thng y t Vit Nam vi nhng ni dung chnh
sau y:
Chng I: Tnh trng sc kho v cc yu t nh hng.
Chng II: Cp nht thc trng h thng y t:
Nhng nhim v trng tm ca ngnh y t nm nm 2014;
Tnh hnh thc hin K hoch bo v, chm sc v nng cao sc khe nhn dn giai
on 2011-2015, bao gm (i) Tng cng nng lc qun l ca ngnh y t; (ii) Nhn
lc y t; (iii) Ti chnh y t; (iv) Dc v trang thit b y t; (v) H thng thng tin
y t; (vi) Cung ng dch v chm sc sc kho ban u (CSSKB), y t d phng
(YTDP), cc chng trnh mc tiu y t quc gia, Dn s-K hoch ho gia nh
(KHHG) v (vii) Cung ng dch v khm cha bnh (KCB).
Tnh hnh thc hin cc ch tiu y t c bn trong K hoch 5 nm, 2011-2015 v
Mc tiu Thin nin k ca Vit Nam.
PHN HAI ca bo co: Phn tch ch v tng cng d phng v kim sot cc
BKLN, vi cc ni dung sau:
Chng III: Tng quan v phng chng BKLN trn th gii v Vit Nam, gm cc ni
dung (i) Tng quan phng chng BKLN trn th gii v trong khu vc Ty Thi Bnh Dng
v (ii) Din bin dch t hc v gnh nng BKLN Vit Nam.
Chng IV: Kim sot cc yu t nguy c chung ca cc BKLN, bao gm (i) Phng
chng tc hi ca thuc l, (ii) Kim sot tc hi ca ru, bia; (iii) Khuyn khch ch dinh
dng hp l v (iv) Tng cng hot ng th lc, rn luyn th dc, th thao.
Chng V: Tnh hnh thc hin cc chng trnh, d n phng chng BKLN, bao gm
d n phng, chng bnh tng huyt p, ung th, i tho ng, bnh phi tc nghn mn tnh
v d n bo v sc kho tm thn cng ng v tr em.
Chng VI: Tng cng p ng ca h thng y t trong phng chng BKLN, vi cc
ni dung v qun l iu hnh, nhn lc, ti chnh, dc-trang thit b y t, h thng thng tin
- gim st BKLN v cung ng dch v y t.
PHN BA ca bo co l kt lun, tng hp cc nhn nh chnh v thc trng h thng
y t Vit Nam v v ch tng cng phng chng BKLN; khuyn ngh cc gii php cho
13

nhng vn u tin ca k hoch 2015 v nhng nm tip theo v cc gii php nhm tng
cng p ng ca h thng y t trong d phng v kim sot BKLN.
PH LC ca bo co gm cc ch s theo di nh gi cc lnh vc y t.
Phng php thc hin

Qu trnh xy dng bo co JAHR 2014 c thc hin da vo mt s phng php
tip cn v yu cu chung, bao gm:
Cn c vo bi cnh kinh t-x hi v c im ca h thng y t Vit Nam ang
trong qu trnh i mi v pht trin, da vo cc tiu ch cng bng, hiu qu ca
h thng y t, nh gi ng nhng kt qu, tin b, nhng kh khn, tr ngi
trong vic thc hin cc mc tiu cn hng ti, c bit l cc nhim v ra,
t xut cc gii php tng ng.
Tm hiu v vn dng cc khung l thuyt ph hp i vi tng cu phn ca h
thng y t, cng nh i vi cc ch v y t c cp trong bo co, bo
m tnh nht qun, khoa hc v quan nim v cch tip cn, ph hp vi xu th
hin i.
Ch trng tho lun vi cn b, chuyn gia cc V, Cc lin quan ca B Y t lm
r nhng vn cn quan tm v tin thc hin cc nhim v ra trong k
hoch 5 nm lin quan n tng V, Cc; kp thi trao i thng tin v cung cp cc
d tho bo co cho nhm xy dng k hoch ca V K hoch - Ti chnh, B Y t.
Cc phng php c th c s dng xy dng bo co, bao gm: (i) Tng hp cc
ti liu c sn, gm cc vn bn chnh sch, php lut v cc ti liu nghin cu, kho st, v
(ii) Thu thp, x l kin ca cc bn lin quan, nht l ca cn b qun l, chuyn gia ngnh
y t v cc b, ngnh lin quan, cc chuyn gia quc t.
Tng hp v x l cc ti liu sn c, gm cc vn bn ca ng, Quc hi, Chnh ph,
B Y t v cc b; cc cng trnh nghin cu, kho st; cc bo co ca cc b, ngnh; bo co
tng kt chuyn ngnh; ti liu ca cc t chc quc t v ca nc ngoi. Nhm iu phi tm
kim v cung cp mt s ti liu v s liu thng k chnh; cc chuyn gia ch ng tm kim
v chia s cc ti liu lin quan.
Thu thp v x l cc kin ca cc bn lin quan c thc hin nh sau:
T chc 8 bui tho lun bn trn vi cc chuyn gia (ch yu l chuyn gia
trong nc) v 3 hi tho ca Nhm i tc y t.
ng cc d tho chng trn website ca JAHR (www.JAHR.org.vn) ly
kin ca cc chuyn gia trong nc v quc t.
Gi cc d tho chng ly kin ca cc cc, v v n v lin quan ca B Y
t v mt s b, ngnh lin quan.
Gi cc d tho ly kin ca mt s cn b qun l v chuyn gia (cng tc
vin ca JAHR) trong qu trnh d tho cc chng.
14
Gii thiu
T chc thc hin

Cng nh cc nm trc, JAHR 2014 c xy dng vi s phi hp ch o ca B Y
t v Nhm i tc y t. C cu t chc iu hnh qu trnh xy dng bo co gm c:
Nhm iu phi, gm i din B Y t, mt iu phi vin quc t, mt iu phi vin
trong nc v mt s cn b h tr, c nhim v gii quyt nhng vn hng ngy v qun l
v hnh chnh, t chc hi tho, tng hp cc kin ng gp, bo m cho qu trnh vit bo
co c s tham gia ca nhiu bn; bin tp, hon thin bo co.
Chuyn gia t vn, gm cc chuyn gia trong nc c kin thc, kinh nghim lin quan
n cc cu phn ca h thng y t, c nhim v d tho cc chng ca bo co, thu thp
kin ca cc bn lin quan v hon thin cc chng ph hp vi cc gp v nhn xt chung.
15
PHN MT: CP NHT THC TRNG H THNG Y T
16
Chng I: Tnh trng sc khe v cc yu t nh hng

Tnh trng sc khe v cc yu t nh hng n sc khe nhn dn l nhng cn c
hng u xc nh phng hng v mc tiu ca cc chin lc, k hoch pht trin h
thng y t. Chng ny c mc ch phn tch nh gi tnh trng sc khe v cc yu t nh
hng ti sc khe, din bin v xu hng thay i trong nhng nm gn y, t xut
nhng nh hng v gii php ln nhm ng ph vi nhng vn v sc khe v cc yu t
nh hng ti sc khe trong thi k ca k hoch 5 nm 2016-2020.
1. Tnh trng sc khe nhn dn

Cc ni dung chnh s cp trong mc ny bao gm: (i) phn tch tnh trng sc khe
nhn dn qua mt s ch s sc khe c bn; (ii) phn tch nguyn nhn gnh nng bnh tt
Vit Nam; (iii) m t tnh hnh mt s bnh cn c quan tm.
1.1. Cc ch s sc khe c bn
Nhng nm gn y, tnh trng sc khe ngi dn Vit Nam c ci thin ng
k, trong c nhiu ch s t cao hn so vi cc nc c cng mc thu nhp bnh qun u
ngi. Tuy nhin, mt s ch s sc khe c bn cn t mc thp v c s chnh lch kh
r rt gia cc vng, min.
Phn di y nh gi tnh trng sc khe nhn dn da vo mt s ch s c bn, nh:
tui th trung bnh (k vng sng khi sinh); t s t vong m; t sut t vong tr em; t l suy
dinh dng tr em; t l mc v t vong do mt s bnh, dch,...
Tui th trung bnh
Tui th trung bnh l mt trong nhng ch s tng hp nht phn nh tnh trng sc
khe dn c. Nm 2013, tui th trung bnh ca ngi Vit Nam t 73,1 tui theo c tnh ca
Tng cc Thng k. S liu c tnh ca Lin Hp Quc cho thy tui th trung bnh ca ngi
dn Vit Nam cao nht trong s cc nc ang pht trin chu c mc thu nhp tng ng
Vit Nam, thm ch cn cao hn so vi mt s nc giu hn (Hnh 1).
17

Hnh 1: Tui th trung bnh cc nc ang pht trin chu , 2005-2010
Tui th trung bnh
76
Vit Nam
74
Trung Quc
Thi Lan
Xri lan-ca
Ma-lai-xi-a
72
70
Cam-pu-chia
68
66
64
Pa-kt-xtan
CHDCND Lo
0
Phi-lp-pin
n
5000
In--n-xi-a
Mng C
Bu-tan
10000
15000
20000
25000
Thu nhp quc gia bnh qun u ngi PPP$

Ch thch: S liu do Lin Hp Quc c tnh da trn cc bin php phn tch gin tip nn khc vi s liu ca
Tng cc Thng k cng b. S liu v thu nhp quc gia bnh qun u ngi tnh bng PPP, tc l iu chnh
tng quc gia cho php so snh v mt sc mua.
Ngun: Life expectancy at birth - United Nations, Department of Economic and Social Affairs, Population Division
(2013). World Population Prospects: The 2012 Revision, DVD Edition [1]. GNI - World Bank, World Development
Indicators.
T s t vong m
c tnh s tuyt i nm 2013, Vit Nam c 690 ph n t vong lin quan vi mang
thai v sinh vi t s t vong m c tnh l 49/100000 tr ra sng [2]. T l ny l tng
i thp so vi cc nc ang pht trin trong khu vc chu . S liu thng k cho thy t s
t vong m ca Vit Nam tng ng vi cc nc t Thi Lan, Ma-lai-xi-a, Trung Quc n
Bu-tan, v thp hn so vi Phi-lp-pin, Pa-kt-xtan v mt s quc gia khc (Hnh 2).
Hnh 2: T s t vong m cc nc ang pht trin chu , 2013
Ngun: WHO, UNICEF, UNFPA, The World Bank and the United Nations Population Division. Trends in Maternal
Mortality: 1990 to 2013. WHO: Geneva. 2014 [2].
18

T sut t vong tr em
T sut t vong tr em c tnh Vit Nam cng thp hn so vi hu ht cc nc ang
pht trin chu (Hnh 3). c tnh nm 2013, t sut t vong tr em di 1 tui (IMR) ca
Vit Nam l 15,3/1000 tr ra sng v t sut t vong tr em di 5 tui (U5MR) l 23,1/1000
tr sng. So vi Trung Quc, t sut t vong tr em di 1 tui ca Vit Nam thp hn, cn
t sut t vong tr em di 5 tui li cao hn. iu ny gi l kt qu gim t vong tr nh
t tng i tt, nhng cn tm hiu su hn tm ra nguyn nhn t vong cao nhm t 1
n 4 tui.
Ma-lai-xi-a
Xri lan-ca
Thi Lan
U5MR
Vit Nam
Trung Quc
Phi-lp-pin
In--n-xi-a
Mng C
Bu-tan
CHDCND Lo
IMR
Cam-pu-chia
80
70
60
50
40
30
20
10
0
Pa-kt-xtan
S t vong trn 1000

tr sinh ra sng
Hnh 3: T sut t vong tr em di 1 tui v di 5 tui cc nc ang pht trin

chu , 2005-2010
Ngun: United Nations, Department of Economic and Social Affairs, Population Division (2013). World Population
Prospects: The 2012 Revision, DVD Edition [1].
T l suy dinh dng tr em di 5 tui

Nm 2013, t l tr em di 5 tui Vit Nam b suy dinh dng th thiu cn l 15,3%
v th thp ci l 25,9% [3]; tng i thp so vi cc nc ang pht trin chu . Hnh 4 cho
thy Vit Nam ng th 4 v t l tr em suy dinh dng th thiu cn v ng th 6 v t l
suy dinh dng thp ci so vi cc nc tham kho. T l suy dinh dng lin quan iu kin
kinh t-x hi km pht trin, tnh trng m au, bnh tt v ch n cho tr nh khng hp l.
19

Hnh 4: T l suy dinh dng th thiu cn v thp ci tr em di 5 tui cc nc
ang pht trin ca chu nhng nm gn y
T l thiu cn
T l thp ci
Trung Quc (2010)

Mng C (2010)
Thi Lan (2006)
Vit Nam (2011)
Bu-tan (2010)
Ma-lai-xi-a (2006)
In--n-xi-a (2010)
Phi-lp-pin (2011)
Xri lan-ca (2009)
Cam-pu-chia (2011)
CHDCND Lo (2006)
Pa-kt-xtan (2011)
n (2006)
Trung Quc (2010)

Thi Lan (2006)
Mng C (2010)
Ma-lai-xi-a (2006)
Xri lan-ca (2009)
Vit Nam (2011)
Bu-tan (2010)
Phi-lp-pin (2011)
In--n-xi-a (2010)
Cam-pu-chia (2011)
Pa-kt-xtan (2011)
CHDCND Lo (2006)
n (2006)
0
10
20
30
40
50
10 20 30 40 50
Phn trm
Phn trm
Ngun: UNICEF. Childinfo. Monitoring the Situation of Children and women. Last updated April 2013. http://www.
childinfo.org/malnutrition.html; Ring Cam-pu-chia v Phi-lp-pin c s liu cp nht hn t WHO Global health
observatory. Child malnutrition country estimates. WHO Global Database. http://apps.who.int/gho/data/
T l nhim HIV trong cng ng

Nhim HIV gy gnh nng bnh tt ln v l bnh u tin ton cu. Vit Nam, nhim
HIV c gnh nng bnh tt (cng gp s nm sng tn tt v s nm sng mt i do t vong
sm) ng th nht trong cc bnh truyn nhim. Tnh n 30/9/2014, Vit Nam c 224223
ngi nhim HIV v 69617 ngi chuyn sang giai on AIDS c bo co l cn sng;
tng s ngi t vong lin quan n HIV/AIDS ly tch l 70734 trng hp. T l nhim HIV
chung trong cng ng l khong 0,26% dn s. Trong thi gian qua, s nhim HIV mi, s
mc AIDS v s t vong lin quan n AIDS hng nm c bo co gim dn. Tuy nhin,
mc gim cha su, cha bn vng v cc ch s ly tch vn tip tc gia tng. Ti mt s
a phng, c bit l khu vc min ni, vng su, vng xa, s lng ngi nhim HIV mi
hng nm vn gia tng. Ngoi ra, cc yu t nguy c lin quan n ly nhim HIV din bin
phc tp, kh kim sot, nh tim chch ma ty, s dng ma ty tng hp, mi dm, tnh dc
nam ng gii[4].
Hnh 5 cho thy kt qu c tnh t l hin nhim HIV nhm 15-49 tui v nam v
n nhm 15-24 tui. Nm 2012, Vit Nam c t l hin nhim HIV ngi ln tng i cao,
tng ng vi Ma-lai-xi-a v In--n-xi-a, nhng thp hn Thi Lan v Cam-pu-chia.
T l hin nhim nam gii 15-24 tui Vit Nam tng ng vi CHDCND Lo v Campu-chia, nhng thp hn In--n-xia v Thi Lan [5].
20

Hnh 5: T l nhim HIV nhm 15-49 tui, 15-24 tui cc nc ang pht trin
chu , 2012
Mng C
Xri-lanca
Phi-lp-pin
Pa-kt-xtan
Bu-tan
CHDCND Lo
n
Vit Nam
Ma-lai-xi-a
In--n-xi-a
Cam-pu-chia
Thi lan
T l hin nhim nam gii

15-24 tui (%)
T l hin nhim ph n
15-24 tui (%)
T l hin mc ngi ln
15-49 tui (%)
0,0
0,2
0,4
0,6
0,8
Phn trm
1,0
1,2
Ch thch: cc nc c kt qu <0,1% trong hnh c th hin mc 0,1%. Khng c s liu cho Trung Quc
theo nhm tui.
Ngun: UNAIDS. Report on the Global AIDS Epidemic - 2013. HIV estimates 1990-2012. http://www.unaids.org/en/
media/unaids/contentassets/documents/epidemiology/2013/gr2013/unaids_global_report_2013_en.pdf. Mng CUNAIDS. Country Progress Report Mongolia. Reporting period 1/1/2012-31/12/2013.
T l mc v t vong do st rt
T l mc st rt Vit Nam rt thp, nm 2012 l 33/100000 dn, thp th 5 trong cc
nc ang pht trin tham kho ti chu (Hnh 6). Trong cc quc gia tham kho, Mng C
khng c trng hp no v khng nm trong vng c kh hu thun li cho mui pht trin. Bi
hc rt ra t thnh cng ca Xri Lan-ca, nc ang pht trin i u trong vic loi tr st rt,
l cn thc hin u n v cht ch cc can thip phng, chng st rt nhm dn c c nguy
c cao, trong c cc can thip chn on, iu tr, gim st dch x l kp thi khi c
dch [6]. Vit Nam, mc d s ngi mc v t vong do st rt gim rt ng k, tuy nhin
vn c 37% dn s sng trong vng nguy c v 18% dn s sng trong vng c nguy c cao [7].
Hnh 6: T l mc st rt cc nc ang pht trin chu , 2012
Mng C
Trung Quc
Phi-lp-pin
Ma-lai-xi-a
Cam-pu-chia
CHDCND Lo
In--n-xi-a
0
500
1000
1500
2000
2500
c tnh s bnh nhn st rt trn 100 000 dn
Ngun: World Malaria Report, 2013.
21
3000

T l mc lao
Vit Nam l mt trong 22 quc gia c t l hin mc v mi mc bnh lao cao vi t l
mc mi c tnh nm 2013 khong 130/100000 dn v t l hin mc vo khong 200/100000
dn [8]. S ngi hin mc lao c pht hin Vit Nam khong 100000 ngi, cha gim
qua cc nm [9]. Vi s bnh nhn lao cao, nguy c ly truyn cng rt cao bi lao l mt bnh
rt d ly truyn t ngi sang ngi qua khng kh. Hn na, trc giai on lao tin trin, cc
triu chng c th m thm trong mt thi gian di nhiu thng, khin cho bnh nhn chm i
khm v iu tr, lm tng nguy c ly truyn vi khun lao cho nhng ngi c tip xc gn gi
vi bnh nhn. Gnh nng bnh tt ca bnh lao ang ng th 3 trong cc bnh truyn nhim
Vit Nam. S liu c tnh cho thy t l hin mc bnh lao Vit Nam thp hn Cam-pu-chia
v Phi-lp-pin (Hnh 7).
Hnh 7: T l hin mc lao cc nc ang pht trin chu , 2012
Trung Quc
Ma-lai-xi-a
Xri-lanca
Thi lan
Vit Nam
Bu-tan
n
In--n-xi-a
Pa-kt-xtan
Mng C
Phi-lp-pin
CHDCND Lo
Cam-pu-chia
200
400
600
800
T l hin mc lao/100 000 dn
1000
Ngun: WHO, Tuberculosis (TB) http://www.who.int/tb/country/data/download/en/
S chnh lch v tnh trng sc khe gia cc vng, min

S chnh lch ng k v tnh trng sc khe gia cc vng, min v gia cc nhm dn
c, l mt vn ln rt ng quan tm, th hin mt s ch s sc khe sau y.
Tui th trung bnh chnh lch 6,2 nm gia vng c dn c sng th nht l vng
ng Nam B v vng c tui th thp nht l Ty Nguyn (Hnh 8). Hai vng c tui th thp
nht l nhng vng c iu kin a l kh i li, mt dn c tha, iu kin nc sch v
v sinh cn hn ch v t l h ngho cao.
22

Hnh 8: Tui th trung bnh theo vng, c tnh nm 2013
76
75,7
74,3
Tui th trung bnh
74
74,4
72,5
72
70,4
70
73,1
69,5
68
66
ng bng Trung du Bc Trung

Ty
sng Hng v min ni B v
Nguyn
pha Bc duyn hi
min Trung
ng Nam ng bng Ton quc

B
sng Cu
Long
Ngun: Tng cc Thng k. Nin gim thng k nm 2013.
T sut t vong tr em cao nht hai vng ngho l Trung du v min ni pha Bc v
Ty Nguyn v thp nht vng ng Nam B (Hnh 9). Ty Nguyn, s tr em di 1 tui
t vong trn 1000 tr sinh sng l 39,8, cao hn 17 tr so vi vng ng Nam B. i vi tr
em di 5 tui, chnh lch s tr t vong ln 26 tr, ni cch khc, t vong tr em di 5 tui
Ty Nguyn cao gp 3 ln t vong tr em di 5 tui ng Nam B.
S t vong trn 1000

tr sinh ra sng
Hnh 9: T sut t vong tr em di 5 tui theo tui v vng, 2013

45
40
35
30
25
20
15
10
5
0
39,8
35,2
25,5
23,1
18,3
13,5
ng
bng
sng
Hng
T vong
t 1 - 4 tui
17,9
Trung du
Bc
Ty
ng
ng
v min Trung B Nguyn Nam B
bng
ni pha v duyn
sng Cu
Bc
hi min
Long
Trung
T vong di
1 tui
Ton
quc
Ngun: Tng cc Thng k. Nin gim thng k nm 2013.
Tng t nh vi t vong tr em, t l suy dinh dng tr em di 5 tui cao nht

hai vng Ty Nguyn v Trung du v min ni pha Bc v thp nht vng ng Nam B
(Hnh 10). Chnh lch gia vng cao nht v vng thp nht l 14 im phn trm i vi t l
tr em thiu cn v 16 im phn trm i vi t l tr em thp ci.
23

Hnh 10: T l suy dinh dng tr em di 5 tui theo vng, 2013
35
33
31
Phn trm
21
20
15
19
T l thp ci
28
30
25
T l thiu cn
17
16
11
26
25
22
14
15
10
5
0
ng bng Trung du v Bc Trung Ty Nguyn ng Nam

sng Hng min ni pha B v duyn
B
Bc
hi min
Trung
ng bng
sng Cu
Long
Ton quc
Ngun: Vin Dinh dng. S liu thng k v tnh trng dinh dng tr em qua cc nm. Cp nht ngy:
26/03/2014. http://www.nutrition.org.vn/news/vi/106/61/0/a/so-lieu-thong-ke-ve-tinh-trang-dinh-duong-tre-em-quacac-nam.aspx
1.2. Gnh nng bnh tt

Phn tch gnh nng bnh tt ng gp bng chng quan trng xc nh cc vn
sc khe u tin khi xy dng chin lc, k hoch v chnh sch ca ngnh y t. Nghin cu
gnh nng bnh tt ton cu nm 2010 l mt hp tc nghin cu ca gn 500 nh khoa hc
50 quc gia do Vin nh gi v o lng Sc khe (IHME) thuc i hc Oa-sinh-tn ch
tr. y l mt nghin cu khoa hc mang tnh h thng ln nht t trc ti nay nhm xc
nh mc v xu hng ca gnh nng bnh tt tnh theo s nm sng mt i do bnh tt,
chn thng v cc yu t nguy c. Mt s tiu ch xc nh u tin l s ngi t vong, s
nm sng mt i do t vong sm (vit tt l YLL, nh ngha l s nm t vong trc tui th
trung bnh, c tnh bng s trng hp t vong nhn vi k vng sng ti thi im t vong),
s nm sng tn tt (vit tt l YLD, nh ngha l s nm sng khe mnh b mt i do bnh
tt). Ch s tng hp gnh nng bnh tt l s nm sng c hiu chnh theo mc bnh tt
(DALY), th hin s mt i nhng nm sng c do tn tt, bnh tt do cht sm v c tnh
bng tng ca YLL v YLD. Mi DALY tng ng vi 1 nm sng kho mnh b mt i. Cc
s c tnh v gnh nng bnh tt da trn s liu nhn khu hc v cc nghin cu c tnh t
l mc, t vong do bnh tt ti tng quc gia.
Chuyn i m hnh bnh tt
S liu v gnh nng bnh tt tnh theo DALY cho thy c s bin i nhanh v m
hnh bnh tt v t vong Vit Nam t nm 1990 n nm 2010 (Hnh 11). Gnh nng bnh tt
do cc bnh truyn nhim, cc vn sc khe ca b m, giai on chu sinh v ri lon dinh
dng gim t 45,6% xung 20,8%. ng thi gnh nng bnh tt do cc bnh/chng bnh
khng ly nhim tng t 42% ln 66% tng s DALY. T trng gnh nng bnh tt do chn
thng tng i n nh, chim khong 13%.
24
Phn trm tng s DALY
Hnh 11: Xu hng m hnh bnh tt o lng bng DALY, 1990-2010

100%
Tai nn, ng c, chn thng
90%
80%
70%
Bnh khng ly nhim
60%
50%
40%
30%
20%
Bnh truyn nhim, vn sc khe
10%
b m, tr s sinh v ri lon dinh dng
0%
1990
2000
2010
Ngun: Global Burden of Disease Study 2010. Global Burden of Disease Study 2010 (GBD 2010) Results by Cause
1990-2010 - Vietnam Country Level. Seattle, United States: Institute for Health Metrics and Evaluation (IHME),
2013.
Hnh 12 trnh by c cu 3 nhm nguyn nhn gy t vong theo tng la tui cho
nam gii bn tri v n gii bn phi. BKLN chim t l ln nht trong tng gnh nng bnh
tt, nhng tp trung nhiu nht cc nhm tui t 40 tr ln. tr em di 5 tui, cc bnh
truyn nhim, bnh tt lin quan n chu sinh chim t l ln nht. Trong tui 15-59, gnh
nng bnh tt do tai nn thng tch v bnh truyn nhim nam gii quan trng hn so vi
n gii.
Hnh 12: C cu nguyn nhn t vong theo tui v gii, 2010
Nam
40%
30%
20%
10%
10%
20%
30%
80+ tui
75-79 tui
70-74 tui
65-69 tui
60-64 tui
55-59 tui
50-54 tui
45-49 tui
40-44 tui
35-39 tui
30-34 tui
25-29 tui
20-24 tui
15-19 tui
10-14 tui
5-9 tui
Di 5 tui
40%
Bnh truyn nhim, sc khe b m, chu sinh, ri lon dinh dng

Bnh khng ly nhim
Tai nn, chn thng
Ngun: Tnh ton t Global Burden of Disease Study 2010. Global Burden of Disease Study 2010 (GBD 2010)
Results by Cause 1990-2010 - Vietnam Country Level. Seattle, United States: Institute for Health Metrics and
Evaluation (IHME), 2013.
25

Nhm 1: Cc bnh truyn nhim, vn sc khe b m, giai on chu sinh v ri lon
dinh dng
Phn tch chi tit gnh nng bnh tt lin quan n Nhm 1 gm cc bnh truyn nhim,
vn sc khe b m, giai on chu sinh v ri lon dinh dng cho thy cc nhm nguyn
nhn quan trng nht l cc bnh truyn nhim thng thng, HIV/AIDS v bnh lao v cc
vn sc khe chu sinh (Hnh 13). C ba nhm ny c gnh nng do t vong sm cao. Nhm
bnh nhit i v ri lon v dinh dng c t l t vong thp nhng gy gnh nng bnh tt do
lm mt i thi gian sng khe mnh.
Hnh 13: Cc nguyn nhn gy gnh nng bnh tt trong nhm bnh truyn nhim, vn
lin quan sc khe b m, cc vn chu sinh v ri lon dinh dng, 2010
Bnh nhim trng khc
Ri lon v dinh dng
Lin quan tr chu sinh
Lin quan sc khe b m
Bnh nhit i
Bnh nhim trng thng thng
HIV/AIDS, bnh lao
YLL
YLD
500
1000 DALYs
1000
1500
Ngun: Tnh ton t s liu nghin cu Global Burden of Disease Study 2010. Global Burden of Disease Study
2010 (GBD 2010) Results by Cause 1990-2010 - Vietnam Country Level. Seattle, United States: Institute for Health
Metrics and Evaluation (IHME), 2013.
Mi bnh gy gnh nng bnh tt quan trng nht trong nhm cc bnh truyn nhim,
vn sc khe b m, tr chu sinh v ri lon dinh dng chim 65% tng s DALY ca c
nhm v 14% tng s DALY chung (Bng 1). Mt s bnh hin nay ang c u tin quan tm
nh nhim HIV, bnh lao. Mt s vn sc khe gy t vong tr chu sinh nh bin chng
do sinh non v ngt th khi sinh ang l nguyn nhn quan trng lin quan t vong tr s sinh
cn c quan tm nu mun t mc tiu ca K hoch 5 nm v Mc tiu Thin nin k. Mt
s bnh quan trng trong nhm ny hin nay cha c quan tm ng mc nh nhim trng
ng h hp di, giun sn, thiu mu do thiu st, tiu chy, vim no v vim mng no,
thng hn v ph thng hn.
Bng 1: Mi bnh c gnh nng bnh tt cao nht trong nhm bnh truyn nhim, vn
lin quan sc khe b m, giai on chu sinh v ri lon dinh dng, 2010
Tn bnh, vn sc kho
DALYs
% tng s DALYs
HIV/AIDS
618323
2,9%
Nhim trng ng h hp di
556658
2,6%
Bnh lao
473572
2,2%
Bin chng do sinh non
375116
1,8%
Giun sn
262435
1,2%
26
Tn bnh, vn sc kho
DALYs
% tng s DALYs
Thiu mu do thiu st
186271
0,9%
Ngt th trong khi sinh
162877
0,8%
Tiu chy
156402
0,7%
Vim no v vim mng no
93521
0,4%
10
Thng hn v ph thng hn
93340
0,4%
Tng s
14%
Trong 10 bnh gy gnh nng bnh tt ln nht thuc nhm 1, giun sn v thiu mu do
thiu st t gy t vong sm, nhng vn to gnh nng bnh tt do lm mt i s nm sng khe
mnh (Hnh 14). Vi 8 bnh cn li, gnh nng bnh tt lin quan n t vong sm, trong
mt s bnh cng c phn quan trng do lm mt i nm sng khe mnh nh bnh lao, bnh
no s sinh v tiu chy.
Hnh 14: S nm sng mt i do t vong sm v s nm sng tn tt ca 10 bnh gy
gnh nng bnh tt ln trong nhm 1 (2010)
1. HIV/AIDS
2. Nhim trng ng h hp di
3. Bnh lao
4. Bin chng do sinh non
5. Giun sn
6. Thiu mu do thiu st
7. Bnh no s sinh
8. Tiu chy
9. Vim no v vim mng no
10. Thng hn v ph thng hn
YLL
YLD
0%
1%
2%
Phn trm tng s DALY
Nhm 2: Cc bnh/chng bnh khng ly nhim
Phn ln trong s 10 nhm bnh thuc cc BKLN gy gnh nng bnh tt do lm tng
s nm sng tn tt, hay ni cch khc l lm mt i s nm sng kho mnh (Hnh 15). Tuy
nhin, 2 nhm bnh gy gnh nng bnh tt ln nht nhm ny l bnh ung th v tim mch,
to gnh nng bnh tt ch yu do t vong sm. Sau ung th v tim mch, 2 nhm bnh quan
trng khc thuc BKLN l bnh tm thn v xng khp, to gnh nng bnh tt ch yu do
lm mt i nm sng khe mnh, khng phi gy t vong sm.
27

Hnh 15: Gnh nng bnh tt ca cc nhm BKLN, 2010
Mng C
Xri-lanca
Phi-lp-pin
Pa-kt-xtan
Bu-tan
CHDCND Lo
n
Vit Nam
Ma-lai-xi-a
In--n-xi-a
Cam-pu-chia
Thi lan
T l hin nhim nam gii

15-24 tui (%)
T l hin nhim ph n
15-24 tui (%)
T l hin mc ngi ln
15-49 tui (%)
0,0
0,2
0,4
0,6
0,8
Phn trm
1,0
1,2
Phn tch c th hn cho thy 10 BKLN gy gnh nng bnh tt cao nht chim 45%
tng s DALY ca nhm v chim 30% tng s DALY chung (Bng 2). Hin nay, c cc d
n phng, chng bnh phi tc nghn mn tnh, ung th, bnh tim mch. Tuy nhin, cc da n
cha tp trung nhiu vo cc bnh gy gnh nng bnh tt cao nht nh tai bin mch mu no.
Cc ri lon tm thn nh trm cm d gy gnh nng bnh tt ln nhng cha c a vo
chng trnh mc tiu quc gia (CTMTQG) v bnh tm thn.
Bng 2: Mi nguyn nhn gy gnh nng bnh tt ln nht trong nhm BKLN, 2010
Tn bnh
DALYs
% tng s DALYs
1251750
5,9%
Tai bin mch mu no do xut huyt
Ri lon trm cm n cc
908353
4,3%
au vng lng di
855530
4,0%
Bnh phi tc nghn mn tnh
702332
3,3%
Ung th gan
552726
2,6%
Bnh tim thiu mu cc b
533058
2,5%
X gan
406724
1,9%
Ung th phi, ph qun, kh qun
395655
1,9%
au na u
384240
1,8%
10
au c
380054
1,8%
Tng s
30%
28

Trong 10 BKLN c gnh nng bnh tt cao nht, c 5 bnh/chng bnh gy gnh nng
ch yu do ngi mc bnh phi sng nhiu nm tn tt l trm cm, au vng lng di, bnh
phi tc nghn mn tnh, au na u v au c (Hnh 16). Cc bnh cn li gy gnh nng bnh
tt ch yu do ngi bnh t vong sm. Quan trng nht trong cc bnh ny l tai bin mch
mu no, chim khong 6% tng s DALY chung, ch yu l do t vong sm.
Hnh 16: S nm sng mt i do t vong sm v s nm sng tn tt ca 10 nguyn
nhn gy gnh nng bnh tt ln nht trong nhm BKLN, 2010
Mng C
Trung Quc
Phi-lp-pin
Ma-lai-xi-a
Cam-pu-chia
CHDCND Lo
In--n-xi-a
0
500
1000
1500
2000
2500
c tnh s bnh nhn st rt trn 100 000 dn
3000
Nhm 3: Tai nn, chn thng, ng c
Tai nn c ba nhm, trong gnh nng bnh tt ln nht l do tai nn, chn thng
khng ch nh khc ngoi tai nn giao thng. T gy hi v bo lc ng gp t hn vo gnh
nng bnh tt. Tai nn, chn thng ch yu gy t vong sm, nhng cng c mt s nht nh
gy gnh nng do sng tn tt (Hnh 17).
Hnh 17: Cc nhm nguyn nhn gy gnh nng bnh tt nhm tai nn, chn thng,
ng c, 2010
T gy hi v bo lc
Tai nn, chn thng khng ch
nh khc
Tai nn giao thng
0
YLL
500
YLD
1000
1500
1000 DALYs
Bng 3 cho thy 10 loi tai nn, chn thng c gnh nng bnh tt cao nht chim 75%
tng s DALY ca nhm ny v 9,7% tng s DALY chung. Quan trng nht trong nhm ny
l tai nn giao thng ng b, ui nc v ng.
29

Bng 3: Mi loi tai nn, thng tch gy gnh nng bnh tt cao nht, 2010
Loi tai nn, chn thng
DALY
% tng s DALY
Tai nn giao thng ng b
577920
2,7%
ui nc
376496
1,8%
Ng
359690
1,7%
T gy thng tch
223409
1,0%
Bo lc
141630
0,7%
Tai nn do tip xc vi lc c kh
108860
0,5%
Tc ng khng mong mun ca dch v y t
80052
0,4%
La, nhit v nng
77671
0,4%
Tai nn giao thng khng phi ng b
70528
0,3%
10
Ng c
65658
0,3%
Tng s
9,7%
Cc loi tai nn, chn thng c th ch yu gy gnh nng bnh tt do t vong sm

(Hnh 18). Tuy nhin nhm tai nn ng b, ng v tai nn giao thng khc cng c s nm
sng tn tt tng i cao. T gy thng tch (nh t t) ng th 4 trong cc nguyn gy gnh
nng bnh tt nhm ny, phn nh mt phn cc vn tm thn cha c x l trong x hi.
Hnh 18: S nm sng mt i do t vong sm v s nm sng tn tt ca 10 loi tai nn,
chn thng gy gnh nng bnh tt ln nht, 2010
1. Tai nn giao thng ng b
2. Cht ui
3. Ng
4. T gy thng tch
5. Bo lc
6. Tai nn do tip xc vi lc c kh
7. Tc ng khng mong mun ca DVYT
8. La, nhit v nng
9. Tai nn giao thng khng phi ng b
10. Ng c
YLL
YLD
0%
1%
2%
3%
Phn trm tng s DALY
4%
5%
Nguyn nhn gy gnh nng bnh tt khc nhau theo gii. Trong 10 nguyn nhn gy
gnh nng bnh tt ln nht, nam v n ch c chung 6 nguyn nhn l tai bin mch mu no,
30

au vng lng di, bnh phi tc nghn mn tnh, bnh tim thiu mu cc b, nhim khun
h hp di v trm cm. Cc nguyn nhn khc c gnh nng bnh tt cao nam gii l chn
thng t tai nn giao thng ng b, HIV/AIDS, ung th gan v x gan trong khi ph n
l au na u, au c, i tho ng v thiu mu do thiu st (Bng 4).
Bng 4: 10 nguyn nhn gy gnh nng bnh tt ln nht theo gii, 2010
Nam
%
DALYs
%
DALYs
Tai bin mch mu no do

xut huyt
6%
Trm cm
6%
Tai nn giao thng
6%

xut huyt
5%
HIV/AIDS
4%
au vng lng di
4%
au vng lng di
4%
4%
Ung th gan
3%
au na u
3%
3%
Nhim khun h hp di
3%
3%
au c
2%
Nhim khun h hp di
3%
i tho ng
2%
Trm cm
3%
Thiu mu do thiu st
2%
10
X gan
3%
10
2%
Tng s
37%
Tng s
29%
Ch thch: % DALY tnh ring theo tng gii.

Phn tch, so snh 20 nguyn nhn gy gnh nng bnh tt cao nht ca nm 1990 v
nm 2010 cng th hin s chuyn i m hnh bnh tt l tng BKLN v gim t l bnh
truyn nhim. Bng 5 th hin cc bnh Nhm 1 mu vng, Nhm 2 mu xanh v Nhm 3
mu xm. Xu hng v xp th t t nm 1990 n 2010 c th hin bng mi tn ct
gia. Trong 20 bnh gy gnh nng bnh tt ln nht, nm 1990 c 11 bnh thuc Nhm 1, n
nm 2010 ch cn 5 bnh thuc nhm ny. Cc bnh nm 1990 khng nm trong 20 bnh quan
trng nht n nm 2010 li rt quan trng l HIV/AIDS, ung th gan, x gan, ung th phi,
ph qun, kh qun, au na u, au c, i tho ng v ng. Mt s bnh trc y gy
gnh nng bnh tt ln, by gi gim quan trng hn nh di tt bm sinh, cc bnh phng
c bng vc xin, tiu chy, thiu mu do thiu st, vim mng no, bnh no chu sinh, suy
dinh dng protein-nng lng. Hu ht cc bnh ny u c chng trnh can thip hiu qu
nh tim chng, phng, chng suy dinh dng tr em, tng cng chm sc sc khe sinh sn
(CSSKSS), cp nc sch, v sinh mi trng ng gp vo gim gnh nng do cc bnh ny.
31

Bng 5: Xu hng 20 nguyn nhn gy gnh nng bnh tt ln nht, 1990-2010
Nguyn nhn gnh nng
bnh tt nm 1990
%
DALYs
Nhim khun ng h hp
di
8,1%

xut huyt
5,8%

xut huyt
4,4%
Tai nn giao thng
4,4%
4,0%
Trm cm
4,2%
D tt bm sinh
3,7%
au vng lng di
4,0%
Cc bnh tr em phng
c bng vc xin (bch
hu, ho g, un vn, si,
thy u)
3,7%
Bnh phi tc nghn mn

tnh
3,3%
Bnh lao
3,5%
HIV/AIDS
2,9%
Tiu chy
3,5%
Nhim khun ng h hp
di
2,6%
ui nc
3,1%
Ung th gan
2,6%
Thiu mu do thiu st
2,7%
2,5%
10
Trm cm
2,5%
10
Bnh lao
2,2%
11
Tai nn giao thng
2,4%
11
2,1%
12
Bnh phi tc nghn

mn tnh
2,4%
12
X gan
1,9%
13
au vng lng di
2,2%
13
Ung th phi, ph qun, kh

qun
1,8%
14
St rt
2,2%
14
au na u
1,8%
15
Vim mng no
1,7%
15
au c
1,8%
16
Bnh no chu sinh (do ngt

th, chn thng trong khi
sinh)
1,7%
16
ui nc
1,8%
17
Giun sn
1,6%
17
Giun sn
1,7%
18
Suy dinh dng protein

nng lng
1,5%
18
i tho ng
1,7%
19
1,4%
19
Ng
1,7%
20
Hen suyn
1,3%
20
Hen suyn
1,4%
Tng s
Nguyn nhn gnh nng

bnh tt nm 2010
57%
Tng s
%
DALYs
52%
32

1.3. Tnh hnh mt s bnh cn quan tm
1.3.1. Cc bnh dch
Nhiu dch bnh nguy him khng c th hin trong s liu v gnh nng bnh tt do
s mc v t vong khng ln, hoc do bnh c phng hiu qu bng vc xin v bin php y t
d phng khc, tuy nhin vn phi duy tr mc u tin cao v nhng l do nht nh. Cc bnh
dch c phn tch trong mc ny gm cc bnh mi ni, cc bnh phng c bng vc xin,
cc bnh c chin lc, k hoch loi tr v mt s bnh dch khc.
Cc bnh mi ni
Ton cu v Vit Nam c nhiu dch bnh mi, c nguy c tim n gy i dch do c
giao lu, i li gia cc quc gia ang c dch bnh, i hi phi gim st cht ch tnh hnh
ton cu, trong vng v trong nc, ti cc ca khu, u t nng lc (nhn lc dch t, labo xt
nghim,), xy dng v cp nht hng dn chn on v iu tr, thit lp c ch phi hp
vi b, ngnh lin quan v c k hoch can thip khi cn thit. Trong nhm bnh ny c c cc
bnh ly t ng vt sang ngi, bnh mi ni ton cu.
Dch cm
C mt s loi cm c bit nguy him v l bnh mi v c nguy c gy t l t vong
cao. Hai loi cm c dch ti Vit Nam l cm A (H5N1) v cm A (H1N1). Cm A (H7N9)
ang c dch ti Trung Quc, nhng Vit Nam cha c trng hp no. Nm 2014, trng
hp nhim cm A (H5N6) u tin ngi c pht hin Trung Quc trong khi cm A
(H5N6) c pht hin trn gia cm mt s tnh ca Vit Nam.
Nm 2009, T chc Y t Th gii (WHO) thng bo c i dch cm A (H1N1) ngun
gc t ln. Theo s liu ca WHO, nm 2009 Vit Nam c 685 trng hp mc v 50 trng
hp t vong (Bng 6). S ca mc nm 2010 gim cn 92, n nm 2011 li tng ln 685. Nm
2013 c 341 ca mc v 35 tun u ca nm 2014 c 82 ca. Cc trng hp t vong ch yu
do c bnh mn tnh km theo.
Cm A (H5N1) xut hin t nm 2003. Mi nm t nm 2009 n 2014 ch c di 10
ca c xc nhn bng xt nghim. Cc trng hp mc v t vong u c tin s tip xc vi
gia cm m, cht, tuy nhin khng c lin quan dch t vi nhau. Cha ghi nhn ca bnh ly
truyn t ngi sang ngi.
Bng 6: Tnh hnh dch cm, 2007-2014
Loi cm n v 2007 2008 2009
Cm A
(H1N1)
Cm A
(H5N1)
2010
2011 2012 2013
2014
(35 tun)
Ngun
S mc
685
92
685
341
82
WHO-Flunet (theo
kt qu xt nghim)
S t
vong
50
11
B Y t
(theo bo co)
S mc
B Y t
(theo bo co)
S t
vong
B Y t
(theo bo co)
Ch thch: -: Thiu thng tin.
33

Bnh do vi rt MERS-CoV
Bnh do vi rt MERS-CoV c kh nng ly truyn t ngi sang ngi ch yu trong
nhm ngi c tip xc gn. Ngi mc bnh c triu chng vim ng h hp cp tnh: st,
ho, vim phi nng v nhanh chng dn n suy h hp cp. Ngoi ra, c th km theo cc triu
chng ng tiu ha nh tiu chy v c th gy suy tng c bit l suy thn, nguy c t
vong cao. Theo WHO, tnh n ngy 21/11/2014, trn ton cu ghi nhn gn 909 ngi mc
vi 331 ngi t vong ti 20 quc gia. Tt c trng hp mc u c lin quan v xut pht t
6 nc ti bn o -rp. Hin nay, Vit Nam cha ghi nhn trng hp no. B Y t ban
hnh K hoch hnh ng phng chng Hi chng vim ng h hp vng Trung ng do
MERS-CoV.
Bnh do vi rt Ebola
Theo nhng thng k mi nht t WHO, n ngy 21/11/2014, t dch Ebola ln ny l
ln nht trong lch s cc nc Ty Phi. WHO ang theo di st sao din bin ca i dch v
cng b tnh trng khn cp v Ebola trn ton th gii. S ngi t vong ln 5459 trong
tng s 15351 trng hp nhim bnh (bao gm c cc trng hp c xc nhn, nhng
trng hp nghi ng v nhng trng hp c kh nng), ch yu Cng ho Ghin, Libria,
Xira Ln v Nigeria. Vi tnh hnh cng thng hin ti, WHO khuyn co cc nc nu c
cng dn qua 4 nc chu Phi ang c i dch trn cn phi c kim tra y t ngt ngho
trc khi xut nhp cnh. iu ny c th gip lm hn ch ti a mc ly lan ca dch bnh.
Vit Nam cnh bo ngi dn trn cc phng tin truyn thng i chng v ln cc
phng n chun b phng chng dch, trin khai cc bin php gim st cht ch ngi nhp
cnh ti cc ca khu, sn bay v trin khai cc bin php d phng, nht l nhng ngi t
cc nc c dch tr v. Bn cnh vic gim st cht ch ti cc ca khu, cc tnh hung dch
cng c a ra, phc iu tr bnh Ebola cng c ban hnh, sn sng p ng iu tr
ngay khi c bnh nhn u tin.
Hi chng vim da dy sng bn tay, bn chn
K t lc pht hin ca bnh u tin ngy vo thng 4/2011, n nay trn a bn tnh
Qung Ngi pht hin 231 trng hp mc hi chng vim da dy sng bn tay, bn chn
ti 7 x ca 2 huyn Ba T, Sn H. u nm 2014 n nay, c mt ca ti pht v mt ca bnh
mi [10]. S Y t Qung Ngi ch o tng cng cng tc tuyn truyn, vn ng, c bit l
khm sng lc thng xuyn sm pht hin ca bnh mi v iu tr kp thi, hn ch nguy
c t vong cho ngi bnh. B Y t xy dng hng dn chn on v iu tr.
Cc bnh dch c th phng bng vc xin
Tim vc xin phng bnh l mt bin php y t d phng hiu qu nht v l bin php
quan trng loi tr bnh trong x hi nh bnh bi lit v un vn s sinh. Nm 1985, Vit
Nam trin khai Chng trnh Tim chng m rng (TCMR) vi 6 loi vc xin phng bnh
Lao, Bch hu, Ho g, Un vn, Si, Bi lit. Nm 1997, bn vc xin mi c trin khai
min ph trong Chng trnh TCMR ca Vit Nam l: vc xin vim gan B cho tt c cc tr
s sinh v vc xin vim no Nht Bn B, thng hn v t cc vng c dch. Thng 6/2010,
vc xin H. Influenzae B (Hib) phng cc bnh vim phi nng v vim mng no m do H.
Influenzae B trong thnh phn vc xin phi hp DPT-VGB-Hib c trin khai trn ton quc,
nh vy c 11 vc xin trong Chng trnh TCMR c cp min ph Vit Nam. Ngoi ra, cn
34

c mt s vc xin phng bnh khc c th tim/ung nhng khng c nh nc tr cp nh
vc xin phng bnh rubella, no m cu1, ph cu khun2, thy u, vi rt Papilloma ngi
(HPV), cm ma, Bn cnh , c mt s vc xin phng bnh ng vt c tc ng quan
trng trong phng bnh ngi nh tim phng di, cm ng vt do ngnh nng nghip v
pht trin nng nghip ph trch.
Gnh nng bnh tt tr em di 5 tui lin quan n mt s bnh c th phng bng
vc xin gim ng k t nm 1990 n nm 2010 (Hnh 19). Bn tri l cc bnh c vc
xin min ph nhiu nm, bn phi l mt s bnh cha trin khai vc xin trong Chng trnh
TCMR. C hai nhm bnh u th hin s gim i trong gnh nng bnh tt v ngoi vc xin,
cn nhiu yu t khc tc ng ti sc khe nh gim suy dinh dng tr em, tng t l tip cn
nc sch, v sinh v tng kh nng tip cn vi dch v y t ni chung.
Hnh 19: Gnh nng bnh tt tr em di 5 tui do cc bnh phng c bng
vc xin, 1990-2010
1 200 000
1990
1 000 000
2010
DALY
800 000
600 000
400 000
200 000
Vi
n
ga
r
vi
Bnh si
Si l mt bnh c kh nng ly nhim cao, do tip xc vi ngi bnh qua ho v ht
hi. Khi mt ngi mc si, 90% ngi tip xc mt thit s b ly bnh si nu h cha c
min dch thu c qua mc bnh si hay c tim vc xin si trc . Triu chng chnh
ca si l st cao, ni ban v ho. Vi rt si lm gim h thng min dch ca c th v dn
n cc nhim trng th pht nh vim phi, mi, m la, tiu chy v vim no. Khong hn
30% cc ca mc si c mt hay nhiu bin chng.
Ti Vit Nam, t gia nm 2013 tnh n thi im 18/6/2014, c nc ghi nhn 31,3
nghn trng hp st pht ban nghi si vi 5,5 nghn ca dng tnh vi si, trong 145 ca t
vong lin quan n si [11]. Bnh xy ra ch yu nhm i tng di 10 tui cha c
tim vc xin si ti nhng ni c t l tim chng vc xin si t thp trong nhng nm trc
y, v nhng vng c bin ng dn c cao. B Y t v ang trin khai k hoch tim vt
1
2
No m cu c tn khoa hc l Neisseria meningitidis hoc meningococcus

Ph cu khun c tn khoa hc l Streptococcus Pneumoniae hoc pneumococcus
35

vc xin si. i tng tim vt l tim mi mt cho tr t chn thng n hai tui cha c
tim vc xin si, tim mi hai cho tr t 18 thng n hai tui tim mt mi vc xin si.
bo m khng b b st, cc a phng ang r sot danh sch tt c cc i tng cn c
tim trn a bn, k c i tng vng lai; ch trng vng su, vng xa, vng gip ranh v ni
c bin ng dn c.
Bnh Rubella
Rubella l bnh truyn nhim cp tnh thng khng c bin chng nng, tuy nhin
nhim rubella khi mang thai, c bit trc 12 tun thai nghn c th dn n di tt bm sinh
nng do hi chng rubella bm sinh.
Theo bo co cha y , tng s ca mc rubella c tng so vi s mc trung bnh 5
nm va qua. Ti mt s bnh vin nhi, s tr b nhim Hi chng rubella bm sinh cng c xu
hng tng hn so vi mi nm. Vit Nam, t nm 2004-2011 lin tc ghi nhn cc v dch
Rubella vi tng s trn 3500 trng hp. Trong s cc tr mc hi chng Rubella bm sinh c
ti trn 90% tr mc cc d tt phc tp nh hng n sc khe ca tr nh cc d tt bm sinh
v tim, c thy tinh th, lch to, gan to, ic v chm pht trin tr tu.
Nhm gim gnh nng bnh tt ca hi chng Rubella bm sinh, tin ti loi tr bnh
Rubella trong tng lai, t nng cao th cht ca tr em Vit Nam, Chng trnh TCMR
Vit Nam ang trin khai chin dch tim vc xin si v rubella min ph t thng 10/2014 n
thng 2/2015 cho khong hn 23 triu tr t 9 thng n 14 tui trong ton quc.
Bnh phi, vim mng no v tiu chy do vi trng v vi rt
Cc loi vi trng Streptococcus pneumoniae (ph cu khun), Haemophilus influenzae
v Neisseria meningitidis (no m cu) l nguyn nhn ch yu gy vim phi, vim mng
no. Vi rt Rota l nguyn nhn quan trng gy tiu chy tr em. C 4 loi vi trng/vi rt ny
u c vc xin, nhng hin nay Vit Nam cha a nhng vc xin ny vo Chng trnh
TCMR, ch cc gia nh c iu kin kinh t c kh nng tip cn vc xin theo dch v v phi
tr ph.
Vit Nam, theo s liu thng k cc c s y t cng lp, nhim khun h hp cp
tnh tr em l nguyn nhn cao nht n khm bnh v vo iu tr ti cc bnh vin v l
mt trong cc nguyn nhn gy t vong cao tr em. Trong cng ng, hng nm trung bnh
tn sut mc nhim khun h hp cp tnh ca mi tr t 4-5 ln. Vi khun hay gp nht trong
vim phi mc phi cng ng tr em l ph cu khun chim ti khong 30-50% trng
hp. H. influenzae tp B l nguyn nhn vi khun ng hng th 2 chim khong 10-30% [12].
Vim mng no m l tnh trng nhim trng mng no do mt s loi vi trng gy ra
trong c 3 loi vi trng thng gp l: vi trng Hemophilus influenza tp B (Hib), no m
cu v ph cu khun. Vit Nam, tc nhn gy vim mng no m tr em ch yu do vi
trng Hib [13].
Theo thng k y t ti Vit Nam, tc nhn gy tiu chy cp nhp vin thng gp nht
l vi rt Rota vco n 95% tre em bi nhim vi rt Rota it nht mt ln trc 5 tui[14].
Theo nghin cu gnh nng bnh tt ton cu nm 2010, c tnh Vit Nam c 261 tr
em di 5 tui t vong do vim mng no lin quan 3 vi trng trn. Cng nm, c 3139 tr em
t vong do vim phi v 470 tr em t vong do tiu chy. Cho n nay, khng c thng tin gim
st v t l mc nhng bnh ny trong cng ng.
36

Dch tiu chy cp nguy him (t)
Sau nhiu nm c khng ch, dch t bng pht tr li vo nm 2007 vi t l mc
l 2,24/100000 dn. Trong giai on t nm 2000-2009, min Bc ghi nhn tng s 8304
ca mc t, tng ti 6 ln so vi giai on t 1990-1999 (1194 ca). Ring nm 2010, c nc ghi
nhn 317 trng hp t (khng c t vong) ti 18 a phng; trong 301 trng hp l ngi
Vit Nam v 16 trng hp l ngi Cam-pu-chia. T cui nm 2012 n u nm 2014, Vit
Nam khng ghi nhn trng hp mc bnh t, nhng hin nay ti TP H Ch Minh ghi nhn
mt s trng hp mc tiu chy cp nghi t. Vic gim st cc trng hp tiu chy cp c
thc hin thng xuyn trn phm vi c nc. Tiu chy l nguyn nhn th 7 gy gnh nng
bnh tt i vi tr em di 15 tui [15].
Mt s bnh truyn nhim c k hoch loi tr hoc thanh ton
Mt s bnh c tim nng loi tr Vit Nam. Vit Nam thanh ton bnh bi lit t
nm 1997, loi tr bnh un vn s sinh t nm 2005 v ang c cc k hoch loi tr mt s
bnh khc nh bnh phong v vim no Nht Bn (2015), bnh si (2017), bnh di (2020) v
bnh st rt (2030) [16]. Bnh vim no Nht Bn v bnh si c phn tch trong mc v
cc bnh phng nga bng vc xin. Mc ny phn tch v tnh hnh bnh phong, bnh st rt,
bnh st xut huyt.
Bnh phong
Bnh phong l mt bnh nhim trng mn tnh gy ra bi trc khun phong (Mycobacterium
Leprae). Bnh phong khng phi l bnh di truyn, khng gy cht ngi, tuy nhin nu khng
c pht hin v iu tr kp thi, bnh c th li nhng tn tt, di chng trm trng. Chnh
nhng tn tt ny lm cho ngi ta s hi v quan nim sai lm v bnh phong. Vit Nam ang
n lc trong vic tin ti loi tr bnh phong.
Nm 2000, s bnh nhn phong mi l 1477, n nm 2012 ch c 296 ngi mi pht
hin bnh phong mi. T l tn tt 2 trn bnh nhn phong mi nm 2000 l 21%, n nm
2012 gim xung cn 14,86% [17]. Tnh n cui nm 2013, c nc c 52/63 tnh3
kim tra/phc tra loi tr bnh phong theo 4 tiu chun ca Vit Nam. Cc tnh cn li cha tin
hnh cng nhn loi tr l Qung Ngi, Bnh nh, An Giang, Kin Giang, Bnh Phc, Ty
Ninh, TP H Ch Minh, Ninh Thun, Bnh Thun, Gia Lai, Kon Tum.
Trn thc t, bnh phong c th c cha khi hon ton v khng li di chng tn
tt nu ngi bnh c khm pht hin sm v iu tr kp thi. Tuy vy, cng tc khm tm
sot bnh phong cho cng ng li khng d thc hin, c th b st bnh nhn. khng nh
khm pht hin ht bnh nhn phong trong cng ng cn phi khm ton da cho t nht 20%
dn s lin tc trong 3 nm. Thnh kin v bnh phong vn cn nng n, trong khu vc c nhiu
dn tc, ngn ng khc nhau, tp qun khc nhau gy khng t kh khn cho cng tc tuyn
truyn gio dc y t v bnh phong cho cng ng.
Bnh di
Bnh di l bnh do vi rt di (rabies vi rt) gy nn. y l mt bnh truyn nhim vi
rt cp tnh ca h thn kinh trung ng dn n t vong chc chn.
3
Bao gm c 58 tnh v 5 thnh ph trc thuc trung ng.
37

Vit Nam l mt trong nhng quc gia c WHO xp trong nhm cc nc c nguy c
cao nhim bnh di. Theo nghin cu, t l t vong do bnh di Vit Nam ng th 14 trn th
gii. Nm 2011, c 110 trng hp, nm 2012 c 98 trng hp, nm 2013 c 102 trng hp
t vong do bnh di. Bnh di rt nguy him v khi b ln cn di th t l t vong l 100%.
Ngi b ng vt nghi di cn cn c iu tr d phng khn cp bng vc xin v
huyt thanh khng di cng sm cng tt. Nm 2000, tng s ngi b ng vt cn phi tim
vc xin di ln 568166 ngi, n nm 2011 gim nhng vn cn mc cao vi 394300
ngi [18]. Trong 5 thng u nm 2014, c 160731 b ch cn v 28 ngi t vong do
bnh di. Chi ph ngi dn tr tin tim vc xin v huyt thanh iu tr d phng bnh di ln
ti hn 300 t ng mi nm. Cc trng hp t vong do bnh di xy ra ch yu min Bc,
chim khong 80%. Theo iu tra, trong s cc trng hp t vong do bnh di th c hn 50%
l do ngi dn ch quan, bit b ch cn cn phi i tim phng nhng vn khng i tim vi
suy ngh chc con ch khng b bnh. Ch c hn 20% ngi khng hiu bit v bnh di,
ch yu nng thn do nhn thc km [19]. B Nng nghip v pht trin nng thn ph trch
Chng trnh quc gia khng ch v tin ti loi tr bnh di giai on 2011-2015 vi cc can
thip v qun l n ch, loi tr bnh di ng vt qua tim phng (Quyt nh 2731/QBNN-TY ngy 7/11/2011).
Bnh st rt
Bnh st rt l mt chng bnh gy ra bi k sinh trng Plasmodium, ly truyn t ngi
ny sang ngi khc qua trung gian mui t. Plasmodium falciparum l chng c kh nng
gy st rt c tnh v a khng thuc, chim 55-60% trng hp st rt Vit Nam. Nhng
ngi b st rt th no thng th hin cc triu chng thn kinh nh hnh vi bt thng, run
git nhn cu hoc hn m.
Tnh hnh st rt Vit Nam c ci thin ng k; t thi k bng n st rt (19911992) c trn 1 triu ngi mc st rt, n nm 2013 c di 30000 ngi mc st rt [20]
v 6 trng hp t vong do st rt. Dch st rt c bn c khng ch, bnh st rt ang tng
bc c y li.
Tuy nhin, cc thnh qu nu trn cha thc s c tnh bn vng do k sinh trng
P.falciparum khng thuc chng st rt; mui trnh hoc nhn ha cht dit cn trng, mng
li y t c s cha kim sot ht c bnh nhn st rt; cc nhm dn di bin ng vo vng
st rt ln ngoi tm kim sot ca mng li y t v cha c bin php phng chng st rt
kh thi cho nhng nhm dn ny; ng bo dn tc thiu s, vng su, vng xa cha c thc
t phng chng st rt. c tnh vn cn 34 triu dn sng trong vng c nguy c st rt, trong
gn 11 triu ngi sng vng c nguy c cao mc st rt, nht l cc vng rng ni,
vng ven bin nc l, vng dn tc t ngi, vng su, vng xa, vng bin gii. (Xem chi tit
Chng II, mc 3 v nh gi tin thc hin Mc tiu Thin nin k).
St xut huyt (SXH)
St xut huyt Dengue v biu hin nng n nht ca bnh l Hi chng sc Dengue
c gy nn bi mt trong bn loi huyt thanh vi rt gn gi nhng li khc nhau. Nhim mt
loi vi rt c kh nng to nn min dch sut i nhng ch chng li chnh loi huyt thanh
vi rt m thi. Chnh v vy m nhng ngi sng trong vng lu hnh dch SXH Dengue
38

c th mc bnh nhiu hn mt ln trong i. Nhim vi rt Dengue c th ch biu hin nh
mt hi chng nhim vi rt khng c hiu hoc bnh l xut huyt trm trng v a n t
vong. Trong nhng nm gn y, bnh tr thnh mi quan ngi ln i vi sc khe cng
ng ton cu. S lan trn v mt a l ca c vc t truyn bnh l mui v vi rt a n
s tng cao t l bnh trong vng 25 nm qua cng nh kh nng xut hin dch do nhiu loi
huyt thanh khc nhau cc th trong vng nhit i.
Tnh hnh nhim st xut huyt Vit Nam khng n nh; dch st xut huyt thng
xy ra theo chu k t 3 n 5 nm mt ln. T l mc st xut huyt trn 100000 dn dao ng
148,1 nm 2010, 80,4 nm 2011, 94,2 nm 2012 v 91,6 nm 2013. Nm 2010, c 113 ngi
t vong do st xut huyt, n nm 2013 s t vong khong 60 ngi [20]. Trn 85% ca mc
v 90% ca t vong do st xut huyt l cc tnh min Nam Vit Nam. Khong 90% s ca t
vong do st xut huyt l nhm tui di 15. Vit Nam thnh cng trong kim sot t l t
vong do st xut huyt. T nm 2005 n nay, t l t vong trn bnh l di 1/1000 ca bnh.
Tuy nhin, Vit Nam vn cha t nhiu thnh cng trong vic gim s ca mc st xut
huyt. Ti Vit Nam, tnh trng thiu ngun cung cp nc sch ng tin cy vng nng thn,
iu kin nh thiu v sinh cng vi thiu cung cp nc v h thng x l nc thi km
cc vng ven ang m rng nhanh chng ng ngha vi vic ngi dn phi tr nc trong
hoc gn nh s dng. iu ny cng lm tng mt vector truyn bnh st xut huyt.
Tnh hnh dch t cng tr nn xu thm bi hn ch ca h thng y t trong vic duy tr kim
sot s lan truyn ca mui Aedes aegypti.
HIV/AIDS
S ngi hin nhim HIV/AIDS c tnh trong cng ng nm 2014 l khong 260000
ngi. c tnh mi nm c khong 12 000-14000 ngi mi nhim HIV [21]. S t vong c
tnh nm 2014 l 2000-3000, gim nhiu so vi mc 7000-8000 nm 2009. Hnh thi ly truyn
HIV qua ng tnh dc trong s nhim mi c xu hng ngy cng tng, t 20% nm 2007 ln
n 45% nm 2013. Trong giai on 2007-2013, t trng ca nhm tui 20-29 trong s ngi
nhim HIV/AIDS gim t 50,8% xung cn 32,9%, trong khi nhm tui 30-39 tng tng ng
t 32,5% ln 45,1%. T l ph n trong nhm i tng mi nhim HIV tip tc gia tng, t
24,2% nm 2007 ln 32,5% nm 2013 [22] (xem thm chi tit mc phn tch tnh hnh thc
hin Mc tiu Thin nin k di y).
Bnh lao
T l mi mc bnh lao c tnh c xu hng gim dn qua thi gian. Tuy nhin, t l
pht hin lao hu nh khng thay i, thm ch c tng ln trong nhng nm gn y (Hnh 20).
Nu s c tnh ng, iu ny c ngha l t l ngi mc lao c pht hin ang tng nhanh,
l mt iu kin thit yu cho s thnh cng trong vic gim dch lao v nhng trng hp mc
lao cha c pht hin tip tc truyn bnh cho ngi khc.
39

Hnh 20: Xu hng t l mi mc lao theo c tnh v t l c pht hin, 1990-2012
S mc lao trn 100 000 dn
400
350
300
80%
T l pht hin cc
trng hp mc
bnh lao
T l mi mc
lao c tnh
70%
60%
250
50%
200
40%
150
30%
100
20%
T l pht hin mc lao
50
0
10%
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
0%
Ngun: T l mi mc lao c tnh ly t s liu ca WHO. T l pht hin mc lao c bo co ly t B Y t,

Nin gim thng k y t. T l mc lao c pht hin tnh bng s mc c bo co chia cho s mc c tnh.
Trong tng s ngi pht hin mc lao, t l iu tr khi tng i cao i vi nhm
mc lao phi mi. Nhng i vi nhm ti pht bnh, thng l nhm mc lao a khng thuc
kh iu tr. Theo s liu c tnh ca WHO, t l ngi mc lao t vong trong mt nm l 9%,
t l ny rt cao so vi cc nc khc trong khu vc.
Mt s bnh truyn nhim gy gnh nng bnh tt ln
Giun sn
Bnh k sinh trng (nh sn l, giun a, giun ln, giun mc, giun tc, giun kim,) l
vn y t cng ng ph bin rng ri Vit nam, ng th 5 v gnh nng bnh tt, ch yu
do gy ra s nm sng tn tt. Hu ht cc iu tra t trc n nay Vit Nam cho thy t l
nhim giun sn khc nhau gia cc vng, min trong min Bc c t l nhim giun, sn
cao hn min Nam (dao ng t 10-90%). c bit l bnh giun mc gy thiu mu ngi.
Giun mc lu hnh cao trn ton quc, t l nhim ty thuc th nhng, ng bng sng Hng
(30%), min ni pha Bc (85%), Ty Nguyn (47%), min Nam (68%), thp nht ng bng
sng Cu Long (10%). Giun, sn c th gy nhng hu qu cp tnh nh au, tc rut, thiu
mu, thiu nc, hoc di hn nh suy dinh dng, chm pht trin th cht, thiu vi cht, mt
mi, chm pht trin tr tu, sinh ra thiu cn. Sn l c th gy bnh nng gan, phi, no.
Bnh k sinh trng truyn ly gia ngi v ng vt (nh hi sn, ln) ng vai tr
quan trng vi t l nhim cao v l gnh nng bnh tt cho cng ng. Bnh giun truyn qua
t c mc lu hnh cao trn ton quc. iu kin thun li cho s pht trin giun, sn l
thiu v sinh trong ch bin thc phm, thiu ngun nc sinh hot, n ung sch, do iu kin
v sinh mi trng v v sinh c nhn km, tp qun n ra sng, n thc n sng cn ph bin
Vit Nam, nn nguy c nhim bnh k sinh trng truyn qua thc n l rt cao v vi phm
vi rng khp trn c nc. V vy, bnh k sinh trng truyn ly gia ngi v ng vt vn l
40

vn bc xc hin nay Vit Nam hin nay [23]. Cn c nhng nghin cu ton din v su
hn v vn ny.
Vim gan
Vim gan l bnh nhim trng do vi rt tn cng gan v c th gy vim gan cp tnh
(vim gan A v E) v mn tnh (vim gan B, C v D). Vit Nam, s ngi mc vim gan
B mn tnh nm 2005 l 8,4 triu ngi, d bo n nm 2025 l 8 triu ngi, v t vong l
40000 ngi [24]. Vim gan B v C, cng nh HIV, ly truyn qua tip xc vi mu hoc cc
cht dch khc ca c th ngi b nhim bnh. Vim gan A v E ly truyn qua nc v thc
phm nhim vi rt v tc ng ti sc khe nh hn. Kh nng nhim vi rt vim gan B tr
thnh mn tnh ph thuc vo tui lc b nhim bnh. Nhim vi rt vim gan B tr di 6
tui rt d tr thnh mn tnh: 80-90% tr s sinh b nhim vi rt vim gan B s tr nn nhim
vi rt mn tnh, 30-50% tr b nhim vi rt vim gan B trc 6 tui s tr nn nhim vi rt mn
tnh. Mc nghim trng ca vim gan B v C dao ng t mt bnh nh, ko di mt vi tun
n tnh trng nghim trng lu di c th dn n x gan hoc ung th gan.
Vc xin vim gan B c s dng t nm 1982. Hiu qu ca vc xin vim gan B t
95% trong ngn nga ly nhim v cc hu qu mn tnh ca n. Cha c vc xin phng vim
gan C, nhng c th iu tr bng thuc khng vi rt, song vic tip cn iu tr Vit Nam cn
hn ch.
Bnh tay-chn-ming
Theo bo co gim st ca cc Vin V sinh Dch t/Pasteur nm 2010, c nc ghi nhn
18 781 trng hp mc tay chn ming ti 47 a phng trong c 52 trng hp t vong
ti 10 tnh, thnh ph trc thuc Trung ng. Bnh tp trung ch yu nhm 1-3 tui. y l
bnh mi v gy nguy him cho tr em. Nm 2013, ghi nhn 37788 trng hp mc, 13 trng
hp t vong. So vi cng k nm 2012, s mc gim 40,57%, s t vong gim 63,89%. Tnh t
u nm 2014 n thng 5/2014, c nc ghi nhn hn 17410 trng hp mc tay chn ming,
trong c 2 trng hp t vong.
1.3.2. Vn sc khe lin quan thi k thai nghn v chu sinh

Bin chng do sinh non (trc 37 tun thai nghn) l nguyn nhn t vong tr em quan
trng ton cu. Nhng tr sng st thng gp nhng kh khn do tn tt, chm pht trin tr
tu, ri lon thnh gic v tm nhn. Mt s nguyn nhn gy sinh non l sinh i, sinh ba,
nhim khun ng sinh sn, bnh mn tnh nh i tho ng, tng huyt p sn ph.
Khong 75% tr em sinh non c th c cu sng vi nhng can thip kh thi v
hiu qu chi ph nh iu tr corticoid trc sinh (tim cho ngi m c nguy c sinh non
cng c phi bo thai), chm sc con kiu kangaroo4, v iu tr nhim khun tr s sinh
bng khng sinh.
Vit Nam, nm 2010, c khong 43% tr chu sinh (t 0-6 ngy) t vong do sinh non.
Bin chng do sinh non l nguyn nhn t vong ca 16% tr em di 5 tui.
Phng php chm sc c s dng khi mt em b sinh non hoc thiu cn c p st vo thn ca ngi
m, da k da, c gi m v cho b thng xuyn.
41

D tt bm sinh
D tt bm sinh c th dn n t vong hoc tn tt vnh vin. Ph bin nht trong cc
d tt bm sinh nng l tt tim bm sinh, khuyt tt ca ng thn kinh v Hi chng Down, gy
gnh nng cho c nhn tr, gia nh v x hi. Nhiu d tt bm sinh c th phng c qua tim
vc xin Rubella, iu tr bnh giang mai ngi m, bo m ngi m ung axit folic v
iod khi mang thai, thn trng khi s dng thuc hoc tip xc ha cht trong thi k mang thai,
khm thai y , trnh sinh con khi cao tui, trnh kt hn cn huyt thng.
Ngt th v sang chn khi sinh
Ngt th v sang chn khi sinh l nguyn nhn quan trng nh hng ti t vong chu
sinh hoc nhng tn thng vnh vin nh bi no, t mu ni s v xut huyt. Nhng yu t
lin quan sang chn i vi tr chu sinh bao gm bt cn xng u-chu, sinh qu nhanh, sinh
qu chm, sinh ngc, c can thip gic ht, fooc-xp, m ,
Can thip hi sc tr chu sinh ngt th c th lm gim t sut t vong. Dng c c bn
cn thit can thip bao gm dng c ht nht v dng c gip th (bng gip th, mt n s
sinh), nhng quan trng nht l cn b c kin thc v k nng cn thit hi sc tr
chu sinh. Phng sang chn bng o to l thuyt v thc hnh k nng cho cn b y t
bit x l trng hp kh v vn chuyn sn ph n c s y t c kh nng can thip
khi cn thit. Ngoi ra, tim Vitamin K ngay sau khi sinh c th gim xut huyt tr chu sinh.
1.3.3. Chn thng
Tai nn ng b
Theo thng k ca Cc Cnh st giao thng ng b - ng st (C67), trong nm
2013, c nc xy ra 31266 v tai nn giao thng, lm cht 9805 ngi, b thng 32253
ngi (bao gm c ng b, ng st, ng thy v ng hng khng). So vi cng k
nm 2012 gim 5008 v (gim 13,8%), tng 44 ngi cht (tng 0,45%), gim 6229 ngi b
thng (gim 16,18%). Ring tai nn giao thng ng b xy ra 30874 v, lm cht 9627
ngi, b thng 31982 ngi. So vi nm 2012 gim 4946 v (gim 13,8%), tng 87 ngi
cht (tng 0,91%), gim 6188 ngi b thng (gim 16,21%). Trong , tai nn giao thng c
bit nghim trng xy ra 58 v, lm cht 219 ngi, b thng 203 ngi. Va chm giao thng
xy ra 19479 v, lm b thng 23968 ngi [25].
Vai tr ca ngnh y t trong tai nn giao thng tp trung vic s cu, a n c s y
t v cha kp thi. Hin nay, thiu thng tin v hot ng xe cp cu trong vic tc ng ti t
vong do tai nn giao thng. Ban An ton giao thng thnh ph H Ch Minh va cng b kt
qu ti nghin cu khoa hc v an ton giao thng thc hin cng Bnh vin Ch Ry. Qua
cho thy vi cc nn nhn b tai nn giao thng c ch nh can thip phu thut, bnh nhn
c thi gian vng (t lc xy ra tai nn giao thng n lc c can thip ca nhn vin y t)
nh hn hoc bng 12 gi th c c hi sng cao gp gn 2,6 ln so vi cc nn nhn c cp
cu mun. Nghin cu cng cp ti thnh ph H Ch Minh, phng tin vn chuyn nn
nhn b tai nn giao thng t hin trng n Bnh vin Ch Ry ch yu l xe gn my, cho
thy s x tr nhanh. Tuy nhin, cc bc s cng cnh bo xe my l phng tin vn chuyn
khng an ton i vi bnh nhn b tn thng vng ct sng, nht l ct sng c. Do , nu
trc khi a i cp cu m khng c s cu ng cch s khin tnh trng chn thng thm
trm trng [26].
42

ui nc
Hng nm Vit Nam c khong 3500 tr em cht do ui nc. Rt nhiu v tr ui
nc (c bit l tr di 10 tui) l do b m bt cn, thiu s gim st cn thit bo m
an ton cho tr. Phn ln cc trng hp ui nc l do cc em khng bit bi, k c nhng
vng sng nc. ng bng sng Cu Long l khu vc nm no cng c nc ngp hng thng,
nhng ch 35 - 36% tr em 12 n 15 tui bit bi. T l ny khu vc min Bc thm ch
thp hn nhiu - di 10% tr bit bi. Hn na, ngay c tr bit bi cng c th cht ui v
thiu hiu bit v k nng chng ui nc. Trong nhng nm qua, c nhiu gii php can
thip nhm hn ch tnh trng tr ui nc nhng kt qu cha c nh mong mun. H
thng truyn thng thng xuyn c cnh bo tai nn ui nc nhng cc thng tin ny cha
n c i tng nguy c cao, c bit l ngi ngho. Gii php truyn thng hiu qu l
thng qua cng tc vin hot ng trong lnh vc bo v chm sc tr em ti cng ng, nhng
lc lng ny cn mng. a gio dc k nng bi vo cng ng thng qua t chc on
Thanh nin Cng sn H Ch Minh v h thng trng hc ang l gii php c k vng.
Va qua, Cc Bo v Chm sc tr em, B Lao ng - Thng binh v X hi phi hp vi
V Cng tc hc sinh sinh vin, B Gio dc v o to xy dng l trnh nm 2015 a b
mn bi vo chng trnh bt buc dnh cho hc sinh ph thng [26].
2. Cc yu t nh hng ti sc khe
Tnh trng sc khe ph thuc vo rt nhiu yu t khc nhau. V vy cn phn tch cc
yu t nh hng ti sc khe xc nh cc can thip v giao trch nhim cho tng b ngnh
trong vic chm sc, bo v v nng cao sc khe nhn dn. Cc yu t v nhn khu v iu
kin kinh t, x hi l hai nhm yu t nh hng sc khe gin tip. Cc nhm yu t nguy
c trc tip theo nghin cu gnh nng bnh tt ton cu gm ch n, li sng, sinh chuyn
ho, mi trng, ngh nghip v bo lc. Ngoi ra c th coi tnh trng thiu tip cn vi dch
v y t c cht lng l mt yu t nh hng ti sc khe.
Phn sau y tp trung phn tch cc yu t nh hng ti sc khe bao gm cc yu t
gin tip (nhn khu hc v kinh t-x hi); cc yu t trc tip gm ch n, dinh dng, li
sng, sinh chuyn ho, mi trng, ngh nghip v bo lc gia nh; v cui cng l cc yu t
lin quan cung cp dch v y t.
2.1. Cc yu t nhn khu hc, kinh t-x hi
2.1.1. Cc yu t nhn khu hc
Quy m v gia tng dn s

Dn s Vit Nam c tnh nm 2013 c nc c 89,71 triu ngi (trong n chim
50,54%; nam 49,46%) [27]. Theo bo co ca Tng cc Dn s-KHHG, B Y t, n 1/11/2013
dn s Vit Nam t 90 triu ngi. Quy m dn s ln v tip tc tng, nn mt dn s
Vit Nam tng t 231 ngi/km2 nm 1999 ln 271/ngi/km nm 2013. Nh n lc trong vn
ng thc hin KHHG, t nm 2006, Vit Nam t c t sut sinh di mc sinh thay
th v c duy tr cho n nay. Tuy nhin vn cn 26 tnh cha t, trong c 10 tnh c mc
sinh rt cao (TFR 2,5 con). S ph n trong nhm tui sinh (15-49 tui) chim 55% tng s
ph n v tui th tip tc tng nn tc tng dn s bnh qun hng nm thi k 2011-2013
l 1,05%, vn cao hn so vi mc tiu l < 0,93%. Trong 2 nm 2012-2013, t sut sinh th
43

tng nn khng t mc tiu gim t l sinh 0,1/nm v dn s tng gn 1 triu ngi gia
nm 2012 v 2013. Tuy nhin, nu tip tc duy tr tng dn s mc ny, n nm 2015 vn
c kh nng t mc tiu ca K hoch 5 nm l duy tr dn s di 92 triu ngi v mc tiu
ca CTMTQG dn s v KHHG l di 93 triu ngi (Bng 7).
Bng 7: Cc ch s c bn v dn s trong K hoch 5 nm ngnh y t, 2010-2015
Ch s
Nm
2010
Nm
2011
Nm
2012
Nm
2013
Mc tiu
2015
Quy m dn s (triu ngi)
86,93
87,84
88,77
89,71
<93*
Mc gim t l sinh ()
gim 0,50
gim 0,50
tng 0,30
tng 0,10
gim 0,10*
Tc tng dn s (%)
1,05
1,04
1,06
1,05
0,93
T s gii tnh khi sinh (s

b trai/100 b gi)
111,2
111,9
112,3
113,8
113
Ch thch: Cc mc tiu t K hoch Bo v, chm sc v nng cao sc khe nhn dn giai on 2011-2015. *Mc
tiu c hiu chnh trong CTMTQG DS-KHHG 2012-2015.
Ngun: Tng cc Thng k. iu tra Bin ng dn s v KHHG 1/4/2012.
Mt cn bng gii tnh khi sinh

Tnh trng mt cn bng gii tnh khi sinh ngy cng cao l mt vn quan trng cn
u tin gii quyt. T s gii tnh khi sinh tng ln trong 10 nm, r nt nht l trong vng
5 nm qua. n 2010 c tnh tng ln 111 b tri/100 b gi; nm 2013 c ln 113,8 b
trai/100 b gi [27], cho thy mt kh nng khng ch t s gii tnh khi sinh mc bng hoc
thp hn 113 nh trong mc tiu ca K hoch 5 nm ca ngnh y t. Cc nguyn nhn l t
tng trng nam khinh n, ni di tng ng (duy tr dng h tc), c con trai chm sc
cha m khi v gi vn cn rt nng n v km theo l cc bin php siu m chn on pht
hin, thng bo gii tnh thai nhi sm ngy cng ph bin c c s y t cng lp v t nhn.
khc phc tnh trng ny, cn c cc bin php can thip hu hiu, a ngnh v c thc
hin tng bc.
C cu tui v t vong
T trng dn s ca nhm di 15 tui gim t 33,1% nm 1999 xung cn 23,9% nm
2012. Ngc li, t trng dn s ca nhm 15-64 tui (nhm tui lao ng) tng t 61,1% nm
1999 ln 69% nm 2012. Vi cu trc dn s vng5 ny, Vit Nam c nhiu li th trong pht
trin kinh t [28]. Tuy nhin, vi s lng v thnh nin v thanh nin (10-24 tui) chim n
mt phn ba dn s, vic xy dng li sng lnh mnh v chm sc sc kho sinh sn cng t
ra nhiu thch thc ng k cho ngnh y t cng nh ton x hi. T l ngi t 60 tui tr ln
tng t 8% nm 1999 ln 10,2% nm 2012. M hnh tui t vong thay i theo c cu tui dn
s v theo mc sng. Cc vng giu hn c t l t vong sm (di 70 tui) thp hn (Hnh 21).
Trong khi cc nc chu -Thi Bnh Dng thu nhp cao, t l t vong sm chim khong
25%, Vit Nam hn mt na s t vong xy ra di 70 tui, gn ging nh vng ng . S
t vong nhm di 14 tui Vit Nam chim khong 5%, cao hn vng ng v vng thu
nhp cao nhng thp hn mt na so vi cc vng chu khc. T l t vong trong nhm tui
Theo UNFPA, quy m dn s vng hay quy m dn s ti u l khi trong dn s, c vi mi ngi ph thuc
th c 2 ngi tr ln trong tui lao ng
44

lao ng Vit Nam (15-69 tui) chim khong 46%, ging nh Trung v ng , nhng
ng t vong tp trung nhiu hn vo nhm gi hn trong khi Vit Nam v Trung , t
l t vong nhm 15-49 tui chim gn 20% tng s t vong.
Hnh 21: C cu tui t vong theo vng quc t, 2010
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Nam
< 5 tui
ng Nam
5-14 tui
Trung
15-49 tui
ng
Thu nhp cao

Chu - Thi
Bnh Dng
50-69 tui
Vit Nam
70+ tui
Ngun: Global Burden of Disease Study 2010. Global Burden of Disease Study 2010 (GBD 2010) Results by Cause
1990-2010 - Vietnam Country Level. Seattle, United States: Institute for Health Metrics and Evaluation (IHME),
2013.
Gi ha dn s
C cu dn s nc ta c s bin i mnh v ang c xu hng gi ho dn s. S liu
gn y cho thy, nm 2012, Vit Nam bc vo thi k gi ha dn s, vi t trng dn
s t 60 tui tr ln tng t 8% nm 1999 ln 10,2% nm 2012; t trng dn s 65 tui tr ln
tng t 5,8% nm 1999, ln 6,4% nm 2009 v 7,1% nm 2012. Ch s gi ho dn s (tng s
ngi trn 60 tui/100 ngi di 15 tui) tng nhanh t 24,3% nm 1999 ln 43,5% nm 2013
[27]. T l ngi cao tui trong dn s cao s lm tng nhu cu chm sc sc kho trong thi
gian ti. Vit Nam, vic chm sc x hi v chm sc sc kho cho ngi cao tui (trong
c vn ngi gi c n) vn cn hn ch. Nhiu ngi cao tui mc d c con, chu nhng
vn thiu s chm sc do con chu phi i lm xa, hoc khng c thi gian.
M hnh bnh tt ca ngi cao tui (70 tui tr ln) gm c nhng bnh gy t vong
cao v nhng bnh khc gy nm sng tn tt, gim cht lng sng v to nhu cu chm sc
cao. Khong mt na s ngi t vong mi nm l ngi cao tui. Nm 2010, mi nguyn
nhn gy t vong cao nht ngi cao tui chim 66% tng s t vong nhm ny, trong
tai bin mch mu no chim 27% t vong ngi cao tui. Ngoi cc BKLN, trong 10 nguyn
nhn t vong quan trng nht ngi cao tui c 2 bnh truyn nhim l nhim khun ng
h hp di v bnh lao (Bng 8). Mi nguyn nhn gy s nm sng tn tt ln nht ngi
cao tui gy ra 64% tng s nm sng tn tt, ch yu do cc bnh/chng bnh mn tnh khng
ly nhim nh cc ri lon thnh gic v tm nhn, bnh xng khp, bnh thn kinh v tm
thn (bnh Alzheimer v trm cm).
45

Bng 8: Cc nguyn nhn gy gnh nng t vong v gy nm sng tn tt ngi cao
tui (70 tui tr ln), 2010
Nguyn nhn t vong
% t
vong
Nguyn nhn
nm sng tn tt
%
YLD
Tai bin mch mu no

do xut huyt
27%
Ri lon thnh gic v tm nhn
19%
8%
au vng lng di
10%
7%
9%
Nhim khun ng h hp di
5%
Vim xng khp
5%
Ung th phi, ph qun, kh qun
4%
Ng
5%
Ung th gan
3%
Bnh Alzheimer
v lo suy khc
5%
i tho ng
3%
Trm cm
4%
Bnh lao
3%
i tho ng
3%
Tai bin mch mu no

do thiu mu cc b
2%
au c
2%
10
Ung th d dy
2%
10
2%
Tng s
66%
Tng s
64%
Ph n v tr em
Ph n v tr em l nhm i tng u tin do c nhng nhu cu CSSK c bit. Gnh
nng bnh tt ca nhm ph n tui sinh khng cao nhng nhu cu chm sc rt ln. Tr em
di 5 tui l nhm c nguy c t vong cao v c nhu cu tim chng, phng chng suy dinh
dng, tiu chy, vim phi v tai nn chn thng rt cao. Ph n tui sinh gm c ph n
c v cha c chng, c nhu cu ln v dch v KHHG phng sinh con ngoi mun. Th
hin nhu cu KHHG cha c p ng, nm 2012 c tng s 88783 ph n c chng no
thai; khng c thng tin y v tng s ph n cha chng no thai. Mt nhm khong
1,5 triu ph n sinh con c nhu cu khm thai, . Trong nc v quc t c bit quan tm
ti cc nhm b m tr em th hin qua cc Mc tiu Thin nin k gim t vong b m v tr
em. Hnh 22 cho thy ph n v tr em chim ti 35,4% dn s, trong 1,7 triu tr em di
1 tui, 5,9 triu tr em t 1 n 4 tui, 24,1 triu ph n tui sinh [27].
46

Hnh 22: Quy m cc nhm tui ph n v tr em, 2013
Tr em di 1
tui (1,7 triu)
Tr em t 1 n 4 tui (5,9 triu)

Ph n sinh con trong 12 thng
(1,5 triu)
Ph n 15-49 tui
khng sinh con
trong 12 thng qua
(22,6 triu)
Dn s cn li
(57,8 triu)
Tng dn s nm 2013:
89,5 triu dn
Ngun: iu tra bin ng dn s KHHG nm 2013 [27].
Kh tip cn v a l v v vn di c
Nhm dn c sng nng thn vng ni, hi o l cc nhm kh tip cn vi dch v
y t hn nhm khc. Khu vc nng thn ca vng ni v cao nguyn c coi l vng kh tip
cn vi dch v y t v mt a l. Nm 2012, 11% dn s sng nng thn Trung du v min
ni pha Bc v 4% dn s sng nng thn Ty Nguyn. Nh nc xc nh 62 huyn
ngho nht c t l ngho vt 50% dn c, hu ht l huyn kh tip cn vi dch v y t c
cht lng v l vng ni v bin gii. c tnh dn s cc huyn ngho khong 2,4 triu ngi,
trong c ti 90% l ngi cc dn tc thiu s6. Mt loi a bn khc cng c xc nh
c nhu cu cao v kh tip cn dch v y t l vng bin, o. Dn s vng bin o chung c
tnh khong 32 triu ngi7. Trong , c tnh dn s ti 11 huyn o khong 250000 ngi.
S ngi di c hng nm rt ln. Di c c lin quan vi sc khe. Trong vng 12 thng
trc thi im 01/04/2013, tng cng c khong 535 000 ngi di c gia cc vng v 1,8
triu ngi di c gia khu vc nng thn v thnh th. Lung di c ch yu t ng bng
sng Cu Long v Bc Trung B v Duyn hi min Trung vo ng Nam B. Bc Trung B
v Duyn hi min Trung cng c tng i nhiu ngi di c vo Ty Nguyn v n ng
bng sng Hng. S ngi nm 2011 nng thn n nm 2012 di c n thnh th khong
343000 ngi. T 2012-2013, c khong 390 000 ngi di c t nng thn n thnh th.
Tuy nhin, lung di c ln nht din ra gia cc khu vc nng thn vi nhau (656 000 ngi).
Ngi di c thng l ngi khe mnh hn ngi khng di c v ch yu tp trung nhm
tui t 15 n 34 tui. T l di c cao hn cc nhm c trnh hc vn cao hn [27].
Di c c th c tc ng tch cc hoc tiu cc ti sc khe. Tc ng tch cc ca di
c i vi sc khe ch yu do ngi di c c thu nhp cao hn gi v cho ngi thn
qu, to ngun kinh ph chi tr dch v y t khi cn thit [29]. T l bao ph Bo him y t
(BHYT) ngi di c vo khu vc cng nghip tng so vi nhm khng di c cn lm vic
Ngh quyt s 30/A/2008/NQ-CP ca Chnh ph ngy 27/12/2008 v Chng trnh h tr gim ngho nhanh v
bn vng i vi 61 huyn ngho
7
Quyt nh s 52/2009/Q-TTg ngy 9/4/2009ca Th tng Chnh ph ph duyt n Kim sot dn s cc
vng bin, o v ven bin giai on 2009 - 2020.
6
47

trong khu vc h kinh doanh, h nng nghip. Tuy nhin, di c cng c nhng mt tiu cc. T
l bao ph BHYT nhm ngi di c vn cn thp do ch s dng lao ng khng tun th
php lut v BHYT bt buc. S dng BHYT ca ngi di c khng thun tin dn n tip
cn v s dng cc dch v y t thp. Nhm ngi di c c nhng nguy c i vi sc khe cao
hn ngi khng di c, c bit lin quan cc bnh ly truyn qua ng tnh dc, HIV/AIDS.
Ngi di c vo min Nam c t l ht thuc l v ung ru nhiu cng tng nguy c i vi
sc khe t cc nguyn nhn ny. Ngi di c cng cha thc y v CSSK v trnh hnh
vi c hi (thuc l, ru, bia, ma ty) [30].
2.1.2 Cc yu t kinh t - x hi
Kinh t pht trin v n nh l iu kin tng u t cho chm sc sc kho. Theo

quy lut chung, khi kinh t cng pht trin th t l u t cho y t cng ngy cng tng ln. Nn
kinh t Vit Nam vt qua nhiu kh khn, thch thc, kinh t v m c bn n nh, duy tr
c tc tng trng kh, tim lc v quy m nn kinh t tng ln. Tc tng trng kinh
t bnh qun/nm khng thp hn 5% trong c giai on t nm 2005 n nm 2013. Tng sn
phm trong nc (GDP) bnh qun u ngi nm 2013 c tnh s b t 39,8 triu ng [31].
Vic lm
Vic lm l yu t quan trng i vi sc khe v lin quan thu nhp lo i sng (gm
n, , y t,), v v kinh t c bo m l yu t bo v sc khe tm thn. Ch s dng lao
ng tun th cc quy nh an sinh x hi, trong bo m ng ph BHYT cho nhn vin,
gip bo m ngi lao ng tip cn c vi dch v y t khi c nhu cu. Lc lng lao ng
t 15 tui tr ln c tnh n ngy 01/01/2014 l 53,65 triu ngi, trong c trn 6 triu
l ngi cao tui. Lao ng c vic lm c phn b ra khu vc nng nghip (46,9%), cng
nghip v xy dng (21,1%) v dch v 32,0%. T l lao ng phi chnh thc chim 34,2%
tng s lao ng 15 tui tr ln, l nhm c nguy c khng c bao ph BHYT cao. T l tht
nghip trong tui lao ng c tnh l 2,2%. T l thiu vic lm l 2,77%, t l tht nghip
ca thanh nin tui 15-24 c tnh l 6,36% [11].
i ngho
khu vc nng thn, nm 2013, c 426,7 nghn h thiu i, gim 5,2% so vi nm
2012, tng ng khong 1,8 triu ngi. T l h ngho c nc nm 2013 c tnh 9,9%,
gim 1,2 im phn trm so vi nm 2012 [11]. cc thnh ph ln, vn cn c mt t l khng
nh ngi dn sng trong cc khu nh ln chim, khu chut khng bo m iu kin v sinh
nh , nh hng n sc khe dn lao ng. Nhiu cng nhn trong cc khu cng nghip phi
thu tr trong nhng ngi nh cht hp, chung nhiu ngi do lng thp, thiu nc sch, iu
kin v sinh cng l yu t nh hng n sc khe ngi lao ng.
Gio dc, o to
Tnh n cui nm 2013, c nc c 61/63 tnh, thnh ph trc thuc trung ng t
chun ph cp gio dc tiu hc ng tui, trong 4 tnh/thnh ph c cng nhn t
chun ph cp gio dc tiu hc ng tui mc 2 (nm 2012 l 3 tnh). Nm hc 2012
- 2013, c nc c 8,9 nghn hc sinh tiu hc b hc, gim 0,1% so vi nm trc; 44 nghn
hc sinh trung hc c s b hc, gim 0,3% v gn 42 nghn hc sinh trung hc ph thng b
hc, gim 0,2%.
48

Nm 2013, ngnh gio dc, o to tip tc nhn c s quan tm u t pht trin.
Tng chi ngn sch Nh nc (NSNN) cho gio dc v o to trong nm l 194,4 nghn t
ng, tng 14,1% so vi nm 2012, trong chi thng xuyn cho gio dc v o to l 164,4
nghn t ng, tng 17,3%; chi cho xy dng c bn l 30 nghn t ng, tng ng mc chi
nm trc.
2.2. Cc yu t nguy c gnh nng bnh tt
Nghin cu gnh nng bnh tt khng ch phn tch gnh nng ca cc bnh m cn
phn tch gnh nng ca cc yu t nguy c. Da trn cc nghin cu xc nh mc tng
yu t nguy c tc ng ti tng loi bnh, nghin cu gnh nng bnh tt c tnh tng s
DALY, YLL, YLD v t vong gy ra bi tng yu t nguy c. Phn sau y s phn tch cc
yu t thuc cc nhm mi trng, li sng, dinh dng/ch n, hot ng th lc, sinh l,
ngh nghip v bo lc a ra bng chng quan trng cho xy dng chnh sch, k hoch.
Bng 9 cho thy ng gp ca tng nhm yu t nguy c trong gnh nng bnh tt theo
s t vong v theo DALY. Theo , yu t nguy c quan trng nht l ch n khng hp l,
hoc thiu nhng thnh phn c li cho sc khe nh rau qu, hoc tha nhng cht c hi cho
sc khe nh tht ch bin hoc ung ngt c ga. Th hai l nhm cc yu t sinh l nh tng
huyt p, tng cholesterol mu v sau l ht thuc l v nhim khng kh.
Bng 9: C cu cc yu t nguy c tnh theo t l t vong v t l DALY, 2010
Yu t nguy c
% t vong
% DALY
Khng bo m ngun nc sch, v sinh mi trng
0,2%
0,4%
nhim khng kh
15,2%
13,7%
Cc yu t mi trng khc
1,6%
1,2%
Ht thuc
14,8%
14,7%
Lm dng ru, bia hoc ma ty
5,4%
10,4%
Ch n khng hp l
31,3%
25,3%
Suy dinh dng tr em v b m
0,7%
4,8%
Thiu hot ng th lc
2,5%
2,5%
Yu t sinh l
26,4%
20,3%
Nguy c ngh nghip
1,5%
5,3%
Bo lc
0,2%
1,5%
Tng
100%
100%
Ngun: Institute for Health Metrics and Evaluation (IHME). Global Burden of Disease Study 2010 (GBD 2010).
Risk Factor Attribution Results 1990-2010 - Country Level. Seattle, United States: Institute for Health Metrics and
49

2.2.1. Cc yu t mi trng
Thiu nc sch v h x hp v sinh

Vic thiu nc sch v iu kin v sinh c bn l nguyn nhn quan trng dn n
nhiu loi bnh, ch yu cc bnh gy tiu chy nh tiu chy do vi rt Rota, dch t, thng
hn v ph thng hn. Mt s bnh khc cng lin quan n nc v v sinh nh vim gan A,
giun sn, au mt ht, cc bnh do mui truyn (st rt, st xut huyt, vim no Nht Bn), v
ui nc. V th cc quc gia cam kt thc hin Mc tiu Thin nin k lin quan n bo
m ngun nc sch v h x hp v sinh. Nh c phn tch mc nh gi tin thc
hin Mc tiu Thin nin k trong Chng II, Vit Nam t mc tiu v hin nay c 75%
ngi dn s dng h x hp v sinh v 95% s dng nc sch. V vy, gnh nng bnh tt
lin quan vi thiu nc sch v h x hp v sinh Vit Nam c tnh thp, ch chim 0,2%
tng s t vong v 0,4% DALY gy ra bi cc yu t nguy c ny. Tuy nhin, nghin cu ny
ch tnh tc ng ca nc sch, v sinh ti bnh tiu chy v thng hn, cha tnh tc ng
ti cc bnh khc nh giun sn, vim gan A, au mt ht, bnh do mui truyn.
D t c mt s kt qu tt trong vic gim yu t nguy c ny, nhng hin vn
cn nhiu vn cn gii quyt. Qu trnh cng nghip ha, th ha dn n nhim ngun
nc, cn tr kh nng bo m ngun nc sch cho nhn dn. c bit do nhiu c s sn
xut quy m nh, thiu thanh tra mi trng nn kh qun l cht thi vo cc ngun nc.
Cn c cc th ch hn ch v gim st nhim nc do nc thi sn xut v tiu dng,
ngi dn c th sng trong mi trng sch, khng nh hng ti sc kho. Bn cnh , cn
mt t l ln h gia nh nng thn vn s dng chung nh v sinh hoc h x cha bo m
v sinh, thm ch cha c h x. thc v iu kin ra tay sau khi i v sinh hoc trc khi
n cha bo m nhiu h dn v trng hc.
nhim khng kh
nhim khng kh bao gm nhim do cht t s dng trong nh, khi, bi t c s
sn xut, nh my, x nghip gn cc khu dn c, do giao thng v zn quang ha. Tc ng
ti sc khe do 3 yu t ny lin quan nhim khun ng h hp, ung th phi, ph qun, kh
qun, bnh tim, tai bin mch mu no v bnh phi tc nghn mn tnh. Theo c tnh, nhim
khng kh lin quan 13,7% gnh nng bnh tt v 15,2% t vong, ch yu do tai bin mch mu
no v bnh tim thiu mu cc b.
Cng vi qu trnh cng nghip ho v th ho, vn nhim mi trng th,
nhim khng kh ngy cng nghim trng, nh hng trc tip n sc kho. Trong cc c
s gy nhim mi trng nghim trng, 13% gy nhim khng kh, ch yu l nh my xi
mng, lng ngh do nhin liu t l than ci, bi rc. thnh th, nhim khng kh ch
yu do giao thng (70%). nhim khng kh do bi cc khu dn c th hin ang l vn
nan gii, nh hng nghim trng ti sinh hot cng nh sc khe nhn dn.
Rc thi
Rc thi v cc bin php x l rc c tc ng ln ti sc khe con ngi. Hnh thc
tp trung rc thi chnh hin nay l cc bi rc. Trong danh mc cc c s gy nhim mi
trng, c 52 bi rc cn phi ng ca, di chuyn, nng cp ci to v khng ch nhim,
x l rc. Trong 91 bi rc trong c nc, ch c 17 a im c gi l bi rc hp v
50

sinh. nhiu ni, tnh trng t hu nh t, chn xung t hoc ra sng, knh rch cn kh
ph bin. Nhng bi rc m gy nhiu vn mi trng cho cng ng xung quanh nh
gy nhim nc v t do r r cc cht khng qua x l, gy nhim khng kh do t rc
thi l nhng nguyn nhn lm tng t l mc bnh ngoi da, tiu ha v bnh ng h hp.
Nhng ngi tham gia thu gom ng nt ti bi rc, c bit tr em (chim 9%) l nhm d
b nhim bnh.
Cht thi y t
Cht thi y t ngy cng gia tng v s lng v phc tp v chng loi. Kinh ph u t
nng cp c s h tng x l rc thi c tng ln trong nhng nm gn y, nhng vn cn
thiu kinh ph vn hnh cc c s x l rc thi. H thng x l cht thi y t c hi ti nhiu
c s y t, c bit tuyn y t c s, cha hon thin, cha bo m theo yu cu quy nh ca
lut mi trng, nht l h thng x l nc thi y t. Lng nc thi c sinh ra ngy cng
nhiu, t l thun vi s gia tng v s bnh nhn, gy ra tnh trng nhim ngy cng phc tp.
Bin i kh hu
Vit Nam nm trong s nhng nc d b tn thng nht bi bin i kh hu. Tc ng
ca bin i kh hu i vi sc khe c phn tch theo 4 kha cnh. Th nht l qua tc ng
ti yu t kinh t-x hi nh kh nng tip cn khng kh sch, nc sch, an ninh lng thc
v ni an ton, qua c tc ng ti sc khe. Th hai l nhit tng lm gia tng bnh tt
v t vong do bnh tim mch v ng h hp trc tip do nhit cao, hoc gin tip qua vic
tng cht gy nhim khng kh hoc cht gy d ng nh bi phn hoa. Th ba l iu kin kh
hu tc ng ti cc bnh lin quan nc v cc vc t bnh sng trong nc, nh mui truyn
bnh st rt, st xut huyt, do ko di ma dch hoc m rng vng cc vc t sinh sng. Th
t, bin i kh hu c th tng tn sut v mc gy hi ca thin tai nh nc bin dng,
l lt, bo dn n ngi dn phi di chuyn vng khc hoc chu sng trong iu kin mt v
sinh ngun nc, thiu n, c nguy c cao ui nc. Hn hn c th gim lng nc sn c
ung, trng trt hoc gi v sinh.
Thin tai thm ha
Trong nm 2013, nc ta chu nh hng ca 15 cn bo vi cng mnh v din
bin phc tp, c bit tnh trng ma, l sau bo gy thit hi nng v ngi v ti sn cho
nhiu tnh, thnh ph. Theo bo co s b ca cc a phng, thin tai lm313ngi cht
v mt tch; 1150ngi b thng;6401ngi nh b sp , cun tri; trn 692000 ngi nh b
ngp nc, h hng;88,2km , k v894km ng giao thng c gii b v, st l;gn 8000
ct in gy, ;hn 17000 hc-ta la v 20000 hc-ta hoa mu b mt trng;gn 117000 hcta la v154000 hc-ta hoa mu b ngp, h hng. Tnh trng chy, n trn a bn c nc c
xu hng gia tng trong thi gian gn y gy thit hi ln v ngi v ti sn. T 15/11/2012
n 15/11/2013, trn a bn c nc xy ra 2500 v chy, 65 v n nghim trng, lm 127
ngi cht v 339 ngi b thng.
2.2.2. Cc yu t v li sng
Nhm yu t li sng bao gm nhiu yu t khc nhau nhng trong mc ny ch cp

ti ht thuc l, lm dng ru, bia v ma ty. V ht thuc l v lm dng ru, bia l 2 yu
51

t quan trng gy gnh nng bnh tt trong nhm BKLN, s c cp chi tit Chng III
nn mc ny ch tm tt ni dung lin quan n BKLN v i su hn vo bnh khc lin quan
hai yu t nguy c ny.
Ht thuc l
Ht thuc l yu t nguy c ca nhiu bnh, ch yu l BKLN nh nhiu loi ung th,
bnh tim mch, tai bin mch mu no, i tho ng, bnh phi tc nghn mn tnh v cc
bnh phi mn tnh khc. Thuc l cng tng nguy c mc cc bnh truyn nhim nh lao,
nhim khun ng h hp. Vit Nam l nc c t l ht thuc l nam gii cao th 19 trn
th gii [32]. Kt qu iu tra nm 2010 cho thy c 47,4% nam gii v 1,4% n gii c ht
thuc, tuy nhin ph n v tr em vn b tc ng do ht khi thuc l th ng [33]. Ht thuc
l gy ra khong 16,9% tng s ca t vong v 8,8% gnh nng bnh tt tnh bng DALY [34].
Lut phng, chng tc hi ca thuc l c Quc hi thng qua nm 2012 v bt u c
hiu lc t 01/05/2013. Chnh ph xy dng cc Ngh nh v Thng t hng dn thc hin
nhm tng cng cc can thip c sn nhng kh thc hin nh cm v x pht ht thuc l
ni cng cng, ni ng ngi.
Lm dng ru, bia
Lm dng ru, bia cng lin quan n nhiu BKLN nh ung th ng tiu ha, h tit
niu, gan, v, bnh tim mch, tai bin mch mu no, x gan, i tho ng, ng kinh v ri
lon tm thn lin quan n ru. ng thi s dng ru, bia cng c lin quan vi bnh lao,
nhim khun h hp di, ng c, tai nn giao thng, v nhiu loi chn thng, bo lc. Hi
ngh trin khai chnh sch quc gia phng, chng tc hi ca lm dng ung c cn thng
5/2014 cho bit ngi Vit Nam ang tiu th hn 3 t lt bia v gn 68 triu lt ru mi nm.
Theo nghin cu ca Vin Chin lc v Chnh sch Y t, c ti 4,4% ngi dn Vit Nam ang
phi gnh chu bnh tt do hu qu ca ru, bia. Mi nm c ti 60% s v tai nn giao thng,
68% s v bo lc gia nh v 38% s v gy ri trt t an ton x hi lin quan ti lm dng
ru, bia. Tng cng, s dng ru, bia gy ra 5% tng s ca t vong v 8% gnh nng bnh
tt tnh bng DALY nm 2010 [34].
Vit Nam cng l mt trong nhng nc c tnh trng s dng ru, bia khi tham gia
giao thng ph bin nht chu . Vi phm v ung ru, bia khi iu khin phng tin giao
thng chim 5-6% cc cc x l vi phm hnh chnh ca cnh st giao thng. Hn 30% ca t
vong giao thng ng b v 60% bnh nhn chn thng nhp vin c nng cn trong mu
vt qu gii hn cho php (cao nht 458 mg/100 ml mu, gp chn ln cho php), a phn l
nam gii, trong 75% tui thanh nin [35]. Theo thng k ca y ban Cc vn x hi
ca Quc hi, mi nm c ti 12 000 ngi cht do tai nn giao thng, trong hn 10% do s
dng ru, bia gy nn. c tnh nm 2012, c nc mt 2,6% GDP, tng ng 3,5 t USD
v tai nn giao thng, 1/3 s ny c lin quan n s dng ru, bia[36].
S dng ma ty
S dng ma ty lin quan vi mt s BKLN nh ung th v x gan, nhng ch yu lin
quan vi ri lon tm thn do ma ty, tm thn phn lit v t gy thng tch, cng nh bnh
ly do dng chung kim tim nh bnh HIV/AIDS, vim gan vi rt. Hin nay, s ngi s dng
ma tu bt hp php Vit Nam rt ln v c xu hng tng nhanh. Theo B Cng an, nu nh
52

thng 6/2010, c nc c hn 118400 ngi nghin ma tu c h s kim sot th n thng 9,
con s ny tng ln 131000. S ngi nghin l cng nhn vin chc, cha c kim tra
pht hin cn tng i ln. S dng ma tu l con ng ch yu gy ly nhim HIV/AIDS
Vit Nam. Khong 45% ngi mi nhim HIV nm 2013 v t l cao hn bnh nhn vim
gan b ly truyn do dng chung bm kim tim [37].
2.2.3. Dinh dng, ch n, an ton thc phm
Dinh dng tr em
Cc yu t nguy c bnh tt lin quan dinh dng tr em gm dng cho b m sm, cho
tr n thc n ngoi sa m v t hoc khng cho b sa m khi di 6 thng, thiu cn tr em,
thiu st, thiu vitamin A, thiu km. Cc bnh lin quan n cc yu t dinh dng bao gm
nhim khun ng tiu ha, nhim khun ng h hp, si, st rt, suy dinh dng proteinnng lng, ri lon do thiu vitamin A, v i vi b m thiu st khi sinh con c th dn n
xut huyt, nhim trng mu hoc thiu mu do thiu st. T l suy dinh dng tr em tip tc
gim qua cc nm. c tnh, thiu dinh dng gy di 1% tng s ca t vong, nhng khong
5% gnh nng bnh tt tnh bng DALY nm 2010.
Ch n
Ngoi dinh dng v vi cht, ch n cng c tc ng ti sc khe. Ch n
rau qu, ng cc nguyn ht, cc loi ht nh ht iu, lc, vng, sa, thiu sa, cht x, calci,
a xt bo omega 3 t hi sn, v a xt bo khng bo ha a c li cho sc khe. Ngc li ch
n tha tht (nh tht b), tht qua ch bin (nh ch, gi), ung c ng v ga, mui,
a xt bo chuyn ha gy nguy c cho nhng bnh khc. Cc bnh c th phng c bng ch
n hp l bao gm nhiu loi ung th ng tiu ha, bnh tim thiu mu cc b, tai bin
mch mu no, bnh suy thn, i tho ng. Nghin cu gnh nng bnh tt c tnh 31,3%
tng s t vong v 25,3% gnh nng bnh tt tnh bng DALY c lin quan n ch n khng
hp l [34].
An ton thc phm
Tnh trng ng c thc phm rt phc tp. Hng nm, xy ra khong gn 200 v ng
c thc phm c trn 30 ngi mc/v. Tng s ngi ng c thc phm trong c nc c
tnh khong 1,2 n 1,5 triu ngi, s ngi t vong do ng c thc phm khong 35 - 40
ngi. Trong 8 thng u nm 2013, ton quc ghi nhn 125 v ng c thc phm vi 3145
ngi mc, 2807 ngi nhp vin v 19 trng hp t vong. Kt qu iu tra cho thy, c
49,6% s v do vi sinh vt, 17,6% s v do c t t nhin, 2,4% s v do ha cht v 30,4%
s v cha xc nh r cn nguyn. So vi cng k nm 2012, ng c thc phm gim c v s
v (gim 7 v), s mc (gim 910 ngi), s nhp vin (gim 406 ngi) v s t vong (gim
6 ngi). Trong , ng c thc phm ti gia nh, bp n tp th v s v ng c thc phm
trn 30 ngi mc gim ng k so vi cng k nm 2012.
Ng c v t vong do cc c t t nhin, n nm c v ho cht vn chim t l cao.
Tnh trng s dng cc ho cht, ph gia thc phm khng ng quy nh trong qu trnh nui
trng, s ch ch bin thc phm vn cn kh ph bin. Trong khi , nng lc ca cc chi Cc
An ton v sinh thc phm ca cc tnh/thnh ph cn hn ch do mi c thnh lp, thiu c
53

s vt cht, phng tin v nhn lc. Cc n v kim nghim cn hn ch v nng lc, cha p
ng c cc yu cu cp bch trong gim st v xc nh nguyn nhn gy ng c thc phm.
2.2.4. Hot ng th lc
Hot ng th lc c lin quan cht ch n tnh trng sc khe. t hot ng th lcl

yu t nguy c gy ra chng long xng, vim xng khp, aulng, bo ph, trm cm, lo
u, cng thng, ung th tin lit tuynv ung thtrctrng. t hot ng th lc gy ra 2,5%
tng s t vong v 2,5% gnh nng bnh tt tnh bng DALY nm 2010. c bit, cc bnh tim
mch, i tho ng v ung th l cc vn sc khe chnh lin quan n tnh trng t vn
ng.
Vit Nam, t l luyn tp th dc th thao thng xuyn tng dn qua thi gian,
nhng t l ny vn cn thp, ch t 27% nm 2013 (Bng 10). T l gia nh luyn tp th dc
th thao thp hn, ch 18,6% [38]. Hin nay, cc thnh ph ln cn thiu khng gian cho ngi
dn hot ng th lc nh i b, chi cu lng, bng, Cc khng gian ny b chim
dng hoc s dng cho cc mc ch khc. Tnh trng nhim khng kh trong thnh ph cng
cn tr vic hot ng th lc. V mt tch cc, nm 2013, khong 95% trng hc bo m
chng trnh gio dc th cht. y l tin vn ng dn s Vit Nam hot ng th lc,
nng cao sc khe. Hot ng th lc s c trnh by chi tit hn Mc 3.2.
Bng 10: T l ngi v gia nh luyn tp th dc th thao, 2010-2013
Nm
T l % ngi luyn tp th dc
th thao thng xuyn
T l % gia nh luyn tp th dc
th thao
2010
23,6
15,8
2011
24,1
16,0
2012
25,5
16,6
2013
27,2
18,6
Ngun: B Vn ha v Du lch. Ch tiu, s liu c bn ngnh vn ha, th thao v du lch cc nm.

http://bvhttdl.gov.vn/vn/thong-tin-thong-ke/0/18/index.html
2.2.5. Cc yu t sinh chuyn ho
Cc yu t sinh l hc gy gnh nng bnh tt bao gm ng huyt lc i cao, tng

huyt p, cholesterol mu cao, ch s khi c th cao, mt xng thp. Cc bnh lin quan
n yu t sinh l hc ch yu l BKLN nh i tho ng, bnh tim mch, bnh suy thn, tai
bin mch mu no. Tha cn (ch s khi c th cao) lin quan c mt s bnh ung th, au
vng lng di v vim xng khp. Tnh hnh cc yu t sinh chuyn ho c phn tch chi
tit hn trong Chng III.
2.2.6. Cc yu t lin quan n ngh nghip
Hn 80% trong tng s 3 t ngi lao ng trn th gii phi sng v lm vic trong iu
kin khng c tip cn dch v y t lao ng c bn. Gn mt na trong s 4 t ngi khu
vc chu - Thi Bnh Dng l ngi lao ng; t l ngi lao ng trong dn s cao hn na
nu tnh c khu vc lao ng phi chnh thc. Nm 2000, khu vc chu - Thi Bnh Dng
54

c 430000 ngi cht v 14 triu DALY b mt do ri ro ngh nghip [39]. Thng 5/2007, k
hp th 60 ca i hi ng Y t th gii thng qua K hoch hnh ng ton cu v Sc
kho ca ngi lao ng giai on 2008-2017 vi nhng mc tiu sau: a ra v thc hin cc
cng c chnh sch v sc khe ngi lao ng; bo v v nng cao sc khe ni lm vic; tng
cng vic thc hin v tip cn vi cc dch v y t lao ng c bn; cung cp v thng tin v
cc bng chng cho hnh ng v thc hin; kt hp vn sc khe ca ngi lao ng vo
cc chnh sch v d n khc. WHO khu vc Ty Thi Bnh Dng xy dng Khung hnh
ng v Sc khe ngh nghip giai on 2011-2015 ca Khu vc.
Nm 2013, Vit Nam c khong 46,8% ngi lao ng lm vic trong khu vc nng
nghip, lm nghip v ngh c, 15,0% lm vic trong lnh vc cng nghip v 6,2% trong lnh
vc xy dng [40]. Nm 2011, s doanh nghip nh v va chim ti 97,6% trong tng s
324691 doanh nghip trn c nc [41]. Vit Nam t c nhng thnh tu to ln v pht
trin kinh t, x hi nh thc y cng nghip ha v hin i ha. Tuy vy, Vit Nam cng phi
i mt vi nhiu thch thc v an ton v v sinh lao ng. Trong qu trnh cng nghip ha
xut hin nhiu nguy c v ri ro mi nh nhng loi ha cht mi s dng trong ngnh sn
xut giy, chi tr em v nhiu loi thuc bo v thc vt dng trong nng nghip. Ngoi
nhng bnh ngh nghip truyn thng (nh vim da ngh nghip, bnh bi phi si-lic, gim
thnh lc do ting n, ng c ha cht, v.v), cc bnh lin quan n ngh nghip cng thng
xy ra, nh ri lon c xng khp, bnh do cng thng ngh nghip v cc yu t tm l x
hi. Tnh n nm 2012, tng s tch ly cc trng hp ngi lao ng c nhn bi thng
tai nn lao ng v bnh ngh nghip l 27246 ngi, trong cc trng hp b bnh bi phi
si-lic ngh nghip chim 75% v gim thnh lc do ting n chim 15% [42]. Cn cng c li
h thng dch v y t sc khe ngh nghip v mi trng lao ng, nht l cc doanh nghip
nh v khu vc kinh t phi chnh thc, nh nng nghip, lng ngh th cng.
2.2.7. Tai nn, chn thng, bo lc
Tai nn thng tch

S v tai nn, s ngi b thng v t vong do tai nn, c bit l tai nn giao thng
ngy cng gia tng trong vng 10 nm qua. T vong do chn thng cc loi v tai nn giao
thng ng hng u trong cc nguyn nhn t vong. Bnh qun mi ngy c khong 30 ngi
cht v 70 ngi b thng gy tn tt sut i. Bn cnh tai nn giao thng l cc tai nn
thng tch xy ra trong cng ng nh ng c, chy n, in git, ui nc,. y l nhng
con s ng lo ngi v p lc ln i vi cc c s y t, c bit l cc c s cp cu ngoi khoa,
chn thng chnh hnh.
Theo Nin gim thng k y t nm 2011, t sut t vong do tai nn giao thng nm 2011
l 20,1/100000 dn (nam cao gp hn 3,5 ln n: 31,9/100000 v n l 8,5/100000 dn).
Nghin cu ca Trng i hc Y t Cng cng v gnh nng bnh tt v chn thng Vit
Nam nm 2008 cho thy s DALY do chn thng khng ch nh nam gii cao hn 2,5 ln
n (1229 so vi 505). Trong s cc chn thng khng ch nh, tai nn giao thng gy ra
gnh nng bnh tt ln nht trong tng gnh nng bnh tt vi 8% nam v 4% n. Ng v
ui nc cng l hai nguyn nhn chnh ca gnh nng do chn thng khng ch nh c
hai gii [43].
55

Bo lc gia nh
Bo lc gia nh lm nh hng nghim trng n sc kho v tinh thn, nht l i vi
ph n. Theo nghin cu ca Hi Lin hip ph n Vit Nam, trong s nhng ph n tng
b chng nh c khong 6% tng phi vo vin iu tr. S liu iu tra quc gia v bo lc
gia nh i vi ph n nm 2009-2010 cho thy c ti 58% ph n b t nht 1 trong 3 loi bo
lc trong cuc i ca h (bo lc th xc, bo lc tnh dc, bo lc tinh thn). T l ny trong
12 thng trc iu tra l 27%. Khong 3% s ph n cho bit b lm dng tnh dc trc
khi n 15 tui; hu ht b lm dng bi ngi l v mt s trng hp l thnh vin gia nh
v ngi khc. V bo lc ni chung, ph n Vit Nam c kh nng b bo lc do chng gy
ra cao gp ba ln so vi bo lc do mt ngi khc gy ra. Trong kho st, 26% ph n tng b
chng gy bo lc th xc hoc tnh dc cho bit b thng tch do hu qu trc tip t hnh
vi bo lc. Trong s ny, 60% b thng tch hai ln tr ln v 17% b thng tch 5 ln tr ln.
Ph n b bo lc do chng gy ra thng nh gi tnh trng sc khe ca h mc km hoc
rt km nhiu hn. H cng gp phi nhiu hn cc vn i li hoc thc hin cc hot ng
thng ngy, b au ngi v mt tr nh, cng thng tinh thn v suy ngh tiu cc, sy thai,
no thai hoc thai cht lu. Ph n c con t 6-11 tui tng b bo lc do chng gy ra cho bit
con ci h cng c nhng vn v hnh vi (nh c mng, i dm, hnh vi hung hng v kt
qu hc tp km) so vi nhng tr c m khng b bo lc do chng gy ra. Tc ng ca bo
lc gia nh i vi sc khe tm thn th hin r trong t l ph n b trm cm.
2.3. Cc yu t lin quan tip cn dch v y t
H thng cung ng dch v y t
Mng li cung ng dch v y t Vit Nam c bao ph rng khp. Cc c s y t
c thit lp 4 tuyn, t trung ng n tnh, huyn, x v thn bn8. Nhn chung, h thng
cung ng dch v y t nc ta ang dn c i mi, ci thin; tng bc c u t nng
cp p ng nhu cu CSSK ngy cng cao ca nhn dn. Nhiu tin b khoa hc, y hc
c p dng trong chn on, pht hin sm v iu tr; nhiu k thut cao, phc tp ang
c thc hin trong cc bnh vin nh ghp gan, thn, ni soi can thip,
Bn cnh nhng thnh tu t c, vic cung ng cc dch v y t hin nay Vit
Nam cn nhiu bt cp nh: m hnh t chc nhiu bin ng; y t c s v CSSK ban u
cn nhiu hn ch; cha c s gn kt cht ch gia cc tuyn; cn tch bit gia phng bnh
v khm, cha bnh; cc hot ng y t tp trung nhiu cho khm, cha bnh; tnh trng qu
ti cc bnh vin tuyn trung ng cn nng n. Chnh sch ti chnh y t cn nhiu bt cp,
c bit l cc phng thc chi tr dch v y t. Cc vn pht sinh trong trin khai thc hin
chnh sch t ch bnh vin, nh tnh trng lm dng cc dch v y t (c bit l lm dng xt
nghim, lm dng thuc,); nng lc qun l bnh vin cn hn ch; thiu cc cng c iu
phi v kim sot bo m tnh minh bch v trch nhim gii trnh trong qu trnh thc hin
t ch dn n nhng bt cp trong cung ng dch v y t, nh hng n tnh cng bng, hiu
qu trong CSSK. Cha xy dng c h thng hiu qu kim sot v nh gi cht lng
dch v y t, trong c cc c s cng lp v t nhn.
Trong bo co ny, tuyn huyn bao gm c huyn, qun, th x v thnh ph trc thuc tnh; tuyn x bao gm
c x, phng v th trn
56
3. Cc vn u tin
Mc ny trnh by nhng vn sc khe u tin v l nhng thch thc m h thng y
t phi gii quyt trong K hoch 5 nm ti (2016-2020).
3.1. Cc vn sc khe u tin
Cc bnh bnh truyn nhim bao gm cc bnh c t l mc v t vong cao nh HIV/
AIDS, lao, st xut huyt; cc bnh c kh nng thanh ton/loi tr nh st rt, vim
no Nht Bn, bnh di v bnh phong; cc bnh mi ni c tim nng ly lan rng, gy
dch ln nh bnh dch do vi rt MERS-CoV, Ebola v mt s bnh ly truyn t ng
vt sang ngi nh cm A (H5N1), cm A (H1N1), cm A (H7N9), cm A (H5N6). Bn
cnh l mt s nguyn nhn gy gnh nng bnh tt quan trng tr em nh: vim
phi, tiu chy, vim no, vim mng no, tay-chn-ming, d tt bm sinh tr em, bnh
no do ngt th/chn thng trong khi sinh; ui nc.
Cc BKLN gy gnh nng bnh tt, t vong cao nh: cc bnh tim mch (tng huyt
p, tai bin mch mu no, bnh tim thiu mu cc b), ung th, bnh phi tc nghn
mn tnh, i tho ng, cc bnh l tm thn, thn kinh (tm thn phn lit, ng kinh,
trm cm, cc ri lon do lm dng ru, bia v ma tu) v tai nn giao thng.
Khc bit gia cc vng min, gia cc nhm dn c v cc ch s sc kho chung (t
sut t vong tr em di 1 tui, di 5 tui; t s t vong m, t l suy dinh dng tr
em) cng nh kh nng tip cn vi cc dch v chm sc sc kho.
3.2. Cc yu t nh hng n sc kho
Gi ha dn s lm gia tng nhu cu CSSK, tng gnh nng i vi cc h gia nh c
ngi cao tui v lm tng gnh nng chi tiu cho y t ca ton x hi, c bit l chi
ph cho iu tr cc BKLN mn tnh v chm sc cui i. H thng CSSK hin ti cha
theo kp vi s bin i mnh m ny;
Gia tng cc yu t nguy c do tc ng ca cng nghip ho, hin i ho v th ho
nh: nhim khng kh t sn xut cng nghip, xe c lu thng; nhim ngun nc
v thc phm; nhim do rc thi cha c x l trit ; bnh ngh nghip v tai nn
lao ng; mi trng cng vic cng thng, nhiu p lc cng cc vn t ra do qu
trnh di c v th ho.
Cc yu t nguy c v hnh vi, li sng, nht l ch n khng hp l (thiu cc thc
n c li v tha thc n c hi cho sc kho), ht thuc l, lm dng ru, bia, s dng
ma tu, li sng t hot ng th lc, cng vi cc yu t nguy c v sinh chuyn ho
nh tng huyt p, tng cholesterol mu.
3.3. H thng cung ng dch v cn nhiu hn ch
H thng cung ng dch v y t hin nay ang phn mnh, chia ct gia cc tuyn gia
YTDP v KCB, cha thc hin tt chm sc lng ghp, lin tc v cha p ng nhu
cu d phng BKLN.
Mng li y t t tuyn huyn tr xung cn yu v thiu phng tin v ng lc
hot ng nhm p ng nhu cu ngy cng cao ca 90 triu ngi, trong c nhu cu
57

c bit cao ca ngi cao tui, b m, tr em, ngi trong tui sinh , Cht lng
dch v y t cha c kim sot y .
4. Khuyn ngh
T nhng nh gi v tnh trng sc khe v cc yu t nh hng n sc khe nhn
dn nu trn, bo co khuyn ngh mt s nhm gii php chnh sch nh sau:
4.1. Xy dng chin lc ph hp vi cc vn sc kho u tin
4.1.1. Cc bnh truyn nhim
Theo di cht ch, ch o cc hot ng gim st, bo co tnh hnh dch bnh trn th
gii v trong c nc; tham kho khuyn ngh ca WHO khi xy dng k hoch ng ph
vi dch khn cp.
Cng c, tng cng cc hot ng bo m an ton tim chng; nghin cu, xem xt
m rng thm cc vc xin hiu qu chi ph trong chng trnh tim chng m rng.
Xy dng cc phng n da trn bng chng d phng v iu tr bnh nhim khun
h hp, tiu chy, vim no v mng no, giun sn, c bit tr em. Tip tc tng cng
cng tc truyn thng, gio dc ngi dn hiu, t gic v ch ng thc hin tt
cc bin php phng chng bnh dch; tip tc vn ng nhn dn trin khai xy dng
phong tro lng vn ho sc kho, phong tro v sinh nng thn vi 3 cng trnh: nc
sch, nh tm, nh tiu hp v sinh hn ch, tin ti xo b nhng tc hi i vi sc
kho nhn dn do tp qun, li sng khng hp v sinh, hoc do mi trng b nhim.
Tip tc trin khai thc hin c hiu qu cc hot ng sng lc v iu tr bnh HIV/
AIDS, lao, st xut huyt; u t v gim st cht ch vic thc hin mc tiu loi tr
vim no Nht Bn, si, st rt, phong v di; nghin cu cc phng n lng ghp cc
Chng trnh mc tiu quc gia phng chng bnh x hi.
u t kinh ph, nhn lc, c s vt cht ca a phng, cc ngun lc x hi, doanh
nghip cho cng tc phng chng HIV/AIDS; lng ghp hot ng phng, chng lao v
HIV/AIDS vo cc hot ng thng xuyn ca h thng y t v vi cc chng trnh,
d n pht trin kinh t - x hi ca a phng.
y mnh cc hot ng thng tin gio dc truyn thng v HIV/AIDS v bnh lao, ch
trng n cc nhm i tng c bit, khu vc min ni, vng dn tc thiu s.
M rng v nng cao cht lng cc hot ng can thip, c bit y mnh m rng
chng trnh iu tr nghin cc cht dng thuc phin bng thuc thay th cho cc
huyn c trn 250 ngi nghin chch ma ty.
4.1.2. Bnh khng ly nhim v tai nn giao thng
Khuyn khch khm sng lc BKLN v yu t sinh chuyn ho lin quan cc bnh ny
trong cng ng, ti ni lm vic, nhm pht hin sm v qun l hiu qu cc BKLN.
Tng cng cc can thip gim tai nn giao thng, trong thng tin truyn thng
GDSK thc hin nghim tc lut an ton giao thng, khng li xe khi ung ru, bia,
i m bo him c cht lng,
58

4.1.3. S khc bit gia cc vng min
Trin khai cc gii php hiu qu gim nhanh v bn vng t l suy dinh dng tr
em, nht l suy dinh dng thp ci, t sut cht tr em di 1 tui, di 5 tui, t s
cht m ti cc vng kh khn (Trung du v min ni pha Bc, Ty Nguyn, vng bin
o, 62 huyn kh khn nht ca Vit Nam). u t trng tm v ph hp vi nhu cu
theo m hnh bnh tt ca ngi dn ti a phng.
Tng cng u t pht trin kinh t cc vng ngho, vng su, vng xa, bo m nc
sch, h x hp v sinh, bo m tip cn vi dch v y t, ngun thng tin tm hiu
v cc bin php nng cao sc khe, phng trnh yu t c hi ti sc khe.
4.2. Gim tc hi ca cc yu t nh hng sc khe
Xy dng c s bng chng v tc hi ca nhim mi trng ti sc khe v vn ng
cc b, ngnh lin quan tng cng u t thc hin cc bin php gim nhim mi
trng, c bit nhim khng kh v ngun nc, bo m ngun nc ung sch v
h x hp v sinh cc huyn ngho v nhng vng cha bo m iu kin c bn ny.
Xy dng, iu chnh v thc hin cc k hoch i ph vi thin tai, bin i kh hu,
bnh dch mi ni, da trn thng tin gim st, nh gi hot ng chun b, ng ph
tng nm, nhm lin tc ci thin s p ng ca ngnh y t.
Tng cng v thc hin quyt lit vic gim st tnh hnh ht thuc l, s dng ru,
bia, ch n, hot ng th lc v tc ng ti cc bnh lin quan. Vn ng cc b,
ngnh iu chnh v hon thin chnh sch, thc thi v gim st tc ng ca cc can
thip ti hnh vi c hi ti sc khe.
Tng cng tuyn truyn vn ng ngi dn c ch dinh dng ph hp (b sung
cc thng ip v ch n gim nguy c BKLN nh trnh n mn), tng cng rn
luyn th lc, b ht thuc l v ma ty, trnh s dng ru, bia mc c hi. Quy nh
cht ch hn v nhn mc thc phm xc nh c ngun gc, nguyn liu c hi
trong thc phm ch bin cng nghip, v.v to iu kin thun li cho ngi dn
thc hin hnh vi c li cho sc khe.
Xy dng v ban hnh nhng chnh sch bo m cc nh my, x nghip, nhng n
v sn xut cng lp v t nhn quan tm nhiu hn na ti mi trng lao ng, sc
khe ca ngi lao ng, tng hiu bit v mi trng lm vic c hi ti sc khe v
cc cc bin php phng nga nhim, gim thiu cc nguy c bnh ngh nghip v tai
nn lao ng.
4.3. i mi v nng cao nng lc cung ng dch v y t
Kin ton v i mi h thng cung ng dch v y t theo hng tng cng phi hp,
lng ghp gia cc tuyn, gia iu tr v d phng;
Tp trung u tin u t cho CSSKB tuyn y t c s, v cho cc i tng d tn
thng nh ph n, tr em, ngi cao tui...
59
Chng II: Cp nht thc trng h thng y t

1. Nhng nhim v trng tm ca ngnh y t nm 2014
Thc hin Ngh quyt s 01/NQ-CP ngy 02/01/2014 ca Chnh ph v nhng nhim
v, gii php ch yu ch o iu hnh thc hin K hoch pht trin kinh t - x hi v d
ton NSNN nm 2014, trong nm 2014, ngnh y t cn tp trung thc hin cc nhim v trng
tm sau y:
1.1. Qun l nh nc v y t
Trnh Quc hi thng qua Lut sa i, b sung mt s iu ca Lut BHYT; Trnh Quc
hi cho kin v d tho Lut sa i, b sung mt s iu ca Lut Dc 2005, Lut v
Mu v t bo gc, Lut Dn s, Lut Phng, chng tc hi ca lm dng ru bia.
Hon thnh d tho cc Ngh nh hng dn cc Lut ban hnh trong nm 2014, cc
Thng t hng dn thc hin cc Ngh nh, c bit l cc Thng t hng dn thc
hin Ngh nh 85, Thng t v danh mc thuc, dch v k thut c BHYT thanh
ton, Thng t hng dn chuyn tuyn trong lnh vc KCB, chuyn tuyn BHYT.
Trnh Th tng Chnh ph ph duyt n tng cng nng lc thanh tra y t giai on
2014-2020; tp trung thanh tra i vi cc lnh vc: chnh sch php lut v BHYT, x
hi ha cng tc y t, qun l nh nc v lnh vc dc, cng tc u thu thuc.
Tng cng ci cch hnh chnh trong lnh vc y t. Bt u th im n o lng s
hi lng ca ngi dn vi dch v y t cng; trin khai K hoch thc hin n y
mnh ci cch ch cng v cng chc.
y mnh thc hin Ch th 03/CT-BYT ngy 01/4/2013 ca B trng B Y t v vic
tng cng thc hin tt quy tc ng x9; Pht huy hiu qu ca ng dy nng trong
ghi nhn phn hi, khiu ni ca ngi dn. Trin khai Thng t s 07 quy nh v quy
tc ng x ca cn b cng chc, vin chc, ngi lao ng ti cc n v s nghip y
t cng lp.
1.2. V nhn lc y t
Trin khai D n th im bc s tr tnh nguyn v cng tc ti min ni, vng su,
vng xa, bin gii, hi o, vng c iu kin kinh t-x hi kh khn (u tin 62 huyn
ngho);10 Thc hin ch lun phin c thi hn i vi ngi hnh ngh ti c s
khm cha bnh.
Trnh Chnh ph ban hnh mc lng khi im, lng c s ph hp vi c th ca
ngnh y t, tng bc tnh tin lng vo gi dch v nh tinh thn Ngh nh 85 v Ngh
quyt 68 ca Quc hi.
H thng y t ang trong qu trnh xy dng k hoch di hn v i mi ton din h
thng o to nhn lc y t; h thng kim nh cht lng o to nhn lc y t cng
nh kim chun cht lng u ra.
9
Ch th 03/CT-BYT ngy 01/04/2013 ca B trng B Y t.

Quyt nh s 585/QD-BYT ngy 20/2/2013 ca B trng B Y t.
10
60

1.3. V ti chnh y t
Tp trung trin khai Ngh nh 85 ca Chnh ph v c ch hot ng, c ch ti chnh
i vi cc n v s nghip y t cng lp. Xy dng v ban hnh khung gi tnh y
cc yu t chi ph p dng cho cc bnh vin c kh nng thu, c kh nng t bo
m ton b chi ph hot ng thng xuyn; sa i, b sung cc quy nh v x hi
ha, lin doanh, lin kt trong bnh vin cng cho ph hp vi tnh hnh thc t. Tng
cng t ch v ti chnh trong cc n v s nghip cng lp. Tng bc xy dng v
thc hin l trnh iu chnh gi dch v y t theo l trnh tnh ng tnh chi ph ca
Ngh nh 85/2012/N-CP ca Chnh ph.
B y t ang trong qu trnh i mi phng thc phn b NSNN cho cc c s y t
theo hiu qu hot ng v kt qu u ra; i mi phng thc chi tr dch v y t. Xy
dng v ban hnh c ch phn b ngn sch cho cc c s y t d phng, cc lnh vc
nh kim nghim, kim nh, dn s/KHHG, truyn thng gio dc sc khe.
Tp trung thc hin L trnh BHYT ton dn; m rng BHYT c v bao ph, gi
dch v v kh nng bo v ti chnh cho cc i tng tham gia BHYT; tip tc trin
khai Ngh quyt 21-NQ/TW ca B Chnh tr v Tng cng s lnh o ca ng i
vi cng tc Bo him x hi (BHXH) - BHYT giai on 2012-2020, Ngh quyt s
68/2013/QH13 ngy 29/11/2013 ca Quc hi v y mnh thc hin chnh sch php
lut v BHYT.
Bo m kinh ph mua, h tr mua th BHYT cho ngi ngho, ngi thuc din
chnh sch v bo tr x hi, tng bc chuyn phn ngn sch cp cho cc bnh vin
sang cp trc tip cho ngi th hng thng qua vic mua hoc h tr mua th BHYT,
tng t l bao ph BHYT gim bt gnh nng ti chnh ca ngi dn khi i khm,
cha bnh.
1.4. V dc v trang thit b y t
Bo m thuc, trang thit b thit yu phc v cng tc d phng v iu tr, trin
khai cc bin php hu hiu bnh n gi thuc.
Tng cng kim tra, gim st bo m cht lng thuc. y mnh trin khai cc
gii php s dng thuc an ton, hp l, tng bc gim vic lm dng thuc trong
iu tr cc c s y t Nh nc v t nhn.
Cc a phng, n v thc hin tt vic u thu mua thuc theo quy nh gp phn
bnh n gi thuc. y mnh cuc vn ng Ngi Vit dng thuc Vit.
Xy dng k hoch hnh ng trin khai Chin lc pht trin ngnh dc Vit Nam
giai on n nm 2020 v tm nhn n nm 2030; trin khai thc hin n Ngi
Vit Nam u tin dng thuc Vit Nam.
1.5. V phng chng dch bnh, an ton thc phm
Tip tc tng cng cng tc truyn thng, gio dc sc khe, trin khai c hiu qu cc
CTMTQG v y t, khng dch ln xy ra, nu xy ra phi c cc bin php khng
ch kp thi;
61

Tp trung ch o cng tc an ton v sinh thc phm; cng tc tim chng m rng
duy tr t l tim chng; xy dng v trin khai cc hot ng phng chng v qun
l c cc BKLN nh bnh tim mch, ung th, tiu ng; bnh ngh nghip; phng
chng tai nn thng tch;
Tip tc trin khai tt cng tc phng, chng HIV/AIDS, m rng iu tr thuc khng vi
rt (ARV), m rng iu tr thay th nghin cc cht dng thuc phin bng Methadone,
thc hin mc tiu 3 gim ca Vit Nam (gim nhim HIV, gim t vong lin quan n
HIV/AIDS, gim k th); hng ng mc tiu 90-90-90 ca Lin Hp Quc v phng
chng HIV/AIDS (90% ngi nhim HIV c pht hin; 90% ngi nhim HIV c
iu tr ARV; 90% bnh nhn c iu tr c ti lng virus HIV thp); trin khai n
bo m ti chnh bn vng cho phng, chng HIV/AIDS;
Xy dng k hoch thc hin Ngh quyt s 05/NQ-CP ca Chnh ph v y mnh vic
thc hin cc Mc tiu pht trin thin nin k trong lnh vc y t.
1.6. V y t c s
Hon thin mt s vn bn v t chc, hot ng ca y t c s: chc nng, nhim v
ca trung tm y t huyn, trm y t x; xy dng n tng cng nng lc y t c s
trong tnh hnh mi;
Cng c v hon thin mng li y t c s v t chc, c s vt cht, trang thit b, i
ng cn b v c ch hot ng nhm nng cao cht lng dch v CSSKB, p ng
nhu cu CSSK ca ngi dn ngay ti cng ng, y mnh vic thc hin n bc s
gia nh rt kinh nghim v trin khai rng ri t 2015-2016.
1.7. V khm bnh, cha bnh
Tp trung y mnh vic thc hin mt s D n trng im nh: hon thnh c s Tn
Triu ca Bnh vin K quy m 1000 ging bnh; Bnh vin Nhi trung ng; D n
Trung tm Ung bu v tim mch tr em, khoa khm bnh thuc Bnh vin Bch Mai;
D n Trung tm ung bu, khoa khm bnh thuc Bnh vin Ch Ry; y nhanh tin
thc hin mt s d n Trung tm Ung bu ca cc bnh vin a khoa thuc B Y
t ti Ung B, Thi Nguyn... Trong nm 2014, khi cng c c s II ca 5 bnh vin
tuyn trung ng v tuyn cui.
Cc a phng phi tp trung vn tri phiu Chnh ph giai on 2012-2015, giai on
2014-2016, ngn sch a phng v cc ngun vn hp php khc hon chnh, a
v s dng cc bnh vin tuyn huyn, tuyn tnh.
Tp trung ci tin khu vc khm bnh, gim thi gian ch i ca ngi bnh, gim s
lt khm/bc s/ngy; tng bc gim tnh trng qu ti, nm ghp, trong tp trung
vo trin khai mnh 15 d n Bnh vin v tinh ca cc chuyn khoa: Ung bu, Tim
mch, Nhi, Sn, Ngoi, Chn thng chnh hnh.
1.8. V dn s - k hoch ho gia nh
Thc hin linh hot cc gii php nhm bo m mc sinh thp, hp l v gim mt cn
bng gii tnh khi sinh.
62

xut sa i, b sung cc chnh sch tn dng giai on dn s vng, thch ng
vi gi ha dn s.
2. Tnh hnh thc hin K hoch bo v, chm sc v nng cao sc

khe nhn dn giai on 2011-2015
2.1. Tng cng nng lc qun l ca ngnh y t
2.1.1 Tnh hnh thc hin
1) Ci thin nng lc v cht lng chin lc, quy hoch, chnh sch y t
Kt qu thc hin
B Y t phi hp vi cc b, ngnh lin quan xy dng, trnh Chnh ph, Th tng
Chnh ph ban hnh nhiu vn bn php quy, n quan trng, lm c s trin khai cc
hot ng ca ngnh; hon thnh d tho Lut sa i, b sung mt s iu ca Lut BHYT
trnh Chnh ph trnh Quc hi xem xt, thng qua vo k hp th 7, thng 6/2014. hon
thnh d tho Lut sa i, b sung mt s iu ca Lut Dc 2005, trnh Quc hi vo thng
5/2014. Tuy nhin, y ban Thng v Quc hi c cng vn s 695/UBTVQH13-PL ngy
22/06/2014 ngh B Y t tip tc nghin cu, chun b d n Lut sa i, b sung mt s
iu ca Lut Dc theo hng m rng phm vi iu chnh xy dng thnh Lut Dc (sa
i). B Y t ang khn trng phi hp vi cc b, ngnh lin quan nghin cu kin ca y
ban Thng v Quc hi hon thin d n Lut. ang tin hnh kho st, nghin cu xy
dng d tho Lut v Mu v t bo gc, Lut Phng, chng tc hi ca lm dng ru, bia,
Lut Dn s.
Trong nm, B Y t t 100% theo k hoch xy dng vn bn quy phm php lut
ng k vi Chnh ph. Nhiu ngh nh, ngh quyt ca Chnh ph, quyt nh, n
c Chnh ph v Th tng Chnh ph ban hnh, trong c Ngh quyt 05/NQ-CP ngy
13/01/2014 ca Chnh ph v y mnh thc hin cc Mc tiu pht trin Thin nin k trong
lnh vc y t; Ngh nh s 176/N-CP ngy 14/11/2013 Quy nh x pht vi phm hnh chnh
trong lnh vc y t; Ngh nh s 178/N-CP ngy 14/11/2013 Quy nh x pht vi phm hnh
chnh v an ton thc phm.
Mt s quyt nh quan trng v cc ch , chnh sch, ph duyt cc n lm c
s trin khai cc hot ng ca ngnh, nh: n gim qu ti bnh vin giai on 20132020; n Bo m ti chnh cho hot ng phng, chng HIV/AIDS giai on 2013-2020;
nPhttrinytbin,oVitNam nnm2020; Chin lc quc gia phng, chng
tc hi ca thuc l n nm 2020; n khuyn khch o to v pht trin nhn lc y t cc
chuyn ngnh Lao, Phong, Tm thn, Php y v Gii phu bnh giai on 2013-2020; n
xy dng h thng cnh bo nhanh v phn tch nguy c v an ton thc phm ti Vit Nam;
Ch lun phin c thi hn i vi ngi hnh ngh ti c s khm bnh, cha bnh; Nng
mc h tr mua BHYT cho mt s i tng ngi thuc h gia nh cn ngho; Quy hoch
tng th pht trin dc liu n nm 2020 v nh hng n nm 2030, n nng cao nng
lc thanh tra y t n nm 2020,.
B Y t cng hon thin v trnh Chnh ph, Th tng Chnh ph i vi d tho
mt s ngh nh, quyt nh, n nh: Ngh nh quy nh chi tit thi hnh mt s iu ca
63

Lut Phng, chng tc hi ca thuc l; Ngh nh v qun l trang thit b y t; Quyt nh v
quy hoch pht trin h thng y t n nm 2020 v tm nhn 2030 thay th Quyt nh 153/
Q-TTg, n kim sot mt cn bng gii tnh khi sinh giai on 2013-2020.
V cng tc xy dng, ban hnh cc vn bn php quy thuc thm quyn ca B Y t,
ban hnh c 12 Thng t lin tch, 23 Thng t ca B Y t v nhiu Quyt nh theo
thm quyn thuc cc lnh vc nh: Khm, cha bnh, Dc v u thu thuc, Trang thit b
v Cng trnh y t, Phng, chng HIV/AIDS, Sc khe b m, tr em, Khoa hc cng ngh v
o to, Y dc c truyn, Bo him y t, Dn s - KHHG, Mi trng y t, Cng ngh thng
tin; ph duyt n bc s tr tnh nguyn v cng tc vng ni, vng su, vng xa, vng kh
khn, ph duyt n bnh vin v tinh; ph duyt n bc s gia nh.
B Y t t chc tp hun cc vn bn quy phm php lut v cng tc theo di, nh
gi tnh hnh thi hnh php lut v k nng thc hin; t chc nh gi vic thi hnh cc vn
bn quy phm php lut; trin khai cc vn bn quy phm php lut v y t mi ban hnh; tham
gia gii thch php lut v gii thiu mt s Lut c Quc hi thng qua.
B Y t cng ang tin hnh tng kt 30 nm i mi ngnh y t, chun b cc ni dung
v y t xut a vo vn kin i hi ng ln th XII v K hoch pht trin kinh t x
hi 2016-2020.
Kh khn, hn ch
Vic trin khai thc hin k hoch xy dng vn bn quy phm php lut i khi cn
chm, t l hon thnh theo ng k hoch cha cao. Mt s n trong Chng trnh xy
dng vn bn quy phm php lut ca B Y t trnh Chnh ph cng chm, thay i thi gian
trnh nhiu ln.
Cng tc nghin cu, nh gi tc ng trong lp d kin chng trnh cn hn ch do
thiu kinh ph, thi gian v nhn lc. Cng tc ph bin, gio dc php lut cn cha c quan
tm ng mc. Vic ph bin, gio dc php lut v cng tc theo di thi hnh php lut ch
yu mi ch c nh gi thng qua bo co bng vn bn t cc n v; vic trin khai php
in h thng quy phm php lut v y t gp nhiu kh khn.
2) Cng c, hon thin v n nh b my t chc ngnh y t t trung ng n a phng
Kt qu thc hin
Quy hoch h thng y t Vit Nam n nm 2020, nh hng 2030 hin ang c
hon thin, trnh Th tng Chnh ph vi mc tiu bo m tnh h thng v tnh lin tc trong
hot ng chuyn mn ca tng tuyn v gia cc tuyn, trnh u t dn tri, nng cao hiu
qu v u t v s dng nhn lc, c s vt cht, trang thit b. i vi mng li khm cha
bnh, thc y vic xp hng bnh vin, khng cng nhc theo tuyn, tin ti khng cn bnh
vin khng c xp hng. Ngi bnh c tip cn c s khm cha bnh khng theo a
gii hnh chnh. i vi lnh vc y t d phng, u t pht trin theo hng thu gn u mi,
chun ho, hin i ho; tng bc sp xp, lng ghp cc trung tm, gim dn u mi tuyn
tnh, thnh lp c quan d phng v kim sot bnh tt tnh, thnh ph.
B Y t tin hnh kin ton t chc cc n v theo Ngh nh 63/2012/N-CP ngy
31/8/2012 ca Chnh ph quy nh chc nng, nhim v, quyn hn v c cu t chc ca B
64

Y t. B trng B Y t ph duyt chc nng, nhim v ca cc V, Cc trc thuc B Y t.
Ch o cc n v xy dng v ban hnh iu l, quy ch t chc v hot ng ca cc n v
trc thuc B Y t v xc nh li chc nng, nhim v ca mt s n v ngnh y t.
V t chc b my y t ti cc a phng, Chnh ph ban hnh Ngh nh s 37/2014/
N-CP quy nh t chc cc c quan chuyn mn thuc U ban nhn dn (UBND) huyn,
qun, th x, thnh ph thuc tnh, trong quy nh Phng Y t l c quan tham mu, gip
UBND cp huyn thc hin chc nng qun l nh nc v y t. B Y t tip tc xy dng
Thng t ca B Y t quy nh chc nng, nhim v, quyn hn v c cu t chc ca Trung
tm Y t huyn, qun, th x, thnh ph thuc tnh, thnh ph trc thuc Trung ng.
B Y t cng ang tip tc d tho Ngh nh quy nh t chc b my v ch chnh
sch i vi cn b y t x, phng, th trn thay th cho Quyt nh s 58/TTg ngy 03/02/1994
ca Th tng Chnh ph. D tho hon thnh, ang xin kin ca cc b, ngnh trc khi
trnh Chnh ph xem xt, ph duyt.
Kh khn, hn ch
Mc d B Y t ang khn trng xy dng Quy hoch h thng y t Vit Nam n
nm 2020, nh hng 2030, tuy nhin tin cn chm, cha p ng c mc tiu ra do
y l ni dung phc tp, lin quan n nhiu vn v t chc, b my, c ch, nhn lc c
trung ng v a phng, mi quan h qun l, iu hnh gia cc c quan trung ng v
a phng.
Vic t chc li m hnh y t tuyn huyn thnh bnh vin huyn, TTYT d phng,
phng y t, v vic phn cng li nhim v gim st hot ng ca trm y t to ra s mt n
nh, xo trn v nhn lc v nng lc cung cp dch v tuyn y t c s. Quy nh v chc
nng nhim v ca cc n v y t tuyn huyn hin vn cn nhiu bt cp, gy cn tr trong
vic thc thi cc nhim v chuyn mn. C cu t chc b my ca cc c s y t, c bit
tuyn y t c s vn cha c chnh sa, hon thin p ng vi s thay i ca m hnh
bnh tt, nhu cu chm sc sc khe ca ngi dn. Thiu s gn kt, phi hp gia y t d
phng v iu tr, gia y t cc tuyn x, huyn, tnh v trung ng. Vic iu chnh t chc y
t tuyn huyn cha th thc hin c do phi iu chnh Lut t chc hi ng nhn dn, y
ban nhn dn.
S mt cn i trong cung ng dch v KCB theo cc tuyn, s thiu kt ni v chm
sc lin tc gia cc tuyn trong iu tr, chm sc, t vn cho ngi bnh. Hu nh khng cn
s gn kt trong KCB gia tuyn huyn v tuyn x nht l i vi cc huyn c bnh vin tch
hot ng c lp vi TTYT huyn, do thay i m hnh t chc qun l y t tuyn huyn din
ra lin tc trong khong gn 15 nm nay.
3) Nng cao vai tr v nng lc qun l, lp k hoch y t
Kt qu thc hin
V cng tc ci cch hnh chnh, B Ni v cng b kt qu xc nh ch s ci cch
hnh chnh nm 2013 ca cc b, c quan ngang b, UBND tnh thnh ph. Theo , mc d
vn trong nhm cui, nhng ch s ny ca B Y t c s ci thin ng k, tng ln gn
10 im so vi nm 2012, t 74,19 im. tng cng cng tc ci cch hnh chnh, B Y t
c Quyt nh 436/Q-BYT ngy 7/2/2014 ban hnh k hoch ci cch hnh chnh ca B
65

Y t nm 2014 gm 8 lnh vc: ci cch th ch, ci cch th tc hnh chnh, ci cch t chc
b my, xy dng v nng cao cht lng i ng cn b cng chc, ci cch ti chnh cng,
thc hin n y mnh ci cch ch cng v, cng chc, hin i ha nn hnh chnh,
cng tc ch o iu hnh.
V cng tc k hoch, B Y t nghim thu v cng nhn ti liu Khung k hoch v
Hng dn xy dng K hoch y t tuyn tnh do D n H tr i mi h thng y t Vit Nam
(Rockefeller Foundation ti tr) v D n H tr nng cao nng lc ngnh y t do Phi on
Lin minh chu u (EC) ti tr (Quyt nh s 1058/Q-BYT ngy 26/3/2014).
B Y t tip tc t chc cc lp tp hun v nng cao nng lc qun l, lp k hoch y
t. Trong khong thi gian t thng 5 n thng 7/2014, B Y t t chc cc lp tp hun
cho cn b ca S Y t v cc n v trc thuc S v nng cao nng lc lp k hoch v ngn
sch y t (do EC v Rockefeller Foundation ti tr thng qua cc d n). Mt s lp tp hun v
qun l, lp k hoch cng s c thc hin trong khun kh cc d n tng cng nng lc
h thng y t do GAVI, Qu Ton cu v cc t chc quc t khc ti tr. Mt s a phng
bt u xy dng K hoch y t tuyn tnh theo cc khung, biu mu mi tp hun, bc u
c nhng chuyn bin nht nh.
Kh khn, hn ch
Ti B Y t, T cng tc k thut v k hoch v ti chnh thuc Nhm i tc Y t
c thnh lp trong nm 2012. Tuy nhin, trong nm 2013 hot ng cn cha c thng
xuyn v thiu cc c ch lm vic c th ng gp chung cho cng tc k hoch-ti chnh
ca ngnh y t. Mc d cc a phng xy dng k hoch theo hng dn mi, nhng vic
trin khai thc hin vn kh khn do a phng ch bo m c mt s ngn sch c nh,
kh c kh nng tng thm, nh mc chi tiu thp nn c s khc bit gia nhu cu kinh ph
k hoch v nhu cu thc t. Cn b lp k hoch vn cha c ng lc ln thay i phng
php lp k hoch theo hng chi tit, c th. Thng tin, s liu y t phc v cng tc lp k
hoch vn cha c nhng chuyn bin ng k. S liu cha bo m tnh kp thi, chnh xc
v tin cy nn vic xy dng k hoch, chnh sch y t da trn bng chng cn gp kh khn.
Cha thc hin thng xuyn vic nh gi tc ng ca cc chnh sch y t nhm xc nh cc
vn vng mc kp thi iu chnh.
4) Tng cng cng tc thanh tra, kim tra, gim st
Kt qu thc hin
B Y t xy dng v trnh Chnh ph Ngh nh v t chc v hot ng ca thanh
tra y t. Trc mt s nhng s vic xy ra trong ngnh y t (phn ng sau tim vc xin, nhn
bn phiu kt qu xt nghim,.), B Y t xy dng v trin khai k hoch thanh tra y t,
tp trung vo cc lnh vc: cng tc qun l nh nc v an ton thc phm, ha cht ch phm
dit cn trng v dit khun s dng trong lnh vc gia dng v y t, kinh doanh, s dng cc
sn phm dinh dng dng cho tr nh, thanh tra ton din mt s bnh vin trc thuc B Y
t, cc c s hnh ngh y dc ngoi cng lp, vic thc hin chnh sch php lut v BHYT,
x hi ha, qun l nh nc v lnh vc dc, u thu thuc, gi thuc v s dng thuc, vic
thc hin ch thu, chi ti chnh v phng chng tham nhng, thc hnh tit kim, chng lng
ph. Qua cng tc thanh tra, kim tra kin ngh khc phc cc s h trong c ch chnh sch
66

v php lut, xut vi Lnh o B cc gii php gip n nh v cng tc t chc ca cc
n v trc thuc, x l nghim cc c nhn, t chc vi phm.
Thanh tra y t ca 63 tnh, thnh ph trin khai thanh tra v cc lnh vc an ton thc
phm, khm cha bnh, dc m phm, trang thit b y t ti 703762 c s. Qua thanh tra
pht hin v x pht vi tng s tin l 30,8 t ng, nh ch 325 c s v y t v tc giy
php c thi hn 19 c s hnh ngh y, dc.
Kh khn, hn ch
Cc kh khn, hn ch trong cng tc thanh tra y dc ch ra trong bo co JAHR
2013 vn cha c gii quyt nh b my t chc v nhn lc thanh tra y t qu mng, mi
tnh ch c mt vi thanh tra, tuyn huyn khng c chc nng thanh tra.
Kinh ph dnh cho cng tc thanh tra, kim tra, gim st cn rt hn ch trong khi y l
mt trong nhng chc nng c bn ca cng tc qun l nh nc v y t.
Cc hot ng thanh tra, kim tra hin nay ch yu mang tnh cht b ng, c thc
hin sau khi c cc s vic xy ra.
Cng tc gim st cha c quan tm mt cch ng mc ti cc c quan qun l nh
nc ti trung ng v a phng do nhiu nguyn nhn: thiu kinh ph, thiu nhn lc, khi
lng cng vic ln, i tng cn kim tra, gim st ln, trch nhim qun l cha c thc
thi y .
Cng tc t kim tra ti mt s n v s nghip y t cn cha c thc hin y .
Thiu cc cng c t gim st, t kim tra cc n v c th pht hin nhng vn ni ti
ca n v mnh v c nhng hnh ng kp thi khi s vic cha xy ra.
5) Tng cng s tham gia cc bn lin quan trong qu trnh hoch nh chnh sch, xy
dng v trin khai k hoch y t
Kt qu thc hin
B Y t tip tc c nhng n lc ln tng cng s tham gia ca cc bn lin quan
trong qu trnh xy dng, hoch nh chnh sch. y l yu cu bt buc trong quy trnh xy
dng chnh sch y t. Trong qu trnh xy dng cc chin lc, quy hoch ca ngnh u ch
trng thu ht s tham gia ca cc bn lin quan, thu thp cc bng chng, nh gi, xin kin
rng ri ca cc cc b, ngnh, U ban nhn dn tnh, thnh ph, S Y t cc a phng, cc
i tc pht trin, ngi dn. D tho cc vn bn, chnh sch ca B Y t c ng ti trn
cng thng tin in t ca B Y t, cng thng tin in t ca Chnh ph ly kin cc bn
lin quan. T chc cc hi ngh, hi tho ly kin trc tip v xin kin bng vn bn ca cc
b, ngnh, cc chuyn gia.
Kh khn, hn ch
Mc d c nhiu n lc, song s tham gia ca cc bn lin quan trong qu trnh hoch
nh chnh sch, xy dng v trin khai hot ng y t cn hn ch, mt s knh ng gp
kin cn nng v hnh thc, th tc, t hiu qu. Vic ng ti thng tin trn website ca B Y
t, trn cng thng tin in t ca Chnh ph t c ngi dn v cc ban, ngnh, on th
quan tm, ng gp kin.
67

6) y mnh cc hot ng x hi ha mt cch hp l. Khuyn khch cc thnh phn kinh
t u t pht trin cc dch v y t
Kt qu thc hin
B Y t ban hnh Ch th s 05/CT-BYT ngy 22/5/2014 v vic Tng cng kim
tra, chn chnh cng tc x hi ha, khm cha bnh theo yu cu11 trong cc c s khm, cha
bnh cng lp. tng cng v pht huy mt tch cc, kp thi pht hin v chn chnh nhng
mt cn tn ti trong vic thc hin chnh sch x hi ha, B Y t ang khn trng xy dng
ban hnh Thng t hng dn khm, cha bnh theo yu cu; sa i, b sung Thng t s
15/2007/TT-BYT. ng thi B Y t cng tng cng cng tc kim tra pht hin nhng
tn ti trong x hi ha cng tc y t. Vo cui nm 2013 v u nm 2014, B Y t t chc
mt s on kim tra, nh gi v yu cu cc n v tng kt, nh gi.
V s pht trin ca lnh vc y t t nhn trong khm cha bnh, theo s liu ca Cc
Qun l KCB, hin c nc c 170 bnh vin t nhn vi 8627 ging bnh, chim 11% tng
s cc bnh vin trn c nc, hn 30000 phng khm t nhn v c s dch v y t. T l
gng bnh vin t chim 4,2% tng s ging bnh, t khong 1 ging bnh/vn dn [44].
Hu ht cc bnh vin ny c c s vt cht, trang thit b kh tt; i ng y bc s tn tnh, chu
o. Vic pht trin cc bnh vin t nhn s gp phn ln trong vic tng s ging bnh, nng
lc p ng nhu cu khm cha bnh ca ngi dn.
V tng cng hp tc cng-t, trong thng 2/2014, B Y t v Ngn hng Th gii
(WB) phi hp t chc Hi tho Kt hp cng t trong cung cp dch v y t. Khai thng mi
trng u t v la chn m hnh. B Y t t chc 2 Hi ngh tng cng phi hp gia
bnh vin nh nc v t nhn, thc hin n gim ti bnh vin ti cc tnh pha Nam. Mt
s gii php ra tng cng s hp tc gia hai loi hnh bnh vin nh phi hp khai thc
k thut cao, t vn, h tr chuyn mn, chuyn bnh nhn t bnh vin nh nc sang t nhn
khi xy ra qu ti, bnh vin t tham gia mng li v tinh, c c ch, chnh sch m cho php
bc s t cng lp sang bnh vin t khm, iu tr cho bnh nhn khi c mi hoc tham gia
lm vic ngoi gi ti cc bnh vin t.
Kh khn, hn ch
Kt qu kim tra, gim st cho thy vn cn mt s hn ch trong qu trnh trin khai
ch trng x hi ha. Mt s n v cha thc hin theo ng quy trnh, th tc nh: cha xy
dng n, cha bn bc cng khai, dn ch, cha bo co c quan qun l cp trn theo di
v qun l; mt s n v cha xy dng c cu gi dch v theo quy nh, cha cng khai gi
ngi dn bit, la chn; mt s n v c xu hng tm nhiu cch tng ngun thu, d
dn n tnh trng lm dng k thut, thuc, xt nghim, hiu sut s dng dch v thp; cch
b tr phng khm, khu iu tr theo yu cu cha hp l dn n ngi bnh cm thy b phn
bit i x, cha yn tm v s minh bch gia cng - t trong khm cha bnh theo yu cu.
Cha c nhiu bnh vin t nhn c thng hiu khin t l khm cha bnh ca khi
ny vn rt thp, ch chim gn 7% iu tr ngoi tr v 6% iu tr ni tr; 56,9% s bnh vin
Bao gm chn bc s iu tr hoc phu thut, yu cu c iu tr trong khu chm sc c bit, yu cu cc
xt nghim, chn on hnh nh khng c ch nh bi bc s hoc thc hin cc dch v chn on hoc iu
tr s dng thit b cng ngh cao hn so vi tiu chun, yu cu iu tr trong cc phng bnh tin nghi hn, hoc
yu cu c khm cha bnh vi thi gian ch i ngn hn, b li bnh nhn phi tr ph cao hn hoc ph
b sung cao hn mc ph chnh thc ca bnh vin.
11
68

c cng sut s dng ging bnh di 60%. c bit, bnh vin t nhn ch phc v khong
di 4% lt khm bo him y t.
Vic trin khai thc hin hp tc cng-t vn cn gp kh khn. Thiu mt h thng c
ch, chnh sch ton din v hp tc cng t trong y t, t loi hnh u t n th tc trin khai
phc tp, c ch s dng vn Nh nc vo cc d n cha r rng khin vic cc d n
hp tc cng t trong lnh vc y t cha thc s hp dn cc nh u t t nhn.
2.1.2. Khuyn ngh cc gii php b sung
1) Ci thin nng lc v cht lng chin lc, chnh sch, quy hoch y t
Nng cao nng lc hoch nh chnh sch cho cc cng chc, vin chc cc v, cc,
vin thuc B Y t bng nhiu bin php, trc mt l t chc o to, tp hun trong
v ngoi nc.
Xc nh r cc ngun ngn sch trong k hoch/chin lc, vi cc phng php huy
ng ph hp, bo m ngun ti chnh cho vic trin khai thc hin.
2) Cng c v n nh b my t chc ngnh y t t trung ng n a phng
T chc tng kt, nh gi m hnh t chc y t ti a phng iu chnh t chc,
b my, chc nng nhim v ca cc n v YTDP v KCB cho ph hp vi thc t ca
a phng.
Xy dng c ch phi hp, lng ghp gia cc n v y t, chng trnh y t trong cung
ng cc dch v khm cha bnh, d phng v nng cao sc kho, c bit ti tuyn y
t c s.
Sm hon thnh xy dng cc vn bn lin quan n t chc h thng cung ng dch v,
tp trung nng cao cht lng cung ng dch v y t v ly CSSK lm nn tng, bo
m tnh hiu qu, kh nng tip cn v kh nng chi tr.
Xy dng chun nng nng lc cung ng dch v c bn cho tuyn huyn v mng li
cc c s y t tuyn di.
3) Nng cao nng lc qun l, lp k hoch y t
Xy dng c ch khuyn khch i mi lp k hoch v lp d ton ngn sch ti cc a
phng, bao gm c ph duyt quy trnh lp k hoch y t cc lnh vc v cc tuyn
khc nhau v ci thin vic lp d ton ngn sch thc hin k hoch.
Sm c nh hng v trin khai xy dng K hoch 5 nm ngnh y t giai on 20162020, c tham vn cc nh ti tr ni dung k hoch gn cht ch vi nhng u tin
ca ngnh trong giai on ti. Gn xy dng k hoch vi theo di nh gi ni dung
ca K hoch thng qua cc K hoch hng nm.
Cng c li thnh phn v xy dng ni dung, chng trnh hot ng ca nhm k
thut v k hoch v ti chnh y t ng gp c hiu qu cho cng tc k hoch v ti
chnh y t.
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4) Tng cng cng tc thanh tra, kim tra, gim st
Tng cng cng tc kim tra, gim st theo di, nh gi thc hin cc chnh sch
y t ti trung ng v a phng, kp thi pht hin cc kh khn, tn ti v iu chnh
cc chnh sch cho ph hp.
B Y t v cc a phng cn dnh mt t l ngn sch thch ng cho cng tc kim
tra, gim st, coi y l mt trong nhng nhim v trng tm trong cng tc qun l nh
nc v y t.
Xy dng c ch tip nhn, phn hi thng tin t kin ca cc bn lin quan (c quan
thc hin chnh sch ti a phng, ngi dn, doanh nghip) trong qu trnh trin khai
thc hin chnh sch.
5) Tng cng s tham gia cc bn lin quan trong qu trnh hoch nh chnh sch, xy
dng v trin khai k hoch y t
Tng cng i thoi chnh sch gia cc c quan hoch nh chnh sch, c quan thc
thi chnh sch, nh nghin cu v ngi dn thng qua cc hi ngh, hi tho, din n,
website.
Tng cng xy dng chnh sch da trn bng chng. Thc hin cc nghin cu c th
theo hnh thc n t hng gia c quan qun l v n v nghin cu sn phm ca
cc nghin cu c th s dng trc tip cho hoch nh chnh sch.
6) y mnh cc hot ng x hi ha mt cch hp l; Khuyn khch cc thnh phn kinh
t u t pht trin cc dch v y t
Tng cng kim tra, gim st hot ng x hi ha trong lnh vc khm cha bnh ti
c Trung ng v cc a phng.
Khn trng xy dng ban hnh Thng t hng dn khm, cha bnh theo yu cu;
sa i, b sung Thng t s 15/2007/TT-BYT v hng dn cng tc x hi ha.
Xy dng hnh lang php l mnh, c th thc y quan h i tc cng t trong
lnh vc y t. Xy dng, trin khai th im cc chng trnh d n u t theo hnh thc
cng-t kt hp c th rt kinh nghim, hon thin v pht trin m hnh. Xy dng
c ch phi hp cng-t nhm pht huy hiu qu, hiu sut ng thi khc phc nhng
hn ch ca x hi ha y t.
2.2. Nhn lc y t
1) Xy dng i ng nhn lc y t v s lng v bo m v cht lng, cn i v c

cu v phn b hp l, p ng nhim v bo v v chm sc sc khe nhn nhn
Kt qu thc hin
S lng nhn lc y t cc loi tng qua cc nm, bao gm c s lng bc s, dc s
70

i hc12 v iu dng. Nm 2013 t 7,5 bc s/vn dn v 2,01 dc s i hc/vn dn
[45]. i chiu vi ch tiu 8 bc s/vn dn v 1,8 dc s i hc/vn dn trong K hoch 5
nm 2011-2015 ca ngnh y t th ch tiu v dc s i hc t c. T s bc s trn vn
dn vn cn mt khong cch kh ln so vi ch tiu t ra [9].
Y t tuyn huyn cng c s ci thin v nhn lc y t. Tng s nhn lc y t trong khu
vc cng lp tng qua cc nm. Tng s bc s tuyn huyn tng t 15521 nm 2010 ln 16213
nm 2011 v 16738 nm 2012. Tng s dc s i hc cc bnh vin huyn tng t 698 nm
2010 ln 1009 nm 2012. T s dc s i hc/bc s cng tng ln, trong tng nhiu nht
vng ng bng Sng Cu Long. T l bnh vin huyn khng c dc s i hc gim t
21,3% nm 2010 xung 19,9% nm 2012 [46].
Ti tuyn x, hin c nhn lc y t lm vic gn nh 100% trm y t trn ton quc.
Nm 2013 c 76,9% trm y t x c bc s lm vic (bao gm c cc trm y t x c bc s lm
vic t 3 ngy/tun tr ln) [45]. T l ny thp hn cc huyn min ni pha bc v Ty
Nguyn, ng bng sng Cu Long, nht l mt s huyn min ni, vng su, vng xa. So
vi mc tiu t ra l 80% trm y t x c bc s lm vic vo nm 2015, t l ni trn khng
cn xa. Nhng trong bi cnh cc ch , chnh sch thu ht nhn lc y t cha c hiu qu, tnh
trng chy mu bc s ang din ra, th vic t c ch tiu ny cng l mt thch thc. C
cu cn b y t tuyn x cha c s thay i, bc s vn ch chim khong 11% tng s cn
b y t x. C cu y s, h sinh, iu dng cao ng, trung cp kh n nh v bo m thc
hin nhim v [47]. C 97,3% trm y t x c h sinh hoc y s sn nhi (so vi ch tiu t ra l
95%); 75,5% thn, bn, p, t dn ph trong c nc c nhn vin y t hot ng (ch tiu
t ra l 90%). Ring khu vc nng thn, t l ny t 95,8% [45].
Ngun b sung cho i ng nhn lc y t kh di do. S lng c s o to v quy
m o to ca cc trng tip tc tng, tuy khng cn tng nhiu nh trc y. S lng
sinh vin i hc ra trng tip tc tng nhanh, nm 2014 c trn 7000 bc s ra trng, tng
hn 1000 so vi nm 2013. c tnh trong 3 nm tip theo, con s ny s tip tc tng vi tc
nh vy. S lng dc s i hc tt nghip tng t hn 1000 nm 2009 ln hn 2000 nm
2012 v vo khong 3000 nm 2013. Ngun nhn lc iu dng bao gm bc i hc, cao
ng, trung cp rt ln. Vi ch tiu tuyn sinh trung cp iu dng t khong trn 10000
nm 2006 v tng dn n trn 20000 vo 2014, ch tiu tuyn sinh cao ng tng nhanh t hn
1000 nm 2006 ln gn 15000 nm 2013, ch tiu tuyn sinh iu dng i hc cng tng u
n t hn 1500 nm 2006 ln gn 5000 nm 2013, ngun cung ca i tng ny ang vt
qu nhiu so vi nhu cu ca h thng y t. Tnh trng cung nhiu hn cu cng xy ra vi y s,
dc trung cp v tng lai khng xa l dc cao ng [48].
tip tc gii quyt vn phn b bt hp l nhn lc y t gia cc vng min v
cc chuyn khoa, B Y t tip tc xy dng v trin khai cc chnh sch pht trin nhn lc y
t. Quyt nh 319/Q-TTg ngy 7/2/2013 ca Th tng Chnh ph v vic ph duyt n
khuyn khch o to v pht trin nhn lc y t cc chuyn ngnh Lao, Phong, Tm thn, Php
y, Gii phu bnh giai on 2013-2020 cng vi cc vn bn quy nh lin quan n chnh sch
u i ngh, ph cp c th bc u gii quyt mt phn thiu ht nhn lc trong lnh vc
ny [49]. D n Th im a bc s tr tnh nguyn v cng tc ti min ni, vng su, vng
xa, bin gii, hi o, vng c iu kin kinh t - x hi kh khn (u tin 62 huyn ngho)
Dc s i hc l nhng ngi tt nghip i hc dc, phn bit vi dc s trung hc (tt nghip trung cp
dc) v dc t (tt nghip s cp dc).
12
71

c B trng B Y t ph duyt v bt u trin khai t 2014. D kin n nm 2016 s c
khong 500 bc s tr v cng tc ti vng su, vng xa, bin gii, hi o, vng c iu kin
kinh t - x hi kh khn, trong u tin 62 huyn ngho trong c nc.
Bn cnh cc chnh sch pht trin s lng nhn lc y t, ngnh y t cng trin khai
cc bin php nhm nng cao cht lng nhn lc y t. Vic cp chng ch hnh ngh c p
dng vi tt c nhng ngi khm cha bnh (bc s, y s, iu dng, h sinh, k thut vin y,
lng y13 v ngi c bi thuc gia truyn14) trong v ngoi cng lp nhm tng bc hi nhp
vi y t cc nc trn th gii v trong khu vc. B Y t ban hnh b Chun nng lc c bn
ca h sinh Vit Nam15 v hin ang hon thin chun nng lc c bn ca bc s a khoa, d
kin s ban hnh trong nm 2015. Chun nng lc c bn ca bc s rng-hm-mt v ca bc
s chuyn khoa I mt s chuyn ngnh Ngoi, Sn ang trong qu trnh xy dng. Cc b chun
nng lc c bn ny s l mt c s php l quan trng qun l cht lng nhn lc y t.
Kh khn, hn ch
Thiu nhn lc y t c trnh cao v c tay ngh vng cc tuyn, c bit l tuyn x,
tuyn huyn v cc vng c iu kin kinh t x hi km pht trin, nn cha p ng c
nhim v. tuyn trung ng, 45% nhn lc y t c trnh i hc tr ln, trong khi a
phng con s ny ch l 23%. Ti a phng, 50% bc s v 69% dc s i hc lm vic
tuyn tnh, 34% bc s v 31% dc s i hc lm vic tuyn huyn, 17% bc s v 1% dc
s i hc lm vic tuyn x [9].
Phn b nhn lc y t vn cha ng u, nhn lc y t c trnh i hc tr ln tp
trung ch yu cc thnh ph v khu vc kinh t pht trin. Nm 2010, s lng dc s i
hc H Ni v thnh ph H Ch Minh chim hn 48% tng s dc s ca c nc. Ch yu
(92%) cc dc s ny lm vic trong khu vc t nhn, chim hn mt na s dc s thuc
khi t nhn ca c nc [50]. T s bc s trn mt vn dn trn c nc tng u v mt s
a phng kh cao, nhng mt s tnh ca ng bng Sng Cu Long v ng Nam B, t
l ny vn cn tip tc thp [47]. Mt trong cc nguyn nhn ca tnh trng ny c th l do dch
chuyn bc s t khu vc cng sang khu vc t nhn. khu vc min Bc ni chung v min
ni pha bc ni ring, y t t nhn km pht trin nn cc bc s ra trng (hu ht l bc s h
lin thng) u lm vic cho cc c s y t cng lp th hin t s bc s trn vn dn tng ln
r rt. Trong khi , min Nam, y t t nhn pht trin hn, thu nhp tt hn, nn cc bc s
lm vic cho khu vc ny nhiu hn.
Cc c s y t tuyn tnh ca khu min ni, vng su, vng xa xy ra tnh trng lin tc
khng tuyn dng bc s v dc s i hc so vi nhu cu ca n v. Ngay trong mt bnh
vin, cc bc s cng ch mun v chn v cng tc cc khoa c thu nhp cao, dn ti mt s
khoa thiu bc s nh Truyn nhim, Nhi [51]. Ti cc bnh vin a khoa tuyn tnh, s lng
dc s i hc ch chim t l 19,6% nhn lc dc chung. C s chnh lch v s dc s
trung bnh/bnh vin tuyn tnh gia cc vng min; cao nht khu vc ng Nam B (8,8
dc s/bnh vin) v thp nht l Ty Nguyn (3,6 dc s/bnh vin). cc thnh ph trc
L nhng ngi am hiu l thuyt v y hc c truyn v c kinh nghim trong khm v iu tr bng phng php
y hc c truyn c hoc khng dng thuc, c cng nhn bi B Y t hoc S S Y t.
14
L nhng ngi s hu cc bi thuc hay cc phng php iu tr c truyn li t mt th h khc ca mt
gia nh, dng h v c cng nhn bi S Y t.
15
Quyt nh s 342/Q-BYT ngy 24/1/2014 ca B Y t v vic ban hnh chun nng lc c bn ca h sinh
Vit Nam.
13
72

thuc trung ng16, c nhiu dc s hn cc tnh cn li. So vi yu cu v t s dc s/bc
s ca Thng t 08/2007/TTLT-BYT-BNV th khng c khu vc, vng min no t t l qui
nh l 1/15-1/8 [52].
Tuyn huyn vn ang phi i mt vi vn cht lng nhn lc y t. T l cn b c
trnh trung cp rt cao, c ni chim ti 84%. C tnh trng cc bc s xin chuyn i ni khc
hoc t b vic [53]. Mt s Trung tm y t huyn phi iu ng bc s i h tr tuyn x cng
lm nh hng n nhn lc bc s ca n v [54]. S lng dc s i hc cc bnh vin
huyn tng, nhng phn b khng ng u, cao nht khu vc ng bng Sng Hng (18%)
v thp nht l Ty Nguyn (9,2%) [46]. Nhiu huyn vn khng c dc s i hc [47].
Trn ton quc c 76,9% s trm y t x c bc s lm vic, nhng nhng khu vc kh
khn, t l trm y t x c bc s ch khong 30%. Nhng vng kinh t kh khn nht nh Ty
Bc, Ty Nguyn, vng Bc Trung B, ng bng Sng Cu Long thiu ht bc s trm trng
nht. T l trm y t c bc s x nhng vng su, vng xa rt thp nh Lai Chu (4,1%), in
Bin (18,8%), k Nng (38%), Qung Nam (24,2%) [18]. Nng lc nhn lc y t tuyn x
yu, t l chn on bnh hp l cha cao, k n thuc cha hp l, t l bnh nhn chuyn
tuyn nhiu, cn lm dng cc xt nghim [55].
T l iu dng/bc s vn rt thp, mi t mc 1,3/1 mc d hng nm c mt s
lng rt ln iu dng cc bc ra trng. L do ca s khng cn bng ny l do cc bnh
vin khng tuyn iu dng do cha thc hin chm sc ton din, ng thi vic thc hin
c ch t ch dn ti tnh trng c s y t lun c gng ct gim chi ph u vo.
Theo Lut Khm bnh, cha bnh, tt c nhng ngi c bng tt nghip i hc ph
hp, sau khi c thi gian thc hnh u c cp chng ch hnh ngh KCB. Chng ch
hnh ngh ny c gi tr sut cuc i hnh ngh ca mt bc s. Do vy, cha c gi tr trong
vic bo m mt mt bng cht lng c bn nhng ngi c cng mt loi bng cp, v d
nh bc s.
Trong D n th im a bc s v cc vng kh khn, mi bc s trc khi n cng tc
vng kh khn trong thi gian khong 3 nm u c bin ch vo mt bnh vin, c s
y t tuyn trn. Nh vy, sau khong 3 nm cng tc vng kh khn, cc bc s tr v vi cc
c s y t tuyn trn, cc a phng li cn tm ngun nhn lc mi. Kinh ph h tr cho i
ng bc s ny cng l vn cn c quan tm d n c tnh bn vng.
2) Tip tc cc n lc, chin lc trong s dng ngun nhn lc y t
Kt qu thc hin
B Y t tip tc trin khai cc gii php ci thin cht lng nhn lc, tng cng nng
lc cho tuyn di thng qua mt s n. n 1816 tip tc c thc hin nhng chuyn
t h tr nhn lc cho tuyn di sang o to, chuyn giao gi k thut. n Bnh vin v
tinh giai on 2013-2020 bt u c trin khai. Giai on 1 t 2013 n 2015, 14 bnh vin
ht nhn c giao nhim v xy dng v pht trin cho45 bnh vin v tinh 32 tnh [49].
Cc hot ng ch yu ca n l cc bnh vin ht nhn o to nhn lc y t, chuyn giao
k thut, cung cp trang thit b y t, t vn khm cha bnh t xa qua mng internet cho cc
bnh vin v tinh. n xy dng v pht trin m hnh phng khm bc s gia nh giai on
16
Bao gm H Ni, thnh ph H Ch Minh, Hi Phng, Nng v Cn Th.
73

2013 - 2020 c B trng B Y t ph duyt ti quyt nh s 935/Q-BYT ngy 22/3/2013,
vi mc tiu xy dng v pht trin m hnh phng khm bc s gia nh trong h thng y t ca
c nc nhm cung cp dch v CSSK c bn, ton din, lin tc cho c nhn, gia nh v cng
ng, gp phn gim qu ti bnh vin. Trong c nc, thnh ph H Ch Minh l a phng
i u trong trin khai m hnh phng khm bc s gia nh. n cui nm 2013, thnh ph c
khong 200 bc s c o to chuyn v y hc gia nh. M hnh ny c nh gi l gp
phn gim ti bnh vin tuyn trn v tng bc tng cng cht lng tuyn y t c s[56].
Ngnh Y t cng c cc chng trnh, d n v hot ng h tr k thut m a s tp trung
tuyn tnh (chim hn 50%), sau l tuyn huyn (36-38%). Cc d n, chng trnh h tr
k thut tng cng trang thit b y t cho mt s bnh vin tnh v khu vc [57].
gii quyt vn giao tip ca cn b y t vi bnh nhn, B Y t t chc 11 lp
tp hun v k nng giao tip, ng x, nng cao o c ngh nghip, hc tp v lm theo tm
gng o c H Ch Minh cho 5042 cn b ch cht cc bnh vin trn ton quc [49]. Thi
ng x, k nng giao tip ca nhn vin y t ti mt s c s y t c thay i theo chiu
hng tch cc, nhn c t l hi lng cao hn ca ngi bnh [58].
Ngh nh s 117/2014/N-CP ca Chnh ph quy nh t chc v ch chnh sch i
vi cn b y t x, phng, th trn c ban hnh thay th cho Quyt nh s 58/TTg ngy
03/02/1994 ca Th tng Chnh ph, sau nhiu hi tho xin kin ca cc a phng v cc
b, ngnh c lin quan
Kh khn, hn ch
Cha c s thay i ng k trong c ch tuyn dng, s dng nhn lc y t ca cc a
phng v cc c s y t. Chnh sch tin lng v ch i ng i vi cn b y t cha ph
hp, cha tng xng vi thi gian hc tp, cng sc lao ng v mi trng, iu kin lm
vic, nht l khu vc min ni, nng thn. Chnh sch thu ht cn b v lm vic cho y t c
s, cc vng kh khn cha ph hp v cha mang li hiu qu [51]. Mt s ni cha thc hin
y ch cho cn b y t nh ph cp c th (thng trc, phu thut, th thut) theo
Quyt nh s 73/2011/Q-TTg, cha chi tr kp thi tin lng tng thm t tng lng ti
thiu do ngn sch kh khn [49].
ng x ca cn b y t vn l mt vn ln ca ngnh. y cng l mt trong cc
nguyn nhn dn n phn ng ca x hi, bnh nhn, ngi nh bnh nhn vi ngnh y t
trong thi gian qua. T l ngi bnh nhn xt khng tt v thi ca cn b y t cn cao
[59]. Ngi bnh, ngi chm sc trc tip ngi bnh cha hi lng vi tt c cc kha cnh
o lng cht lng CSSK ti bnh vin, trong c cht lng phc v v giao tip ca bc
s, thi ca nhn vin y t [60].
Trin khai n bnh vin v tinh v n 1816 vn cn kh khn. Nhiu ni cha
xc nh c c th cc k thut cn c chuyn giao, v vic chuyn giao cha da trn
iu kin c s vt cht, trang thit b ca tuyn di [61]. Mc d n bnh vin v tinh v
n 1816 c trin khai trong mt s nm, nhng tnh trng qu ti tuyn trung ng vn
cha c ci thin nhiu. Nhiu hot ng h tr k thut ang qu l thuc vo ngun h tr
nc ngoi [57].
Cng tc qun l nhn lc mt s a phng v c s y t cn hn ch. Vic iu ng
cn b y t i khi dn n tnh trng cn b y t b vic do i ng khng tha ng, phi sng
74

xa gia nh, c s vt cht ca c s y t km [51]. C ch qun l c s y t v s dng cn
b lnh o, qun l cc cp trong c s y t cn nhiu bt cp lm gim nhn lc chuyn mn
[51]. Mi trng lm vic ca cc c s y t cha p ng c yu cu cng vic, nhiu ni
trang thit b cn thiu, lc hu, v vy, nhn vin y t khng yn tm lm vic.
3) Tip tc ci thin cht lng o to ti cc c s o to nhn lc y t
Kt qu thc hin
Ngy 4/11/2013, Hi ngh ln th 8 Ban Chp hnh Trung ng kha XI ban hnh
Ngh quyt 29-NQ/TW v i mi cn bn, ton din gio dc v o to, trong a ra quan
im ch o v s cn thit phi i mi c v s lnh o ca ng, qun l ca nh nc,
cc hot ng qun tr ca cc c s gio dc o to, v s tham gia ca x hi, cng ng, bn
thn ngi hc, i mi tt c cc bc hc, ngnh hc. B Y t hin ang xy dng k hoch
hnh ng trin khai Ngh quyt ny.
H thng vn bn php quy, hng dn v o to nhn lc y t ang c xy dng,
hon thin nhm mc tiu nng cao cht lng o to. Cc Thng t hng dn o to chuyn
khoa I, chuyn khoa II, bc s ni tr ang c xy dng mi thay th cc Thng t hin ti
khng cn ph hp. Hin nay, cc bn tho ang c ly kin cc n v lin quan nh c
s o to, c s s dng nhn lc y t. gii quyt tnh trng cht lng o to thp cc
kha o to lin thng khi ngnh khoa hc sc khe, c bit l o to bc s lin thng, B
Y t trin khai xy dng Thng t hng dn o to lin thng trnh cao ng, i hc khi
ngnh khoa hc sc khe. Thng t ny s thay th Thng t 06/2008/TT-BYT trc y v
hng dn tuyn sinh lin thng trnh cao ng, i hc y dc v cng vn s 1915/BYTK2T ngy 8/4/2013. ng thi, B Y t cng c mt s vn bn gi B Gio dc v o
to ngh kim sot ch tiu tuyn sinh mt s ngnh ang o to qu nhiu, kim sot vic
o to lin thng, o to theo a ch, qui nh cht ch v m m ngnh o to mi. B Y t
cng bt u t chc trin khai xy dng vn bn qui phm php lut v kt hp vin - trng
trong o to thc hnh thay th Thng t 09/2008/TT-BYT ngy 1/8/2008 v hng dn
vic kt hp gia cc c s o to cn b y t vi cc bnh vin thc hnh trong cng tc o
to, nghin cu khoa hc v CSSK nhn dn khng cn ph hp trong tnh hnh cc bnh
vin thc hin c ch t ch ti chnh v sinh vin c rt t c hi c thc hnh.
Nm 2014, B Y t bt u trin khai D n Gio dc v o to nhn lc y t phc
v ci cch h thng y t nhm mc tiu: (i) i mi gio dc nhn lc y t thng qua xy dng
h thng kim nh cht lng gio dc, i mi chng trnh o to v (ii) nng cao nng lc
cho tuyn y t c s. D n Chng trnh pht trin ngun nhn lc y t vay vn Ngn hng
Pht trin chu tip tc c trin khai 17 trng i hc v cao ng y dc, u t trang
thit b cho dy hc cc mn c s, c bn v o to ging vin, xy dng chng trnh o
to cho cc mn c s, c bn. D kin sau khi kt thc giai on I, d n s tip tc h tr cc
trng giai on II. Nhiu d n h tr pht trin chnh thc (ODA) khc cng u c cc hot
ng o to, tp hun nng cao nng lc cho cn b y t c v chuyn mn v qun l.
Cng tc bo m cht lng gio dc bt u i vo hot ng thng xuyn ca nh
trng. Cc c s o to i hc, cao ng u c b phn bo m cht lng. Cc trng
i hc, cao ng y dc trin khai hot ng t nh gi theo hng dn ca B Gio dc
v o to.
75

Kh khn, hn ch
Cht lng o to ca cc trng, c bit l o to thc hnh bnh vin, ang l
vn ln cn c quan tm. Do s lng sinh vin, hc sinh, hc vin sau i hc ca cc
trng tuyn hng nm rt ln, trong khi s lng bnh vin thc hnh vn gi nguyn hoc
tng khng ng k, nn c hi cho ngi hc c thc hnh lm sng rt kh khn. Bn cnh
, c ch t ch ca bnh vin v ti chnh cng dn ti nhiu bnh vin khng to iu kin
thc hnh cho ngi hc. Cht lng o to ca cng mt loi hnh nhn lc y t, v d nh
bc s, khng ng u gia cc trng v gia cc hnh thc o to lin thng v chnh qui do
cht lng tuyn sinh u vo khc nhau, yu cu trong qu trnh o to khc nhau. Tnh trng
ny dn ti cht lng sinh vin tt nghip ca cc trng cng c nng lc khc nhau ng
k trong khi ngnh y t l c quan s dng nhn lc y t li cha c mt h thng kim chun
u ra quc gia bo m nhn lc y t khi hnh ngh s c mt nng lc tng ng nhau.
Cng tc bo m cht lng gio dc cha thc s hiu qu. Thc hin cc qui nh ca
B Gio dc v o to v cng tc kim nh cht lng, bo m cht lng gio dc trong
cc trng, cc trng u thc hin t nh gi v thnh lp b phn bo m cht lng
ca trng. Tuy nhin, cng tc bo m cht lng nhiu trng vn cn l hnh thc, mang
tnh i ph vi cc qui ch, m cha thc s gp phn nng cao cht lng o to ca trng.
Nu cng tc bo m cht lng khng c thc hin nghim tc th s khng nhng khng
em li hiu qu m cn gy tn km ngun lc.
4) Tip tc ci thin cng tc qun l o to lin tc nhn lc y t
Kt qu thc hin
B Y t ang tng bc hon chnh h thng vn bn qun l cng tc o to nhn lc
y t. xc nh cc chnh sch, chin lc cho nhng nm sp ti v o to lin tc cho cn
b y t, B Y t ang trin khai xy dng Chin lc o to lin tc nhn lc y t. Thng t
22/2013/TT-BYT ngy 9/8/2013 c ban hnh thay th Thng t s 07/2008/TT-BYT ngy
28/5/2008 hng dn cng tc o to lin tc i vi cn b y t. B Y t c cng vn s
2034/BYT-K2T ngy 18/4/2014 gi cc s y t, bnh vin, vin nghin cu trc thuc B Y
t v tng cng cht lng cng tc o to lin tc cn b y t. Trong nhn mnh v bo
m cht lng cho cc kha o to lin tc v yu cu cc kha o to lin quan n chuyn
giao k thut phi c tiu ch nng lc c th, hc vin phi t c cc tiu ch mi c
cp chng ch. B Y t bt u t chc xy dng Thng t v t chc thc hnh sau tt nghip
cp chng ch hnh ngh.
S lng cc c s o to lin tc c cng nhn tip tc tng. B Y t cp php cho
cc n v tham gia o to lin tc nh cc bnh vin, cc S Y t, trung tm y t, cc trng.
Hai trung tm o to cn b qun l y t nm trong i hc Y t Cng cng v Vin Y t Cng
cng thnh ph H Ch Minh c thnh lp v s m nhn nhim v o to v qun l cho
cn b y t ton ngnh.
Kh khn, hn ch
S lng cc kha o to lin tc gim do cc d n vi ngun ti tr quc t ng vai
tr ch o trong vic t chc cc kha o to lin tc b gim i. Cht lng nhiu kha o
to lin tc cha bo m thng qua h thng kim nh. Nhiu kha hc cp chng ch c
76

cc c s y t c ngi i hc nh gi l km hiu qu. Nhiu cn b y t tuyn c s khng
c o to lin tc do thiu kinh ph, cc kha hc t chc qu xa, thiu cc kha hc ng
nhu cu. Mt s ni do thiu nhn lc y t nn khng th c cn b y t i hc nng cao trnh
, nht l vi cc kho o to ko di [51].
2.2.2. Khuyn ngh v cc gii php b sung
thc hin thnh cng k hoch y t 5 nm 2011-2015, ngnh y t v cc c quan lin

quan cn trin khai cc gii php sau:
1) Xy dng i ng nhn lc y t v s lng v bo m v cht lng, cn i v c
cu v phn b hp l, p ng nhim v bo v v chm sc sc khe nhn dn
Phi hp gia y t cng lp v ngoi cng lp bo m c nhn lc y t cc vng
c y t t nhn pht trin.
Bo m tnh nghim tc v tun th tt cc qui nh trong tuyn dng, s dng, thc thi
cc chnh sch u i cng nh trong t chc o to mi, o to thc hnh lm sng
v o to lin tc.
Chnh sch u tin tuyn dng khng th ch ca ngnh m cc tnh thiu nhn lc cn
phi t xy dng chnh sch, ch u i ring ca mnh cho bc s, dc s i hc v
mt s nhn vin y t bc i hc khc.
Xy dng chnh sch thu ht nhn lc dc ti cc a phng; Thng xuyn t chc
cc lp tp hun v dc lm sng v cng tc qun l m phm cho cc dc s ti cc
a phng. S dng ph hp cn b dc ti trm y t.
2) Tip tc cc n lc, chin lc trong s dng ngun nhn lc y t
Trin khai cc ch , chnh sch ban hnh, bo m ch u i cho cn b y t
thc s c thc hin.
Nhm tng cng s dng i ng iu dng, cn trin khai th im chm sc bnh
nhn ton din mt s c s y t lm c s nhn rng tng bc. c th trin
khai chm sc bnh nhn ton din, vn thi , hnh vi ca nhn vin y t cn c
ci thin trc.
Sa i Lut khm cha bnh, quy nh cp chng ch hnh ngh c thi hn thay v cp
mt ln nh hin nay. Mt trong cc iu kin chnh cp li chng ch hnh ngh l
tham gia cc kha o to lin tc. ng thi, nn c l trnh t chc thi cp chng
ch hnh ngh cho nhng ngi hnh ngh khm bnh, cha bnh bo m h p
ng c mc nng lc c bn cho d c o to u v theo hnh thc no.
3) Tip tc ci thin cht lng o to ti cc c s o to nhn lc y t
Trin khai kim nh cht lng gio dc cho cc chng trnh o to khi ngnh khoa
hc sc khe, c bit cn c cc tiu ch v o to thc hnh bnh vin.
Cc trng cn trin khai cc gii php bo m cht lng gio dc v o to, bao
gm c cn nhc c mt s lng tuyn sinh hp l.
77

4) Tip tc ci thin cng tc qun l o to lin tc nhn lc y t
Trin khai cng tc bo m cht lng cho cc c s o to lin tc v cc kha o
to lin tc.
Cc c s y t cn c k hoch o to lin tc v pht trin ngh nghip cho i ng
nhn lc, s dng cc hnh thc nng cao nng lc khc nhau.
2.3. Ti chnh y t
Phn di y r sot, cp nht vic thc hin cc nhim v v cng tc ti chnh y t

theo K hoch 5 nm ca ngnh y t v cc nhim v u tin nm 2014 theo Ngh quyt 01/
NQ-CP ca Chnh ph v tnh hnh thc hin, nhng kh khn, hn ch v xut cc khuyn
ngh b sung.
1) Tng chi NSNN cho y t, tng t l chi cng cho y t, gim t l chi tin ti cho y t
Kt qu thc hin
Trong nm 2013-2014, vi bi cnh kinh t v m ang gp nhiu kh khn, thch thc,
Chnh ph ch trng tht cht chi tiu, song NSNN vn c b tr theo cc nhim v chi
thng xuyn cho y t, bao gm: chi cho cng tc khm cha bnh, chi phng chng dch bnh;
d phng kinh ph phng, chng dch. Kinh ph thc hin ch ph cp u i theo ngh i
vi cng chc, vin chc cng tc ti cc c s y t cng lp theo quy nh ti Ngh nh s
56/2011/N-CP ngy 4/7/2011 ca Chnh ph v d kin chi b sung, sa i ch ph cp
c th i vi cng chc, vin chc ngi lao ng trong cc c s y t cng lp v ch
ph cp chng dch theo 73/2011/Q-CP ngy 28/12/2011 c bao gm trong NSNN cp cho
y t. NSNN cng bo m mt phn kinh ph thc hin cc chng trnh mc tiu quc gia theo
quyt nh ca c quan c thm quyn v bo m kinh ph chi mua th BHYT cho ngi
ngho, tr em di 6 tui, h tr c nhn thuc h gia nh lm nng nghip, lm nghip, ng
nghip v dim nghip, h tr ngi cn ngho, hc sinh, sinh vin mua th BHYT theo Lut
BHYT v u tin ca Chnh ph theo Ngh quyt 01/NQ-CP nm 2014.
Bn cnh ngun chi thng xuyn cho y t, tng mc chi t NSNN cho y t cn bao gm
chi vn i ng tip nhn cc d n ODA, chi u t xy dng c bn, chi t ngun thu x s
kin thit, tri phiu chnh ph (Hnh 23). Trong tng chi t NSNN cho y t, chi thng xuyn
chim t l 53% trong 46% phn b v cc a phng theo chi s nghip y t theo nh mc
u dn. Phn chi t NSNN mua ton b hoc h tr mt phn th BHYT cho cc i tng
quy nh theo Lut BHYT chim t l 23% tng NSNN chi cho y t nm 2012. Phn kinh ph
cp t tri phiu chnh ph cho cc n nng cp cc c s y t bao gm n nng cp bnh
vin huyn theo Quyt nh 47/2008/Q-TTg v n nng cp bnh vin tuyn tnh v trung
ng theo Quyt nh 930/Q-TTg (2009) v u t pht trin trung tm y t huyn v trm y
t x theo Quyt nh s 950/Q-TTg (2007) chim t l 8% (Hnh 23).
78

Hnh 23: Cc mc chi NSNN cho y t, c thc hin nm 2012
Chi u t XDCB
23%
Chi TPT t TPCP
46%
Chi CTMTQG
53%
5%
8%
Chi mua BHYT cho cc T

Chi TX cho TW
7%
Chi TX cho a phng
11%
Ch thch: XDCB=Xy dng c bn;TPT=u t pht trin; TPCP=tri phiu chnh ph; T=i tng; TX=thng
xuyn; TW=trung ng.
Ngun: S liu V K hoch - Ti chnh, B Y t, 2014.
K hoch NSNN iu chnh theo lm pht bng cch s dng h s iu chnh GDP
cho thy mt xu hng tng n nh chi ph y t theo d ton (Hnh 24). Nm 2011 l mt nm
quan trng trong phn b kinh ph cho pht trin c s h tng. Nm 2012, khi quy nh h tr
mua th BHYT cho nng dn c thu nhp trung bnh theo Lut BHYT c hiu lc, mt lng
ngn sch ln c phn b nhng cha c chi tiu nn b gim bt trong nm 2013.
Nm 2014, ngun kinh ph ny li tng ln do s gia tng chung ca vic phn b ngn sch
cho tt c cc nhm i tng c nhn tr cp ca Chnh ph cho bao ph BHYT. Theo k
hoch ngn sch, chi tiu cho cc CTMTQG vn tng i n nh trn thc t, nhng tng chi
thng xuyn cho cc hng mc khc vn tip tc tng. Tuy nhin, y ch l s tin d ton,
khng nht thit l s tin thc chi. S liu v kinh ph c thc hin trong giai on 2010-2013
cho thy kinh ph chi tiu nm 2010 v c bn bng kinh ph d ton, trong khi nm 2011 v
2012, tng chi tiu thc t ch chim 88-89% ngn sch d ton. Vic chi tiu thp hn d ton
xy ra vi u t c s h tng v thc hin CTMTQG trong c hai nm 2011 v 2012, ch xy
ra vi BHYT trong nm 2012 khi kinh ph h tr mua BHYT cho nng dn c phn b,
nhng khng c chi tiu ht, v trong nm 2011 vi tng chi thng xuyn b ct gim.
Hnh 24: Xu hng chi NSNN theo mc ch s dng t 2010-2014, theo gi nm 2014
Chi NSNN theo mc ch s dng, tnh bng ng (2014)
120
Nghn t ng
100
80
60
40
20
0
2010
DTXDCB
2011
CTMTQG
2012
BHYT cho i tng x hi
2013
2014
Chi thng xuyn khc
Ngun: S liu V KHTC, B Y t, 2014. Ch s gim pht GDP do Tng cc Thng k tnh ton.
79

Trong bi cnh cc ngun vin tr cho Vit Nam c xu hng b ct gim, ngnh y t
vn tng cng huy ng cc ngun vin tr. Nm 2013, mc d tng s d n ODA do B Y
t qun l l 41 d n gim i so vi con s 52 d n nm 2012 song tng gi tr vn duy tr
mc 1,5 t USD nh nm trc [62].
Kh khn, hn ch
Kh khn v kinh t v m nh hng n vic thc hin mc tiu tng chi NSNN
cho y t. Theo s liu d ton ngn sch ca B Y t trong hai nm 2010-2014, ngn sch dnh
cho y t tng 14,2% (sau khi iu chnh theo ch s gim pht), trong khi ngn sch chung
ch tng 2,8%. Tc tng d ton NSNN cho y t giai on 2011-2013 chm i, di 7%/
nm so vi mc tng ngn sch chung hn 9%/nm. Tuy nhin, nm 2014, d ton NSNN cho
y t tng nhanh chng mc 16,7% so vi nm 2013, gn nh gp i so vi mc tng tng
NSNN (Hnh 25).
Hnh 25: T l gia tng thc t chi NSNN chung v cho y t hng nm, 2010-2014
T l gia tng thc NSNN hng nm
25%
17%
14%
15%
12%
9%
10%
5%
21%
20%
20%
3%
11%
7%
7%
2011-2012
2012-2013
8%
2%
0%
2010-2011
D ton NSNN
D ton NSNN cho y t
2013-2014
D ton NSNN chi y t thng xuyn
Ngun: V K hoch - Ti chnh, B Y t. c tnh v d ton NSNN cho y t 2010-2014. iu chnh theo gi thc
t da trn ch s iu chnh GDP ca Tng cc Thng k.
Mc tiu phn u t c t l chi tiu cho sc khe mc 10% tng chi tiu NSNN
kh t c. T l ny nm 2011 t 8,5%, gim trong nm 2012 v 2013, nhng sau tng
ln 8,6% nm 2014 (da trn d ton ngn sch nh nc)17. Vi chi tiu cho y t chim t l
thp trong tng chi, NSNN khng thc hin c hiu qu mt s chc nng cng cng quan
trng trong lnh vc y t nh thanh tra, kim tra, thng k y t, truyn thng gio dc sc khe,
phng chng v kim sot BKLN trong cng ng.
Chi cng trong tng chi tiu y t (bao gm NSNN, BHYT v vin tr) trong vi nm qua
c xu hng gim, t 46,6% nm 2010 xung cn 42,6% nm 2012 theo s liu Ti khon y
t quc gia c tnh mi nht nm 2014 [63]. Tnh trng ny cho thy kh nng t c mc
tiu t l chi cng cho y t bng 50% vo nm 2015 rt kh thc hin. Hu qu tiu cc ca xu
hng ny l chi tiu t tin ti ca h gia nh cho y t, tng c xu hng gim nh mong
mun, gi bt u tng tr li, chim 48,8% tng chi tiu cho y t nm 2012 (Hnh 26).
17
V K hoch - Ti chnh, B Y t: c tnh v d ton NSNN 2010-2014
80
70
60
50
40
30
20
10
0
48,8
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
44,8 45,6
1998
Phn trm
Hnh 26: T l chi tiu tin ti h gia nh trong tng chi tiu cho y t, 1998-2012
Ngun: Ti khon Y t quc gia 2010-2012.
2) u tin phn b NSNN cho y t d phng, y t c s, chm sc sc kho ban u, thc

hin chnh sch x hi v y t
Kt qu thc hin
Chnh sch u tin phn b NSNN cho y t d phng tip tc c thc hin theo tiu
ch c xc nh theo Ngh quyt s 18/2008/QH12 Dnh t nht 30% ngn sch y t cho
y t d phng. Theo s liu Ti khon Y t quc gia, trong tng NSNN cho y t, bao gm c
trung ng v a phng, t l chi cho YTDP v nng cao sc khe chim 69,8% nm 2011
[64]. T l chi cho y t d phng v nng cao sc khe trong tng NSNN cp cho y t ti cc
a phng tng ln qua cc nm (Hnh 27). Tuy nhin, cng cn lu l t l ny tnh tng chi
cho d phng v nng cao sc khe so vi tng NSNN cp cho y t khng bao gm vin ph v
BHYT. Nu tnh t l chi cho y t d phng so vi tng ngn sch y t c xc nh theo Lut
Ngn sch l bao gm c Cc khon ph, l ph, thu t cc hot ng s nghip v cc khon
thu khc np vo ngn sch th t l ny l 43,9% cn nu so vi tng chi y t ton x hi th
t l chi cho y t d phng ch cn l 27,9%.
Hnh 27: T l NSNN chi cho YTDP v nng cao sc khe, 2009-2011
80
68,6
70
Phn trm
60
50
40
69,8
53,7
Trung ng
38,5
a phng
30
Chung
20
10
0
2008
2009
2010
Ngun: Ti khon y t quc gia, 2009-2011.
81
2011

Trong tng kinh ph 3912 t ng thc hin cc CTMTQG y t giai on 2011-2013,
ngun kinh ph t NSNN chim 82,8%. Nm 2013, tng kinh ph cho CTMTQG l 1515 t
ng, trong kinh ph t vn ngoi nc chim xp x 30% [65]. Trong n lc hng ti
mc tiu bao ph CSSK ton dn, vic cng c mng li y t c s v tng cng chm sc
sc kho ban u (CSSKB) ng vai tr c bit quan trng. B Y t hin ang chun b D
tho Ngh quyt v n v Tng cng y t c s trong tnh hnh mi trnh Chnh ph.
Khi c ph duyt thc hin, n c k vng s to bc chuyn bin t ph v ton
din v t chc, c s vt cht, trang thit b, i ng cn b v c ch hot ng ca y t c
s nhm nng cao cht lng dch v y t, p ng nhu cu CSSKB ca ngi dn ngay ti
cng ng, gp phn gim qu ti bnh vin tuyn trn, bo m cng bng, hiu qu v pht
trin s nghip bo v, chm sc v nng cao sc khe nhn dn. n s l c s php l quan
trng b tr ngun lc ti chnh thc hin mc tiu tng cng y t c s sau nhiu nm
cha c c u t tha ng.
Tnh n 12/2013, theo s liu bo co s b ca BHXH Vit Nam, tng s th BHYT
cn ngho c pht l 2234597 t t l 38,8% so vi tng s ngi cn ngho. Nhiu a
phng nh Nam nh, Ninh Thun, Bnh Dng trin khai thc hin tt Quyt nh 797
ca Th tng Chnh ph, cn i ngn sch a phng h tr 20-30% cn li mua th cho
ngi cn ngho. Vic ban hnh Quyt nh 705/Q-TTg ca Th tng Chnh ph bo m
ngun ti chnh cho cc i tng cn ngho mi thot ngho, vng kh khn trong khm,
cha bnh.
Vic thc hin chnh sch x hi v y t c c th ha bng vic bo m NSNN h
tr trc tip cho mt s nhm i tng yu th. Hng nm, kinh ph t ngn sch trung ng
cp h tr mua th BHYT cho ngi ngho, ngi dn tc thiu s v tr em di 6 tui v h
tr mt phn cho ngi cn ngho, hc sinh sinh vin v ngi thuc h lm nng nghip, lm
nghip c mc sng trung bnh c xc nh ngay trong D ton NSNN cp hng nm. Tng
kinh ph t NSNN h tr mua BHYT cho cc i tng ny tng ln qua cc nm (Hnh 28).
Hnh 28: Kinh ph t NSNN h tr mua BHYT cho cc i tng theo Lut BHYT (triu
ng)
40
35
Nng dn c mc sng
trung bnh
Hc sinh, sinh vin
Nghn t ng
30
25
20
Tr em di 6 tui
15
Ngi ngho v dn
tc thiu s
Cn ngho
10
5
0
2010
2011
2012
2013
2014
Ngun: S liu V KHTC, B Y t, 2014.
82
2015

Kh khn, hn ch
Mt s a phng cn cha b tr chi s nghip y t theo mc B Ti chnh cn
i, nh mc phn b ngn sch y t ca mt s a phng cn thp.
Kinh ph xy dng c bn dnh cho y t x theo n 950 cha c ngun chc chn, nh
hng ti vic chm trin khai ci to trm y t x, trong khi kinh ph cho cc bnh vin tuyn
trung ng, tnh, huyn c u tin.
Cc CTMTQG b ct gim kinh ph. Nm 2013, kinh ph cho hot ng truyn thng
gio dc sc kho b ct gim gy kh khn cho trin khai hot ng ca nhiu chng trnh v
d n. Nm 2014, hu ht cc CTMTQG u b ct gim kinh ph, trong cc chng trnh
phng chng BKLN b ct gim rt ln, ti trn 66% nh chng trnh bo v sc kho tm
thn, phng chng i tho ng v phng chng hen v bnh phi tc nghn mn tnh. Trong
khi , mc chi ngn sch thng xuyn cho y t d phng kh thp (c tnh ngoi lng ch chi
13 triu ng/bin ch) [49]. Nhiu kh nng nm 2015 s khng cn kinh ph cho CTMTQG.
Vic ct gim hon ton cc CTMTQG trong bi cnh cha trin khai c vic lng ghp cc
chng trnh ny vo hot ng chung ca h thng y t s gy nhiu tc ng bt li cho thc
hin mc tiu kim sot cc vn y t cng cng u tin.
3) Thc hin l trnh tin ti BHYT ton dn
Kt qu thc hin
Trong nm qua, B Y t tip tc tp trung cho cng tc hon thin h thng chnh sch,
php lut v BHYT nhm mc tiu pht trin BHYT ton dn bn vng. B Y t lm vic rt
tch cc xy dng D tho Lut sa i b sung mt s iu ca Lut BHYT. Trong qu trnh
xy dng D tho, B Y t nhiu ln t chc ly kin t vn t pha cc n v, t chc,
c nhn v c bit huy ng s tham vn hiu qu t pha cc t chc quc t nh WHO,
Ngn hng Th gii, Lin minh chu u. Lut sa i, b sung mt s iu ca Lut BHYT
c Quc hi thng qua ngy 13/6/2014. Nhng ni dung mi ca Lut bao gm: Quy
nh bt buc tham gia BHYT; B sung i tng tham gia BHYT; Quy nh tham gia BHYT
theo h gia nh; Quy nh gi dch v y t c bn; B gim cng chi tr vi mt s i tng
(ngho, cn ngho, thn nhn ngi c cng vi cch mng); B sung quyn li; M thng
tuyn KCB18; S dng 20% kt d; Phn cng trch nhim cc bn lin quan. Song song vi
vic hon thin D tho Lut sa i b sung, B Y t cng tin hnh sa i Thng t 09
v Thng t 10 gii quyt mt s vng mc, bt cp trong qu trnh thc hin Lut BHYT
2008 ng thi xy dng mt s thng t thuc phm vi ban hnh ca B Y t theo Lut BHYT
bao gm: Thng t Ban hnh danh mc thuc thuc phm vi thanh ton ca Qu bo him y t,
Thng t ban hnh danh mc v t l, iu kin thanh ton i vi cc dch v k thut thuc
phm vi thanh ton ca Qu BHYT.
Tip tc m rng i tng tham gia BHYT l nhim v u tin trong giai on hin nay
i vi cng tc BHYT. Sau khi B Chnh tr ban hnh Ngh quyt s 21-NQ/TW nm 2012,
Th tng Chnh ph ban hnh n thc hin l trnh BHYT ton dn giai on 2012-2015
Lut BHYT sa i cho php ngi ngho v ng bo dn tc thiu s sng vng kh khn c b qua tuyn
x n khm ti bnh vin huyn, hoc iu tr ni tr ti bnh vin tuyn tnh hoc trung ng v vn nhn
c hon tr bo him y t. Nm 2016, tt c bnh nhn c bo him y t c th c khm v iu tr ti bt k
c s y t tuyn huyn, x no trong tnh v vn c BHYT thanh ton y .
18
83

v 2020 theo quyt nh s 538/Q-TTg ph duyt n, B Y t lm vic v ngh mt
s tnh, thnh ph xy dng k hoch trin khai n cho ph hp vi thc t ca a phng.
B Y t phi hp vi B Ti chnh xy dng v trnh Th tng Chnh ph ban hnh Quyt
nh 705/Q-TTg ngy 08/5/2013 v vic h tr 100% mc ng BHYT cho ngi cn ngho
mi thot ngho trong 5 nm, ngi cn ngho sinh sng cc huyn ngho v huyn c
hng chnh sch nh huyn ngho. Theo s liu ca BHXH, tnh n cui nm 2013, tng s
ngi tham gia BHYT l 61,4 triu ngi, t t l 68,5%19 dn s. Trong tng s ngi tham
gia BHYT, nhm ngho, cn ngho chim t l cao nht vi 26% (Hnh 29). Cc i tng
c NSNN h tr ton b hoc mt phn kinh ph tham gia BHYT chim t l 60% tng s
ngi c BHYT.
Hnh 29: C cu cc nhm i tng tham gia BHYT, 2013
Do ngi
i tng lao ng v
t nguyn ngi s dng
(10,8)
lao ng cng
ng (16,7)
Do BHXH
Hc sinh, sinh
ng (hu tr,
vin (18,7)
bo tr x hi,
v.v.) (12,4)
Tr em di
6 tui (15,4)
Ngi ngho,
cn ngho (26,1)
Ngun: Bo him X hi Vit Nam, 2014
Kh khn, hn ch
Tin m rng t l bao ph c xu hng chm li trong thi gian qua. Cha tm c
gii php hiu qu tho g nt tht trong thc hin l trnh BHYT ton dn lin quan n nhng
thiu ht trong quy nh chnh sch php lut cng nh nhng hn ch trong trin khai thc
hin. l vic thiu cc quy nh php l bo m tnh tun th quy nh tham gia BHYT bt
buc, cha c quy nh c quan BHXH thc thi c vai tr bn mua dch v y t p ng
cc tiu ch an ton, hiu qu, cht lng v gi chp nhn c, vic qun l, s dng Qu
BHYT cn hn ch v tnh bn vng v hiu qu, phng thc thanh ton dch v y t cha ph
hp, nng lc qun l ca c quan BHXH cha p ng yu cu, h thng qun l thng tin
yu, tnh trng lm dng qu BHYT c biu hin gia tng.
Vic thc hin l trnh tin ti bao ph BHYT ton dn ch yu ang da trn h tr t
NSNN vi hn 60% i tng c bao cp mt phn hoc ton b. Nhng kh khn v kinh
t v m cng vi ch trng tht cht chi tiu c nh hng nht nh n vn ny.
Bn cnh tin m rng din bao ph BHYT (t l dn s tham gia BHYT) v ci thin
gi th hng th kh nng bo v ti chnh ca BHYT cn hn ch. Nguyn nhn ch yu l
do cc chi ph gin tip trong khm, cha bnh nc ta cn cao (tin i li, n, , chi ph cho
ngi nh i km), trong khi BHYT mi ch chi tr mt phn cc chi ph trc tip cho khm,
cha bnh.
19
BHXH Vit Nam. T trnh Phng n cn i qu BHYT giai on 2015 - 2020.
84

4) i mi c ch hot ng, c ch ti chnh trong cc n v s nghip y t cng lp
Kt qu thc hin
Trong thi gian qua, B Y t ang tp trung xy dng cc vn bn hng dn thc hin
Ngh nh s 85/2012/N-CP v c ch hot ng, c ch ti chnh i vi cc n v s nghip
y t cng lp v gi dch v khm bnh, cha bnh ca cc c s y t cng lp c ban hnh
ngy 5/10/2012. Trong bao gm Thng t quy nh v tnh gi y theo cc yu t chi
ph. Thng t lin tch s 04 v khung gi 447 dch v y t iu chnh c p dng tt c
63 tnh, thnh ph tho g mt phn kh khn cho cc bnh vin.
Vic trin khai iu chnh gi vin ph theo Thng t lin tch s 04/2012/TTLT-BYTBTC c iu tit mt cch ph hp. Thc hin ch o ca Th tng Chnh ph, B Y t
phi hp vi B Ti chnh hng dn v t chc trin khai thc hin iu chnh gi dch v
theo l trnh, ph hp vi iu kin kinh t x hi, t l tham gia BHYT v thu nhp ca ngi
dn tng a phng nhm mc tiu kim ch lm pht, n nh kinh t v m, nh: (i) Khng
thc hin iu chnh ng lot m c phn chia tin iu chnh; Nm 2012, ch iu chnh
ca mt s bnh vin trc thuc cc b, ngnh v 45/63 tnh, ri u trong cc thng; 8 thng
u nm 2013 c 17/63 tnh thc hin (ring thnh ph H Ch Minh thc hin t 1/6/2014); (ii)
V mc iu chnh: cha thc hin iu chnh mc ti a ngay m ch yu trong khong
t 60-80% mc gi ti a theo quy nh, ch c mt s bnh vin c bit, cha tr ngi bnh
nng, him ngho, trin khai cc k thut cao c mc chi ph (theo 03 yu t) ln c iu
chnh mc trn di 90% mc gi ti a. B Y t cng tin hnh nh gi s b kt qu sau
hn 1 nm thc hin. Hu ht cc kin t pha bnh vin, a phng nh gi vic thc
hin iu chnh gi vin ph to iu kin cho cc c s KCB c thm ngun thu trang
tri cc chi ph phc v ngi bnh, gp phn tng bc nng cao cht lng khm cha bnh;
cc bnh vin dnh 15% tng s thu khm bnh v ngy ging bnh (c bnh vin chi
hng chc t ng) u t nn khu vc khm bnh, cc bung bnh c ci thin, khang
trang, sch s hn trc, ci tin quy trnh khm bnh, k c vic thu vin ph gim thi gian
ch i, ngi bnh hi lng hn. Khuyn khch cc bnh vin tuyn di thc hin cc k
thut mi c chuyn giao, gp phn nng cao trnh chuyn mn tuyn di, tng bc
gim qu ti cho tuyn trn, Qu BHYT vn cn i c.
Kh khn, hn ch
Vic ban hnh cc vn bn hng dn thc hin Ngh nh 85 b chm so vi tin
ra. Trong qu trnh xy dng vn bn gp cc vng mc lin quan n vic thc hin cc chnh
sch khc nh x hi ha, qun l gi dch v cng ch, v.v
Tn ti nhiu vn hn ch hiu sut s dng cc ngun lc ti cc n v y t cng lp
nh: kim sot lng ph, hn ch trong kim sot ch nh thuc/dch v hp l, kim sot gi
thuc/dch v y t, phng thc thanh ton cha ph hp.
Cha c nghin cu nh gi xc nh c cc yu t tc ng i vi hot ng
KCB v thanh ton chi ph KCB BHYT, kh nng cn i qu BHYT v chi tr tin ti ca
ngi dn.
Vic thc hin t ch ti chnh ca cc n v cng lp gp kh khn nu khng bo m
ngun cn i ti chnh. Mt s a phng cha b tr chi s nghip y t theo mc B
85

Ti chnh cn i, nh mc phn b ngn sch y t ca mt s a phng cn thp (c tnh
ch phn b 25 hoc 37 triu ng/ging bnh). Kinh ph giao t ch cho cc bnh vin hu
ht khng bo m phn chi cho con ngi. Trong khi , khung gi vin ph hin nay cho 447
dch v mi ch tnh 3/7 cu phn gi dch v, d nh nm 2015 mi b sung thm cu phn
nhn lc, tin cng trong gi dch v, n nm 2018 mi tnh cc cu phn.
Nhiu tnh ph duyt mc gi ca nhiu dch v thp hn nhiu so vi khung gi dch v
(60-70%) mc d khung gi c tnh tng i st vi thc t, v vy bnh vin cng thc
hin, cng phi b l. Chi y t d phng cn thp (c tnh ngoi lng ch chi 13 triu ng/bin
ch), nh mc chi cha hp l v hu ht cc tnh, nh mc phn b cho bnh vin c thu cao
hn bnh vin khng c thu, nh mc tuyn tnh cao hn tuyn huyn.
5) i mi phng thc chi tr dch v khm cha bnh
Kt qu thc hin
Nhim v ny c B Y t rt ch trng ch o thc hin trong thi gian qua, tp trung
vo vic sa i phng thc thanh ton theo nh sut v y mnh th im thanh ton theo
trng hp bnh. Trn c s kho st nh gi thc trng v tham kho cc kin t vn trong
nc v quc t, Ban son tho thng t sa i phng thc thanh ton theo nh sut xem
xt, trao i v cc phng n sa i thanh ton nh sut v xut vic trin khai th im
cc phng n ny lm c s xy dng thng t hng dn trin khai trn ton quc.
Ngy 30/12/2013, B trng B Y t k Quyt nh s 5380/Q-BYT ph duyt
n trin khai th im sa i thanh ton chi ph khm cha bnh BHYT theo nh sut trong
bao gm hai phng n sa i. n th im c trin khai ti 4 tnh bao gm Bc Ninh,
Ninh Bnh, Tha Thin Hu v Khnh Ha. Trong , Bc Ninh v Ninh Bnh p dng m hnh
thanh ton nh sut cho dch v KCB ngoi tr ti tuyn huyn x trong khi Tha Thin Hu
v Khnh Ha thc hin thanh ton nh sut cho c KCB ngoi tr v ni tr ti tuyn huyn
x. Vic trin khai v nh gi kt qu th im cc phng n sa i s l cn c thc tin xy
dng thng t hng dn trin khai thanh ton nh sut trn quy m ton quc t nm 2016.
Kt qu n s cung cp c s cho vic la chn phng n ti u hon thin Thng t
mi v thanh ton theo nh sut trn c s nh gi kt qu thc hin cc phng n sa i,
bao gm c v thit k nh tnh ton sut ph, phm vi dch v cng nh cc yu t trin khai
thc hin.
D n nghin cu th im chi tr theo trng hp bnh vi 26 nhm bnh thng gp
trong D n Pht trin ngun nhn lc y t do Ngn hng Pht trin chu ti tr vn c tip
tc trin khai trong thi gian qua. Vic thc hin thanh ton theo nhm bnh c nhng bc
chuyn bin tch cc. B Y t ch o xy dng n th im phng thc thanh ton theo
nhm chn on, theo hot ng ny s c iu phi v hot ng hiu qu hn cng nh
thun li trong huy ng cc ngun lc trin khai. Trong thi gian qua, cng tc nng cao nng
lc cn b v thanh ton theo trng hp bnh/nhm chn on cng c y mnh. B Y t
t chc 2 on cn b sang hc tp ti Thi Lan v ni dung ny. B Y t ang trin khai xy
dng quy trnh chuyn mn v tiu chun cht lng lm sng, c ch kim nh cht lng lm
sng i vi khong 20 bnh phc v kim sot cht lng dch v v chi ph khi m rng
th im thanh ton theo trng hp bnh.
86

Kh khn, hn ch
i mi phng thc thanh ton l cng vic kh khn, phc tp lin quan trc tip ti
li ch cc bn lin quan. Do , bn cnh vn k thut s hp tc, phi hp v ng thun
ca cc bn lin quan, c bit gia ngnh y t ti trung ng cng nh a phng l cc k
quan trng.
Vn nng lc cung ng dch v y t cn hn ch v c s chnh lch ln gia cc c
s y t cng tuyn, cng hng, cng a bn to ra vng mc, kh khn trong vic thit k v
trin khai cc phng thc thanh ton tr trc v da trn mc bnh qun chung nh nh sut
hay DRG. Mt khc, gi dch v y t cha tnh ng, tnh v khng thng nht gia cc bnh
vin, thiu cn c php l kim sot vic cung cp DVYT cng dn n nhng kh khn
trong p dng cc phng thc thanh ton mi.
Vic trin khai m hnh phng thc thanh ton mi i hi nhng iu kin nht nh
v nng lc k thut, tnh p ng ca h thng thng tin d liu, cc nghin cu h tr. Trong
iu kin thc t Vit Nam hin nay cc iu kin ny u rt hn ch.
Quy nh mi v thng tuyn khm cha bnh BHYT theo Lut sa i, b sung Lut
BHYT, c hiu lc t 1/1/2016 i vi phm vi tnh v t 1/1/2021 i vi phm vi c nc s
l thch thc rt ln i vi vic thc hin thanh ton theo khon nh sut, nht l trong bi
cnh c s chnh lch ln v nng lc cung ng dch v y t gia cc c s da trn s th ng
k khm cha bnh ti cc c s y t cng tuyn, cng hng, cng a bn.
1) Tng chi NSNN cho y t, tng t l chi cng v gim t l chi tin ti cho y t
Vn u tin
Thc hin cc ch tiu v bo m chi NSNN cho y t c Quc hi thng qua;
Gim chi tin ti ca h gia nh cho CSSK.
Gii php b sung
Tng cng gim st vic thc hin cc nhim v, ch tiu v bo m chi NSNN cho y
t c Quc hi thng qua.
Xy dng cc d ton ngn sch chi thng xuyn cho cc hot ng hin nay cha c
kinh ph thc hin hiu qu, nh thanh tra y t, dc, truyn thng gio dc sc
khe, thc hin nhim v v thng k y t.
Ch trng xy dng chin lc/chnh sch kim sot chi ph y t nhm hn ch thc trng
chi cho y t tng cao hn kh nng chi tr ca x hi v c bit ca BHXH v NSNN.
2) u tin phn b NSNN cho y t d phng, y t c s, CSSKB, thc hin chnh sch x
hi v y t
Vn u tin
Bo m kinh ph mua, h tr mua th BHYT cho ngi ngho, ngi thuc din
chnh sch v bo tr x hi, tng bc chuyn phn ngn sch cp cho cc bnh vin
sang cp trc tip cho ngi th hng thng qua vic mua hoc h tr mua th BHYT;
87

Bo m ngun lc thc hin tt CSSKB p ng yu cu trong tnh hnh mi ti
tuyn x.
Gii php b sung
u tin b tr kinh ph thc hin n 950 v tng cng c s vt cht cho trm y t x;
Hon thin c thng qua n Tng cng y t c s trong thi k mi kt hp
h tr quc t trin khai n;
Trin khai theo di, nh gi vic thc hin h tr NSNN mua BHYT cho cc i tng
theo quy nh;
Xy dng gi dch v y t c bn cho CSSKB ti tuyn c s lm c s phn b kinh
ph t NSNN v BHYT;
Xem xt kh nng huy ng cc ngun ti chnh mi nh s dng ngun qu phng,
chng tc hi ca thuc l, thu ph mi trng, thu thu ru, bia tng cng hot
ng YTDP, tuyn truyn lin quan cc BKLN.
3) Pht trin BHYT ton dn bn vng; thc hin l trnh tin ti BHYT ton dn
Vn u tin
Tng t l bao ph BHYT gim bt gnh nng ti chnh ca ngi dn khi i khm,
cha bnh.
Tp trung thc hin L trnh BHYT ton dn; m rng BHYT c v bao ph, gi dch
v v kh nng bo v ti chnh cho cc i tng tham gia BHYT.
Tip tc trin khai Ngh quyt 21-NQ/TW ca B Chnh tr v Tng cng s lnh o
ca ng i vi cng tc Bo him x hi- Bo him y t giai on 2012-2020, Ngh
quyt s 68/2013/QH13 ngy 29/11/2013 ca Quc hi v y mnh thc hin chnh
sch php lut v BHYT.
Gii php b sung
Hon thnh k hoch xy dng vn bn quy phm php lut v BHYT, c bit l cc
vn bn hng dn trin khai Lut sa i b sung mt s iu ca Lut BHYT, tho g
kp thi cc vng mc bt cp trong thc hin chnh sch BHYT;
Tin hnh cc bin php nng cao hiu qu kinh ph t BHYT bao gm: vic r sot danh
mc dch v k thut c BHYT tng cng s dng cc bng chng v nh gi cng
ngh y t trong xc nh u tin; tng cng theo di gim st s dng v chi ph KCB
BHYT thng qua h thng thng tin d liu KCB BHYT.
Trin khai BHYT theo h gia nh c l trnh ng thi tng cng h thng c s d
liu thng tin.
4) i mi c ch hot ng, c ch ti chnh trong cc n v s nghip y t cng lp
Vn u tin
Tp trung trin khai Ngh nh 85 ca Chnh ph v c ch hot ng, c ch ti chnh
i vi cc n v s nghip y t cng lp. Xy dng v ban hnh khung gi tnh y
88

cc yu t chi ph p dng cho cc bnh vin c kh nng thu, c kh nng t bo m
ton b chi ph hot ng thng xuyn; sa i, b sung cc quy nh v x hi ha,
lin doanh, lin kt trong bnh vin cng cho ph hp vi tnh hnh thc t.
Gii php b sung
Xy dng v thc hin l trnh iu chnh gi dch v y t theo l trnh tnh ng tnh
chi ph ca Ngh nh 85, bo m iu kin duy tr v pht trin cc c s KCB, ph
hp vi s pht trin kinh t x hi.
Xy dng b ch s theo di, nh gi hiu sut hot ng ca cc bnh vin cng lp i
i vi vic tng cng h thng qun l thng tin bnh vin.
Sa i, b sung cc quy nh v x hi ha, lin doanh, lin kt trong bnh vin cng
cho ph hp vi tnh hnh thc t
Xy dng thng t hng dn thanh ton dch v y t d phng.
5) i mi phng thc chi tr dch v khm cha bnh
Vn u tin
i mi phng thc chi tr dch v y t.
Xy dng v ban hnh c ch phn b ngn sch cho cc c s y t d phng, cc lnh
vc nh kim nghim, kim nh, dn s/KHHG, truyn thng gio dc sc khe.
Gii php b sung
y nhanh tin thc hin nhim v i mi phng thc thanh ton theo nh sut v
DRG trn c s theo di, nh gi cht ch cc m hnh th im v tin hnh cc nghin
cu v tham vn quc t hon thin thit k phng thc thanh ton theo nh sut ph
hp trong iu kin Vit Nam;
Nhanh chng thc hin ng b ha h thng thng tin phc v thit k v theo di
phng thc thanh ton gia cc c s KCB v c quan BHXH.
2.4. Dc v trang thit b y t
2.4.1. Kt qu thc hin
1) Bo m thuc thit yu phc v cng tc iu tr

Kt qu t c
V c bn nhim v bo m cung ng thuc thit yu, p ng yu cu cng tc iu
tr c thc hin tt. y l nhim v hng u c xc nh trong vn bn chnh sch v
lnh vc Dc. Chin lc quc gia pht trin ngnh Dc Vit Nam giai on n nm 2020
v tm nhn n nm 2030 c ph duyt theo Quyt nh 68/Q-TTg ngy 10/1/2014 ca
Th tng Chnh ph cng xc nh r mc tiu chung Cung ng y , kp thi, c cht
lng, gi hp l cc loi thuc20.
Quyt nh 68/Q-TTg ngy 10/1/2014 ca Th tng Chnh ph ph duyt Chin lc quc gia pht trin ngnh
Dc Vit Nam giai on n nm 2020 v tm nhn n nm 2030.
20
89

B Y t ban hnh Danh mc thuc thit yu tn dc ln VI theo Thng t 45/2013/
TT-BYT ngy 26/12/2013. Trong Danh mc ln ny c 466 thuc theo tn hot cht, chia thnh
29 nhm thuc theo tc dng dc l21. Nh vy, sau 8 nm k t nm 2005, Danh mc thuc
thit yu ca Vit Nam c cp nht. So vi Danh mc thuc thit yu ln th V ch c 355
hot cht, Danh mc thuc thit yu ln VI tng thm 111 thuc, tng thm 2 nhm thuc.
Ti Vit Nam, ngoi Danh mc thuc thit yu cn c Danh mc thuc ch yu s dng
trong xy dng danh mc thuc u thu ti cc bnh vin v thuc phm vi thanh ton BHYT.
u nm 2014, B Y t ban hnh Thng t hp nht s 01/TTHN-BYT ban hnh v hng
dn thc hin Danh mc thuc ch yu s dng ti cc c s khm bnh, cha bnh c qu Bo
him y t thanh ton thay th cho danh mc thuc ch yu s dng ti cc c s y t trc y22.
Theo s liu thng k hng nm, tng gi tr thuc s dng tng ln qua cc nm, t
2775 triu USD vo nm 2013, trong tr gi thuc sn xut trong nc l 1300 triu USD
(cha bao gm gi tr thuc xut khu); tr gi thuc nhp khu l 1845 triu ng (cha bao
gm gi tr nguyn liu lm thuc nhp khu). Mc chi tin thuc bnh qun u ngi cng
tng ln t 22 USD nm 2010 ln 31,2 USD nm 2013 [66].
thc hin mc tiu bo m cung ng thuc thit yu, Chin lc quc gia pht
trin ngnh Dc Vit Nam giai on n nm 2020 v tm nhn n nm 2030 c bit ch
trng vic pht trin sn xut thuc trong nc bao gm c chnh sch u i i vi vic sn
xut, cung ng v s dng thuc sn xut trong nc, c bit l thuc generic. Gi tr thuc
sn xut trong nc nm 2012 t 1,2 t USD, chim 48,2% tng gi tr thuc s dng ti Vit
Nam [9]. Thuc sn xut trong nc hin p ng c hai phn ba hot cht trong Danh mc
thuc thit yu ca Vit Nam ln th V. Vi cc quy nh u tin thuc sn xut trong nc
trong cng tc u thu cho thy t l thuc sn xut trong nc tng ng k v c s lng v
gi tr. Theo kt qu nh gi nhanh ca Cc Qun l Dc ti 7 S Y t v 8 bnh vin/vin
c ging bnh trc thuc B Y t cho thy theo kt qu u thu nm 2013, s lng v gi tr
thuc sn xut trong nc tng gn 2 ln. Ti 7 S Y t, s lng thuc sn xut trong nc nm
2013 l 700 triu n v so vi nm 2012 l 338 triu n v v v mt gi tr, gi tr thuc sn
xut nm 2013 l 768 t ng so vi nm 2012 l 385 t ng. Ti cc bnh vin trung ng, s
lng thuc sn xut trong nc nm 2013 l 73 triu n v so vi nm 2012 l 38 triu n v
v v mt gi tr, gi tr thuc sn xut nm 2013 l 256 t ng so vi nm 2012 l 120 t ng.
Ngoi vic cp php xut nhp khu thuc thng xuyn, Cc Qun l Dc cn gii
quyt nhng trng hp nhp khu thuc him, thuc theo nhu cu iu tr ca bnh vin, nhp
khu thuc cung ng cho cc chui nh thuc t tiu chun thc hnh nh thuc tt (GPP),
nhp khu thuc song song, bo m nhu cu thuc phng v cha bnh cho nhn dn. Th
tng ban hnh Quyt nh s 42/2013/Q-TTg sa i, b sung mt s iu ca Quy nh
v vic nhp khu thuc cha c s ng k ti Vit Nam ban hnh km theo Quyt nh s
151/2007/Q-TTg gii quyt mt s trng hp nhp khu thuc cha kp hoc thiu iu kin
ng k.
Vi mng li cung ng thuc ph rng ton quc vi mt trung bnh 2269 ngi/c
s bn l thuc (2012), kh nng tip cn thuc ca ngi dn trong cng ng kh thun li.
Mng li cung ng thuc khu vc bin o, vng su, vng xa cng c quan tm pht trin.
Thng t 45/2013/TT-BYT ngy 26/12/2013 ca B Y t ban hnh Danh mc thuc thit yu tn dc ln VI.
Thng t s 01/TTHN/BYT ca B Y t ngy 23/01/2014 v vic Ban hnh v hng dn thc hin Danh mc
thuc ch yu s dng ti cc c s khm bnh, cha bnh c qu Bo him y t thanh ton.
21
22
90

V lnh vc vc xin, mc d Vit Nam cha phi l nc c nn cng nghip dc pht
trin nhng sn xut c vc xin p ng c bn nhu cu s dng trong Chng trnh
TCMR. 10/11 loi vc xin trong Chng trnh TCMR c sn xut trong nc (ch c vc
xin Hib hin nay Vit Nam cha sn xut c). T 2006 n nay, sn lng vc xin sn xut
trong nc ca 10/11 loi vc xin trong Chng trnh TCMR cn cao hn so vi nhu cu s
dng, ch tr vc xin 5 trong 1 [Quinvaxem l vc xin phi hp 5 gii c t vi khun bch hu,
un vn, vi khun ho g bt hot, khng nguyn vi rt vim gan B v khng nguyn vi khun
Haemophilus influenzae tp B (Hib)] trong nc cha sn xut c [67].
Kh khn, hn ch
Bn cnh nhng kt qu t c nu trn vn tn ti mt s vn kh khn, hn ch
trong thc hin bo m cung ng thuc thit yu.
Vic cung ng v s dng thuc thit yu trong KCB BHYT cn mt s hn ch. Ch
c 316 trong tng s 1143 thuc trong Danh mc thuc c BHYT thanh ton l thuc thuc
Danh mc thuc thit yu ln th V [68]. Ti cc trm y t x, cn din ra tnh trng cp thuc
chm, thiu v c cu thuc khng p ng nhu cu iu tr [69].
Vic bo m cung ng thuc p ng nhu cu iu tr mt s bnh thuc CTMTQG
gia nh HIV, lao, st rt gp kh khn, thch thc trong thi gian ti khi cc chng trnh vin
tr gim dn v kt thc, trong khi cho ti nay vic cung ng thuc cho cc bnh ny, c bit
l thuc ARV cho bnh nhn HIV vn ang ch yu da vo ngun vin tr. Nhng kh khn
ny lin quan n nhiu vn trong c t chc mua sm, cung ng v thanh ton BHYT.
Cha c c ch gim st vic d tr, d bo nhu cu s dng vc xin i vi mt s loi
vc xin tim dch v (cc loi vc xin khng do Chng trnh TCMR cung cp) cha st vi
thc t nn vic cung ng gp kh khn.
Cha c c ch gim st nn cha c thng tin v tnh hnh thuc thit yu phc v cng
tc d phng v iu tr. Trong h thng bo co s dng thuc ti cc c s y t khng c ch
s v s dng v chi tiu cho thuc thit yu.
2) Kim sot gi thuc
Kt qu t c
Trong thi gian qua cng tc qun l gi thuc c B Y t rt ch trng v t c
kt qu nht nh. Th trng thuc c bn bnh n, p ng thuc phc v cng tc iu
tr v kim sot c vn tng gi thuc. Nm 2013, ch s gi dc phm l 3,45% so vi
ch s gi tiu dng chung (CPI) l 6,04% v ng th 9/11 nhm hng trng yu. Ch s gi
dc phm 5 thng u nm 2014 l 1% so vi CPI l 1,08% v d bo nm 2014 ch s gi
nhm hng dc phm thp hn CPI. So snh gi thuc trng thu ca Vit Nam vi gi thuc
tng ng ti Thi Lan v Trung Quc cho thy gi Vit Nam thp hn t 2,25 n 3,17
ln. Nghin cu gi thuc generic v bit dc theo phng php ca WHO cng cho thy gi
trng thu Vit Nam mc thp hn hoc trung bnh so vi s liu quc t[66].
Mt trong nhng bin php quan trng qun l gi thuc hin nay l thc hin cc quy
nh v u thu mua thuc do NSNN, Qu Bo him y t chi tr v ngun thu Vin ph qun
l. Hin ti, cc n v ang thc hin u thu theo cc quy nh mi v u thu thuc cnh
91

tranh.23 Cc Qun l Dc ci thin vic cung cp thng tin h tr cc n v thc hin u
thu theo Thng t 01 trong xy dng k hoch u thu cng nh thm nh, xt duyt kt qu
trng thu. Vic cung cp thng tin v thuc bit dc gc, danh mc thuc c ti liu chng
minh tng ng sinh hc, thuc b rt Danh mc thuc c ti liu chng minh tng ng
sinh hc c cng b thng xuyn trn trang in t ca Cc Qun l Dc v cc cng thng
tin v vn bn php lut khc.
Vic trin khai cc vn bn quy phm php lut v qun l gi thuc v u thu thuc
bc u pht huy tc dng, gip tit gim chi ph mua thuc ti cc bnh vin. Ti nhiu a
phng, gi tr thuc trng thu gim c 20-30% so vi gi k hoch ca cc gi thu [49].
Theo d liu thng k kt qu trng thu ca 26 S Y t v cc bnh vin, vin c ging bnh
trc thuc B, cc quy nh mi v u thu mua thuc gip gim 35,33% gi thuc trng
thu [66]. T trng thuc sn xut trong nc trong tng gi tr tin thuc trng thu ti cc bnh
vin tng ln mc 1,01% ti cc bnh vin trung ng v 2,41% ti cc bnh vin tnh v huyn.
Mc tng ny t mc tiu ra trong n Ngi Vit Nam u tin dng thuc Vit Nam.
Thc hin chc nng mua thuc v dch v y t cho gn 60 triu ngi c th BHYT,
BHXH Vit Nam ngy cng tng cng vai tr trong vic kim sot chi ph v gi thuc thanh
ton BHYT. Trn trang thng tin in t ca BHXH Vit Nam thng xuyn ng ti kt qu u
thu thuc v vt t y t ca tt c cc n v v a phng. Nu pht hin vn ng lu v
gi trng thu v gi thanh ton thuc BHYT, BHXH cng c kin kp thi vi cc bnh vin,
a phng ngay v vn ny.
Kh khn, hn ch
Cha t c s ng thun v t chc v phn cng trch nhim n v u mi trong
qun l nh nc gi thuc. Vic qun l gi thuc mc hp l theo kh nng chi tr ca
ngi dn v BHYT cn nhiu kh khn do cha c c ch hu hiu nh gi tnh hp l ca
gi thuc k c gi k khai.
Cha c bin php qun l gi hu hiu i vi thuc bn ti c s bn l thuc khng
thuc c s y t. Thc t, lng thuc tiu th trn th trng do h thng nh thuc t nhn
phn phi chim 65-70%. n th im qun l gi thuc bng thng s bn bun ton chng
c thc hin t nm 2013 song cha c bo co theo di, nh gi.
Cha sa i quy nh u thu tnh n chi ph ca c liu trnh iu tr. Cha c bin
php khuyn khch bc s quan tm n chi ph/hiu qu khi ch nh thuc.
Thng tin v gi thuc bao gm c gi k khai, gi k khai li v kt qu u thu
cnh tranh trn trang web ca Cc Qun l dc Vit Nam khng c cp nht mt cch kp
thi, thng tin khng c chun ha (v d nh tn ca thnh phn hot cht thuc hoc liu
dng), trng lp hoc thiu chnh xc.
3) Tng cng qun l cht lng thuc v s dng thuc an ton hp l
Kt qu t c
Vic bo m cht lng thuc lin quan n c chui hot ng bao gm sn xut, bo
qun n kim sot cht lng thng qua h thng kim nghim. i vi qu trnh sn xut v
Thng t lin tch s 01/2012/TT-BYT-BTC ngy 19/1/2012; Thng t 36/2013/TTLT-BYT-BTC ngy 11/11/2013
sa i, b sung Thng t lin tch s 01/2012/TT-BYT-BTC; Thng t s 37/2013/TT-BYT ngy 11/11/2013 ca B
Y t hng dn lp H s mi thu mua thuc trong cc c s y t thay th cho Thng t s 11/2012/TT-BYT ngy
28/6/2012.
23
92

bo qun, vic thc hin cc tiu chun thc hnh tt l bin php c bn bo m cht lng
thuc. B Y t v ang tch cc trin khai thc hin ch trng qun l ton din cht lng
thuc thng qua vic trin khai p dng cc nguyn tc Thc hnh tt (GPs) trong ton b h
thng t khu sn xut (GMP), bo qun, tn tr (GSP), kim nghim (GLP), phn phi (GDP)
v cung cp thuc cho n tn ngi s dng (GPP). Hin nay, ton b cc doanh nghip sn
xut tn dc t tiu chun thc hnh tt sn xut thuc (GMP), tt c c s kim nghim
thuc t thc hnh tt kim nghim thuc (GLP). S lng cc n v t tiu chun thc hnh
tt tng ln qua cc nm (Bng 11).
Bng 11: S lng cc c s t tiu chun thc hnh tt qua cc nm
2008
2009
2010
2011
2012
2013
n T6/2014
GMP
89
98
105
113
121
127
131
GLP
88
98
104
113
124
142
136
GSP
106
126
137
158
164
142
227
Ch thch: S liu GMP t 2010 n 2014 gm c 4 c s sn xut vc xin ca Vit Nam; S liu GLP bao gm c
cc Phng kim nghim c lp; S liu GSP bao gm c kho bo qun thuc t nhn v ca S Y t.
Ngun: Cc Qun l Dc Vit Nam, Cng vn s 755/QLD-KHTC ngy 22/7/2014 v vic gp d tho Bo co
tng quan ngnh y t nm 2014 v lnh vc dc & m phm.
Tng cng kim tra, gim st bo m cht lng thuc l nhim v c ch trng
trong cng tc qun l nh nc v thuc. Nng lc h thng kim nghim thuc t trung ng
n a phng c tng cng r rt trong nhng nm gn y. D n H tr h thng
y t do Qu ton cu phng chng AIDS, lao v st rt ti tr, giai on 2012-2013 c h tr
h thng kim nghim dc phm trong ton quc do Vin Kim nghim thuc trung ng
thc hin. D n gip u t trang b thit b phn tch, h tr v cht chun, t chc o to v
k thut v xy dng h thng thng tin, bo co v cht lng thuc trn ton h thng kim
nghim c nc gp phn nng cao nng lc kim tra, gim st cht lng thuc cho khi kim
nghim nh nc. Vi ngun kinh ph t NSNN v vin tr quc t, trang thit b ca h thng
kim nghim c ci thin c s lng, chng loi v mc hin i. H thng kim nghim
hin nay c th kim tra cht lng c hu ht cc thuc thit yu. Nm 2013, h thng kim
nghim kim tra cht lng c trn 56000 mu thuc, trong , s mu ly kim tra
cht lng gn 40000; thc hin nh gi tng ng sinh hc (do Cc Qun l Dc tip
nhn, thm nh v cng b) c 75 thuc sn xut trong nc [66]. Kt qu kim tra pht
hin nhiu mu thuc khng t cht lng, thuc gi. Vic ly mu kim tra cht lng thuc
lu hnh trn th trng v x l cc l thuc khng t tiu chun cht lng c tng cng.
C quan qun l nh nc v thuc kp thi ban hnh cc quyt nh thu hi, rt s ng k
i vi cc l thuc khng t cht lng. y mnh thanh tra, x l cc trng hp vi phm
thng tin qung co thuc. Theo thng bo ca Cc Qun l Dc, nm 2013 c 28 l thuc b
nh ch lu hnh, 6 thng u nm 2014 c 22 l b nh ch lu hnh.
Vic trin khai cc gii php s dng thuc an ton, hp l, tng bc gim lm dng
thuc trong iu tr cc c s y t Nh nc v t nhn c y mnh. B Y t ban hnh
Thng t 21/2013/TT-BYT quy nh v t chc v hot ng ca Hi ng Thuc v iu tr
trong bnh vin; B Y t cng c cng vn s 2299 ngy 28/4/2014 gi cc S Y t v bnh
vin trong ton quc nhc nh tng cng cng tc ch o, kim tra vic thc hin Quy ch
k n thuc trong iu tr ngoi tr, trong c bit nhn mnh vai tr ca Hi ng Thuc
v iu tr ch trng cng tc kim tra, gim st k n an ton, hp l v hiu qu. Trc thc
93

trng bo ng v tnh hnh khng thuc trong thc t iu tr ti Vit Nam, B Y t ban hnh
K hoch hnh ng quc gia v chng khng thuc giai on t nm 2013 n nm 2020 theo
Quyt nh 2174/Q-BYT ngy 21/6/2013 vi 6 mc tiu c th, trong ng ch l c mc
tiu tng cng hon thin h thng gim st quc gia v s dng khng sinh v khng thuc
v tng cng kim sot nhim khun.
Vic theo di, gim st phn ng c hi ca thuc c nhng chuyn bin tch cc trong
thi gian qua. B Y t ban hnh Quyt nh 1088/Q-BYT nm 2013 hng dn hot ng
gim st phn ng c hi ca thuc (ADR) ti cc c s KCB. Trung tm quc gia v thng tin
thuc v theo di phn ng c hi ca thuc i vo hot ng n nh v ngy cng t c
nhiu kt qu. K t ngy 1/1/2010 tt c cc bo co t nguyn theo di ADR trn c nc s
c gi v Trung tm Quc gia v Thng tin thuc v Theo di phn ng c hi ca thuc. S
lng bo co v phn ng c hi ca thuc gi v Trung tm tng ln qua cc nm (Hnh 30).
Hu ht cc bo co c gi v t h thng cc bnh vin trong c nc (trn 90%). Trung tm
xy dng c s d liu tra cu thng tin thuc; bin son v phn bin nhiu chuyn lun v
a vo h thng MEDLIB.
Hnh 30: S lng bo co phn ng c hi ca thuc gi v Trung tm Thng tin thuc
v theo di phn ng c hi ca thuc, 2010-2013

7000
S bo co
6000
6016
5000
4000
3000
2000
1000
0
1807
2010
2407
2011
3236
2012
2013
Ngun: Trung tm Thng tin thuc v Theo di phn ng c hi ca thuc.
Kh khn, hn ch
Thng tin v cc mt hng thuc b nh ch lu hnh cha c tng hp mt cch h
thng theo hnh thc c s d liu thun tin cho vic tra cu, tham kho.
Cha c h thng thng tin gim st tnh hnh s dng thuc an ton hp l, theo ng
hng dn iu tr ca B Y t. Tnh trng lm dng thuc trong iu tr ti cc c s nh nc
v t nhn cha c nh gi mt cch y v tha ng.
Cn thiu nhn lc dc ti cc a phng c bit cc vng su, vng xa. S lng
dc s lm sng, dc s cng tc trong lnh vc qun l m phm cn thiu.
Cha c quy nh r rng v pht trin m hnh phn phi thuc ph hp vi tnh hnh
ti Vit Nam c kh nng bo m cht lng thuc.
94

4) y mnh pht trin thuc ng y v thuc t dc liu
Kt qu t c
Vic ban hnh Danh mc thuc thit yu ln th VI ca Vit Nam c mt s thay i
khc so vi cc ln trc; thay v a danh mc thuc ng y v thuc t dc liu vo phn
cui ca Danh mc, B Y t cho ban hnh ring mt Thng t quy nh Danh mc thuc
thit yu thuc ng y v thuc t dc liu ln VI theo Thng t 40/2013/TT-BYT. S thay
i ny cho thy ch trng nng cao v th v y mnh vic s dng thuc ng y v thuc
t dc liu.
Ngy 30/10/2013, Th tng Chnh ph ban hnh Quyt nh 1976/Q-TTg v vic
ph duyt quy hoch tng th pht trin dc liu n nm 2020 v nh hng n nm 2030.
Ni dung ca quy hoch khng ch bao gm vic quy hoch cc vng bo tn v khai thc dc
liu t nhin, quy hoch cc vng trng dc liu m cn quy hoch h thng cc c s ch
bin, chit xut v bo qun dc liu, cng c h thng lu thng cung ng dc liu. Quy
hoch ny gp phn gii quyt vn cng nghip dc liu cha thc s pht trin tng xng
vi tim nng hin c. Nhu cu v thuc c truyn nc ta rt ln do thi quen v truyn
thng ca ngi tiu dng. Hin nay, nhu cu dc liu hng nm phc v sn xut thuc s
dng trong YHCT khong 40000-60000 tn dc liu vi khong 500 loi dc liu, p ng
50% tng lng nhu cu dc liu s dng trong khm cha bnh v sn xut thuc. Nhiu
hot ng nhm pht trin ngun dc liu v tng cng vic qun l, khai thc, s dng bn
vng ngun dc liu ang c trin khai. Vic xy dng cc vng nui, trng dc liu theo
tiu chun thc hnh tt nui trng, thu hoch dc liu theo quy m cng nghip ang c
Cc Qun l Y Dc c truyn, Cc Qun l Dc v Tng cng ty Dc phi hp trin khai.
Vin Dc liu ang ch tr n pht trin cc trung tm nghin cu, nui trng dc liu. K
hoch trin khai thc hin Chin lc quc gia pht trin ngnh dc Vit Nam xut 6 ni
dung hot ng c xut nhm trin khai nhim v Ban hnh chnh sch u i cho vic
nghin cu sn xut thuc c ngun gc t dc liu Vit Nam mang thng hiu quc gia24.
Thi gian qua, cng tc qun l ngun gc v cht lng dc liu kh c ch trng
trong hot ng qun l nh nc ca B Y t. Vic xy dng, hon thin cc vn bn c ni
dung lin quan ang c trin khai nh D tho Thng t hng dn qun l ngun gc, cht
lng dc liu s dng theo l lun y hc c truyn. T chc i kim tra cht lng dc liu,
v thuc YHCT ti mt s tnh (Thanh Ha, Cao Bng). T chc 2 lp tp hun cho cn b
YHCT v kim tra, kim sot cht lng dc liu, v thuc YHCT ti ng Thp v Yn Bi.
Theo nh gi ca Cc qun l YDCT, cht lng dc liu ngy cng c kim sot cht ch,
nht l trong cc c s KCB bng YHCT [70].
Hot ng sn xut thuc t dc liu trong nhng nm gn y c nhng bc pht
trin r rt. Cc doanh nghip sn xut thuc nghin cu v sn xut nhiu loi thuc t dc
liu, c dng bo ch mi, thun tin cho vic s dng. Bn cnh , nhiu nh sn xut thuc
chuyn hng i mi l sn xut cc thuc b tr, thc phm chc nng, m phm, hng liu
nhm trnh s qun l cht ch ca cc quy ch qun l thuc ng thi n bt xu hng s
dng thc phm chc nng ngy cng gia tng [71].
Quyt nh s 2614 ngy 16/07/2014 ca B trng B Y t ban hnh K hoch trin khai thc hin Chin lc
quc gia pht trin ngnh dc Vit Nam giai on n nm 2020 v tm nhn 2030 theo quyt nh s 68/Q-TTg
ngy 10/01/2014 ca Th tng Chnh ph.
24
95

Kh khn, hn ch
Cng tc pht trin dc liu cn mang tnh t pht, khai thc dc liu t nhin b
bung lng.
Kh khn trong qun l ngun gc v cht lng ng dc v dc liu ti cc c s
sn xut v cung ng. Ngun dc liu trong nc hin nay phn ln ph thuc vo ngun dc
liu nhp khu nc ngoi, trong khi vic kim sot nhp khu v ngun gc, gi c v cht
lng rt hn ch25. Cht lng dc liu cha c kim sot thng xuyn.
Cht lng sn xut thuc t dc liu cn nhiu hn ch. Trong s 322 c s sn xut
thuc t dc liu, ch c 10 c s t tiu chun GMP. Hn 200 c s sn xut l h c th,
iu kin c s vt cht trang thit b rt hn ch.
5) Tng cng sn xut trang thit b y t trong nc
Kt qu t c
Tip tc trin khai cc ni dung ch o ca Chnh ph v trin khai chnh sch quc gia
v trang thit b y t v nghin cu sn xut trang thit b y t trong nc. phi hp vi B
Ti chnh kim tra v nghin cu xut gii php h tr chnh sch thu i vi cc doanh
nghip sn xut trang thit b y t trong nc. C nc hin c hn 1000 bnh vin v 50
n v, cng ty sn xut, kinh doanh thit b y t. Trong s thit b y t sn xut trong nc,
c khong 600 chng loi c B Y t thm nh v cp php lu hnh nhng ch yu l cc
dng c c kh cm tay, ging bnh, bm kim tim, dy truyn dch, gng tay cao su, ni hp
tit trng hay cc my vt l tr liu ng dng cng ngh laser.
B Y t tng bc ng dng cng ngh thng tin trong cng tc cp php nhp khu
trang thit b y t nhm ci cch cc th tc hnh chnh. Phi hp lm vic vi Cc Gim qun
- Tng Cc Hi quan v cc n v lin quan thng nht gii quyt cc vng mc v sn phm
gip ranh trong nhp khu trang thit b y t.
Kh khn, hn ch
Cha c chnh sch u tin trong mua sm v s dng trang thit b y t sn xut trong
nc. Vic p dng cng ngh thng tin trong qun l nhp khu trang thit b y t cn hn ch.
6) Tng cng c s vt cht ca cc n v s nghip y t
Kt qu t c
Ti tuyn trung ng, B Y t tp trung y mnh vic thc hin mt s D n trng
im nh: Hon thnh C s Tn Triu ca Bnh vin K quy m 1000 ging bnh; Bnh vin
Nhi Trung ng; D n Trung tm Ung bu v Tim mch Tr em, Khoa Khm bnh thuc
Bnh vin Bch Mai; D n Trung tm Ung bu, Khoa Khm bnh thuc Bnh vin Ch Ry;
y nhanh tin thc hin mt s d n Trung tm Ung bu ca cc bnh vin a khoa thuc
B Y t ti Ung B, Thi Nguyn, Trong nm 2014, c s II ca 5 bnh vin tuyn trung
ng v tuyn cui c khi cng; Th tng Chnh ph cng ph duyt d n u t
xy dng v nng cp cc bnh vin y hc c truyn cho giai on 2014-2025 (Quyt nh s
Cc Qun l dc (2013), n hp nht Chnh sch quc gia v dc giai on n nm 2020 tm nhn n
nm 2030.
25
96

362/Q-TTg ngy 11/3/2014). Trong 11 d n do B Y t qun l, hon thnh mt phn d
n gm c: Bnh vin Lao v Bnh phi Trung ng Phc Yn, Bnh vin K (C s Tn Triu)
v cc hng mc c bn ca Trng i hc Y Dc Cn Th. Th tng Chnh ph ph
duyt n u t xy dng mi 5 bnh vin tuyn trung ng v tuyn cui t ti thnh ph
H Ch Minh (Quyt nh s 125/Q-TTg ngy 16/01/2014).
i vi mng li y t a phng, vic thc hin n 47, giai on 2008-2012
hon thnh 460 bnh vin huyn (hon thnh ton b hoc hon thnh cc hng mc trin
khai) v 70 phng khm a khoa khu vc. i vi n 930, giai on 2008-2012 c 73 bnh
vin hon thnh a vo s dng (trong c bnh vin hon thnh ton b hoc hon thnh
cc hng mc chnh) gm c nng cp, ci to c s vt cht, trang thit b, o to cn b v
cung cp thuc thit yu.
Bn cnh ngun u t t tri phiu Chnh ph thng qua 2 n trn, cc d n nng
cao nng lc y t thng qua vn u t ODA, vn vay Ngn hng Th gii cho mt s khu vc
gp phn ci thin ng k nng lc k thut cho cc bnh vin tnh, huyn. Vic iu chnh
cc quy nh lin quan n h thng y t tuyn huyn vn ang c tip tc nghin cu. Quy
hoch mng li bnh vin ang c thc hin theo Quyt nh s 30/2008/Q-TTg. Hin
nay, B Y t cng ang xy dng v hon thin quy hoch pht trin ngnh y t, trong c
mng li khm, cha bnh. n Ch trng quy hoch bnh vin trung ng v bnh vin
khu vc ang c xy dng v trnh Chnh ph.
Kh khn, hn ch
Cha c c bo co nh gi hin trng trang thit b y t, vt t y t t c chin
lc u t trang thit b thch hp cho cc tuyn y t.
Cn 185 bnh vin huyn cha hon thnh trong n 47: trang thit b cn thiu so vi
quy nh, vn cn n khi lng xy dng
Mng li bnh vin tuyn tnh v huyn c u t t n 47 v n 930 c
trin khai; tuy nhin, tin b nh hng do kh khn v ngun tri phiu Chnh ph nn
ngun vn b ct gim. Mt s d n phi gin, hon, tin ; mt s d n phi tm dng
u t sau nm 2015 hoc phi chuyn i hnh thc u t. Mt s a phng s dng vn
tri phiu cn dn tri, cha tp trung nn khng pht huy ht hiu qu. Vic tch mt s bnh
vin chuyn khoa (Nhi, Sn) ti mt s tnh cng lm nh hng n cht lng chuyn mn
do thiu nhn lc.
1) Bo m thuc thit yu phc v cng tc iu tr

Cc vn u tin
Thc hin tt cung ng v s dng thuc thit yu trong KCB BHYT - c xem l mt
phn ca gi dch v y t c bn quy nh trong Lut BHYT sa i, t khu la chn,
mua sm, cung cp v s dng.
Xy dng l trnh v phng n ti chnh bn vng bo m cung ng thuc iu tr
cho cc bnh ang da vo ngun thuc vin tr nc ngoi nh HIV, lao. Tho g cc
vng mc, khi thng ngun ti chnh kh dng thay th ngun vin tr duy tr cung
ng thuc.
97

y mnh sn xut v s dng thuc sn xut trong nc, ch trng thuc thit yu.
Cc gii php b sung
Xem xt b sung vo Lut Dc cc quy nh v Chnh sch thuc generic, Chnh sch
thuc thit yu v bo m thuc sn c v Chnh sch pht trin mng li phn phi
thuc v h tr nhn dn tip cn thuc.
R sot v tng cng h thng qun l cung ng thuc KCB BHYT.
R sot cc vng mc v xut cc gii php thc hin cung ng thuc iu tr cho
cc bnh ang da vo ngun thuc vin tr nc ngoi nh HIV, lao thng qua BHYT.
Xy dng chnh sch u i nhm thc y nghin cu, sn xut, cung ng v s dng
thuc thit yu sn xut ti Vit Nam v vic nhp khu thuc thit yu Vit Nam cha
sn xut c.
2) Kim sot cht ch gi thuc
Cc vn u tin
Thng qua Lut Dc sa i trong c quy nh v t chc, phn cng nhim v v
phng thc qun l nh nc v gi thuc.
Trin khai cc bin php hu hiu bnh n gi thuc.
Trin khai cc chnh sch u thu mua thuc theo quy nh.
Trin khai cuc vn ng Ngi Vit dng thuc Vit.
Cc gii php b sung
Tng cng theo di, gim st kt qu thc hin u thu mua thuc. Nghin cu m
hnh u thu thuc tp trung.
nh gi, rt kinh nghim vic thc hin n th im qun l gi thuc bng thng
s bn bun ton chng. Xy dng chnh sch ph hp qun l gi thuc ti n v
bn bun, bn l thuc.
Sa i quy nh u thu tnh n chi ph ca c liu trnh iu tr.
3) Tng cng qun l cht lng thuc v s dng thuc an ton hp l
Cc vn u tin
Tng cng kim tra, gim st bo m cht lng thuc.
y mnh trin khai cc gii php s dng thuc an ton, hp l, tng bc gim vic
lm dng thuc trong iu tr cc c s y t nh nc v t nhn.
Cc gii php b sung
Nng cao nng lc c quan kim nghim, kim nh thuc v vc xin, c s nghin cu
tng ng sinh hc v c l trnh m rng danh mc thuc phi nghin cu tng
ng sinh hc;
98

Cn c chnh sch thu ht nhn lc dc ti cc a phng, thc hin chnh sch o
to theo a ch; ngh B Y t nghin cu tham mu vi B Ni v quy nh bin
cn b dc ti trm y t x, phng, th trn v phng y t, nh bin k thut vin ly
mu theo Thng t 09/2010/TT-BYT ngy 28/4/2010 hng dn vic qun l cht lng
thuc;
Tng cng vic theo di gim st tnh hnh s dng thuc an ton hp l ti cc c s
iu tr, c bit l h thng qun l thng tin bnh vin;
Thc hin k hoch hnh ng quc gia v chng khng thuc, trong c vic Xy
dng ch s nh gi s dng thuc an ton hp l, nht l vi thuc khng sinh.
4) y mnh pht trin thuc ng y v thuc t dc liu
Cc vn u tin
Thc hin cc n theo Quy hoch tng th pht trin dc liu n nm 2020 v nh
hng n nm 2030.
Hon thin h thng vn bn quy phm php lut v qun l cht lng thuc ng y v
thuc t dc liu.
Gii php b sung
Tng cng cng tc thanh tra, kim tra v ngun gc v cht lng thuc ng y v
dc liu ti cc c s sn xut v cung ng.
Xy dng K hoch trin khai Quy hoch tng th pht trin dc liu n nm 2020
v nh hng n nm 2030.
Thc hin cc hot ng pht trin thuc t dc liu mang thng hiu quc gia.
5) Tng cng sn xut trang thit b y t trong nc
Vn u tin
K hoch hnh ng trin khai Chin lc pht trin ngnh sn xut v cung ng trang
thit b y t.
Gii php b sung
Bn cnh vic khuyn khch sn xut, cn c cc chnh sch u tin trong mua sm v
s dng trang thit b y t sn xut trong nc.
Xy dng c s d liu v trang thit b y t gip cc c s y t trong vic mua sm
trang thit b y t ph hp ng thi xy dng mng li thng k trang thit b v n
v nh gi cng ngh y t.
6) Tng cng c s vt cht ca cc n v s nghip y t
Vn u tin
Tp trung y mnh mt s D n xy dng c s KCB trng im c ph duyt.
99

Cc a phng phi tp trung vn tri phiu Chnh ph giai on 2012-2015, giai on
2014-2016, ngn sch a phng v cc ngun vn hp php khc hon chnh, a
v s dng cc bnh vin tuyn huyn, tuyn tnh.
Bo m trang thit b thit yu phc v cng tc d phng v iu tr.
Gii php b sung
R sot, nh gi hin trng v nhu cu trang thit b y t ti c s y t cc tuyn; cp
nht danh mc trang thit b y t thit yu cho cc c s y t.
Xy dng quy hoch mng li KCB giai on 2015-2020 v tm nhn 2030 vi s phn
b hp l cc c s KCB theo lnh th, ph hp vi s thay i m hnh bnh tt v nhu
cu ca ngi dn.
Ch trng vic chun ha v ng b ha trong thit k xy dng v u t c s vt
cht, trang thit b cho cc c s khm cha bnh ti cc tuyn.
y nhanh tin gii ngn ngun ngn sch ca cc n h tr pht trin c s h
tng cc bnh vin tuyn tnh, huyn.
R sot danh mc cc d n, cng trnh trong n 47 cn ko di tip tc ngh
b sung vn giai on 2014-2016 trnh Chnh ph theo Ngh quyt s 65/2013/QH13
ca Quc hi.
u tin b tr kinh ph thc hin n 950 tng cng c s vt cht cho trm y t x.
2.5. Thng tin y t
2.5.1. Tnh hnh thc hin
1) Hon thin chnh sch, k hoch pht trin h thng thng tin y t n nm 2015 vi tm
nhn 2020
Kt qu thc hin
Trong hai nm gn y, Chnh ph v B Y t rt quan tm n vic tng cng h thng
thng tin thng k ni chung v h thng thng tin y t ni ring. Mt lot chnh sch lin quan
n cng tc thng k c ban hnh nh:
Ngh nh s 79/2013/N-CP ngy 19/7/2013 v quy nh x pht vi phm hnh chnh
trong lnh vc thng k. Ngh nh ny quy nh r hnh vi vi phm hnh chnh; hnh thc x
pht, mc x pht, bin php khc phc hu qu i vi tng hnh vi vi phm hnh chnh; thm
quyn x pht, mc pht tin c th theo tng chc danh v thm quyn lp bin bn i vi vi
phm hnh chnh trong lnh vc thng k.
Chnh sch ph bin thng tin c ban hnh theo Quyt nh s 34/2013/Q-TTg ngy
4/6/2013 ca Th tng Chnh ph bt u c hiu lc t ngy 1/8/2013. Theo Quyt nh,
thng tin thng k Nh nc cng b theo quy nh ca Lut Thng k v cc vn bn quy
phm php lut khc phi c ph bin ng thi hn, cng khai, minh bch v ngun thng
tin. Chnh sch ph bin thng tin nhm nng cao hiu qu phi hp cng tc trong hot ng
thng k gia cc b, ngnh trong vic sn xut, cung cp, ph bin v chia s thng tin thng
100

k nhm to ra h thng thng tin thng k ng b, thng nht, thng sut v hiu qu gia h
thng thng k tp trung v thng k b, ngnh.
Ch bo co thng k tng hp p dng cho cc b, ngnh c ban hnh theo Quyt
nh s 15/2014/Q-TTg ngy 17/2/2014 ca Th tng Chnh ph thay th Quyt nh s
111/2008/Q-TTg p dng cho b, ngnh t nm 2008 n nay, nhm p ng yu cu ca
H thng ch tiu thng k quc gia (ban hnh km theo Quyt nh s 43/2010/Q-TTg ngy
2/6/2010 ca Th tng Chnh ph). B, ngnh c giao qun l Nh nc lnh vc no chu
trch nhim thu thp, tng hp thng tin thng k lnh vc bao gm c nhng thng tin thng
k ca cc n v thuc quyn qun l ca b, ngnh khc v a phng.
K hoch tng th pht trin h thng thng tin giai on 2014-2020 tm nhn n 2030
c ban hnh theo Quyt nh s 3040/Q-BYT ngy 14/8/2014, vi mc tiu tng qut n
nm 2020 h thng thng tin y t gp phn tng cng sc khe ngi dn, phn phi cng
bng cc ngun lc, ci cch ngnh y t, nng cao kh nng qun l, theo di nh gi cc chnh
sch y t v tng cng ci cch hnh chnh cng.
Quyt nh 4445/Q-BYT ca B Y t v vic ban hnh Quy ch pht ngn v cung
cp thng tin cho bo ch ca B Y t. Theo quy ch ny, ngi pht ngn v cung cp thng
tin cho bo ch l ngi ng u c quan qun l nh nc giao nhim v. Chc nng, nhim
v quyn hn ca ngi pht ngn c quy nh c th, r rng, thi gian pht ngn, cung
cp thng tin cho bo ch. H tn, chc v, s in thoi v a ch email ca Ngi pht ngn
phi c cng b bng vn bn cho cc c quan bo ch, c quan qun l nh nc v bo ch
c ng ti trn Cng thng tin in t B Y t. Quy ch s to iu kin cung cp thng
tin cng khai, minh bch, ng thi gip cng tc pht ngn v cung cp thng tin cho bo ch
t hiu qu cao hn p ng tt cng tc tuyn truyn, nh hng cho ngi dn.
Nhiu vn bn chnh sch v pht trin cng ngh thng tin c ban hnh nh Quyt
nh 2565/Q-BYT ca B Y t v vic thay i v kin ton Ban ch o trin khai ng dng
v pht trin cng ngh thng tin ngnh y t; Quyt nh s 2035/Q-BYT ngy 12/6/2013 v
vic cng b danh mc k thut v ng dng cng ngh thng tin trong lnh vc y t, Quyt
nh 04/Q-BYT ca B Y t v vic ban hnh Quy ch thm nh, kim tra v nghim thu d
n ng dng cng ngh thng tin trong ngnh y t.
Kh khn, hn ch
B Y t cha phn b kinh ph thc hin i vi cc h thng thng k tng hp, cc
tiu h thng thng tin (hnh chnh) v cc cuc iu tra.
Thiu vn bn quy phm php lut v ph bin thng tin thng k ngnh y t quy nh
nhng thng tin cn c ph bin, n v chu trch nhim, thi gian v hnh thc cng b
thng tin y t trong lnh vc ngnh qun l.
Thiu chnh sch quy nh s phi hp, phn cng trch nhim, ngha v cung cp, chia
s thng tin gia B Y t vi b, ngnh lin quan nh Tng cc thng k, B Ti chnh, B T
php, Bo him x hi
B Y t v B Ni v cha quy nh v tr, chc danh, nh mc thng k i vi cc
n v trong ngnh y t.
101

2) Hon thin h thng ch s, s sch ghi chp v bo co thng k y t cho c khu vc y t
nh nc v t nhn. Ban hnh Thng t v ch s y t, chun ha h thng ch s c bn
ngnh y t
Kt qu thc hin
Trong hai nm qua, B Y t ch ng cp nht v hon thin cc vn bn quan trng
nhm i mi, hon thin v nng cao cht lng hot ng thu thp thng tin y t. Thng t
s 06/2014/TT-BYT, ban hnh ngy 14/2/2014 ca B Y t v ban hnh danh mc h thng
ch tiu c bn ngnh y t p ng nhu cu thng tin ca H thng ch tiu thng k quc gia
(Theo Quyt nh s 43/2010/Q-TTg ngy 2/6/2010), phc v cng tc qun l, iu hnh
ca Ngnh ng thi phc v cho vic bo co Mc tiu Thin nin k v cc bo co thng
nin cho cc t chc quc t. H thng ch tiu c bn ngnh y t gm 88 ch tiu ca cc lnh
vc khc nhau, c phn loi theo 6 tr ct ca ngnh y t v c phn chia thnh nhm ch
tiu u vo, qu trnh, u ra, kt qu v tc ng theo khuyn ngh ca WHO v cc i tc
pht trin (IHP +). Rt nhiu ch tiu trong danh mc ch tiu c bn c phn t theo gii,
theo vng, dn tc nhm nhm gim st v nh gi tnh hnh bnh ng gii cng nh nh
gi s mt cng bng trong vic tip cn v s dng dch v y t. B Y t ban hnh b ch tiu
c bn phn cp theo tuyn tnh, tuyn huyn v tuyn x26. Mt b t in ch tiu trong
mi ch tiu c chun ha v khi nim, cch tnh ton, ngun s liu, phn t ch yu, bnh
lun km theo Thng t s 28/2014/TT-BYT27 to iu kin gip cc cn b y t tra cu, s
dng d dng.
Ch bo co p dng i vi c s tuyn tnh, huyn, x c ban hnh theo Thng
t s 27/2014/TT-BYT28 thay th Quyt nh 3440/Q-BYT t nm 200929 n nay. Thng t
quy nh h thng biu mu thng k y t p dng i vi c s tuyn tnh, huyn, x s dng
thng nht trn ton quc, cc thng tin c ghi chp khoa hc trnh trng cho, to iu kin
chia s thng tin, trnh tnh trng qu ti biu mu ti tuyn y t c s.
Y t t nhn ngy cng pht trin v ng gp khng nh trong vic cung cp cc dch
v khm cha bnh cho ngi dn. Trong nm qua, B Y t v cc S y t trin khai cp
chng ch hnh ngh i vi ngi hnh ngh v cp giy php hot ng i vi c s khm
bnh, cha bnh. Th tc cp chng ch hnh ngh v cp php hot ng c ng ti cng
khai trn trang in t ca S Y t. B Y t ban hnh Thng t s 29/2014/TT-BYT ngy 14
thng 8 nm 2014 quy nh c th v ngha v v trch nhim cp nht, bo co s liu ca cc
c s khm bnh, cha bnh t nhn v ngha v tng hp bo co i vi cc c quan qun
l nh nc i vi lnh vc ny ti cc cp. y l quy nh bt buc i vi cc c s khm,
cha bnh t nhn c s liu phc v cho h thng thng tin y t quc gia.
Kh khn, hn ch
Cht lng s liu v tnh kp thi ca cc bo co b nh hng bi khi lng ch s
cn bo co, cc ch s cha phn t (gii, tui, dn tc,) theo yu cu ca cc nh qun l,
chm ng dng cng ngh thng tin trong thng tin y t.
Thng t s 32/2014/TT-BYT ca B Y t ngy 30/09/2014 ban hnh danh mc ch tiu thng k y t c bn p
dng cho tuyn tnh, huyn, x.
27
Thng t s 28/2014/TT-BYT ca B Y t ngy 14/08/2014 ban hnh ni dung h thng ch tiu thng k ngnh
y t.
28
Thng t s 27/2014/TT-BYT ngy 14 thng 8 nm 2014 ca B Y t quy nh h thng biu mu thng k y t
p dng i vi c s tuyn tnh, huyn, x.
29
Quyt nh s 3440/Q-BYT ngy 17/09/2009 ca B trng B Y t.
26
102

Cha c c ch kim sot v phn hi thng tin do vy cht lng s liu vn cha c
ci thin r rt.
Cha c ch ti bt buc bo co v x pht nu khng chp hnh bo co ca h thng
y t t nhn.
Ngh nh 79 v x pht vi phm hnh chnh trong lnh vc thng k ban hnh nhng
cha c quy nh ring trong lnh vc thng k y t.
3) Tng cng kh nng p ng nhu cu s dng thng tin, s liu; kh nng tng hp,
phn tch v x l s liu, v ph bin thng tin y t vi cc hnh thc a dng v ph hp
Kt qu thc hin
Mng li thu thp s liu thng tin thng k y t bao ph trn ton quc t y t thn
bn ln n tuyn trung ng ch yu thng qua h thng bo co nh k. V c bn, h thng
ny p ng c yu cu c bn ca cc nh qun l, lp k hoch cc cp. B Y t c k
hoch phi hp, chia s i vi cc thng tin lin quan n y t, cn phn t chi tit theo tnh/
thnh ph, tui, gii, thu nhp vo cc cuc iu tra chn mu hoc tng iu tra Dn s v
nh ca Tng cc thng k. Ngoi ra, ngnh y t xut cc nghin cu, iu tra chuyn
bit thng qui nh iu tra dinh dng v cc cuc iu tra chuyn ngnh khc gip cung cp
thng tin hu ch cho cc nh qun l v gip hiu chnh s liu t cc bo co nh k. Trung
tm tch hp d liu ca B Y t ang c nhng k hoch c th thng nht tch hp s liu
gia cc lnh vc trong ngnh y t v gia ngnh y t vi cc ngnh khc nh bo him x hi,
B T php.
Cun nin gim thng k Y t c xut bn u n, cng b trong v ngoi nc cc
ch tiu c bn ngnh y t. S liu thng k trong nin gim cung cp thng tin phc v cho
nghin cu, nh gi tnh hnh thc hin k hoch 5 nm ca ngnh v xy dng mc tiu chin
lc cho cc nm tip theo. Lnh vc y t d phng cng xy dng cun nin gim v tnh hnh
mc, t vong do cc bnh truyn nhim gy dch theo tnh v theo thi gian. Bo co tng quan
chung ngnh y t (bo co JAHR) cng c coi l n phm quan trng trong h thng thng
tin y t. Trong nhng nm qua, bo co JAHR gp phn quan trng trong qu trnh xy dng,
hoch nh chnh sch y t nh xc nh cc vn u tin ca h thng y t, theo di nh gi
thc hin chnh sch v k hoch hng nm v phn tch su mt s chuyn a ra khuyn
ngh chnh sch v cc gii php tng ng ngn hn, di hn.
Ngoi s liu thng k, cn c nhiu sn phm thng tin b ch tng hiu bit ca
ngi dn v chm sc sc khe, phng bnh v tng kin thc ca cc cn b y t thng qua
knh bo ch hoc ph bin theo cc trang bo in t nh Bo Sc khe v i sng, Bo Gia
nh v X hi v website ca B Y t, website Chng trnh phng chng HIV/AIDS, Tp ch
Y hc Thc hnh, Tp ch Dc hc, Thng tin Y Dc, Y hc Vit Nam...
Mt knh cung cp thng tin lin quan n thng tin y t t cc n phm ca Tng cc
Thng k nh Nin gim thng k Vit Nam, iu tra bin ng dn s v k hoch ha gia
nh, iu tra MICS, iu tra mc sng dn c...
Kh khn, hn ch
C qu nhiu cc ch s cn thu thp v phng php thu thp ch yu thng qua bo
co nh k, do to ra lng cng vic qu ln cho cc cn b y t trong vic thu thp v ghi
chp vo cc biu mu bo co ng thi nh hng ti tin cy ca s liu.
103

Hin nay, vic cp chng ch hnh ngh v cp php cho c s khm bnh, cha bnh
t nhn cn thp cha bao ph ht ton b h thng. S n v y t t nhn rt ln nhng hu
ht cc n v ny cha c o to v v ghi chp, tng hp bo co, tnh ton cc ch s v
thiu cn b trong ngnh y t gim st cht lng thng tin bo co ca cc c s y t c
cng lp v t nhn.
S dng thng tin lm bng chng cho vic lp k hoch, qun l cn yu c bit ti
tuyn huyn v tuyn x do thiu nhn lc c trnh chuyn mn su v phn tch, d bo
s liu.
Cha c nh gi nhu cu thng tin t pha ngi s dng, sn phm thng tin cn hn
ch, nhiu ngun thng tin nhng c ch cng b thng tin cha r rng, cha c u mi ph
bin s liu ca ngnh v s liu lin quan t cc ngnh khc.
C s d liu hnh chnh ti cc tuyn cn ngho nn, c s d liu cha c xp xp
khoa hc, cha bao gm cc lnh vc, cc ngun khc nhau.
4) Tng bc hin i ha h thng thng tin y t, p dng cng ngh thng tin trong lnh
vc thng tin y t
Kt qu thc hin
ng dng cng ngh thng tin l mt trong nhng u tin ca ngnh v ca hu ht cc
lnh vc. B Y t ban hnh danh mc cc giao thc tiu chun k thut ng dng cng ngh
thng tin trong cc h thng thng tin y t c p dng lm cn c trong hot ng ng
dng cng ngh thng tin trong ton ngnh. Kin trc tng th v y t in t ang nghin cu,
ng dng trong mt s lnh vc. Th tc hnh chnh cng c u tin cung cp trc tuyn nh
ng k dc, m phm, cp php hnh ngh, hng dn qun l cht lng bnh vin
Nhiu d n cng ngh thng tin c B Y t ph duyt v trin khai c bit l cc
d n ti cc bnh vin, vin trung ng. D n th im c trin khai nh p dng th bo
him y t in t trong qun l bnh nhn bo him y t, bnh n in t. Vi s h tr ti chnh
v k thut ca Ngn hng Pht trin chu , Cc Qun l KCB xy dng h thng thng
tin ng k cp chng ch hnh ngh, cung cp c thng tin v nhn lc lm trong khu vc
y t t nhn.
Theo kt qu xp hng ca cc b, ngnh v ch s sn sng v pht trin ng dng
CNTT-TT-ICT nm 2013, B Y t ang ng mc trung bnh (14/24). Tuy nhin, bng xp
hng cng ch ra ch s mi trng t chc v chnh sch cho cng ngh thng tin ca B Y
t t kh cao so vi mt s b, ngnh c ch s mc sn sng cho ng dng v pht trin
cng ngh thng tin th hng cao. iu ny khng nh s quan tm c bit ca lnh o B
Y t i vi lnh vc ny. B Y t ang chun b ni dung hp tc v cng ngh thng tin v
vin thng vi Tp on Vin thng Qun i (Viettel) - mt n v ang c nh gi l c
nng lc cung cp dch v hin i, ng b v chuyn nghip ca Vit Nam trong lnh vc
cng ngh thng tin. Trong tha thun hp tc, Tp on Viettel s phi hp, gip B Y t v
h tng ng truyn tc cao, ng dng cng ngh thng tin trong cng tc qun l ch o
iu hnh, qun l khm cha bnh, bo him y t Hp tc ny m ra mt hng mi t
c ng dng cng ngh thng tin ng b trong ngnh Y t.
104

Kh khn, hn ch
Ti tuyn y t c s, ch yu x l v tng hp s liu th cng, vic ng dng cng
ngh thng tin cn hn ch. Cha c phn mm tng hp s liu trc tuyn p dng t trm y
t x bo co ln tuyn trn.
Phn loi ch s, m ha c s y t, quy trnh lm sng, thuc, m ha cc dch v k
thut, thut ng y t cn c tin hnh ng thi vi vic ban hnh cc chun p dng cng
ngh thng tin.
Thng tin ng ti trn trang web ca B Y t, S Y t cha c cp nht thng xuyn.
2.5.2. Cc vn u tin
u t cho h thng thng tin y t cn chuyn dch u t thay v u t theo cch tip
cn theo chiu dc chuyn thnh theo chiu ngang. u t vo h thng thng tin y
t cn hng vo c cu y t ti tuyn tnh, tuyn huyn v tuyn x.
Kin ton t chc, mng li thng k: b tr nhn lc v cn b c trnh chuyn
mn
o to nng cao nng lc cho cn b thng k thng qua cc hnh thc o to ti ch,
ngn hn cng nh cc kha o to chnh quy. Tng cng cc kha o to ngn hn
v thng k c bn, o to v s dng my tnh, s dng v phn tch s liu, kh nng
d bo thng k.
Cp nht cc ch s c bn, ng b ha b cng c thu thp s liu ti cc c s y t
cng lp v t nhn.
ng dng cng ngh thng tin: hon thin kin trc tng th ng dng cng ngh thng
tin trong tng lnh vc; xy dng kho d liu tch hp, trc mt cn xy dng mt c
s d liu trc tuyn ti tuyn trung ng v tuyn tnh sau l cc tuyn thp hn ti
tuyn huyn v tuyn x; chun ha t vic phn loi ch s, m ha c s y t, nhn lc,
thuc, quy trnh v th thut lm sng.
1) Hon thin chnh sch, k hoch tng th pht trin h thng thng tin
B Y t xy dng n tng cng cng tc thng k y t giai on 2014-2020 trnh lnh
o B xem xt, ph duyt.
B Y t xy dng quy ch phi hp, phn cng trch nhim, ngha v cung cp, chia s
thng tin gia cc n v trong ngnh y t v vi cc b, ngnh lin quan, c bit vi
Tng cc Thng k.
B Y t xy dng Thng t ban hnh quy ch ph bin thng tin thng k y t.
105

2) Hon thin h thng ch tiu thng k, s sch ghi chp v bo co thng k y t cho c
khu vc y t nh nc v t nhn. Ban hnh Thng t h thng ch tiu, chun ha h thng
ch tiu c bn ngnh y t;
Ph bin danh mc h thng ch tiu quc gia, ni dung chun ha tng ch tiu; h
thng ch tiu phn cp cho tuyn tnh, tuyn huyn v tuyn x.
o to v ghi chp biu mu, tng hp bo co mi ban hnh i vi c s cng lp v
cc c s khm bnh, cha bnh t nhn.
Xy dng cc c ch kim sot cht lng s liu.
Trin khai Ngh nh s 79/2013/N-CP quy nh v x pht vi phm hnh chnh trong
lnh vc thng k trong ngnh y t.
3) Tng cng kh nng p ng nhu cu s dng thng tin, s liu; kh nng tng hp,
phn tch v x l s liu, v ph bin thng tin y t vi cc hnh thc a dng
Xy dng c s d liu thng tin thng k, c s d liu quc gia v y t.
Xy dng c ch chia s thng tin gia B Y t vi cc b, ngnh lin quan (s liu t
cc cuc iu tra ca Tng cc thng k, B Ti chnh, v,v.)
Kho st nhu cu thng tin; xy dng Thng t ca B Y t v ph bin thng tin
thng k.
Nghin cu, xy dng h thng thu thp thng tin v t vong v nguyn nhn t vong
lng ghp trong h thng thng tin qun l.
Tng cng mng li thu thp thng tin BKLN.
T chc cc cuc iu tra theo Quyt nh ca Chnh ph phn cng cho ngnh y t.
4) p dng cng ngh thng tin trong thng tin y t
Xy dng kin trc tng th y t in t cho mt s lnh vc.
Xy dng phn mm bo co thng k tng hp trc tuyn ti cc tuyn. Phn mm tch
hp vi cc lnh vc lin quan nh khm cha bnh, bo him
M ha c s y t v cc chun i vi cc lnh vc chuyn mn to iu kin ti u cho
vic trin khai ng dng cng ngh thng tin thng nht, ng b.
2.6. Cung ng dch v y t
2.6.1. Tnh hnh thc hin
1) Kin ton v cng c h thng y t d phng v mng li y t c s

Kt qu thc hin
Cc a phng hu ht c s n nh v t chc, c cc n v thc hin cc chc
nng YTDP. Thi gian gn y, ngnh y t tp trung cng c mng li y t ti vng bin, o.
Cc hot ng phng chng BKLN bt u c trin khai tuyn x, huyn.
106

Nm 2009, Th tng Chnh ph ph duyt n Kim sot dn s cc vng bin,
o v ven bin giai on 2009-2020 trong c nhim v p ng yu cu qun l, iu hnh
chng trnh dn s v KHHG nhm gp phn thc hin mc tiu Chin lc bin Vit Nam
n 2020. Cho n nay n c trin khai thc hin ti 151 qun huyn, th x, thnh ph
v cc x ca 28 tnh ven bin. Thnh lp c 169 i y t - KHHG tuyn huyn, 19 i lu
ng ca Trung tm CSSKSS cc tnh.
Nm 2013, Chnh ph ban hnh Quyt nh s 317/Q-TTg ph duyt n pht
trin y t bin, o n nm 2020 vi cc mc tiu nhm tng cng nng lc cho mng li y
t, pht trin ngun nhn lc y t ph hp vi c th hot ng bo v CSSK v cp cu vn
chuyn cp cu khu vc bin o, nng cao kin thc v k nng ca ngi dn sinh sng v
lm vic khu vc bin o. Cc ch tiu c th tp trung vo xy dng c b tiu ch chun
v y t cho khu vc bin o, bo m 100% trung tm YTDP cc tnh ven bin v cc ngnh
c 1 n v nng lc khm d phng, t vn sc khe phng bnh ngh nghip v cc vn
y t c th khu vc bin o v bo m o to nng cao kin thc cho cc bc s 70% cc
bnh vin, trung tm y t huyn vng ven bin, o v y hc bin. Bo m 100% x o c
lp c trm y t x vi 50% t chun y t cho vng bin o, mt khc bo m c 40% cc
bnh vin/Trung tm Y t huyn o c kh nng trin khai k thut ngoi khoa tng ng
bnh vin hng II cng vi xy dng 2 m hnh tr gip y t t xa (Telemedicine) v 4 trung
tm cp cu 115 c th khu vc bin o kt hp vi 6 bnh vin giao nhim v lm trung tm
thu nhn v iu tr bnh nhn t khu vc bin o. Vi ngi dn v ngi lao ng khu vc
bin o cng phn u t 100% s i tng c kin thc ph hp v t bo v sc khe v
s cp cu ban u.
Mng li y t c s tip tc c cng c. B Y t ban hnh Thng t s 07/2013/
TT-BYT quy nh tiu chun, chc nng, nhim v ca y t thn, bn vi s gn kt v l cnh
tay ni di ca trm y t x, tng cng s tip cn ca y t i vi ngi dn. n Th
im a bc s tr tnh nguyn v cng tc ti min ni, vng su, vng xa, bin gii, hi o,
vng c iu kin kinh t-x hi c bit kh khn (u tin 62 huyn ngho) theo Quyt nh
s 585/Q-BYT.
Y t c s c pht trin rng khp ton quc, trong bao gm c mng li y t thn,
bn, to iu kin thun li ngi dn tip cn cc dch v y t. n nm 2013, 98,9%
x, phng, th trn c nh trm; 76,9% trm y t x c bc s lm vic (bao gm c cc x
c bc s lm vic t 3 ngy/tun tr ln); 97,3% trm y t x c n h sinh hoc y s sn nhi;
75,5% thn, bn, p t dn ph trong c nc c nhn vin y t hot ng, trong t l ny
khu vc nng thn, min ni l 95,8%.
Cng tc CSSKB bc u c i mi, m rng dch v y t cho tuyn x, th
im thc hin qun l mt s bnh mn tnh nh hen ph qun, tng huyt p, i tho ng
ti cng ng, gp phn gim ti cho tuyn trn, khong 80% trm y t x thc hin KCB
bng BHYT. Chng trnh qun dn y kt hp cng u t cho cc c s y t qun dn y
nh nng cp v nh trm, b sung trang thit b y t cho 171 trm y t khu vc bin gii, vng
su, vng xa, vng trng im quc phng an ninh; h tr kinh ph u t trang b y t cho 5
im sng y t kt hp qun dn y; phi hp vi B Quc phng thnh lp 8 bnh vin qun
dn y; mt s a phng thnh lp phng khm a khoa qun dn y, bnh vin qun dn y
tuyn huyn.
107

Thng t s 43/2013/TT-BYT c ban hnh vi hn 17 000 k thut, m rng k
thut thc hin c ti tuyn huyn v tuyn x. M rng cc c s khm cha bnh ban u
BHYT ti trm y t x v cc phng khm, bnh vin t nhn. Thng t s 16/2014/TT-BYT
hng dn th im v bc s gia nh v phng khm bc s gia nh c ban hnh. C 8
tnh, thnh ph s tin hnh p dng th im m hnh ny, ngoi ra, cc tnh, thnh ph khc
vn c th thnh lp phng khm bc s gia nh di s hng dn ca B Y t. M hnh CSSK
ngi cao tui ti cng ng cng c trin khai [72].
Kh khn, hn ch
Hn ch trong cc n lc u t, thc hin v gim st thc hin cc d n u t c s
h tng, trang thit b, nhn lc cho cc n v YTDP., y t c s dn ti cc trm y t x v cc
trung tm y t huyn, cc trung tm thuc h YTDP tuyn tnh cha c u t ng mc v
t cc tiu ch ra v cc chun quc gia (tiu ch quc gia v y t x, chun trung tm YTDP
tuyn tnh,). iu ny lm cho cc n v y t c s b hn ch trong cung ng dch v c v
s lng ln cht lng.
Mc d tuyn k thut c m rng nhng nng lc thc hin ti tuyn huyn
v tuyn x cn hn ch. Mt s m hnh qun l bnh mn tnh nh tng huyt p, i tho
ng, hen ph qun ti tuyn huyn, x c trin khai nhng quy m cn hp s t tnh
v cn gp mt s kh khn v c ch thanh ton BHYT v nng lc chuyn mn. Thng t
s 16/2014/TT-BYT hng dn th im v bc s gia nh v phng khm bc s gia nh mi
c ban hnh cn c thi gian trin khai v nh gi hiu qu.
2) y mnh cc hot ng y t d phng, trin khai hiu qu cc d n ca chng trnh
mc tiu quc gia v y t
Kt qu thc hin
D n phng chng cc bnh truyn nhim: Chin lc quc gia phng chng bnh lao
n nm 2020 v tm nhn n nm 2030 c ban hnh theo Quyt nh s 374/Q-TTg
v c trin khai30. Thc hin Chin lc Quc gia pht trin y t d phng n nm 2020,
Chin lc Quc gia phng chng HIV/AIDS n nm 2020 tm nhn 2030, K hoch bo v,
chm sc v nng cao sc khe nhn dn giai on 2011-2015 v Chin lc phng chng mt
s bnh truyn nhim nguy him khc nh lao, st rt v thc hin CTMTQG v y t giai
on 2012-2015 theo Quyt nh 1208/Q-TTg nm 2012 do Th tng Chnh ph ban hnh,
ngnh y t t c mt s thnh qu nht nh trong cng tc kim sot bnh dch. Ngnh
y t bo m duy tr kim sot tt a s cc bnh truyn nhim nguy him thuc tiu thnh
phn D n 1. Chng trnh TCMR thuc D n 2 ca CTMTQG v y t giai on 2012-2015
thng t trn 90%, ring nm 2013 t 88% (do b nh hng ca mt s s kin t vong
trong tim chng). Ngnh y t cng phi hp cng B Nng nghip Pht trin nng thn
lun bo m kim sot c tnh hnh cm H5N1 v H1N1 khng dch xy ra; vn hnh c
hiu qu h thng kim dch bin gii (kim dch y t, kim dch ng vt). T l mc bnh tay
chn ming vn mc cao, SXH vn lu hnh trn din rngnhng t l t vong gim ng
k (xem chi tit Chng I v tnh hnh cc bnh truyn nhim khc).
Chng trnh phng chng lao quc gia t c nhiu thnh tu trong kim sot bnh
lao ti Vit Nam theo k hoch ra. Nm 2013, Chng trnh pht hin trn 100000 bnh
Quyt nh s 374/Q-TTg ca Th tng Chnh ph ph duyt Chin lc quc gia phng chng bnh lao giai
on n nm 2020 v tm nhn n nm 2030.
30
108

nhn lao. Chng trnh chng lao bao ph 100% vng lnh th; ci thin hot ng pht hin
vi trng tm l chn on lao phi AFB dng tnh bng k thut soi m trc tip, trin khai cc
hot ng chn on lao tr em; p dng iu tr cng thc 8 thng c kim sot (DOTS) vi phc
th nht cho bnh nhn lao mi t t l khi bnh cho bnh nhn AFB dng tnh trn 90% v
phc lao th hai cho bnh nhn ti pht v tht bi vi t l khi t trn 80%.
Chng trnh phng chng HIV/AIDS: Chng trnh phng, chng HIV/AIDS c trin
khai rng ri. Tnh n thng 10/2014, trn ton quc c gn 90 000 ngi c iu tr ARV
ti 318 phng khm ngoi tr HIV/AIDS. iu tr v d phng ly truyn HIV t m sang con
cho khong 94000 b m. iu tr thay th nghin cc cht dng thuc phin bng Methadone
trin khai 38 tnh/thnh ph, vi 122 c s, iu tr cho hn 22 000 bnh nhn, mang li
hiu qu rt ln v sc khe, gim ly nhim HIV, n nh an ninh, trt t x hi v gp phn
vo pht trin kinh t - x hi ni chung. Chng trnh phn pht bao cao su tip tc c trin
khai 63 tnh, thnh ph; chng trnh phn pht bm kim tim sch trin khai 88% s tnh,
thnh ph. Cng tc t vn v xt nghim HIV t nguyn c m rng 485 phng t vn
ti 63 tnh v 84 phng xt nghim HIV khng nh c HIV dng tnh ti 54 tnh thnh ph,
thnh ph. Tng s ngi c t vn v xt nghim HIV min ph l gn 2 triu lt ngi.
Nh , trong nhiu nm lin tc, Vit Nam gim c s ngi mi nhim HIV v cht do
HIV/AIDS hng nm.
Chng trnh phng chng m la: nm 2009, B Y t ban hnh Quyt nh s 4322/
Q-BYT v K hoch Quc gia phng chng m la giai on 2009-2013. Mt trong nhng
mc tiu chnh ca k hoch l kim sot c cc bnh gy m c th phng cha c nh
c th thy tinh, mt ht, kh mt do thiu vitamin A, tt khc x vi cc ch tiu c th l
phu thut c thu tinh th t t l ti thiu 2000 ca/mt triu dn vo nm 2013, m 3000040000 ca qum/nm v thanh ton qum trn 4 lng vo cui 2014 v thc hin trin khai th
im khm sng lc v cp pht knh cho hc sinh (nhm tui 6-15) 20 tnh c hp tc quc
t, sau trin khai rng ra ton quc. Kt qu thc hin tnh n nm 2012 cho thy nhiu ch
tiu thc hin c cn thp hn nhiu so vi k hoch ra. C th l s ca c m c thy
tinh th ch t 1764 ca/triu dn/nm, m c mi nm 10000 ca qum (nm 2011) v s ca
qum tn ng c tnh > 200000 ca [73].
Kt qu thc hin chng trnh quc gia An ton thc phm: thc hin Chin lc quc
gia An ton thc phm giai on 2011-2020 v Tm nhn 2030 theo Quyt nh s 20/2012/
QTTg ca Th tng Chnh ph, ngnh y t c nhng kt qu tin b. n nm 2012,
xy dng c cc tiu chun v quy chun k thut quc gia trong ban hnh c 50
quy chun k thut quc gia v an ton thc phm, trnh cng b 35 TCVN v phng php
th. Thnh lp c cc Ban Ch o lin ngnh ti c 3 tuyn tnh (100%), huyn v x (trn
99% s huyn v x), t chc c cc chng trnh th nghim thnh tho quc t cho cc
labo trung ng, khu vc v cho cc labo tuyn tnh. Xy dng h thng chng nhn hp quy
cho 2 n v: Trung tm ng dng Khoa hc k thut An ton thc phm, Vin Kim nghim
An ton V sinh thc phm Quc gia. c bit l gim c cc v ng c tp th v vn
kim sot c s ca ng c so vi cc nm trc.
Vic tng cng v c s phi hp cht ch gia ngnh y t vi cc ban ngnh lin
quan trong cng tc thanh tra, kim tra mang li hiu qu tch cc, gp phn lp li trt t
k cng trong hot ng sn xut, kinh doanh thc phm: t l c s vi phm v an ton thc
phm gim t 21,2% (2012) xung cn 20,1% (2013), s mu c kim nghim t yu
109

cu tng t 82,3% (2012) ln 88,8% (2013). Nhiu vi phm v an ton thc phm c pht
hin kp thi, x l kin quyt v cng khai trn cc phng tin thng tin i chng. Cng tc
phng chng ng c thc phm tip tc c tng cng vi nhiu gii php hu hiu, cng
vi l vic y mnh gim st mi nguy, cnh bo nguy c qua vic ch ng ly mu thc
phm nh k, t xut kim nghim, cnh bo cho cc ngnh chc nng v cng ng,
x l kp thi, hiu qu trn 20 s c v an ton thc phm, tnh hnh ng c thc phm trong
nm 2013 gim so vi nm 2012.
Qun l mi trng y t: B Y t bt u trin khai k hoch truyn thng cho Chng
trnh Mc tiu quc gia v Nc sch v V sinh mi trng nng thn giai on 2012-2015
v d tho D n v sinh nng thn thuc Chng trnh mc tiu quc gia Nc sch v V
sinh mi trng nng thn giai on 2012-2015 c s h tr ti chnh v k thut ca Ngn
hng th gii. Xy dng v trin khai K hoch chng trnh quc gia v an ton lao ng, v
sinh lao ng giai on 2011-2015; K hoch cng tc qun l ha cht gia dng; ha cht dit
cn trng, dit khun dng trong lnh vc gia dng v y t giai on 2012-2015, Nm 2012,
B Y t ban hnh Thng t s 08/2012/TT-BYT hng dn cp php vn chuyn hng ha
nguy him l ha cht dit cn trng, dit khun dng trong lnh vc gia dng v y t bng
phng tin giao thng c gii ng b, Thng t s 12/2012/TTLT/BLTBXH-BYT hng
dn vic khai bo, iu tra, thng k v bo co tai nn lao ng; Thng t s 13/2012/TTLT/
BLTBXH-BYT hng dn thc hin ch bi dng bng hin vt i vi ngi lao ng
lm vic trong iu kin c yu t nguy him, c hi. ang xy dng Thng t hng dn
kim tra, gim st cht lng nc n ung v sinh hot; Thng t hng dn kim tra, gim
st nh tiu h gia nh; Thng t hng dn quan trc mi trng trong cc c s khm, cha
bnh,
Trong nm 2012, ngnh y t cng tp trung gii quyt trit tnh trng nhim mi
trng ti cc c s gy nhim mi trng nghim trng i vi sc khe cng ng, n ht nm
c 49/84 c s (chim 58,3%) c cng nhn x l trit nhim mi trng, 23/84 c s
(chim 27,4%) ang lm cc th tc trnh chng nhn hon thnh vic x l nhim mi trng
trit , 12 c s (chim 14,3%) ang chun bi u t xy dng cac h thng x ly cht thai y t.
Cng tc y t hc hc ng: Hin ang c c s php l phn cng trch nhim
thc hin cng tc y t trong cc trng hc v tng cng cng tc y t cc trng hc gm
Ch th s 23/2006/CT-TTg ngy 12/7/2006 v vic tng cng cng tc y t trong cc trng
hc; Thng t lin tch s 03/2000/TTLT-BYT-BGDT phn cng, quy nh chc nng nhim
v ca tng c quan n v thuc h thng y t, gio dc v c ch phi hp lin ngnh trong
cng tc y t trng hc; Quyt nh s 73/2007/Q-BGDT quy nh c th v ni dung,
iu kin bo m v phn cng trch nhim trong hot ng y t hc ng; Thng t lin tch
s 35/2006/TTLT-Q&BGDT-BNV v nh mc bin ch vin chc cc c s gio dc
ph thng cng lp trong c cp n nh bin i cn b cho hot ng y t hc ng;
Thng t 46/2010/TT-BYT v Quy chun k thut quc gia v v sinh phng bnh truyn
nhim trong cc c s gio dc thuc h thng gio dc quc dn.
Cc can thip nng cao sc khe khc: Trong nm 2012, B Y t trnh v c Quc
hi thng qua Lut phng chng tc hi thuc l v Lut ny chnh thc c hiu lc t 1/5/2013.
B Y t bin son cc vn bn di lut trong c Ngh nh quy nh mt s iu Lut
nh t vn cai nghin, cc hnh thc x pht, v.v Hin nay, B Y t ang hon thin d tho
Lut phng chng tc hi ca lm dng ru, bia v a vo k hoch ngh s vn bn php
lut ca Quc hi.
110

Kh khn, hn ch
Chng trnh phng chng bnh truyn nhim vn cha kim sot c cc bnh lao,
HIV/AIDS, st xut huyt, chn tay ming. HIV/AIDS vn l mt trong nhng nguyn nhn
gy t vong hng u Vit Nam; s ngi nhim HIV v s bnh nhn AIDS ly tch vn tip
tc gia tng; mc bao ph cc dch v xt nghim, d phng gim hi v iu tr ARV vn
cn thp so vi nhu cu thc t, trong khi cc d n vin tr (chim n 80% tng kinh ph
cho phng, chng HIV/AIDS) ang gim nhanh.
Bnh lao vn cn ang l mt thch thc ln v Vit Nam vn ng th 12 trong 22 nc
c gnh nng bnh lao cao trn ton cu ng thi l nc ng th 14 trong s 27 nc c
gnh nng bnh lao khng thuc cao. Kh khn ch yu l cha kim sot c cc yu t lin
quan n mi trng sng v nhn thc ca ngi dn. Dch si bng pht cui nm 2013 v
u nm 2014 vi hn 11000 trng hp st pht ban dng si, 146 trng hp t vong do si
v c lin quan n si (tnh n ngy 30/6/2014) l hu qu ca t l tim chng cha t yu
cu v hn ch trong vic kim sot ly nhim si ti cc c s y t v cng ng.
Chng trnh phng chng BKLN cha t c phn ln cc ch tiu mc tiu theo k
hoch trong l cc ch tiu v sng lc pht hin, qun l i tng ti tuyn CSSKB, cc ch
tiu v xy dng mng li t chc v o to nhn lc cho chng trnh. Nguyn nhn ch yu
l do thiu s u t ng mc cho cc chng trnh phng chng BKLN, thiu s phi hp gia
cc c s y t d phng v cc c s khm cha bnh tt c cc tuyn trong pht hin, qun l
v iu tr cho cc i tng thuc nhm nguy c v bnh nhn mc BKLN. Hin nay, vic qun
l mt s bnh ly nhim v khng ly nhim ang c t chc qun l theo cc chng trnh
dc c lp v thc hin ng thi c cc hot ng gim st bnh ln cung ng dch v cho cc
nhm i tng m thiu s qun l thng nht v r rng gia hot ng kim sot bnh v hot
ng cung ng dch v CSSK c th cho cc nhm i tng. Thiu s lng ghp hot ng gia
cc chng trnh y t.
Chng trnh v sinh an ton thc phm c nhng kt qu ban u nhng cha c s
bn vng, c bit l trong kim sot cc ch tiu v sinh an ton thc phm v kim sot cc v
ng c thc phm. Nguyn nhn ch yu vn l hn ch trong thc hin trch nhim ca cc cp
chnh quyn v s phi hp lin ngnh trong qun l, kim sot v sinh an ton thc phm mt
cch ng b trong sut chui thc phm.
Vic thc hin cng tc y t hc ng cn yu. Theo mt nghin cu nh gi trn ton
quc c thc hin vo nm 2010-2011 cho thy ch 6% s trng ph thng c s, 38,3% s
trng ph thng trung hc c phng y t, 40,5% s trng tiu hc v 19,4% s trng trung hc
c s c cn b y t chuyn trch. Trong khi , vn cn 15,5% s trng tiu hc v 61,5% trng
ph thng c s hon ton cha c cn b lm cng tc y t trng hc. Cc cn b lm cng tc y
t trong cc trng hc c chuyn ngnh y ch chim 53% trong ch c 0,4% l bc s cn li l
trnh iu dng v y t. Ch 50% - 60% tng s lp hc t cc tiu chun v sinh trng hc
nh chiu sng, thng gi v kch thc bn gh ph hp vi hc sinh. Trung bnh ch c 61,1%
s trng trung hc c s v 75% trng tiu hc c nh v sinh hp tiu chun.
Cc chng trnh nng cao sc khe thng qua cc chnh sch v can thip kim sot tc
hi thuc l, lm dng ru bia mi ch c th hin qua tin trnh dn hon chnh v ban hnh
cc vn bn Lut, cc vn bn quy nh di Lut tuy nhin cc vn bn hng dn, cc cng c
chnh sch cn cha c y v ng b dn n cc can thip cha c trin khai c th v
thiu s phi hp v cam kt cht ch t cc cp chnh quyn, lin ngnh v s tham gia ca cng
111

ng. Hot ng nng cao th lc ca ngi dn cng cha c ch trng, c bit l cc hot
ng nng cao th lc cho la tui hc sinh trong cc trng hc v lc lng lao ng.
3) Hon thin h thng chnh sch, cng c mng li v thc hin tt cc hot ng dn
s-KHHG v chm sc sc khe sinh sn
Kt qu thc hin
Trin khai cc hot ng, nhiu m hnh v DS-KHHG nhm t cc ch tiu v mc
gim t l sinh (c nm 2013 l 2,02 con, t mc tiu duy tr mc sinh thay th). T l s
dng bin php trnh thai hin i ca cc cp v chng trong tui sinh tip tc mc
cao, c nm 2013 l 69%. Ngy 1/11/2013 quy m dn s t 90 triu, chm hn 11 nm so vi
d bo mc tiu ca Chin lc dn s n nm 2010.
n lc trin khai cc hot ng nhm gim t vong m, t vong s sinh, gim suy dinh
dng thc hin Mc tiu pht trin thin nin k s 1, 4 v 5. C th l: tng cng nng lc
cho cn b y t cc tuyn thng qua t chc cc kha o to v hi sc cp cu sn khoa v s
sinh thit yu c bn v ton din ti tuyn x v tuyn huyn, hng dn ph thai an ton; trin
khai n nguyn s sinh ti bnh vin huyn, hng dn x tr cc tai bin sn khoa; o to v s
dng c thn bn cho cc vng ng bo dn tc thiu s v tp trung cc can thip gim suy
dinh dng thp ci, suy dinh dng vng su, vng xa.
Cc ch tiu c bn phn nh cht lng chm sc sc khe b m - tr em nm 2013 thc
hin u t v vt so vi ch tiu ra. Nm 2013, t l ph n c thai c qun l thai l
96,6%; t l ph n c khm thai 3 ln trong 3 thi k l 87,5%; t l ph n do cn b
c o to h tr l 97,7%; t l b m v tr s sinh c khm sau l 92,6%; t l suy dinh
dng tr em di 5 tui th cn nng/tui c tnh l 15,6%, gim 0,6% so vi nm 2012.
Sau 2 nm trin khai D n CSSKSS v ci thin tnh trng dinh dng tr em thuc
CTMTQG v y t, cc hot ng ca D n c trin khai ti 55 tnh, thnh ph, trong 37
tnh trng im c trin khai cc ni dung ch yu ca cng tc CSSKSS, ch trng vo ni dung
lm m an ton; 18 tnh, thnh ph ch tham gia thc hin ni dung Chm sc sc khe sinh sn v
thnh nin. Hin nay, B Y t ang hon thin v trnh ph duyt gi can thip y t ti thiu trong
lnh vc sc khe b m tr em, trong bao gm 5 gi dch v ti thiu l: chm sc trc sinh,
chm sc khi sinh, chm sc sau sinh, chm sc s sinh v chm sc tr nh.
Kh khn, hn ch
Mc d cng tc dn s-KHHG v CSSKSS c nhng tin b ng k nhng cn
mt s ch tiu cha kim sot tt v c s chnh lch ln gia cc vng min, nh: t s t
vong m, t sut t vong tr em di 1 tui v di 5 tui, t l suy dinh dng, t s gii tnh
khi sinh. T s gii tnh khi sinh nm 2013 tng ln 113,8 b trai/100 b gi [27], cho thy mt
kh nng khng ch t s gii tnh khi sinh mc 113 nh c t ra trong k hoch 5 nm
ngnh y t. Mt s ch tiu cha t mc tiu mt s vng min thuc khu vc min ni, hi
o nh t l s dng cc bin php trnh thai, cha kim sot n nh t l sinh.
4) Nng cao cht lng dch v KCB
Kt qu thc hin
H thng vn bn quy phm php lut v KCB tip tc c hon thin. Trong nm
2013 v u nm 2014, B Y t ban hnh nhiu thng t, ch th, quyt nh lin quan n
112

cc quy nh, tiu chun chuyn mn nh: Thng t s 02/2013/TT-BYT quy nh v vic phi
hp gia cc c s y t trong qun l bnh lao; Thng t s 18/2013/TT-BYT quy nh v tr,
thit k, iu kin c s vt cht, k thut, thit b ca c s KCB truyn nhim; Thng t s
21/2013/TT-BYT quy nh v t chc v hot ng ca Hi ng Thuc v iu tr trong bnh
vin; Thng t s 26/2013/TT-BYT hng dn hot ng truyn mu; Thng t s 34/2013/TTBYT ban hnh Danh mc bnh cn cha tr di ngy; Thng t s 35/2013/TT-BYT quy nh
v thu hi chng ch, giy php hot ng v nh ch hot ng chuyn mn ca ngi hnh
ngh, c s KCB; Thng t s 40/2013/TT-BYT ban hnh Danh mc thuc thit yu ng y v
thuc t dc liu ln VI; Thng t s 43/2013/TT-BYT quy nh chi tit phn tuyn chuyn
mn k thut i vi h thng c s khm bnh, cha bnh; Thng t s 01/2014/TT-BYT Quy
nh chc nng, nhim v, t chc v hot ng ca Khoa Y, Dc c truyn trong bnh vin
nh nc. Thng t s 14/2014/TT-BYT hng dn cng tc chuyn tuyn trong khm bnh,
cha bnh.
Thng t s 19/2013/TT-BYT ngy 12/07/2013 ca B Y t Hng dn thc hin qun
l cht lng dch v khm bnh, cha bnh ti bnh vin c ban hnh. Chng trnh
hnh ng quc gia v nng cao cht lng khm, cha bnh ang c hon thin v xem xt
ban hnh. B trng B Y t ban hnh Quyt nh s 1313/Q-BYT ngy 22/4/2013 hng
dn quy trnh khm bnh ti khoa khm bnh ca bnh vin vi cc ch tiu v gii php c th
nhm lm gim thi gian ch, to thun li cho ngi bnh khi i khm bnh. Quy trnh khm
bnh c rt ngn t 12-14 bc xung cn t 4-8 bc vi thi gian ch gim c trung
bnh 40 pht. Bng k thanh ton vin ph rt gn t 6 ch k xung cn 4 ch k [49]. Nm
2013, B Y t cp nht b sung hn 2000 quy trnh k thut trong khm, cha bnh, ang
nghim thu 1000 quy trnh k thut chun b ban hnh, hn 300 hng dn iu tr c
ban hnh. Hng trm quy trnh, hng dn khm cha bnh tuyn x c xy dng, ban
hnh v c trin khai th im ti 6 tnh vo nm 2013.
B Y t ban hnh v trin khai thc hin Thng t s 01/2013/TT-BYT ngy
11/01/2013 hng dn qun l cht lng xt nghim ti c s khm bnh, cha bnh. Thng
t ny yu cu cc c s khm cha bnh phi cng khai cng tc kim chun xt nghim.
y l c s cc bnh vin c cn c tin tng cht lng xt nghim v cng nhn kt
qu ca nhau, qua hn ch mt phn vic phi lm li cc xt nghim. Hin c 3 trung tm
kim chun cht lng xt nghim ti H Ni v thnh ph H Ch Minh ang trin khai cc
chng trnh ngoi kim. D kin c 1175 phng xt nghim tham gia chng trnh ngoi kim.
Chng trnh nng cao cht lng xt nghim tip tc c trin khai, i ng ging vin v
qun l cht lng xt nghim ang c o to. B ch s cht lng bnh vin c xy
dng v ang chun b trin khai th im mt s bnh vin.
Hi ngh v Tng cng cc gii php nng cao cht lng khm, cha bnh v Din
n quc gia v cht lng Bnh vin ln th hai do B Y t v EC t chc thng 12/2013 vi
ch An ton ngi bnh. Hi ngh ny c s chia s kinh nghim t cc t chc quc t,
nc ngoi v cc bnh vin c kinh nghim to s chuyn bin trong nhn thc ca lnh
o bnh vin, s quan tm ca cc cp lnh o v cng ng v qun l cht lng dch v
khm cha bnh v c bit l vn an ton ngi bnh.
Cht lng dch v y t tuyn c s cng ang c quan tm. X t tiu ch quc gia
v y t l mt trong cc tiu ch ca Nng thn mi. B Y t ang hon thin n Tng cng
y t c s trong tnh hnh mi, trnh Th tng Chnh ph ban hnh. B Y t cng ang xy
dng d n ODA vay vn Ngn hng Th gii u t cho y t c s. Mt s chng trnh,
113

d n ODA hin c cng ang tch cc h tr cho y t c s, nh cc d n do GAVI, Qu ton
cu phng chng HIV, lao v st rt ti tr.
Tiu ch cht lng bnh vin vi 83 tiu ch c xy dng v ban hnh theo Quyt
nh s 4858/Q-BYT ngy 03/12/2013 v c tin hnh nh gi ti cc bnh vin. Tnh
n thng 2/2014, c 90% s bnh vin ton quc tin hnh t nh gi v trn 60% s y t
tin hnh phc tra [49]. y l cng c o lng cht lng bnh vin; l tiu ch c th
gip bnh vin nng cao cht lng, ng thi l cng c gim st ca cc c quan qun l v
ngi dn.
B Y t trin khai nhiu gii php nhm nng cao o c ngh nghip, gim bc xc
ca ngi dn khi i khm, cha bnh. Ch th s 09/2013/CT-BYT ngy 22/11/2013 v tng
cng hiu qu tip nhn v x l thng tin thng qua ng dy nng c ban hnh vi
vic cng khai s in thoi ng dy nng ca B Y t, trung bnh tip nhn hng nghn cuc
gi mi thng. Cc ng dy nng cng c thit lp ti cp s y t, cp bnh vin. B Y t
cng ban hnh Thng t s 07/2014/TT-BYT ngy 25/2/2014 quy nh v quy tc ng x
ca cng chc, vin chc, ngi lao ng lm vic ti cc c s y t, to hnh lang php l cho
vic nng cao o c ngh nghip cho nhn vin y t.
Tip tc trin khai cp php, cp chng ch hnh ngh theo quy nh ca Lut Khm
bnh, cha bnh nm 2009, Ngh nh s 87/2011/N-CP nm 2011, Thng t s 41/2011/TTBYT v Thng t s 03/2013/TT-BTC. n ngy 10/5/2014 tin hnh cp php 160 bnh
vin t nhn (t 100%), 26 bnh vin trc thuc B Y t (t 74%) v bnh vin ngnh mi t
23%. S giy php hot ng cp cho cc bnh vin thuc s y t t 61%. i vi cp chng
ch hnh ngh, B Y t cp 21205 chng ch hnh ngh, t 92,2%; S Y t ti 63 tnh/thnh
ph cp chng ch hnh ngh t 80% i tng cn cp chng ch [74]. B Y t ang trin
khai xy dng h thng phn mm trc tuyn v cp chng ch hnh ngh qua mng, ang th
im ti 6 tnh/thnh ph nhm h tr nghip v v thng nht cng tc qun l ng k cp
chng ch hnh ngh, ng thi xy dng c s d liu ngi hnh ngh trn ton quc.
Kh khn, hn ch
Mt s vn bn quy phm quan trng c xy dng, nhng cha c ban hnh,
nh: Chng trnh hnh ng quc gia v nng cao cht lng KCB. B Y t xy dng
n Xy dng cng c nh gi hi lng ca nhn dn i vi dch v y t cng nhng vn ch
trong giai on xy dng cng c v trin khai th im nh gi s hi lng ca ngi dn v
dch v KCB. Cha thnh lp c T chc chng nhn cht lng c lp theo Lut Khm
bnh, cha bnh v Ngh nh s 87/2011/N-CP; cha c c quan c lp chu trch nhim
kim nh cht lng khm cha bnh.
Tin cp php, cp chng ch hnh ngh cn chm do mt s kh khn v nhn lc
thc hin v mt s quy nh lin quan n l lch t php i vi ngi hnh ngh. H thng
c s d liu v ng k, qun l cp php, cp chng ch hnh ngh trn ton quc cha c
trin khai. Vic cp chng ch, cp php mt ln v ch da trn h s, cha cn c trn trnh
thc hnh v st hch tay ngh, khng gn vi o to lin tc nh hng n cht lng nhn
lc chuyn mn v y t.
H thng vn bn php quy v khm cha bnh vn cha y : quy ch bnh vin
c ban hnh t nm 1997 n nay c nhiu ni dung c thay th bng cc thng t, vn
bn hng dn mi (kim sot nhim khun, iu dng, dinh dng, dc bnh vin, cp cu,
114

hi sc, qun l cht thi,). Tuy vy, nhiu ni dung cn c iu chnh, thay th cho ph
hp vi Lut Khm bnh, cha bnh, to thun li cho cc bnh vin thc hin. H thng quy
chun k thut v cc c s khm, cha bnh (theo Lut Khm bnh, cha bnh) cha c
ban hnh.
H thng cc vn bn hng dn chuyn mn ang trong qu trnh xy dng mi v cp
nht, nhng vi trn 17000 dch v k thut v hng ngn hng dn iu tr l mt khi lng
ln to gnh nng cho B Y t, trong khi cha c c ch giao nhim v cho cc hi chuyn
ngnh nn tin cha t c nh mong mun.
5) Gim qu ti bnh vin
Kt qu thc hin
n gim qu ti bnh vin giai on 2013-2020 c Th tng Chnh ph ph
duyt ti Quyt nh s 92/Q-TTg ngy 9/1/2013 vi mc tiu trc mt tp trung gii quyt
gim qu ti cc chuyn khoa ung bu, ngoi-chn thng, tim mch, sn v nhi mt s
bnh vin tuyn cui ti 2 thnh ph H Ni v H Ch Minh, nng cao cht lng khm, cha
bnh v nng cng sut s dng ging bnh ca bnh vin tuyn huyn v tuyn tnh hin
c cng sut s dng ging bnh thp t 60% v nm 2015 v 80% vo nm 2020. Tip
, n bnh vin v tinh c B Y t ph duyt theo Quyt nh s 774/Q-BYT ngy
11/3/2013, trong , giai on 1 thnh lp mng li 45 bnh vin v tinh ti 32 tnh, thnh ph
ca 14 bnh vin ht nhn, tng ti thiu 7150 ging bnh ca 5 chuyn khoa ny. B Y t
cng ph duyt n Bc s gia nh theo Quyt nh s 935/Q-BYT ngy 22/3/2013 vi
mc tiu xy dng c m hnh, c ch qun l v th im vn hnh m hnh phng khm
bc s gia nh ti mt s tnh. n 1816 tip tc c trin khai nhng c s ci tin phng
php thc hin thng qua chuyn giao k thut cho tuyn di.
Kho st ca Cc Qun l KCB thng 5/2014 cho thy v c bn khng c tnh trng qu
ti bnh vin tuyn tnh, huyn v a s cc bnh vin trc thuc b, ngnh. Ch c 9 bnh
vin trc thuc B Y t v mt s bnh vin tuyn cui thuc S Y t thnh ph H Ch Minh
c ngi bnh nm ghp, ch yu l cc chuyn khoa ung bu, nhi, ph sn, tim mch, v chn
thng. B Y t ang xy dng bng kim nh gi thc trng qu ti bnh vin tip tc c
hng ch o trin khai n t hiu qu.
Kh khn, hn ch
S ging bnh tng trong nm 2013 cha theo kp s gia tng v s lt khm bnh
ngoi tr v iu tr ni tr, bn cnh , c ch t ch ti chnh, mt s yu t lin quan n
tuyn k thut, danh mc thuc BHYT, nng lc k thut tuyn di cn hn ch nn tnh trng
qu ti cc bnh vin tuyn trung ng vn cha c ci thin ng k. Cng sut ging
bnh thc k gim chm, cng sut ca 12/38 bnh vin trc thuc B vt qu 100%. Tnh
trng qu ti cc bnh vin tuyn cui, c bit mt s chuyn khoa nh ung bu, nhi, tim
mch, ph sn, ni tit vn din ra ph bin. 30% s bnh nhn BHYT iu tr tuyn trung
ng v 23% bnh nhn BHYT iu tr tuyn tnh l vt tuyn. L do chnh ca tnh trng
vt tuyn l ngi bnh cha tin tng vo cht lng iu tr tuyn di.
Pht trin ngun nhn lc y t c s hin gp nhiu bt cp, kh khn v c s lng v
cht lng, chnh sch v ph cp u i cha sc thu ht cn b y t v cng tc tuyn
c s, nht l vng su, vng xa (xem chi tit Chng II, mc 2.2). Cc n u t nng
115

cp cho y t tuyn tnh, huyn trin khai chm do gp kh khn trong vic huy ng tri phiu
Chnh ph hoc c duyt nhng cha cn i c ngun vn ( n 950, n 47) (xem
chi tit Chng II, mc 2.4).
Ch trng lin doanh lin kt gia bnh vin cng v t nhn mang li li ch l pht
trin k thut v ngi bnh c cung ng dch v thun li, nhng d pht sinh tnh trng lm
dng thuc, xt nghim v cc dch v k thut cao, d to ra s mt cng bng trong chm sc
ngi bnh. C ch khm, cha bnh theo yu cu ti cc bnh vin cng cha c hng dn
c th nn c th ny sinh vng mc (xem chi tit Chng II mc 2.1, nhim v s 6).
6) Nng cao nng lc qun l bnh vin
Kt qu thc hin
thnh lp Trung tm o to qun l bnh vin ti Trng i hc Y t Cng cng.
Cc trung tm o to v qun l bnh vin thuc Cc Qun l KCB v cc trng tip tc m
nhiu kha o to qun l bnh vin, an ton ngi bnh, qun l cht lng dch v y t cho
cc cn b qun l. Hng nghn cn b qun l bnh vin c o to hng nm v cc
lnh vc qun l nhn lc, ti chnh, k hoch, cht lng, an ton, BHYT, chm sc, kim sot
nhim khun, dc, trang thit b v c s h tng
Kh khn, hn ch
Mc d t chc nhiu kha o to qun l bnh vin, qun l cht lng nhng do
nhu cu ln nn cha p ng c. Hn na, mt s chnh sch lin quan n KCB thng
xuyn thay i nn nhu cu cp nht v o to v qun l bnh vin vn mc cao, cha c
p ng.
7) Cng tc y hc c truyn
Kt qu thc hin
H thng khm cha bnh bng y hc c truyn c hnh thnh v pht trin t
tuyn trung ng n tuyn x. Nm 2014, c tng cng 61 bnh vin y hc c truyn, trong
c 2 bnh vin tuyn trung ng v 59 bnh vin tuyn tnh. Ngoi ra, cn c 4 bnh vin YHCT
t nhn. S liu t 44 tnh nm 2014 cho thy dch v YHCT cng c cung ng rng ri ti cc
bnh vin a khoa vi 59,1% bnh vin c khoa YHCT v 32,1% bnh vin c t YHCT. T l
bnh vin tuyn tnh v huyn c n v YHCT tng ng k t 26,3% nm 2003 ln hn 58% vo
nm 2014. n nm 2014, c 42% trm y t t tiu ch quc gia v y t x v YHCT v 61,5%
c BHYT thanh ton cho cc dch v YHCT. Ngoi ra, nm 2014, c tng cng 7157 c s
YHCT t nhn c cp php, ch yu l cc phng khm YHCT do cc thy thuc ngi Vit
Nam hnh ngh (61,8%) v cc c s sn xut thuc YHCT [75].
T l khm bnh bng y hc c truyn so vi tng s lt khm bnh chung tng tuyn
c ci thin ng k, song vn cn khim tn, ch chim 8,7% tuyn tnh, 8,95% tuyn huyn
v 18,8% tuyn x. T l bnh nhn ni tr c iu tr bng YHCT hoc kt hp y hc hin
i vi YHCT cng ch t mc thp, vi 9,2% tuyn tnh v 24,9% tuyn huyn. T l iu tr
ngoi tr bng YHCT trong tng s lt iu tr ngoi tr cao hn i cht, t 13,4% tuyn tnh,
16,4% tuyn huyn v 26,8% tuyn x [75].
116

Kh khn, hn ch
T l khm bnh bng YHCT so vi tng KCB chung cha chim t trng cao. Mt s
vng mc trong KCB BHYT, cp chng ch hnh ngh, cp giy php hot ng i vi cc
bnh vin YHCT phn no nh hng n s pht trin ca lnh vc ny.
1) Cng c v tng cng mng li y t c s

Cn khn trng cng c, tng cng u t tng cng hn na mng li y t c
s, c v m hnh t chc, iu kin c s vt cht, trang thit b, pht trin nhn lc bn
vng, i mi c ch hot ng v c ch ti chnh, qua tng cng CSSK ban u
gim gnh nng qu ti cho tuyn trn.
2) y mnh cc hot ng d phng, trin khai hiu qu cc chng trnh mc tiu quc
gia v y t
y nhanh tin u t t NSNN cho cc chng trnh nng cp Trung tm YTDP
tuyn tnh, trung tm y t huyn, duy tr v pht trin cc trung tm YTDP tnh t chun
quc gia theo Quyt nh s 4696/Q-BYT v thc hin cc tiu ch quc gia v y t
x. Thc hin c hiu qu cc chnh sch ti chnh, nhn lc, h thng thng tin y t lin
quan tng cng h thng YTDP nh c cp trong cc mc trn.
Cn s cam kt tham gia mnh m hn na ca cc cp chnh quyn v cc ban ngnh
trong ci thin mi trng v nng cao nhn thc ca ngi dn.
Thc hin cc gii php chuyn mn nhm kim sot c cc dch bnh st xut huyt,
chn tay ming theo cc ch tiu k hoch ra.
u tin u t cho chng trnh phng chng cc BKLN, trong ch trng cc gii
php nhm thng nht qun l gim st kim sot bnh v cc yu t nguy c, tng
cng lng ghp v phi hp trong cc hot ng chuyn mn v cung ng dch v gia
cc n v thuc h YTDP v KCB, gia cc tuyn.
Xy dng v thc hin cc gii php chnh sch nhm cao vai tr v trch nhim ca
chnh quyn, cc ban ngnh cc cp trong vic ch o v phi hp thc hin cc hot
ng nng cao sc khe, phng bnh v CSSKB.
Xy dng v thc hin cc quy nh v vai tr, trch nhim ca ngnh gio dc trong
bo m dinh dng v nng cao sc khe cho tr em, hc sinh trong cc trng hc.
3) Hon thin h thng chnh sch, cng c mng li v thc hin tt cc hot ng v dn
s-KHHG v chm sc sc khe sinh sn
nh gi li vic t chc thc hin nhim v v cung ng dch v dn s-KHHG v
CSSK sinh sn ca mng li dn s cc cp v cc n v y t c lin quan phn
cng hp l nhim v ca cc c quan dn s v cc c s y t trong cc hot ng
chuyn mn lm sng v phi lm sng (chuyn chc nng chuyn mn lm sng v
KHHG cho cc n v y t).
117

Cn c s cam kt, tham gia tch cc ca cc cp chnh quyn, ban ngnh trong cc hot
ng phi hp v h tr t ngnh gio dc trong bo m dinh dng cho tr em, cc
hot ng trong kim sot v nng cao cht lng dn s, c bit kim ch s gia tng
t s gii tnh khi sinh.
4) Nng cao cht lng dch v KCB
Xy dng b sung cc vn bn quy nh v hng dn nng cao cht lng dch v, xy
dng chng trnh hnh ng vi cc n c th theo tng lnh vc nhm thit k h
thng cht lng quc gia v trin khai cc hot ng c hiu qu. Tng cng o to
v hng dn trin khai p dng cc phng php cht lng ti cc c s khm, cha
bnh.
Hon thin b Tiu ch nh gi cht lng bnh vin: Xy dng tiu ch cht lng
KCB i vi trm y t x v cc c s khm, cha bnh khc; Xy dng v ban hnh quy
nh v xt nghim thng quy i vi ngi bnh ni tr, ngoi tr, khm bnh; Xy
dng v ban hnh th im chun cht lng lm sng i vi mt s bnh.
Thit lp c ch khuyn khch ti chnh, phi ti chnh cho cc c s cung ng dch v c
cht lng. Trong , nghin cu xy dng m hnh KCB BHYT tuyn x ph hp v
c chnh sch khuyn khch i vi trm y t x t cht lng.
Chun ha v tng cng chuyn giao k thut cho tuyn di nhm nng cao kh nng
p ng v trnh chuyn mn k thut ca tuyn di. Tng cng thanh tra, kim tra
hot ng y t t nhn vi s phi hp vi chnh quyn a phng v Mt trn t quc,
thnh lp thanh tra khm, cha bnh cc cp nhm qun l cht ch hot ng chuyn
mn v vic tun th cc quy nh php lut.
Thnh lp t chc chng nhn cht lng c lp v thc hin c ch kim nh cht
lng c lp nhm nh gi v cng nhn cht lng i vi cc c s khm, cha
bnh; Xy dng n kim nh cht lng v n nh gi cng nhn cht lng
bnh vin.
Trin khai n xy dng phng php nh gi s hi lng ca ngi bnh.
R sot, la chn u tin bin son v xy dng hng dn chuyn mn c tnh cht ph
bin, thng thng ban hnh trc. Xy dng v ban hnh hng dn phng nga v
x l s c y khoa ti cc c s khm, cha bnh.
Xem xt iu chnh Lut Khm bnh, cha bnh theo hng: cp chng ch cho ngi
hnh ngh c st hch tay ngh, cp chng ch c thi hn v gn kt vi o to lin tc.
5) Gim qu ti bnh vin
Tch cc trin khai cc n gim qu ti bnh vin, bnh vin v tinh, tp trung chuyn
giao k thut, nng cao nng lc cho tuyn di, ch trng n vic qun l cc bnh
mn tnh, BKLN. Pht huy vai tr, chc nng, nhim v ca cc c s y t d phng
trong vic truyn thng gio dc, qun l v nng cao sc khe, phng bnh tch cc v
ch ng.
118

Tng cng chuyn tuyn c phn hi hiu qu t tuyn trn v tuyn di.
Tng cng kim sot cht lng cung ng dch v, c bit l tng cng iu tr ngoi
tr, kim sot nhp vin iu tr ni tr, m rng cc loi hnh iu tr ban ngy, phu
thut ban ngy, b sung loi hnh ny vo cc loi hnh c s KCB trong Lut Khm
bnh, cha bnh v c chnh sch gi dch v y t ph hp.
6) Nng cao nng lc qun l bnh vin
a tiu chun c o to v qun l bnh vin l iu kin b nhim v tr lnh
o, qun l bnh vin.
To iu kin cho cc nh qun l bnh vin tham gia cc din n qun l bnh vin
trong nc v quc t.
7) Cng tc y hc c truyn
Tip tc thc hin Quyt nh 2166/Q-TTg ca Th tng Chnh ph v k hoch pht
trin y dc c truyn n nm 2020 v Quyt nh 1976/Q-TTg ca Th tng Chnh
ph ngy 30/10/2013 v Quy hoch tng th pht trin dc liu n nm 2020 v nh
hng n nm 2030. Ch o thc hin hiu qu Quyt nh s 362/Q-TTg (2014)
v vic ph duyt n u t xy dng nng cp c s h tng, trang thit b cho cc
bnh vin y hc c truyn trong ton quc giai on 2013-2025.
y mnh cng tc kim tra hot ng hnh ngh YDCT t nhn c bit i vi cc c
s hnh ngh KCB bng YHCT c thy thuc nc ngoi.
3. Tnh hnh thc hin cc ch tiu y t c bn trong K hoch 5 nm,

2011-2015 v Mc tiu Thin nin k
Nm 2013 qua mt na thi gian thc hin K hoch 5 nm ngnh y t giai on
2011-2015. Tin thc hin cc mc tiu k hoch c theo di trong Bng 12. Trong nhm
cc ch tiu u vo, so snh vi ch tiu nm 2013, kt qu thc hin mt s ch tiu c tnh
t hay vt k hoch bao gm s dc s i hc/vn dn, t l trm y t x c bc s, t l
trm y t x c y s sn nhi, h sinh v ging bnh vin cng lp/vn dn. Hai ch s khng
t mc tiu l s bc s/vn dn v t l thn, bn, p, t dn ph c nhn vin y t hot ng.
Hin nay h thng thng tin y t v ng k hnh ngh cha c s liu v s bc s t nhn nn
s ny ch th hin s bc s lm vic trong khu vc cng lp/vn dn. Nu tnh c c cc bc
s hnh ngh t nhn, kt qu s vt ch tiu. T l thn, bn, p, t dn ph c nhn vin y t
hot ng l 75,5%.
Trong nhm cc ch tiu hot ng, c mt ch tiu vt mc k hoch ra v mt ch
tiu khng t k hoch. T l tr em di 1 tui c tim chng y vt k hoch ra
cho n nm 2015. Vi t l x t chun quc gia v y t, nm 2013 l nm u tin thu thp
s liu hon ton theo tiu ch mi trong K hoch 5 nm. Kt qu cho thy, ch c 42% s x
t cc tiu ch quc gia mi v y t x, thp hn nhiu so vi mc tiu 50% vo nm 2013.
119

Bng 12: Tnh hnh thc hin cc ch tiu y t c bn trong K hoch 5 nm, 2011-2015
TT
1
2
3
Ch s
11
12
13
Cc ch tiu u vo
S bc s/vn dn
S dc s i hc/vn dn
T l thn, bn c nhn vin y t
hot ng (%)
T l trm y t x c bc s (%)
T l trm y t x c y s sn nhi,
h sinh (%)
Ging bnh vin cng lp/vn
dn (khng k TYT x)*
Cc ch tiu hot ng
T l tr em < 1 tui tim y
(%) (7 loi vc xin nm 2010 v 8
loi nm 2011-2015)
T l x t tiu ch quc gia v
y t (S liu bo co khng tch
c s x p dng chun c v
s x p dng tiu ch mi nn
c s pha trn trong s liu 2011,
2012)
Cc ch tiu u ra
T l dn s tham gia BHYT (%)
Tui th trung bnh (tui)
14
T s t vong m (/100000)
15
16
T sut t vong tr em < 1 tui ()

T sut t vong tr em < 5 tui ()
17
Quy m dn s (triu ngi)
18
Mc gim t l sinh ()
19
Tc tng dn s (%)
T s gii tnh khi sinh (s tr
trai/100 tr gi)
T l suy dinh dng th nh cn
tr em di 5 tui (%)
T l hin nhim HIV/AIDS trong
cng ng (%)
4
5
6
7
8
9
10
20
21
22
Nm
2010
Nm
2011
Nm
2012
7,20
1,8
7,33
1,9
7,46
1,96
78,8
82,9
82,2
70,0
71,9
95,6
Nm 2013
Mc tiu
2015
8
1,8
73,5
7,5 (7,6)
2,1 (1,5)
75,5 (c)
(88)
76,9 (76)
95,3
96,4
97,3 (>95)
>95
21,7
22,5
23,5
24,2 (22,0)
23,0
94,6
96,0
95,9
91,4 (>90)
>90
80,1
(chun
c)
76,8
73,4
42 (50)
60
60,3
72,9
69
(2009)
15,8
23,8
65,0
73,0
66,4
73,0
68,5
73,1 (73,6)
70
74,0
..
..
..
58,3
15,5
23,3
15,4
23,2
14,8
19,3
86,9
87,8
88,77
Gim
0,5
1,05
Gim
0,5
1,04
Tng
0,30
1,06
111,2
111,9
112,3
15,3 (15,2)
23,1 (22,0)
89,71
(89,57)
Tng 0,1
(gim 0,1*)
1,05 (0,95)
113,8
(113)
17,5
16,8
16,2
15,3 (15,5)
15,0
0,212
0,225
0,237
0,242
(<0,3)
<0,3
90
80
<93*
Gim
0,10*
0,93
113
Ch thch:
S liu tnh n ngy 26/07/2014
Cc mc tiu t K hoch Bo v, chm sc v nng cao sc khe nhn dn giai on 2011-2015. S trong ( ) l
ch tiu nm 2013. Mc tiu c hiu chnh trong n thc hin l trnh tin ti BHYT ton dn (538/2013/QTTg) *Mc tiu c hiu chnh trong CTMTQG DS-KHHG 2012-2015 (1199/2012/Q-TTg). S ngi mc HIV
(gm c giai on AIDS v t vong trong nm) trn tng s dn c tnh ca Tng cc Thng k.
Ngun: Ch s 1-9: Phng Thng k, V K hoch Ti chnh, B Y t; Ch s 10 v 12-17: Tng cc Thng k. iu
tra Bin ng dn s v KHHG 1/4/2013; Ch s 11: Tng iu tra dn s v nh 1/4/2009 [76]; Ch s 18: Vin
Dinh dng, Thng k dinh dng; Ch s 19: S ngi mc HIV ly t h thng gim st Cc Phng chng HIV/
AIDS. B Y t. Dn s c tnh t Nin gim thng k, Tng cc Thng k.
120

Trong nhm cc ch s u ra, ch c 2 ch s t v vt mc tiu nm 2013, l t l
hin nhim HIV/AIDS duy tr di 0,3% dn s v t l suy dinh dng l 15,3%, gim di
mc tiu nm 2013 (15,5%). i vi t s t vong m, thiu s liu cp nht nh gi tnh
hnh sau nm 2009. T l tham gia BHYT gn t mc tiu nm 2015 (l mc tiu iu chnh
theo n thc hin l trnh tin ti BHYT ton dn). Mt s ch s gn t mc tiu nm 2013
bao gm t sut t vong tr em di 1 tui, quy m dn s. Cc ch s cha t mc tiu l: t
sut t vong tr em di 5 tui cn rt cao, tui th trung bnh cn thp, tc tng dn s cao,
t l sinh vn tng v mc tng t s gii tnh khi sinh vn cao hn mc tiu.
D nhiu ch s cha t mc tiu ra cho nm 2013, nhng hu ht u theo xu hng
ci thin v c kh nng n nm 2015 s t mc tiu ca K hoch 5 nm. Tuy nhin, vn cn
mt s mc tiu s kh t theo k hoch.
Khi xy dng K hoch 5 nm ngnh y t 2011-2015, s chnh lch kh ln v tnh trng
sc khe gia cc vng, min, gia cc nhm mc sng c nu r l vn cn gii quyt.
Kt qu gim st cc ch s c bn v sc khe cho thy d xu hng chung l ci thin cc ch
s, nhng s chnh lch gia cc vng hu nh khng gim (Bng 13).
Bng 13: Chnh lch vng i vi cc ch s sc khe c bn
Ch s o lng mc chnh lch (ch s
ca vng cao nht so vi vng thp nht)
2010 2011 2012
2013
(c)
Kt qu gim
chnh lch
Tui th trung bnh
1,1
1,1
1,1
1,1
Khng thay i
IMR (s t vong trn 1000 tr sinh ra sng)
2,8
2,6
2,9
2,9
Chnh lch tng
U5MR (s t vong trn 1000 tr sinh ra sng)
2,9
2,7
2,9
2,9
Khng thay i
MMR (trn 100000 tr ra sng)
n/a
2,9
3,6
n/a
Chnh lch tng
T l SDD-thiu cn
2,3
2,4
2,5
2,7
Chnh lch tng
T l hin nhim HIV (tnh trn 100 000 dn)
6,9
n/a
n/a
6,5
Chnh lch gim
Ngun: Tui th, IMR, U5MR - Tng cc Thng k. iu tra Bin ng dn s v KHHG 1/4/2013 [27]; MMR - S
liu t V Bo v B m Tr em, B Y t. SDD- Vin Dinh dng [3]. T l hin nhim HIV - S liu t Cc Phng
chng HIV/AIDS [77].
4. Tnh hnh thc hin cc Mc tiu Pht trin Thin nin k trong lnh
vc y t
Mc tiu Pht trin Thin nin k gm 8 mc tiu c 189 quc gia thnh vin Lin
Hp Quc, trong c Vit Nam, nht tr phn u t c vo nm 2015. Trong 8 mc tiu
MDG, c 5 mc tiu lin quan trc tip n n lnh vc y t, bao gm MDG 1 v xa b tnh
trng ngho cng cc v thiu i, MDG 4 nhm gim t sut t vong tr em, MDG 5 nng
cao sc khe b m, MDG 6 v phng chng HIV/AIDS, st rt v cc bnh dch khc v MDG
7 lin quan bo m bn vng v mi trng.
121

Tnh hnh thc hin cc MDG c nh gi da trn cc ch s gim st ca Lin Hp
Quc. Bng 14 tm tt tin thc hin cc MDG v nh gi kh nng hon thnh mc tiu.
i vi cc mc tiu kh t, tnh hnh c phn tch su hn nhm tm ra gii php ph hp.
Mt s ch tiu khng c s liu thng xuyn khng c trong bng nhng vn c phn tch
di y.
Vit Nam t hoc c kh nng t hu ht cc MDG, nhng vn cn mt s mc
tiu cn n lc mi t c. n ht nm 2013, cc MDG t bao gm gim t l suy dinh
dng tr em, gim t l mc v t l t vong do st rt v t l tip cn vi nc sch, h x
hp v sinh. Mt s mc tiu c kh nng t nu tip tc tin hin nay nh t sut t vong
tr em di 1 tui, tng t l ngi nhim HIV cn iu tr c tip cn vi thuc khng vi rt
v t l hin mc bnh lao. Mt s ch s khng c mc tiu c th, nhng c xu hng ci thin
nh tng kh nng tip cn ton din vi CSSKSS (th hin cc ch s v t l khm thai, t l
ph n sinh con c cn b y t , t l s dng bin php trnh thai v t sut sinh v thnh
nin) v tng t l ph n mi dm s dng bao cao su khi quan h vi khch. ng lo ngi l
mt s mc tiu kh t vo nm 2015 hoc ch s theo xu hng khng tch cc nh mc tiu
gim t sut t vong tr em di 5 tui v t s t vong m. Mt s mc tiu ph cng ng cn
quan tm nh mc tiu tng t l s dng bao cao su ngi nghin chch ma ty v gn y
l s suy gim trong t l iu tr ARV i vi tr em c nhu cu.
Bng 14: Ch s nh gi tin t cc Mc tiu Pht trin Thin nin k
Mc tiu
Ch tiu y t
S liu
v nm c s
Nm 2012
Nm 2013
Mc tiu
2015
Ngun
d liu
20,5%
t c
Vin Dinh
dng [3]
Mc tiu 1: Xo i gim ngho

Ch tiu 1C:
Gim mt
na s
ngi i
n
1.8 T l suy
dinh dng
tr em di
5 tui
41% (1990)
16,2%
15,3%
Mc tiu 4: Gim t vong tr em

Ch tiu 4A:
Gim 2/3
t sut t
vong tr em
di 5 tui
4.1 T sut
t vong tr
em di 5
tui
58 (1990)
23,2
23,1
4.2 T sut
t vong tr
em di 1
tui
44,4 (1990)
15,4
15,3
Tng cc
19,3
Thng k
Kh t c
[27]
14,8
C th t
c
Tng cc
Thng k
[27]
Mc tiu 5: Nng cao sc kho b m v tip cn ton dn vi SKSS vo nm 2015

Ch tiu 5A:
Gim 3/4 t 5.1 T s t
s t vong vong m
m
233/100000
(1990)
69/100000
(2009)
122
n/a
58,3/100000 Tng cc
Thng k
Kh t c
[76]
Mc tiu
Ch tiu y t
Ch tiu 5B:
t kh
nng tip
cn ton
din vi
chm sc
sc kho
sinh sn
5.5 T l ph
n sinh con
c khm
thai t nht 3
ln trong 3
thi k (VN)
S liu
v nm c s
Nm 2012
Nm 2013
Mc tiu
2015
Ngun
d liu
n/a
Thng k
y t, B
Y t
89,7%
87,9% (2004)
89,4%
Mc tiu 6: Phng chng HIV/AIDS, st rt v cc bnh dch khc

Ch tiu 6A:
Chn ng
v gim s
ly nhim
HIV/AIDS
6.1 T l
hin nhim
HIV nhm
tui 15-24;
cc nhm
nguy c cao
Ch tiu 6B:
n 2010
bao ph
ton b vic
cha tr
HIV/AIDS
cho cc i
tng cn
6.4 T l
ngi nhim
HIV giai
on nng
c tip
cn vi
thuc khng
vi rt
6.6 T l
mc v t
vong do st
rt
Ch tiu 6C:
n nm
2015, chn
ng v bt
u gim s
bnh nhn
mc st rt
Ch tiu 6D:
6.7 T l
Khng ch
hin mc lao
bnh lao
15-24 (2000)
0,22%
PNMD: 5,3%
MSM: 1,8%
NCMT: 22,1%
15-24: 0,16%
15-24: 0,17%
PNMD: 6,9%
PNMD: 6,9%
MSM: 13,9%
MSM: 12,5%
NCMT:
NCMT: 24,7%
23,9%
Cc
Phng
chng
HIV/AIDS
[21].
5% (TDB,
2005)
Chung 59,9%
Ngi ln:
58,9%
Tr em: 86,3%
Chung 67,6%
Ngi ln:
67,1%
Tr em:
79,2%
70%
C th t
c
Cc
Phng
chng
HIV/AIDS
[78]
Mc
96/100000
T vong:
0,031/
100000 (2000)
Mc
39/100000
T vong:
0,006/
100000
Mc
33/100000
T vong:
0,006/
100000
Mc:
<40/100000
T vong:
<0,02/
100000
t c
Cc
YTDP
[20]
375/100000
(2000)
113,8/ 100000
111,2/
100000
187/100000
t c
BYT [da
trn s
pht hin]
403/100000
(1990)
218/100000
n/a
187/100000
Kh t c
LHQ [s
c tnh]
Mc tiu 7: Bo m mi trng bn vng (trng tm vo nc sch v iu kin v sinh)

Ch tiu
7C: Gim
mt na
s ngi
khng c
tip cn bn
vng vi
nc ung
sch v
iu kin v
sinh c bn
7.1 T l dn
s s dng
h x hp v
sinh
37% (1990)
75%
n/a
68,5%
t c
WHO/
UNICEF
JMP [79]
7.2 T l dn
s s dng
ngun nc
ung hp v
sinh
57% (1990)
95%
n/a
78,5
t c
WHO/
UNICEF
JMP [79]
123

Mc tiu 1C: Gim mt na s ngi i n
Kt qu t c:
Ch s nh gi mc tiu ny l t l tr suy dinh dng th nh cn (cn nng/tui). Trn
ton quc Vit Nam t c mc tiu ny trc thi hn nm 2015 vi cc mc suy dinh
dng nh, va v nng (Bng 15).
Bng 15: Tnh hnh gim suy dinh dng tr em trong thi gian t 1990 n 2015
Ch s
1990
2013
Mc tiu 2015
T l SDD nh cn tr em <5 tui
41%
15,3%
20,5%
11%
1,5%
5,5%
30%
13,8%
15,0%
T l SDD nh cn mc nng
tr em <5 tui
T l SDD nh cn mc va
tr em <5 tui
Tnh trng
t c, cn duy
tr bn vng
t c, cn duy
tr bn vng
t c, cn duy
tr bn vng
Ngun: Vin Dinh dng. S liu thng k v tnh trng dinh dng tr em qua cc nm.
Kh khn, hn ch:
T l suy dinh dng tr em cn c s khc bit kh ln gia cc vng min (Hnh 31).
T l suy dinh dng tr em cn rt cao vng min ni pha Bc, Bc Trung B v c bit
Ty Nguyn, vng duy nht cha t mc tiu. T l suy dinh dng thp ci (chiu cao/tui)
tr em di 5 tui nm 2013 cn mc cao (25,9%), so vi cc nc ang pht trin trong
khu vc Vit Nam ng th 6, vi t l thp ci cao hn Trung Quc, Thi Lan, Mng C, Malai-xi-a v Xri Lan-ca. n nm 2013, vn cn 4 tnh c t l ny mc trn 35%, c coi l
mc rt cao theo xp loi ca WHO.
Nhiu yu t nh hng ti dinh dng tr em nh cc yu t mi trng, kinh t, x
hi v chnh tr, c bit tnh trng ngho i [80]. Tuy nhin, cc can thip y t v dinh dng c
th khc phc thiu dinh dng tr em. Theo WHO, cc chng trnh can thip c hiu qu Vit
Nam cng nh trn th gii gm b sung vi cht dinh dng cho ph n tui sinh , c bit l khi
c thai, ty giun, gio dc dng v nui con bng sa m, b sung vitamin A v km, cho tr n
b sung hp l t 5-24 thng tui v chuyn giao/h tr tin mt c iu kin [81].
Hnh 31: Xu hng gim t l thp ci theo vng, 2010-2013
40
Phn trm
35
30
25
20
15
10
5
0
2010
2011
ng bng sng Hng

Bc Trung B v duyn hi min Trung
ng Nam B
Ton quc
2012
Trung du v min ni pha Bc
Ty Nguyn
ng bng sng Cu Long
124
2013

Kin thc, thc hnh dinh dng cha hp l cn ph bin cc b m v cc thnh vin
trong gia nh, c bit vng su, vng ng bo dn tc thiu s [82], [83]. Nm 2014, ch
26,5% tr em c b sa m trong vng 1 gi sau khi sinh, ch 24,3% tr em c b sa
m hon ton di 6 thng v 49% ch yu b sa m di 6 thng, ch 65,6% tr em tip tc b
sa m khi c 1 tui. Khi bt u cho n b sung thc n, ch 90,5% tr em t 6-23 thng tui
c s ln n ti thiu, ch 46,9% c ch ph hp vi tui. Ch 83,4% tr em c b sung
vitamin A [84]. Tnh hnh trm cm sau sinh cng c tng quan vi tnh trng dinh dng tr
em; c tnh khong mt phn ba ngi m Vit Nam c triu chng trm cm sau sinh [85].
Mng li trin khai hot ng v dinh dng cha n nh, i ng cn b lm cng tc dinh
dng cng ng, trng hc v trong bnh vin cn thiu v yu. Chin lc dinh dng c
thc hin o to cn b v dinh dng S quan tm ca cp y, chnh quyn cc cp mt
s a phng v dinh dng cn hn ch. Ngn sch u t cn hn hp, trong khi , kinh ph
h tr ca quc t cho cc hot ng v dinh dng Vit Nam ngy cng gim dn.
Mc tiu 4: Gim t vong tr em
Cc kt qu t c:
Trong vng 10 nm qua, t sut t vong tr s sinh, tr em di 1 tui v di 5 tui
gim tng nm. Nm 2013 c tnh t sut t vong tr em di 1 tui ca Vit Nam gim
gn 2/3, c kh nng n nm 2015 s t mc tiu.
Kh khn, hn ch:
T 1990 n 2013, t sut t vong tr em di 5 tui ch gim c 60%, cn cn n
lc ln mi t c mc tiu gim tip gn 4 ca t vong di 5 tui trn 1000 tr sinh ra trong
2 hai nm 2014 v 2015 (Hnh 32). C s khc bit kh ln v t vong tr em gia cc vng
min. Ty Nguyn v Trung du v min ni pha Bc l 2 vng c t sut t vong tr em di
1 tui v di 5 tui cao nht c nc. T sut t vong tr em ti khu vc nng thn cng cao
hn gp 2 ln so vi khu vc thnh th. Nm 2013, c tnh tng s t vong di 5 tui Vit
Nam l khong 26600 tr em. C 1000 tr em sinh ra, c tnh l c 6,9 tr em t vong trong
tui t 0-6 ngy tui, 2,6 tr t vong trong nhm t 7-28 ngy tui, 3,7 tr t vong trong nhm
t 29 ngy n 365 ngy tui v 5,4 tr t vong trong nhm t 1 n 5 tui [86] Nh vy, trong
tng s tr em t vong trc 5 tui, hn mt na t vong trc 1 thng tui, khong 30% t
vong trong giai on t 1 n 5 tui.
S t vong trn 1000 tr sinh ra sng
Hnh 32: T sut t vong tr em di 5 tui theo vng, 2010-2013

50
40
39.8
35.2
30
25.5
23.1
18.3
17.9
13.5
20
10
19.3
0
2010
2011
2012
ng bng sng Hng

Bc Trung B v duyn hi min Trung
ng Nam B
Ton quc
2013 (c)
2014
2015 mc tiu
Trung du v min ni pha Bc

Ty Nguyn
ng bng sng Cu Long
125

Nm nguyn nhn chnh gy t vong tr em di 5 tui l bin chng trc sinh (27,0%),
d tt bm sinh (19,3%), ngt th khi sinh (10,3%), vim phi (10,0%), bnh truyn nhim khc
(9,1%) (Hnh 33). Tai nn/chn thng chim 4,6% tng s t vong tr em di 5 tui [87]. Suy
dinh dng l yu t quan trng nh hng ti bnh tt v t vong tr em[80]
Hnh 33: Nguyn nhn chnh gy t vong tr em Vit Nam, 2010
Chn thng khc
35%
Cht ui
30%
Bnh khng ly nhim khc
25%
D tt bm sinh
20%
Cc bnh truyn nhim khc
15%
Cc bnh truyn nhim thng

thng khc
Nhim khun ng h hp di
Phn trm tng s t vong tr em di

5 tui
40%
10%
HIV/AIDS v bnh lao
5%
0%
0-6
ngy
7-27
ngy
28-364
ngy
1-4
nm
Bnh no tr chu sinh (do ngt

th/chn thng lc sinh)
Bin chng v sinh non
Tui tr em
WHO nghin cu hiu qu chi ph ca cc can thip thit yu nht nhm gim t vong
tr em, trong c cc can thip trc sinh, trong sinh, sau sinh c th thc hin k c trong
iu kin khim tn v ngun lc. Cc can thip c chia theo loi ch c th thc hin ti c
s chuyn tuyn, hoc ti c s CSSKB hoc ti cng ng [88].
Vit Nam, mt s nghin cu pht hin cc yu t kinh t-x hi nh hng ti t
vong tr em nh m c trnh hc vn thp, gia nh dn tc thiu s [89], t s dng dch v
y t do khong cch a l [90]. Vit Nam thc hin nhiu can thip trong danh mc cc can
thip thit yu c WHO khuyn co, nhng mc bao ph cha cao v tc ng cha
hiu qu. Cc can thip lin quan thi k mang thai v sinh con rt quan trng nhm gim
t vong lin quan non, thiu cn, khuyt tt bm sinh. Cc can thip ci thin dinh dng
gip gim t l sinh thiu cn, v nng cao sc khng tr em chng li bnh tt. Tim chng
m rng bao ph nhiu loi vc xin c cp min ph, nhng kt qu ca iu tra nh gi
cc mc tiu tr em v ph n nm 2014 cho thy t l tim chng y thp hn so vi t l
tim chng theo bo co, nh t l tim phng 3 mi vc xin phng bch hu, ho g v un
vn ch t 88,6% v t l tim phng si ch t 86,2% [84]. Vc xin Haemophilus influenza
tp B (Hib) mi c a vo Chng trnh TCMR trong mi tim kt hp vim gan B, un
vn, ho g v bch hu (Quinvaxem) t nm 2010. n nm 2013, do nhiu ca tai bin, t vong,
B Y t cho ngng tim iu tra. Khi trin khai li tim Quinvaxem, li c thm mt s
trng hp tr t vong. Do nhng bin chng ny, mt b phn ngi dn mt tin tng vo
Chng trnh tim chng v khng a con i tim. Hu qu l nm 2014 c nhiu trng hp
mc v t vong do bnh si. Vn cn mt s vc xin cha c a vo chng trnh d c
WHO khuyn co nh vc xin phng nga ph cu khun lin hp (pneumococcal), vi rt Rota
126

(Rotavirus), vim mng no (meningococcal) [88], v rubella [91] Theo iu tra nh gi cc
Mc tiu tr em v ph n nm 2014, qun l mt s bnh hay mc tr em cha hiu qu, nh
t l tr em b tiu chy c iu tr mt nc v tip tc cho n ch t 57,8%, t l tr em c
du hiu vim phi c chm sc ti c s y t ph hp l 81,1% v c iu tr khng sinh
ch t 88,2%. Theo kt qu iu tra nm 2011, nguy c tai nn chn thng tr em rt cao,
94% tr em di 5 tui b nh mt mnh hoc ch c mt tr khc di 10 tui chm
sc [84].
Mc tiu 5: Nng cao sc kho b m v tip cn ton dn vi CSSKSS vo nm 2015
Cc kt qu t c
T s t vong m Vit Nam gim hn 3 ln t 233/100000 tr sng vo nm
1990 xung cn 69/100000 tr sng vo nm 2009, nm gn y nht c s c tnh tn
cy c ca Vit Nam. n nm 2013, mt nghin cu so snh quc t c tnh t s t vong
m Vit Nam l 49/100000 tr sng, nhng khong khng chc chn dao ng t 29 n
84/100000 nn cha khng nh c chc chn rng Vit Nam t MDG lin quan t vong
m. Vi s liu c tnh ny, Vit Nam c xp th 34 trn th gii v thnh tch gim t
vong m [2]. Bo co cp nht tin thc hin cc Mc tiu Thin nin k v b m tr em
ca WHO (Countdown) nm 2014 cho thy Vit Nam gim c 4,4 trng hp t vong
m/100000 tr sng/nm trong giai on 1990-2013 v c xp th 13 trong s 75 nc
c mc gim gnh nng t vong m nhanh [92].
Ngoi vic gim t vong m, cng tc CSSKSS c rt nhiu tin b nh tng t l
khm thai t nht mt ln bi cn b y t (ln 95,8%), t l c bi cn b y t c chuyn
mn (93,8%) v t l sinh con ti c s y t (93,6%) theo kt qu iu tra nh gi cc mc tiu
tr em v ph n nm 2014 [84]. Mng li cung cp dch v CSSKSS ngy cng c m
rng. min ni, vng ng bo dn tc thiu s, ni c t l sn ph ti nh cao, cng vi
vic tuyn truyn vn ng, khuyn khch sn ph n ti c s y t, B Y t quan tm
trin khai cc loi hnh o to c thn bn bit v qun l thai v sch, an ton,
pht hin v chuyn tuyn kp thi cc trng hp nguy c cao nhm gim tai bin sn khoa,
gim t vong m.
Kh khn, hn ch
Mc d t vong m gim ng k trong giai on 1990-2009, nhng giai on 20062009, t s t vong m gim khng ng k. Do , hon thnh c Mc tiu vo nm
2015, Vit Nam cn phi n lc rt ln. T vong m tuy gim nhng vn cn c s chnh
lch kh ln gia cc khu vc, cc vng min (ti cc vng min ni ch s ny gp ti 3 ln so
vi vng ng bng).
Trnh mang thai ngoi mun l yu t quan trng gim t vong m. Cc ch s v
t l s dng bin php trnh thai, t l ph n c nhu cu KHHG khng c p ng v
t sut sinh v thnh nin l ba ch s nh gi tnh hnh ny. Hnh 34 cho thy vng Trung du
v min ni pha Bc c t sut sinh v thnh nin cao. Ti hai vng ngho nht (Ty Nguyn,
Trung du v min ni pha Bc), t l khng c p ng nhu cu KHHG cao hn v t l
s dng bin php trnh thai thp hn vng khc.
127
Phn trm
Hnh 34: Mt s ch s lin quan tip cn dch v KHHG theo vng, 2011
100
90
80
70
60
50
40
30
20
10
0
ng bng
sng Hng
S dng BPTT (%)
Trung du v Bc Trung B
min ni pha v duyn hi
Bc
min Trung
Ty Nguyn
T sut sinh v thnh nin ()
ng Nam B
ng bng
sng Cu Long
Cha p ng nhu cu KHHG (%)
Ngun: Tng cc Thng k. iu tra nh gi cc Mc tiu Tr em v Ph n 2011 (MICS).
Cc can thip gim t vong m bao gm mt gi khm thai c sng lc v qun l tng
huyt p bng thuc chng tin sn git, sng lc v iu tr thiu mu, t vn v cc du
hiu nguy him cn n c s y t ngay, cc can thip c th cung cp ti c s CSSKB c
cn b y t c o to y . Khi sinh, c mt s can thip hiu qu c th thc hin ngay
ti c s CSSKB bi cc cn b c chuyn mn nh iu tr sn git bng magnesium sulphat,
cp thuc tng trng lc t cung v qun l tch cc giai on III chuyn d d phng xut
huyt, qun l xut huyt hu sn, pht hin v iu tr nhim trng mu sau sinh. Mt s can
thip khc cn thc hin ti bnh vin nh khi pht chuyn d i vi ph n c ch nh, m
theo ch nh [88].
Hnh 35: T l ph n sinh con cha c p ng nhu cu khm thai, theo vng,
2011
70
Phn trm
60
50
40
30
20
10
0
ng bng
sng Hng
Trung du v Bc Trung B
min ni pha v duyn hi
Bc
min Trung
Ty Nguyn
ng Nam B
Khng c cn b y t c chuyn mn
Khng c cn b y t khm thai ln no
Khng c cn b y t khm thai 4 ln tr ln
Ngun: Tng cc Thng k. iu tra nh gi cc Mc tiu Tr em v Ph n 2011 (MICS).
128
ng bng
sng Cu
Long

Tnh hnh ti Vit Nam cho thy cn c nhm dn c cha tip cn vi cc can thip
cn thit bo m an ton khi sinh (Hnh 35). T l ph n sinh con khng i khm thai ch
5,4%, nhng cao hn nhiu ti Trung du v min ni pha Bc (16,2%), Ty Nguyn (11,2%),
nhm dn tc thiu s (24,9%), ph n ngho nht (19,9%) v nhm ph n cha hc ht
bc tiu hc (57%). Cht lng khm thai cha bo m cc dch v cn thit. Chung ton
quc, ch 42,5% ph n khm thai c o huyt p, xt nghim nc tiu v mu, cc bc
cn thit pht hin trng hp cn iu tr chng sn git, thiu mu. T l khm thai c ba
thnh phn ny ng Nam B rt cao (73,7%) nhng Trung du v min ni pha Bc ch
20,7% v Ty Nguyn ch 19,3%.
Tnh hnh v cc can thip trong giai on chuyn d v sinh con cng tng t nh vy.
D t l bi cn b c chuyn mn v t l ti c s y t rt cao, nhng c s khc
bit rt ln gia cc vng, min. Trong khi trn 99% ph n ng bng sng Hng v ng
bng sng Cu Long c bi cn b y t c chuyn mn, t l ny Trung du v min
ni pha Bc ch 78,3% v Ty Nguyn ch 79,7%. T l ny i vi ph n thiu s ch t
63,4%. T l ph n ti nh vn cn rt cao: 22% Trung du min ni pha Bc, 20,7%
Ty Nguyn v 38,3% vi ph n dn tc thiu s, so vi t l chung ton quc l 7,4%[84].
K c ph n c bi cn b c chuyn mn hoc ti c s y t, nhng nhiu c s y t, k c
n nguyn s sinh ti bnh vin huyn, vn thiu trang thit b, vt t, thuc hoc k nng cn
thit bo m can thip khi cn thit cu mng tr mi sinh.
Mc tiu 6: Phng chng HIV/AIDS, st rt v cc bnh dch khc
Chn ng v gim s ly nhim HIV/AIDS

Kt qu t c
S ca HIV/AIDS mi pht hin trong nhng nm gn y gim ng k so vi nm
2007, l nh dch HIV/AIDS ti Vit Nam. Nm 2007, c 30846 trng hp nhim HIV mi
pht hin, nm 2013, con s ny l 12559 trng hp, nh vy gim khong 60% so vi nm
2007. Cng trong thi k ny, s bnh nhn AIDS v s t vong lin quan n HIV/AIDS cng
gim khong 50%. Vit Nam vn gi c t l nhim HIV di 0,3% dn s, thp hn mc
tiu t ra trong k hoch hnh ng giai on 2004-2010. Cc nhm nguy c chnh lin quan
n HIV/AIDS Vit Nam l nghin chch ma ty, ph n bn dm v tnh dc ng gii
nam. Cc chng trnh can thip gim hi c trin khai rng ri, gm c pht bm kim tim
sch, pht bao cao su. Chng trnh iu tr thay th nghin cc cht dng thuc phin bng
methadon ang c nhanh chng m rng. Tnh n thng 10/2014, c 38/61 tnh, thnh ph
trin khai iu tr methadon, vi 122 c s, iu tr cho hn 22000 bnh nhn, mang li hiu
qu rt ln v sc khe, phng chng ly nhim HIV, cng nh gp phn vo n nh trt t, an
ninh v pht trin kinh t - x hi. iu tr ARV cng c trin khai rng ri, vi 318 phng
khm ngoi tr trn ton quc, iu tr cho gn 90000 bnh nhn HIV/AIDS, t 67,6%, v c
kh nng tt s t mc tiu l 70% vo nm 2015 [78].
Kh khn, hn ch
Vit Nam vn cn nhiu thch thc trong phng chng HIV/AIDS. D s ngi nhim
HIV mi c pht hin hng nm gim nhng vn cn kh cao. Hin nay, mi nm Vit
Nam vn pht hin c khong 12000-14000 ngi nhim HIV mi. Theo cc chuyn gia
tnh ton, nu mun khng ch c i dch HIV/AIDS, Vit Nam cn phi h s ngi nhim
129

HIV mi hng nm xung di 1000 ngi/nm [37]. Mc d s nhim mi hng nm gim,
nhng s ngi nhim HIV lu tch trn ton quc tip tc tng, c tnh n cui nm 2013
c nc c khong 256 000 ngi nhim HIV [77]. HIV/AIDS vn l mt gnh nng ln i
vi sc khe ngi dn, l nguyn nhn gy t vong sm ng hng th 3 v l nguyn nhn
gy gnh nng bnh tt tnh theo DALY ng hng th 6 [93]. i dch HIV/AIDS Vit Nam
vn ang giai on tp trung, ch yu mt s nhm c nguy c cao, nh: tim chch ma ty
(chim 32%), ph n mi dm v khch hng ca h (chim 31%), v nhng ngi c quan h
tnh dc thng xuyn vi cc nhm nguy c cao, nh nghin chch, tnh dc ng gii nam
(chim 24%), mc d mt s khu vc, t l hin mc t n mc dch [21].
Mc bao ph cc dch v phng chng HIV/AIDS cn hn ch. D t l c hiu bit
ton din v HIV/AIDS c tng nhm ph n 15-24 tui (25,% nm 2000 ln 51,1% nm
2011), nhng nam gii t l ny gim t 50,3% nm 2005 xung cn 44,1% nm 2009
[94]. Nm 2013, t l ph n mi dm tip cn vi chng trnh d phng HIV/AIDS l 51% v
nam quan h tnh dc ng gii l 42,3%. T l s dng bao cao su c tng ph n bn dm,
nhng i vi nam quan h tnh dc ng gii hu nh khng thay i v i vi ngi nghin
chch ma ty t l s dng bao cao su gim (Hnh 36) [78]. Tc tng s lng bnh nhn
tham gia iu tr methadon vn cn chm, so vi ch tiu t ra nm 2015 (80000 ngi c
iu tr) th hin nay ch t khong 27% [4].
Hnh 36: T l dng bao cao su trong ln quan h tnh dc nguy c cao gn y nht,
2009-2013
92%
100%
80%
66%
60%
41%
40%
20%
0%
PNMD
MSM
2009
2011
2012
NCMT
2013
Ch thch: Khng c s liu ca nm 2010. Ngun: UNGASS 2012, 2014 [78].
Dch v phng ly truyn HIV t m sang con ch p ng c 50% nhu cu. T l xt

nghim pht hin HIV ph n mang thai ch t 49,7% nm 2013 v t l ph n nhim HIV
mang thai c s dng thuc khng vi rt d phng tng t 49,1% nm 2010 ln 57% nm
2013 nhng vn cha p ng nhu cu [78]. Nm 2013, theo d bo tng s tr em t 0 n 14
tui nhim HIV l 5904 ngi [21]. Hin ti mi ch c 226 c s d phng ly truyn HIV t
m sang con, trong c 132 c s thuc tuyn huyn, chim 25% s huyn ton quc. iu
tr ARV c m rng, nhng cha p ng c nhu cu; t l bnh nhn iu tr mun
vn cn cao.
u t cho phng, chng HIV/AIDS t NSNN mc rt thp v ang gim nghim
trng. Khong 80% kinh ph cho phng chng HIV/AIDS l da vo vin tr nc ngoi.
130

Khong 95% kinh ph mua thuc ARV v 100% kinh ph mua thuc methadon l do cc t
chc quc t vin tr. Cc ngun vin tr cn h tr mua sm trang thit b, chi tr lng, ph
cp cho cn b, h tr cc kha o to chuyn mn... Hin nay, Vit Nam tr thnh nc
c mc thu nhp trung bnh thp, nhiu ngun vin tr cho phng chng HIV/AIDS ang b
ct gim nhanh v s ht vin tr vo nm 2016-2017. Nu khng c cc ngun NSNN v cc
ngun kinh ph khc b sung kp thi, Vit Nam kh c th t v duy tr c cc thnh qu
thc hin mc tiu pht trin Thin nin k v phng chng HIV/AIDS. Cc c s iu tr HIV/
AIDS cha p ng c cc iu kin ca Thng t s 09/2011/TT-BYT nn cha c php
thanh ton qua BHYT [95]. Trong bi cnh cc ngun vin tr cung cp dch v cho iu tr
HIV ang b ct gim th vic cung cp dch v qua h thng BHYT c xem xt nh l ngun
chnh nhm duy tr s bn vng ca cng tc iu tr HIV/AIDS.
Tnh trng phn bit, k th i x i vi ngi nhim HIV/AIDS vn cn cao v l ro
cn quan trng cho vic xt nghim pht hin HIV sm v chuyn gi n dch v chm sc
iu tr [78] cha c nhiu can thip lm gim k th v phn bit i x.
Chng trnh phng, chng HIV/AIDS ang thiu ht nghim trng i ng cn b ti tt
c cc tuyn. y l ro cn cho vic m rng chng trnh iu tr v cng tc can thip gim
tc hi. Nguyn nhn chnh do cng vic cng thng v vt v, trong khi thu nhp cn qu thp.
Chn ng v bt u gim s bnh nhn mc st rt
Kt qu t c
Chng trnh Phng chng st rt t c nhng thnh cng ln trong vic lm
gim mc v gim t vong do st rt. So vi nm 2000, s bnh nhn st rt nm 2012 gim
gn 77% v s t vong do st rt gim gn 94% (Hnh 37). Vit Nam t c mc tiu
quc gia l gim t l mc st rt di 40/100000 dn v t l t vong di 0,02/100000 dn.
T l mc v t l t vong do st rt Vit Nam tng i thp so vi nhiu nc ang pht
trin chu (xem thm Hnh 6). C kh nng tt Vit Nam s t mc tiu loi tr st rt
trc nm 2030.
S t vong
160
140
120
100
80
60
40
20
0
80
60
40
20
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
S t vong do st rt
T l mc
100
2000
S bnh nhn xc nhn

st rt (+) trn 100 000 dn
Hnh 37: Xu hng mc v t vong do st rt, 2000-2012
Ngun: S bnh nhn st rt (+) v s ca t vong do st rt - World Malaria Report 2013. Dn s - Tng cc Thng
k, Dn s trung bnh phn theo gii tnh v thnh th, nng thn.
131

Kh khn, hn ch
Vit Nam hin nay trong giai on kim sot st rt nhm duy tr bn vng nhng thnh
qu gim t l mc v t vong do st rt v tin ti loi tr bnh ny ton quc vo nm 2030.
D t l mc v t vong gim ng k, hng nm vn c gn 20000 ngi mc st rt v t
l mc hu nh khng gim t 2009 n 2012. Theo c tnh ca WHO, hin nay c 34 triu
ngi sng trong vng lu hnh st rt, trong 16 triu ngi sng trong vng c nguy c cao,
hu ht l vng rng ni, vng su vng xa, ngho. Hng nm, hn 3 triu lt ngi c
xt nghim do nghi st rt [7]. Di bin ng dn c vo vng st rt lu hnh v qua li bin
gii cn nhiu. Hiu qu phng chng st rt vng ng bo dn tc t ngi cn thp do mt
s tp qun sinh hot, lao ng (nh thng xuyn ng rng, ry khng s dng mn,). K
sinh trng st rt khng thuc c xu hng gia tng v c nguy c lan rng ra cc a phng
khc trn ton quc.
Cc hot ng chnh ngn chn st rt l kim sot vc t truyn bnh st rt v bo
v c nhn ch yu da vo vic s dng mn ng tm ha cht dit mui thng thng theo
khuyn co ca WHO. Kh khn ch yu l thiu kinh ph thc hin k hoch v chin lc
phng, chng st rt.
Khng ch bnh lao
Kt qu t c
Cng tc chng lao c trin khai rng khp ton quc. T l pht hin bnh nhn
lao trn tng s c tnh mc lao c tng ln qua cc nm t 29% nm 1990 ln 56% nm 2000,
v 76% nm 2012. T l iu tr khi bnh lao bnh nhn AFB (+) cng t t l cao, 92%
tr ln cc nm t 2000 n 2012. Nh hiu qu ca Chng trnh phng, chng lao, t l mc
lao cc th/100000 dn gim t 353 (nm 2000) xung cn 218/100000 vo nm 2012 theo
c tnh ca WHO [8]. Nh vy, nu tip tc n lc ln, c kh nng t c mc tiu gim
t l mc xung 187/100000 dn vo nm 2015.
Kh khn, hn ch
Tnh hnh dch t bnh lao c din bin phc tp v s bnh nhn cn cao, s bnh nhn
c pht hin bnh lao c xu hng tng nh trong giai on 2010-2013 (Hnh 20). Hin nay,
vi s ngi mc lao c tnh khong 200000 ngi, Vit Nam c WHO xp th 12 trong
22 nc c s bnh nhn lao cao nht v xp th 14 trong 27 nc c lao a khng cao nht th
gii. T l ln bnh nhn lao AFB m tnh v lao ngoi phi gy kh khn trong chn on bnh
(Hnh 38). S bnh nhn lao a khng thuc c xu hng tng, nm 2013 c tnh khong 3800
bnh nhn (khong 4% s ngi c xt nghim xc nhn mc bnh lao) gm c bnh nhn
mi v ti pht. Trong nhm bnh nhn ti pht, c tnh 23% mc bnh lao a khng thuc.
c tnh khong 9300 ngi nhim HIV cng mc bnh lao nhng hin nay ch c khong 66%
bnh nhn lao c xt nghim pht hin HIV [8].
Ngun lc thc hin Chng trnh phng, chng lao thiu nghim trng. Nm 2013
ngn sch c tnh 66 triu USD, trong 8% c NSNN cp kinh ph, 20% c vin tr
quc t cp kinh ph, cn li cha c ngun ti chnh [8]. Nhn lc mng li chng lao thiu
v thng xuyn thay i. Cc k thut mi trong phng chng lao ha hn hiu qu cao, nhng
cn t tin, cn u t kinh ph ln.
132

Hnh 38: C cu cc loi bnh nhn lao c pht hin, 2005-2013
110000
100000
S ca pht hin
90000
80000
70000
Ti pht
Khc
60000
50000
Lao ngoi phi
40000
AFB (-)
30000
20000
AFB (+)
10000
0
2005
2006
2007
2008
2009
2010
2011
2012
2013
Ngun: 2005-2012: WHO-tuberculous data v 2013: NTP tuberculous data.
Nc sch, v sinh, mi trng

Kt qu t c
Ti Vit Nam, theo kt qu iu tra Joint Monitoring Program for Water Supply and
Sanitation (JMP) do WHO, UNICEF phi hp vi Tng Cc Thng k tin hnh cho thy Vit
Nam t Mc tiu Thin nin k v lnh vc nc v v sinh t nm 2010. T l ngi dn
c tip cn nc sch nm 1990 l 62%, n nm 2012 tng ln 95%. T l ngi dn c
nh tiu hp v sinh l 37% nm 1990, tng ln 75% nm 2012. Gnh nng bnh tt do s dng
nc khng sch v h x khng hp v sinh ch yu do cc bnh tiu chy. Nm 1990, nhm
bnh tiu chy ng th 6 trong cc bnh gy gnh nng bnh tt Vit Nam, nhng n nm
2010 cc bnh tiu chy khng cn trong 25 nhm bnh gy gnh nng bnh tt quan trng
nht [93].
Kh khn, hn ch
D tin b r rt trong t l ngi dn tip cn nc sch v v sinh mi trng, nhng
vn c s chnh lch ln gia cc vng a l, cc nhm dn tc v gia thnh th vi nng
thn. Tin trnh bao ph nh tiu hp v sinh c nh gi rt tch cc, vt mc tiu ra,
nhng t l ny vn cn thp khu vc nng thn (Hnh 39). nng thn vn cn 3% dn s
khng c h x v 26% c h x khng hp v sinh. Tip tc ci thin tnh hnh v sinh nng
thn l mc tiu i hi s phi hp lin ngnh cao, gm c B Xy dng (qun l cp nc
v v sinh th), B NNPTNT (qun l cp nc nng thn), B Ti nguyn v Mi trng
(qun l ti nguyn nc v bo v ngun nc) v B Y t (ban hnh cc tiu chun v sinh
nc n ung, sinh hot, nh tiu hp v sinh).
133
Phn trm
Hnh 39: C cu loi h x khu vc nng thn, 2000-2012

100
90
80
70
60
50
40
30
20
10
0
2000
H x c ci thin
2005
H x khc cha c ci thin
2010
2012
H x dng chung vi h khc
Khng c h x
Ngun: WHO and UNICEF, Progress on Drinking-water and sanitation, 2014 Update.
Kt lun
Nhng phn tch nu trn cho thy sau hn 20 nm thc hin Mc tiu thin nin k,
vi nhng cam kt v n lc mnh m ca Chnh ph cng cch tip cn ph hp, Vit Nam
c cng ng quc t ghi nhn l mt trong nhng quc gia i u trong vic thc hin cc
Mc tiu Thin nin k trong lnh vc y t. Trong s 74 nc trn th gii, Vit Nam l 1 trong
3 nc c tc gim t vong m cao [92]. Tuy nhin, vic thc hin cc Mc tiu Thin nin
k trong lnh vc y t cn nhiu kh khn, hn ch, l:
Thi gian thc hin cc mc tiu cam kt khng cn nhiu, trong khi nhiu mc
tiu cn phi c n lc ln mi c th t c. Mc tiu gim t vong m kh c kh
nng t c nu khng c n lc ln. Mc tiu phng chng HIV/AIDS c kh nng
khng t c nu khng c s n lc vo cuc ca ton h thng chnh tr v u t
tha ng. Mc tiu ph cp dch v CSSKSS cng kh hon thnh v tnh trng khng
khm thai nh k, ti nh khng c cn b y t h tr cc vng kh khn vn
cn ph bin. Mc tiu v phng chng st rt, lao v cc bnh khc cn tip tc n lc
c th t c mc tiu vo nm 2015. Ngoi ra, xut hin mt s vn cn gii
quyt nh tnh trng tha cn, bo ph, suy dinh dng th thp ci, lao khng thuc,
ng nhim lao v HIV, cc bnh dch mi ni khc.
C s khc bit ln gia cc vng, min, gia cc nhm dn c v s khc bit ny c
xu hng gia tng. T s t vong m, t vong tr em mt s khu vc min ni cao gp
3-4 ln so vi khu vc ng bng, th v gp gn 2 ln so vi mc trung bnh ton
quc. T l suy dinh dng th nh cn tr em chung ton quc hon thnh trc
thi hn, nhng vn cn cao vng Ty Bc, Ty Nguyn. Mt s ch tiu gim kh
thp nn tc gim trong nhng nm gn y chm li r rt, cn phi c n lc rt ln
mi c th t c mc tiu ra vo nm 2015.
u t cho cc Mc tiu thin nin k v y t cha tha ng. Nhiu chng trnh, d n
thc hin mc tiu pht trin Thin nin k v y t ch yu s dng ngun vin tr nc
ngoi. Trn 70% kinh ph ca Chng trnh phng chng HIV/AIDS v 97% lng
134

thuc ARV ang iu tr cho ngi nhim HIV hin nay l do cc t chc quc t vin
tr. Hin nay, Vit Nam tr thnh nc c mc thu nhp trung bnh thp, v vy, nhiu
ngun vin tr cho cc chng trnh, d n ang b ct gim nhanh. Nu khng c ngun
NSNN v cc ngun kinh ph khc b sung kp thi, Vit Nam kh c th t v duy tr
c cc thnh qu thc hin mc tiu pht trin Thin nin k v y t.
S quan tm lnh o, ch o ca cc cp y ng, chnh quyn i vi thc hin Mc
tiu Thin nin k v y t cn cha cao; nhn thc ca ngi dn, s tham gia ca cc t
chc, on th x hi cn hn ch, ch yu l do ngnh y t trin khai l chnh.
Nng lc cung cp v mc bao ph dch v y t cn hn ch; y t c s cn rt nhiu
kh khn, thiu cn b, c s vt cht xung cp, trang thit b y t ngho nn, lc hu,
nht l min ni, vng su, vng xa, vng ng bo dn tc thiu s.
H thng thng tin bo co cn nhiu hn ch, s liu thu thp cha phn nh ng thc
t v tnh hnh t vong tr em, c bit khng c s liu v t vong s sinh, chu sinh,
cha bo m tnh kp thi, cha p ng c yu cu ca cng tc hoch nh chnh
sch cng nh xy dng k hoch can thip.
khc phc cc kh khn, hn ch nu trn, to s thm sc bt Vit Nam thc hin
thnh cng cc Mc tiu Pht trin Thin nin k ca Lin Hp Quc trong lnh vc y t vo
nm 2015, ng thi duy tr bn vng v tip tc pht huy cc kt qu t c sau nm 2015,
Chnh ph ban hnh Ngh quyt s 05/NQ-CP v vic y mnh thc hin cc Mc tiu pht
trin Thin nin k ca Lin Hp Quc trong lnh vc y t, trong ra 6 nhm gii php l:
Nng cao nhn thc, tng cng lnh o, ch o ca cp y ng, chnh quyn cc cp
v thc hin cc Mc tiu thin nin k trong lnh vc y t;
Tng cng huy ng cc ngun ti chnh thc hin cc Mc tiu Thin nin k v
y t;
Cng c, nng cao nng lc h thng y t, c bit l y t c s, y t min ni, vng su,
vng xa;
Trin khai tt cc cc gii php chuyn mn k thut t c cc Mc tiu Thin
nin k v y t;
Tng cng hp tc quc t;
Tng cng phi hp lin ngnh, tng cng s tham gia ca cc on th, qun chng
v ngi dn vo thc hin cc Mc tiu Thin nin k v y t.
Ngh quyt ch r trch nhim ca B Y t, cc b ngnh lin quan, UBND cc tnh,
thnh ph trc thuc trung ng, Mt trn T quc Vit Nam. Thi gian cn li thc hin cc
Mc tiu Thin nin k khng cn di, v vy cn c n lc ln ca B Y t vi vai tr hng
dn chuyn mn k thut v n lc ca tng a phng trong vic thc hin cc gii php, can
thip c th.
135
PHN HAI: TNG CNG D PHNG V KIM SOT

BNH KHNG LY NHIM
136
Phn 2: Tng cng d phng v kim sot bnh khng ly nhim
Gii thiu
Phn chuyn ca Bo co JAHR nm 2014 tp trung phn tch v tnh hnh phng,
chng BKLN nhm ng gp vo xy dng chnh sch v k hoch p ng vi nhm bnh gy
gnh nng bnh tt rt ln cha c quan tm ng mc trong nc v quc t. Khung phn
tch bo co c trnh by trong Hnh 40.
Hnh 40: Khung phn tch chuyn bnh khng ly nhim trong bo co JAHR 2014
Tng quan phng chng bnh khng ly nhim trn
th gii v trong khu vc; Din bin dch t hc v
gnh nng BKLN Vit Nam (Chng III)
Kim sot cc yu t nguy c

chung ca cc bnh khng ly
nhim (Chng IV)
Tnh hnh thc hin cc chng

trnh, d n phng chng BKLN
(Chng V)
Kim sot cc yu t
nguy c ti Vit Nam
Tng cng p ng ca h
thng y t trong phng chng
BKLN (Chng VI)
p ng ca h
thng y t trong
phng, chng
BKLN
Khuyn ngh nhm tng cng p ng ca

Vit Nam i vi bnh khng ly nhim
Trn c s tham kho bng chng v khuyn ngh quc t, xem xt tnh hnh Vit
Nam v bnh khng ly nhim, p ng ca h thng y t vi bnh khng ly nhim, c bit
l p ng ca cc chng trnh mc tiu quc gia phng, chng bnh khng ly nhim, bo
co chuyn s a ra cc khuyn ngh tng cng p ng quc gia. Trong , Chng
III s phn tch v tnh hnh bnh khng ly nhim trn th gii v cc khuyn ngh quc t
p ng vi bnh khng ly nhim, ng thi cung cp thng tin v din bin dch t v bnh
khng ly nhim Vit Nam. Chng IV s cp ti p ng ca Vit Nam i vi cc yu t
nguy c cn phng, chng gim gnh nng bnh tt do 4 bnh khng ly nhim chnh (bnh
tim mch, bnh ung th, bnh i tho ng v bnh ng h hp mn tnh). Chng V
cp ti cc D n lin quan bnh khng ly nhim trong Chng trnh mc tiu y t quc gia.
Chng VI kt thc bng phn tch p ng ca h thng y t vi bnh khng ly nhim theo
6 thnh phn c bn.
137
Chng III: Tng quan v phng, chng BKLN trn th gii

v Vit Nam
1. Phng chng BKLN trn th gii v khu vc Ty Thi Bnh Dng
1.1. Khi nim v bnh khng ly nhim v sc khe tm thn
BKLN l bnh khng truyn t ngi ny sang ngi khc hoc t ng vt sang ngi.
Hu ht BKLN l bnh mn tnh, kh cha khi. Phn ln BKLN c chung 4 yu t nguy c
l thuc l, ru, bia, t hot ng th lc v ch n khng hp l. Trong nhm bnh ny, c
mt s bnh c pht hin c phn nguyn nhn truyn nhim nhng bn thn bnh khng ly
nhim (nh mt s loi ung th).
C nhiu loi BKLN khc nhau, tuy nhin hin nay nhiu chnh sch ca Lin Hp Quc
(UN), WHO tp trung vo 4 nhm bnh chnh, gm bnh tim mch (tng huyt p, t qu, suy
tim, bnh mch vnh,), i tho ng (ch yu l tp 2), ung th, bnh ng h hp mn
tnh (bnh phi tc nghn mn tnh v hen suyn), do nhng BKLN ny ngoi vic c t l mc
ln v l nguyn nhn ch yu gy tn tt v t vong ngi trng thnh, chng cn c chung
cc yu t nguy c (cc yu t gp phn lm bnh pht trin) [96].
Nm 2003, WHO a ra khi nim sc khe tm thn: l trng thi khe mnh
ca mi c nhn h nhn bit c cc kh nng ca bn thn, c th ng u vi nhng
cng thng thng thng trong cuc sng, c th hc tp v lm vic mt cch hiu qu v c
th tham gia, gp phn vo cc hot ng ca cng ng [97]. Bnh tm thn l cc chng
bnh ca b no, c th lm mt kh nng suy ngh, cm xc, tng tc vi nhng ngi khc
v thc hin cc chc nng hng ngy ca ngi bnh. Bnh tm thn thng bao gm trm
cm, tm thn phn lit, ri lon lng cc, ri lon cng thng sau sang chn, lo u[98].
Trong bo co ny, bnh tm thn c quan nim l mt loi BKLN.
1.2. Gnh nng bnh tt ca BKLN
Cc BKLN l thch thc ca ton cu v ang l gnh nng rt ln i vi x hi v h
thng y t. Hin nay, cc BKLN thng b hiu nhm ch l vn sc khe ca cc nc c
thu nhp cao. Trong khi , gnh nng ca cc bnh ny cc nc c thu nhp thp v trung
bnh, thm ch cn cao hn so vi cc nc c thu nhp cao [99].
T vong do cc BKLN lun chim t l cao v c xu hng tng ln hu ht cc quc
gia trn th gii. Theo Nghin cu gnh nng bnh tt ton cu 2010, trong tng s 52,7 triu ca
t vong nm 2010, c 65,5% l do cc BKLN. Nh vy, t l ny tng 30% so vi nm 1990,
ch yu do tng trng dn s v gi ha dn s [100]. Nm trong 10 nguyn nhn t vong
chnh ton cu l BKLN, d ch 3 trong 10 nguyn nhn t vong sm (t vong sm c o
bng YLL) l do BKLN (bnh tim mch, nhi mu c tim v i tho ng) [101]. iu ng
bo ng l cc ca t vong do cc BKLN cc nc ang pht trin xy ra nhm tui tr hn.
Theo WHO, nm 2011 c tnh cc nc c thu nhp cao, t l t vong do BKLN i vi
ngi di 70 tui khong 26%, trong khi cc nc thu nhp thp v trung bnh ti ng Nam
l 56% v Ty Thi Bnh Dng l 40% [102]. Tui trung bnh ca nhng ngi b cn au
tim ln u tin Nam l 53 tui, thp hn 6 tui so vi tui trung bnh trn ton cu [103].
138
Chng III: Tng quan v phng chng BKLN trn th gii v Vit Nam
T l t vong theo loi BKLN v t sut t vong do BKLN dao ng gia cc vng. T
vong do bnh tim mch chim t l cao nht so vi tng s ca t vong lin quan BKLN ti cc
nc thu nhp cao (39%), thu nhp thp v trung bnh ti ng Nam (43%) v Ty Thi Bnh
Dng (50%). Ung th l BKLN gy t vong ng th hai cc nc thu nhp cao (31%) v
Ty Thi Bnh Dng (26%), nhng ng th 3 ti ng Nam (15%). Trong khi cc bnh
tm thn ng th 3 ti cc nc thu nhp cao, chng ch chim t l thp (1%-3%) ti cc nc
thu nhp thp v trung bnh ti chu . Ngc li, cc bnh h hp mn tnh ch chim 7% tng
s t vong do BKLN ti cc nc thu nhp cao, nhng 13% ti cc nc thu nhp thp v trung
bnh ti Ty Thi Bnh Dng v 18% ti ng Nam [102].
D bo ca WHO cho thy trn ton cu t l t vong do BKLN s tng 15% trong
khong thi gian t 2010-2020 (s l khong 44 triu ca t vong) [104]. T l tng cao nht
(khong 20%) l khu vc chu Phi, ng Nam , ng u. Khu vc c s ca t vong do
BKLN cao nht vo nm 2020 l ng Nam (10,4 triu ca) v Ty Thi Bnh Dng (12,3
triu ca) [105]. Vo nm 2030, s ca t vong do cc BKLN cc nc c thu nhp thp s cao
hn 8 ln so vi cc nc c thu nhp cao [106].
Bn cnh cc thng tin v t l t vong do cc BKLN, cc s liu v t l mc bnh cng
rt quan trng trong cng tc qun l h thng CSSK v cng tc lp k hoch, nh gi vic
cung cp dch v y t. Tuy nhin, hin nay nhiu quc gia khng c cc s liu tin cy v t l
mc cc BKLN. S liu v t l mc ton din nht hin c l ca cc bnh ung th qua h thng
ghi nhn ti cng ng hoc bnh vin.
T l mc v cht do ung th c d bo s ngy cng tng ln trong vi thp k ti
tt c cc khu vc trn th gii, nhng tng nhanh hn cc nc c thu nhp thp [107]. Vi
nhng thay i d bo v dn s hc trong 2 thp k ti th d t l mc ung th trn ton cu
khng thay i, t l mi mc cc bnh ung th c tnh 12,7 triu ca (c t l mc l 189,6
trn 100000 ngi) vo nm 2008 s tng ln thnh 17 triu ca vo nm 2020 v 21,4 triu ca
vo nm 2030. Trong , gn 2/3 s ca ung th l cc nc thu nhp thp v trung bnh. WHO
c tnh so vi nm 2008 vo nm 2030 t l tng cc ca mi mc ung th l khong 82% cc
nc c thu nhp thp, 70% cc nc c thu nhp trung bnh thp v 58% cc nc c thu
nhp trung bnh cao, v 40% cc nc c thu nhp cao [108].
T l hin mc bnh i tho ng trn ton cu vo nm 2008 c tnh l 10% ngi
trng thnh trn 25 tui. T l ny cao nht khu vc ng a Trung Hi v chu M (11%)
v thp nht khu vc chu u v Ty Thi Bnh Dng (9%) [107], [108]. Quy m ca vn
cn ln hn na nu tnh c cc trng hp tin i tho ng, l nhm c nguy c cao ca
i tho ng tp 2 v cng c th gy nn cc bin chng vi mch nh bnh vng mc, bnh
thn. T l mc i tho ng tng i u trong cc nhm quc gia phn theo thu nhp d
cc nc thu nhp thp c t l mc thp nht (8%) v cc nc thu nhp trung bnh cao c t
l cao nht (10%) [108].
Theo bo co gnh nng bnh tt ton cu nm 2010, gnh nng do t vong v tn tt
do cc BKLN tng ln ng k vo nm 2010 so vi nm 1990 hu ht cc khu vc trn
th gii. nhiu quc gia, cc BKLN chim t l ln trong tng s gnh nng bnh c o
bng DALYs. BKLN chim ti 54% tng gnh nng bnh tt ton cu vo nm 2010 trong khi
nhm chim th 2 trong gnh nng bnh tt ton cu, gm cc bnh truyn nhim cc vn
v b m, s sinh v dinh dng ch l 35%. M hnh gnh nng bnh tt nm 2012 cng
139

tng t nh vy vi bnh khng ly nhim chim ti 55,1%, bnh truyn nhim v cc vn
v b m, s sinh v dinh dng ch chim 33,7%, cn li l do ti nn thng tch (11,1%)
[109]. So vi nm 1990, cc bnh truyn nhim gy ra gnh nng bnh tt ln nht, chim 47%,
v gnh nng do BKLN ch chim 43% [110]. hu ht cc quc gia (tr cc nc khu vc
Tiu Sahara), cc BKLN gy ra t nht 50% trong tng s nm sng khe mnh b mt. Con s
ny cao ti trn 80% c, Nht v cc nc giu Ty u v Bc M [101]. Theo c tnh, t
trng DALY gy ra do cc BKLN cc nc thu nhp thp v trung bnh s tng t 33% nm
2002 ln khong 45% vo nm 2030 [111].
1.3. Cc yu t nguy c chung ca BKLN v cc yu t nh hng n sc khe
tm thn
Bn nhm BKLN chnh cng c chung bn nhm yu t nguy c v hnh vi, l ht
thuc l, s dng ru bia mc c hi, ch n khng hp l v thiu hot ng th lc
(Bng 16). c bit cc yu t nguy c ny c xu hng ngy cng tng cc nc ang pht
trin. Theo Ngn hng th gii, nu ch da vo cc gii php iu tr ng ph vi cc BKLN
th ht sc tn km, v hn mt na gnh nng ca cc BKLN c th phng trnh c thng
qua cc sng kin phng v nng cao sc khe. V vy tp trung vo u t sm cho cc hot
ng d phng cc yu t nguy c, c bit trong nhm ngi tr tui l rt quan trng [112].
Bng 16: Cc yu t nguy c chung ca bn BKLN
Bnh
Ht thuc
l
S dng
ru, bia
mc c hi
Ch n
khng hp l
Thiu hot
ng th lc
Tim mch, tng huyt p

i tho ng
Ung th
Ngun: Combatting NCDs: Protecting health, promoting development (WHO, 2011)
C nhiu yu t nh hng n sc khe tm thn, trong nhng yu t tch cc, tc

ng lm gim nh cc nh hng tiu cc, tng cng sc khe tm thn, c gi l yu t
bo v. Bn cnh , nhng yu t c tc ng tiu cc, lm tng kh nng xut hin cc vn
sc khe tm thn, c gi l yu t nguy c. Vic xc nh r cc yu t ny gip chng ta
xy dng gii php can thip thch hp ci thin sc khe tm thn. Theo WHO, cc yu t
nguy c v bo v i vi sc khe tm thn khng ch l cc thuc tnh v hnh vi ca mi c
nhn m cn l nhng yu t v tnh trng/hon cnh kinh t, x hi v cc yu t thuc v mi
trng (Bng 17). iu quan trng cn nhn mnh l cc yu t ny tng tc qua li vi nhau
v c th tc ng tch cc hoc tiu cc ti tnh trng sc khe tm thn ca mi c nhn [113].
140
Bng 17: Cc yu t nh hng n sc khe tm thn
Cp
Yu t nguy c
Yu t bo v
Cc c im
c nhn
Ngh lc, t trng thp

Non km v nhn thc/tnh cm
Kh khn trong giao tip
Cc chng bnh tm thn v lm
dng cht gy nghin
T trng, t tin
Kh nng gii quyt cc vn v ng ph
vi cng thng
K nng giao tip
Sc khe th cht
Thc trng/
hon cnh
kinh t-x hi
S c n, au kh
B b ri, mu thun gia nh
Tri nghim bo lc/b lm dng
Thu nhp thp, ngho i
Hc km
Cng vic qu cng thng hoc tht
nghip
H tr ca gia nh v bn b
Nui dy v tng tc tt ca cha/m
Bo m an ton khng b xm hi thn th
Kinh t c bo m
Hc tp tt
Hi lng v thnh cng trong cng vic
Cc yu t
mi trng
Kh khn hoc khng c tip cn

cc dch v x hi c bn
K th, phn bit i x
Bt bnh ng x hi v gii
Tri nghim chin tranh hoc thm
ha
Cng bng trong tip cn cc dch v x

hi c bn
Cng bng, chia s ca x hi
Bnh ng gii
Mi trng sng c bo m v an ninh
v an ton
Ngun: WHO, 2012 [113].
Cc bnh tm thn nh hng ti v b nh hng bi cc BKLN khc. Bnh tm thn

c th dn n hoc l hu qu ca cc BKLN [114] hoc l kt qu ca s tng tc ca cc
nh hng ny. V d, c cc bng chng cho thy trm cm lm cho bnh nhn c th b nhi
mu c tim v ngc li nhi mu c tim lm tng nguy c b trm cm. ng thi cc yu t
nguy c ca cc BKLN nh hnh vi t vn ng th lc v s dng ru, bia mc c hi cng
c lin quan vi bnh tm thn. Cc vn v mi trng x hi nh ngho i, tht nghip
u l cc yu t nguy c ca c cc BKLN v bnh tm thn [115].
Xu hng chung v cc yu t nguy c
Cc yu t nguy c chung ca BKLN c th coi l nguyn nhn t vong v tn tt hu
ht cc quc gia cc mc pht trin khc nhau. Yu t nguy c t vong cao nht ton cu l
tng huyt p (khong 13% tng s t vong ton cu), tip theo l ht thuc (9%), ng huyt
cao (6%), thiu hot ng th lc (6%) v tha cn/bo ph (5%) [109].
T l mc cc yu t nguy c ny khc nhau gia cc nhm quc gia. cc nc thu
nhp trung bnh, cc yu t nguy c ph bin nht l ht thuc l nam gii v tha cn, bo
ph. T l thiu hot ng th lc tng theo thu nhp quc gia. T l tng huyt p tng i cao
cc nhm quc gia khc nhau (40%), cc quc gia thu nhp cao c t l mc 35%. Xu hng
chung cho thy t l mc tng huyt p khng gim trong 3 thp k qua, nhng m hnh dao
ng khc nhau theo tng nhm quc gia. cc quc gia thu nhp thp v trung bnh thp, s
gia tng t l tha cn, bo ph trong 3 thp k qua cao hn s gia tng cc nc thu nhp cao
v trung bnh cao. cc nc thu nhp trung bnh thp, t l bo ph tng gp i gia nm
1980 v 2008 (t 3% ln 6%) trong khi t l tha cn cng tng nhanh t 15% ln 24% [113].
141

T l ht thuc cc nc thu nhp trung bnh cao hn cc nc thu nhp thp v thu
nhp cao, v tt c cc nhm quc gia t l ht nam gii cao hn n gii. T l ht thuc
cao nht l 39% trong nhm nam gii cc nc thu nhp trung bnh thp, tip theo l 35%
trong nam gii cc nc thu nhp trung bnh cao. i vi n, t l ht thuc cao nht l cc
nc thu nhp cao v trung bnh cao (khong 15%) v thp hn nhiu cc nc thu nhp thp
v trung bnh thp (2%-4%) [116].
1.4. Mi quan h gia tnh hnh kinh t - x hi v cc BKLN
iu kin kinh t- x hi nh hng trc tip hoc qua cc yu t trung gian lm tng
nguy c mc cc BKLN v bnh tm thn. Cc yu t nguy c, cc BKLN, vn sc khe
tm thn v cc tc ng ca chng ti sc khe, kinh t li cn tr vic t cc mc tiu thin
nin k v ng thi tc ng ti pht trin kinh t x hi nh c trnh by trong Hnh 41.
Hnh 41: Mi quan h gia i ngho, BKLN v cc mc tiu pht trin
Cc yu t nguy c chung
Ht thuc l
Ch n nhiu m, mui v ng
t hot ng th lc
S dng ru, bia qu mc
Cc yu t kinh t x hi

i ngho
iu kin lm vic
Gio dc
Hip nh thng mi
Chnh sch nng nghip
v giao thng
Dng vn quc t
Hot ng cng ty a
quc gia
BKLN
Cn tr
MDG
Cc mc tiu pht trin

Bnh tim mch

Tai bin mch mu no
Ung th
i tho ng
Bnh ng h hp
mn tnh
Ri lon tm thn
Tc ng ti sc khe
T vong sm v khuyt tt
Tc ng ti h gia nh
Nng sut thp
Chi tiu cho dch v y t
Tc ng kinh t v m
Gim tng trng kinh t
Cn tr
MDG

MDG 1: Gim ngho

MDG 4: Sc kho tr em
MDG 5: Sc khe b m
MDG 6: HIV/AIDS, bnh
lao, bnh st rt
Cn tr
MDG
Ngun: Beaglehole R., Bonita R, Horton R, et al. Priority actions for the non-communicable disease crisis in The
Lancet, April 6,2011. DOI:10.1016/S0140-6736(11)60393-0 [117].
V vy, cc BKLN l vn ca s pht trin cc quc gia ch khng phi ch l vn

ca y t. Chnh v th m i Hi ng Lin Hp Quc quyt nh tho lun v cc BKLN
trong cuc hp r sot cc mc tiu thin nin k nm 2010. Cc BKLN e da tin trnh
t c cc kt qu pht trin, c bit l cc mc tiu thin nin k s 4, 5, 6 v 8 (Bng 18)
[100].
142
Bng 18: nh hng ca BKLN n cc mc tiu thin nin k
MDGs
Lin quan vi cc BKLN
1. Trit loi tr tnh

trng bn cng (ngho
cng cc) v thiu n
Chi ph tin ti cho y t v mt kh nng lao ng do cc BKLN lm

trm trng thm s ngho i.
Chi tiu ca h gia nh cho cc hnh vi nguy c ca cc BKLN nh
thuc l, ru, bia cng lm gim tin chi cho thc phm, nh
2. Hon thnh ph cp
gio dc tiu hc
Gnh nng ca cc BKLN c th l l do lm cho cc h gia nh

ngho khng c kh nng cho con n trng.
3. Nng cao bnh ng

gii v v th, nng lc
ca ph n
Ph n thng l ngi phi hy sinh cng vic v hc tp chm

sc cho cc thnh vin gia nh b m au.
Ph n cng l ngi gnh chu kh khn trong vic thng thuyt
c c mi trng khng khi thuc cho h v con ci ca h.
Ph n l nhm gnh chu mt s BKLN nht nh nh ung th v, c
t cung, bung trng.
4. Gim t l t vong
tr em
5. Ci thin sc khe
b m
Mt na s ca t vong lin quan n ht thuc l th ng hng nm

l ph n v mt phn t l tr em di 5 tui. Ph n mang thai v
bo thai gnh chu nguy c ca ht thuc l th ng.
Qu cn v bo ph ph n lm tng nguy c i tho ng
thai nghn gy nguy c n sc khe ca c m v con trong thi
k mang thai v khi sinh. a tr sinh ra cng c nguy c mc tiu
ng tp 2 v bnh tim mch cao hn khi trng thnh.
6. Phng chng HIV/AIDS,

st rt v cc bnh dch
khc
i tho ng lm tng nguy c ca bnh lao do gim sc

khng.
iu tr ARV c th tng nguy c mc bnh tim mch do lm thay i
mc cholesteron, chuyn ha.
1/5 s ca t vong do lao c lin quan n ht thuc v ht thuc cng
lm gim sc khe ca ngi c HIV bao gm cc bnh v phi v
cc chng tm thn lin quan n AIDS.
7. Bo m s bn vng
ca mi trng
S dng thuc tr su v ph rng do trng thuc l lm nh hng

nghim trng ti mi trng.
8. Tng cng quan h

i tc ton cu cho pht
trin
Chng trnh ngh s chnh tr ton cu nhn r mc v phm vi

ca cc thch thc ca cc BKLN cng nh s cn thit ca vic ng
ph a ngnh.
Nhiu bn lin quan bao gm cc chnh ph, x hi dn s, khu vc
t nhn v cc qu t thin ang sn sng hnh ng phng
chng cc BKLN.
Chng li cc BKLN i hi vic tip cn cc thuc thit yu vi gi c
c th chi tr c, c bit cc nc ang pht trin.
Ngun: UNDP, 2013 [99].
Gnh nng kinh t

Chi ph cho cc BKLN l rt ln v tip tc tng ln cc nc c thu nhp thp v
trung bnh v to gnh nng ln ln kinh t v m. Ch tnh ring mt trong cc yu t nguy c
quan trng ca BKLN, l ht thuc l, ly i mng sng ca 6 triu ngi hng nm v
chim 1-2% tng sn phm ton cu mi nm [118]. Theo d bo trong vng 20 nm ti, bn
nhm BKLN chnh (tim mch, ung th, i tho ng, h hp mn tnh) v cc bnh tm thn
s ly i ca nn kinh t ton cu khong 47 nghn t USD. i vi cc quc gia c thu nhp
143

thp v trung bnh, chi ph kinh t cho 4 nhm bnh chnh trong cc BKLN c tnh vt 7
nghn t USD trong khong thi gian t 2011-2025 [99]. Bn nhm BKLN chnh v cc bnh
tm thn s ly i ca cc nc ang pht trin khong 21 nghn t USD trong vng 2 thp k
ti [119].Nghin cu ca Ngn hng Th gii vo nm 2011 cho thy cc bnh mn tnh
lm gim 1/5 kh nng cung cp lc lng lao ng ca Ai Cp. Hu qu l GDP gim khong
12% so vi tim nng m t nc ny c th t c [120].
Cc BKLN cng to gnh nng rt ln ln h thng y t, chim khong 75% chi tiu cho
CSSK ton cu v con s ny s tip tc tng ln [121]. Vo nm 2011, ch ring bnh i tho
ng ly i ca h thng y t t nht l 465 t USD hay 11% tng chi tiu CSSK ton cu.
Ti nm 2030, con s ny c tnh l hn 595 t USD[122]. Con s v chi ph ca h thng y
t cc nc c thu nhp thp v trung bnh l tng i him, ch yu l do hn ch ca h
thng gim st cc BKLN. Nm 2007, khu vc cng ca Thi Lan chi 21% tng chi ph cho
iu tr ni tr cho bn nhm BKLN chnh v cc bnh tm thn [123]. Mt nghin cu gn y
ca trng i hc Harvard, M c tnh tng chi phi cho 5 nhm bnh (tim mch, ung th, h
hp mn tnh, i tho ng v tm thn) trong giai on 2012-2030 ca Trung Quc l 27,8
t USD v ca n l 6,2 t USD (theo gi USD nm 2010). Vi c hai quc gia chi ph cao
nht l cho cc bnh tim mch, sau l tm thn v tip theo l bnh h hp mn tnh (Hnh
42) [124]. Theo c tnh, chi ph cc khu vc c thu nhp thp s tip tc tng nhanh v trong
mt s trng hp vt c chi ph cc quc gia c thu nhp cao[119].
Hnh 42: T l chi ph ca cc bnh trong tng chi ph cho 5 BKLN ca Trung Quc
v n
n
Trung Quc
2%
2%
i tho ng
34%
30%
Bnh tim mch
37%
37%
Bnh phi mn tnh

Ung th
14%
21%
Ri lon tm thn
5%
19%
i vi tt c cc quc gia, gi phi tr nu chng ta khng hnh ng s ln hn rt

nhiu so vi chi ph cho hnh ng phng chng BKLN nh c khuyn ngh trong K hoch
hnh ng ca WHO. C nhiu can thip phng, chng BKLN c th to ra thm mt nm sng
khe mnh m chi ph thc hin di mc GDP bnh qun u ngi v nh vy quc gia no
cng chi tr dc. Tng chi ph thc hin mt gi cc can thip hiu qu-chi ph cp ton
dn v cp c nhn, so vi chi ph y t hin nay, tng ng khong 2% ti cc quc gia c
mc thu nhp trung bnh thp v di 1% cc quc gia c thu nhp cao hoc trung bnh cao.
Nu khng thc hin cc hnh ng phng, chng BKLN, c nguy c gim nng sut v gia
tng nhanh cc chi ph y t. Hin nay c tnh tng thit hi do 4 BKLN chnh v cc ri lon
tm thn tng ng 47 nghn t USD [125].
144
1.5. Tng quan mt s chnh sch ton cu v khu vc v phng chng BKLN
ng ph vi mc nh hng ngy cng tng ca cc BKLN quy m ton cu,
cc t chc quc t (nh Lin Hp Quc, WHO,) ban hnh nhiu vn bn chnh sch, c
th c tm tt trong Hnh 43 di y. ng lu l cc vn bn ny u nhn mnh tm
quan trng ca vic kim sot cc yu t nguy c v thc y cch sng lnh mnh.
Hnh 43: Mt s chnh sch ton cu v cc BKLN t nm 2000 n nay
2000
2001
2003
2004
2007
2008
2009
2010
Chin lc ton cu v phng chng v kim sot cc bnh khng ly nhim 2000.
Bo co Y t th gii 2001 v sc khe tm thn.
Cng c Khung v kim sot thuc l.
Chin lc ton cu v ch n ung, hot ng th lc v sc kho.
Ngh quyt v Phng chng BKLN: thc hin chin lc ton cu.
K hoch hnh ng: chin lc ton cu v phng v kim sot BKLN giai on 2008-2013.
Chin lc ton cu v gim tc hi ca ru bia.
B khuyn co ca WHO v qung b cc thc phm v ung khng cn cho tr em.
2011
Tuyn b chnh tr ca T chc Lin Hp Quc v cc bnh khng ly nhim.

Hi ngh B trng ln th nht v li sng lnh mnh v kim sot BKLN- Tuyn b Moskva.
2013
Chng trnh hnh ng ton cu v phng chng v kim sot cc BKLN giai on 2013-2020.
K hoch hnh ng v sc khe tm thn 2013-2020.
WHO khu vc Ty Thi Bnh Dng, xy dng mt s vn bn chin lc quan trng

lin quan n BKLN v bnh tm thn, trn c s tham kho cac Chin lc va K hoach hanh
ng ton cu v da trn cc thnh tu v bi hc kinh nghim ca cc quc gia trong khu vc.
Nm 2000, c Ngh quyt ngh cc quc gia trong khu vc xy dng chin lc v k hoch
hnh ng phng chng BKLN. Nm 2006, Ngh quyt mi tip tc thc y hnh ng quc
gia v s ng h k thut ca WHO. Nm 2008, cc nc thnh vin thng qua K hoch
hnh ng phng, chng BKLN ca Khu vc Ty Thi Bnh Dng giai on 2008-2013.
Nm 2011, Ngh quyt nhm m rng v tng cng phi hp gia cc quc gia trong cng
tc phng, chng BKLN. n nm 2013, cc nc thnh vin trong khu vc tn thnh K
hoch hnh ng phng, chng BKLN ca Khu vc Ty Thi Bnh Dng cho giai on 20142020. Nm 2013, ASEAN c Tuyn ngn Bandar Seri Begawan v cc BKLN ti ASEAN,
tn thnh cc hot ng ca WHO phng, chng cc BKLN. i vi sc khe tm thn, khu
vc Ty Thi Bnh Dng c Chin lc v sc khe tm thn trong khu vc t nm 2002,
11 nm trc khi WHO c K hoch hnh ng ton cu v sc khe tm thn u tin.
145

Tm nhn ca K hoch Hnh ng ton cu v phng, chng BKLN nm 2013 l Th
gii khng cn gnh nng c th phng trnh c v BKLN. Trong khu vc Ty Thi Bnh
Dng, tm nhn l Cc chnh ph v x hi duy tr cc cam kt chnh tr v ti chnh phng,
chng cc BKLN chng khng cn cn tr s pht trin kinh t-x hi. i vi sc khe
tm thn, k hoch hnh ng ton cu a ra tm nhn l mt th gii trong sc khe tm
thn c nh gi cao, c nng cao v bo v, cc ri lon tm thn c phng chng v
nhng ngi mc cc ri lon tm thn c th hng cc quyn con ngi v tip cn dch
v CSSK v x hi c cht lng ph hp vi vn ha, kp thi thc y hi phc sc khe,
t c mc sc khe cao nht c th v tham gia y trong x hi, cng vic, khng
b k th v phn bit i x.
Cac nguyn tc thc hin k hoach hanh ng phong, chng cac BKLN toan cu v ti
Khu vc Ty Thi Bnh Dng ging nhau v cng c nhiu im trng vi K hoch hnh
ng ton cu v bnh tm thn (Bng 19). Tuy nhin, c mt s khc bit ni bt - K hoch
khu vc v BKLN cha cp n cac vn v xung t v li ich, d bng chng quc t
cho thy tac ng cua cac nganh thuc la, ru va thc phm chng lai chinh sach co li cho y
t cng cng [126].
Bng 19: Nguyn tc thc hin k hoch hnh ng phng, chng cc BKLN va bnh
tm thn
BKLN
Bnh tm thn
Ton cu (2013-2020)
Ty Thi Bnh Dng

(2014-2020)
Hnh ng quc gia; on

kt v hp tc quc t
Lnh o v iu phi
thng nht
Cch tip cn nhn quyn
Tn trng quyn con ngi
Tn trng quyn con ngi
Trao quyn cho ngi dn

v cng ng
Trao quyn cho cng ng
Trao quyn cho ngi b ri

lon tm thn hoc khuyt tt
tm thn
Cc chin lc da vo
bng chng
Thc hnh da trn bng chng
Thc hnh da trn bng

chng
S dng cch tip cn

da vo vng i
Can thip ton b qu trnh theo

vng i
Tip cn da vo vng i
Hnh ng a ngnh
Hnh ng lin ngnh
Tip cn a ngnh
Bao ph CSSK ton dn;

Cch tip cn da trn
cng bng
Bao ph CSSK ton dn

v cng bng
Bao ph CSSK ton dn
Ton cu (2013-2020)
Qun l xung t li ch (gm

xung t li ch thc s, do
cm nhn v tim nng)
Ngun: Cac k hoach hanh ng BKLN toan cu, khu vc Ty Thi Bnh Dng v K hoch hnh ng ton cu
v sc khe tm thn.
Mt s iu chnh trong mc ch phng, chng BKLN qua thi gian th hin nhng bi
hc rt ra c t hnh ng i ph vi BKLN trong giai on trc. Giai on 2008-2013,
K hoch ton cu u tin vo vic thit lp v tng cng cc chng trnh, chnh sch quc
146
gia v phng, chng BKLN, nhng trong giai on sau nhn mnh nhiu hn vo cng c h
thng y t trong phng, chng v kim sot BKLN. Trong giai on trc, c mc ch tch
hp cng tc phng, chng v kim sot cc BKLN vo cc chnh sch ca cc c quan chnh
ph, trong khi trong giai on mi, nhn mnh nhiu hn vo vic tng cng nng lc quc
gia, lnh o, iu hnh, hnh ng a ngnh tng tc p ng ca quc gia i vi kim
sot cc BKLN (Bng 20). Cc mc ch ca K hoch hnh ng trong Khu vc Ty Thi
Bnh Dng n nm 2020 ging nh trong K hoch hnh ng ton cu. K hoch hnh ng
ton cu v sc khe tm thn c nhiu iu trng vi K hoch hnh ng v BKLN. Cha c
K hoch hnh ng v sc khe tm thn trong khu vc c cp nht v hi ho ha vi K
hoch hnh ng ton cu mi.
Bng 20: So snh mc ch phng, chng BKLN giai on 2008-2013 v giai on 20132020
Phng chng bnh khng ly nhim
2008-2013
2013-2020
Tng cng u tin phng chng

BKLN trong cc chnh sch pht
trin cp ton cu v quc gia, tch
hp phng chng v kim sot cc
BKLN vo cc chnh sch ca tt c
cc c quan chnh ph
Tng cng cc mi quan h hp
tc trong phng chng v kim sot
BKLN.
Tng cng u tin cho phng

chng v kim sot cc BKLN trong
chng trnh ngh s ton cu, khu
vc v quc gia v trong cc mc
tiu pht trin c quc t cng
nhn, thng qua tng cng vn
ng v hp tc quc t.
Sc khe tm thn
2013-2020
Tng cng s lnh

o v qun l hiu
qu i vi sc khe
tm thn.
Tng cng nng lc quc gia,

lnh o, iu hnh, hnh ng a
ngnh v quan h i tc tng
tc p ng ca quc gia trong
vic d phng v kim sot cc
BKLN.
Cng c v nh hng h thng y
t nhm phng chng v kim sot
BKLN v cc yu t x hi thng
qua CSSK ly con ngi lm trung
tm v bao ph CSSK ton dn.
Cung cp cc dch
v x hi v sc
khe tm thn ton
din, lng ghp v
p ng nhu cu ti
cng ng
Tin hnh cc chng trnh can

thip lm gim cc yu t nguy c
ca BKLN gm: ht thuc l, ch
n khng lnh mnh, thiu hot
ng th lc v ung ru bia
Gim cc yu t nguy c ca cc
BKLN v kim sot cc yu t x
hi khc thng qua vic to mi
trng thun li nng cao sc
kho.
Thc hin cc chin

lc nng cao sc
khe tm thn v
phng chng ri lon
tm thn
u tin cc nghin cu v phng

nga v kim sot BKLN
Thc y v h tr nng lc quc

gia v nghin cu c cht lng
cao nhm d phng v kim sot
cc BKLN.
Theo di xu hng ca cc BKLN,

cc yu t quyt nh cc BKLN v
nh gi tin trnh cp quc
gia, khu vc v ton cu
Theo di cc xu hng v cc yu
t quyt nh cc BKLN; nh gi
tin phng chng v kim sot
cc yu t ny.
Thit lp v tng cng cc

chng trnh, chnh sch quc gia
v phng chng BKLN
147
Tng cng h
thng thng tin, tp
hp bng chng v
thc hin cc nghin
cu nng cao sc
khe tm thn

Cc vn bn chin lc ton cu v trong khu vc ch mang tnh hng dn. Tng quc
gia phi da trn cc vn u tin v tnh hnh c th trong nc xy dng cc K hoch
hnh ng hoc chin lc quc gia. n nm 2013, 31 trn 35 quc gia c chnh sch quc
gia hoc chin lc hoc k hoch hnh ng quc gia v BKLN v cc yu t nguy c. Tuy
nhin, hnh ng i ng ca tng quc gia rt khc nhau. V d, ti Hng Kng c chin lc
phng chng BKLN, nhng khng c chng trnh ln v c th cho tng BKLN. Ma-lai-xi-a
c cc chng trnh c th v phng chng i tho ng v bnh tim mch, ung th, bo lc
v tai nn thng tch, s dng ru, bia mc c hi, kim sot thuc l, sc khe mi trng
v ngh nghip. Ti Thi Lan, cuc vn ng gim st, kim sot v phng BKLN tp trung ch
yu vo bnh i tho ng v tng huyt p v yu t nguy c thuc l v ru, bia.
Vic u tin tp trung vo CSSKB v to mi trng h tr phng, chng BKLN
c th hin cc quc gia theo hnh thc khc nhau. K hoch quc gia v BKLN ca Trung
Quc giai on 2012-2015 a ra mc tiu xy dng mi trng x hi ng h phng, chng
BKLN. Thi Lan, hnh ng ng ph bao gm c tng cng nng lc h thng y t tuyn
huyn/qun v k hoch chin lc v li sng lnh mnh nhm tng nng lc ca cc cng
ng chng li mi e da ca cc bnh lin quan vi li sng khng lnh mnh. Ti Xinhga-po, chuyn trng tm t chm sc tch cc phc hi triu chng sang m hnh CSSK
ton din lu di, nhn mnh CSSKB, to mi trng h tr tng cng sc khe. Ti Hn
Quc, Trung tm kim sot dch bnh Hn Quc pht trin Hng dn hng nm cho D n
qun l cc BKLN cp nht hng dn quc gia cho phng chng cc BKLN da vo cng
ng[127].
Ngoi ra mi quc gia ang to ra nhng sng kin mi nhm gii quyt cc vn
ring. V d, Chin lc quc gia ca Nht Bn c kt ni cht ch vi c im dn s gi
ho ca quc gia ny bao gm c h thng BHYT di hn v cc gii php nhm tng cng
hot ng th cht v tinh thn cho ngi cao tui. Ti Trung Quc cc chnh quyn a phng
phi hp vi cc c quan khc nhau ca chnh ph ch tr cc sng kin Thnh ph lnh
mnh. Trong nhng nm gn y, cc sng kin ny c nhng tin b ng k v ang m
rng t cc thnh phi ln sang cc thnh ph nh hn [128].
Mt nghin cu tng quan gn y v cc BKLN v h thng y t khu vc chu -Thi
Bnh Dng cho thy ng ph ca h thng y t vi BKLN cng nh bng chng cho xy dng
chng trnh v chnh sch vn cn kh yu. Cha c cch tip cn ton din pht trin vic
ng ph ca h thng trong khu vc v nhn chung cc can thip thc hin cng cha c
nh gi bi bn. Nghin cu tng quan cng cho thy khong trng v cc can thip c
thit k gii quyt tnh hnh BKLN ang tng ln trong khu vc. iu ny i hi cn c cc
nghin cu c cht lng v mang tnh h thng v vic trin khai cc chng trnh v dch v
lng ghp cho cc BKLN, ch khng ch hng vo tng bnh ring bit [129].
148
Hnh 44: Khung can thip Khu vc Ty Thi Bnh Dng da trn khuyn co ca WHO
Ngun: Da vo WHO, 2009 [130].
Hnh 44 biu din quan h gia cc nhm dn c, cc hot ng phng v iu tr v cc

bn chu trch nhim. C th chia dn c thnh nhm cha c bnh v nhm c bnh. Trong
nhm cha c bnh, c nhm cha c yu t nguy c v nhm c yu t nguy c. Trong nhm
c bnh c th chia ra mc bnh t nh n nng. i vi nhm cha mc bnh, cn tp
trung vo vic phng bnh v nng cao sc khe thng qua cc can thip trong cng ng. Khi
mc bnh ri, h thng y t phi p ng nhu cu qun l, chm sc v iu tr i vi tng
c nhn mc bnh. Vn ng, gim st v nh gi ng vai tr quan trng trong vic kim sot
yu t nguy c v t l mc bnh, cng nh trong nh gi cc can thip lin quan tng nhm
dn c. Khi chuyn t nhm khng c bnh n nhm ngi mc bnh (t nh n nng), trch
nhim ca ngnh y t tng dn. Ngc li, trch nhim ca chnh ph v x hi rt cao i vi
nhm cha mc bnh, nhm vo vic nng cao sc khe v phng bnh.
1.6. Cac giai phap phng chng BKLN
t c cac mc ich trn (Bng 20), WHO khuyn ngh cc nc thnh vin la
chn cc chnh sch v can thip hiu qu-chi ph nhm h tr cc quc gia thc hin mt cch
ph hp tu thuc vo bi cnh. Trong c th chia thnh cac nhm giai phap v: (i) tng
cng u tin v nng lc cho cng tc phng, chng v kim sot BKLN; (ii) gim st v
nghin cu; (iii) kim sot cc yu t nguy c; v (iv) cng c h thng y t ng ph vi vi
BKLN v bnh tm thn.
149

1.6.1. Nng mc u tin v tng cng nng lc phng chng v kim sot BKLN
K hoch hnh ng ton cu phng chng BKLN a ra hai mc ch i hi s tham

gia tch cc khng ch ca ngnh y t m ca ton Chnh ph trong ch o vic ng ph quc
gia. Th nht l nng mc u tin cho phong chng va kim soat cac BKLN. Th hai l thc
y nhanh ap ng cua quc gia trong vic ngn chn va kim soat cac BKLN thng qua tng
cng nng lc quc gia, lanh ao, iu hanh, hanh ng a nganh va quan h i tac.
nng mc u tin, WHO khuyn khch ba nhm nhim v: (i) xy dng c s bng
chng v ph bin thng tin v cc chnh sch hiu qu nhm can thip trong mi quan h gia
BKLN v pht trin kinh t-x hi bn vng; (ii) thc y bao ph CSSK ton dn v vic lng
ghp phng chng BKLN trong qu trnh thc y bao ph CSSK ton dn, v (iii) thit lp
cc quan h i tc thc y hp tc gia cc c quan chnh ph, t chc x hi dn s v
khu vc t nhn cc cp trong cng tc phng, chng BKLN. K hoch hnh ng ca Khu
vc Ty Thi Bnh Dng nhn mnh hn vo vic quan tm ti cc nhm d b tn thng,
v ngh a 9 mc tiu t nguyn ton cu vo mc tiu quc gia phng chng v kim sot
BKLN.
tng cng nng lc quc gia, WHO ngh mt s la chn chnh sch. Th nht l
lng ghp phng, chng BKLN vo qu trnh lp k hoch ca ngnh y t v k hoch pht trin
kinh t-x hi. ng thi xy dng k hoch quc gia phng chng BKLN km theo ngn sch
thc hin da trn nh gi nhu cu v nh gi tc ng thc hin cc can thip. Tip theo l huy
ng ngun lc n nh v s dng hiu qu, kt hp vi vic nng cao trch nhim gii trnh
thng qua gim st v nh gi tc ng. Th ba l tng cng cc chng trnh phng, chng
BKLN quc gia kt hp vi cng c nng lc th ch v nhn lc. Pht huy vic hp tc gia
cc nhm i tc trong thc hin hot ng phng chng BKLN v huy ng cng ng, ngi
dn ng ph vi cc BKLN. K hoch hnh ng ca Khu vc Ty Thi Bnh Dng nhn
mnh xy dng chnh sch a ngnh, xy dng c ch phi hp v bo m ngun lc n nh.
i vi sc khe tm thn, mc ch th nht cng i hi tng cng hiu qu ca s
lnh o v qun l nh nc. Nhm khuyn ngh th nht l xy dng, tng cng v cp nht
cc chnh sch lin quan n sc khe tm thn trong cc ngnh lin quan, bao gm c c ch
gim st bo v nhn quyn ca ngi b bnh tm thn v vic thc hin cc quy nh. Th
hai l lp k hoch da trn nhu cu c o lng, ph hp vi ngun lc cn thit thc
hin cc k hoch v hnh ng c ban hnh. Th ba l thc y s tham gia ca cc bn
lin quan, gm c ngi b ri lon tm thn, ngi chm sc v gia nh ngi bnh, trong vic
xy dng v thc hin cc chnh sch v sc khe tm thn thng qua mt c ch c xc
nh. Cui cng l bo m rng nhng ngi b ri lon tm thn v khuyt tt x hi -tm l
c vai tr v quyn lc chnh thc trong qu trnh thit k, lp k hoch v thc hin cc chnh
sch, lut v dch v.
So vi mc tc ng (c v b rng v chiu su) i vi sc khe cng ng th
hu ht cc ng ph ca cc quc gia dng nh l cha c iu phi tt v cha c u
t kinh ph ph hp hoc cha c da trn cc bng chng y . c bit, gnh nng ca
BKLN i vi ngi ngho trong bi cnh th ha nhanh chng cha c thu thp thng
tin y hoc cha c th hin r trong chnh sch [129].
Nm 2012, Vn phng WHO Khu vc Ty Thi Bnh Dng t chc hi tho h
tr cc nc trong khu vc xy dng cc k hoch a ngnh [131]. Ti Trung Quc, k hoch
150
quc gia i vi BKLN (2012-2015) kt hp cht ch 15 b ngnh khc nhau c ban hnh
vo nm 2012 [128].
1.6.2. Gim st va nghin cu
Mt trong cc mc tiu chnh ca K hoch hnh ng ton cu l theo di, gim st tnh
hnh BKLN v cc yu t nguy c, cng nh cc hot ng phng, chng bnh v kim sot yu
t nguy c. Nm 2011, ti Hi ngh cp cao ca Lin Hp Quc v BKLN [132], i din Chnh
ph ca cc nc tham d cam kt xy dng cc mc tiu quc gia v cc ch s da trn
hng dn ca WHO, v tng cng u tin vic gim st. Thng 5/2013, i Hi ng WHO
thng qua khung gim st BKLN gm 25 ch s v 9 mc tiu. Cc ch s c la chn da
trn nh gi tnh hiu qu ca tng can thip. Cc mc tiu v ch s c trnh by trong Bng
21 di y. Cc mc tiu c coi l t nguyn v nhiu ch s cho php nh ngha linh hot
theo hon cnh v iu kin ca tng quc gia. n nm 2016, 2021 v 2026 cc nc thnh
vin s bo co v tin thc hin 9 mc tiu lin quan n BKLN theo khung gim st ny.
Bng 21: Cc mc tiu v ch s gim st BKLN ton cu
Lnh vc
Mc tiu t nguyn
Ch s
T vong v bnh tt
(1) Gim 25% t l t vong do cc
bnh tim mch, ung th, i tho
ng, bnh phi mn tnh.
Ch s b sung
(1) Xc sut t vong tui t 30 n 70 t cc

bnh tim mch, ung th, i tho ng v bnh
ng h hp mn tnh.
(2) T l mi mc ung th (theo tng loi ung th)
trn 100000 ngi.
Cc yu t nguy c
(2) Gim t nht 10% vic s dng

ru, nu thch hp, trong bi
cnh tng quc gia.
(3) Lng tiu th ru bnh qun u ngi t

15 tui tr ln trong mt nm.
(4) T l (chun ha theo tui) ung ru qu mc
v thnh nin v ngi ln.
(5) Bnh tt v t vong lin quan n ru v
thnh nin v ngi ln.
(3) Gim 10% t l ngi thiu cc

hot ng th lc.
(6) T l thanh nin hot ng th lc khng

(< 60 pht hot ng cng trung bnh/nng
mi ngy).
(7) T l (chun ha theo tui) ngi 18 tui tr
ln hot ng th lc khng (< 150 pht hot
ng cng trung bnh mi tun).
(4) Gim 30% lng mui/natri s

dng cng ng.
(8) Lng tiu th mui (NaCl) trung bnh (chun

ha theo tui) mi ngy tui 18 tr ln.
(5) Gim 30% t l ht thuc l

ngi 15 tui tr ln.
(9) T l ht thuc hin nay v thnh nin.

(10) T l (chun ha theo tui) ht thuc hin nay
tui 18 tr ln.
(6) Gim 25% t l tng huyt p,

tu thuc bi cnh mi quc gia.
(11) T l (chun ha theo tui) tng huyt p

tui 18 tr ln.
151
Lnh vc
Mc tiu t nguyn
Ch s
(7) Ngn chn s gia tng bnh

i tho ng v bo ph
(12) T l (chun ha theo tui) tng ng huyt/

bnh i tho ng tui 18 tr ln.
(13) T l tha cn, bo ph v thnh nin.
(14) T l (chun ha theo tui) tha cn v bo
ph tui 18 tr ln.
Cc ch s b sung
(15) T trng (chun ha theo tui) tng nng

lng t cc cht bo bo ha tui 18 tr ln.
(16) T l (chun ha theo tui) tiu dng t hn 5
sut (400 g) rau qu mi ngy.
(17) T l (chun ha theo tui) c cholesterol
cao tui 18 tr ln.
H thng y t
(8) t nht 50% s ngi c yu t
nguy c c iu tr bng thuc
v c t vn (bao gm c kim
sot ng huyt) ngn chn
nhi mu c tim v tai bin mch
mu no
(18) T l ngi c nhu cu (40 tui tr ln c

nguy c bnh tim mch 30% trong 10 nm ti)
c iu tr bng thuc v t vn phng nhi
mu c tim v tai bin mch mu no.
(9) 80% c s y t cng v t c

thuc v cc cng ngh thit yu
c bn, gi c hp l, bao gm
c thuc generic, iu tr cc
BKLN ch yu.
(19) S sn c v kh nng chi tr cc thuc thit

yu c cht lng, an ton v hiu sut iu
tr cc BKLN, bao gm thuc generic, v cc cng
ngh c bn ti cc c s cng lp v t nhn.
Cc ch s b sung
(20) Kh nng tip cn chm sc gim nh c

nh gi trn tiu ch tiu dng thuc gim au
opiat bnh qun mt ca t vong do ung th.
(21) Thng qua cc chnh sch quc gia gii hn
cht bo bo ha v loi tr du thc vt hydro
ha mt phn (cht bo chuyn ha).
(22) S sn c, nu ph hp v hiu qu chi ph,
cc vc xin phng HPV theo cc chng trnh v
chnh sch quc gia.
(23) Cc chnh sch nhm gim tc ng i vi
tr em t vic qung co thc n v ung khng
c cn nhng cha nhiu cht bo bo ha, cht
bo chuyn ha, ng hoc mui.
(24) Tim phng vim gan B y 3 liu cho tr
em di 1 tui.
(25) T l ph n tui 30-49 c khm sng
lc ung th c t cung t nht mt ln.
Ngun: Khung gim st v cc mc tiu phng, chng cc BKLN ton cu.
i vi sc khe tm thn, K hoch hnh ng ton cu xut mt s ch s gim st

tin thc hin, trong c mt s mc tiu v ch s tm v m, nhng cha c cc ch s
chi tit nh i vi cc BKLN (Bng 22).
152
Bng 22: Cc mc tiu v ch s gim st hnh ng phng, chng bnh tm thn
Mc tiu (n nm 2020)
Ch s
Mc ch 1: Tng cng lnh o hiu qu v qun l nh nc v sc khe tm thn

80% cc quc gia c xy dng hoc cp nht
chnh sch/k hoch v sc khe tm thn hi
ha ha vi cc cng c quc t v khu vc v
nhn quyn.
S tn ti ca chnh sch/k hoch v sc khe

tm thn ph hp vi cc cng c nhn quyn
quc t.
50% cc quc gia c xy dng hoc cp nht

Lut sc khe tm thn ph hp vi cng c
nhn quyn quc t v khu vc.
Vic c lut quc gia v sc khe tm thn ph

hp vi cng c nhn quyn quc t.
Mc ch 2: Cung cp dch v x hi v sc khe tm thn ton din, lng ghp v p ng

nhu cu ti cng ng
2. Bao ph dch v i vi cc ri lon tm thn
nng tng 20%.
T l ngi b ri lon tm thn nng (chng lon

thn, ri lon lng cc, trm cm trung bnh v
nng) ang s dng dch v (%).
Mc ch 3: Thc hin cc chin lc nng cao sc khe tm thn v phng ri lon tm thn
3.1. 80% cc quc gia c t 2 chng trnh tr
ln ang thc hin nhm nng cao sc khe
tm thn, phng bnh tm thn mang tnh a
ngnh, cp quc gia.
Cc chng trnh a ngnh ang thc hin nhm

nng cao sc khe tm thn, phng bnh tm thn.
3.2. T l t t gim 10%
S t vong do t t trn 100000 dn.
Mc ch 4: Tng cng h thng thng tin, bng chng v nghin cu v sc khe tm thn
4. 80% cc quc gia thu thp v bo co nh
k t nht mt b ch s sc khe tm thn c
bn mi 2 nm mt ln trong h thng thng tin
y t-x hi quc gia.
B ch s sc khe tm thn ( c xc nh,

thng nht), c thu thp v bo co nh k 2
nm mt ln.
Ngun: K hoch hnh ng ton cu v sc khe tm thn 2013-2020.
Da trn khung gim st trn, WHO khuyn ngh cc quc gia xy dng cc mc tiu
quc gia, tng cng nhn lc v nng lc v gim st, theo di v nh gi thc hin hiu
qu. V lu di, cc quc gia cn lng ghp gim st cc BKLN vo h thng thng tin y t
quc gia thng qua thit lp v tng cng mt cch ton din h thng gim st nguyn nhn
t vong, ghi nhn ung th, thc hin iu tra nh k v cc yu t nguy c v gim st vic
p ng ca quc gia. Cc khuyn ngh i vi sc khe tm thn cng xut lng ghp cc
ch s v sc khe tm thn trong h thng thng tin y t v s dng cc d liu trong vic ci
tin dch v v bo co.
Nghin cu phng, chng BKLN c a vo cc mc ch chnh ca K hoch hnh
ng ton cu v khu vc v phng, chng BKLN v cc u tin hnh ng nn da trn bng
chng v tnh hnh mc v yu t nguy c cng nh tnh hiu qu, hiu sut v tnh chp nhn
ca cc can thip mi quc gia. ng thi kt qu can thip tng quc gia l bi hc quan
trng cn chia s cho cc quc gia khc. Kh nng nghin cu hiu qu thng ph thuc nhiu
vo kh nng cung cp s liu v thng tin t h thng thng tin cp trn. WHO xut
mt s hot ng c th thc y hot ng nghin cu bt u t vic xy dng v thc
hin chng trnh nghin cu quc gia v BKLN. Phn b kinh ph, tng cng ngun nhn
lc, cng c cc quy nh v nghin cu v tng cng nng lc nghin cu thng qua hp tc
quc t v trong nc u l nhng gii php h tr cho chng trnh nghin cu quc gia. Cc
153

khuyn ngh i vi sc khe tm thn tng t nh i vi BKLN, c nhn mnh v nghin
cu lin quan trc tip ti pht trin v thc hin dch v sc khe tm thn v bo v nhn
quyn ca ngi b ri lon tm thn, c bit cc nghin cu c s tham gia ca cc bn lin
quan, nh ngi b ri lon tm thn.
Mt s nc trong khu vc u t nhiu vo vic tng cng gim st v nh gi.
Trung Quc ang trin khai mt nghin cu theo di tnh trng sc khe trong mt thi gian t
15 n 20 nm ti nhm xy dng c s d liu da trn xt nghim mu, s dng cc kha cnh
di truyn, mi trng v li sng iu tra v tm hiu cc nguyn nhn, yu t nguy c, s
pht sinh bnh, t l mc, m hnh v xu hng ca bnh mn tnh ti nc ny [133]. Ti Thi
Lan, c nhiu d n gim st BKLN nh D n tng cng h thng gim st cc yu t nguy
c BKLN v D n ci thin cht lng ca h thng ghi nhn ung th v phn tch s liu ghi
nhn xy dng chnh sch. Xinh-ga-po cng u t cho cc mc tiu lin quan n BKLN
v nh gi kt qu mt cch ch ng.
1.6.3. Kim sot cc yu t nguy c c th thay i c
Nhm kim sot cc yu t nguy c, i hi ng WHO tn thnh Cng c Khung

v kim sot thuc l, Chin lc ton cu v ch n ung, hot ng th lc v sc khe,
Chin lc ton cu v kim sot tc hi ca ru, B khuyn co v qung b cc thc phm
v ung khng cn cho tr em, v Tuyn b Moskva v li sng lnh mnh v kim sot
BKLN. Cc vn bn mang tnh chin lc xut nhiu gii php c th v chi tit kim
sot cc yu t nguy c lin quan n hnh vi, cng nh cc yu t kinh t x hi lin quan v
WHO khuyn khch thc hin y cc ni dung.
Tuy nhin, khi iu kin c hn, cn xc nh u tin la chn cc hnh ng thc
hin trc. Trong Khu vc Ty Thi Bnh Dng, WHO xut cc can thip c coi la rt
hiu qua so vi chi phi phong nga cc yu t nguy c gy BKLN (Bng 23).
Bng 23: Cc can thip kim sot yu t nguy c lin quan n hnh vi, li sng
Nhm tc ng
Can thip hiu qu
S dng thuc l
Gim kh nng chi tr cho cc sn phm thuc l bng cch tng thu tiu
th c bit.
Xy dng lut v mi trng khng khi thuc ti tt c cc ni lm vic,
ni cng cng v phng tin i li cng cng.
Cnh bo mi ngi v s nguy hi ca thuc l v khi thuc l thng qua
cc cnh bo v sc khe v chin dch truyn thng i chng hiu qu.
Cm tt c cc hnh thc qung co, khuyn mi v tip th thuc l.
S dng ru, bia

qu mc
Kim sot vic mua bn v sn c ru bia trong cng ng.

Gii hn v cm qung co ru, bia v cc hnh thc khuyn mi.
p dng chnh sch v gi, v d nh thu tiu th c bit i vi ru, bia.
Ch n khng
lnh mnh
Gim tiu th mui trong thc n.

Thay th a xt bo chuyn ha (transfat) bng cht bo khng bo ha.
Thc hin cc chng trnh nng cao nhn thc v ch n lnh mnh.
Thiu hot ng
th lc
Thc hin cc hot ng nng cao nhn thc thc y li ch ca li

sng nng vn ng th lc.
Ngun: WPRO Regional Action Plan on NCDs 2014-2020.
154
K hoch hnh ng ton cu cng nhn rng hiu qu ca hnh ng a ngnh i hi
vic giao trch nhim c th cho tng c quan/nhm i tc, bo v li ch cng v trnh tc
ng ca mu thun li ch i vi ni dung chnh sch v vic thc hin chnh sch. Tuyn b
chnh tr ca T chc Lin Hp Quc v cc BKLN nu r tm quan trng ca vic gim mc
phi nhim vi cc yu t nguy c v tng cng nng lc ca ngi dn la chn li
sng c li cho sc khe trong sut vng i, v vai tr quan trng ca cc quy nh php lut
kim sot cc ngnh lin quan v cc can thip nng cao sc khe.
i vi vic nng cao sc khe tm thn v phng chng ri lon tm thn, nhiu yu
t nguy c quan trng lin quan n hon cnh kinh t x hi ca gia nh, ngoi phm vi kim
sot ca ngnh y t. Tuy nhin, c mt s hot ng nm trong phm vi trch nhim ca ngnh
y t. Th nht l vn ng thay i chnh sch lin quan cc vn mi trng, nui dng tr,
iu kin lm vic, hc tp, phng, chng bo lc gia nh phng nga tc ng xu ti sc
khe tm thn. Th hai l chng s dng ru, bia mc c hi nh i vi BKLN khc. Th
ba l tng cng kh nng ngi mc BKLN c th tip cn vi t vn trong qu trnh iu tr
trnh bnh tt dn n ri lon tm thn nh trm cm, lo u.
Cc khuyn ngh v nng cao sc khe tm thn v phng nga ri lon tm thn cha
xut cc can thip hiu qu-chi ph c th nh i vi BKLN, nhng ngh cc quc
gia ch o v iu phi chin lc a ngnh c cc can thip ton dn cng nh nhm vo cc
i tng ch c th nng cao sc khe tm thn; phng nga ri lon tm thn; gim k
th, phn bit i x v vi phm nhn quyn; p ng nhu cu ca cc nhm d b tn thng
theo vng i c lng ghp vo cc chin lc quc gia v sc khe tm thn v nng cao
sc khe. ng thi cc quc gia cn xy dng v thc hin cc chin lc ton din phng
nga t t, ch c bit ti cc nhm c nguy c cao hn.
Phn ln cc chnh sch/chin lc ca cc quc gia, vng lnh th chu hin nay u
tp trung vo cc yu t nguy c c th phng nga c. Tuy nhin, c s khc bit gia cc
quc gia tu thuc vo bi cnh kinh t, x hi, t chc v tnh hnh dch t hc [128].
1.6.4. Cng c h thng y t
WHO xy dng danh mc la chn chnh sch lin quan n cng c v nh hng
h thng y t ng ph vi cc BKLN thng qua CSSKB v CSSK ton dn. K hoch hnh
ng ton cu c nm nhm khuyn ngh lin quan n lnh o, cung cp ti chnh, cht lng
dch v, nng lc ca ngun nhn lc, v kh nng tip cn ca ngi dn [125]. K hoch hnh
ng ca khu vc Ty Thi Bnh Dng a ra 8 khuyn ngh trong lnh vc ny. Di y tm
tt cc khuyn ngh ton cu v ca khu vc Ty Thi Bnh Dng.
Lin quan n tng cng hiu qu trong qun tr v trch nhim gii trnh c bn la
chn. Th nht l phi c trch nhim bo m s sn c cc dch v phng chng BKLN trong
h thng y t. Th hai l c s tham gia ca cng ng khi thit k, thc hin, gim st v nh
gi cc chng trnh phng, chng BKLN bo m hiu qu v cng bng. Th ba l lng
ghp dch v phng, chng BKLN vo cng tc i mi ngnh y t. Th t l nh hng h
thng y t nhm ng ph vi tc ng ca yu t kinh t-x hi nh hng ti sc khe thng
qua cc can thip c xc nh da trn bng chng v c h tr bi cc hot ng nhm
CSSK ton dn. Trong khu vc Ty Thi Bnh Dng, c hai khuyn ngh c th hn. Th nht
l nu bt tm quan trng ca phng chng BKLN trong CSSK ton dn. Th hai l nng cao
155

vai tr ca dch v CSSKB v chm sc chuyn khoa (secondary care) cng vi h thng
chuyn tuyn trong n lc phng, chng v qun l cc BKLN.
V ti chnh i vi cc BKLN c ba la chn chnh sch. Th nht l chuyn t h
thng y t da trn vin ph chi tr trc tip khi s dng dch v y t thnh h thng chi tr trc,
c chia s ri ro v bao ph chi tr dch v cho cc BKLN. Th hai l m rng bao ph CSSK
ton dn, u tin chi tr cho cc can thip hiu qu-chi ph i vi cc BKLN v bnh km theo.
Xy dng cc gii php sng to ti a phng bo v ngi bnh trc ri ro ti chnh do
cc BKLN gy ra. Khu vc Ty Thi Bnh Dng c thm khuyn ngh to ra c ch ti chnh
y t bao ph phng, sng lc, qun l v kim sot BKLN.
V pht trin nhn lc, th nht l tin hnh xc nh cc nng lc cn thit v u t
nng cao kin thc, k nng v ng lc lm vic ca nhn lc y t hin c v lp k hoch
o to trong tng lai da trn d bo nhu cu. Th hai, lng ghp ni dung v phng chng
BKLN trong chng trnh o to nhn lc y t cng nh nhn lc thc hin cng tc x hi,
nhn mnh vo CSSKB. Th ba l bo m ch i ng v iu kin lm vic huy
ng nhn vin y t phc v vng kh khn. Th t l tng cng o to sau i hc chuyn
v BKLN i vi cn b y t, dc, v lnh vc khc lin quan n chm sc ngi mc BKLN.
Th nm, ti u ha phm vi hnh ngh ca iu dng v nhn vin cn lm sng loi b
cc cn tr v tng cng s ng gp ca h trong phng chng cc BKLN. Th su l tng
cng nng lc lp k hoch, thc hin, gim st, nh gi cung ng dch v phng chng
BKLN. khu vc Ty Thi Bnh Dng, cc khuyn ngh nhn mnh vo vic nng cao nng
lc ca nhn lc y t v th ch thc hin phng chng BKLN thng qua m hnh cung cp
dch v ly con ngi lm trung tm, cc i/nhm lm vic a k nng, cc bin php bo m
cht lng v hot ng o to lin tc.
i vi vic nng cao hiu sut, cng bng, bao ph v cht lng dch v phng, chng
cc BKLN v cc yu t nguy c, c by la chn c xut. Th nht l cng c v t chc
cc dch v gn ngi dn trong mng li CSSKB c lng ghp vi cc c s y t tuyn
trn, bao gm c iu tr chuyn khoa, phc hi chc nng v chm sc gim nh. To iu
kin cung cp dch v mt cch cng bng cho ngi mc BKLN ca cc c s cung cp dch
v (k c khu vc cng lp v t nhn). Tng cng hiu sut cung cp dch v v a ra cc
mc tiu quc gia ph hp vi mc tiu ton cu m rng bao ph cc can thip hiu qu-chi
ph c tc ng mnh ng ph vi cc BKLN, lin kt dch v phng, chng BKLN vi dch
v y t khc, c bit dch v CSSK tm thn (Xem danh mc mt s dch v rt hiu qu- chi
ph trong Bng 23). p ng nhu cu chm sc lu di ca ngi mc BKLN km theo khuyt
tt v bnh km theo thng qua m hnh chm sc hiu qu, sng to, lng ghp gia cc n
v trong h thng y t v cng ng. Thit lp h thng qun l cht lng, c bit i vi
CSSKB, bao gm hng dn iu tr da trn bng chng, v cc cng c h tr qun l cc
BKLN, yu t nguy c. Vn ng v to iu kin cho ngi dn khm sm pht hin bnh
v t qun l bnh hiu qu. R sot li cc chng trnh sc khe hin c tm c hi lng ghp
vi chng trnh phng, chng BKLN.
tng kh nng tip cn cc chng trnh phng chng BKLN, gm c thuc v cng
ngh thit yu, WHO xut nm la chn chnh sch. Th nht l thc y kh nng tip cn
dch v ton din, hiu qu-chi ph v c lng ghp phng, cha v chm sc trong vic qun
l cc BKLN, gm c thuc, cng ngh chn on v iu tr, tn dng ti a cc quyn linh
156
hot trong thc hin TRIPS trnh tc ng xu i vi y t cng cng.31 Th hai l ngh
cc quc gia nn thng qua cc chin lc quc gia da trn bng chng nhm nng cao kh
nng ngi bnh tip cn vi thuc vi gi hp l (v d a cc thuc ph hp vo danh mc
thuc ch yu hoc thc hin cc chnh sch qun l gi thuc). Th ba l thc y mua sm v
s dng cc loi thuc an ton, cht lng, hiu qu v gi hp l nhm phng chng BKLN,
gm c thuc gim au (trong chm sc gim nh), v vc xin phng mt s loi ung th lin
quan n bnh ly nhim thng qua mt s bin php nh qun l cht lng thuc, th tc u
i ng k thuc, thay th thuc generic, bt buc s dng tn hot cht trong mua sm v
gio dc ngi k n cng nh ngi bnh. Th t l tng tnh sn c ca cc cng ngh v
thuc thit yu qun l cc BKLN trong giai on u ng ph vi thin tai. Th nm l h
tr tip cn vi cc bin php phng v cha bnh, phc hi chc nng cng nh thc hin chi
tr ph cp i vi cc BKLN (c coi l bnh ngh nghip), ph hp vi cc lut v quy nh
quc t v quc gia. Trong khu vc Ty Thi Bnh Dng, khuyn ngh th nht l m rng
kh nng tip cn cc dch v phc hi chc nng ti cng ng v th hai l ci tin kh nng
tip cn dch v chm sc gim nh, gim au i vi ngi bnh b ung th v cc bnh khc
e da n sinh mng trong h thng cung cp dch v lin tc. Th ba l m rng kh nng
tip cn vi cc can thip thit yu nhm phng, chng BKLN, v d nh a phng ha gi
dch v thiu yu v BKLN ca WHO trong h thng CSSKB v chuyn tuyn hp l trong
c ch CSSK ton dn.
Gi dch v thit yu phng, chng BKLN c khuyn ngh bao gm 9 thnh phn.
Th nht l m rng bao ph khm sng lc v iu tr, ng thi u tin cc can thip hiu
qu- chi ph cao ng ph vi cc yu t nguy c lin quan n hnh vi. Th hai l cung ng
dch v t vn v gio dc cho ngi bnh, trong c ni dung v cai nghin thuc l v gim
s dng ru, bia mc c hi. Th ba l nh gi, qun l v x l cc yu t nguy c gn
lin vi cc cch tip cn ti h gia nh v cng ng nhm thay i li sng. Th t l chuyn
tuyn iu tr nhng ngi c nguy c cao b BKLN hoc tai bin. Th nm l phng ung th
gan thng qua tim phng vim gan B trong h thng tim chng m rng. Th su l phng
ung th c t cung thng qua cc bin php khm sng lc hiu qu-chi ph, v d nh VIA hoc
PAP smear, gn vi iu tr cc vt lot tin ung th. Th by l phng nga th cp st thp
khp v bnh thp tim. Th tm iu tr a thuc, bao gm kim sot ng huyt i vi bnh
nhn i tho ng, v cc thuc iu tr ngi bnh b nhi mu c tim hoc tai bin mch
mu no hoc c nguy c cao. Cui cng l cp thuc aspirin cho ngi ang b nhi mu c
tim hoc phng nga ti pht nhi mu c tim.
2. Din bin dch t hc v gnh nng bnh khng ly nhim Vit Nam
2.1. Din bin dch t hc mt s bnh khng ly nhim
BKLN bao gm nhiu loi bnh khc nhau c chung yu t l khng phi l bnh ly
truyn t ngi hoc t ng vt sang ngi. Theo Nghin cu gnh nng bnh tt ton cu
nm 2010, Vit Nam, BKLN chim 66% tng gnh nng bnh tt tnh bng DALY. Trong
phm vi bo co ny, chng ti tp trung vo 5 nhm BKLN chim t trng ln gnh nng t
vong v DALY, bao gm: ung th, tim mch, i tho ng, bnh phi mn tnh v bnh tm
thn-thn kinh. Tuy nhin, trong mc ny cng c cp thm mt s BKLN quan trng cha
c quan tm y Vit Nam.
TRIPS l Hip nh v cc kha cnh lin quan n thng mi ca quyn s hu tr tu m Vit Nam cam kt
khi gia nhp T chc Thng mi Th gii. Trong cc quyn linh hot ca TRIPS, c nhp khu song song v giy
php cng ch (bt buc chuyn giao quyn s dng i vi sng ch).
31
157

Bnh tim mch: Bnh tim mch l mt thut ng ch mt nhm bnh pht trin khng
ch do tnh trng bnh l ca tim, mch, c v van tim m cn do tnh trng cao huyt p,
bnh l ca no b v h thng mch ngoi vi [134]. Nhm bnh tim mch bao gm cc loi
bnh nh: bnh tim mch vnh, tai bin mch mu no, bnh mch ngoi vi, thp tim, tt tim
bm sinh, huyt khi tnh mch su v thuyn tc phi. Hu ht cc bnh tim mch c th phng
c bng gim cc yu t nguy c nh ht thuc l, ch n thiu thc n c li v tha thc
n c hi cho sc khe tim, bo ph, t hot ng th lc, tng huyt p, i tho ng v ri
lon lipid mu. Hin nay Vit Nam, Chng trnh mc tiu quc gia ch yu can thip x
l tng huyt p, tc l mt yu t nguy c quan trng ca bnh tim mch. Cha c ngun s
liu ton quc v t l hin mc v t l mi mc cc bnh tim mch. T l ngi b tng huyt
p s c phn tch mc v yu t nguy c di y.
Ung th: Ung th l mt nhm cc bnh lin quan n vic phn chia t bo mt cch
v t chc v nhng t bo c kh nng di cn. Hin c khong 200 loi ung th. S ngi
mi mc ung th mt nm Vit Nam c tnh l 125036 theo Globocan nm 2012 [135] v
126307 theo s liu c tnh t h thng ghi nhn ung th t 6 tnh, thnh ph nm 2010 [136].
D bo vo nm 2020 s c t nht 189344 ca ung th mi mc. Trong s ca ung th, n chim
43% v nam gii 57%. Bn loi ung th ph bin nht nam gii l ung th gan, phi, d dy
v i trc trng, chim 66% tng s ca ung th mi mc nam gii. n gii, bn loi ph
bin nht l ung th v, phi, gan, c t cung, chim gn 50% tng s ca ung th mi mc n
[135]. T l bnh nhn ung th n khm v iu tr sm cn thp, nm 2009 mt nghin cu
ti 5 bnh vin ung th cho thy chung cc loi ung th 28,6% bnh nhn n giai on I v II,
i vi ung th v 50,5% n sm, ung th c t cung 46,0% n sm v ung th i trc trng
32,2% n sm [136]. Lu cc s liu ny da vo cc trng hp c pht hin v n iu
tr, nhng trng hp khng n c s y t khng c ghi nhn.
Nhiu loi ung th c th phng c bng trnh tip cn vi yu t nguy c nh thuc
l, ru, ho cht gy ung th trong ni lm vic hoc trong thc phm. Mt s loi ung th c
th phng bng vc xin nh ung th gan (tim phng vi rt gy vim gan B), ung th c t cung
(tim phng vi rt Papilloma ngi) hoc bng iu tr bnh H. pylori phng ung th d
dy. Mt s loi ung th nu c pht hin sm c kh nng iu tr khi.
i tho ng: Theo Hi i tho ng Hoa K 2004: i tho ng l mt nhm
cc bnh l chuyn ha c trng bi tng glucose mu do khim khuyt tit insulin, khim
khuyt hot ng insulin, hoc c hai. Tng glucose mu mn tnh trong i tho ng s gy
tn thng, ri lon chc nng hay suy nhiu c quan, c bit l mt, thn, thn kinh, tim v
mch mu [137]. i tho ng cng l yu t nguy c ca nhng bnh khc nh bnh tng
huyt p v bnh thn.
Kt qu iu tra v i tho ng Vit Nam cho thy, t l mc bnh i tho ng la
tui 30-69 tui ton quc l 2,7% vo nm 2002 [138], tng gp i ln 5,4% nm 2012 [139].
y l iu ng bo ng khi t l i tho ng gia tng nhanh hn d bo. T l ri lon dung
np glucose cng tng ln t 7,7% nm 2002 ln 12,8% nm 2012 [139]. c tnh, nm 2010 t
l i tho ng nhm tui t 20-79 tui l 2,9% tng ng 1,65 triu ngi b bnh v d bo
s tng ln 3,42 triu ngi vo nm 2030, gia tng 88000 ngi mt nm [140].
i tho ng tp 1 c cc yu t kh thay i (di truyn, min dch) v yu t mi
trng c th thay i c. Trong mi trng, cc yu t c pht hin lm tn thng ty
dn n i tho ng bao gm bnh quai b, rubella, vi rt coxsackie B4, v cc tc nhn
158
c ha hc nh nitrophnyl-urea c cho chut, hydrogen cyanide t bt sn h hng hay t
c sn. i vi i tho ng tp 2, cng c cc yu t di truyn v mi trng. Yu t mi
trng gy nguy c i tho ng tp 2 bao gm tui cao, bo ph (nht l bo bng) v c
li sng tnh ti, qun th c gia tng bt thng m m, tng lipoprorein c t trng rt thp
(VLDL), tng huyt p.
Bnh phi mn tnh: Bnh ng h hp mn tnh l cc bnh mn tnh nh hng ti
ng th v cc c cu ca phi. Nhng bnh ph bin nht trong nhm bnh ny l bnh phi
tc nghn mn tnh, hen suyn (hen ph qun), d ng ng h hp, bnh phi ngh nghip.
T l hin mc bnh phi tc nghn mn tnh c tnh l 4,2%, trong t l mc nam gii
l 7,1% v n gii l 1,9% [141]. T l hin mc hen ph qun Vit Nam l 3,9%; tr em
l 3,3% v ngi ln l 4,4%. Hen ph qun thng gp hn nam so vi n, vi t s gia
nam v n l 1,63 v 1,24 ngi ln. c tnh t l hin mc hen ph qun cc tnh dao
ng t 1,5% n 6,9% [142].
Cc yu t nh hng ti bnh h hp mn tnh ch yu l ht thuc l, nhim khng
kh trong nh, nhim khng kh bn ngoi nh, tc nhn gy d ng, yu t mi trng lm vic.
Ri lon tm thn - thn kinh: Ri lon tm thn bao gm phm vi rng cc vn c
nhng triu chng khc nhau, nhng ni chung c kt hp nhng bt thng v suy ngh, cm
ng, hnh vi v giao tip vi ngi khc. Mt s v d in hnh l bnh tm thn phn lit,
trm cm, chm pht trin tr tu v nhng ri lon lin quan s dng ru, bia v ma ty. Bnh
thn kinh l nhng ri lon ca h thn kinh do bt thng c cu, sinh ha hoc in trong no,
ct sng hoc nhng thn kinh khc. Mt s triu chng bao gm lit ngi, c bp yu, mt
cm gic, au n, hoc co git. Nhng bnh ph bin nhm ny bao gm ng kinh, au na
u, sa st tr tu, bi no, bnh Parkinson, hoc hu qu ca tai bin mch mu no v chn
thng no. Chng trnh mc tiu quc gia v bo v sc kho tm thn ti cng ng v tr
em ch yu tp trung vo hai bnh l tm thn phn lit v ng kinh.
Ti Vit Nam, cho n nay, mi c mt cuc kho st dch t hc c tin hnh vo u
nm 2000 ca Bnh vin Tm thn Trung ng I phm vi ton quc. Kt qu cho thy 10 bnh
ri lon tm thn ph bin nht cng li nh hng n 14,9% dn s [143]. Trong s ny, ph
bin nht l lm dng ru, bia (5,5%), trm cm (2,8%) v lo lng (2,6%). Gn 3 triu ngi
Vit Nam mc cc ri lon tm thn nghim trng in hnh (tm thn phn lit, trm cm, ri
lon lng cc v cc biu hin nghim trng khc v lo u v trm cm).
2.2. Gnh nng t vong ca mt s bnh khng ly nhim
Ti Vit Nam, trong tng s ngi t vong, t trng do BKLN tng t 56% nm 1990 ln
72% nm 2010 [144]. Trong , bnh tim mch chim 30% tng s trng hp t vong, ung th
21%, bnh ng h hp mn tnh 6%, bnh i tho ng 3%, bnh tm thn - thn kinh 2%.
Khong mt na s t vong xy ra trc 70 tui. Xc nh nguyn nhn t vong sm rt
quan trng trong xy dng chnh sch v k hoch y t. V vy, khi nh gi gnh nng bnh
tt thng phi tnh s nm sng mt i do t vong sm (xem thm mc 1.2, chng II). Bng
24 trnh by s nm sng mt i do t vong sm theo gii ca nhng nhm bnh sp xp theo
tnh trng c hay cha c chng trnh mc tiu y t can thip. Kt qu cho thy BKLN gy ra
56,1% tng s YLL, trong nam gii l 35,1% v n gii l 20,9%. Khong 25,5% tng s
YLL l do nhng BKLN hin ang c chng trnh mc tiu can thip, cn li 30,6% cha c
chng trnh can thip trc tip, d cc chng trnh d phng yu t nguy c nh chng tng
159

huyt p hoc chng tc hi ca thuc l, ru bia u c tc ng ti nhng BKLN cha c
chng trnh.
Bng 24: T vong v YLL do bnh khng ly nhim theo gii v tnh trng c hay cha
c chng trnh can thip, 2010
Tng s BKLN
S t vong
S YLL
318 425
6 760 146
Cc BKLN hin c chng trnh can thip

Vit Nam
% tng s YLL
Chung
Nam
56,1%
35,1%
20,9%
25,5%
15,5%
10,0%
Ung th
91 476
2 319 533
19,2%
12,0%
7,2%
Bnh tng huyt p
6 817
105 300
0,9%
0,3%
0,5%
18 598
240 685
2,0%
1,3%
0,7%
Hen ph qun
5 455
101 317
0,8%
0,5%
0,3%
ng kinh
1 939
83 129
0,7%
0,4%
0,3%
292
9 543
0,1%
0,1%
0,0%
11 297
213 558
1,8%
0,8%
0,9%
30,6%
19,7%
10,9%
Bnh tm thn phn lit

Bnh i tho ng
Cc BKLN cha c chng trnh can thip
c th
Tai bin mch mu no do xut huyt
80 833
1 241 050
10,3%
6,5%
3,8%
27 077
469 474
3,9%
2,6%
1,3%
X gan
14 098
399 778
3,3%
2,7%
0,6%
Bnh thn mn tnh
9 094
204 275
1,7%
1,0%
0,7%
Tai bin mch mu no do thiu mu cc b
6 830
104 902
0,9%
0,5%
0,3%
Thp tim
2 956
66 091
0,5%
0,3%
0,3%
Bnh lot d dy-t trng
2 380
49 992
0,4%
0,3%
0,1%
Ri lon tm thn do ru, bia
1 132
42 045
0,3%
0,3%
0,0%
Cc BKLN khc
38 151
1 109 474
9,2%
5,4%
3,8%
Ch thch: Cc t l phn trm c tnh trn tng s YLL gm c bnh truyn nhim, tai nn chn thng v
BKLN.
Ngun: Tnh ton t Global Burden of Disease Study 2010 (GBD 2010) Results by Cause 1990-2010 - Vietnam
Country Level. Seattle, United States: Institute for Health Metrics and Evaluation (IHME), 2013.
2.3. Gnh nng bnh khng ly nhim tnh theo DALY

Tng gnh nng bnh tt Vit Nam khng phi ch do t vong v c nhng bnh t gy
t vong, nhng to ra gnh nng do ngi bnh phi sng tn tt. DALY, n v o lng gnh
nng bnh tt, c tnh bng tng s nm sng b mt do t vong sm (YLL) v s nm sng
tn tt (YLD) cho tng bnh c th.
Bng 25 cho thy 66,3% tng gnh nng bnh tt tnh bng DALY Vit Nam nm 2010
l do BKLN (Bng 25) [144]. ng lu l cc BKLN Vit Nam hin c chng trnh can
160
thip ch chim 19,6% tng gnh nng bnh tt ca Vit Nam nm 2010, a phn gnh nng
bnh tt do BKLN cha c chng trnh can thip. Th hng cc bnh theo t trng trong tng
DALY c s khc bit vi th hng ca cc bnh theo gnh nng t vong. Trong khi ung th
chim 19,2% tng s nm sng mt i do t vong sm, khi tnh c nm sng tn tt th t l
gnh nng bnh tt gim xung 11% do nhiu loi ung th gy t vong nhanh, s nm sng st
tn tt thp. Ngc li, mt s bnh khng gy t vong sm nhng to ra gnh nng do nm
sng tn tt cao nh trm cm, ri lon thnh gic v tm nhn v thp khp. Trong nhm bnh
cha c chng trnh can thip, c mt s bnh gy gnh nng ln nh tai bin mch mu no,
bnh tim thiu mu cc b, suy thn mn tnh, x gan c tc ng gin tip do cc hot ng
can thip gim cc yu t nguy c nh ru, bia, thuc l, i tho ng (yu t nguy c bnh
thn,) v tng huyt p (yu t nguy c ca bnh tim, tai bin mch mu no). Nhng vn
c mt s BKLN cha c chng trnh can thip ton din nh cc bnh khp xng, ri lon
thnh gic, tm nhn, v mt s loi bnh tm thn-thn kinh.
Bng 25: Gnh nng bnh tt tnh theo DALY do BKLN theo gii, 2010
DALY
% tng s DALY
Chung
Nam
66,3%
36,2%
30,1%
19,6%
11,3%
8,3%
2 357 549
11,0%
6,8%
4,2%
Bnh tng huyt p
108 666
0,5%
0,2%
0,3%
702 332
3,3%
1,8%
1,5%
Hen suyn
300 572
1,4%
0,7%
0,7%
ng kinh
186 336
0,9%
0,5%
0,4%
Bnh tm thn phn lit
183 354
0,9%
0,5%
0,4%
Bnh i tho ng
367 031
1,7%
0,8%
0,9%
46,7%
24,9%
21,8%
1 251 750
5,8%
3,7%
2,2%
Trm cm
908 353
4,2%
1,5%
2,7%
au vng lng di
855 530
4,0%
2,1%
1,9%
533 058
2,5%
1,6%
0,9%
Ri lon thnh gic, tm nhn
503 511
2,3%
1,1%
1,2%
X gan
406 724
1,9%
1,5%
0,4%
au na u
384 240
1,8%
0,6%
1,2%
au c
380 054
1,8%
0,8%
1,0%
Ri lon tm thn do s dng ru
275 078
1,3%
1,1%
0,1%
Suy thn mn tnh
265 188
1,2%
0,7%
0,5%
Ri lon tm thn do s dng ma ty
251 197
1,2%
0,8%
0,3%
Tng s DALY do BKLN
14 219 115
Cc BKLN hin c chng trnh can thip

Vit Nam
Ung th
Cc BKLN cha c chng trnh can thip

c th
Tai bin mch mo no do xut huyt
161
DALY
% tng s DALY
Chung
Nam
Thp khp
234 475
1,1%
0,4%
0,7%
Tai bin mch mu no do thiu mu

cc b
136 299
0,6%
0,4%
0,3%
Thp tim
86 041
0,4%
0,2%
0,2%
Vim lot d dy-t trng
69 505
0,3%
0,2%
0,1%
3 472 272
16,2%
8,0%
8,1%
Cc BKLN khc
Ch thch: Cc t l phn trm c tnh trn tng s YLL gm c bnh truyn nhim, tai nn chn thng v
BKLN.
Ngun: Tnh t Global Burden of Disease Study 2010 (GBD 2010) Results by Cause 1990-2010 - Vietnam Country
Level. Seattle, United States: Institute for Health Metrics and Evaluation (IHME), 2013.
2.4. Gnh nng kinh t

Ngoi gnh nng bnh tt tnh bng DALY, cc BKLN cn gy gnh nng rt ln v kinh
t thng qua cc chi ph trc tip v gin tip nh hng khng ch n ngnh y t m cn n
s pht trin kinh t-x hi. Th nht, chi ph trc tip dnh cho y t l cc chi ph lin quan
trc tip ti vic iu tr BKLN, bao gm cc chi ph vn hnh bnh vin, phng khm, lng
cho cn b, thuc, vt t tiu hao phc v vic iu tr. Ngoi ra, cn cc chi ph dnh cho vic
i li, n trong qu trnh iu tr ca ngi bnh v ngi nh bnh nhn. Th hai l cc chi
ph gin tip bao gm cc chi ph do vic mt nng sut lao ng hay thu nhp mt i do vic
bn ti sn iu tr.
Ti Vit Nam, cho n nay cha c c tnh tng th gnh nng kinh t cho cc BKLN.
Tuy nhin, c mt vi tnh ton cho mt s bnh c th cho thy gnh nng kinh t cng rt ng
quan tm. Tng cc chi ph y t v mt nng sut lao ng lin quan ti 3 cn bnh do thuc l
ti Vit Nam nm 2005 t nht l 1160 t ng (khong 77,5 triu USD) [145]. Mt nghin cu
khc c tnh gnh nng kinh t do ht thuc l gy ra trong 5 nhm bnh lin quan n ht
thuc l (ung th phi, tai bin mch mu no, bnh tim thiu mu cc b, bnh phi tc nghn
mn tnh, ung th ng h hp v tiu ha trn) Vit Nam nm 2011 l 23139,3 t ng
(0,91% tng GDP; 5,07% chi cho y t) [146].
2.5. Cc yu t nguy c
Bn trong 5 nhm BKLN chnh trnh by trong bo co ny c 4 nhm yu t nguy c
chung c th can thip thay i c v do , c th gim c gnh nng ca BKLN. Hnh
45 m t BKLN v cc yu t nguy c. Theo , BKLN b gy ra bi cc yu t sinh chuyn
ho nh tng huyt p, ri lon dung np glucosa, tha cn tip l cc yu t hnh vi c
th thay i c nh: ht thuc, dinh dng khng hp l, t vn ng th lc v s dng ru,
bia mc c hi. Cui cng l mt s yu t mang tnh v m lin quan ti ton cu ha, kinh
t-x hi, th ha v gi ha dn s. Chng ti s trnh by ln lt cc nhm yu t nguy c
v trong kh nng cho php s cung cp s liu c tnh gnh nng.
162
Hnh 45: Bnh khng ly nhim v cc yu t nguy c
2.5.1. Cc yu t kinh t x hi v dn s
Kinh t-x hi v th ha
Tc tng trng n nh ca nn kinh t Vit Nam trong vi thp nin gn y gp
phn quan trng trong vic lm tng thu nhp ca ngi dn, ci thin tnh trng dinh dng.
Tuy nhin, mt tri ca tng trng kinh t v qu trnh th ha nhanh chng Vit Nam
thi gian qua l lm thay i ch n ung (tiu th cc thc n cha nhiu m, ung c
ga), gia tng nhim mi trng v cc hnh vi khng c li cho sc khe (s c trnh by
phn yu t hnh vi) nh s dng ru, bia mc c hi, ht thuc l hay t vn ng th lc.
Gi ha dn s
Gi ha dn s Vit Nam l yu t quan trng nh hng ti gnh nng bnh tt do
BKLN. Tui th trung bnh ca ngi Vit Nam tng t 65 tui nm 1989 [76] ln 73,1 tui
vo nm 2013 [40], a Vit Nam tr thnh mt trong s cc quc gia c t l gi ha dn s
nhanh nht.
Nm 2010, nhm ngi t 70 tui tr ln, t vong do BKLN chim 85% tng t vong
v 86% gnh nng bnh tt tnh bng DALY. i vi nhm 50-69 tui, BKLN chim 82% tng t
vong v 82% tng gnh nng bnh tt tnh bng DALY. T l dn s tui cao cng ln, gnh nng
do BKLN cng tng. Chng I phn tch gi ha dn s cho thy BKLN chim 8 trn 10 nguyn
nhn gy t vong v 9 trn 10 nguyn nhn gy nm sng tn tt ca ngi 70 tui tr ln.
163

2.5.2. Nhm cc yu t nguy c c th thay i c
Ht thuc l
Ht thuc l yu t nguy c ca hng lot BKLN: tai bin mch mu no, bnh ng
h hp mn tnh nh bnh phi tc nghn mn tnh, ung th (phi, gan, d dy, vm hng, thc
qun, ty, c t cung, ming, bch cu) bnh tim thiu mu cc b, i tho ng, [147].
Nm 2010, c tnh ht thuc l gy ra 16,9% tng s ca t vong tng ng 74710 ca t
vong v 8,8% tng gnh nng bnh tt tnh bng DALY, ch yu l do cc BKLN (97% tng t
vong v 94% tng s DALY lin quan ht thuc l l do BKLN) [148].
Xu hng ht thuc l Vit Nam bt u gim, nhng t l ht vn cn cao. Nm
1992/93 t l hin ht thuc l (gm c thuc lo) nam gii t 15 tui tr ln l 60,5% [149],
n nm 2001/02 gim xung mc 56,1% [150] v n nm 2010 gim tip n 47,4% [33].
n gii, t l hin ht nm 1992/93 l 4,2% n nm 2001/02 l 1,8% v nm 2010 l 1,4%.
T nm 1992/93 n nm 2010, t l hin ht gim tng nhm tui (Bng 26). Nm 1992,
t l ht thuc l cao nht l nhm 25-44 tui, n nm 2010 nhm c t l ht cao nht l nhm
45-64 tui. Vit Nam nm trong nhm 15 nc c s ngi ht thuc l nhiu nht trn th gii
vi khong 15,3 triu ngi trng thnh ang ht thuc l [33]. c bit, t l ht thuc l
ca thanh thiu nin Vit Nam vn mc cao v tui bt u ht thuc l ngy cng tr. C
43,6% nam thanh thiu nin cho bit tng ht thuc vi tui trung bnh khi bt u ht
thuc l l 16,9. Trong s nhng nam thanh nin tng ht thuc, c ti 71,7% hin nay vn
ang ht [151].
Bng 26: T l hin ht thuc l theo tui v gii Vit Nam, 1992-2010
1992
2010
Nhm tui
Nam
Nam
15-24
37,8
0,5
26,1
0,3
25-44
75,4
2,6
56,7
0,9
45-64
68,3
9,2
59,5
2,9
65+
55,8
11,5
33,3
2,9
Ngun: 1992/93: iu tra mc sng dn c nm 1992/93; 2010: Global Adult Tobacco Survey 2010.
C n 73,1% ngi trng thnh b phi nhim vi khi thuc ti nh (67,6%, tng
ng 33 triu ngi b phi nhim ti nh l ngi khng ht thuc) v 55,9% ngi lao ng
phi nhim vi khi thuc l ti ni lm vic (49,0%, tng ng 5 triu ngi b phi nhim
li l ngi khng ht thuc). T l ht thuc th ng cao nht l cc qun ru/c ph/tr
vi 92,6% v nh hng vi 84,9%. T l ny cc trng i hc v cc cng s ln lt l
54,3% v 38,7% [33].
So vi cc nc khc trn th gii, tnh trng ht thuc Vit Nam ang mc cao
(Hnh 46).
164
Bu-tan (2007)
n (2009)
CHDCND Lo (2008)
Chung
Pa-kt-xtan (2003)
Thi lan (2007)
Xri lan-ca (2009)
Cam-pu-chia (2011)
Nam
Ma-lai-xi-a (2011)
Vit Nam (2010)
Mng C (2009)
Trung Quc (2009)
Phi-lp-pin (2009)
80
70
60
50
40
30
20
10
0
In--n-xi-a
Phn trm
Hnh 46: Ht thuc l hin ti cc nc ang pht trin chu nhng nm gn y
Ngun: World Health Organization. WHO report on the global tobacco epidemic 2013. Tobacco control country
profiles. http://www.who.int/surveillance/policy/country_profile/en/.
nhim khng kh c th lm trm trng thm cc vn sc kho lin quan n thuc

l. Mt nghin cu ca Trng i hc YTCC H Ni nm 2010 cho thy nng PM2.5 trong
khng kh trong nh v ngoi tri ti tt c cc a im cng cng u cao hn tiu chun ca
WHO (25 g/m3), c bit l cc im vui chi gii tr. Tng t nh vy, nng nicotin
trong khng kh c pht hin tt c cc im nghin cu, cao nht cc im vui chi gii
tr (2,5 g/m3 ti khu vc ht thuc v 1,3 g/m3 ti khu vc khng ht thuc) v cao nht ti
cc trng hc (0,03 g/m3)[152].
S dng ru, bia qu mc
S dng ru, bia qu mc lin quan ti nhiu bnh mn tnh v chn thng [147].
Gnh nng quy thuc cho mt s vn sc kho lin quan n s dng ru, bia, bao gm ri
lon tm thn do s dng ru, x gan, tai bin mch mu no, ung th gan, ung th ming/
hu hng, ung th thc qun, ung th v, ng kinh, chn thng do tai nn giao thng v bo
lc. Tng cng, s dng ru, bia gy ra 5,7% tng s ca t vong v 4,7% tng gnh nng bnh
tt tnh bng DALY ca Vit Nam nm 2010 [148]. Khong 3/4 gnh nng bnh tt lin quan
ru, bia l do BKLN.
Mc tiu th ru, bia bnh qun u ngi tng nhanh. Mc tiu th ung c cn
bnh qun mt ngi 15 tui tr ln mt nm tng t 3,8 lt cn nguyn cht giai on 20032005 n 6,6 lt cn nguyn cht giai on 2008-2010, bao gm c ung c cn c ghi
nhn v khng ghi nhn32 (v d nh ru khng thu thu ti nc tiu dng v c sn xut
trong khu vc khng chnh thc, l hng xch tay, hoc bun lu). Giai on 2008-2010, nam
gii bnh qun tiu th 12,1 lt/nm trong khi n gii tiu th 0,2 lt/nm. Tnh ring ngi c
tiu th ru (15 tui tr ln) nam gii l 27,4 lt/nm v n gii l 0,9 lt/nm [153]. So snh
quc t cho thy mc tiu th ru, bia ca Vit Nam mc cao so vi cc nc ang pht
trin khc chu (Hnh 47).
32
Tnh bng cn nguyn cht gm c ung c ghi nhn v khng ghi nhn.
165

Mc bia c tiu th bnh qun u ngi nm 2013 c tnh l 35,6 lt [31]. Vit Nam
l nc c thu nhp bnh qun u ngi ng th 8 trong khu vc ASEAN nhng c mc tiu
th ru, bia ng th nht ASEAN v th 3 ti chu [154]. Bnh qun mt nm, ngi Vit
Nam chi gn 3 t USD cho tiu th bia, chim khong 1,8 % GDP [155].
14
12
10
8
6
4
2
Nam
Pa-kt-xtan
In--n-xi-a
Bu-tan
Ma-lai-xi-a
Xri lan-ca
Phi-lp-pin
Cam-pu-chia
Trung Quc
Mng C
Vit Nam
CHDCND
Lo
Thi Lan
Lt cn nguyn cht bnh qun u

ngi 15 tui tr ln
Hnh 47: Tiu th ung c cn bnh qun u ngi cc nc ang pht trin chu
, trung bnh trong giai on 2008-2010
Ngun: Global status report on alcohol and health 2014. World Health Organization, Geneva 2014.
M hnh s dng ru bia rt khc nhau theo tui v gii, tuy nhin tnh hnh s dng
ru, bia qu mc ang tng ln. Bng 27 cung cp s liu v t l s dng ru, bia c trng
theo tui nm 2008. Theo , t l nam s dng ru, bia mc nguy c v nguy him cao hn
hn so vi n v tp trung nhm tui trung nin. Kt qu iu tra v cc yu t nguy c ca
mt s BKLN nm 2009 cho thy 6% n v 70% nam t 25-64 tui c ung ru, bia trong
thng; trong khong 40% nam gii tui ny tiu th ru, bia mc c hi v nguy
him (t 4 ly chun tr ln mt ngy, tng ng khong 56 g cn nguyn cht) [156]. T l
ung ru qu mc (t nht 60 g trong t nht mt ln trong 30 ngy qua) l 5,5% nam gii
ung ru v 0,8% n gii ung ru [153].
Bng 27: T l s dng ru, bia (%) c trng theo tui - gii, 2008
Nhm tui
Nam
15-29
30-44
45-59
60-69
70-79
80+
Khng/t s dng
68,9
62,0
64,4
69,4
73,8
76,9
Mc thp
25,4
23,2
21,7
20,1
18,7
17,8
Mc c nguy c
1,4
5,0
4,8
4,2
3,3
2,7
Mc nguy him
4,3
9,8
9,1
6,3
4,2
2,6
Khng s dng
99,4
98,6
97,8
97,6
97,2
96,9
Mc thp
0,5
1,2
1,7
1,7
2,1
2,2
Mc c nguy c
0,0
0,2
0,4
0,4
0,3
0,3
Mc nguy him
0,1
0,0
0,1
0,3
0,4
0,6
Ngun: Nghin cu Gnh nng bnh tt gy ra bi mt s yu t nguy c ti Vit Nam [157].
166
T l s dng ru, bia tui v thnh nin, thanh nin v ph n u ang gia tng
nhanh. Kt qu iu tra v v thnh nin Vit Nam cho thy, sau 5 nm (2003-2008), t l thanh
thiu nin (16-30 tui) s dng ru, bia tng thm 10 im phn trm. Nm 2008, c gn 80%
nam v trn 36% n v thnh nin v thanh nin c s dng ru, bia, so vi 69% v 27% nm
2003. Tui trung bnh bt u ung ru, bia ca nam l 16,5 tui v n khong 17,5 tui.
Trong nhm thanh thiu nin (16-30 tui) tng ung ru, bia, c 60% nam v 22% n cho
bit h tng say ru, bia [151]. Mt iu tra khc nm 2013 cho thy, trong s hc sinh t
13 n 17 tui, 31,7% nam gii v 16,5% n gii tha nhn l tng ung t nht mt ly
ung c cn trong 30 ngy qua; trong s , 27,8% nam gii v 15% n gii tha nhn tng
ung ru qu nhiu v tng say. Trong s sinh vin 13-17 tui tng ung ru, c n
47,2% tng s dng ru, bia trc 14 tui, (52,7% nam v 40,1% n) [158].
Tc ng v mt sc kho ca vic s dng ru, bia l rt ln. Theo thng k ca Vin
Chin lc v Chnh sch Y t, c ti 4,4% ngi dn Vit Nam phi gnh chu bnh tt do hu
qu ca ru, bia mang li [159]. Nm 2010, c tnh c 8,7% nam v 0,9% n tui t 15 tr ln
c cc ri lon lin quan n s dng ru [153]. Trong , l thuc vo ru (alcoholism) chim
t l 5,9% nam v 0,1% n t 15 tui tr ln. Tnh trng nghin hoc lm dng ru ph bin
nht thnh ph ln v min ni, tuyt i a s l nam gii tui 20-40, nhng ngi thng bt
u ung khi cn tr (15-30 tui) [160]. S liu ca Bnh vin Tm thn Trung ng I cho bit
6,5% tng s ngi iu tr ni tr nm 2010 ang iu tr cc ri lon tm thn do ru, t l
ny c xu hng tng ln, t 4,4% (nm 2001) ln 7,03% (nm 2005) [161]. Theo Bnh vin
Tm thn thnh ph H Ch Minh, cc ri lon tm thn do lm dng ru chim 4,68% dn
s, bng tng ca hai loi bnh tip theo l trm cm (2,47%) v ri lon lo u (2,27%) [162].
t hot ng th lc
t hot ng th lc lin quan nhiu loi BKLN nh chng long xng, vim xng
khp, aulng, bo ph, bnh tim mch, ung th v ung th tin lit tuyn, ung thtrctrng,
trm cm, lo u, cng thng. t hot ng th lc gy ra 2,8% tng s t vong (12648 ca t
vong) v 1,5% gnh nng bnh tt tnh bng DALY theo c tnh ti Vit Nam nm 2010. c
bit, theo nghin cu Vit Nam, gnh nng bnh tt lin quan t hot ng th dc hon ton
do BKLN, trong ch yu l cc bnh tim mch, ung th i trng v i tho ng l cc
vn sc khe chnh lin quan n tnh trng t vn ng [148].
S liu Chng I (Bng 10) cho thy t l ngi luyn tp th dc th thao thng
xuyn ang tng ln, tuy nhin n nm 2013 mi ch t 27,2%. Bng 28 di y trnh by t
l hot ng th lc theo tui. S liu cho thy, t l hot ng th lc mc n cao
hn nam ti cc la tui. T l ngi hot ng th lc gim dn theo tui. Nm 2009, 30,4%
ngi 25-64 tui vn ng th lc mc thp, vi t l ny thnh th cao hn nng thn
[157]. Kt qu iu tra gn y trn 900 ngi dn H Ni, Hu, thnh ph H Ch Minh cho
thy c n 34% khng tham gia bt k hot ng th thao no vi cc nguyn nhn ch yu l
khng c thi gian (84%), ngi dy sm, ngi vn ng (9%) v thiu phng tin v a im
tp luyn (2%) [163].
167

Bng 28: T l hot ng th lc c trng theo tui - gii theo 3 mc (%)
Nhm tui
Nam
30-44
45-59
60-69
70-79
80+
89,9
86,8
81,3
80,1
77,7
Khng
1,3
2,2
2,3
3,3
3,8
Khng/ t vn ng
8,8
11
16,3
16,6
18,5
94,0
91,0
84,2
84,1
81,8
Khng
0,9
1,8
2,4
2,6
2,9
Khng/ t vn ng
5,2
7,2
13,4
13,3
15,3
Ch thch: Khng hoc rt t hot ng th lc ti ni lm vic, khi nh, i li hoc khi rnh ri; Hot ng
khng l thc hin mt vi hot ng th lc nhng thi gian hot ng t hn 150 pht/tun vi cc hot ng
cng trung bnh hoc 60 pht/tun vi cc hot ng cng nng ni lm vic, nh, i li hay khi rnh
ri; Hot ng l hot ng ti thiu 150 pht/tun cng trung bnh hoc 60 pht/tun vi cng nng
ni lm vic, nh, i li hay khi rnh ri; hoc i b t nht 600 m/tun (nh ngha ny ph hp vi khuyn co
hin nay nhiu quc gia) [157].
Ngun: Nghin cu Gnh nng bnh tt gy ra bi mt s yu t nguy c ti Vit Nam[157].
Khi ng hot ng th lc tui tr l yu t thit yu trong vic thnh lp li sng

lnh mnh, nhng Vit Nam, t l thanh thiu nin tham gia hot ng th lc cn rt thp.
Theo kt qu ca iu tra quc gia v v thnh nin v thanh nin ln th hai, c n 23% thanh
thiu nin him khi hay khng bao gi tp th dc th thao, 45% thnh thong mi tp [164].
Mt nghin cu theo di 5 nm t 2004-2009 thanh thiu nin ti thnh ph H Ch Minh
cho thy thi gian dnh cho hot ng th lc gim c ngha thng k t 87 pht xung cn
50 pht/ngy. Thi gian dnh cho cc hot ng tnh trong 5 nm tng t 512 pht ln 600
pht mi ngy [165].
Trong cng vin, s lng thanh nin tham gia chy b, i b hoc tp th dc t hn so
vi ngi ln. Nm 2013, trong s cc hc sinh t 13 n 17 tui, ch c 19,7% bo co hot
ng th lc vi t nht 60 pht mi ngy trong 5 ngy tr ln trong mt tun qua, 26,8% nam
gii v ch c 13,4% n gii. Ch c 4,5% hc sinh bo co tham d cc lp hc gio dc th
cht t 3 ngy tr ln mt tun trong sut nm hc. Ngc li, khong 42,4% thanh thiu nin
ngi tnh ti t ba gi tr ln trong mt ngy bnh thng [158]. Kt qu ny cho thy Vit
Nam khng tun th khuyn ngh ca WHO v hot ng th lc, v so snh quc t cho thy
Vit Nam c kt qu yu i vi s gi tham gia gio dc th cht cc trng hc (Hnh 48).
H qu l t l tha cn, bo ph ang c xu hng tng ln c ngi trng thnh, nht l ti
khu vc thnh th (xem thm phn di v ch s khi c th).
168
Mng C (2013)
n (2007)
Ma-lai-xi-a (2012)
Trung Quc
Bc Kinh (2003)
Vit Nam (2013)
In--n-xi-a (2007)
Pa-kt-xtan (2009)
Thi lan (2008)
Xri Lan-ca (2008)
Phi-lp-pin (2011)
50
45
40
35
30
25
20
15
10
5
0
Cam-pu-chia (2013)
Phn trm
Hnh 48: Cc ch s hot ng th lc i vi thiu nin cc nc ang pht trin

chu , nm gn y nht
Hot ng th lc t 60 pht tr ln mt ngy trong 7 ngy qua

Tham gia lp gio dc th cht 3 ngy tr ln mt tun trong nm hc
Ch thch: Mt s nc khng c s liu v cc lp hc th cht. tui 13-15, ngoi tr Ma-lai-xi-a, Mng C v
Cam-pu-chi-a, c gp chung l tui v thnh nin 13-17 tui.
Ngun: WHO. Global school-based student health survey (GSHS). Country data sheets. http://www.who.int/chp/
gshs/factsheets/en/
Ch dinh dng khng hp l

Ch dinh dng khng hp l bao gm nhiu hnh vi khc nhau. Lin quan cc bnh
tim mch c cc yu t nguy c l n qu t rau, qu, ng cc nguyn cm, ht (nh lc, vng),
cht x, hi sn cha a xit bo Omega 3, a xit bo bo ha a, v n tha mui, tht ch bin
(nh ch, gi, gim bng), cht bo chuyn ha (TFA). Yu t nguy c ca ung th, ch yu
ung th d dy v i-trc trng l n qu t cht x, rau, qu, sa, can-xi v n tha tht b, tht
ch bin v mui. i tho ng lin quan n thiu ng cc nguyn cm v n tha tht b,
tht ch bin v ung c ng. Tha cn, bo ph l hu qu ca vic n tha thc phm,
c bit ung ngt, ng thi l yu t nguy c ca nhiu bnh tt. Tha cn v bo ph s
c phn tch mc ch s khi c th di y. Gnh nng bnh tt do ch n nm 2010
c tnh l 23% tng s t vong v 9,5% tng s DALY.
Trong khi suy dinh dng th thiu cn gim mnh do s lng protein v nng lng
tiu th tng ln, c cu (protein, lipid, gluxid) cng c ci thin. Xu hng tiu th thc
phm t nm 1981 n nm 2010 cho thy s gia tng mnh hu ht cc loi thc phm nh
tht (tng t 11,1 n 84g/ngi/ngy), c (tng t 35 n 59,8g), trng v sa (tng t 0,8g ln
29,5g), qu chn (tng t 2,2g ln 61,9g), du m (tng t 1,6g ln 8g) v lc vng (tng nh t
3 ln 5,4g) (Bng 29). Vin Dinh dng nh gi cn bng lipid, gluxid v protein hin nay l
mc l tng [166].
169

Bng 29: Bin ng khu phn n ca ngi Vit Nam 2000-2010 (n v gam/ngi/
ngy)
Loi thc phm
Nm 1981
Nm 2000
Nm 2010
Tht
11,1
51,0
84,0
35,0
45,5
59,8
Trng, sa
0,8
10,3
29,5
Du m
1,6
6.8
Rau
214
178,6
190,4
Ngun: Vin Dinh dng Quc gia. Tng iu tra dinh dng 2009-2010.
Mc d c nhng ci tin v dinh dng, vn c mt s m hnh ng lo ngi lin

quan n ch n ung, c bit l lin quan n BKLN. S lng mui tiu th bnh qun
u ngi hng ngy ln ti 18-22g, cao hn mc khuyn co 3-4 ln [167]. T l nhng ngi
n t hn 5 khu phn rau qu mi ngy l kh cao, 77,1% thnh th v 83,7% nng thn
[157]. Tng iu tra v dinh dng nm 2010 cho thy mc tiu th rau ch c t 57% mc
khuyn co. Kt qu kho st cng cho thy tiu th tht mc cao v tiu th thy sn thp hn
so vi mc khuyn co. Vin Dinh dng Quc gia khuyn co tiu th 1,5 kg tht mi ngi
mi thng. Tiu th tht trong tt c cc vng vt qu mc khuyn co 1,5 kg/ngi/thng ca
Vin Dinh dng, c bit l ng bng sng Hng vi mc tiu th ti 216% so vi khuyn
co. Trong khi , mc tiu th hi sn ch t 83% so vi mc khuyn co 2,5 kg/ngi/thng,
thp nht l vng trung du v min ni khu vc pha Bc [166].
S mt cn bng trong ch n ung c bit ni bt trong mt s nhm dn s v
khu vc. c bit vic tiu th qu nhiu nng lng tr em, s dng qu nhiu cht bo
chuyn ho v cht bo bo ho hc sinh v ngi dn thnh th, v mt s nhm nhn vin
vn phng. Xu hng tiu th thp hn khuyn co cc loi rau v tri cy cng kh ph bin
nhng nhn vin vn phng v hc sinh ph thng, c bit l trong trng tiu hc. Mt
nghin cu gn y cho thy cc em hc sinh trng tiu hc thnh ph H Ch Minh ch n
50% lng rau khuyn co v 30% lng tri cy c khuyn co mi ngy [168]. So vi mc
khuyn co, tiu th rau rt thp, c bit l ng bng sng Cu Long v Bc Trung B (49%
mc khuyn co) v Ty Nguyn (53%). Mc tiu th cao nht cng ch t 72% mc khuyn
co, vng trung du v min ni Bc B [166].
Cc loi thc phm c ngi dn la chn ang c xu hng ngy cng km lnh
mnh. Vi mc tiu th 5,1 t gi m n lin trong nm 2012, Vit Nam l nc ng th 4 trn
th gii v tiu th sn phm ny nhng cha c quy nh c th v cha kim sot c hm
lng cc cht bo chuyn ho v mui. 100% mu m tm (62/62 mu) kim tra ti thnh ph
H Ch Minh gn y u c axit oxalic vi nng t 30,8 - 449 ppm. Trong khi , Hip hi
Ngi tiu dng Penang, Ma-lai-xi-a mi y va thng bo n nhiu m n lin tng nguy c
t qu cng nh suy thn, tng huyt p
Nm 2013, Vit Nam tiu th khong 925 triu lt nc ngt c ga, khng cn. Kho st
ti cc cng-tin ca 16 trng tiu hc thnh ph H Ch Minh nm hc 2010-2011 cho thy
nhiu loi thc phm nh nc ngt, bnh cc loi, m gi tuy khng c li cho sc khe nhng
p ng th hiu v gi thnh nn c mua bn ph bin nht ti cc cng-tin vi t l ln lt
170
l 60%, 41,2% v 23,9% trong khi tri cy chim t l thp nht trong cc nhm thc phm bn
ti cng-tin (1,1%). Bn cnh , ch c 12,5% nhn vin cng-tin c tp hun v dinh dng
hp l [169]. Chng ta cha c cc quy nh kim sot vic tip th mt hng ny vi tr em v
cha c cc chnh sch nhm lm gim lng ng trong nc gii kht.
2.5.3. Nhm yu t nguy c sinh, chuyn ha
Tng huyt p
Tng huyt p l yu t nguy c chnh gy ra tai bin mch mu no, bnh mch vnh,
v cc bnh tim mch khc [170]. Theo iu tra ca Vin Tim mch Trung ng, t l mc cao
huyt p ngi trng thnh l 25,1% [171], nam cao hn n (28,3% v 23,1%), tng 48% so
vi t l mc cng b bi iu tra y t ton quc nm 2001-2002 [150]. Trong nhm c pht
hin huyt p cao trong iu tra, ch 48,4% bit trc l b tng huyt p, 29,6% ang iu tr v
10,7% ang qun l huyt p hiu qu (t huyt p <140/90mmHg). T l ngi b tng huyt
p tng theo tui c nam v n. T l tng huyt p thnh th cao hn nng thn (32,7
v 17,3%). Huyt p cao gy ra 91560 ca t vong nm 2010, chim 20,8% tng s t vong v
7,2% tng s DALY, ch yu do tai bin mch mu no v bnh tim thiu mu cc b [148].
Tng cholesterol mu
Hm lng cholesterol ton phn trong mu cao l yu t nguy c ca bnh tim thiu
mu cc b v tai bin mch mu no do thiu mu cc b [170]. S liu iu tra cc yu t
nguy c nm 2008 cho thy t l m mu cao (trn 5 mmol/l) Vit Nam l 30,1% [156]. Nguy
c quy thuc ca hm lng cholesterol ton phn trong mu cao i vi bnh tim thiu mu
cc b v tai bin mch mu no n cao hn nam gii. Hm lng cholesterol ton phn
trong mu cao gy ra 1,4% ca t vong v 0,7% tng s DALY Vit Nam nm 2010 [148].
ng huyt tng lc i v i tho ng
ng huyt tng lc i l ch s chn on i tho ng, nhng ng thi l yu
t nguy c cho nhiu vn sc khe khc, nh bnh tim thiu mu cc b, tai bin mch mu
no v suy thn khi ng mu cha n mc c chn on i tho ng [170]. Ri lon
dung np ng huyt c chn on khi ng huyt lc i t 5,6 mmol/l tr ln (theo Hi
i tho ng M) v i tho ng c chn on khi ng huyt lc i t 7 tr ln.
Nm 2009, ti Vit Nam, 3,8% dn s t 25 n 64 tui c ng huyt lc i t 5,6 mmol/l
tr ln. T l ny thnh th (4,6%) cao hn nng thn (3,4%), nam (4,4%) cao hn n
(3,2%) [156].
T l mc i tho ng theo tui v gii c trnh by ti Bng 30 di y. Theo ,
t l mc i tho ng c xu hng tng theo tui v n cao hn nam. Yu t nguy c ny gy
6,3% tng s t vong v 3% tng gnh nng bnh tt tnh bng DALY Vit Nam nm 2010.
Nguy c quy thuc qun th ca i tho ng n cao hn nam cho c bnh tim thiu mu
cc b v tai bin mch mu no [148].
171

Bng 30: T l hin mc i tho ng (%) theo tui v gii, 2008
Nhm tui
30-44
45-59
60-69
70-79
80+
Nam
1,2
4,6
7,6
8,7
9,6
1,5
5,3
8,6
10,3
11,8
Ngun: Nghin cu Gnh nng bnh tt gy ra bi mt s yu t nguy c Vit Nam
Tha cn v bo ph (ch s khi c th cao)

Ch s khi c th (BMI) c s dng nh gi tnh trng dinh dng ngi ln,
c bit xc nh tnh trng tha cn, bo ph. Tha cn, bo ph l yu t nguy c i vi
ung th ng tiu ha v mt s loi ung th khc, bnh tim mch (nh tai bin mch mu no
do thiu mu cc b, bnh tim do thiu mu cc b, bnh tng huyt p), bnh thn mn tnh,
thp khp v au vng lng di [170].
Trn ton quc, t l nam v n c BMI t 23-24,9 (tha cn theo tiu chun ngi chu
) xp x nhau (14,6% nam; 15,1% n), t l ngi c BMI t 25-29,9 (qu cn) nam
(11,3%) cao hn n (10,4%) (Hnh 49). Nh vy, nm 2012, nu ly im ct BMI t 23 tr ln,
26,1% dn s Vit Nam tha cn v bo ph c nguy c mc BKLN.
khu vc thnh th, t l ngi tha cn, bo ph cao hn hn khu vc nng thn (t l
tha cn ca nam khu vc thnh th l 37%, khu vc nng thn l 21,3%; t l tha cn ca
n khu vc thnh th l 31,5%, khu vc nng thn ch c 19,9%)[156].
T l tha cn v bo ph ngi ln tng nhanh, c bit cc thnh ph ln, do
ch n tha nng lng v li sng t vn ng. Nm 2006, 16,3% ngi t 25 n 64 tui
tha cn v bo ph [172], n nm 2010 ln 26,9% [156].
1.1
1.0
10.9
10.4
11.3
8.9
8.7
BMI t 30+
BMI t 25 n 29,9
15.1
14.9
14.6
13.2
13.9
12.6
Nam
18.6
BMI t 23 n 24,9
17.9
10
0.9
0.8
0.9
20
15
1.2
1.6
1.5
15.5
25
19.4
Phn trm
30
17.6
35
13.6
40
1.8
Hnh 49: C cu BMI ngi trng thnh theo gii v khu vc thnh th/nng thn,
2009
Chung
0
Chung Nam
Thnh th
Chung Nam
Nng thn
Ton quc
Ngun: B Y t, Bo co kt qu nghin cu ti khoa hc cng ngh: Nghin cu cc yu t nguy c ca mt

s BKLN Vit Nam, 2012 (cha cng b).
172
Trong giai on 2000 - 2010, t l tha cn v bo ph tr em di 5 tui tng gp 9
ln t 0,62% n 5,6%, vt gii hn cho php l 5% theo mc tiu ca chnh sch. khu vc
thnh th, 6,5% tr em tha cn v bo ph, v trung tm thnh ph, t l ny vt 12% [166].
iu tra ti 2 trng hc ti thnh ph H Ch Minh cho thy 60% hc sinh c m mu cao;
khong 38,5% bo bng hoc ch s khi c th cao [173]. Mt nghin cu khc nm 2011 cho
thy trong nhm tr em t 6 thng n 12 nm tui ti khu vc thnh th, 29% tha cn hoc
bo ph [174].
Tha cn, bo ph gy ra khong 1% tng s ca t vong v 0,9% gnh nng bnh tt tnh
bng DALY ti Vit Nam nm 2010. i tho ng, bnh tim thiu mu cc b, thp khp v
au vng lng di l cc vn sc khe chnh ca gnh nng do ch s khi c th cao [148].
2.5.4. Cc yu t nguy c i vi bnh tm thn
Trong khi cha c cc nghin cu mang tnh h thng v cc yu t nguy c v yu t

bo v i vi cc bnh l tm thn, ngy cng c nhiu cc bng chng v vn ny. Ru
v ma ty l nhng yu t nguy c chnh i vi bnh tm thn. Cc vn v ru c
tho lun trong chng ny, trong khi cc vn lin quan n ma tu c tho lun trong
Chng I. y, chng ta s tp trung vo cc yu t nguy c khc nhau c xc nh trong
cc nghin cu v sc khe tm thn Vit Nam.
Mt nghin cu v sc khe tm thn ngi trng thnh t 18 tui tr ln cho thy
ngho i l mt yu t nguy c quan trng i vi bnh tm thn. Kt qu nghin cu cng
cho thy ph n, nhng ngi tr v nhng ngi rt gi d b suy sp tinh thn hn so vi n
ng v nhng ngi trong tui trung nin [175]. Ri lon tm thn trong giai on sau sinh
kh ph bin ti Vit Nam v chu nh hng bi mt s yu t. Nhng ngi sng trong cc
x ngho nng thn v nhng ngi b bo lc gia nh (bao gm c lm dng th cht v
tinh thn) c nguy c mc cc ri lon tm thn ph bin trong giai on chu sinh cao gp i
so vi nhng ngi sng cc khu vc tng i giu c th v nhng ngi khng c
tnh trng bo lc gia nh. C hai yu t ny kt hp vi nhau cng lm tng nguy c mc ri
lon tm thn chu sinh. S thng cm ca chng v m chng dng nh l mt yu t bo v
lm gim t l ri lon tm thn chu sinh [176].
Tr em v thanh thiu nin l nhm c bit d b tn thng bi cc vn sc khe
tm thn. Mt nghin cu nm 2011 v thnh nin t 11 n 18 tui cho thy h gia nh c
thu nhp cao, ngi gi, v tn gio l nhng nhn t quan trng bo v sc khe tm thn
Vit Nam [177]. Mi quan h tin cy gia cha m v con, v vic gim st cn thn ca cha m
c th l nhng yu t bo v quan trng; thiu nhng yu t ny c th lin quan n s xut
hin ca cc vn sc kho tm thn. D liu v thanh thiu nin t 13 n 17 tui cho thy
khong 10% tr em Vit Nam vng hc khng php; 70% thanh thiu nin cho bit cha m ca
h ch i khi hoc khng bao gi bit nhng g con ci ca h ang lm v 80% cho bit cha
m ca h ch thnh thong hoc khng bao gi hiu c cc vn h gp phi trong 30 ngy
qua. Cc ch s ny cho thy thanh thiu nin Vit Nam khng c bo v y , v do d
b cc vn sc khe tm thn hn so vi khi thanh thiu nin c cha m gim st hot ng
cht ch hn v lng nghe mt cch cn thn hn cc mi quan tm ca h[158].
173

2.6. Kt lun v khuyn ngh
Kt lun
Cc BKLN hin nay chim t trng ln trong m hnh bnh tt Vit Nam trn cc kha
cnh lin quan ti dch t hc, gnh nng bnh tt tnh bng t vong, s nm mt i do
t vong sm, DALY v gnh nng kinh t.
Cc chng trnh can thip phng, chng BKLN hin nay ch bao ph khong 30% tng
s BKLN gy gnh nng bnh tt. Mt s nhm BKLN chim t l gnh nng bnh tt
ln nhng cha c quan tm l bnh tai bin mch mu no, x gan, bnh thn mn
tnh, bnh xng khp, v bnh trm cm.
BKLN chu nh hng ca nhiu nhm nguy c khc nhau, trong , ch n khng
hp l, ht thuc l, tng huyt p v s dng ru, bia qu mc l 4 yu t nguy c
quan trng nht i vi gnh nng bnh tt t BKLN. Xu hng v cc yu t nguy c
cho thy t l ht thuc l bt u gim nhng vn cn mc cao i vi nam gii, t l
tng huyt p, mc tiu th ru, bia v t l b tng huyt p ang tng ln.
Trong nhm BKLN, c nhiu bnh khng gy t vong sm, nhng bnh ko di nhiu
nm sng tn tt, cn iu tr, qun l bnh ko di sut vng i ngi bnh.
S liu dch t cc BKLN v yu t nguy c Vit Nam khng y , thiu tin cy
v kh tm do cc c quan lin quan khng cung cp d liu cp nht trn trang web ca
n v hoc ca B Y t. Nhiu lc phi da trn s liu quc t cng b, mc d ngun
s liu ca t chc quc t chnh l cc n v ca ngnh y t Vit Nam. B ch s theo
di, gim st phng, chng BKLN Vit Nam cha c hon thin.
Khuyn ngh
Ngnh y t cn phi hp lin ngnh, huy ng s tham gia ca cc ban, ngnh, t chc
x hi v cng ng gim cc yu t nguy c ca BKLN.
a vic phng chng v kim sot BKLN vo thnh chng trnh u tin ca Chnh
ph v ngnh y t. Thc hin 3 bc c bn sau: (i) nng cao nhn thc v BKLN cho
cc nh hoch nh chnh sch, c bit l nhng ngi ngoi ngnh y t; (ii) phn tch
la chn cc can thip da trn cc tiu ch: hiu qu chi ph, cng bng, thch hp vi
iu kin vn ha x hi ca a phng v (iii) trn c s xy dng Chin lc quc
gia v phng, chng BKLN.
R sot loi cc ch s gim st BKLN ca Vit Nam v xy dng k hoch, cp kinh
ph thu thp thng tin cn thit gim st tnh hnh BKLN v nh gi tc ng ca
cc can thip. Thit lp, hon thin v vn hnh h thng theo di gim st, trong tp
trung vo ghi nhn t vong, gim st ti cng ng, iu tra phi nhim vi yu t nguy
c, v p ng ca h thng y t.
174
Chng IV: Kim sot cc yu t nguy c chung ca cc bnh khng ly nhim
Chng IV: Kim sot cc yu t nguy c chung ca cc

bnh khng ly nhim
Kim sot cc yu t nguy c l mt trong ba nhm gii php chnh c WHO
khuyn co phng chng cc BKLN ton cu. Tnh hnh cc yu t nguy c BKLN c
gii thiu trong chng III. Chng ny s tng hp cc chnh sch, chin lc ca Vit Nam
v kim sot bn yu t nguy c chung ca cc BKLN, bao gm: ht thuc l, lm dng ru,
bia, ch dinh dng khng hp l v li sng t vn ng. Bo co cng s phn tch, nh
gi nhng kt qu t c cng nhng kh khn, thch thc trong t chc trin khai thc
hin cc chnh sch, chin lc ny. Trn c s , xc nh nhng thiu ht v mt chnh sch,
cc vn v cc gii php u tin nhm kim sot c hiu qu cc yu t nguy c BKLN
Vit Nam, nhn mnh cc gii php lin ngnh, huy ng s tham gia ca ton x hi v tham
chiu vi 10 can thip ti u i vi cc yu t nguy c theo khuyn co ca WHO (Bng 23,
chng III) [178].
1. Phng chng tc hi ca thuc l

1.1. Mc tiu
Theo Quytnh s229/Q-TTgca Th tng Chnh ph ph duyt Chin lc quc
gia phng, chng tc hi ca thuc l n nm 2020, mc tiu cn t c n nm 2020 bao
gm:
Mc tiu chung
Gim nhu cu s dng v kim sot tng bc gim mc cung cp cc sn phm

thuc l tiu th ti th trng Vit Nam nhm gim nguy c bnh tt v t vong do s dng
thuc l gy ra.
Mc tiu c th
Gim t l ht thuc l trong mt s nhm i tng sau:

Thanh thiu nin (t 15 - 24 tui): t 26% nm 2011 xung 18% nm 2020.
Nam gii: t 47,4% nm 2011 xung 39% nm 2020.
N gii: xung di 1,4% nm 2020.
Tng cng thc tun th php lut ca ngi dn v thc hin mi trng khng khi
thuc.
1.2. Kt qu thc hin
Xy dng v ban hnh chnh sch
Hot ng phng chng tc hi ca thuc l (PCTHTL) bt u c a vo chnh sch

quc gia Vit Nam t nm 2000 vi Ngh quyt s 12/2000/NQ-CP ca Chnh ph ph duyt
Chnh sch quc gia phng, chng tc hi ca thuc l giai on 2000-2010. Vit Nam
175

ph chun Cng c khung v kim sot thuc l ca WHO vo nm 2004 (c hiu lc t ngy
17/3/2005). Nm 2005, Chnh ph ban hnh Ngh nh s 45/2005/N-CP quy nh v mt s
a im cm ht thuc v vic x pht hnh vi ht thuc l ti cc a im b cm. Sau ,
Th tng Chnh ph ban hnh Ch th 12/2007/CT-TTg nm 2007 v vic tng cng hot
ng PCTHTL v Quyt nh 1315/Q-TTg nm 2009, ph duyt k hoch thc hin Cng
c khung v kim sot thuc l, c hiu lc t ngy 1/1/2010.
Hot ng PCTHTL Vit Nam bc sang mt giai on mi khi Lut PCTHTL (s
09/2012/QH13) c Quc hi thng qua ngy 18/6/2012 v bt u c hiu lc t 1/5/2013.
y l vn bn c tnh cht php l cao nht i vi hot ng PCTHTL Vit Nam. Trn c
s , B Y t ch tr v phi hp vi cc b, ngnh c lin quan xy dng v trnh ph duyt
cc vn bn hng dn thc hin Lut PCTHTL theo thm quyn quy nh, gm:
Quytnh s229/Q-TTgnm 2012 ca Th tng Chnh ph ph duyt Chin lc
quc gia phng, chng tc hi ca thuc l n nm 2020.
Nghnh s67/2013/N-CP ca Chnh ph quy nh chi tit mt s iu v bin php
thi hnh Lut PCTHTL v kinh doanh thuc l.
Nghnh s77/2013/N-CP ca Chnh ph quy nh chi tit thi hnh Lut PCTHTL
v mt s bin php phng, chng tc hi ca thuc l.
Quytnh s47/2013/Q-TTg ca Thtng Chnh phv vic thnh lp, ph duyt
iu l t chc v hot ng ca Qu PCTHTL v Khoch s801/KH-BYT ca B Y t trin
khai thc hin Quyt nh s 47/2013/Q-TTg.
Nghnh s176/2013/N-CP ca Chnh ph quy nh x pht vi phm hnh chnh
trong lnh vc y t, trong c vic x pht ht thuc l ni cng cng.
Nghnh s185/2013/N-CP ca Chnh phquy nh xpht vi phm hnh chnh
trong lnh vc thng mi, bun bn hng gi, hng cm, vbo vquyn li ngi tiu dng.
Thng tlin tch s05/2013/TTLT-BYT-BCT ca B Y t v B Cng thng hng
dn vic ghi nhn, in cnh bo sc khe trn bao b thuc l.
B Y t cng giao cho Cc An ton Thc phm lm u mi son tho Quy chun
kthut quc gia vthuc liu. Hin vn bn ny ang trong giai on hon thin vchun
b ban hnh.
Vi s ra i ca Lut PCTHTL cng cc vn bn hng dn, h thng chnh sch,
PCTHTL ca Vit Nam tng i hon chnh v bao gm c 4 nhm can thip ti u theo
khuyn co ca WHO. Mc d vy, vn cn mt s im cha hon thin trong chnh sch
PCTHTL so vi khuyn co (Hp 1).
176

Hp 1. Mt s im cha hon thin trong chnh sch PCTHTL Vit Nam so vi khuyn
co ca WHO
Bo v ngi dn trc khi thuc l

Cha cm ht thuc tt c cc a im cng cng (v d qun c ph, qun
nc,..) v trn tt c cc phng tin giao thng cng cng.
Cha phn b kinh ph cho vic thc thi x pht vi phm.
H tr cai nghin thuc
Cha c ng dy t vn cai nghin min ph; cha c liu php thay th nicotin,
BHYT cha thanh ton cho iu tr cai nghin.
Cnh bo tc hi ca thuc l i vi sc kho
Cha c quy nh c th v quy cch bao b (khng c thng tin thng hiu, lm
cho bo b km hp dn, km sang trng,...).
Cha bt buc c thng tin v cai nghin thuc trn bao b.
Cha cm bn thuc l khng khi.
Cm qung co, khuyn mi, ti tr thuc l
Cha c quy nh cm hoc hn ch thi gian xut hin sn phm thuc l trn TV.
Ngun: WHO Report on the Global Tobacco Epidemic, 2013 - Country profile: Vietnam [179] v Tobacco Control in
Vietnam [180]
T chc trin khai chnh sch
Ban ch nhim chng trnh phng chng tc hi ca thuc l (VINACOSH) c

thnh lp theo quyt nh ca Th tng Chnh ph s467/Q-TTg ngy 17/4/2001 do B
trng B Y t lm ch nhim, 01 Th trng B Y t lm ph ch nhim thng trc, 01 Th
trng B Vn ho - Thng tin (nay thuc B Thng tin v Truyn thng) lm ph ch nhim
cng vi 11 thnh vin i din lnh o ca cc b, ngnh, on th c lin quan.
Vi t cch l c quan thng trc, B trng B Y t cng k cng vn s 1767/
BYT-KCB v cng vn s 1766/BYT-KCB (nm 2013) ngh cc b, ngnh v UBND cc
tnh, thnh ph phi hp t chc cc hot ng trin khai Lut PCTHTL. n nay, B Y t
nhn c k hoch v chin lc PCTHTL ca 6 b, ngnh, 36 tnh, thnh ph v 10 t chc
on th.
Trn c s Lut PCTHTL v cc vn bn quy phm php lut c lin quan, cc b,
ngnh, on th v a phng thnh lp Ban ch o, ban hnh cc quyt nh, ch th v
vic t chc thc hin Lut PCTHTL v tng cng cc hot ng phng chng tc hi ca
thuc l trong phm vi ngnh, t chc ca mnh. B Y t ban hnh Ch th s 05/CT-BYT; B
Giao thng Vn ti c Ch th 02/2005/CT-BGTVT v Ch th s 20/CT-BGTVT; B Gio dc
v o to c Ch th 56/2007/CT-BGDT v Quyt nh s 3323/Q-BGDT; B Cng an
c Quyt nh s 1959/Q-BCA; Tng Lin on Lao ng Vit Nam c Hng dn 1350/
HD-TL v Hng dn 29/HD-TL.
177

nh gi theo MPOWER
Hot ng theo di, gim st, nh gi

Gim st c cp nh l mt gii php quan trng thc hin Chin lc quc
gia phng chng tc hi ca thuc l n nm 2020 mc d cha c mt vn bn chnh thc no
dnh ring cho hot ng ny. Trc , nm 2011, B Y t c Quyt nh s 2180/Q-BYT
v vic ban hnh B ch s theo di, nh gi hot ng phng, chng cc BKLN, trong c
5 ch s lin quan n thuc l, gm: t l % ngi nghin ht, t l % ngi nghin ht hng
ngy, tui trung bnh bt u ht thuc hng ngy, s iu thuc trung bnh/ngy ca nhng
ngi c ht thuc hng ngy v t l % ngi b ht thuc l th ng hng ngy. Nhim v
thu thp thng tin gim st c giao cho B Y t, S Y t v Trung tm Truyn thng gio dc
sc kho cc a phng33.
Chnh sch bo v ngi dn trc khi thuc l
Chnh sch bo v ngi dn trc khi thuc l c cp t trong Lut Bo v sc
kho nhn dn nm 1989 vi vic cm ht thuc trong phng hp, rp chiu bng, nh ht
v nhng ni cng cng theo quy nh khc. Cc a im cm c m rng dn cng vi
vic quy nh tng cng x pht vi phm trong Chin lc quc gia v kim sot tc hi ca
thuc l 2000-2010, Ngh nh 45/2005 ca Chnh ph nm 2005 v Quyt nh 1315/Q-TTg
ca Th tng Chnh ph nm 2009.
Lut PCTHTL quy nh quyn ca ngi dn c sng trong mi trng khng c
khi thuc l. Vic ht thuc l b cm ht hon ton, c bn trong nh v bn ngoi, ti cc c
s y t, c s gio dc (tr trng i hc, cao ng v vin ch cm ht thuc trong nh), c
s trng tr v c s gii tr cho tr em. nhng ni cng cng khc v ni lm vic, cm ht
thuc l trong nh, tr ti khu vc ch ti sn bay, qun ru, bia, phng karaoke, v hi, khch
sn, nh ngh c php c ni dnh ring cho ngi ht thuc nu c h thng thng gi ph
hp. Cc vn bn hng dn thc hin Lut cng quy nh vic xy dng, trin khai cc m
hnh im v cng ng, c quan, t chc khng c khi thuc l; pht trin v nhn rng cc
m hnh c hiu qu v quy nh vic x pht vi cc hnh vi vi phm.
Trn c s cc vn bn quy nh, hng dn, mt s a phng trin khai th im d
n xy dng thnh ph khng khi thuc nh H Long, Thi Nguyn, H Ni, Hu, Nng,
Hi An, Nha Trang v Tin Giang vi cc hot ng ch yu l tuyn truyn, gio dc phng
chng tc hi ca thuc l; cung cp cc bin cm v cnh bo tc hi ca thuc l, vn ng
thnh lp ban ch o, h tr v gim st thc hin chnh sch khng khi thuc ti cc c quan,
cng s, a im cng cng, phng tin giao thng.
B Gio dc v o to pht ng cuc vn ng Xy dng trng hc thn thin, hc
sinh tch cc t nhiu nm nay. Cuc vn ng bc u to c mt s thnh cng ban
u trong vic thay i b mt trng hc, nng cao thc xy dng trng lp trong mi hc
sinh, Ngnh y t cng pht ng phong tro vn ng khng ht thuc l ti cc bnh vin,
c quan, n v trong ngnh. Ti Bnh vin a khoa Ch Linh (Hi Dng), nh c s vo cuc
kin quyt ca lnh o, phi hp cht ch vi cng an trong kim tra, gim st v x pht,
bnh vin thc hin c hiu qu m hnh khng khi thuc vi 100% cn b ca bnh vin
khng ht thuc. Ngoi ra, Bnh vin cn thc hin x l pht c ngi nh cn b, bnh nhn
Quyt nh s 2180/Q-BYT ca B trng B Y t ngy 28 thng 6 nm 2011 v vic ban hnh B ch s theo
di, nh gi hot ng phng chng cc BKLN.
33
178

vi phm ti ht thuc ti Bnh vin [181]. Tng Lin on Lao ng Vit Nam, lc lng cng
an nhn dn, b i,... cng hng ng v pht ng xy dng mi trng khng khi thuc
trong ni b ngnh mnh.
B Y t cng t chc cc hi tho, tp hun v chun b cho vic trin khai thc hin
vic x pht vi phm v vic cm ht thuc l ti cc a im b cm theo Ngh nh 176/2013/
N-CP c hiu lc t ngy 1/1/2014.
nh gi bc u ca Trng i hc YTCC H Ni v vic trin khai th im d n
Thnh ph khng khi thuc ti 2 thnh ph Hu v Nha Trang cho thy nhng kt qu
ng khch l trong vic nng cao nhn thc ca cng ng v tc hi ca thuc l, gim t l
ngi ht thuc v t l phi nhim th ng vi khi thuc l ti ni lm vic. Kt qu phng
vn hn 1200 ngi vo thng 1/2014 cho thy t l nam gii hin ht thuc l 39,3%, gim
10,1% so vi iu tra ban u nm 2012 (49,4%). T l ngi lao ng phi nhim vi khi
thuc th ng ti ni lm vic cng gim 9,3% ti Nha Trang (t 57% xung 47,7%); v
19% ti Hu (t 62,5% xung 43,5%). Ba phn t s i tng c phng vn Nha Trang
v hn mt na (56,9%) Hu bit v Lut PCTHTL [182].
Mt kho st khc ca Hi YTCC ti 5 tnh/thnh ph (H Ni, Thi Bnh, ng Thp,
H Tnh v Khnh Ha) cho thy 90% ngi lao ng ng h quy nh cm ht thuc cc khu
vc bnh vin, trng hc, giao thng v vn phng cng s; 93,8% ng h cm ht thuc ti
trng hc; 100% cc cn b lnh o s, ban, ngnh ng h hon ton chnh sch khng khi
thuc ti ni cng cng [181].
Cc chnh sch h tr, t vn cai nghin thuc l
Vic h tr t vn, cai nghin thuc l c t ra trong Chin lc quc gia phng,
chng tc hi ca thuc l giai on 2000-2010 v c nhn mnh, lm r hn vi cc gii
php h tr c v k thut v ti chnh trong Quyt nh s 1315/Q-TTg nm 2009, ph duyt
k hoch thc hin Cng c khung v kim sot thuc l.
Lut PCTHTL quy nh Khuyn khch, to iu kin cho c quan, t chc, c nhn
trong nc v nc ngoi tham gia cung cp dch v t vn, cai nghin thuc l; nghin cu
v tc hi ca thuc l, cc phng php cai nghin thuc l; nghin cu v sn xut thuc cai
nghin thuc l; hp tc, ti tr cho phng chng tc hi ca thuc l; ngi s dng thuc l
t nguyn cai nghin thuc l. Ngh nh 77/2013/N-CP cho php cc cc t chc hoc c
nhn c iu kin t chc cung ng dch v cai nghin, t vn cai nghin thuc l min ph
hoc thu ph (c th nhn h tr ca Qu PCTHTL).
Trn c s , B Y t phi hp vi VINACOSH xy dng cm nang cai nghin
thuc l v ang bin son hng dn t cai nghin thuc l sm ban hnh trong thi gian
ti. Trang ch ca VINACOSH cung cp thng tin cm nang cai nghin thuc l v cc
thng tin khc nhm t vn, chia s kinh nghim, h tr cai nghin thuc l. Thng tin lin h
ca hai Trung tm cai nghin thuc l thuc Bnh vin Bch Mai v Bnh vin i hc Y Dc
thnh ph H Ch Minh cng c chia s trn mng (http://www.vinacosh.gov.vn/vi/tu-vancai-nghien-thuoc-la/cac-trung-tam-cai-nghien-thuoc-la/).
Cnh bo tc hi ca thuc l
Ngh nh 119/2007/N-CP quy nh t ngy 1/8/2008, tt c cc gi thuc u phi
in nhn cnh bo Ht thuc c th gy ung th phi hoc Ht thuc c th gy bnh phi tc
179

nghn mn tnh vi ch en trn nn trng chim 30% din tch b mt gi thuc.
Vic in cnh bo bng hnh nh c xut trong Quyt nh 1315/Q-TTg ngy
21/08/2009 ca Th tng Chnh ph, sau c quy nh r trong Lut PCTHTL v hng
dn thi hnh theo Thng tlin tch s05/2013/TTLT-BYT-BCT, c hiu lc t 1/5/2013. Theo
, vic ghi nhn thuc l phi c thc hin bng ting Vit; din tch in cnh bo sc khe
bng hnh nh phi chim t nht 50% din tch ca mi mt chnh trc v mt chnh sau trn
bao b thuc l. Mi loi sn phm thuc l ca mt nhn hiu thuc l phi in trn bao b thuc
l mt trong 06 mu cnh bo sc khe quy nh ti Thng t 05/2013/TTLT-BYT-BCT ngy
8/2/2013. Nhn thuc l khng c s dng t ng to cho ngi tiu dng hiu sai v tnh
cht, tc ng ca thuc l i vi sc khe nh t hc n, nh, siu nh, du m,... lm cho
ngi tiu dng hiu sn phm thuc l ny t c nh hng ti sc khe hn sn phm thuc
l khc.
Vi cc quy nh ny, Vit Nam l 1 trong 4 nc ng Nam v trong khong 40
nc trn th gii thc hin vic in cnh bo bng hnh nh. Cng ty thuc l Thng Long l
n v u tin thc hin vic in cnh bo bng hnh nh trn v bao thuc l t 1/8/2013; Cng
ty Phillip Morris l n v th hai p dng t 1/12/2013. n nay, tt c cc n v trong Tng
Cng ty Thuc l Vit Nam thc hin in cnh bo sc khe bng hnh nh trn bao b sn
phm thuc l sn xut tiu th trong nc v sn phm thuc l nhp khu.
Cm qung co, khuyn mi, tip th v ti tr thuc l
Cm qung co thuc l trn cc phng tin thng tin i chng c quy nh trong
Ch th 13/TTg ca Th tng Chnh ph nm 1992. Sau , Chin lc quc gia phng, chng
tc hi ca thuc l giai on 2000-2010 quy nh cm tt c cc hot ng qung co, tip
th thuc l. Vic cm tt c mi hnh thc qung co, ti tr v tip th thuc l c khng
nh v nhn mnh trong Ch th 12/2007/CT-TTg v Quyt nh 1315/Q-TTg ca Th tng
Chnh ph. c bit, khon 2, iu 9 ca Lut PCTHTL ghi r nghim cm vic qung co,
khuyn mi thuc l; tip th thuc l trc tip ti ngi tiu dng di mi hnh thc. Theo
quy nh ca Ngh nh 176/2013/N-CP, vi phm hnh chnh v qung co thuc l c th b
x pht ti a ln ti 40 triu ng.
Bn cnh vic thc hin cm qung co thuc l trn cc phng tin thng tin i
chng, cm ti tr thuc l ti cc s kin vn ho, th thao, B Vn ha - Th thao v Du lch
cng ban hnh Thng t s 02/2014/TT-BVHTTDL ngy 14/05/2014 quy nh hn ch s
dng thuc l trong tc phm sn khu, in nh. Theo , hnh nh nhn vt ht thuc ch c
s dng khng qu 2 ln trong mt v kch, mt b phim hoc mt tp phim (i vi phim di
tp) vi tng thi lng khng c qu 20 giy.
Vit Nam l mt trong 83 nc cng b lnh cm ton din vic qung co, khuyn
mi v ti tr thuc l v c nh gi l mt trong 7 nc t kt qu cao nht trong vic
trin khai chnh sch ny [32].
Chnh sch tng thu i vi thuc l
Thu tiu th c bit i vi thuc l bt u c p dng t nm 1990 vi mc thu
52% vi thuc c u lc sn xut t nguyn liu nhp khu, 70% vi thuc u lc sn xut t
nguyn liu trong nc v thuc x g nhp khu v 32% vi thuc l khng u lc. n nm
180

1999, thu tiu th c bit c gim 5-7% vi tt c cc mt hng thuc l cng lc vi vic
p mc thu gi tr gia tng 10%. T nm 2006, tt c cc mt hng thuc l u phi chu mc
thu tiu th c bit 55%; mc thu ny tng ln 65% t nm 2008. Bn cnh cc doanh
nghip sn xut thuc l cng phi chu thu thu nhp doanh nghip.
Theo quy nh ca Lut thu tiu th c bit hin hnh (hng dn thi hnh theo Ngh
nh s 26/2009/N-CP v Thng t 05/2012/TT-BTC), thuc l iu, x g v ch phm khc
t cy thuc l c p mc thu sut 65%. Theo Lut thu tiu th c bit sa i va c
Quc hi thng qua chiu 26/11/2014 mc thu sut i vi thuc l c nng ln 75% t
ngy 1/7/2015 v 85% t ngy 1/1/2018. Ring thuc l iu v x g chu thu nhp khu t
150% n 225% gi CIF. Hin nay cha p dng thu i vi thuc lo [180].
Cc chnh sch khc
Cc chnh sch lin quan n vic gim cung cp thuc l
Lut PCTHTL quy nh kinh doanh thuc l l ngnh, ngh kinh doanh c iu kin v
phi c giy php do c quan nh nc c thm quyn cp; quy hoch kinh doanh thuc l do
B Cng thng ch tr, phi hp vi cc b, ngnh lin quan xy dng v trnh Th tng
Chnh ph ph duyt. Lut cng quy nh cc bin php kim sot sn xut thuc l ph hp vi
quy hoch v qun l sn lng thuc l tiu th trong nc. B Cng thng cng c cc
quy nh v kim sot nhp khu thuc l v phng chng hot ng bun lu thuc l.
Lut PCTHTL v cc vn bn hng dn thc hin Lut cng quy nh r cm vic
s dng ngi di 18 tui, mua, bn thuc l cho v vi ngi di 18 tui; cm bn thuc
l bng my bn thuc l t ng.
Thng tin, gio dc, truyn thng phng chng tc hi ca thuc l
Lut PCTHTL coi thng tin, gio dc, truyn thng l mt gii php quan trng trong
phng chng tc hi ca thuc l v quy nh trch nhim cho cc b, ngnh, t chc on th
nh Y t, Thng tin - Truyn thng, Vn ho - Th thao v Du lch, Cng thng, Gio dc v
o to cng UBND v Mt trn t quc cc cp trong cng tc ny.
L c quan thng trc, B Y t phi hp vi VINACOSH t chc nhiu hi tho,
hi ngh, bui ni chuyn ph bin Lut PCTHTL v cc vn bn php lut lin quan cho nhiu
i tng khc nhau thuc cc b, ngnh, on th, t chc chnh tr x hi v cc a phng.
Hng chc ngn cun sch gii thiu, hi p v Lut PCTHTL cng hng trm ngn t ri,
tranh p phch, hng trm a DVD tuyn truyn c in n v cp cho cc b, ngnh, a
phng. B Y t cng phi hp vi Trung ng on Thanh nin pht ng chin dch
truyn thng gim thiu vic s dng thuc l, t chc chin dch nhn tin qua in thoi v truy
cp website http://vn0khoithuoc.com/ ng h thc thi Lut Phng chng tc hi ca thuc l
v t chc Cuc thi sng tc video, tranh nh, p phch c ng Cuc sng khng khi thuc
l [183].
Hot ng tuyn truyn PCTHTL cng c tin hnh vi nhiu hnh thc a dng
trn cc phng tin thng tin i chng nh: VTV1, O2TV, Thng tn x Vit Nam, VOV
giao thng; thng qua hng trm bi bo tuyn truyn trn cc bo vit v bo mng; t chc
cc bui mt tinh hng ng ngy th gii khng thuc l v tun l quc gia khng thuc l; t
chc cc cuc thi tm hiu, cc bui biu din ngh thut tuyn truyn v tc hi ca thuc l.
181

Cc pano, p phch tuyn truyn v tc hi ca thuc l c dng dc theo cc tuyn ng
giao thng, cc khu dn c c thnh th cng nh nng thn[184].
Khng ch cc ngnh, cc a phng m cc c quan nghin cu, cc t chc on th
chnh tr x hi nh on Thanh nin. Hi Lin hip Ph n, Hi cu chin binh, v.v cng tham
gia vo cc hot ng truyn thng PCTHTL. Nhiu t chc nh HealthBridge Canada, Hi
YTCC, Trng i hc YTCC H Ni trin khai nhiu nghin cu v tnh hnh ht thuc,
phng chng tc hi ca thuc l; t vn, h tr k thut cho cc d n th im xy dng mi
trng khng khi thuc.
Quy nh cc tiu chun k thut ca thuc l
Vit Nam cng c cc quy nh v v sinh an ton i vi cc sn phm thuc l
(Quyt nh 02/2007/Q-BYT) v B Y t ang hon thin d tho quy nh v hm lng cc
cht c trong sn phm thuc l: cc quy nh v tiu chun Vit Nam i vi sn phm thuc
l. Quy chun k thut quc gia v thuc l iu ang c B Y t hon thin v s c ban
hnh trong thi gian ti.
Quy nh v vic x pht vi phm php lut v phng, chng tc hi ca thuc l
Lut PCTHTL quy nh trch nhim ca cc b, ngnh, a phng trong x l vi
phm php lut v Phng chng tc hi ca thuc l. c 4 Ngh nh c ban hnh trong
nm 2013 gm Ngh nh 81, Ngh nh 158, Ngh nh 176 v Ngh nh 185 lin quan vic
x l vi phm php lut v PCTHTL lin quan n nhiu lnh vc khc nhau nh sn xut, kinh
doanh thuc l, ht thuc l ni cng cng,
Quy nh lin quan n ti chnh cho hot ng phng, chng tc hi ca thuc l
Lut PCTHTL quy nh vic thnh lp Qu PCTHTL t khon ng gp bt buc ca
cc c s sn xut, nhp khu thuc l vi t l 1% t ngy 1/5/2013; 1,5% t 1/5/2016 v 2%
t 1/5/2019, theo gi tnh thu tiu th c bit.
1.3. Kh khn, hn ch
Chnh sch phng chng tc hi ca thuc l cn bt cp
Mc d c Lut PCTHTL song mt s quy nh, ch ti trong cc vn bn di lut

hin vn cha sc rn e, chng cho v chc nng nhim v v kh kh thi. Chng hn, quy
nh vic x l vi phm hnh chnh v PCTHTL c lin quan n 4 Ngh nh (s 81, s 158,
s 176 v s 185) vi 9 n v c thm quyn x pht, gm: ch tch UBND cc cp, thanh tra
Y t, qun l th trng, cng an, b i bin phng, cnh st bin, hi quan, c quan thu v
thanh tra ti chnh. Trong khi cc hng dn vn cn chung chung, m h khin cho vic x
pht kh thc thi. Vic cm ht thuc cc im cng cng ch mi p dng vi thuc l m
cha p dng i vi thuc lo.
Chnh sch thu tiu th c bit vi thuc l vn cha hp l. Vi mc thu sut 65%,
gi thuc l hin chim cha ti 45% gi bn l (sau thu), thp hn nhiu so vi mc 65-80%
theo khuyn co ca WHO [185]. Gi thuc bn l Vit Nam vn thp hn mc gi mt s
nc trong khu vc ng Nam nh In--n-xi-a, c bit l vi thuc l sn xut trong nc
[186]. T nm 1995 n nm 2006, gi thuc gim i. S iu ht mt ngy trong nhm
182

ngi ht thuc tng t 9,6 ln 13,5 gia nm 1995 v nm 2010. Mc chi mua thuc l bnh
qun mt nm i vi nhm ngi ht tng t 49 USD ln 86 USD, tuy nhin, t l tng chi
mua thuc l chm hn t l tng kinh t v sc mua ca cc h gia nh, nn thu cha c tc
ng mong mun tng chi ph ht thuc ca cc h gia nh [180]. Trong khi , vic tng
thu tiu th c bit i vi thuc l ang gp phi sc p t ngnh sn xut thuc l trong
nc vn a li ngun thu ngn sch 14000 t ng/nm v gii quyt vic lm cho 20000
cng nhn, 200000 lao ng nng nghip [187].
Vic gia nhp Hip nh i tc xuyn Thi Bnh Dng (TPP) hung n t do ha
ton din, xa bo 100% thu nhp khu san phm thuc l, lm cho cc san phm thuc l nhp
khu re hon v kha nang s ngui tip cn v s dung thuc l se tang ln. Nu khng c nhng
gii php c hiu qu, vic gia nhp TPP c th cn tr vic thc hin mc tiu giam nhu cu
s dung thuc l kt hp vi bin php kim sot tng buc giam ngun cung cp thuc l.
iu ny i hi phi c tnh n khi m phn gia nhp TPP cng nh cn chun b cc
chin lc, chnh sch i ph hu hiu.
T chc, ch o, trin khai chnh sch vn cn hn ch
Kt qu gim st ca y ban cc vn x hi ca Quc hi v vic trin khai Lut

Phng chng tc hi ca thuc l ti Bn Tre, Tin Giang, v Qung Ninh cho thy cc a
phng ch yu dng mc ban hnh vn bn, t chc mt s hot ng b ni nh truyn
thng qua cc phng tin thng tin i chng, pht hnh cc ti liu tuyn truyn Chnh
quyn cc cp, ngi ng u c quan, t chc cha ch trng trin khai Lut, cc quy nh
treo bin cm ht thuc l ti cc tr s x, phng khng p dng nghim tc.
Cng tc tuyn truyn v Lut PCTHTL ch yu tp trung ti mt s knh truyn thng
trung ng vi thi lng vn cn khim tn, hot ng tuyn truyn cc a phng vn cn
rt hn ch. Bi vy, cc quy nh ca Lut PCTHTL cha c truyn thng rng ri trong
cng ng, nhn thc ca ngi dn v Lut cn hn ch, thm ch nhiu cn b lnh o, cc
thanh tra vin lin quan n cng tc ny cng cha thc s hiu r ni dung ca Lut. thc
chp hnh php lut ca mt b phn ngi dn cha cao trong khi cng tc thanh tra, kim tra
vic thc thi Lut PCTHTL, c bit l vi quy nh cm ht thuc l ti cc a im cm ht
thuc theo quy nh cha c thc hin nghim.
Vic t chc trin khai cc bin php t vn, cai nghin, p dng cc liu php thay th
nicotine thuc l vn cha c quan tm ng mc. Cha xy dng c cc m hnh t vn,
cai nghin thuc l c hiu qu; cha qun l c cc c s cai nghin t pht; thuc l in
t vn c qung co rm r trn mng mc cho tnh hiu qu, cht lng v an ton vn
cha c kim chng [188].
Tnh trng vi phm cc quy nh v PCTHTL vn din ra ph bin
Vi phm trong qung co ti cc im bn thuc l vn cn din ra trn lan

Kho st ca Trng i hc YTCC H Ni ti 1530 im bn thuc l ti 10 tnh, thnh
ph nm 2009 cho thy 95,4% im vi phm quy nh cm qung co, khuyn mi thuc l, ph
bin nht l trng by qu s lng (91,2%); t, quy trng by c mu sc nhn hiu thuc l
(41,5%), [189]. Tnh hnh vi phm khng c xu hng gim trong kho st nm 2011 vi
58,1% im bn vi phm t nht mt quy nh cm qung co; 35,8% im bn vi phm ng
183

thi quy nh cm qung co v khuyn mi thuc l. Ca hng tp ha v xe y vn l cc
im bn c hot ng qung co v khuyn mi thuc l rm r nht vi 90% vi phm trng
by qu mt bao/tt ca mt nhn hiu thuc l, gn 36% im bn vi phm quy nh, by nhiu
t thuc l ca cc hng khc nhau, 33% im bn kinh doanh thuc l gi nh hn 20 iu;
5,6% im bn c tng phm cho ngi mua [190]. Kho st u nm 2013 cho thy 100%
im bn ti thnh ph H Ch Minh, Khnh Ha, Hi Phng u vi phm quy inh cm trng
by qu mt bao/tt/hp ca mt nhn hiu thuc l [191].
Kim sot vic mua bn thuc l vn cha cht ch
Vic mua thuc l d dng l mt nguyn nhn lm gia tng t l ngi ht thuc l.
Khong 98,1% nam thanh nin khi c hi cho bit c th mua c thuc l d dng bt c
u [164]. Vic cm bn thuc l cho ngi di 18 tui gn nh cha thc hin c do cc
c quan chc nng khng qun l c h thng bn l thuc l, vic cp php mi ch dng li
cc i l bn bun. Thuc l c bn khp ni, vic mi cho mua ht th cc loi thuc
l mi vn din ra. Bi vy, mi trng Vit Nam vn kh thun li v d dng nam thanh
thiu nin tip cn v ht thuc l.
Thuc l nhp lu vn tn ti tri ni trn th trng. bt c u, c bit l ti th,
ngi tiu dng u c th mua c thuc l nhp lu. c tnh ca Tng cng ty Thuc l
Vit Nam (Vinataba) cho thy, thuc l nhp lu ngy cng tng mnh, nm 2013 l 930 triu
bao, chim ti 22,2% th phn, khin Nh nc tht thu khong 7000 t ng tin thu cng
400 triu USD nhp lu thuc l. D kin nm 2014 thuc l lu c th chim th phn ln
ti 25%.
Tnh trng ht thuc l cc a im cng cng vn cn ph bin
Tnh hnh ht thuc l ti cc tr s, c quan cn din ra, c bit ti cc hnh lang, snh
lm vic v ngoi sn trong khi cha c cc khu vc dnh ring cho ngi ht thuc l ti tr s
lm vic [192]. Tnh trng ht thuc l cc a im cng cng vn rt ph bin; nhiu ngi
cha bit n cc quy nh ny trong khi cc c quan qun l gp kh khn trong vic x l.
Tnh n nay, s ngi b x pht vn ch m trn u ngn tay.
Kho st ca Hi YTCC ti H Ni, Thi Bnh, ng Thp, H Tnh v Khnh Ha cho
thy mc d vic cm ht thuc cc c quan, cng s, trng hc, bnh vin, cc im cng
cng nhn c s ng h cao ca lnh o v ngi lao ng song trn thc t t l vi phm
vn mc cao: 92% cc nh ga, bn xe; 74,7% cc c s y t; 63,8% cc trng hc v
37,4% cc c quan, cng s. L do vi phm l do thi quen, kh b (53%); khng c ch ring
cho ngi ht thuc (36%) hay khng thy c ngi x pht (32,4%) [181].
T l ht thuc l ch ng v th ng vn cn mc cao
T l ht thuc l nam gii trng thnh nm 2010 ch gim 2% so vi nm 2006, vn
cn mc 47,4%, so vi mc tiu 20%. Vit Nam vn l mt trong 15 nc c ngi s dng
thuc l cao nht th gii (khong 15,3 triu ngi) [33]. c bit, t l ht thuc l ca thanh
thiu nin Vit Nam vn mc cao v tui bt u ht thuc l ngy cng tr. C 43,6% nam
thanh thiu nin cho bit tng ht thuc vi tui trung bnh khi bt u ht thuc l l 16,9.
Trong s nhng nam thanh nin tng ht thuc, c ti 71,7% hin nay vn ang ht [164].
184

C n 73,1% ngi trng thnh b phi nhim vi khi thuc ti nh (67,6% trong s
ngi khng ht thuc) v 55,9% ngi lao ng phi nhim vi khi thuc l ti ni lm vic
(49,0% vi ngi khng ht thuc). T l ht thuc th ng cao nht l cc qun ru/c
ph/tr vi 92,6% v nh hng vi 84,9%. T l ny cc trng i hc v cc cng s ln
lt l 54,3% v 38,7% [33].
1.4. Cc vn u tin
Thiu mt u mi qun l thng nht, mang tnh lng ghp kh nng huy ng lin
ngnh v ton x hi tham gia phng chng tc hi ca thuc l mt cch c hiu qu.
Cc nhim v chnh vn do ngnh y t m nhn, vai tr ca VINACOSH cn hn ch
trong vic vn ng chnh sch v huy ng ti chnh. Thu tiu th thuc l cha hp
l dn n gi thuc bn l cn thp.
H thng thng tin v cng tc kim tra, gim st v nh gi cc hot ng phng chng
tc hi ca thuc l cn hn ch, vic thu thp cc thng tin cha c thc hin mt
cch thng xuyn, lin tc; cc ngun thng tin khng c sn mt u mi thng
nht, kh tip cn.
Hot ng ca cc b, ngnh, a phng ch yu vn tp trung vo vic ban hnh cc
vn bn ch o v t chc cc hot ng tuyn truyn, vn ng trong ni b; thiu cc
bin php trin khai c th v cc m hnh phi hp lin ngnh c hiu qu (gia ngnh
cng thng vi ngnh y t trong kim sot sn xut, kinh doanh; gia qun l th trng
v cng an, thanh tra y t trong thanh tra, x pht).
Vic thanh tra, kim tra, x pht cha c thc hin nghim dn n cc vi phm nh
ht thuc l cc a im b cm, qung co thuc l ti cc im bn l, bn thuc cho
i tng di 18 tui vn cn din ra ph bin.
Nhn thc ca cng ng v Lut PCTHTL cn hn ch, thc chp hnh Lut ca
ngi dn cha cao trong khi cng tc truyn thng cha c t chc su rng, cc
bin php x l cn thiu tnh rn e.
1.5. Khuyn ngh
Xem chi tit mc 5 ca chng ny.
2. Kim sot tc hi ca s dng ru, bia

2.1. Mc tiu
Mc tiu kim sot tc hi ca s dng ru, bia c th hin trong Quyt nh s
244/Q-TTg ca Th tng Chnh ph v Chnh sch quc gia phng chng tc hi ca lm
dng ung c cn n nm 202034.
Mc tiu chung
Phng nga v gim tc hi ca lm dng ru, bia v ung c cn khc (sau y gi

chung l ru, bia) i vi sc khe cng ng, trt t an ton x hi bo v sc khe cng
ng, gp phn pht trin kinh t - x hi n nh v bn vng.
Quyt nh s 244/Q-TTg ngy 12/2/2014 ca Th tng Chnh ph v Chnh sch quc gia phng chng tc
hi ca lm dng ung c cn n nm 2020.
34
185

Mc tiu c th
n nm 2020, xy dng v hon thin chnh sch, php lut v phng, chng tc hi
ca lm dng ru, bia.
Gim dn tin ti chm dt vic lu thng ru, bia khng bo m tiu chun cht
lng trn th trng.
Gim mc gia tng t l tiu th ru bnh qun/ngi trng thnh (15 tui tr ln)/
nm quy i theo ru nguyn cht t 12,1% giai on 2007 - 2010 xung cn 10% giai
on 2013 - 2016 v 6,5% giai on 2017 - 2020.
Phng nga, ngn chn vic tip cn, s dng ru, bia ca ngi di 18 tui; cn
b, cng chc, vin chc, ngi lao ng, ngi lm vic trong cc lc lng v trang
khng s dng ru, bia trc v trong gi lm vic, ti ni lm vic, trong ba n gia
hai bui trong ngy lm vic v ngy trc.
Phng nga ngi iu khin phng tin giao thng s dng ru, bia; phng nga bo
lc gia nh, gy ri trt t cng cng do lm dng ru, bia.
n nm 2016, 70% dn c trong cng ng c tip cn thng tin, gio dc, truyn
thng v tc hi ca lm dng ru, bia; 50% dn c trong cng ng c nhn thc ng
v vn ny, n nm 2020 t l tng ng l 80% v 60%.
n nm 2016, 30% s ngi nghin ru, bia c sng lc pht hin sm, 25% s
ngi nghin ru, bia c t vn, iu tr cai nghin v chng ti nghin ti cng
ng, 20% s ngi nghin ru, bia c iu tr bnh mn tnh pht sinh c lin quan
n ru, bia; n nm 2020 t l tng ng l 50%, 40% v 30%.
2.2. Kt qu thc hin
Xy dng chnh sch
T nm 1954, Ch tch H Ch Minh ban hnh Sc lnh kim sot sn xut v s

dng ru. T n nay, Quc hi ban hnh mt s lut c nhng ni dung quy nh c
lin quan n hn ch sn xut, kinh doanh, tiu th v s dng ru, bia; Chnh ph, cc b,
ngnh cng ban hnh nhiu Ngh nh, Thng t hng dn thi hnh lut c lin quan n
lnh vc phng chng tc hi ca ru, bia.
Mi y nht, ngy 12/02/2014, Th tng Chnh ph k ban Quyt nh s 244/QTTg v Chnh sch quc gia phng chng tc hi ca lm dng ung c cn n nm 2020.
Chnh sch ny c xy dng da trn quan im Nh nc khng khuyn khch ngi tiu
dng s dng ru, bia; mi ngi c quyn c bo v khi nh hng bi tc hi ca lm
dng ru, bia; vic sn xut, kinh doanh, s dng ru, bia c kim sot ton din, ng
b ph hp vi yu cu pht trin kinh t-x hi vi 7 mc tiu c th v 5 nhm gii php
thc hin cc mc tiu.
Nh vy, Vit Nam c nhiu vn bn php lut quy nh lin quan n cc hot ng
sn xut, kinh doanh, bun bn v s dng ru, bia, bao gm c cc can thip ti u kim
sot tc hi ca s dng ru, bia theo khuyn co ca WHO. Cc chnh sch, chin lc trong
lnh vc kim sot s dng ru, bia mc c hi c th c phn chia thnh cc nhm sau:
186

Chnh sch lin quan n gim cu ru, bia
p thu tiu th c bit i vi ru, bia
Ti Vit Nam, ru, bia c xp vo nhm mt hng chu thu tiu th c bit.
Theo quy nh ca Lut thu tiu th c bit s 27/2008/QH12, Ngh nh s 26/2009/
N-CP v Ngh nh s 113/2011/N-CP, mc thu sut dnh cho ru di 20
l 25%; mc thu sut dnh cho ru trn 20 35 v bia chai l 45% (trc ngy 1/1/2013) v
50% k t ngy 01/01/2013. Lut sa i b sung mt s iu ca Lut thu tiu th c bit
theo hng tng thu sut vi bia v ru trn 20 ln 65%; vi ru di 20 ln 35% k
t ngy 1/7/2015.
Cm s dng ru, bia mt s i tng
Ngay t nm 1996, Th tng Chnh ph c Ch th 351/TTg v vic cm ung ru
trong gi lm vic v say ru ni cng cng. Ch th s 05/2008/CT-TTg ca Th tng Chnh
ph ngy 31/01/2008 v vic nng cao hiu qu s dng thi gian lm vic ca cn b, cng
chc, vin chc nh nc cng quy nh cm cc i tng ny ung ru, bia trc, trong
gi lm vic, k c vo ba n gia hai ca trong ngy lm vic v ngy trc.
Chnh sch v gim cung ru, bia
Hn ch qung co, tip th ru, bia v ung c cn
Lut Qung co s 16/2012/QH13 c hiu lc thi hnh t ngy 1/1/2013 quy nh
mt hng ru c cn t 15 tr ln l sn phm cm qung co di bt k hnh thc no
(khon 3, iu 7). iu 22 ca Ngh nh s94/2012/N-CP cng nu r vic qung co,
khuyn mi sn phm ru tri php lut; ti tr cc hot ng c gn vi qung co sn phm
ru; s dng sn phm ru lm gii thng cho cc cuc thi, tr cc cuc thi v sn phm
ru l vi phm quy nh ca php lut v sn xut, kinh doanh ru.
Hn ch s sn c ca ru, bia bn l
Theo Ngh nh 94/2012/N-CP v Thng t s 39/2012/TT-BCT,ru thuc nhm
hng ha nh nc hn ch kinh doanh; t chc, c nhn sn xut, kinh doanh sn phm ru
phi c giy php. Vic cp php sn xut, kinh doanh ru c xc nh khng qu mt giy
php kinh doanh bn l sn phm ru/1000 dn trn a bn huyn, khng qu mt giy php
kinh doanh bn bun sn phm ru/100000 dn trn a bn tnh; khng qu mt giy php
kinh doanh phn phi sn phm ru/400000 dn c nc. Ngh nh 94/2012/N-CP cng
quy nh cm bn sn phm ru cho ngi di 18 tui; bn ru bng my t ng v bn
ru qua internet.
Chnh sch v sn xut, nhp khu ru, bia
Nm 2009, B Cng thng c Quyt nh 2435/Q-BCT ph duyt Quy hoch pht
trin ngnh bia, ru, nc gii kht n nm 2015, tm nhn n nm 2025; theo sn lng
sn xut n nm 2015 s t 4 t lt bia, 188 triu lt ru cng nghip, v n nm 2025 l 6
t lt bia v 440 triu lt ru cng nghip36.
cn biu th nng cn trong ru tnh theo th tch.
Quyt nh 2435/Q-BCT ngy 21/05/2009 ca B Cng thng ph duyt Quy hoch pht trin ngnh bia,
ru, nc gii kht n nm 2015, tm nhn n nm 2025.
35
36
187

B Y t ban hnh cc quy nh v v sinh an ton thc phm trong sn xut ru,
bia: Quyt nh s 3542/2000/Q-BYT v quy chun VSATTP i vi ru v Quyt nh s
1283/2004/Q-BYT quy nh thng quy k thut xc nh metanol trong ru.
Nm 2013, B Khoa hc Cng ngh cng ban hnh Quyt nh s 2338/Q-BKHCN
ban hnh b tiu chun Vit Nam dnh cho cc sn phm ru, bia bao gm: TCVN 6057:2013
dnh cho bia hp, TCVN 7042: 2013 dnh cho bia hi, TCVN 7043: 2013 dnh cho ru
trng, TCVN 7044: 2013 dnh cho ru mi, TCVN 7045: 2013 dnh cho ru vang, TCVN
9779:2013 dnh cho ru chng ct.
Chnh sch lin quan n gim s dng ru, bia mc c hi
Truyn thng phng chng tc hi ca s dng ru, bia
C nhiu vn bn quy phm php lut cp n cng tc truyn thng phng chng
tc hi ca s dng ru, bia, nht l trong cc c quan, cng s, trng hc.
Lut thanh nin s 53/2005/QH11 ngy 29/11/2005 quy nh Cc t chc thanh nin c
trch nhim vn ng thanh nin khng nghin ru, khng say ru (iu 21) v gia nh
c trch nhim qun l, gio dc thanh nin t mi su tui n di mi tm tui khng
ung ru v ung c nng cn t 14% tr ln (iu 29).
Ngh nh 94/2012/N-CP quy nh trch nhim ca U ban nhn dn cc tnh, thnh
ph trc thuc Trung ng trong vic tuyn truyn, gio dc nhn dn nng cao nhn thc
v nguy c, tc hi ca vic lm dng ru (iu 29).
Nm 2013, Th tng Chnh ph ban hnh Quyt nh s 2043/Q-TTg ph duyt
n Tuyn truyn v an ton giao thng giai on 2013-2015, trong c ni dung tuyn truyn
tc hi ca lm dng ru, bia i vi sc khe v an ton x hi.
Quyt nh s 244/Q-TTg ca Th tng Chnh ph cng coi thng tin, gio dc,
truyn thng l mt trong cc gii php quan trng trong gim tc hi ca lm dng ru, bia
vi nhiu hnh thc v trn nhiu nhm i tng khc nhau.
Cai nghin v iu tr, phc hi chc nng cho ngi nghin ru
Lut phng, chng bo lc gia nh s 02/2007/QH12 cng quy nh ngi nghin ru
l mt i tng cn tp trung quan tm t vn v gia nh phng nga bo lc gia nh v
giao cho B Y t chu trch nhim ban hnh Quy trnh cha tr nghin ru. Chin lc quc
gia v phng, chng tc hi ca lm dng ung c cn n nm 2020 coi cai nghin v iu
tr cho ngi nghin ru l mt trong nhng mc tiu cn hng ti v l mt trong nhng
gii php t c mc tiu cn li. B Y t cng c quyt nh s 5140/Q-BYT ngy
23/12/2013 v vic ban hnh ti liu chuyn mn Hng dn chn on v iu tr cc ri lon
tm thn thng gp do ru.
X pht hnh chnh vi phm cc quy nh v sn xut, kinh doanh v s dng ru, bia
Ngh nh 94/2012/N-CP dnh mt chng (chng IV) quy nh cc hnh vi vi
phm v x l vi phm trong sn xut, kinh doanh ru. Ngh nh 185/2013/N-CP gm 12
iu quy nh c th v vic x pht cc hnh vi vi phm v sn xut, kinh doanh ru vi mc
pht ti a ln n 70 triu ng. Pht tin t 500 ngn n mt triu ng vi hnh vi bn sn
188

phm ru cho ngi di 18 tui. Mc pht c th ln n 50 triu ng vi hnh vi khuyn
mi ru, bia hoc s dng ru, bia khuyn mi cho ngi di 18 tui.
Lut Giao thng ng b c hiu lc t 1/7/2009 quy nh cm hon ton vic s dng
ru, bia i vi li xe t khi tham gia giao thng v hn ch n mc thp nht nng cn
trong mu i vi ngi li xe gn my. Chnh ph cng ban hnh cc Ngh nh s 34/2010/
N-CP, Ngh nh s 71/2012/N-CP sa i Ngh nh 34/2010/N-CP v sau l Ngh
nh s 171/2013/N-CP quy nh x l vi phm hnh chnh trong lnh vc giao thng ng
b, ng st quy nh r mc x pht tng nng vi hnh vi iu khin phng tin tham gia
giao thng c nng cn trong mu. Cc quy nh v cm s dng ru, bia khi tham gia giao
thng nu c thc hin nghim tc s gin tip gp phn gim tnh trng s dng ru, bia
mc c hi.
Hp 2. Mt s im cha hon thin trong chnh sch kim sot tc hi ca s dng
ru, bia
Cha c chnh sch quc gia v kim sot tc hi ca s dng ru, bia.
Khng hn ch thi gian (ngy gi) bn ru, bia; cm bn ru bia cho ngi say.
Cha c quy nh v vic ti tr sn phm ru, bia.
Cha c quy nh bt buc dn nhn cnh bo sc kho trn sn phm ru, bia.
C
ha phn b kinh ph cho kim sot tc hi ca s dng ru, bia; cha c h tr cho
vic t chc cai nghin ti cng ng.
C
ha c h thng gim st quc gia v s dng ru bia v kim sot tc hi ca s
dng ru, bia.
Ngun: Country Profiles in Global status report on alcohol and health 2014. World Health Organization. Geneva.
2014 [153].
T chc, ch o trin khai
Vic tuyn truyn phng chng tc hi ca ru, bia c thc hin thng qua cc
knh truyn thng i chng nh i pht thanh, truyn hnh, bo vit v bo mng; qua vic
t chc cc hi ngh, hi tho, cc cuc mt tinh, t chc cc s kin, nht l trong t chc
thanh nin, trong h thng t chc cng on, trong ngnh y t v nhiu ngnh khc. V d,
B Gio dc v o to ban hnh Ch th 7484/BGDT-CTHSSV v vic tng cng cng tc
tuyn truyn vic chp hnh cc quy nh ca php lut v nng cn i vi ngi iu khin
phng tin c gii ng b hng dn vic thc hin tuyn truyn tc hi ca ru, bia khi
tham gia giao thng; B Quc phng t chc v hng ng Tun l khng ht thuc l v hn
ch s dng ru, bia trong qun i.
Mt s a phng, ban ngnh thc hin vic cm ung ru, bia i vi cn b cng
chc, ng vin trong gi hnh chnh, gi ngh tra ca ngy lm vic, khi tham gia giao thng
nh Hi Phng, Ngh An, Vnh Phc, H Ni, Long An, An Giang, Bc Giang, H Tnh, Qung
Nam, Tng Cng ty in lc min Trung,
Ngnh cng thng thc hin vic cp php sn xut, kinh doanh sn phm ru vi
cc c s bn bun; phi hp vi cc ngnh c lin quan tng cng kim tra hot ng sn
189

xut, kinh doanh ru, nht l cc v trng, nh hng, qun n,. hn ch vic bn l
ru, bia, thnh ph H Ch Minh ang xut cm kinh doanh ru sau 23 gi.
Cc An ton Thc phm (B Y t) trin khai 8 trung tm trn ton quc gim st
cc sn phm ru ang lu thng trn th trng. Hng nm, Cc u xy dng k hoch gim
st mi nguy an ton thc phm, ch o cc Vin chuyn mn v 63 a phng tin hnh gim
st cc mu thc phm, bao gm c cc sn phm ru lu thng trn th trng. Sp ti, Cc
s th im thanh tra chuyn ngnh cc thnh ph ln; mng li thanh tra s c b sung
tng cng kim tra, gim st
Bnh vin Tm thn Trung ng 1 thnh lp Khoa Nghin cht, trong c c cai
nghin ru v c trang web hng dn thng tin v cai nghin ni chung v cai nghin ru
ni ring. Trang web ca Bnh vin tm thn thnh ph H Ch Minh cng c chuyn dnh
ring cho iu tr nghin ru v cc ri lon tm thn do ru. Bnh vin Chm cu Trung
ng cng ng ti cc thng tin v h tr cai nghin ru.
Kt qu hot ng phng chng tc hi ca s dng ru, bia
Cha c nhiu nghin cu, nh gi kt qu cc hot ng kim sot s dng ru, bia
mc c hi; nht l vi cc tc ng i vi phng chng cc BKLN. Cc s liu thng k
thng ch tp trung vo tnh hnh tai nn giao thng do s dng ru, bia. S liu thng k trn
a bn An Giang cho thy sau khi thc hin k cam kt vi 40000 cn b cng chc trong tnh
v vic khng ung ru, bia trong gi lm vic v khi tham gia giao thng th s v tai nn
giao thng do ru, bia gim t 60% xung cn 30%.
Cc Qun l mi trng y t, B Y t kt hp vi S Y t Ninh Bnh xy dng m hnh
t vn phng chng ru, bia khi li xe ti 3 bnh vin v xy dng cng ng an ton v tai
nn giao thng, phng chng ru, bia khi li xe ti 2 x trn a bn tnh. Thng qua cc hot
ng tuyn truyn vi nhiu hnh thc phong ph, k cam kt thc hin xy dng cng ng an
ton v phng chng ung ru, bia khi li xe, sau 3 thng thc hin, t 9-11/2013, c 60% cc
h gia nh nhn thc c nguy c ca vic ung ru, bia khi iu khin phng tin giao
thng; trn 80% ngi dn thc hin khng ung ru, bia khi iu khin phng tin tham
gia giao thng v gim c 10% s trng hp tai nn giao thng c nguyn nhn t s dng
ru, bia.
2.3. Kh khn, hn ch
V vn bn, chnh sch
Lut phng chng tc hi ca ru, bia cha c ban hnh. Vn cn mt khong trng
trong cc quy nh v sn xut, s dng bia. Cha c quy nh v ti chnh cho vic trin khai
cc hot ng phng chng tc hi ca ru, bia.
Quy hoch sn xut kinh doanh ru, bia cha ch trng n vic kim sot, gim thiu
tc hi ca ru, bia. Quan im pht trin ngnh cng nghip sn xut bia, ru, nc gii
kht theo hng huy ng mi ngun lc t cc thnh phn kinh t, di mi hnh thc y
mnh sn xut bia, ru, nc gii kht p ng nhu cu ngy cng cao v a dng ca x hi
dng nh i ngc li vi cc n lc phng chng tc hi ca ru, bia.
Nhn chung, cc chnh sch v gii php hin hnh ch yu tp trung vo mc tiu gim
tc hi ca ru, bia i vi vn an ninh trt t, an ton giao thng ch cha ch trng n
190

gim thiu tc hi vi sc kho ni chung v phng chng BKLN ni ring. c bit cha c
cc quy nh, hng dn c th v vic trin khai cc m hnh cai nghin ru v phc hi chc
nng, ti ho nhp cng ng cho ngi nghin ru. Vic t chc t vn, cai nghin ru vn
cha c qun l cht ch c v cht lng, an ton v tnh hiu qu.
V t chc, ch o, trin khai thc hin
Trong kim sot ngun cung

Cn gp nhiu kh khn trong vic kim sot ngun cung nht l vi cc loi bia c,
ru t nu th cng. Ru th cng khong 250-300 triu lt/nm, c ti 95,7% ngi dng
v chim hn 70% lng tiu dng x hi. Tuy nhin, vic qun l, cp php ng k sn xut
kinh doanh, dn nhn mc gp kh khn do a phn l cc h kinh doanh nh l, khng lin
tc; bn thn cc h sn xut, kinh doanh cha hiu r cc quy nh ca Ngh nh 94; nhiu a
phng cha thc s quan tm n qun l ngun cung ru th cng.
Vic kim sot kinh doanh ru gi, ru lu cha tt, hng nm vn ghi nhn mt s
trng hp ng c bi methanol trong ru. Bt c u ngi tiu dng u c th mua c
ru ngoi xch tay, nhp lu vi mi cht lng, t cao cp ti c hi. Lc lng
qun l th trng ti cc a phng cn mng, cha p ng yu cu nhim v. Cha c s
hp tc tch cc ca cc hip hi, doanh nghip trong vic cung cp thng tin v cc v vic
lm gi, lm nhi ru, xy dng chun ha quy trnh sn xut ru th cng, hng dn ngi
tiu dng.
Kim sot sn xut bia vn cha c quan tm ng mc. Vic gim thu tiu th c
bit i vi bia sau khi gia nhp WTO gp phn h tr ngnh bia, nht l cc c s sn xut
nh, nhng ng thi cng gp phn khuyn khch cc nh my bia thi nhau mc ln v thc
y ngnh cng nghip sn xut bia tng trng mnh [193].
Trong hn ch tiu dng
Vic kim sot nhu cu v hnh vi tiu dng ru, bia hu nh ang b b ng. Cha
kim sot c tnh trng bn ru cho ngi di 18 tui. Ngi tiu dng vn thiu cc kin
thc la chn nhng sn phm ru an ton v ni khng vi cc sn phm ru khng r
ngun gc v khng c thng hiu. Cha c bin php hn ch ngi say ru tip tc s dng
ru, bia cc qun n, nh hng; hn ch ung ru, bia trong gi trc ng ca hn ch
li xe khi say ru,.
Cng tc tuyn truyn v phng chng tc hi ca s dng ru, bia c s tham
gia hng ng ca cc b, ngnh, on th, a phng tuy nhin cc hot ng vn cha i
vo thc cht; chng hn cc hot ng ca on Thanh nin thng hay kt thc bng ung
ru, bia.
Cha c chnh sch v cha huy ng c cc c s sn xut, kinh doanh sn phm
ru, bia tham gia vo vic cnh bo tc hi ca ru, bia. Hin nay, ch mi c 4 n v l bia
Larue, Heineken, Tiger, Bivina ng in cc khuyn co trn chai tuy nhin, dng ch cnh
bo trn nhn mc qu b nn ngi s dng kh pht hin.
S dng ru, bia ph n mang thai cha c quan tm ng mc. Cha c cc quy
nh v hn ch tiu dng ru, bia ph n mang thai. Nhn thc v tc hi ca ru, bia vi
thai nhi vn cn hn ch, nht l ph n ng bo dn tc thiu s.
191

Trong h tr cai nghin, phc hi chc nng
Mc d B Y t c Quy trnh hng dn iu tr cai nghin ru, tuy nhin hot ng
ny cha c trin khai rng ri cc c s khm cha bnh, iu tr. Vic sng lc t vn
cho ngi nghin ru cha c p dng trong thng quy khm cha bnh. Cc m hnh t
vn cai nghin ru, phc hi chc nng v ti ho nhp cho ngi nghin ru cng ng
cha c trin khai. Nhiu c s cai nghin t nhn qung co trn lan cha c kim sot
v cht lng v hiu qu.
2.4. Cc vn u tin
Cha c u mi thng nht qun l cc hot ng; thng tin v gim st, nh gi cn
hn ch (chung cho c 4 yu t nguy c).
Cc vn bn chnh sch v phng chng tc hi ca ru, bia vn cha hon thin (cha
c Lut phng chng tc hi ca lm dng ru, bia; ch trng nhiu hn vo cc tc
hi cp tnh, trt t tr an; cha c quy nh v gi bn ru, bia; cm bn ru bia cho
ngi say; cha c quy nh bt buc dn nhn cnh bo vi mt hng ru bia...).
Chnh sch vn cn nhiu im cha ph hp hoc thiu hng dn thc hin, kh p
dng trn thc t (qun l cht lng ru th cng, cai nghin ru,...). Thiu kinh ph
cho vic trin khai cc hot ng.
Phi hp lin ngnh trong kim sot sn xut, kinh doanh, tiu th ru, bia cn gp
nhiu kh khn c v c ch phi hp v nng lc thc thi (kim sot c ngun cung
v cht lng ru th cng; nhu cu v hnh vi tiu th ru, k c trong cn b, vin
chc; mua bn ru cho vi ngi di 18 tui).
Nhn thc v tc hi ca ru, bia v thc tun th php lut v phng chng tc hi
ca ru, bia cn hn ch trong khi vic tuyn truyn hn ch s dng ru, bia vn cn
mang tnh cht chung chung, kh thc hin.
Vic t chc t vn cai nghin, iu tr nghin ru, phc hi chc nng cho ngi
nghin cha c quan tm ng mc: cha c hng dn y v sng lc ngi
nghin, m hnh cai nghin ti cng ng; thiu ngun lc v cc chnh sch h tr.
2.5. Khuyn ngh
3. Khuyn khch ch dinh dng hp l

3.1. Mc tiu
Quyt nh 226/Q-TTg ca Th tng Chnh ph ph duyt Chin lc quc gia
v dinh dng giai on 2011-2020 v tm nhn 2030 nu r cc mc tiu n nm 2020
nh sau:
Mc tiu chung
n nm 2020, ba n ca ngi dn c ci thin v s lng, cn i hn v cht

lng, bo m an ton v sinh; suy dinh dng tr em, c bit th thp ci c gim mnh,
192

gp phn nng cao tm vc v th lc ca ngi Vit Nam, kim sot c hiu qu tnh trng tha
cn, bo ph gp phn hn ch cc bnh mn tnh khng ly nhim lin quan n dinh dng.
Cc mc tiu c th lin quan n phng chng BKLN
Ci thin tnh trng dinh dng ca b m v tr em: Khng ch t l bo ph tr em

di 5 tui mc di 5% nng thn v di 10% thnh ph ln vo nm 2015 v
tip tc duy tr n nm 2020.
Tng bc kim sot c hiu qu tnh trng tha cn - bo ph v yu t nguy c ca mt
s bnh mn tnh khng ly lin quan n dinh dng ngi trng thnh.
Kim sot tnh trng bo ph ngi trng thnh mc di 8% vo nm 2015
v duy tr mc di 12% vo nm 2020.
Khng ch t l ngi trng thnh c cholesterol trong mu cao (>5,2 mmol/l)
di 28% vo nm 2015 v duy tr mc di 30% vo nm 2020.
Nng cao nng lc v hiu qu hot ng ca mng li dinh dng ti cng ng v
c s y t.
3.2. Kt qu thc hin
Xy dng chnh sch
Tuy cha c cc chnh sch, chin lc v dinh dng phc v mc tiu phng chng
cc BKLN nhng Vit Nam c cc chnh sch chin lc chung v dinh dng, cc hng
dn khuyn ngh v ch dinh dng hp l.
Chin lc quc gia v dinh dng cho tng giai on
Chin lc quc gia v dinh dng giai on 2001-2010 c ban hnh km theo quyt
nh s 21/2001/Q-TTg nm 2001 c mc tiu chung l Bo m n nm 2010, tnh trng
dinh dng ca nhn dn c ci thin r rt... Hn ch cc vn sc khe mi ny sinh c
lin quan ti dinh dng37.
Tip , nm 2012, Th tng Chnh ph ban hnh Quyt nh 226/Q-TTg ph
duyt Chin lc quc gia v dinh dng giai on 2011-2020 v tm nhn 2030, trong c
mc tiu Tng bc kim sot c hiu qu tnh trng tha cn - bo ph v yu t nguy c ca
mt s bnh mn tnh khng ly lin quan n dinh dng ngi trng thnh. Chin lc
ny cng cp ti cc gii php lin quan ti phng chng BKLN nh: Trin khai cc hot
ng truyn thng i chng nhm nng cao hiu bit v thc hnh dinh dng hp l c bit
l phng chng suy dinh dng thp ci, khng ch tha cn - bo ph v cc bnh mn tnh
khng ly lin quan n dinh dng cho mi tng lp nhn dn v p dng kinh nghim v
thnh tu khoa hc dinh dng trong d phng bo ph, hi chng chuyn ha v cc bnh mn
tnh khng ly lin quan n dinh dng38.
Quyt nh s 21/2001/Q-TTg ngy 22/02/2001 ca Th tng Chnh ph v vic ph duyt Chin lc quc
gia v dinh dng giai on 20012010.
38
Quyt nh s 226/Q-TTg ngy 22/02/2012 ca Th tng Chnh ph v vic ph duyt Chin lc quc gia
v dinh dng giai on 20112020 v tm nhn 2030.
37
193

Cc hng dn, khuyn ngh v dinh dng hp l
B Y t ban hnh Quyt nh s 05/2007/Q-BYT nm 2007 v Mi li khuyn
dinh dng hp l giai on 2006-2010 v Quyt nh s 189/Q-BYT nm 2013 v Mi
li khuyn dinh dng hp l n nm 2020 lm c s cho cng tc truyn thng, gio dc
dinh dng nhm nng cao kin thc v thc hnh dinh dng hp l trong nhn dn. Cc li
khuyn ny tp trung vo: khuyn khch n a dng nhiu loi thc phm; phi hp thc n
m ng v thc vt, du thc vt v m ng vt; hn ch n mn; tng cng n rau qu;
bo m v sinh an ton thc phm; ung nc sch, cho b ngay sau sinh, b hon ton 6
thng u v ko di 24 thng; s dng b sung sa cho tr sau 6 thng v ngi trng thnh;
tng cng hot ng th lc, hn ch n ngt v ung c ga, ru, bia, thuc l.
B Y t cng ban hnh thng t 08/2011/TT-BYT yu cu cc bnh vin t tuyn
huyn tr ln tng bc phi thnh lp khoa dinh dng - tit ch. Theo , cc bnh vin phi
thc hin vic ch nh v t chc phc v ch n iu tr cho cc bnh nhn ni tr v thng
qua , tuyn truyn cho bnh nhn v ngi nh v ch n ph hp vi bnh l, bo m
v sinh, an ton, phng chng bnh tt, c bnh ly nhim v khng ly nhim.
Chnh sch lin ngnh c lin quan n vn dinh dng
Lut An ton thc phm ban hnh nm 2010, trong ghi r khuyn khch cc c s
sn xut kinh doanh thc phm t cht lng cao, bo m an ton v a dng cc hnh thc,
phng thc tuyn truyn, gio dc nng cao nhn thc ngi dn v tiu dng thc phm an
ton. Chnh ph cng ban hnh Ngh inh s 38/2012/N-CP nm 2012 quy nh chi tit
thi hnh mt s iu ca Lut An ton thc phm.
Vic thc hin ch chm sc nui dng hp l cho tr em c th gp phn hnh thnh
thi quen v dinh dng hp l v sau ny ng thi qua gin tip lm gim cc nguy c mc
cc bnh BKLN khi trng thnh. Ngh nh s 21/2006/N-CP v Thng t lin tch 10/2006/
TTLT/BYT-BTM-BVHTT-UBDSGTE quy nh v vic kinh doanh v s dng cc sn
phm dinh dng dng cho tr nh, tp trung vo vic thng tin, gio dc, truyn thng v nui
dng cho tr, khuyn khch nui con bng sa m, cm cc hnh thc tuyn truyn, khuyn
khch cho tr b bnh hoc khng khuyn khch nui con bng sa m. Th tng Chnh ph
k Quyt nh s 149/2006/Q-TTg ph duyt n Pht trin Gio dc mm non giai on
2006 - 2015 v Quyt nh s 239/Q-TTg ph duyt n Ph cp gio dc mm non cho
tr em nm tui giai on 2010-2015. Cc chnh sch ny cp n c vic bo m dinh
dng cho tr trc khi bc vo la tui hc ng.
Nm 2012, Chnh ph ban hnh Quyt nh s 01/2012/Q-TTg v mt s chnh
sch h tr vic p dng Quy trnh thc hnh sn xut nng nghip tt trong nng nghip, lm
nghip v thy sn. Lin B K hoch v u t, Nng nghip v Pht trin nng thn, Ti
chnh ban hnh Thng t lin tch s 42/2013/TTLT-BNNPTNT-BTC-BKHT hng dn
thc hin Quyt nh s 01/2012/Q-TTg. Cc chnh sch ny lin quan n vic khuyn khch
thc hnh sn xut cc sn phm nng sn ph hp vi quy chun k thut, bo m v sinh an
ton thc phm, phng chng bnh tt ni chung.
T chc, ch o trin khai chnh sch
B Gio dc v o to a ra ni dung gio dc dinh dng sc khe vo chng

trnh chm sc gio dc tr nh tr mu gio vi mc tiu khng ch t l suy dinh dng
di 15% v t l bo ph khng qu 5% tr mm non vo nm 2015.
194

B Y t t chc pht ng Tun l nui con bng sa m t ngy 1-7/8 v Tun l
dinh dng v pht trin t 16-23/10 hng nm vi cc ch khc nhau; tham gia sng kin
bnh vin thn thin v thc hin hng dn Mi bc cho con b thnh cng nhm h tr
v thc y vic nui con bng sa m v cho con b ng cch; t chc cc hnh thc tuyn
truyn Mi li khuyn dinh dng hp l. B Y t cng thc hin thnh lp Khoa dinh
dng lm sng ti cc bnh vin.
Vin Dinh dng a ra Chng trnh o to dinh dng hc ng bc hc mm
non nhm trang b y v cp nht nht nhng kin thc v chm sc dinh dng v an ton
v sinh thc phm i vi la tui mm non cho gio vin v cn b qun l trong cc nh tr,
mu gio vi thi gian o to 3 thng. Cng trong nm 2013, Trng i hc Y H Ni bt u
trin khai vic o to c nhn dinh dng cng ng nhm cung cp ngun nhn lc c trnh
cao v dinh dng cho cc c s y t, qua gp phn nng cao cht lng dinh dng cho
bnh nhn ni ring v ngi dn ni chung.
Mt s a phng nh thnh ph H Ch Minh ban hnh K hoch thc hin Chin
lc quc gia v dinh dng trong tng giai on 2001-2005, 2006-2010 v 2011-2015. Cc
a phng cng t chc cc bui mt tinh tuyn truyn hng ng tun l Dinh dng v
pht trin hng nm.
H Ni v thnh ph H Ch Minh ph duyt cc n sn xut v tiu th rau an ton
(Quyt nh 2083/Q-UBND ca UBND thnh ph H Ni v Quyt nh s 1494/Q-UBND
ca UBND thnh ph H Ch Minh). Ti H Ni, n nm 2012, ton thnh ph c 154 c s ti
94 x phng t tiu chun sn xut rau an ton vi tng din tch 3800 ha. Cc qun, huyn
cng lp 31 d n xy dng vng rau an ton tp trung vi tng din tch l 2080 ha. n
nm 2013, din tch rau an ton s m rng 4500 ha, phn b 166 x. Ton thnh ph c 35
siu th v 58 ca hng c cp giy chng nhn iu kin kinh doanh rau an ton, ngoi
ra thnh ph cn xc nh c 300 im phn phi rau an ton ti cc khu dn c, trong , c
50 im chnh thc vn hnh [194].
Ti thnh ph H Ch Minh, n cui nm 2012 c 182 t chc sn xut, c nhn c
chng nhn t tiu chun sn xut rau an ton vi tng din tch 90,16 ha v sn lng rau
khong 11450 tn/nm. Thnh ph t mc tiu n nm 2025 din tch canh tc rau an ton
t 3817 ha vi tng sn lng 471580 tn/nm.
B Ti chnh ang a ra xut nh thu tiu th c bit ln nc gii kht c gas
khng cn trn c s bng chng t mt s nghin cu cnh bo vic s dng nc gii kht
c gas tc hi ln n sc khe ngi tiu dng nh bnh tiu ng, bo ph, tro ngc d
dy - thc qun, v bnh tim mch [195], [196].
Kt qu tng iu tra dinh dng nm 2010 cho thy c cu sinh nng lng trong khu
phn n (t l gia tinh bt/cht bo/cht m) ca cc h gia nh ni chung v tr em ni ring
thay i theo hng cn i hn so vi nm 2000 [166].
3.3. Kh khn, hn ch
Chin lc dinh dng n nm 2020 vn ch trng nhiu hn vo cc gii php phng
chng suy dinh dng mc d gim t l tr em bo ph cng l mt nhim v c nhn mnh
trong phn mc tiu. Ch c hai gii php a ra lin quan n phng chng nguy c ca BKLN
l: Gio dc v ph cp kin thc dinh dng cho ton dn v Phng chng cc bnh mn
tnh lin quan n dinh dng.
195

Nhn chung, cc gii php ch yu vn tp trung vo cc hot ng tuyn truyn, gio
dc, ph bin kin thc chung chung v dinh dng hp l ch cha c cc khuyn co v
ch n chun hng ngy. Ngi tiu dng vn thiu thng tin v vic n nh th no bo
m hp l, la chn cc thc phm nh th no, u bo m an ton, phng trnh c
bnh tt.
Cc can thip ti u theo khuyn co ca WHO nh khuyn khch ngi dn gim s
dng mui, gim lng mui trong thc n, thay th cht bo chuyn ho bng cht bo khng
no cha c quan tm ch ng mc v cha c cc gii php k thut c th thc y,
h tr cho vic thc hin dinh dng hp l ca ngi dn.
Cc nh dinh dng khuyn co, thnh phn cht bo chuyn ha trong thc phm
khng nn vt qu 2% tng cht bo. Hin ti Vit Nam cha c tiu chun quy nh v hm
lng cht bo chuyn ho trong thc phm v cha c quy nh bt buc cc doanh nghip sn
xut thc phm phi ghi r thng tin v t l cht bo chuyn ha trn bao b sn phm. Ngi
tiu dng Vit Nam cng t c cnh bo v s c mt cng tc hi ca cht bo chuyn ha.
Tuy nhin kho st ca Trung tm dch v phn tch th nghim thnh ph H Ch Minh nm
2010 cho thy, trong 34 mu m gi, pht hin ti 38% s mu cha cht bo chuyn ho, trong
, c n 3 mu cha t l cht bo chuyn ha vt qu mc khuyn co [197].
Cha c nh gi tc ng sc kho ca cc chnh sch, cc d n, k hoch pht trin
kinh t, x hi. Quy hoch mng li sn xut, kinh doanh nc gii kht v cc loi thc n
nhanh, k c m n lin vn cha gn vi mc tiu thc y dinh dng hp l phng chng
cc BKLN. Gim st cht lng v cc quy chun k thut dnh cho cc nhm thc n nhanh
cha cht ch.
Quy m ca cc n sn xut v tiu th rau sch ni ring v thc phm an ton ni
chung cc a phng vn cn khim tn. Cha c cc gii php h tr, khuyn khch sn
xut, kinh doanh cc thc phm sch, an ton cc thc phm ny n c vi ngi tiu
dng mt cch rng ri hn. Cht lng ca cc c s kinh doanh thc phm sch vn cha
c kim sot dn n mt lng tin ca ngi tiu dng.
Tnh trng nhim thc phm bi cc ho cht c hi khng r ngun gc ang mc
ng bo ng c trong khu sn xut, bo qun, lu thng, phn phi v ch bin. Cc phng
tin thng tin i chng lin tc a tin v cc v s dng ho cht kch thch tng trng rau
qu, ng vt nui; s dng ho cht c hi bo qun hi sn, tht, tri cy; s dng ho
cht ch bin tht i thiu thnh tht ti; cc thc phm gi, lm cho ngi tiu dng hoang
mang, mt nim tin vo cc hng ho lu thng trn th trng. Phn ng ca c quan qun l
nh nc trong lnh vc ny dng nh cn b ng, mang tnh i ph khi c cc v vic c
phanh phui v do cha th trn an c ngi tiu dng.
3.4. Cc vn u tin
Ni dung tuyn truyn dinh dng hp l cn chung chung, cha tp trung vo trng
tm gim tiu th mui, ng v thc phm nhiu cht bo chuyn ho. Nhn thc ca
ngi dn v cc loi thc phm c li cho sc kho ni ring v ch dinh dng hp
l ni chung vn cn hn ch, nht l vi cc thng tin lin quan n hm lng mui
v cht bo chuyn ho bo ho trong thc phm;
196

Cha c chnh sch v gii php k thut nhm kim sot hm lng mui v cht bo
chuyn ho trong thc phm, hn ch vic sn xut, kinh doanh cc loi thc phm nhiu
mui, ng v cht bo;
Thiu cc chnh sch v ch ti ng b v kinh t, x hi khuyn khch, h tr vic
sn xut, kinh doanh, phn phi cc loi thc phm lnh mnh, c li cho sc kho v d
gim thu, tr gi cho sn xut kinh doanh rau qu, thc phm sch; thc hin nh gi
tc ng sc kho (HIA) vi cc chnh sch, d n, k hoch pht trin kinh t, x hi.
Tnh trng nhim thc phm do s dng trn lan cc ho cht c hi trong sn xut,
bo qun v ch bin thc phm ang mc bo ng, kh kim sot.
3.5. Khuyn ngh
4. Tng cng hot ng th lc

4.1. Mc tiu
Hin Vit Nam cha c mt chin lc c th dnh ring cho vic tng cng hot ng
th lc phng chng BKLN. n tng th pht trin th lc, tm vc ngi Vit Nam giai
on 2011 - 2030 cp n cc mc tiu sau:
Mc tiu tng qut
Pht trin th lc, tm vc ngi Vit Nam trong 20 nm ti nng cao cht lng
ngun nhn lc, phc v s nghip cng nghip ha, hin i ha t nc; tng bc nng cao
cht lng ging ni v tng tui th khe mnh ca ngi Vit Nam.
Mc tiu c th (lin quan n phng chng BKLN)
Tng cng CSSK tr em, ngi cha thnh nin v thanh nin nhm gim thiu cc
bnh v tim mch, bnh bo ph, bnh gy bt bnh thng v chiu cao thn th, gp phn nng
cao cht lng cuc sng.
4.2. Kt qu thc hin
Xy dng chnh sch
Quan im khuyn khch ton dn rn luyn th dc th thao vi phng chm dn

cng, nc thnh c th hin ngay t nhng ngy u thnh lp nc. Sau khi c quyt
nh thnh lp Nha th dc Trung ng, Ch tch H Ch Minh ra li ku gi ton dn tp
th dc, coi luyn tp th dc, bi b sc khe l bn phn ca mi mt ngi yu nc v
mong ng bo ta, ai cng gng tp th dc.
Vi quan im , pht trin th dc th thao v rn luyn th lc lun nhn c s
quan tm trong lnh o, ch o ca ng, Nh nc v Chnh ph. Gn y nht, B Chnh
tr ban hnh Ngh quyt s 08-NQ/TW, ngy 01/12/2011 v tng cng lnh o ca ng,
to bc pht trin mnh m v th dc, th thao n nm 2020. C t nht 6 vn bn lut
197

cc lnh vc khc nhau c ban hnh, cp n vic pht trin th dc th thao nng
cao th lc v sc kho ca ngi dn, bao gm: Lut Th dc, th thao ban hnh nm 2006 (s
77/2006/QH11); Lut Bo v sc kho nhn dn ban hnh nm 1989; Lut Gio dc ban hnh
ln u nm 1998, ln hai nm 2005 v sa i nm 2009 (s 44/2009/QH12); Lut Bo v v
chm sc, gio dc tr em ban hnh ln u nm 1991 v ln hai nm 2004 (s 25/2004/QH11);
Lut Thanh nin ban hnh nm 2005 (s 53/2005/QH11); Lut Ngi cao tui nm 2009 (s
39/2009/QH12).
im chung ca cc Lut ny l u nu r li ch ca rn luyn th dc th thao i vi
sc kho, quyn ca ngi dn c tp luyn th dc th thao, chm lo pht trin th cht v
cc c quan nh nc c trch nhim tuyn truyn, vn ng, t chc v to mi iu kin cho
ngi dn thuc cc i tng khc nhau (nht l tr em, thanh nin v ngi cao tui) c
rn luyn th dc th thao nng cao sc kho. Trong , Lut Ngi cao tui v Ngh nh
06/2011/N-CP quy nh chi tit v hng dn thi hnh mt s iu ca Lut Ngi cao tui
quy nh cc b, ngnh lin quan c trch nhim to iu kin thun li ngi cao tui
tham gia luyn tp dng sinh v cc hot ng th dc, th thao ph hp vi sc khe, tm l
v gim gi v dch v luyn tp th dc th thao cho ngi cao tui.
Trn c s cc vn bn Lut ny, Chnh ph v cc b, ngnh c lin quan ban hnh
cc chnh sch, chin lc khuyn khch v to iu kin cho cc hot ng tp luyn th dc,
th thao, rn luyn th lc nng cao sc kho. Tip theo quy hoch pht trin ngnh TDTT
giai on 2001-2010 v cc chng trnh pht trin TDTT qun chng v pht trin TDTT x
phng, nm 2010, Chnh ph ph duyt Chin lc pht trin ngnh TDTT giai on 20112020 (Quyt nh s 2198/Q-TTg), trong xc nh Gio dc th cht, th thao trong Nh
trng l mt trong nhng gii php thc hin Chin lc ny.
Quyt nh 2160/Q-TTg nm 2013 ph duyt Quy hoch pht trin th dc, th thao
Vit Nam n nm 2020, nh hng n nm 2030 ra mc tiu t l ngi dn luyn tp th
dc th thao thng xuyn t 28% dn s vo nm 2015, t 33% dn s vo nm 2020 v trn
40% dn s vo nm 2030. Quyt nh ny cng quy nh din tch sn tp dnh cho gio dc th
cht v th thao trong nh trng cc cp hc, bc hc. B Vn ho, th thao v du lch cng ban
hnh Thng t 02/2009/TT-BVHTTDL hng dn vic t chc v nh gi phong tro th dc th
thao qun chng ti a phng.
Nm 2001, Chnh ph ban hnh Quyt nh s 201/2001/Q-TTg ph duyt Chin
lc gio dc 2001-2010. n nm 2012, Chnh ph li ban hnh Quyt nh s 711/Q-TTg
ph duyt Chin lc gio dc 2011-2020. B Gio dc v o to cng ang xy dng D tho
Ngh nh ca Chnh ph Quy nh v gio dc th cht v th thao trong nh trng, trong
nu r gio dc th cht trong cc c s gio dc l mt hot ng gio dc bt buc. D tho
Ngh nh cng ra cc quy nh v ni dung chng trnh, tiu chun c s vt cht v cc iu
kin khc bo m cho gio dc th cht v th thao trong cc c s gio dc v quy nh r trch
nhim ca cc b, ngnh lin quan nh: Gio dc v o to, Vn ho - Th thao v Du lch, Lao
ng - Thng binh v X hi, v U ban nhn dn cc tnh, thnh ph trong cng tc gio dc
th cht v hot ng th dc th thao.
Thng t lin b s 22/2013/TTLT-BGDT-BYT yu cu bt buc cc c s mm
non phi c sn chi v cy xanh; Thng t s 02/2014/TT-BGDT cng c iu quy
nh cc c s gio dc mm non t chun bt buc phi c phng gio dc th cht
vi kch thc ti thiu 60 m2. B Gio dc v o to cng t ra mc tiu n nm
198

2015 phi chun ha gio vin dy th dc, khng cn gio vin trnh trung cp v s
cp v n nm 2020 bo m 100% cc trng ph thng cc cp c gio vin chuyn
trch ph trch mn gio dc th cht tt nghip chuyn ngnh gio dc th cht39.
Bn cnh , B Lao ng-Thng binh v X hi cng ban hnh Thng t s 15/2013/
TT-BLTBXH ngy 28/08/2013 quy nh v vic t chc hot ng th dc, th thao cho hc
sinh, sinh vin trong cc c s dy ngh.
Quyt nh s 641/Q-TTg ph duyt n tng th pht trin th lc, tm vc ngi Vit
Nam giai on 2011-2030 c iu khon quy nh Tng cng CSSK tr em, ngi cha thnh
nin v thanh nin nhm gim thiu cc bnh v tim mch, bnh bo ph, bnh gy bt bnh thng
v chiu cao thn th, gp phn nng cao cht lng cuc sng.
B Y t cng xy dng v ban hnh Mi li khuyn dinh dng hp l cho tng
giai on 2006-2010 (Quyt nh 05/2007/Q-BYT) v 2011-2020, trong c khuyn co hot
ng th lc u n, duy tr cn nng mc hp l.
T chc, ch o trin khai chnh sch
Vn phng Ban iu phi n 641 c thnh lp, ng vai tr l n v iu phi

cc hot ng ca 4 chng trnh thnh phn trong n tng th pht trin th lc, tm vc
ngi Vit Nam giai on 2011-2030. Vn phng c k hoch trin khai nhiu hot ng nh
t chc cc cuc mt tinh, i b, t chc thi vit bi ht v v biu trng cho n nhm tuyn
truyn su rng cc ni dung ca n ti ng o ngi dn trong c nc.
Nhiu b, ngnh, a phng xy dng cc k hoch, n tng cng cng tc rn
luyn th cht, luyn tp th dc th thao trong ngnh gio dc, i tng thanh nin cng nh
kt hp vi cng on cc cp y mnh cng tc tuyn truyn gio dc, vn ng cc on
vin cng on tch cc tham gia cc hot ng rn luyn th cht, cc hi thao th dc th thao
ton ngnh, a phng qua khuyn khch mi ngi tch cc tham gia tp luyn th dc th
thao, rn luyn v nng cao sc kho [198]. Chng trnh O2TV cng dnh mt thi lng
ng k cho cng tc tuyn truyn phng chng tc hi ca ht thuc, ung ru, dinh dng
khng hp l v li sng t vn ng nhm mc ch khuyn khch ngi dn t bo v v nng
cao sc kho.
B Vn ho - Th thao v Du lch v ang xy dng v trin khai cc ni dung phi
hp vi B Quc phng, B Cng an, B Gio dc v o to, y ban Dn tc, Tng Lin on
Lao ng Vit Nam, Hi Lin hip Ph n Vit Nam, Trung ng on Thanh nin Cng sn
H Ch Minh, Hi Nng dn, Hi Ngi cao tui v cc b, ngnh, on th khc trong pht
trin th dc th thao.
B Vn ho - Th thao v Du lch cng pht ng trn phm vi ton quc cuc vn
ng Ton dn rn luyn thn th theo gng Bc H v i giai on 2012-2020, lng ghp
trin khai vi phong tro Ton dn on kt xy dng i sng vn ha, Chng trnh mc
tiu quc gia v xy dng nng thn mi giai on 2010-2020, n tng th pht trin th
lc, tm vc ngi Vit Nam giai on 2011-2030 v cc chng trnh, n ca Chnh ph
v CSSK, y t, v sinh mi trng. Ch tiu ca Cuc vn ng Ton dn rn luyn thn th
theo gng Bc H v i c a vo ngh quyt ca cc cp y ng, k hoch ca cc cp
chnh quyn tp trung lnh o, ch o thc hin.
Thng bo 1001/TB-BGDT kt lun ca Th trng Trn Quang Qu ti Hi ngh Tng kt cng tc gio dc
th cht v phong tro Hi khe Ph ng giai on 2008 - 2012 do B Gio dc v o to ban hnh.
39
199

Vic khuyn khch vn ng, rn luyn th lc cng c quan tm lng ghp vi chin
lc quy hoch tng th ca mt s b, ngnh, a phng. u thng 2/2014, Th tng Chnh
ph ch o cc b v UBND 5 thnh ph trc thuc Trung ng l H Ni, thnh ph H Ch
Minh, Hi Phng, Nng v Cn Th nghin cu trin khai n th im cung cp dch v xe
p cng cng. Ti thnh ph Hi An, tnh Qung Nam t ngy 1/4/2014, ton th gn 2000 cn
b vin chc ca thnh ph bt u thc hin vic i lm bng xe p. UBND thnh ph cng
ng vin khuyn khch ngi dn i li trong thnh ph bng phng tin xe p.
Mt s khu th mi c quy hoch gn y bo m tun th t l cy xanh, cng
vin, khu vui chi gii tr, tp luyn th dc th thao. Nhiu trung tm, cu lc b th dc th
thao t nhn c thnh lp cc thnh ph ln, thu ht c nhiu thanh nin, nhn vin
vn phng n tp luyn.
Hot ng gio dc th cht c t chc thng xuyn v rng ri trong nh trng
cc cp nhm thc hin mc tiu gio dc ton din cho hc sinh. Tnh n ht nm 2013, c
nc c trn 90% s trng hc thc hin tt chng trnh gio dc th cht chnh kho c nn
np theo quy nh; trn 60% s trng hc c hot ng th dc th thao ngoi kho c nn np,
t chc thng xuyn cc hot ng th thao cho hc sinh, sinh vin [199]. Phong tro th thao
trng hc c pht ng vi nh cao l Hi kho ph ng cc cp v ton quc (c t
chc 4 nm/ln t nm 1984) v i hi th thao sinh vin ton quc cng gp phn khuyn
khch tinh thn thi ua luyn tp th dc th thao trong i ng hc sinh, sinh vin.
Trong nhng nm qua, phong tro tp luyn TDTT ca qun chng nhn dn c bc
pht trin c b rng v chiu su. Theo tng kt ca B Vn ho - Th thao v Du lch, tnh
n nm 2011, c nc c khong 15% s h gia nh vi 24% dn s thng xuyn tp luyn
TDTT; c 40000 cu lc b TDTT c s. Tnh ring trong khu vc ng bo dn tc thiu s
v min ni t cng c khong 6-8% dn s v khong 2-3% tng s h gia nh t chun
gia nh luyn tp TDTT [198]. Hot ng th dc th thao, rn luyn th lc c bit si ni
i tng ngi cao tui c thnh th cng nh nng thn, di hnh thc cc cu lc b cu
lng, bng bn, yoga, th dc nhp iu,
4.3. Kh khn, hn ch
Hot ng rn luyn th lc, luyn tp th dc th thao c cp trong nhiu vn
bn, chnh sch v c lin quan vi rt nhiu ban ngnh, a phng khc nhau nhng ch yu
tp trung vo pht trin th thao thnh tch cao hn l huy ng s tham gia ca cng ng
trong rn luyn th lc, nng cao sc kho. Cc chnh sch v khuyn khch rn luyn th lc
vn ang c t trong tng th hot ng th dc th thao ni chung ch cha gn kt cht
ch vi hot ng ca ngnh y t, nht l trong cng tc phng chng BKLN.
Cng tc lp quy hoch, k hoch ca cc b, ngnh, a phng vn cha bo m tnh
ng b, cha ch trng v to iu kin mi trng thun tin v an ton cho hot ng rn
luyn th lc, nng cao sc kho ca ngi dn. V d nh quy hoch cc thnh ph ln vn
thiu cc khu vui chi, luyn tp dnh cho ngi gi, tr em v thanh nin; ng s cha bo
m din tch va h, ln ng u tin dnh ring khuyn khch ngi i b, i xe p, Cha
c s quan tm ng mc ti vic to thun li cho rn luyn th lc trong mi trng cng s,
ti ni lm vic.
Gio dc th cht trong trng hc vn thng b coi nh so vi cc mn hc khc. H
thng cc c s, sn bi phc v gio dc th cht v th dc, th thao trng hc cn trong tnh
200

trng thiu thn, cha t tiu chun. Gio vin th dc cn thiu v s lng, hn ch v cht
lng chuyn mn; ch , chnh sch i vi i ng gio vin th cht cn nhiu bt cp. Ni
dung hot ng th thao ngoi kho trong nh trng cn ngho nn, cha thc s to c s
hng th cho hc sinh, sinh vin [200].
Vic trin khai cc chnh sch v khuyn khch, tng cng hot ng th lc cha c
theo di, gim st, nh gi cht ch. Thiu mt ngun kinh ph bn vng cho cc hot ng ny
trong khi vic to iu kin huy ng ngun u t ca x hi cha pht huy c hiu qu; cc
cu lc b th dc th thao t nhn kh tip cn c bi phn ln ngi dn.
Hp 3. Mt s vn cha hon thin trong chnh sch khuyn khch thc hin ch
dinh dng lnh mnh v tng cng hot ng th lc so vi khuyn co ca WHO
C
ha c chnh sch quc gia v khuyn khch dinh dng lnh mnh v tng cng
hot ng th lc.
C
ha lng ghp hot ng khuyn khch dinh dng lnh mnh v tng cng hot
ng th lc vo trong cc k hoch pht trin kinh t x hi v cc chng trnh y t
khc.
C
ha c hng dn quc gia v ch dinh dng lnh mnh (hn ch mui, cht
bo,...) v ch hot ng th lc cho cc i tng khc nhau.
T
hiu mi trng khuyn khch v h tr thc hnh dinh dng lnh mnh v hot
ng th lc y .
Cha c ngun kinh ph cho cc hot ng.
Thiu h thng theo di, gim st, nh gi tm quc gia.
Ngun: Global strategy on diet, physical activity and health. WHO 2004 [201]; A guide for population-based
approaches to increasing levels of physical activity: implementation of the WHO global strategy on diet, physical
activity and health. WHO 2007 [202]; Diet and Physical Activity for the Prevention of noncommunicable diseases in
low- and middle-income countries: A systematic policy review [203].
4.4. Cc vn u tin
Thiu mt h thng thng tin theo di, gim st v nh gi cc hot ng thc y rn
luyn th lc nng cao sc kho (nh vi cc yu t nguy c khc).
Truyn thng gio dc v hot ng th lc phng chng BKLN cha hiu qu. Nhn
thc v thc ca ngi dn trong hot ng th lc nng cao sc kho, vn cn hn ch,
c bit trong thanh thiu nin v gii tr.
Thiu mi trng thun tin v cc iu kin c s vt cht h tr ngi dn tng cng
rn luyn th lc nng cao sc kho, nht l trong trng hc cc cp, tr s c quan.
Cn thiu cc n lc mang tnh lin ngnh trong vic khuyn khch hot ng th lc
nng cao sc kho, c trong hot ng tuyn truyn, gio dc; cng tc quy hoch, lp k hoch
xy dng. Hot ng gio dc th cht trong nh trng vn cha p ng c yu cu, phong
tro th dc th thao qun chng cha c pht trin su rng.
4.5. Khuyn ngh
201
5. Khuyn ngh chung v ii php kim sot cc yu t nguy c chung

ca BKLN
Phng chng, kim sot cc yu t nguy c chung ca cc BKLN i hi cc n lc lin
ngnh vi s cam kt ca Chnh ph, s tham gia ca ton x hi trong vic xy dng chnh
sch cng nh t chc trin khai thc hin cc hnh ng. Trong nhng nm qua, Vit Nam
c nhiu chnh sch lin quan n kim sot cc yu t nguy c nhng cc chnh sch vn
cha hon chnh v vic thc hin vn cn gp nhiu kh khn. Cc vn u tin trong chnh
sch kim sot cc yu t nguy c chung ca BKLN hin nay l:
Chnh sch kim sot cc yu t nguy c BKLN vn cha hon chnh v cn nhiu im
bt cp, nht l trong khuyn khch ch dinh dng lnh mnh v tng cng rn
luyn th lc, trong khi nng lc vn ng, xy dng chnh sch cn hn ch.
Thiu mt u mi t chc thng nht c nng lc v thm quyn trong vic huy
ng v phi hp lin ngnh trin khai c hiu qu cc chnh sch kim sot cc yu t
nguy c BKLN.
Thiu mt h thng theo di, gim st, nh gi y v cc yu t nguy c v kt qu
thc hin phng chng cc yu t nguy c BKLN.
Nhn thc v thc hnh ca ngi dn trong kim sot cc yu t nguy c BKLN vn
cn hn ch.
Trn c s cc phn tch, nh gi nh trn, chng ti xut cc khuyn co i vi
kim sot cc yu t nguy c chung BKLN nh sau:
Khuyn co
Nng cao nng
lc vn ng
xy dng chnh
sch, tng bc
hon thin cc
chnh sch kim
sot cc yu t
nguy c chung
ca cc BKLN
Gii php ngn hn

2014-2015
Gii php di hn
(2016-2020 v sau 2020)
Tham kho kinh nghim ca

cc nc trong khu vc v trn
th gii trong vn ng v xy
dng chnh sch kim sot cc
yu t nguy c
B Y t phi hp vi cc b,
ngnh r sot v iu chnh
cc bt cp trong cc quy nh,
chnh sch v phng chng tc
hi ca thuc l v ru bia
(x pht vi phm quy nh cm
ht thuc l ti cc im cng
cng, qun l sn xut kinh
doanh ru th cng; b sung
quy nh cm hon ton vic
ht thuc trong nh, bt buc
dn nhn cnh bo tc hi ca
ru, bia,...).
Xy dng chin lc, gii php
trong m phn gia nhp TPP
gim thiu cc tc ng ca
Hip nh trong phng chng
tc hi ca thuc l v ru, bia
Nng cao nng lc vn ng chnh sch ca

ngnh y t, huy ng s tham gia ca cc b,
ngnh, t chc on th trong vn ng v xy
dng chnh sch kim sot cc yu t nguy c
B Y t phi hp vi cc b, ngnh lin quan
vn ng thng qua Lut phng chng tc hi
ca ru, bia.
Tng bc xy dng, hon thin cc chnh
sch khuyn khch ch dinh dng v hot
ng th lc hp l: hn ch sn xut, kinh
doanh, tiu th thc phm ch bin v ung
ngt, thc n nhanh, cc thc phm c nhiu
mui, ng v cht bo chuyn ho; khuyn
khch sn xut cc thc phm lnh mnh, cc
chnh sch h tr cho hot ng th lc.
Xy dng Chin lc phng chng cc BKLN
cho giai on 2015-2020 v tm nhn 2030,
trong c ni dung kim sot cc yu t nguy
c vi cc mc tiu c th cho tng yu t.
Xem xt a dch v cai nghin ru, thuc l
vo danh mc dch v c BHYT thanh ton.
202
Khuyn co
Gii php ngn hn

2014-2015
Gii php di hn
(2016-2020 v sau 2020)
Nghin cu xut thnh lp Qu nng cao
sc kho t ngun thu thu tiu th c bit
i vi ru, bia v thuc l
Xy dng v ban hnh chnh sch quy nh
nh gi tc ng sc khe (HIA) phi c
thc hin trong mi d n, k hoch pht trin
kinh t x hi. Trong quy hoch th, ng
s, trng hc, quy hoch phng tin giao
thng cn tnh n vic to mi trng thun
li cho hot ng th cht, rn luyn th dc,
th thao nng cao sc khe.
Xy dng m
hnh t chc
thng nht qun
l hot ng
kim sot cc
yu t nguy c
trong khun kh
mt u mi t
chc, ch o
phng
chng
BKLN c
nng lc,
thm quyn huy
ng lin ngnh
v s tham gia
ca ton x hi
- Xy dng m
hnh t chc ph
hp v nng cao
nng lc ca
c quan iu
phi trong ch
o, iu phi
cc hot ng
d phng, kim
sot cc yu t
nguy c
- Tng cng
phi hp lin
ngnh c hiu
qu trong trin
khai cc hot
ng
phng
chng cc yu t
nguy c
Lng ghp hot ng kim

sot s dng ru, bia mc
c hi, thc y ch dinh
dng v hot ng th lc
hp l vi chc nng ca Ban
ch o PCTHTL.
nh gi thc trng v xut
cc gii php nng cao vai tr
v nng lc ca Cc Y t d
phng, B Y t trong vic ch
o, iu phi lng ghp cc
hot ng phng chng cc yu
t nguy c BKLN.
Cc b, ngnh, t chc on
th, a phng cn xy dng
k hoch c th v lng ghp
d phng v kim sot cc yu
t nguy c BKLN.
Vin Dinh dng phi hp vi
Cc An ton Thc phm nghin cu xy dng hng dn
c th v mc tiu th ru,
bia bo m phng trnh c
cc BKLN, mc tiu th mui,
ng, cht bo chuyn ho;
tiu chun hn ch cc cht
ny trong thc phm ch bin
bo m phng trnh c cc
BKLN.
203
Th im m hnh t chc cc tuyn, xy

dng chc nng nhim v, c ch hot ng,
c ch ti chnh v c ch phi hp lin ngnh
trong trin khai hot ng phng chng cc
yu t nguy c BKLN.
a ch tiu v kim sot cc yu t nguy c
ni ring v phng chng cc BKLN ni chung
vo ch tiu k hoch hot ng, pht trin kinh
t x hi ca cc a phng, b ngnh.
B Y t nghin cu, hon thin cc hng dn,
quy nh v t chc cai nghin, iu tr, phc
hi chc nng cho ngi nghin ru, thuc
l; phi hp vi B Lao ng - Thng binh
v X hi v cc b, ngnh lin quan t chc
th im v nhn rng cc m hnh cai nghin,
phc hi chc nng ti cng ng. Huy ng
s tham gia ca cc t chc, on th, cng
ng trong vic t chc cai nghin, phc hi
chc nng cho ngi nghin. a vic sng
lc, t vn cho ngi nghin ru, thuc l
trong cng tc khm cha bnh thng xuyn.
Cc An ton Thc phm xy dng l trnh cng
b, ghi nhn hm lng cht bo chuyn ho
trong thc phm; nghin cu cc gii php k
thut h tr cc c s sn xut thay th cht
bo chuyn ho bng cht bo khng bo ho;
tng cng kim tra gim st thc hin cng
b hm lng v ghi nhn hm lng cht
bo chuyn ho, nht l vi n nhanh.
u t nng cao nng lc cc c s kim
nghim thc phm, tng cng kim tra, gim
st, bo m an ton v sinh thc phm, gim
st cht lng ru, bia nht l vi ru, bia
sn xut th cng.
Gii php ngn hn

2014-2015
Gii php di hn
(2016-2020 v sau 2020)
Thit lp mt h
thng gim st
c hiu qu v
cc yu t nguy
c v cc hot
ng kim sot
cc yu t nguy
c chung ca
cc BKLN
- Thit lp h
thng thng nht
qun l, gim st
cc yu t nguy
c
- Tng cng
kim tra, nh
gi kt qu hot
ng kim sot
cc yu t nguy
c
R sot, b sung v cp nht

cc ch s gim st cc yu t
nguy c bnh khng ly nhim
theo khuyn co ca WHO vo
trong h thng thu thp thng
tin gim st bnh khng ly
nhim ca Vit Nam.
Trong k hoch hnh ng
kim sot cc yu t nguy c,
phng chng cc BKLN ca cc
b, ngnh, t chc, a phng
cn c hot ng kim tra, gim
st, nh gi kt qu thc hin
k hoch.
Nghin cu xut mt mng li thu thp

thng tin gim st cc yu t nguy c chung
ca cc BKLN vi mt u mi qun l thng
nht.
Nghin cu, xut thc hin ch bo co
nh k v cc yu t nguy c v tnh hnh thc
hin phng chng cc yu t nguy c.
B tr kinh ph cho cc cuc iu tra nh k v
gim st cc yu t nguy c v nh gi kt
qu hot ng phng chng cc yu t nguy
c.
Nng cao nhn

thc v cc yu
t nguy c,
thc tun th
cc chnh sch
kim sot cc
yu t nguy c
v khuyn khch
thc hnh d
phng kim sot
cc yu t nguy
c
- y mnh
cng tc tuyn
truyn, gio dc
sc kho, ph
bin php lut
v phng chng
cc yu t nguy
c
- Tng cng
phi hp lin
ngnh trong thc
y thc hnh
d phng, kim
sot cc yu
t nguy c v
kim tra, x pht
nghim cc vi
phm
Thc hin vic tuyn truyn tp

trung vo cc i tng ch
u tin ca tng yu t nguy
c: Khuyn co cc c s sn
xut hn ch mui v cht bo
chuyn ho trong thc phm;
vn ng cc c s sn xut,
cc h gia nh ni khng vi
ho cht c hi trong sn xut
v ch bin thc phm; tuyn
truyn vn ng ni khng
vi ru, bia, thuc l v tng
cng hot ng th lc trong
thanh thiu nin, hc sinh, sinh
vin v nhn vin vn phng.
Tng cng phi hp gia nh,
cng ng, cc c quan, on
th v ton x hi trong cng
tc tuyn truyn nng cao nhn
thc v thc tun th cc quy
nh v kim sot, phng chng
cc yu t nguy c.
y mnh thc hin x pht
vi phm cc quy nh cm ht
thuc ni cng cng, cm
qung co ru, bia, thuc l,
cm bn thuc l, ru bia cho
ngi di 18 tui,..
Trung tm truyn thng gio dc sc kho

phi hp vi cc c quan chuyn mn nghin
cu pht trin cc thng ip truyn thng n
gin, d nh, d hiu, d thc hin v phng
chng cc yu t nguy c BKLN, tp trung vo
cc vn u tin. V d phi hp vi Vin
dinh dng xy dng cc hng dn khuyn
co v cc thc phm u tin la chn v cc
thc phm cn hn ch; to thi quen kim
tra hm lng mui, cht bo chuyn ho trn
bao b sn phm la chn thc phm hp
l, lnh mnh cho ba n gia nh.
Tng cng vai tr v trch nhim ca ngi
ng u t chc, c quan n v, cng ng
trong vic thc hin cc quy nh v kim sot,
phng chng cc yu t nguy c nh cm s
dng ru, bia, thuc l,... a cc tiu chun
v tun th chnh sch kim sot cc yu t
nguy c BKLN vo trong vic bnh xt danh
hiu thi ua, danh hiu vn ho i vi c
nhn, t chc v cng ng.
Tip tc tng cng phi hp lin ngnh trong
x l nghim cc vi phm, k c trong lnh vc
sn xut kinh doanh, ch bin thc phm.
Khuyn co
204
Chng V: Tnh hnh thc hin chng trnh, d n phng chng BKLN
Chng V: Tnh hnh thc hin cc chng trnh, d n

phng chng BKLN
Nhm thc hin mc tiu phng chng v qun l cc bnh khng ly nhim, mt
trong 4 mc tiu c th ca Chin lc chm sc v bo v sc kho nhn dn giai on 2001
- 201040, t nm 2002 Th tng Chnh ph ph duyt v trin khai Chng trnh quc gia
phng chng BKLN giai on 2002-201041 bao gm 4 nhm bnh: tim mch, i tho ng,
ung th v ri lon tm thn. Trc , D n bo v sc khe tm thn cng ng c ph
duyt v trin khai thc hin t nm 1999. Bnh phi tc nghn mn tnh c a vo chng
trnh quc gia mun nht, bt u trin khai t nm 2011 (Bng 31). 4243 44 45 46
Bng 31: Cc giai on thc hin nm d n phng chng BKLN, 1998-2015
D n phng chng
Cc giai on theo Quyt nh ca Th tng Chnh ph

1998-200542
2006-201043,44
201145
2012-201546
Tng huyt p
Ung th
i tho ng

Bo v sc kho tm thn
Mt s ni dung hot ng chnh ca cc d n phng chng BKLN theo Quyt nh s

1208/2011/Q-TTg ca Th tng Chnh ph (Bng 32) bao gm: (i) Nng cao nhn thc ca
ngi dn v phng chng BKLN; (ii) o to v pht trin nhn lc; (iii) sng lc, pht hin
sm BKLN; (iv) qun l, hng dn iu tr; (v) xy dng m hnh chm sc ti y t c s; (vi)
lng ghp vi y t x, phng; v (vii) phc hi chc nng, gim t l tn ph.
Cc d n c c im chung ca mt chng trnh dc, c xc nh r mc tiu ca
chng trnh, nhim v v cc gii php thc hin. Di y l nh gi kt qu thc hin cc
d n, xc nh cc kh khn, hn ch v cc vn u tin, khuyn ngh cc gii php khc
phc.47
Quyt nh s 35/2001/Q-TTg ngy 19/3/2001 ca Th tng Chnh ph ph duyt Chin lc chm sc v
bo v sc kho nhn dn giai on 2001-2010.
41
Quyt nh s 77/2002/Q-TTg ngy 17/ 6/2002 ca Th tng Chnh ph v vic ph duyt Chng trnh
Phng, chng mt s bnh khng ly nhim giai on 2002 - 2010.
42
Quyt nh s 196/1998/Q-TTg ca Th tng Chnh ph ngy 10/10/1998, b sung thm 2 mc tiu bo v
sc kho tm thn cng ng v phng chng st xut huyt vo Chng trnh quc gia thanh ton mt s bnh
x hi v bnh dch nguy him.
43
Quyt nh s 108/2007/Q-TTg ngy 17 thng 7 nm 2007 ca Th tng Chnh ph ph duyt Chng trnh
mc tiu Quc gia phng, chng mt s bnh x hi, bnh dch nguy him v HIV/AIDS giai on 2006 - 2010
44
Quyt nh s 172/2008/Q-TTg ngy 19/12/2008 V vic b sung Quyt nh s 108/2007/Q-TTg ngy 17
thng 7 nm 2007 ca Th tng Chnh ph ph duyt Chng trnh mc tiu Quc gia phng, chng mt s bnh
x hi, bnh dch nguy him v HIV/AIDS giai on 2006 - 2010.
45
Quyt nh s 2331/Q-TTg ca Th tng Chnh ph ban hnh danh mc cc chng trnh mc tiu quc gia
nm 2011.
46
Quyt nh s 2406/Q-TTg ngy 18/12/2011ca Th tng Chnh ph ban hnh danh mc cc Chng trnh
mc tiu quc gia giai on 2012 2015.
47
Chng ny c tng hp t cc bo co chuyn ca 5 chuyn gia: TS. Phm Thi Sn (v tng huyt p),
PGS.TS. Trn Vn Thun (ung th), GS.TS. Ng Qu Chu (COPD v hen ph qun), ThS. Phan Hng Dng
(i tho ng) v ThS. Trng L Vn Ngc (sc kho tm thn).
40
205

Bng 32: Tm tt mt s ni dung hot ng chnh ca cc d n phng chng BKLN
theo Q 1208/2012/Q-TTg
Mc tiu
Tng huyt p
Nng cao
nhn thc ca
ngi dn v
d phng v
kim sot
50% ngi dn
hiu ng
o to pht
trin ngun
nhn lc
o to cho
80% cn b y
t trong phm vi
d n
Sng lc, pht

hin sm
Ung th
50% s bnh
nhn tng huyt
p nguy c cao
c iu tr
ng theo phc
Xy dng m
hnh qun l
ti y t c s
Xy dng, trin
khai v duy tr
bn vng m
hnh qun l
tng huyt p ti
tuyn c s
Bnh phi
tc nghn
mn tnh
Bo v sc
khe tm thn
Nng cao
nhn thc
phng v
pht hin
sm bnh
ung th
o to v
o to li
cn b d
n tuyn
tnh
Tng 5 - 10%
t l bnh
nhn ung th
c pht
hin giai
on sm
Qun l,
hng dn
iu tr
i tho
ng
o to
v pht
trin ngun
nhn lc
ti cc
tuyn y t
Tng
cng
sng lc ti
cng ng
Qun l
c 60%
ngi tin
i tho
ng
v 50%
i tho
ng
tp 2
Pht hin sm,

qun l v iu tr
sm cho 90% s
bnh nhn ng
kinh
50% s
BN c
k n
ng theo
hng dn
iu tr ca
B Y t
iu tr n nh,
chng ti pht
cho 85% s bnh
nhn ng kinh
c pht hin
v qun l
Xy dng,
trin khai
v duy tr
bn vng
m hnh
qun l ti
cc tuyn
y t
Trin khai v
qun l 90% s
x v bnh nhn
ng kinh
Lng ghp,
chm sc
tuyn x
70% s x/
phng trin khai
m hnh lng
ghp
Phc hi chc
nng, gim t
l tn ph
PHCN, gim t
l tn ph di
20% bnh nhn
ng kinh
206
1. D n phng, chng tng huyt p

Mc d Th tng Chnh ph ph duyt D n t thng 12 nm 2008 (Quyt nh
s 172/2008), nhng ti u nm 2010 d n mi c cp kinh ph cho hot ng. D n do
Vin Tim mch - Bnh vin Bch Mai chu trch nhim trin khai di s ch o ca B Y t.
D n bao ph ton b 63/63 tnh, 474 huyn. Cc n v phng chng tng huyt p t
ti cc bnh vin tnh, thnh ph v 96 n v phng chng tng huyt p tuyn qun, huyn
ca 16 tnh th im (xem Hnh 50 v t chc mng li qun l tng huyt p tch hp vi h
thng y t).
Hnh 50: T chc mng li qun l tng huyt p ti Vit Nam
Ngun: Phm Thi Sn 2014 [204].
207

1.1. Kt qu thc hin
Kt qu thc hin theo mt s mc tiu chnh ca d n nh sau:
Nng cao nhn thc ca ngi dn: Hot ng truyn thng gio dc sc khe ca d
n bao gm cc chng trnh trn truyn hnh (VTV, O2TV, VOV), ti liu truyn thng (pan,
p phch, t ri, tranh lt), cc chng trnh truyn hnh gio dc sc kho v tng huyt p
pht ti cc i a phng. S kin Ngy tim mch th gii v Ngy tng huyt p th gii
c t chc hng nm. Cu lc b tng huyt p c thnh lp ti cng ng v t chc sinh
hot nh k hng thng l ni hi vin trao i, chia s v c t vn ca chuyn gia tim
mch v d phng v iu tr tng huyt p. Cho ti nay, cha c hot ng kho st nh gia
s thay i nhn thc ca ngi dn nh cc hot ng truyn thng rng ri v a dng trong
hai nm 2010-2011.
Sng lc, pht hin sm: Khm sng lc pht hin sm tng huyt p c thc hin
theo m hnh khm sng lc da trn qun th trn i tng nguy c. n ht nm 2013,
trin khai khm sng lc ti 1116 x (khong 10% tng s x trn ton quc) vi 2,5 triu ngi
c khm v 724 695 ngi c qun l iu tr.
o to v pht trin ngun nhn lc: L mt trong cc hot ng chnh v mc tiu
chnh ca D n, hnh thc o to c thc hin theo phng php vt du loang. Cc
chuyn gia tim mch c ba min tham gia trong d n c mi ging dy cho cc ging
vin tuyn tnh 63 tnh/thnh; cc ging vin tuyn tnh s ging cho cc nhn vin y t a
phng ti cc tuyn qun/huyn v x/phng. Tnh ti cui nm 2013, D n t chc 2476
kho o to, nng cao nng lc khm sng lc, qun l v iu tr tng huyt p, qun l v
gim st thc hin d n, truyn thng gio dc sc khe cho 71 378 cn b qun l v bc s
lm sng tim mch ti 63 tnh/thnh ph. Tp hun cho nhn vin y t x v cch o huyt p
ng, cc bin php thay i li sng d phng v iu tr tng huyt p bng thuc, m hnh
d phng v qun l iu tr tng huyt p ti cng ng.
Qun l, hng dn iu tr: Ti liu hng dn chn on v iu tr tng huyt p
c ban hnh nm 2010 v c ph bin rng ri. Ngoi ra, 35 hng dn chn on v iu
tr cc bnh tim mch c xy dng; 5 cun sch v bnh tim mch v tng huyt p c
xut bn. V qun l thuc v trang thit b: Cc tnh/thnh ph thc hin tng bc cc hot
ng mua sm trang thit b v thuc a vo s dng trong D n. C th, 16 tnh mua
103 my o in tim, 1846 my o huyt p v 6 351 000 vin thuc iu tr tng huyt p cc
loi cp cho cc x phng tham gia d n.
Hot ng iu tra, gim st bnh tng huyt p c trin khai nm 2010 v cho
kt qu ng lo ngi vi t l tng huyt p trong cng ng kh cao vi 28,3% nam gii v
23,1% n gii. Trong s nhng ngi bnh tng huyt p, ch c 48,4% bit c tnh trng
tng huyt p v 29,6% c iu tr bnh [204].
1.2. Kh khn, hn ch
Mc bao ph d n n ngi dn cn hp v tin bao ph chm, qun l iu tri
tng huyt p ch yu mi tuyn tnh. Tuy d n c trin khai tt c 63 tnh, thnh ph
trn c nc, trn 70 ngn cn b y t c o to, tp hun v phng chng tng huyt p
nhng cho ti nay mi c 10% tng s x, phng thc hin c cng tc qun l iu tr tng
208
huyt p ti trm y t x, phng. Ngoi ra, c nhiu tr ngi khc trong qun l iu tr tng
huyt p ti tuyn x, nh cha c c ch khuyn khch i vi nhn vin trm y t x tham gia
qun l, iu tr tng huyt p ti cng ng; thuc iu tr huyt p ti trm y t x thiu; cha
c c ch chi tr cho hot ng t vn iu tr tng huyt p.
Thuc iu tr tng huyt p tuyn y t x, phng cha y . Cc nhm thuc h
huyt p c trong danh mc thuc c BHYT chi tr cc c s KCB tuyn tnh v tuyn
huyn (tc l cc bnh vin hng c bit n hng IV) kh y , nhng hn ch tuyn x
(c s y t khc) (Bng 33).
Bng 33: Danh mc thuc h huyt p c BHYT thanh ton tuyn y t x
Tn thuc
Loi
Amlodipin
Thuc chn knh canxi
Nifedipin
Thuc chn knh canxi
Clonidin
2 adrenergic agonist
v imidazoline receptor
Methyldopa
Alpha-adrenergic agonist
Enalapril
Thuc c ch men chuyn
Captopril
Thuc c ch men chuyn
Perindopril
Thuc c ch men chuyn
Perindopril+indapamid
Thuc c ch men chuyn

cng li tiu nh thiazid
Ch nh c bit
Ph n mang thai
Ngun: Thng t s 31/2011/TT-BYT ngy 11 thng 07 nm 2011.
M hnh sng lc pht hin sm cha ph hp. M hnh khm sng lc hin nay l m
hnh sng lc tp trung, nh k trong qun th i tng nguy c (t chc nh k cc t khm
sng lc ti trm y t x, phng cho ngi t 40 tui tr ln). Thc hin sng lc tp trung,
nh k cho khong 25 triu ngi trong i tng sng lc i hi chi ph ln v khng kh
thi. Trong khi , vic o huyt p cha c coi nh l mt ni dung hot ng thng quy
trong KCB cho ngi dn ti trm y t x, phng.
Pht hin tng huyt p cn lng ghp vi cng tc khm cha bnh thng quy ti cc
c s y t. Cc i tng t 40 tui tr ln n khm bnh bt k no ti cc c s y t cn
c o huyt p v khm sng lc v tng huyt p. y l hnh thc sng lc c hi gip
lng ghp vic khm sng lc tng huyt p vi cng tc KCB thng quy ti cc c s y t (c
cng lp ln t nhn). C s y t c th s dng Bng phn tng nguy c tim mch tng th
xc nh nhm c nguy c cao b cc bin c tim mch trong 10 nm ti nh trong Hng dn
chn on v iu tr tng huyt p 2010 ca B Y t (Bng 34). Sng lc c hi gip tn dng
c ngun nhn lc hin c ca h thng y t v gim bt chi ph cho vic khm sng lc tng
huyt p qua lng ghp tr th lao khm vi cc hot ng khm bnh thng quy.
209

Bng 34: Bng phn tng nguy c tim mch tng th xc nh nhm c nguy c cao
b cc bin c tim mch trong 10 nm ti
Bnh cnh
Huyt p
bnh thng
Tin tng
huyt p
Tng huyt p
1
Tng huyt p
2
Tng huyt p
3
Huyt p tm
thu 120-129
mmHg v
Huyt p tm
trng 80-84
mmHg
Huyt p
tm thu 130139 mmHg
v/hoc
huyt p tm
trng 8589 mmHg
Huyt p tm
thu 140-159
mmHg v/hoc
huyt p tm
trng 90-99
mmHg
Huyt p tm
thu 160-179
mmHg v/hoc
huyt p tm
trng 100-109
mmHg
Huyt p
tm thu 180
mmHg v/hoc
huyt p tm
trng 110
mmHg
Nguy c thp
Nguy c trung
bnh
Nguy c cao
Khng
c yu t
nguy c
tim mch
no
C t 1-2
yu t
nguy c
tim mch
Nguy c thp
Nguy c
thp
Nguy c
trung bnh
Nguy c trung
bnh
Nguy c
rt cao
C 3 yu
t nguy c
tim mch
hoc hi
chng
chuyn
ha hoc
tn thng
c quan
ch hoc
i tho
ng
Nguy c
trung bnh
Nguy c cao
Nguy c cao
Nguy c cao
Nguy c
rt cao
c bin
c hoc c
bnh tim
mch hoc
c bnh
thn mn
tnh
Nguy c rt
cao
Nguy c
rt cao
Nguy c rt cao
Nguy c
rt cao
Nguy c
rt cao
Ngun: Quyt nh s 3192/Q-BYT ngy 31 thng 8 nm 2010 ca B trng B Y t v vic ban hnh Hng
dn chn on v iu tr tng huyt p.
1.3. Khuyn ngh

Ngn hn (2014-2015)
Tng cng cc hot ng truyn thng v tng huyt p, lng ghp vi truyn thng
phng chng cc BKLN khc.
Th im m hnh khm sng lc c hi pht hin tng huyt p bng cch lng ghp
o huyt p v khm sng lc tng huyt p trong qu trnh khm cha bnh i vi i
tng c nguy c cao (ngi t 40 tui tr ln) bt k c s y t cng, t no pht
210
hin sm tng huyt p, thay cho m hnh khm sng lc ng lot cho ton b i tng
c nguy c cao.
T chc iu tr tng huyt p ti cc tuyn c s, ch yu l cc trm y t, nht l i
vi nhm ngi dn tng huyt p 1 hoc 2 khng c bin chng. Thc hin chin
lc iu tr ngi dn b tng huyt p sau khi sng lc v phn tng nguy c tng th
b cc bin c tim mch trong 10 nm ti da vo Hng dn chn on v iu tr tng
huyt p ca B Y t 2010.
Xy dng quy chun v pht hin, qun l, iu tr tng huyt p ti trm y t x, lng
ghp vo tiu ch quc gia v y t x.
Nhn mnh qun l tng huyt p bng thay i li sng, c th l gim cn nu tha
cn, bo ph; b ht thuc; n nhiu hoa qu, rau, sn phm t sa, t cht bo, c bit t
cht bo bo ha; gim tiu th mui; tng tiu th kali, hot ng th lc thng xuyn;
hn ch lng ru, bia c tiu th [205].
Xem xt iu chnh cc quy nh lin quan n thi gian cp thuc iu tr tng huyt
p theo nh k ph hp v loi bnh nhn cn dng n tng loi thuc ty thuc bnh
km theo hoc iu kin chng ch nh. Cc thuc h huyt p cn a vo danh mc
thuc ch yu c BHYT chi tr, ging nhau tuyn qun huyn v x, phng, vi
5 nhm thuc c bn: (i) Li tiu thiazid; (ii) thuc c ch men chuyn; (iii) thuc chn
knh canxi; (iv) thuc chn th th AT1; (v) thuc chn bta giao cm c chn lc trn
tim.48
B sung mt s dch v lin quan ti phng chng tng huyt p vo danh mc cc dch
v KCB c BHYT chi tr.
Di hn (2016-2020 v sau 2020)
Lng ghp khm sng lc tng huyt p vi cng tc khm bnh thng quy ti tt c
cc c s khm cha bnh cng lp cng nh y t ngoi cng lp, c BHYT chi tr.
B Y t c hng dn vic khm sng lc c hi cng nh khm nh k tng huyt p
c th thc thi ti tt c cc tuyn c bit l ti cc trm y t x/phng.
Cng vi sng lc c hi trong khm cha bnh thng thng, thc hin sng lc sc
kho nh k cho ngi t 40 tr ln ti ni lm vic, lng ghp sng lc nhiu BKLN
v cc yu t nguy c.
2. D n phng chng ung th

D n phng chng ung th l mt d n trong Chng trnh mc tiu quc gia phng,
chng mt s bnh x hi, bnh dch nguy him v HIV/AIDS giai on 2006-2010, c Th
tng Chnh ph ph duyt ngy 17/7/2007 ti quyt nh s 108/2007/Q-TTg. Mc tiu ca
d n l tng bc gim t l mc v t l cht do ung th v ci thin cht lng cuc sng
cho bnh nhn ung th. Giai on 2012-2015 mc tiu khim tn hn, c th l nng cao nhn
thc ca cng ng v phng v pht hin sm bnh ung th v tng 10-15% t l bnh nhn
ung th c pht hin giai on sm, ng thi gim t l t vong ca mt s loi ung th:
v, c t cung, khoang ming v i trc trng.
In English: Diuretics, calcium channel blockers, angiotensin converting enzyme (ACE) inhibitors, angiotensin
receptor blocker, beta blockers.
48
211

D n c bt u trin khai t nm 2008, vi cc hot ng chnh l tuyn truyn,
sng lc pht hin sm, o to v mt s hot ng nh l khc. Bnh vin K c giao trch
nhim trin khai thc hin D n vi ngun kinh ph dnh khng ln v khng n nh. Nm
2008, d n c cp 20 t, cc nm 2009, 2010, 2011, 2012 v 2013 c cp ln lt l 24
t, 33 t, 38 t, 36 t v 35,6 t. Nm 2014, s tin c cp gim xung cn 12,5 t. Bn cnh
, mt s t chc phi chnh ph nh WHO, C quan Nng lng Nguyn t Quc t (IAEA)
cng trin khai mt s hot ng v o to, chuyn giao k thut.
2.1. Kt qu thc hin
D n c trin khai ti 37 tnh, thnh ph (tnh ti u nm 2014). Hu ht cc mc
tiu ca D n phng chng ung th giai on 2006-2010 u khng t hoc khng c
thng tin nh gi (Bng 35). Mt s mc tiu kh kh thi (nh mc tiu t l tim vc xin
vim gan B t 100%). Hin nay cha c nghin cu nh gi mc thc hin mc tiu giai
on 2012-2015.
Bng 35: Kt qu thc hin D n phng chng ung th giai on 2006-2010, nh gi
theo mc tiu
Mc tiu
Mc tiu chung:
Gim t l mc ung th
Gim t l cht do ung th
Ci thin cht lng cuc sng
cho bnh nhn ung th
Tnh hnh thc hin

1. T l mc ung th tng 28% i vi nam v 33% i vi
n, t nm 2000 n 2010
2 v 3. Khng c thng tin y nh gi
Mc tiu c th:
Gim t l mc cc loi ung th c
lin quan n thuc l xung 30%
so vi nm 2000;
Mc tiu 1. T l mc cc bnh ung th lin quan ti thuc l

nam gii tng: 20% i vi ung th phi v 167% i vi
ung th thc qun, n gii khng c thay i ng k
Thc hin tim phng vim gan B

cho 100% tr s sinh;
Mc tiu 2. T l tr s sinh c tim phng vim gan B l

48,2 % (theo bo co MICS 4, 2011).
Gim t l t vong ca mt s loi

ung th: v, c t cung, ming,
i-trc trng.
Mc tiu 3. Khng c thng tin nh gi s thay i v

t l t vong.
Gim t l ngi bnh ung th

giai on mun n cc c s
chuyn khoa t 80% xung 50%
Mc tiu 4. S dng d liu t 135 bnh vin 5 tnh thnh

ln (nm 2010): trong s 22,7% cc trng hp ung th v
c th c chn on c giai on mc, 64,2% trng
hp giai on mun (giai on> III). Khng c d liu th
hin s thay i t l bnh nhn n mun theo thi gian.
Ngun: Nguyn Thanh Hng, Ha Thanh Thy. Bo co r sot chnh sch phng chng BKLN trn th gii v
Vit Nam, 2013.
o to, pht trin nhn lc: hot ng o to, tp hun nng cao trnh nghip v tp
trung vo i ng cn b y t chuyn khoa ung th v cn b ghi nhn ung th. D n t chc
cc lp tp hun v phng v pht hin sm mt s bnh ung th ph bin; ghi nhn ung th,
chm sc gim nh, chm sc bnh nhn ung th cho iu dng, o to, chuyn giao h tr
k thut (Ngoi khoa ung th, ni khoa ung th, x tr ung th.).
212
T chc mng li cc trung tm ghi nhn ung th ti 9 tnh, thnh ph l H Ni, Hi
Phng, Thi Nguyn, Thanh Ha, Hu, Nng, thnh ph H Ch Minh, Cn Th v Kin
Giang, trong , trung tm ghi nhn ung th H Ni v thnh ph H Ch Minh c C quan
nghin cu Ung th Quc t (IARC) cng nhn cht lng. Kt qu ghi nhn ung th gip
a ra s liu cc ca ung th mc mi (ti thiu 126000 ca mc mi nm 2010, d bo 189300
ca mc mi vo nm 2020) [206].
Hot ng sng lc pht hin sm bnh ung th c thc hin i vi 4 nhm bnh
ung th, bao gm: ung th v, c t cung, khoang ming, i trc trng; phi hp gia sng lc
ch ng49 (ngi dn c nhn thc v ch ng tm n c s y t khm sng lc) v c t
chc (sng lc da trn qun th). Sng lc c thc hin ch yu cc thnh ph ln - H
Ni, thnh ph H Ch Minh. Trong giai on t 2008-2013 c nc sng lc c khong trn
120000 ph n tui t 40-54 pht hin sm hai loi ung th ph bin l ung th v v ung
th c t cung [207]. Ring trong nm 2013, k hoch s lt sng lc pht hin sm 4 loi ung
th ph bin l 100000. Bc u cho thy hiu qu cao ca sng lc; cc trng hp c
pht hin u giai on tin ung th v ung th giai on sm. Sau khi c pht hin, cc
trng hp ny c chuyn v cc trung tm ung bu cha tr, vi chi ph ch bng 20%
so vi cha tr mun.
Cng tc chn on, iu tr ung th c nhiu tin b trong nhng nm va qua, c
bit sau khi D n Phng, chng ung th c a vo chng trnh mc tiu quc gia nm
2008 v B trng B Y t ph duyt pht trin mng li phng, chng ung th Vit Nam
giai on 2009-2020. Bn cnh , n 1816 v n Bnh vin v tinh v ung th pht
huy c hiu qu.
Mng li chn on, iu tr ung th c pht trin c ba min Bc, Trung, Nam. C
nc hin c 6 bnh vin ung bu bao gm Bnh vin K, Bnh vin Ung bu thnh ph H
Ch Minh, Bnh vin Ung bu H Ni, Bnh vin Ung bu Ngh An, Bnh vin Ung th
Nng v Bnh vin Ung bu Cn Th. Bn cnh , c 43 Trung tm/Khoa/n v ung bu
nm cc bnh vin a khoa, chuyn khoa tuyn trung ng v tnh.
2.2. Kh khn, hn ch
Cc hot ng tuyn truyn phng chng ung th c tin hnh ri rc, theo thi v,
khng c mt k hoch, chin lc r rng, thiu s phi hp gia cc bin php truyn thng
v hu nh cha c s lng ghp tuyn truyn trong cc BKLN dn ti hiu qu khng c
cao nh mong mun. Kinh ph cho hot ng truyn thng b ct hon ton trong nhng nm
cui ca d n.
Hn ch trong ghi nhn thng k ung th: Cng tc ghi nhn, thng k ung th ch yu
thng qua h thng thng k bo co nh k ca ngnh y t, hu ht bnh nhn ung th cht
nh nn b st rt nhiu thng tin, s liu phn nh tnh hnh ung th. Chn trung tm ghi nhn
ung th ti 9 tnh, thnh ph mi bao ph c 20% dn s, trong mi ch c trung tm ti
H Ni v thnh ph H Ch Minh c C quan Nghin cu Ung th Quc t (IARC) cng
nhn cht lng v mi ch ghi nhn t l mc, cha ghi nhn t l t vong. Do vy, s liu
thng k t l ung th v t vong ung th cha p ng tt cho cng tc d bo, hoch nh
chin lc.
Sng lc ch ng hay th ng c xt trn gc ngi s dng dch v. Sng lc ch ng l ngi dn
t tm n c s y t thc hin sng lc, khc vi sng lc th ng l do c s y t t chc sng lc cho c
qun th ti cng ng. Ngoi ra, sng lc c hi l cn b y t tn dng c hi khi i tng n cc c s y t
khm cha bnh thc hin sng lc cho i tng.
49
213

Hot ng sng lc pht hin sm ung th mi ch c thc hin th im ti mt s
a phng. Cng tc sng lc pht hin sm bnh ung th Vit Nam c tin hnh th im
thng qua chng trnh hp tc Vit- M v phng chng ung th c t cung v Chng trnh
phng chng ung th ca B Y t v sng lc v pht hin sm ung th v, c t cung ti H
Ni, Hi Phng, thnh ph H Ch Minh, Cn Th. Cc kh khn chnh trong sng lc l thiu
ngun nhn lc, thiu trang thit b v BHYT cha chi tr cho khm sng lc. Ngay c i vi
nhng bnh ung th ph bin v d sng lc khc nh ung th khoang ming, i - trc trng
cng mi dng li mc nghin cu, thm d mu di 20000 i tng.
Thiu ht nhn lc c trnh chuyn mn v chn on, iu tr ung th: Vic pht
trin chn on m bnh hc, t bo ung th cn nhiu kh khn do thiu trm trng nhn lc.
Mc d rt cn thit, nhng chuyn ngnh chn on m hc, t bo ung th khng c sc hp
dn vi bc s.
T chc ca cc c s chuyn khoa ung bu khng hon chnh, thiu nhn lc v trang
thit b. Cc Bnh vin/Trung tm/Khoa/n v ung bu c thnh lp trong 5 nm tr li
y nhng trnh , nng lc cn hn ch v ch yu l cc trung tm, khoa ung bu khng
hon chnh do thiu my x tr. Ngun nhn lc thiu, c bit tuyn tnh. Ch 10% s khoa
ung bu c 4 n v: n v phu thut, n v x tr, n v ha tr, n v iu tr au v
chm sc triu chng theo quy ch cng tc khoa ung bu do B trng B Y t ban hnh
nm 2003.
Cc bnh vin ung bu phn b khng ng u, xy ra tnh trng qu ti H Ni v
thnh ph H Ch Minh. Tng s my x tr ti Vit Nam hin c l 51, ch yu tp trung H
Ni v thnh ph H Ch Minh dn ti s qu ti 2 khu vc ny. Kh nng chn on, iu tr
khng ng u gia cc a phng. Mng li khm cha bnh, mng li phng, chng ung
th c quy hoch nhng pht trin khng theo ng l trnh, a im. Mng li phng,
chng ung th hin ti mi p ng c khong 30-40% nhu cu khm, cha bnh ung bu
ca nhn dn [207].
Cng tc chm sc, gim nh cha c quan tm tha ng v cn nhiu hn ch. Nhu
cu chm sc gim nh l rt ln do c ti trn 70% ngi bnh n khm, iu tr ti cc c s
y t giai on mun v phn ln trong phi chu ng au n v kh chu do bnh v do
iu tr. iu kin cung cp dch v chm sc gim nh nh o to, cc n v chuyn khoa
chm sc gim nh, cng nh hot ng gim st nhn chung ch mi c sn tuyn trung ng
ch cha c tuyn huyn, x. Phn ln bnh nhn c chm sc cui i ti nh, khng c
s hng dn ca nhn vin y t. Trong s nhng ngi c chm sc, hu ht khng nhn
c cc t vn v tm l, cc li khuyn hoc cc bin php chm sc cho cc triu chng
khc ngoi triu chng au. Hin nay, m hnh chm sc ti nh theo hng dn ca nhn vin
y t c o to cha c pht trin [208].
Kh tip cn thuc gim au trong chm sc gim nh. B Y t ban hnh hng dn
nghim ngt v vic s dng morphin ti cc y t trong mt n lc tng kh nng tip cn thuc
gim au cho bnh nhn nhng gim thiu nguy c cung cp thuc cho nhng ngi nghin
ma tu. Mc d vy, bnh nhn vn phi i mt vi kh khn trong vic tip cn vi cc loi
thuc gim au bc ba, c bit l vi nhng bnh nhn ngoi tr tuyn x hoc bnh nhn
ang c iu tr ti nh. L do chnh l lng c cung cp khng , lng thuc d tr
t, hoc bc s min cng khi phi k n cc loi thuc ny [208].
214
2.3. Khuyn ngh
Ngn hn
Tip tc trin khai mnh m, lng ghp cc hot ng nhm nng cao nhn thc cng
ng v phng chng ung th: b tr ngun kinh ph cho hot ng truyn thng phng
chng ung th, lng ghp vi cc chng trnh truyn thng gio dc sc kho khc,
vi cc hnh thc nh tuyn truyn trn phng tin thng tin i chng, tuyn truyn
qua i ng tuyn truyn vin/cng tc vin y t tuyn huyn. Xy dng ti liu truyn
thng, ti liu tp hun cng tc truyn thng. Khuyn khch cc t chc x hi, hip hi
y t, c s y t tham gia tuyn truyn v phng chng ung th.
Tng cng nng lc ghi nhn v qun l ung th: tng cng nng lc ghi nhn ung
th ti 9 n v hin c xy dng v nh gi k hoch hot ng phng chng ung
th c hiu qu, thng qua cc hot ng o to, tp hun cn b cho cc trung tm ghi
nhn, gim st vic ghi nhn v nng lc phn tch, bo co kt qu. Trin khai m hnh
ghi nhn ung th ti cng ng
o to, pht trin ngun nhn lc: tip tc thc hin m hnh o to vt du loang:
Tuyn trung ng c nhim v o to gio vin cho cc trung tm khu vc, ph cp
kin thc v phng chng ung th bao gm phng bnh, pht hin bnh sm, chn on
v iu tr bnh ung th cho cc bc s tuyn tnh. Cc gio vin qua o to ti tuyn
trung ng s tin hnh m cc lp tp hun ti tnh v huyn.
Tip tc u t xy dng cc c s chn on, iu tr ung bu tuyn trung ng v
tuyn tnh v kin ton mng li theo quy hoch kt hp nng cao chuyn mn nghip
v thng qua n Bnh vin v tinh, chuyn giao k thut;
M rng cc c s dch v chm sc gim nh. Thnh lp v a vo hot ng cc n
v iu tr au v chm sc gim nh ti cc c s phng chng ung th hin c.
Di hn
Thc hin khm sng lc pht hin sm ung th trn din rng: nng cao trnh chuyn
mn, la chn c ch ti chnh ph hp (trong c BHYT) m rng khm sng lc
pht hin sm ung th, tp trung vo cc loi ung th d pht hin sm: ung th v, ung
th c t cung; ung th khoang ming, ung th i trc trng, ung th tin lit tuyn v
ung th tuyn gip trn phm vi c nc.
Xy dng m hnh chm sc ngi bnh ung th giai on cui ti c s: o to cho
cn b y t tuyn c s v kin thc v k nng gip cho vic trin khai m hnh chm
sc; Xy dng cc hng dn v m hnh chm sc bnh nhn ung th giai on cui
ti c s.
y mnh nghin cu dch t trong phng chng ung th v hon thin h thng d liu
quc gia v ung th;
3. D n phng chng bnh i tho ng

D n phng chng bnh i tho ng c xy dng v c Th tng Chnh
ph ph duyt nm 2008 (Quyt nh s 172/2008/Q-TTg), chnh thc hot ng vo nm
215

2010. D n c tip tc a vo Chng trnh mc tiu quc gia y t giai on 2012 - 2015
theo Quyt nh s 1208/Q-TTg ca Th tng Chnh ph.
D n n giai on 2010 c mc tiu chung l gim t l mc, bin chng v t vong
do bnh i tho ng v c cc mc tiu c th nh sau:
Phn u t ch tiu 50% ngi dn trong cng ng hiu bit v bnh i tho ng
v cc yu t nguy c.
Gim t l ngi mc i tho ng khng c pht hin trong cng ng xung di 60%.
Xy dng, trin khai v duy tr m hnh qun l bnh i tho ng trn phm vi c nc.
Theo di v iu tr c h thng 50% s ngi mc bnh i tho ng c pht
hin theo phc B Y t quy nh.
Cc mc tiu ca D n giai on 2012-2015 c Th tng Chnh ph ph duyt
bao gm:
Tng cng sng lc ti cng ng nhm pht hin sm nhng ngi tin i tho
ng v i tho ng. Qun l c 60 % s ngi tin i tho ng v 50% i
tho ng tp 2 c pht hin thng qua sng lc;
o to v o to li ngun cn b tham gia d n, nng cao nng lc thc hin d n
ca cc cn b d n tuyn tnh. n nm 2015, 100% cc cn b tuyn tnh c kh nng
t thc hin d n; 100% cn b tham gia d n c o to v bin php d phng,
pht hin sm, qun l v iu tr i tng nguy c v ngi mc bnh i tho ng;
Hon thin mng li iu tr, phn u n nm 2015, 100% bnh vin tuyn tnh c
khoa Ni tit. Duy tr v cng c mng li d phng ti cc tnh, nh bin v s cn
b bin ch ti mi n v tham gia cng tc d phng gp phn lm gim t l bnh.
3.1. Kt qu thc hin
Hot ng truyn thng c thc hin trn phm vi ton quc vi nhiu hnh thc
phong ph. Hot ng Trung tm Gio dc Sc khe cng ng c trin khai trn a bn c
63 tnh/thnh ph vi nhiu hnh thc phong ph. Phi hp vi cc c quan truyn thng (i
truyn hnh Vit Nam (VTV2, O2TV) pht cc bui ni chuyn trn truyn hnh. T chc mt
tinh hng ng Ngy Th gii phng chng bnh i tho ng (14/11) hng nm trong
c lng ghp hot ng khm min ph. M hnh truyn thng thay i hnh vi da vo cng
ng c trin khai th im ti 5 tnh, thnh ph: Thanh Ha, Ninh Bnh, Hi Phng, Lm
ng, Tin Giang.
Hng nm, d n thc hin sng lc ti cng ng pht hin sm tin i tho ng
v i tho ng cho hng trm ngn ngi. Nhm tng cng cng tc sng lc pht hin
sm bnh nhn tin i tho ng, bnh i tho ng, hng nm D n dnh phn ln kinh
ph cho cng tc sng lc ti cng ng. Nm 2011, sng lc 248466 i tng nguy c cao
v pht hin 18738 trng hp tin i tho ng (7,5%) v 38315 bnh nhn i tho ng
(15,4%). Nm 2012 khm sng lc 268373 i tng nguy c cao v pht hin 19778
(7,4%) trng hp tin i tho ng v 36123 (13,5%) bnh nhn i tho ng. Nm 2013
khm sng lc 266480 i tng nguy c cao pht hin 19026 (7,1%) trng hp tin
216
i tho ng v 45966 (17,3%) bnh nhn i tho ng. Ngoi ra, hot ng khm pht
hin sm bnh i tho ng, tin i tho ng cn c tin hnh ti cc phng khm ca
cc n v thc hin D n cng nh cc c s khm cha bnh theo hng dn ca D n khi
ngi bnh n khm sc khe ti cc c s y t (sng lc ch ng).
Thc hin t vn cho hng trm ngn lt ngi trn phm vi ton quc, trin khai m
hnh qun l v iu tr ngi bnh tin i tho ng v i tho ng mt s a phng.
Cng vi cc bnh vin ni tit, trung tm ni tit c cc phng khm, t vn, cc trung tm
y t d phng thuc h thng u thnh lp cc phng khm, t vn phng chng bnh i tho
ng. Nm 2012, c 111743 lt t vn v nm 2013 c 119896 lt ngi c t vn v
dinh dng v luyn tp ti cc phng khm, t vn ti tuyn huyn. D n phi hp vi
WHO v Qu i tho ng Quc t (IDF) khu vc xy dng v trin khai m hnh qun l
v iu tr i tho ng ti tuyn tnh cho cc tnh: Thi Bnh, Thanh Ha, k Lk v Bnh
Thun. Ti liu Hng dn chn on v iu tr i tho ng tp 2 c ban hnh nm
2011 theo Quyt nh s 3280/Q-BYT.
Tp hun o to nng cao nng lc qun l d n ti a phng, nng cao trnh
chuyn mn cho cn b d n. Trong 2 nm 2010-2011 o to ngn ngy v chn on, iu
tr i tho ng cho 4020 lt cn b tuyn tnh v o to v chn on, iu tr v truyn
thng cho 15021 cn b tuyn huyn. Hng nm, D n phi hp vi Hi Ni tit - i tho
ng v cc trng i hc m cc lp tp hun chuyn mn ngn hn, di hn cho cc cn b
thuc h thng v cc bnh vin ngoi h thng. Bn cnh , D n cn m cc lp tp hun
dnh cho cc cn b thuc h thng tuyn tnh v cc lnh vc thc hin d n: lp k hoch,
trin khai k hoch, bo co, cng tc ti chnh, x l s liu Bnh vin Ni tit Trung ng
m 4 lp chuyn khoa nh hng ni tit v tip nhn cc cn b tuyn di n hc tp v
thc hnh. 100% cc n v phng chng i tho ng tuyn tnh thng xuyn c ngi
tham gia tp hun.
Mng li phng chng bnh i tho ng tuyn tnh c t chc trn phm vi
c nc. D n phng chng i tho ng c trin khai ti 63 tnh/thnh ph v 6 n
v y t ca 6 b/ngnh. Hin nay, h thng phng, chng i tho ng tuyn tnh bao gm 6
bnh vin ni tit tnh, 9 trung tm ni tit, 1 trung tm dinh dng v 47 khoa ni tit thuc
cc trung tm y t d phng. Trn 90% cc n v thuc h thng u c phng khm, phng t
vn dinh dng v tp luyn phng chng bnh i tho ng. Cc tnh cn li do thiu nhn
lc nn cha thnh lp c phng t vn ca trung tm. Tm tt kt qu thc hin d n c
trnh by Bng 36.
Bng 36: nh gi kt qu thc hin d n theo mc tiu ca D n phng chng bnh
i tho ng giai on 2006-2010
Mc tiu
Tnh hnh thc hin
Phn u t ch tiu 50% ngi dn trong cng

ng hiu bit v bnh i tho ng v cc yu
t nguy c.
Gim t l ngi mc i tho ng khng c
pht hin trong cng ng xung di 60%.
217
Cha c s liu nh gi.

Nm 2012, 63,4% ngi mc bnh i tho
ng trong cng ng cha c pht hin
[209].
Mc tiu
Tnh hnh thc hin
Xy dng, trin khai v duy tr m hnh qun l

bnh i tho ng trn phm vi c nc.
Trn 90% cc n v thuc D n c phng

khm, phng t vn dinh dng v tp luyn.
65,4% tnh/thnh ph c Bnh vin Ni tit/
Trung tm Ni tit hoc khoa ni tit thuc
bnh vin a khoa tnh.
Theo di v iu tr c h thng 50% s ngi

mc bnh i tho ng c pht hin theo
phc B Y t quy nh.
Cha c s liu nh gi.
Ngun: Nguyn Thanh Hng, Ha Thanh Thy. Bo co r sot chnh sch phng chng BKLN trn th gii v
Vit Nam, 2013
3.2. Kh khn, hn ch
Kinh ph dnh cho truyn thng thp, thiu phi hp gia n v phng chng i tho
ng v Trung tm Truyn thng gio dc sc khe tnh (n v thc hin cng tc truyn
thng). Cha pht huy hiu qu s tham gia ca cc t chc x hi, c s y t ang tch cc
tuyn truyn v phng chng bnh i tho ng.
Phng php sng lc ti cng ng (sng lc th ng) i hi chi ph tn km, khng
th thc hin rng ri. Phng php sng lc c d n s dng hin nay l sng lc th ng,
c thc hin ti x, phng, cho cc i tng c nguy c cao. l nhng ngi 45 tui
c thm t nht mt trong s cc yu t nguy c sau: tha cn hoc bo ph (BMI 23 kg/m2);
tng vng eo ( 90 cm i vi nam gii, 80 cm i vi n gii); tng huyt p; ri lon lipid
mu; tin s gia nh c ngi thn trc h b bnh i tho ng typ 2; tng c chn
on ri lon glucose mu lc i v/hoc ri lon dung np glucose; ph n c tin s sinh con
> 3,6 kg; ph n c tin s i tho ng thai k. Sng lc ti cng ng theo phng php
nu trn i hi ngun lc ln v nhn lc v kinh ph. S x c sng lc mi nm ch bng
6,8% tng s x trong ton quc, vi chi ph pht hin bnh cao, c bit ti khu vc vng su,
vng xa.
D n ang chuyn dn sang phng php sng lc ch ng (ngi dn t n c s
KCB khm sng lc) hoc sng lc c hi (khm sng lc cho tt c i tng nguy c, khi
h n khm bnh thng thng ti c s KCB). Do khng c s lng ghp, phi hp gia n
v thc hin d n (l cc n v thuc h thng y t d phng) v cc c s iu tr, nn cha
c gii php qun l, chm sc, theo di hiu qu i tng nguy c v ngi bnh c pht
hin sau sng lc, c bit tuyn x.
Nng lc chuyn mn cha p ng c yu cu phng chng bnh i tho ng.
Mng li d phng v iu tr cc bnh ni tit - chuyn ha thiu cn b chuyn khoa, do
trong thi gian qua h thng o to khng o to bc s chuyn khoa ni tit chuyn ha. Ni
tit - chuyn ho ch c coi l mt phn trong chng trnh o to chuyn khoa ca khi
Ni khoa. Trnh chuyn mn ca i ng cn b y t tuyn tnh, tuyn y t c s trong qun
l, iu tr bnh i tho ng cn yu. Mt kho st v kin thc ca cn b y t tuyn tnh
v bnh ni tit chuyn ha cho thy 18,1% cn b c kin thc km, 64% c kin thc trung
bnh v 17,8% c kin thc kh [210]. Nhn s trong cc n v thc hin d n, c bit cc
trung tm y t d phng thng c thay i. Thiu nhn lc chuyn ngnh iu dng c kh
nng thc hnh iu tr bnh i tho ng.
218
Hot ng t vn cha p ng c yu cu phng chng i tho ng. Phng t
vn dinh dng v vn ng ch yu mi ch c tuyn tnh, s lng cc phng t vn tuyn
huyn t. Ngi bnh cng ng, sau khi c pht hin tin i tho ng hoc tin i tho
ng kh tip cn c phng t vn ti tuyn tnh. Phng tin h tr t vn cn ngho nn,
ch dnh cho ngi t vn cn thp nn rt kh ng vin cn b tham gia cng tc t vn.
Kinh ph dnh cho hot ng phng chng i tho ng b ct gim, ngun ti chnh
cho phng chng i tho ng cha bn vng. Nm 2014, kinh ph cho D n b ct gim
gn 70% t trung ng n a phng, dn ti cc hot ng ca D n t trung ng n a
phng phi ct gim nhiu, khng p ng c yu cu ca D n. Cc hot ng t vn,
khm sng lc chn on i tho ng, tin i tho ng khng c BHYT chi tr.
3.3. Khuyn ngh
Tng cng cc hot ng truyn thng gio dc sc khe; tp hun nghip v cho cn
b truyn thng.
o to, pht trin nhn lc: tng cng v m rng cc hnh thc o to v ni tit
chuyn ha, bao gm o to bc s chuyn khoa cho cc trung tm Ni tit, o to lin
tc, o to thc hnh v qun l iu tr bnh nhn i tho ng ti cng ng cho
cc bc s a khoa tuyn y t c s.
Chuyn i m hnh sng lc, t ch yu l sng lc th ng ti cng ng (sng lc
th ng) chuyn sang phng php sng lc ch ng v sng lc c hi. Thc hin
sng lc ti cc trm y t c nng lc tin hnh xt nghim glucose mu pht hin
sm bnh i tho ng v tin i tho ng.
Hon thin mng li phng chng i tho ng bao gm bnh vin ni tit hoc khoa
ni tit ti bnh vin a khoa tnh thc hin cng tc iu tr v Phng ch o tuyn
thuc bnh vin ni tit, khoa ni tit thuc trung tm y t d phng tnh thc hin cng
tc phng chng ti cng ng.
Xy dng v m rng cc phng t vn dinh dng cho bnh nhn i tho ng,
khng ch thuc cc n v ca D n m cn ti cc phng khm ca cc bnh vin
nhm bo m cht lng t vn, cng nh s tip cn hot ng t vn phng chng
bnh ca ngi dn.
iu chnh, sa i chnh sch chi tr BHYT cho cc dch v sng lc, t vn cho ngi
phng chng bnh i tho ng.
4. D n phng chng bnh phi tc nghn mn tnh v hen ph qun

D n Phng chng bnh phi tc nghn mn tnh v hen ph qun l d n c ph
duyt v trin khai thc hin mun nht trong cc d n phng, chng BKLN hin c Vit
Nam. Ngy 20/12/2010, Th tng Chnh ph quyt nh ban hnh danh mc cc Chng trnh
mc tiu quc gia nm 2011, trong c D n phng chng phng chng bnh phi tc nghn
mn tnh, v ngy 4/9/20123 Th tng ph duyt cc Chng trnh mc tiu quc gia giai on
2012 - 2015 trong c d n Phng chng bnh phi tc nghn mn tnh v hen ph qun. D
n c B Y t giao Bnh vin Bch Mai chu trch nhim trin khai. Mc tiu chung ca d
n l: (i) Nng cao nhn thc ng ca nhn dn v bnh phi tc nghn mn tnh v hen ph
219

qun v cc yu t nguy c; (ii) Nng cao cht lng chn on, iu tr, d phng v qun l
bnh phi tc nghn mn tnh v hen ph qun cc tuyn y t v (iii) Tin ti gim t l mc,
t vong ca bnh. D n a ra cc mc tiu c th gm:50
Phi hp vi D n Nng cao nng lc truyn thng v gim st nh gi thc hin
Chng trnh tin hnh tuyn truyn, gio dc nng cao nhn thc ca nhn dn v
d phng v qun l bnh phi tc nghn mn tnh v hen ph qun.
o to v pht trin ngun nhn lc lm cng tc qun l v iu tr bnh phi tc
nghn mn tnh v hen ph qun ti cc tuyn y t. n nm 2015, phn u o to
c 70% s bc s tham gia khm, chn on v iu tr bnh phi tc nghn mn tnh
v hen ph qun cc tnh tham gia d n.
Xy dng, trin khai v duy tr bn vng m hnh qun l bnh phi tc nghn mn tnh
v hen ph qun ti cc tuyn y t, xy dng mng li qun l bnh phi tc nghn
mn tnh v hen ph qun t trung ng xung a phng. n nm 2015, phn u
xy dng c Phng qun l bnh phi tc nghn mn tnh v hen ph qun ti 70%
s tnh tham gia d n.
Gim t l mc bnh phi tc nghn mn tnh v hen ph qun, ci thin t l bnh nhn
bnh phi tc nghn mn tnh v hen ph qun c chn on v iu tr ng theo
mc nng ca bnh. Phn u 50% s bnh nhn cc tnh tham gia d n, c chn
on bnh phi tc nghn mn tnh v hen ph qun c k n ng theo Hng dn
iu tr ca B Y t.
4.1. Kt qu thc hin
D n mi c trin khai thc hin trong mt thi gian ngn nn cha thc hin c
cc nghin cu kho st, nh gi kt qu thc hin so vi cc mc tiu ca d n. Cc hot
ng di y c thc hin nhm cc mc tiu ra ca d n:
Hot ng truyn thng c thc hin vi nhiu hnh thc nh: Pht thanh vi 13216
lt vi tng thi lng 198240 pht, truyn hnh 27 lt vi 482 pht, ni chuyn trc tip
14 lt vi 420 pht. Ngoi ra, in 335 000 t ri, 4500 p phch v 285 bng rn, khu hiu.
Cc hot ng truyn thng nh phng vn, ta m trn truyn hnh c thc hin vi s
tham gia ca cc chuyn gia u ngnh [211].
o to, nng cao nng lc cho cn b chuyn mn tham gia d n t c kt qu
quan trng. Sau 3 nm thc hin, c 9 kha o to ging vin ngun cho d n c trin
khai v o to c tng cng 439 bc s hin ang cng tc ti cc a phng tr thnh
ging vin ngun ca d n. y l lc lng rt quan trng gip o to cho cn b y t ti
tuyn y t c s. C 11 kha o to v chc nng h hp c t chc v o to c 316
bc s v k thut vin v thm d chc nng h hp, gip cho vic trin khai cc phng qun
l bnh nhn theo tiu chun v phc v cho cng tc khm sng lc pht hin sm bnh nhn
ti cng ng. tp hun trang b kin thc cho 9441 cn b y t l bc s, iu dng hin
ang cng tc ti tuyn tnh, huyn v x thuc 25 tnh tham gia d n.
T chc hi ngh khoa hc kt hp vi o to y khoa lin tc thng nin: hi ngh
khoa hc ngy Hen ph qun ton cu thng xuyn t chc vo thng 5 hng nm nhn ngy
Quyt nh s 1208/Q-TTg, ngy 4/9/2012 ca Th tng Chnh ph v vic ph duyt cc Chng trnh mc
tiu Quc gia giai on 2012 - 2015.
50
220
hen ton cu v Hi ngh khoa hc ngy Bnh phi tc nghn mn tnh ton cu thng xuyn
t chc vo thng 11 hng nm. Duy tr u n hot ng ca cu lc b bnh nhn bnh phi
tc nghn mn tnh v cu lc b bnh nhn hen ph qun ti Bnh vin Bch Mai v ti cc
tnh. Cu lc b bnh nhn l ni cc bnh nhn c giao lu, chia s kinh nghim trong iu
tr hen ph qun, bnh phi tc nghn mn tnh v c bc s khm, t vn v cch phng trnh
t cp ca bnh.
Hng dn chuyn mn: hng dn chn on, iu tr hen ph qun c B Y t
ban hnh t nm 2009 (Quyt nh s 4776/Q-BYT ngy 04/12/2009). Cc ti liu chuyn
mn hng dn chn on iu tr hen ph qun, hng dn chn on iu tr t cp bnh
phi tc nghn mn tnh, hng dn chn on iu tr bnh phi tc nghn mn tnh giai on
n nh c bin son chi tit v pht hnh di nhiu hnh thc: sch hng dn, sch
hi p.
Cng tc khm sng lc ch yu mi thc hin c tuyn tnh vi m hnh phng
qun l bnh phi tc nghn mn tnh v hen ph qun ti bnh vin a khoa, chuyn khoa lao
v bnh phi tuyn tnh. C 93 451 ngi c cc triu chng h hp mn tnh c khm
lm sng v 11 994 ngi dn c o chc nng h hp. Qua , pht hin c 2521
(2,69%) bnh nhn hen ph qun v 1941 (2,07%) bnh nhn bnh phi tc nghn mn tnh
trong cng ng a vo cc phng qun l ti cc tuyn y t.
M hnh qun l, iu tr bnh phi tc nghn mn tnh v hen ph qun c p dng
trong khun kh d n l Phng Qun l bnh phi tc nghn mn tnh v hen ph qun.
thnh lp c 42 phng qun l bnh phi tc nghn mn tnh v hen ph qun t chun trn
25 tnh ang trin khai d n. xy dng c mt mng li qun l vi s kt ni gia a
phng v trung ng, gia S Y t v Bnh vin a khoa tnh, Bnh vin lao v bnh phi
Ti cc tnh/thnh ph u thnh lp cc Phng qun l l n v qun l cc bnh nhn ngoi
tr bnh phi tc nghn mn tnh v hen ph qun. Hon thin phn mm qun l bnh nhn
bnh phi tc nghn mn tnh v hen ph qun da trn cc gp ca cn b y t tuyn di.
Duy tr hot ng ca trang web d n, thng xuyn vit bi ng trn bn tin ca d n.
4.2. Kh khn, hn ch
Thiu nhn lc trin khai thc hin d n tt c cc tuyn: trung ng, Ban iu
hnh d n ti Bnh vin Bch Mai cn thiu thnh vin, cc thnh vin Ban ch o kim
nhim nhiu chc v. Ti cc a phng, mt s cn b cha qua tp hun nhng c gia
nhim v trong d n, mt s cn b tuyn di c tp hun nhng khng tham gia trin
khai d n. Thiu cn b c o to chuyn trch cho phng qun l bnh phi tc nghn
mn tnh v hen ph qun c kh nng c kt qu chc nng h hp v k n thuc, s dng
phn mm qun l bnh nhn.
Ngun kinh ph t ngn sch trung ng b ct gim ti 65%, khng c ngun vn i
ng ca a phng. Ti hu ht cc tnh, kinh ph thc hin cc hot ng cn thit cn t,
trong khi vic xy dng v ph duyt k hoch hot ng v kinh ph mt s tnh vn chm.
Mt s hot ng do vng mc th tc hnh chnh nn thc hin chm hoc khng thc hin
c khin cho gii ngn d n kh khn. mt s tnh, cha c s kt ni cht ch trong hot
ng gia s y t vi cc n v trin khai d n.
Hn ch trong tip cn thuc: cc thuc thit yu dnh cho iu tr bnh phi tc nghn
mn tnh v hen ph qun khng sn c ti tuyn y t c s; cc thuc iu tr theo khuyn co
221

ca Chng trnh Khi ng ton cu v bnh phi tc nghn mn tnh (GOLD) cha c
BHYT khng chi tr. mt s tnh, c quan BHXH khng chp nhn chi tr cho thuc iu tr
ngoi tr ti phng qun l bnh phi tc nghn mn tnh v hen ph qun, do phng qun l
ni trn khng c coi l c s KCB c th k hp ng KCB BHYT.
Thiu trang thit b: thiu my o chc nng h hp trin khai khm sng lc v xy
dng cc phng qun l bnh nhn bnh phi tc nghn mn tnh v hen ph qun t chun.
4.3. Khuyn ngh
Cung cp thuc v pht cho bnh nhn iu tr: cn b sung, iu chnh danh mc
thuc thit yu iu tr bnh phi tc nghn mn tnh v hen ph qun, c qu BHYT chi tr
trong iu tr ngoi tr cho tt c cc tuyn t y t c s cho n tuyn trung ng hng thng
ging nh bnh mn tnh khc. Tng cng cc hot ng d phng v qun l iu tr bnh
ti tuyn huyn, x.
o to nng cao kin thc cho nhn vin y t: cn phi o to, tp hun, cp nht kin
thc, nng cao trnh chuyn mn cho cn b y t lm cng tc KCB chn on v iu tr
bnh nhn theo ng phc hng dn. Cn c o to bc s chnh quy theo vng min vi
a bn hnh ngh quy nh v o to lin tc cp nht kin thc, bo m ngun lc ti ch.
B sung trang thit b cho chn on, iu tr: cn trang b cho tuyn y t c s my o
chc nng h hp t chun v dng c filter lc khun gip cho tuyn y t c s c th chn
on chnh xc v qun l theo di bnh nhn c tt. Bn cnh my o chc nng h hp,
cng cn thit phi trang b thm my th khng xm nhp, my th xm nhp cho tuyn tnh
v mt s bnh vin a khoa khu vc c kh nng iu tr c nhng bnh nhn hen v bnh
phi tc nghn mn tnh c suy h hp.
Tng cng qun l, phi hp lin ngnh: B Y t ph duyt k hoch d n sm
nhanh chng trin khai cc hot ng ti Trung ng v a phng. Bn cnh , cp kinh ph
kp thi Ban iu hnh d n Trung ng trin khai cc hot ng ng vi mc tiu ra.
Cn c s phi hp tt gia: s y t tnh, bnh vin a khoa tnh, bnh vin lao v bnh phi
trong trin khai d n. Nn giao u mi thc hin cho cc bnh vin a khoa tnh ni c ngun
bnh nhn di do v c thm cc n v trin khai khc nh: bnh vin lao v bnh phi tnh,
bnh vin a khoa thnh ph, cc trung tm y t, cng phi hp thc hin. Cc a phng
xy dng sm k hoch hot ng trnh UBND tnh/thnh ph ph duyt v ch ng xin kinh
ph i ng ca a phng trin khai hiu qu cc hot ng.
5. D n Bo v sc khe tm thn cng ng v tr em

T nm 1998, D n bo v sc khe tm thn cng ng c Th tng Chnh ph
ph duyt. Chng trnh Phng chng mt s BKLN giai on 2002-201051 v Chng trnh
mc tiu quc gia y t phng, chng mt s bnh x hi, bnh dch nguy him v HIV/AIDS
giai on 2006 - 201052, u c ni dung v bo v sc khe tm thn. Giai on 2006-2010 cc
mc tiu bao gm: (i) 100% s tnh/thnh ph trin khai d n; 70% s x/phng trin khai
m hnh lng ghp ni dung chm sc sc khe tm thn cng ng vo hot ng ca trm y
t c s; (ii) pht hin v qun l iu tr ti cng ng cho 50% s bnh nhn tm thn (tm
thn phn lit, trm cm, ng kinh); v (iii) iu tr n nh cho 70% s bnh nhn tm thn
c pht hin; h tr ngi bnh sng ha nhp vi gia nh v cng ng.
51
52
Quyt nh s 77/2002/Q-TTg.
222
Bo v sc khe tm thn cng ng v tr em trong D n Phng chng mt s bnh
c tnh cht nguy him vi cng ng, thuc Chng trnh mc tiu quc gia y t giai on
2012-201553 c 4 mc tiu c th l: (i) Pht hin sm, qun l v iu tr sm cho 90% s bnh
nhn ng kinh trong ton quc; (ii) Trin khai v qun l 90% s x v bnh nhn ng kinh
trong ton quc; (iii) iu tr n nh, chng ti pht cho 85% s bnh nhn ng kinh c
pht hin v qun l v (iv) Phc hi chc nng, gim t l mn tnh tn ph xung di 20%
s bnh nhn ng kinh c pht hin v qun l. D n c giao cho Bnh vin Tm thn
Trung ng I trin khai, thc hin.
Bn cnh cc d n bo v sc khe tm thn cng ng do ngnh y t qun l, B
LTBXH ang trin khai n 1215 v tr gip x hi v phc hi chc nng cho ngi
tm thn, ngi ri nhiu tm tr da vo cng ng (theo Quyt nh s 1215/Q-TTg, ngy
22/07/2011 ca Th tng Chnh ph ph duyt n tr gip x hi v phc hi chc nng
cho ngi tm thn, ngi ri nhiu tm tr da vo cng ng giai on 2011 - 2020). Mc tiu
c th ca n l (i) 90% s ngi bnh tm thn c hnh vi nguy him n gia nh, cng
ng v s ngi bnh tm thn lang thang c phc hi chc nng lun phin ti cc c s
bo tr x hi; (ii) 90% s ngi ri nhiu tm tr c nguy c cao b bnh tm thn, ngi bnh
tm thn c t vn, tr liu tm l v s dng cc dch v cng tc x hi khc; (iii) 100%
gia nh c ngi bnh tm thn, 70% ngi ri nhiu tm tr c nguy c cao b bnh tm thn
c nng cao nhn thc v tr gip v phc hi chc nng cho ngi bnh tm thn da vo
cng ng; (iv) Hnh thnh cc nhm cn b, nhn vin v cng tc vin cng tc x hi kt
hp vi nhn vin y t tr gip v phc hi chc nng cho ngi bnh tm thn ti x, phng,
th trn c ng i tng. n c trin khai chnh thc t nm 2012, cha cc thng
tin nh gi thc hin cc mc tiu.
5.1. Kt qu thc hin
D n bo v sc khe tm thn cng ng v tr em ca ngnh y t trin khai tt c
cc tnh, thnh ph trc thuc trung ng, thc hin qun l bnh nhn ti cng ng, v tuyn
truyn gim bt tnh trng k th bnh nhn tm thn (Bng 37). Nm 2013, trn 23% s x
trong c nc trin khai m hnh qun l bnh tm thn ti trm y t x vi khong 34% s
bnh nhn tm thn phn lit v bnh nhn ng kinh c qun l ti cng ng. Chng trnh
truyn thng, nng cao nhn thc cng ng v m hnh qun l iu tr bnh thc hin cc
hot ng nhm gim bt tnh trng k th v phn bit i x i vi bnh nhn bnh tm thn.
Cc ti liu hng dn chuyn mn trong sng lc, pht hin sm, qun l ngi ri lon tm
thn do D n bo v sc khe tm thn cng ng v tr em c xy dng, tuy nhin cha
c chun ha tr thnh ti liu hng dn quc gia.
Nh nc thi hnh chnh sch h tr cho bnh nhn tm thn. Chnh ph c chnh
sch h tr ti thiu 270000 ng/thng cho nhng ngi mc bnh tm thn ( c cha
tr nhiu ln nhng bnh cha thuyn gim) sng ti cng ng do x, phng, th trn qun
l. Nhng ngi ri lon tm thn sng ti c s bo tr x hi, mc tr cp nui dng hng
thng ti thiu l 450000 ng/thng (theo Ngh nh s 13/2010/N-CP ngy 27/2/2010 ca
Th tng Chnh ph v sa i, b sung mt s iu ca Ngh nh s 67/2007/N-CP ngy
13/4/2007 ca Chnh ph v chnh sch tr gip cc i tng bo tr x hi). Thc t mt s
tnh, thnh ph, mc h tr cao hn mc quy nh ti thiu do ngun ngn sch ca a phng
h tr.
53
Quyt nh s 1208/Q-TTg.
223

Bng 37: Kt qu thc hin D n Bo v sc khe tm thn cng ng v tr em theo
mc tiu
2011
2012
2013
(c tnh)
Trin khai D n Bo v sc khe tm thn cng ng

v tr em (s x)
782
(7,1%)
1771
(16%)
2541
(23%)
Pht hin v qun l v iu tr sm cho 90% s bnh nhn

ng kinh trong ton quc (s bnh nhn)
11730
(7,2%)
44175
(26,8%)
55725
(33,8%)
iu tr, phng ti pht cho 85% v iu tr sm cho 90%

s bnh nhn ng kinh (s bnh nhn)
9970
6%
37548
22,7%
47366
28,7%
Phc hi chc nng, gim t l tn ph xung di 20% s

bnh nhn ng kinh c pht hin v qun l (s bnh nhn)
1700
6000
8000
Mc tiu/hot ng
Ngun: BYT, Bo co S kt 3 nm (2011-2013) thc hin Chng trnh mc tiu quc gia y t (Kem theo Cng
vn s 4435/BYT-KH-TC ngay 19/7 /2013 cua B Y t.
5.2. Kh khn, hn ch
Chnh sch v sc khe tm thn cha ton din, thiu tm nhn di hn. Lut v sc
khe tm thn cha c xy dng. Cc chnh sch hin hnh cha da trn mt chin lc
tng th, ton din, di hn vi cc tm nhn, mc tiu, gii php c th v sc khe tm thn.
D n bo v sc kho tm thn mi tp trung vo tm thn phn lit, ng kinh, trm cm,
cha quan tm n mt s ri lon tm thn ph bin khc, cha quan tm ton din n cc i
tng c bit: tr em, v thnh nin, ph n c thai, b m, ngi trong cc tri giam, ngi b
ri lon tm thn sau thin tai, thm ha Qun l bnh nhn trm cm hin ti ch c thc
hin ti mt s m hnh im, cha c a vo chng trnh qun l thng xuyn. Cha c
can thip lin quan gim yu t nguy c bnh tm thn trong cng ng, trng hc, gia nh,
c quan,
Cha c s tham gia, phi hp ca cc ngnh lin quan, cc can thip dn tri v s
lng hot ng, v phng din y t v x hi. S phi hp lin ngnh cn rt hn ch, c
bit l s phi hp gia Y t v Lao ng Thng binh v X hi, Gio dc v o to, T
php, Cng an. Cha phn nh r trch nhim ca y t, Lao ng Thng binh v X hi trong
cung cp dch v CSSK tm thn ti cng ng. Cha c Ban chuyn trch lin ngnh quc gia
ph trch v tm thn. Cha c cn b/b phn chuyn trch v sc khe tm thn ca B Y t.
Cha c c ch ti chnh duy tr cho lnh vc sc khe tm thn ti c quan qun l. Cha c
cc h thng theo di, nh gi hiu qu d n. Trong h thng y t, s tham gia ca y t tuyn
huyn vo mng li CSSK tm thn cn hn ch, ch yu l h tr t bnh vin tm thn, c
s chuyn khoa tm thn ca tuyn tnh n x.
Cng tc truyn thng v phng chng bnh tm thn cn nhiu hn ch. Cha xy dng
chng trnh v k hoch tng th truyn thng gio dc v sc khe tm thn. Cha nh gi
hiu qu cc chng trnh truyn thng. Hot ng truyn thng ti cng ng thng qua h
thng loa i a phng (c chi ph thp, hiu qu cao), truyn thng lng ghp trong cc hot
ng y t ti tuyn x, truyn thng trc tip cha c ch trng. Cha c chnh sch ti chnh
h tr cho hot ng truyn thng qua cc phng tin thng tin i chng qua cc i truyn
hnh, i pht thanh t trung ng, n a phng (nh min, gim ph pht thanh, truyn
hnh), nn cc hot ng ny ch c thc hin khi c ngn sch ca D n. Hot ng truyn
224
thng gio dc sc khe ti cc x, phng ch c thc hin ti cc x c trin khai d n.
Nng lc v truyn thng, t vn ca nhn vin y t cn hn ch. Vic lng ghp cc hot ng
truyn thng gio dc sc khe v bnh tm thn vo cc chng trnh truyn thng sc khe
cha mang tnh ch ng, thng quy.
Thiu ht v nhn lc trong CSSK tm thn. Vit Nam l mt trong nhng quc gia rt
thiu bc s chuyn khoa tm thn. Phn ln cn b y t tham gia chn on, iu tr, qun l
bnh tm thn, c bit l tuyn huyn, x cha c o to y . Rt t cc kha o to
v tm thn c t chc cho cc cn b cc trm y t x, phng, y t thn bn [212]. Mt
trong nhng ro cn thu ht nhn lc, c bit l bc s cho chuyn ngnh tm thn l chnh
sch h tr cha ph hp mc d hin ti mc ph cp u i ngh l 70% p dng i vi
cng chc, vin chc thng xuyn, trc tip lm cng vic xt nghim, khm, iu tr, chm
sc ngi bnh tm thn. Ngun nhn lc trong CSSK tm thn ca Vit Nam ch yu l bc s,
iu dng, trong khi , CSSK tm thn ton din, hiu qu, cn c nhn lc a lnh vc:
bc s, iu dng, cn b tm l, cn b cng tc x hi, cn b phc hi chc nng Vit
Nam c rt t chuyn gia tm l lm vic trong cc c s khm, cha bnh tm thn. i ng
nhn vin cng tc x hi ang c thit lp v o to thng qua trin khai n pht trin
ngh cng tc x hi giai on 2010 - 2020 theo Quyt nh s 32/Q-TTg ngy 25/3/2010 ca
Th tng Chnh ph, tuy nhin, vic thiu ht nhn lc c v s lng, cht lng v sc thu
ht vn cn l vn rt kh khn, cn cc gii php tng th.
Hot ng sng lc, pht hin sm cc ri lon tm thn ch yu c thc hin theo
m hnh sng lc th ng, tn km, t hiu qu. Hin nay, sng lc chn on sm c thc
hin thng qua vic t chc cc t, cc on khm sng lc cho cc i tng nguy c, nghi
ng mc bnh tm thn ti cc trm y t x phng do cc bnh vin tm thn, c s chuyn
khoa tm thn tuyn tnh, tuyn trung ng thc hin. M hnh sng lc ny khng c s tham
gia ca nhn lc y t c s, tn km, khng ph hp vi ngun kinh ph rt hn ch ca D n.
Hnh thc sng lc ch ng cha c trin khai.
Mng li y t c s, CSSKB cha c nng lc chn on v iu tr, qun l bnh tm
thn. Hu ht cc trng hp ri lon tm thn u phi c chn on xc nh bi cc c s
chuyn khoa v tm thn ca tuyn tnh, trung ng. Cc bnh vin huyn gn nh khng tham
gia hot ng khm, chn on, iu tr, qun l bnh tm thn. Ch c s rt t tnh, thnh ph
c hot ng khm, cha bnh ti phng khm tm thn ti Trung tm y t huyn (nh thnh
ph H Ch Minh). Cc trm y t x, phng ch yu tham gia qun l bnh tm thn theo ch
nh trong h s bnh n ca ngi bnh c c s chuyn khoa tm thn ca tnh cp.
Hot ng chuyn mn trong khm, cha bnh cho ngi bnh tm thn ti cc c s y t, tp
trung ch yu v iu tr bng thuc, cc hot ng khc nh t vn, phc hi chc nng, tm
l tr liu, liu php ngh, h tr x hi cha c ch trng.
Qun l thuc trong iu tr bnh tm thn cn hn ch. Thuc thit yu iu tr bnh
tm thn tuy c cung cp min ph nhng khng sn c, v c nhiu tc dng ph. Ngi
bnh t khi c ch nh cc thuc iu tr th h mi, t tc dng ph, c trong danh mc
thuc ch yu ca B Y t .
Theo di, gim st bnh v cc yu t nguy c cha c trin khai y v ng b.
iu tra dch t hc bnh tm thn ph bin c tin hnh t nm 2002, nhng cha iu tra
li nh gi xu hng, s thay i trong m hnh bnh tt v ri lon tm thn. H thng bo
co ca d n khng c gim st v cht lng.
225

5.3. Khuyn ngh
Ngn hn
Xy dng Chin lc quc gia v sc khe tm thn giai on 2015-2020, vi nhng

mc tiu, ch tiu c th v kh thi, quy nh trch nhim, nhim v c th ca cc Ban,
ngnh, on th lin quan, cng vi khung theo di, nh gi hot ng.
Tng cng lnh o, qun l, hp tc lin ngnh hiu qu v sc khe tm thn thng
qua thit lp Ban ch o quc gia v sc khe tm thn vi nhng quy ch, k hoch
hot ng v c ch duy tr hot ng ca Ban. Ch ti cc yu t bo v v yu t
nguy c xy dng chin lc phng chng bnh tm thn ton din.
Xy dng, chun ha cc ti liu o to, gio trnh o to v sc khe tm thn. Xy
dng gio trnh, ti liu o to v CSSK tm thn v chm sc x hi. Hon thin cc
quy trnh chuyn mn, k thut trong khm sng lc, chn on, iu tr ri lon tm
thn. R sot cc quy trnh chuyn mn khm, cp thuc, qun l bnh tm thn.
R sot c ch ti chnh hin hnh, bo m ngun ti chnh bn vng cho CSSK tm
thn t ngun BHYT v NSNN.
Di hn
B Y t xut Chnh ph v Quc hi v vic xy dng d n Lut Sc khe tm thn.

Cung cp dch v sc khe tm thn v chm sc x hi ton din, lng ghp v da vo
cng ng. Chun ha m hnh ton din v sc khe tm thn c cc dch v y t v x
hi chm sc, h tr v phc hi ngi bnh tm thn mi la tui (bao gm tip
cn c hi v vic lm, nh , gio dc v cc hot ng cng ng). c bit, CSSK
tm thn cho tr em, ph n, ngi ngho, sau thin tai, thm ha.
Xy dng, hon thin chnh sch nhm dch chuyn cc cng tc chm sc, iu tr di
ngy i vi mt s bnh l tm thn t cc c s iu tr chuyn khoa tm thn sang cc
c s y t khng chuyn khoa (non-specialized healh settings) v lin kt mng li dch
v sc kho tm thn da vo cng ng (network of linked community-based mental
health services), bao gm iu tr ni tr ngn ngy, iu tr ngoi tr ti cc bnh vin
a khoa, chm sc sc kho ban u, trung tm sc kho tm thn, trung tm chm sc
ban ngy [213].
B Y t lm u mi phi hp vi cc ban, ngnh lin quan tng cng nng lc cho cn
b y t, gio dc, cn b x hi cung cp dch v CSSK tm thn v chm sc x hi,
c bit cc dch v chm sc khng chuyn khoa. Pht trin mng li nhn vin cng
tc x hi (social workers), tm l lm sng p ng nhu cu CSSK tm thn.
Thc hin nghin cu, iu tra dch t hc v cc ri lon tm thn Vit Nam. Tng
cng h thng thng tin, bng chng v nghin cu v sc khe tm thn. Xy dng v
trin khai khung theo di, nh gi thc hin chin lc.
226
Chng VI: Tng cng p ng ca h thng y t trong phng chng BKLN
Chng VI: Tng cng p ng ca h thng y t trong

phng chng BKLN
p ng mc tiu d phng v kim sot BKLN, cc h thng y t cn c tng
cng v nh hng li, thng qua CSSKB vi ngi dn l trung tm v bao ph ton dn54.
Chng ny s phn tch nh gi thc trng p ng ca h thng y t, cc kh khn, hn ch
tng cu phn ca h thng y t, bao gm cc cu phn qun tr, nhn lc y t, ti chnh y t,
dc v trang thit b y t, h thng thng tin y t v cung ng dch v y t. T la chn cc
vn u tin, xut cc gii php nhm tng cng kh nng ng ph trong d phng v
kim sot BKLN.
1. Qun l, iu hnh
Theo WHO, 80% cc bnh l tim mch, t qu v i tho ng tp 2 cng nh 40%
cc bnh ung th c th phng trnh c thng qua cc can thip d phng, kim sot cc yu
t nguy c [214]. Do phn ln cc BKLN c cng chung cc yu t nguy c v hnh vi v li
sng, vic kim sot cc yu t nguy c phng trnh BKLN i hi s phi hp a ngnh, v
chm sc iu tr cc BKLN mn tnh i hi s lng ghp v phi hp cht ch, lin tc gia
cc tuyn, gia cc nh cung ng dch v, gia cn b y t v ngi bnh. Nguyn tc tip cn
ton chnh ph, ton x hi v hnh ng a ngnh l mt trong nhng nguyn tc c bn
ca phng chng BKLN.
Nhm xut cc gii php tng cng hiu qu phng chng BKLN, phn trnh by
sau y nh gi vic thc hin chc nng qun l/qun tr, iu hnh ca h thng y t Vit
Nam trong phng chng BKLN, c tham kho cc nguyn tc tip cn v mt s mc tiu ca
Chin lc ton cu v phng v kim sot BKLN giai on 2008-2012, Chng trnh hnh
ng ton cu v phng chng v kim sot cc BKLN giai on 2013-2020 v K hoch hnh
ng v sc khe tm thn 2013-2020 ca WHO (chi tit xem chng III, mc 3.5).
Trong Chng trnh hnh ng ton cu v phng chng v kim sot cc BKLN 20132020, WHO khuyn co 4 la chn chnh sch tng cng hiu qu qun tr h thng y t
p ng phng chng BKLN bao gm: (i) C trch nhim bo m s sn c cc dch v phng
chng BKLN trong h thng y t; (ii) C s tham gia ca cng ng trong xy dng, thc hin,
gim st v nh gi cc chng trnh phng, chng BKLN lin tc, sut vng i tng
cng tnh hiu qu, cng bng; (iii) Lng ghp dch v phng, chng BKLN vo cc chng
trnh, k hoch ci cch tng cng hiu qu ca h thng y t v (iv) nh hng h thng
y t nhm ng ph vi tc ng ca yu t x hi nh hng ti sc khe thng qua cc can
thip da trn bng chng, h tr bng chnh sch bao ph CSSK ton dn.
1.1. Kt qu, tin b
Vit Nam xy dng v trin khai mt s chnh sch kim sot cc yu t nguy c
chung ca BKLN v cc chng trnh mc tiu y t quc gia phng chng BKLN.
n nay, Vit Nam xy dng v ban hnh mt h thng vn bn chnh sch v chng
trnh y t lin quan ti phng chng BKLN, bao gm cc vn bn chnh sch v chng trnh y
t phng chng BKLN ni chung; cc d n c th i vi tng nhm bnh c th: ung th, i
Mc tiu th 4 trong 6 mc tiu ca K hoch hnh ng ton cu d phng v kim sot BKLN giai on 20132020 ca WHO.
54
227

tho ng, tng huyt p, bnh phi tc nghn mn tnh, sc kho tm thn v cc chnh sch
lin quan ti kim sot cc yu t nguy c ca bnh [215] (xem chi tit Chng IV).
Cc kt qu v thnh tu t c trong xy dng chnh sch kim sot cc yu t nguy
c v cc chng trnh mc tiu y t quc gia c cp chi tit chng IV v chng
V. Phn trnh by di y lit k cc chng trnh, d n phng chng BKLN c B Y
t xy dng trnh Chnh ph ph duyt thc hin theo trnh t thi gian:
Cc chng trnh mc tiu quc gia phng chng BKLN c xy dng v trin khai
thc hin trn phm vi ton quc
Nm 1998, D n bo v sc khe tm thn cng ng c Th tng Chnh ph
ph duyt trong Chng trnh mc tiu quc gia v y t phng chng mt s bnh dch
nguy him. D n tp trung vo bnh tm thn phn lit v ng kinh v th im qun
l trm cm ti cng ng.
Nm 2002, Chng trnh phng chng BKLN ca Vit Nam bt u c thit lp theo
Quyt nh s 77/2002/Q-TTg ngy 17/6/2002 ca Th tng Chnh ph: Chng
trnh tp trung vo phng, chng 4 nhm bnh l nhm bnh tim mch, i tho ng,
ung th v ri lon tm thn.
Nm 2007, D n phng, chng bnh ung th, D n Bo v sc kho tm thn cng
ng c a vo Chng trnh mc tiu quc gia phng, chng mt s bnh x hi,
bnh dch nguy him v HIV/AIDS giai on 2006-2010 ti Quyt nh s 108/2007/
Q-TTg ngy 17/7/2007 ca Th tng Chnh ph.
Nm 2008, D n phng, chng bnh tng huyt p v D n phng, chng bnh i
tho ng c b sung vo Chng trnh mc tiu Quc gia ti Quyt nh s
172/2008/Q-TTg ngy 19/12/2008.
Nm 2010, Th tng Chnh ph k ban hnh Quyt nh s 2331/Q-TTg ban hnh
danh mc cc chng trnh mc tiu quc gia nm 2011, trong c D n phng,
chng BKLN (bao gm: d n phng, chng bnh ung th; D n phng chng bnh
tng huyt p, d n phng, chng bnh i tho ng; D n phng chng bnh phi
tc nghn mn tnh v d n bo v sc khe tm thn cng ng).
Gn y nht, ngy 4/9/2012, Th tng Chnh ph k ban hnh Quyt nh s 1208/
Q-TTg ph duyt Chng trnh mc tiu quc gia giai on 2012-2015, trong c
chng trnh mc tiu quc gia y t. D n 1 ca chng trnh mc tiu quc gia y t:
phng, chng mt s bnh c tnh cht nguy him vi cng ng, trong c bnh
phong, bnh lao, bnh st rt, bnh st xut huyt, bnh ung th, bnh tng huyt p,
bnh i tho ng, bo v sc khe tm thn cng ng v tr em, bnh phi tc
nghn mn tnh.
1.2. Kh khn, hn ch
1.2.1. Cha c s u tin tng xng cho phng chng BKLN
Tuy chnh sch kim sot cc yu t nguy c chung v chng trnh, d n phng chng
BKLN c xy dng v trin khai, song gnh nng bnh tt v gnh nng kinh t ca
BKLN cha c nhn thc y , nn cha dnh u tin tng xng cho hot ng phng
228

chng BKLN. Phng chng BKLN khng c cp trong Vn kin i hi ng ln th
XI; Ngun ti chnh cho cc d n phng chng BKLN b ct gim trong nhng nm gn y.
Trong khi , theo WHO, u t cho phng chng BKLN l u t c tnh hiu qu - chi ph
cao: chi ph c th chp nhn c mi quc gia k c nc ngho nht[125]. Tng chi
ph ca gi cc can thip phng chng BKLN c hiu qu-chi ph cao cho cng ng v c nhn
ch chim khong 2% tng chi tiu y t cc nc c thu nhp bnh qun thp.
Mc u tin i vi phng, chng BKLN cn th hin trong vic bo m nguyn
tc CSSK phi c trong mi chnh sch (health in all policies). Lut Bo v mi trng quy
nh v nh gi tc ng mi trng (Environment Impact Assessement - EIA) m khng quy
nh v nh gi tc ng sc kho (Health Impact Assessement - HIA); yu cu v nh gi
tc ng v sc khe c quy nh trong Lut phng chng bnh ly nhim nhng ch gii
hn vi mt s d n.
1.2.2. Chnh sch phng chng BKLN cha ton din, cha y
Hin nay, Vit Nam cha c mt chnh sch, chin lc ton din phng chng BKLN,
cha c Lut bo v sc kho tm thn v chin lc bo v sc kho tm thn. Do thiu k
hoch chin lc ton din nn cc chnh sch kim sot yu t nguy c cha c xy dng
y . Cho ti nay, mi ch c 1 trong 4 yu t nguy c chung ca BKLN c iu chnh,
kim sot bng Lut (Lut phng chng tc hi thuc l). Ba yu t nguy c chung ca BKLN
cn li (lm dng ru, bia, ch n khng lnh mnh v t hot ng th lc (chi tit xem
chng IV) v cc yu t nh hng ti sc kho tm thn cha c iu chnh bng Lut.
Cc chng trnh phng chng BKLN mi ch bao ph phn nh cc BKLN. Nm d n
phng chng BKLN hin ang thc hin mi ch tp trung vo 5 nhm BKLN, gnh nng bnh
tt ca 5 nhm bnh ny (tnh theo DALY) mi ch chim gn 1/3 gnh nng bnh tt ca cc
BKLN Vit Nam. Nh vy, cc BKLN cn li, chim trn 2/3 gnh nng bnh tt ca nhm
BKLN, vn nm ngoi cc chng trnh phng chng BKLN hin hnh (chi tit v cc mc
bao ph ca cc chng trnh phng chng BKLN tnh theo gnh nng bnh tt DALY c
trnh by chng III bo co ny).
1.2.3. T chc ch o, qun l phng chng BKLN khng ph hp vi nguyn tc tip
cn ton chnh ph v ton x hi, hnh ng a ngnh
Phng chng BKLN i hi hnh ng a ngnh, tip cn ton chnh ph, ton x
hi. BKLN c nhng nguyn nhn lin quan n cc yu t kinh t x hi nm ngoi kh nng
can thip ca ngnh y t. Do vy cn phi c s tham gia, phi hp hnh ng ton chnh ph,
ton x hi trong xy dng v trin khai cc chnh sch lin nganh, tc ng vo cc yu t
kinh t-x hi nhm to ra mi trng c li cho sc khe, ngn nga cc hnh vi nguy c gy
BKLN. Ti Hi ngh cp cao ai hi ng Lin Hp Quc nm 2011 v phong chng BKLN
(thng 9/2011), cc nh lnh o ng u nh nc v chnh ph cc nc trn th gii cam
kt thit lp v cng c chnh sch a ngnh v phng chng BKLN v lng ghp cc chnh sch,
chng trnh phng, chng BKLN vo cc k hoch pht trin quc gia v k hoch y t [132].
Theo quyt nh ca Th tng Chnh ph55, B Y t chu trch nhim ch tr, phi hp
vi b, ngnh lin quan v cc a phng qun l, t chc thc hin cc d n phng, chng
BKLN. Phn cng trch nhim nh vy khng quy nh r vai tr, nhim v ca cc b, ngnh,
55
Quyt nh s 2406/Q-TTg.
229

cc c quan ngoi ngnh y t. Trong mc tiu, k hoch hnh ng ca cc chng trnh phng
chng BKLN cha c cu phn r rng v kim sot cc yu t nguy c chung cua BKLN;
trong khi kim sot cc yu t nguy c chung cua BKLN c vai tr quyt nh ti hiu qu ca
phng chng cc BKLN, i hi chng trnh hnh ng ca ton chnh ph, ton x hi, phi
hp a ngnh.
Ban ch o Chng trnh phng, chng BKLN ca B Y t 56 ch bao gm cc thnh
vin thuc ngnh y t: Trng ban l mt Th trng B Y t, Ph Trng ban thng trc l
Cc trng Cc Qun l Khm cha bnh, mt Ph Trng ban l Cc trng Cc Y t D
phng. Cc y vin l i din lnh o mt s Cc, V v mt s c s y t trc thuc v mt
s thnh vin t cc V, Cc, Bnh vin tham gia T Th k (Hnh 51).
Hnh 51: S t chc Chng trnh Phng chng cc BKLNM
Chc nng, nhim v ca Ban ch o Chng trnh phng chng BKLN khng bo
m c s phi hp, hnh ng a ngnh. Ban ch o c nhim v xy dng v trin khai
cc Chin lc, k hoch hnh ng, chng trnh, d n v phng chng BKLN; xut xy
dng cc vn bn quy phm php lut v phng chng BKLN trnh cc cp c thm quyn
ban hnh; theo di, kim tra, gim st v nh gi kt qu thc hin cc hot ng ca cc
Chng trnh, D n v phng chng BKLN v nh k hng nm tng kt Chng trnh phng
chng BKLN, bo co B trng B Y t v cc c quan lin quan v tin v kt qu thc
hin Chng trnh.
Tuy cc chc nng, nhim v ca Ban ch o nh trn l ph hp vi quy ch qun
l, iu hnh thc hin cc chng trnh mc tiu quc gia57 ca Chnh ph, nhng kh c th
thc hin c vai tr phi hp, hnh ng a ngnh - mt nguyn tc c bn trong hot ng
phng chng BKLN.
Quyt nh s 2812/Q-BYT ngy 03/8/2011 ca B trng B Y t v vic thnh lp Ban ch o Chng trnh
phng chng BKLN..
57
Quyt nh s 135/2009/Q-TTg ngy 4/11/2009 ca Th tng Chnh ph v vic ban hnh Quy ch qun l,
iu hnh thc hin cc Chng trnh mc tiu quc gia.
56
230

1.2.4. Vn lng ghp trong phng, chng BKLN
Trong mt thi gian di, hot ng phng, chng cc BKLN ti cc nc ang pht trin
thng c t chc thc hin thng qua cc chng trnh dc - cc chng trnh mc tiu y t
quc gia, mi chng trnh tp trung vo mt bnh hoc nhm bnh. Tuy nhin, do cc BKLN
tr thnh bnh rt ph bin, cn c chm sc sut i, cn c d phng ngay t khi cn
tr, c chung cc yu nguy c nn chng trnh dc phng, chng BKLN khng cn ph hp.
Gii php tt nht phng, chng BKLN l lng ghp trong h thng CSSKB lng ghp
(Integrated primary care) [216].
Nm 2009, i hi ng WHO ku gi cc nc thnh vin lng ghp cc chng trnh
mc tiu y t quc gia (NTP) vo h thng chm sc sc kho ban u lng ghp [217]. Lng
ghp trong phng, chng BKLN trc ht, theo WHO, l s lng ghp phng, chng BKLN
vi CSSKB. iu ny c th hin trong Mc tiu th 4 ca K hoch hnh ng ton cu
phng, chng BKLN giai on 2013-2020. Mc tiu ny l tng cng v nh hng h thng
y t ng ph vi BKLN v cc yu t x hi lin quan thng qua CSSKB ly ngi dn lm
trung tm v bao ph CSSK ton dn (to strengthen and orient health systems to address the
prevention and control of noncommunicable diseases and the underlying social determinants
through people-centred primary health care and universal health coverage).
Phng, chng BKLN c WHO khuyn co lng ghp trong mt s ni dung c th
sau y [125]:
Lng ghp ni dung o to v phng, chng BKLN vo cc chng trnh o to nhn
lc y t.
Lng ghp cc dch v phng, chng BKLN trong hot ng CSSKB, mng li
CSSKB c lng ghp vi cc n v chm sc chuyn khoa tuyn trn (secondary,
tertiary care).
Lng ghp chm sc sc kho tm thn v iu tr vo cc bnh vin a khoa v vo
mng li CSSKB [213].
p ng yu cu chm sc di hn ca bnh nhn BKLN, vi cc bnh i km v tn
tt, thng qua cc m hnh chm sc sc kho lng ghp, lin thng vi dch v chm
sc sc kho ngh nghip, dch v sc kho cng ng v ton b h thng cung ng
dch v y t cn li.
Lng ghp vic theo di, gim st cc yu t nguy c v BKLN trong h thng thng
tin y t sn c.
Cc chng trnh mc tiu phng chng mt s BKLN Vit Nam hin hnh c thit
k theo m hnh ca cc chng trnh dc tch bit, ngun lc thc hin cc chng trnh c
theo di, qun l ring bit, mi chng trnh, d n do mt bnh vin chuyn khoa iu phi.
Do vy, kh c th thc hin lng ghp gia cc chng trnh t trung ng ti a phng,
khng c s lng ghp vi h thng cung ng dch v. Thc trng t chc ch o v iu phi
cc chng trnh c nhng hn ch sau:
(i) T chc ca Ban ch o kh p ng c nhu cu lng ghp cc chng trnh
phng chng BKLN v hnh ng a ngnh.
231

Ton b thnh vin ca Ban ch o Chng trnh phng chng BKLN58 v th k ca
Ban ch o l cc thnh vin kim nhim, cc v tr cng tc vi nhiu trng trch ln, thuc
ngnh y t (nh Th trng B Y t, lnh o cc V, Cc v cc bnh vin). Cc d n thnh
phn ang hot ng hon ton c lp vi nhau (Hnh 51), do cc Ban iu hnh ti cc bnh
vin trc tip iu hnh.
Thnh phn, chc nng v nhim v ca Ban ch o tuy ph hp vi quy ch qun l,
iu hnh thc hin cc chng trnh mc tiu quc gia59 ca Chnh ph, nhng kh c th
thc hin c vai tr phi hp a ngnh, mt nguyn tc c bn trong hot ng phng chng
BKLN.
(ii) Thiu s lng ghp gia cc d n thnh phn trong chng trnh phng chng
BKLN cp trung ng v a phng.
Cc Vin/Bnh vin u ngnh l Vin Tim mch, Bnh vin Ni tit, Bnh vin K,
Bnh vin tm thn Trung ng I, Bnh vin Bch Mai c giao lm u mi cho cc d n
thnh phn trong Chng trnh Phng, chng BKLN. Mi d n thnh phn c mt Ban iu
hnh D n, chu trch nhim lp k hoch hot ng hng nm v t chc trin khai thc hin
sau khi c ph duyt; cung cp cc hng dn ch o v mt chuyn mn cho cc tnh, thnh
ph; qun l, s dng ngun kinh ph ca cc D n v nh k bo co 6 thng, 1 nm cho Ban
ch o Chng trnh phng chng BKLN. Nh vy, cc d n thnh phn hot ng hon ton
c lp vi nhau (Hnh 50).
Do tnh cht ca chng trnh dc nn ti cp tnh cng khng c t chc u mi chung
qun l v iu hnh lng ghp cc chng trnh phng chng BKLN; cc n v u mi
ca tng chng trnh ti cc tnh, thnh ph c t chc a dng, theo cc d n ring bit.
1.2.5. u t cho hot ng nghin cu phng chng BKLN cha tng xng vi gnh
nng ca cc BKLN
Ngun ti chnh hn hp t NSNN cho cc d n phng, chng BKLN mi ch tp trung

ch yu cho cc hot ng truyn thng nng cao nhn thc cng ng, o to nng lc cn b
y t, xy dng m hnh sng lc, xy dng m hnh qun l iu tr bnh nhn, theo di nh
gi. Theo quy nh hin hnh, ngun ti chnh t BHYT ch c php chi tr chi ph iu tr.
Chnh v vy, u t cho nghin cu phng chng BKLN rt hn hp, khng thc hin
cc hot ng iu tra, nghin cu mt cch c h thng, cung cp thng tin ton din v tnh
hnh BKLN.
1.3. Cc vn u tin
Gnh nng ca BKLN cha c nhn thc y , phng chng BKLN cha c c
mc u tin tng xng;
Thiu k hoch chin lc quc gia phng chng BKLN, chin lc v bo v sc kho
tm thn mang tnh ton din;
Cc chng trnh phng, chng BKLN c thit k v t chc thc hin theo chiu
dc, hot ng ring r; thiu s lng ghp gia cc chng trnh t trung ng ti a
phng, thiu s lng ghp phng, chng BKLN vo h thng y t.
58
59
Quyt nh s 2812/Q-BYT.
232

Thnh phn ca Ban ch o chng trnh phng chng BKLN khng ph hp vi
nguyn tc hnh ng a ngnh; s kim nhim ca cc thanh vin Ban ch o khng
ph hp vi chc nng, nhim v ca Ban.
Thiu cc nghin cu v BKLN p ng c nhu cu xy dng, la chn chnh sch
phng chng BKLN.
1.4. Khuyn ngh
Tng cng tuyn truyn, vn ng nng cao nhn thc v gnh nng bnh tt v gnh
nng kinh t ca BKLN cho phng, chng BKLN tr thnh mt u tin, c xem xt
trong xy dng v trin khai cc k hoch pht trin kinh t - x hi quc gia; K hoch
chin lc phng chng BKLN cho giai on t 2015 ti 2025, tm nhn ti 2030 c
xy dng v ban hnh.
Chin lc d phng v kim sot BKLN nn bao gm cc nguyn tc c bn, bao trm
theo khuyn co ca WHO, nh nguyn tc hnh ng a ngnh, la chn can thip da
trn bng chng, qun l xung t li ch, tip cn cng bng
Ban ch o lin ngnh v phng chng BKLN nn c s tham gia ca i din cc b,
ngnh, t chc x hi bo m s ch o, phi hp hnh ng a ngnh; nn c mt
s thnh vin chuyn trch, c phn b kinh ph hot ng thc hin c tt hn
chc nng ch o, iu hnh.
V lng ghp trong phng, chng BKLN: thc hin lng ghp theo l trnh, bt u t
vic la chn mt s hot ng lng ghp gia cc chng trnh dc giai on u,
tin ti lng ghp ton din cc hot ng vo h thng y t trong giai on sau. iu
kin c th lng ghp ton din cc dch v phng chng BKLN vo h thng y t
l c c mt mng li CSSKB lng ghp, nhn lc c trnh chuyn mn v
BKLN [125] v trang thit b cn thit cung cp cc dch v tuyn truyn, t vn d
phng, nng cao sc kho, pht hin sm, iu tr, phc hi chc nng, chm sc gim
nh, qun l bnh nhn BKLN. Nh vy, ngay trong giai on u, song song vi vic
lng ghp mt phn hot ng gia cc chng trnh dc, cn trin khai thc hin k
hoch chin lc nng cao nng lc ca h thng cung ng dch v y t ly CSSKB lm
nn tng, nhm nng cao cht lng, hiu qu, kh nng tip cn, vi mc chi ph thp.
Nhng hot ng c th lng ghp gia cc chng trnh phng chng BKLN trong giai
on u l cc hot ng truyn thng, o to lin tc nng cao nng lc, sng lc
pht hin sm.
2. Nhn lc y t
Cc la chn chnh sch nhm pht trin nhn lc ng ph vi BKLN c WHO
khuyn co [125] bao gm: (i) Xc nh cc nng lc cn thit v u t nng cao kin thc,
k nng v ng lc lm vic ca nhn lc y t hin c v lp k hoch o to trong tng lai
da trn d bo nhu cu; (ii) Lng ghp ni dung v phng chng BKLN trong chng trnh
o to nhn lc y t cng nh nhn lc thc hin cng tc x hi, nhn mnh vo CSSKB;
(iii) Bo m ch i ng v iu kin lm vic huy ng nhn vin y t phc v vng
kh khn; (iv) Tng cng o to sau i hc chuyn v BKLN i vi cn b y t, dc, v
lnh vc khc lin quan n chm sc ngi mc BKLN; v) Ti u ha phm vi hnh ngh ca
233

iu dng v nhn vin cn lm sng loi b cc cn tr v tng cng s ng gp ca h
trong phng chng cc BKLN v (vi) Tng cng nng lc lp k hoch, thc hin, gim st,
nh gi cung ng dch v phng chng BKLN.
Mt s la chn chnh sch theo khuyn co nu trn c tham kho phn tch, nh
gi thc trng, xc nh vn u tin v khuyn ngh gii php pht trin nhn lc y t nhm
mc tiu phng, chng BKLN.
2.1. Kt qu, tin b
2.1.1. S dng nhn lc y t
i ng nhn lc y t, trong c nhn lc trong lnh vc BKLN, lin tc pht trin v

s lng v khng cn tnh trng thiu trm trng, ngoi tr i vi chuyn khoa tm thn. T
s bc s trn mt vn dn, trong c cc bc s cng tc cc chuyn ngnh thuc BKLN,
tng u qua cc nm v t mc 7,5 vo nm 2013. gii quyt tnh trng thiu s lng
nhn lc y t, cc gii php v o to, nh tng cng ch tiu tuyn sinh ca cc trng, u
tin o to theo a ch cho cc vng kh khn c thc hin t gn hai thp k, B Y
t cng c mt s gii php ring v s dng nhn lc y t. n 1816, bt u c trin
khai t nm 2008 c cc chuyn gia c kinh nghim t cc c s y t tuyn trn h tr v
chuyn giao k thut cho tuyn di. Trong nm u, c 1037 lt cn b, thuc 19 chuyn
khoa i h tr tuyn di trong thi gian t 1 tun n 3 thng. Ngay sau nm u thc hin,
c tnh s bnh nhn chuyn v tuyn trn gim khong 30% [218]. D n Th im a bc
s tr tnh nguyn v cng tc ti min ni, vng su, vng xa, bin gii, hi o, vng c iu
kin kinh t - x hi kh khn (u tin 62 huyn ngho) c B trng B Y t ph duyt v
bt u trin khai t 2014. D kin n nm 2016, s c khong 500 bc s tr v cng tc ti
vng su, vng xa, bin gii, hi o, vng c iu kin kinh t - x hi kh khn, trong u
tin 62 huyn ngho trong c nc60.
Nhn lc trong lnh vc cc BKLN c hng cc ch , chnh sch i ng chung
cho nhn lc ca ngnh y t v cho mt s lnh vc c bit. Ring nhn lc y t thuc chuyn
khoa tm thn c xp vo nhm u tin cao nht.
Ngh nh s 56/2011/N-CP ngy 7/4/2011 ca Chnh ph quy nh ch ph cp
u i chung theo ngh i vi cng chc, vin chc cng tc ti cc c s y t cng lp. Trong
, cc cn b y t tham gia khm, iu tr, chm sc bnh nhn c hng ph cp t 20%
n 70%, ty theo lot cng vic. Chnh ph cng c Ngh nh s 64/2009/N-CP ngy
30/7/2009 qui nh cc chnh sch i vi cn b, vin chc y t cng tc vng c iu kin
kinh t - x hi c bit kh khn. Theo , cn b, vin chc y t, cn b qun y ang cng tc
hoc c iu ng n cng tc ti cc c s y t thuc vng c iu kin kinh t - x hi c
bit kh khn c hng ph cp u i, ph cp thu ht mc 70% mc lng theo ngch,
bc hin hng cng vi ph cp chc v lnh o, ph cp thm nin vt khung (nu c).
Bn cnh , cn b, vin chc y t, cn b qun y cn c hng cc tr cp v tham quan,
hc tp, bi dng chuyn mn, nghip v nh c h tr 100% tin hc ph, tin ph cp i
li, tin thu nh .
Th tng Chnh ph c quyt nh s 73/2011/Q-TTg ngy 28/12/2011 qui nh
mt s ch ph cp c th i vi cng chc, vin chc, ngi lao ng trong cc c s y
60
234

t cng lp nh ch ph cp thng trc, ph cp phu thut, th thut,..v ch ph cp
chng dch ca cn b y t.
hng dn chi tit Thng t s 07/2005/TT-BNV ngy 05/01/2005 ca B Ni v,
B Y t c cng vn s 6608/BYT-K2T ngy 22/8/2005 hng dn chi tit v ch ph
cp c hi, nguy him i vi cn b, vin chc ngnh y t. Trong , c cc qui nh v ph
cp thm cho cn b y t tham gia phc v bnh nhn chy thn nhn to, bnh nhn tm thn,
ung th, xut huyt no
Nm 2013, Chnh ph ban hnh Quyt nh s 317/Q-TTg ph duyt n pht
trin y t bin, o n nm 2020 vi cc mc tiu nhm tng cng nng lc cho mng li y
t, pht trin ngun nhn lc y t ph hp vi c th hot ng bo v CSSK v cp cu vn
chuyn cp cu khu vc bin o, nng cao kin thc v k nng ca ngi dn sinh sng v
lm vic khu vc bin o.
2.1.2. o to v cc BKLN cho h chnh quy
Chng trnh o to cp bng bc s, iu dng hin nay bao gm cc ni dung

quan trng lin quan n BKLN. Chng trnh khung gio dc i hc cho ngnh y a khoa61
xc nh mt trong cc k nng cn t ca bc s mi ra trng l Chn on, x l, theo di
v d phng cc bnh thng gp v cc cp cu thng thng; nh hng chn on mt s
bnh chuyn khoa;.... Chng trnh c mt s mn hc quan trng cung cp cc kin thc, k
nng v cc BKLN nh Ni c s (8 n v hc trnh), Ni bnh l (16 n v hc trnh), Thn
kinh (3 n v hc trnh), Tm thn (3 n v hc trnh), Ung th (3 n v hc trnh). Mn hc
Ni c s cung cp cc kin thc v k nng sinh vin c th khm ni khoa ton thn, bit
cc triu chng ca cc chuyn khoa h hp, tim mch, tiu ha, hi sc cp cu, thn kinh, c
xng khp, tit niu, ni tit. mn Ni bnh l, sinh vin c hc cch chn on v iu
tr cc bnh thuc cc chuyn khoa ny. Mn Thn kinh cung cp cc kin thc, k nng khm
v pht hin mt s triu chng thn kinh thng gp. Mn Tm thn cung cp cc khi nim
v sc khe tm thn, cc nguy c ch yu v sc khe tm thn hin nay, cc biu hin triu
chng, hi chng hc trong thc hnh tm thn hc, x tr cc trng thi cp cu trong tm thn,
t chc chm sc, theo di bnh nhn cng ng, cc phng php iu tr, d phng cc ri
lon tm thn. Mn Ung th cung cp cc kin thc c bn v ung th, cc phng php chn
on s b mt s bnh ung th thng gp Vit Nam, d phng v pht hin sm mt s bnh
ung th thng gp. Ngoi cc kin thc, k nng v cc bnh, sinh vin y khoa c hc v
truyn thng v gio dc sc khe (2 n v hc trnh) gm cc hnh vi sc khe, cc k nng
v cc phng php, phng tin truyn thng gio dc sc khe. Cc k nng ny c bc
u thc hnh ti cng ng mn Thc tp cng ng 1 (2 n v hc trnh). Cn trong mn
Thc tp cng ng 2, sinh vin c thc hnh thit k v thc hin chn on, cp cu thng
thng, theo di, iu tr sc khe gia nh v cng ng v bc u lp k hoch can thip.
Chng trnh khung gio dc i hc cho ngnh iu dng,62 bn cnh cc mn iu
dng c s chung, cn c cc mn hc quan trng lin quan nhiu n chm sc ngi b
BKLN nh Chm sc sc kho ngi ln c bnh ni khoa (10 n v hc trnh), Chm sc
sc kho ngi cao tui (2 n v hc trnh), Chm sc sc kho tm thn (4 n v hc trnh),
Chm sc cho ngi cn c phc hi chc nng (3 n v hc trnh), CSSK cng ng (4
Thng t s 01/2012/TT - BGDT ngy 13/1/2012 ca B trng B Gio dc v o to v vic ban hnh cc
Chng trnh khung gio dc i hc khi ngnh sc khe.
62
Thng t s 01/2012/TT - BGDT.
61
235

n v hc trnh). Chng trnh o to cng c 4 n v hc trnh dy v k nng giao tip v
3 n v hc trnh dy v gio dc sc khe trong thc hnh iu dng. Mn CSSK ngi ln
c bnh ni khoa cung cp nhng kin thc c bn v CSSK cho ngi ln mc cc bnh ni
khoa v chuyn khoa h ni, thc hin cc k thut v quy trnh chm sc ni khoa. Mn CSSK
ngi cao tui cung cp nhng kin thc c bn v nhng thay i v tm sinh l v cc vn
sc khe ca ngi cao tui, nhu cu chm sc ca ngi cao tui v vai tr ca ngi iu
dng, cc k thut v quy trnh chm sc iu dng cho ngi cao tui. Mn CSSK tm thn
cung cp nhng kin thc c bn v sc khe tm thn v CSSK tm thn; cc phng php tr
liu, chm sc cho ngi mc cc bnh tm thn; cc k thut v quy trnh chm sc cho ngi
mc bnh tm thn. Mn Chm sc cho ngi cn c phc hi chc nng cung cp nhng
kin thc c bn v phc hi chc nng, mt s phng php vt l tr liu v phc hi chc
nng; vai tr, nhim v ca ngi iu dng trong qu trnh CSSK ngi bnh v cng ng
bng vt l tr liu v phc hi chc nng; mt s phng php vt l tr liu v phc hi chc
nng. Mn CSSK cng ng gm nhng kin thc c bn v sc khe cng ng v CSSK
cng ng; cc phng php CSSK cng ng v vai tr, nhim v ca ngi iu dng trong
chm sc sc kho cng ng; thc hin cc k thut v quy trnh chm sc iu dng sc
khe cng ng.
Chng trnh o to y s ch c thi gian 2 nm, do vy, cc ni dung v thi gian o
to v BKLN cng hn ch hn rt nhiu.
Nhiu chng trnh o to sau i hc ti cc trng i hc, vin, bnh vin, cung
cp kin thc, k nng chuyn su hn v BKLN. Cc chng trnh o to chuyn khoa I,
chuyn khoa II, thc s hin c cc chuyn ngnh Ni tiu ha, Ni h hp, Ni thn tit niu,
Ni tit, Tim mch, Lo khoa, Thn kinh, Tm thn, Ung th. Ti thi im 31/12/2013, c 21
trng, vin, bnh vin tham gia o to chuyn khoa II, 27 n v tham gia o to chuyn
khoa I v 15 n v tham gia o to bc s ni tr v thc s.63 Nm 2013, c trn 500 bc
s tt nghip chuyn khoa II, gn 2700 bc s tt nghip chuyn khoa I, v gn 300 ngi tt
nghip bc s ni tr [219].
gp phn gii quyt tnh trng c bit kh khn v nhn lc trong mt s lnh vc,
nm 2013, Th tng Chnh ph ph duyt n khuyn khch o to nhn lc cho cc
chuyn ngnh kh tuyn64, trong c chuyn ngnh tm thn vi mt s mc tiu lin quan ti
nhn lc ca chuyn ngnh tm thn nh sau: (i) n nm 2020, 600 nhn lc y t ca chuyn
ngnh Tm thn s c o to cc kha sau i hc; (ii) 90 - 100% bnh vin, vin tuyn
trung ng v cc c s o to c nhn lc cc chuyn ngnh Lao, Phong, Tm thn, Php
y, Gii phu bnh; (iii) 70 - 90% bnh vin, vin tuyn tnh v cc c s o to c nhn
lc cc chuyn ngnh Lao, Phong, Tm thn, Php y, Gii phu bnh; (iv) 50 - 70% bnh vin
tuyn huyn c nhn lc cc chuyn ngnh Lao, Phong, Tm thn. Cc gii php khuyn
khch o to cho cc chuyn ngnh ny bao gm xy dng v trin khai cc ch , iu kin
khuyn khch sinh vin, hc vin theo hc cc chuyn ngnh ny v bo m cc iu kin cn
thit nhn lc y t cc chuyn ngnh ni trn lm vic c hiu qu, lu di v bn vng ti
cc c s y t nhm p ng nhu cu chn on, iu tr v phng bnh thuc cc chuyn ngnh
trn ti cc tuyn trong c nc.
S liu thng k ca Cc Khoa hc cng ngh v o to, B Y t. Thng 1/2014
Quyt nh s 319/Q-TTg ngy 7/2/2013 ca Th tng Chnh ph ph duyt n Khuyn khch o to v
pht trin nhn lc y t cc chuyn ngnh Lao, Phong, Tm thn, Php y v Gii phu bnh giai on 2013-2020
63
64
236

2.1.3. o to lin tc
Cng tc o to lin tc c trin khai trong tt c cc d n, chng trnh mc

tiu quc gia phng chng cc BKLN. Cc D n, chng trnh s dng cc chin lc o
to kh tng ng: o to nh hng chuyn khoa (o to chuyn khoa ngn hn trong vi
thng), o to ngn hn cho mt ch c th, o to v chuyn mn, o to v qun l, o
to v truyn thng. Cc chng trnh, d n hu nh u c cc kha o to cho tuyn trung
ng, tnh, huyn, x, vi cc trnh khc nhau vi mong mun tng cng nng lc cho c
h thng. D n phng chng bnh i tho ng trong nm 2013 t chc 74 lp tp hun
cho 3369 nhn vin y t, t chc o to chuyn khoa nh hng ni tit cho 34 hc vin, o
to cp nht cho bc s tuyn tnh ca Thanh Ha, Ha Bnh, o to k nng sng lc cho h
thng, o to v chm sc bnh nhn i tho ng cho iu dng, tp hun k nng truyn
thng [220]. D n phng, chng bnh ung th trin khai cc hot ng o to, chuyn giao
h tr k thut, tp hun v phng v pht hin sm mt s bnh ung th, tp hun v chm sc
gim nh cho tuyn tnh, bin son ti liu o to, [221]. D n bo v sc khe tm thn
cng ng v tr em t chc cc lp o to cho tuyn trung ng, tuyn tnh v cc x [222].
Bn cnh cc kha o to ca cc d n phng, chng mt s BKLN, mt s t chc
phi chnh ph, cc hi ngh nghip, mt s bnh vin, trng i hc cng t chc o to v
cc BKLN vi phm vi, bao ph, ngun kinh ph khc nhau.
Cc bnh vin lin quan n lnh vc BKLN cng v ang hon thin v mt t chc,
qun l cho cng tc o to lin tc. Nm 2013, B Y t ban hnh Thng t 22/2013/TTBYT ngy 9/8/2013 thay th Thng t s 07/2008/TT-BYT ngy 28/5/2008 hng dn cng
tc o to lin tc i vi cn b y t. Thng t mi hng dn v qui nh c th hn v
t chc, thc hin o to lin tc. Nhiu bnh vin tuyn trung ng ng k v c cng
nhn iu kin l c s o to lin tc cho nhn vin y t, v d nh Bnh vin Ni tit
Trung ng, Bnh vin Bch Mai, Bnh vin Vit c, Bnh vin K. Nm 2015, s bt u th
im kim nh o to lin tc.
2.2. Kh khn, hn ch
Nhn lc y t cng tc trong lnh vc BKLN c nh gi l cn yu, thiu v khng
ng b [220]. Bo co ca cc d n phng chng BKLN u cp ti s thiu ht ny.
Nguyn nhn l do mt s chuyn ngnh nh ni tit chuyn ha cha c cc kho o to sau
i hc, hoc mt s chuyn ngnh (nh ngnh tm thn) cha c nhiu hc vin la chn.
i ng bc s c nng lc chn on v iu tr tp trung cc thnh ph ln nh H Ni,
thnh ph H Ch Minh, Hu, Nng v cc c s y t trung ng. Nng lc ca i ng
cn b y t tuyn tnh hn ch do h t c o to v c cc chuyn gia c kinh nghim
hng dn. Cn b y t c s t hiu bit v BKLN [207].
Nng lc ca i ng cn b y t tuyn x hin nay khng p ng c nhim v
qun l cc BKLN, bnh mn tnh. Cc ti liu trong nc v quc t u khng nh vai tr
quan trng ca tuyn y t c s trong qun l BKLN. Vit Nam c mng li y t c s rng
khp cc x, phng. n cui nm 2012, s lng cn b y t cng tc ti cc trm y t x t
khong 70000 ngi, t 6,1 cn b y t/trm, a s c trnh trung cp, cao ng. Trn ton
quc c 76,9% trm y t c bc s, thp nht l Trung du v min ni pha bc (66,4%) v cao
nht khu vc ng Nam B (83,4%) v ng bng sng Cu Long (87,2%) [18]. Hu ht
cc bc s tuyn x c o to theo hnh thc lin thng (chuyn tu c) vi u vo c cht
237

lng thp v cha c mt h thng nh gi cht lng u ra theo chun chung (v d nh
thi cp chng ch hnh ngh. Mt s nghin cu cho thy nng lc ca i ng y bc s trm y
t x ti mt s a phng cn yu [223], khng kh nng chn on v x tr cc bnh
thng thng nh tng huyt p65. Trong mt nghin cu nh gi nng lc chuyn mn ca
nhn vin y t tuyn x cho thy hn 50% bc s v y s tr li sai cc cu hi v bnh tim mch
v bnh ni khoa [224]. Y s hin ang tham gia cng tc phng v khm cha bnh trm y
t x v cc BKLN, nhng thi gian c o to cho cc ni dung ny trong chng trnh o
to y s rt hn ch, ch l 5 n v hc trnh (75 tit) l thuyt v 4 tun thc hnh cho tt c
cc bnh thng thng ni khoa66. Vi chng trnh o to ch 2 nm nh hin nay, y s sau
khi ra trng khng th nng lc khm, pht hin bnh v rt kh tham gia vo qun
l cc BKLN67.
S dng nhn lc y t trong phng chng v qun l BKLN cn lng ph, khng c s
lng ghp nhim v ca nhn lc cc tuyn v gia cc c s trong mt tuyn, c bit l
tuyn di. Cng tc phng chng v qun l cc BKLN ch yu c thc hin da trn tng
bnh, tng yu t nguy c, cha c s phi hp gia cc nguy c [223]. Bn thn cc nhn vin
y t cha thc hin ht chc nng, nhim v do hn ch v nng lc v do c ch gim st, theo
di cng vic khng thc s hiu qu. C ch khuyn khch pht trin ngh nghip km. V
ch chnh sch, chi tr cho cc nhn vin y t tuyn c s thp so vi vai tr quan trng ca
h trong phng chng BKLN [223].
Cc ch chnh sch u tin cho cn b y t ni chung v cho cc khu vc, lnh vc
kh khn c ban hnh, nhng vn bt cp. Mc u tin cha hp dn cn b y
t sn sng chp nhn cc kh khn v iu kin lm vic, iu kin sng ca bn thn v gia
nh. i vi nhng ngi nm trong phm vi p dng ca hai loi ch u tin tr ln cng
ch c hng mt mc u tin cao nht. V vy, vi mc u i ln nht l thm 70% lng
v ph cp, cng cha khuyn khch cn b y t c nng lc nhn cng tc ti cc khu
vc v lnh vc kh khn. iu ny th hin r nt qua tnh trng thiu nhn lc chuyn khoa
Tm thn, l mt chuyn khoa c thu nhp ngoi lng km so vi cc chuyn khoa khc.
Cha c c ch bo m mt bng chung v cht lng ca cc chng trnh o to
i hc, o to i hc theo a ch v o to sau i hc khi ngnh khoa hc sc kho dn
n cht lng nhn lc mi ra trng cha ng u. Mt s chng trnh o to b nh
gi l cha c cht lng [225]. cc nc pht trin v nhiu nc ang pht trin, c th
hnh ngh khm cha bnh, cc bc s, iu dng phi tri qua mt k thi quc gia cp chng
ch hnh ngh. K thi ny s bo m cc bc s, iu dng tt nghip cc trng khc nhau
vi cc chng trnh o to khc nhau s t c mt mc nng lc c bn v p ng
c yu cu ca ngh nghip. Nhng Vit Nam cha c k thi ny, v vy, cha c thc o
chung nh gi cht lng o to nhn lc y t t cc c s o to khc nhau, cha cp
chng ch hnh ngh theo kt qu st hch trnh chuyn mn.
Cht lng ca mt s chng trnh o to cp bng cha bo m dn n cc nng
lc phng v qun l BKLN ca cc sinh vin mi ra trng b hn ch. Trong thi gian qua,
p ng nhu cu v nhn lc ca cc a phng, B Gio dc v o to cho php o to
theo a ch cho nhng tnh thiu nhiu bc s. o to theo a ch tc l nhng th sinh d k
Theo Vin Chin lc v Chnh sch Y t.
Thng t s 19/2010/TT-BGDT ngy 29/6/2010 ca B trng B Gio dc v o to ban hnh chng trnh
khung khi ngnh khoa hc sc khe trnh trung cp chuyn nghip.
67
Thng t s 19/2010/TT-BGDT.
65
66
238

thi tuyn thng thng b thiu im, nhng khng chnh lch nhiu vi im tuyn chnh thc,
ca a phng thiu bc s, dc s, s c nhn vo hc vi iu kin sau khi tt nghip
h s phi quay li cng tc theo s phn cng ca a phng c i hc. Ch ring trong 4 nm
t 2008 n 2011, c 3357 sinh vin y khoa v 1355 sinh vin dc i hc c tuyn v
theo hnh thc ny [226]. y l mt hnh thc u tin pht trin nhn lc y t cho cc tnh
kh khn. Nhng trn thc t, hnh thc ny ang mt phn b li dng. Nhiu ngi sau khi
tt nghip khng nhn s phn cng ca a phng hoc xin bi thng tin o to i
xin vic ni khc [227].
Hiu qu o trong cc d n, chng trnh mc tiu quc gia phng, chng BKLN khng
cao. Cc hot ng o to t ra mc tiu, ch tiu v s lng nhn vin y t c o to,
nhng cha c mc tiu r rng v u ra ca o to. nh gi ca cc chng trnh, d n lin
quan n cc BKLN v hiu qu ca o to vn cn hn ch. Bn cnh , mi chng trnh,
d n ch tp trung c vo mt s a phng, trong khi cc BKLN ang bao ph ton quc.
o to lin tc cho cc tuyn di c t chc ring r cho tng loi bnh, cha c
s lng ghp trong o to va c s chia s, phi hp trong thc hin nhim v chm sc
ngi b BKLN, va tit kim ngun lc. Cc chng trnh mc tiu quc gia ca ngnh y t
c ngun kinh ph hn hp, nn s lng cn b y t c o to mi giai on v hng nm
khng nhiu. Hot ng o to trong cc d n c ngun vn nc ngoi hu ht chim mt
phn nh hoc c qui m nh, s lng cn b y t o to c t. Vi tc trin khai v
chin lc tip cn nh hin nay, s mt mt thi gian nhiu nm c th o to bao ph ht
c nc.
Hot ng o to ca mt s trung tm o to trong bnh vin cn dn tri, cha c
nh hng r rng. Mt s bnh vin tuyn trung ng mc d qu ti, nhng ngoi cc kho
o to chuyn khoa su v cc BKLN, cn t chc cc kho o to v cc lnh vc m cc
trng i hc c th lm tt hn.
2.3. Cc vn u tin
gp phn ci thin cng tc phng v khm, cha, qun l BKLN, cn thit u tin
gii quyt cc vn sau:
Nhn lc y t lnh vc BKLN bao gm c tuyn tnh, huyn, x cn yu v cht lng
v thiu v s lng, m s dng nhn lc cha hp l l mt nguyn nhn.
Trnh chuyn mn ca cn b y t x, phng cha p ng c yu cu phng
chng cc BKLN, chm sc, qun l bnh mn tnh.
Cht lng i ng nhn lc y t mi o to ra trng cha ng u, cha c
chun ho.
Chin lc o to lin tc trong phng chng BKLN cha ph hp, hiu qu cha cao,
cha ci thin c nhiu v s lng v nng lc cho cn b y t.
2.4. Khuyn ngh
S dng hp l nhn lc y t trong phng chng BKLN: Nn phn nh r chc nng,
nhim v phng chng BKLN (c lng ghp cc nhim v v d phng, kim sot cc
239

yu t nguy c, chm sc, qun l bnh) v mc chuyn su ca tng tuyn y t;
chc nng, nhim v ca mi chuyn ngnh dc (cho tng BKLN) i vi tng tuyn.
Trong , tuyn y t c s thc hin tt CSSK BD trong phng chng v qun l BKLN,
cc tuyn trn c nhim v trong h tr chuyn mn, o to, theo di gim st v iu
tr chuyn su. Cn tng cng i ng, khuyn khch nhn lc cng tc y t c s.
Tng cng hot ng o to lin tc c lng ghp gia cc chng trnh mc tiu
quc gia, cc d n v cc c quan, ph hp vi nhu cu ca tng tuyn CSSK, c gim
st cht lng o to, xc nh mc tiu u ra. Tip tc t chc cc kha o to v
phng chng v qun l BKLN, nhng c lng ghp cc ni dung, ph hp vi nhim
v ca mi tuyn, u tin o to nhn lc y t c s. Nn c s phi hp o to vi h
tr, gim st chuyn mn sau o to. Hnh thc gim st nn c ci tin, nn p dng
h tr qua mng internet, in thoi (hin nay i hc Y Dc thnh ph H Ch Minh
ang p dng h tr hc vin Bc s gia nh). Cc kha o to lin tc v phng
chng v qun l BKLN cn c u ra r rng, cn theo di, gim st cht ch cht lng
o to. Trong iu kin trnh nhn lc y t x cn thp, nn xy dng cc hng dn
n gin, r rng v qun l cc BKLN.
C chnh sch, ch h tr khuyn khch cn b y t c s tham gia o to lin
tc, tng cng hnh thc o to v h tr lin tc ti ni lm vic cho cn b y t x.
Cng vi chnh sch h tr khuyn khch tham gia cc kha hc o to lin tc, thc
hin gii php bt buc tham gia o to lin tc nh cp chng ch hnh ngh c thi
hn. Khi c iu kin th nn trin khai thi kim tra trnh tay ngh chuyn mn
cp chng ch thay v xt cp chng ch nh hin nay. Nn nh k cp li chng ch,
mt trong cc iu kin cp li chng ch l hon thnh chng trnh o to lin tc.
Vic thi cp chng ch hnh ngh ch nn trin khai khi Vit Nam c th t chc k thi
minh bch, cng bng trn phm vi ton quc.
T chc h tr pht trin ngh nghip cho cc nhn vin y t trong lnh vc BKLN ngay
ti ni lm vic. V d: bc s chuyn khoa II h tr bc s chuyn khoa I, bc s chuyn
khoa I h tr bc s mi ra trng, H tr ca tuyn trn vi tuyn di qua in thoi,
internet, Cc h tr ny nn l mt nhim v bt buc ca mi nhn vin y t.
3. Ti chnh trong phng chng BKLN

3.1. Kt qu, tin b
Trc s gia tng v t l mc v gnh nng bnh tt ca cc BKLN, Vit Nam c
nhng p ng chnh sch nht nh trong c u t ti chnh cho phng chng BKLN. Cc
p ng ny bao gm chi hot ng thng xuyn v chi cho u t t ngun NSNN, chnh
sch v gi BHYT v cc ngun ti tr khc.
NSNN bt u cung cp kinh ph cho cc chng trnh kim sot v d phng cc BKLN
t nm 2002. Tng NSNN chi cho cc chng trnh kim sot v d phng cc BKLN trong hai
nm 2012-2013 l gn 200 t ng (Hnh 52). Mc d kinh ph t NSNN cho cc CTMTQG
cn hn ch, y l ngun kinh ph n nh cho cc hot ng phng chng cc BKLN. Cc
hot ng chnh c NSNN h tr l o to nhn vin y t, sng lc, xy dng cc m hnh
qun l iu tr bnh nhn, truyn thng gio dc sc kho, gim st v nh gi.
240

Hnh 52: NSNN phn b cho chng trnh phng chng BKLN 2012-2013
200
180
15
14,7
75
74,2
160
T VND
140
Bnh phi tc nghn

mn tnh
Sc khe tm thn
120
100
80
60
i tho ng
36
35,8
Tng huyt p
33
32,6
36
35,6
2012
2013
Ung th
40
20
0
Ngun: Cc cng vn ca B Y t v vic phn b ngn sch ca cc Chng trnh mc tiu quc gia (S 305/
BYT-KH-TC ngy 17/1/2012; S. 6941/BYT-KH-TC ngy 11/10/2012).
Mc d ngun kinh ph nh nc cp cn hn hp nhng vn l ngun ti chnh bo m

cc hot ng theo k hoch trong cc CTMTQG phng chng BKLN. Cc hot ng ny ch
yu bao gm: o to nng lc cn b y t, sng lc, xy dng m hnh qun l iu tr bnh
nhn, truyn thng, theo di nh gi.
Bn cnh vic chi tiu cho hot ng thng xuyn, ngun NSNN cng c u t cho
vic xy dng, ci to, nng cp cc bnh vin chuyn khoa ph v iu tr cc BKLN.... Theo
Quyt nh s 930/Q-TTg (2009), NSNN cng c phn b cho vic xy dng c s h tng
cho 35 bnh vin chuyn khoa tm thn cng vi 5 bnh vin v trung tm ung th.
Bn cnh , kinh ph t BHYT cng l ngun ti chnh quan trng cho hot ng khm
cha bnh cho cc BKLN. Cng vi vic tng bao ph BHYT theo l trnh thc hin BHYT
ton dn, phm vi quyn li ca BHYT ngy cng c m rng, p ng yu cu khm cha
bnh ngy cng tng cao cho ngi c th BHYT, trong c cc BKLN. Danh mc thuc
thanh ton BHYT theo Thng t 31/2012/TT-BYT gm 1243 tn thuc trong c y cc
nhm thuc cho iu tr cc BKLN t iu tr ung th (57 thuc v 57 cht phng x), cc bnh
tim mch (97 thuc), iu tr ri lon tm thn (38 thuc) n i tho ng (11 thuc)Tng
s dch v k thut cho KCB ang c BHYT thanh ton ln ti hn 17000 dch v trong
c nhiu dch v k thut cao, chi ph ln dng cho iu tr BKLN nh can thip tim mch, iu
tr ung th bng thuc phng x, phu thut s dng dao GammaNgoi ra, kinh ph cho hot
ng phng chng BKLN cn c huy ng t ngun khc nh ngun vin tr v vn vay v
ng gp ca bnh nhn qua vin ph.
3.2. Kh khn, hn ch
Ti chnh cho phng chng BKLN s dng t nhiu ngun, thiu lng ghp, ang b ct
gim, khng tng xng vi gnh nng ca cc BKLN
Thc t rt kh c c s liu thng k chi tit v t trng cc ngun ti chnh ny trong
tng kinh ph cho hot ng phng chng BKLN. Hin nay cc ngun ti chnh chia ct, ri rc
theo tng chng trnh phng chng BKLN. Mt khc, h thng d phng v iu tr gn nh
tch ri v c t chc, nhn lc cng nh kinh ph. Kinh ph cho hot ng iu tr bao gm
241

cc ngun t NSNN, BHYT v bnh nhn t tr. Kinh ph cho hot ng d phng ch yu t
ngun NSNN thng qua ngun ngn sch chi thng xuyn cp cho cc n v d phng v
kinh ph cho cc CTMTQG.
Mc kinh ph hin ti cho hot ng phng chng BKLN kh hn hp. Theo s liu Ti
khon y t quc gia 2011, tng kinh ph cho hot ng phng chng BKLN chim 3,5% tng
chi y t quc gia v chim 12,5% tng chi cho ton b hot ng d phng v nng cao sc
khe. Phn tch s liu thng k giai on 2005-2011 cho thy t l chi cho phng chng BKLN
trong tng chi y t quc gia tng khng ng k, t 2,5% ln 3,5%. Trong khi t l mc BKLN
chim ti 2/3 tng s ca mc cc bnh tt v gnh nng bnh tt do BKLN chim ti hn 70%
tng gnh nng bnh tt ca nc ta th r rng ngun ti chnh dnh cho hot ng d phng
bnh ny hon ton khng tng xng. Khon vin tr cho cc d n phng, chng BKLN
trong CTMTQG vn cn rt thp.
Phn tch ngun kinh ph cho cc CTMTQG cho thy, ngn sch cp cho chng trnh
mc tiu phng chng 5 BKLN (ung th, tng huyt p, i tho ng, bo v sc khe tm
thn, bnh phi tc nghn mn tnh v hen ph qun) trong tng kinh ph CTMTQG y t kh
thp ch chim 12,7% nm 2013 gim so vi nm 2012 (15,6%). Thm ch, kinh ph nm 2014
phn b cho cc chng trnh phng chng BKLN nm 2014 b ct gim ti 66% so vi kinh
ph nm 2013 v ch p ng mc bnh qun 23% so vi d ton do cc chng trnh xy dng
cho nm 2014 (Hnh 53).
Hnh 53: Kinh ph cp cho cc CTMTQG phng chng BKLN 2012-2014
200
2012
2013
2014
T VND
150
100
50
0
BKLN
Ung th
Tng huyt
p
i tho
ng
Sc khe
tm thn
Bnh phi
tc nghn
mn tnh
Ngun: Cc cng vn ca B Y t v vic phn b ngn sch ca cc Chng trnh mc tiu quc gia (S 305/
BYT-KH-TC ngy 17/1/2012; S. 6941/BYT-KH-TC ngy 11/10/2012 v S 6517/BYT-KH-TC ngy 14/10/2013).
Nhiu hot ng phng chng BKLN khng c chi tr t qu BHYT, do y t d phng

khng nm trong phm vi quyn li BHYT; cha c hng dn chi tr i vi cc dch v sng
lc chn on sm, hn ch nng lc ca y t c s v s hn ch trong danh mc thuc c
BHYT chi tr y t c s.
i vi cc dch v d phng, phm vi quyn li ca BHYT hin nay ch tp trung ch
yu vo cc dch v khm cha bnh. Cc dch v khm sng lc bnh khng c a vo
phm vi quyn li BHYT trong Lut BHYT sa i. Mc bao ph ca BHYT i vi dch
v lin quan n cc BKLN cn mt s hn ch do cc nguyn nhn sau y:
Do nng lc cung ng cc dch v chm sc v iu tr cc BKLN hin nay ti tuyn y t
c s cn rt hn ch, bnh nhn BHYT phi chuyn tuyn hoc vt tuyn ln bnh vin tnh
242

hay T hng cc dch v lin quan n iu tr v chm sc BKLN. Cc quy nh chuyn
tuyn v ro cn v a l v iu kin i li ang hn ch mc th hng quyn li t BHYT
vi bnh nhn BHYT b mc BKLN.
Danh mc thuc c BHYT chi tr theo cc tuyn chuyn mn k thut cha ph hp
vi yu cu iu tr cng nh tnh chi ph - hiu qu trong phng chng BKLN.
Theo quy nh, BHYT khng chi tr cc dch v y t ang c NSNN bao cp. Do ,
khi CTMTQG bao gm vic cp thuc iu tr nh chng trnh tm thn th thuc cho bnh
nhn tm thn s khng c BHYT thanh ton na. Trn thc t, ang ny sinh vng mc
l trong khi kinh ph cho chng trnh MTQG phng chng BKLN b ct gim ti 66%, vic
cung cp thuc ca chng trnh theo cng gim mnh nhng li cha c hng dn ch
thanh ton BHYT kp thi b p s thiu ht trong bo m thuc cho bnh nhn. Kt qu
l bnh nhn li phi t chi tr cho cc chi ph iu tr ny.
Phm vi quyn li ca BHYT hin nay cha bao gm y cc dch v cn thit cho
phng chng BKLN. Ngoi mt mng ln cc dch v d phng BKLN nh nu trn, ngay
c dch v iu tr v chm sc trong mt s trng hp cng nm ngoi phm vi thanh ton
BHYT nh t t (thng c xem l hu qu ca ri lon tm thn) hoc khng c trong cc
dch v c chi tr qua BHYT (khng c trong biu gi vin ph nh dch v t vn tm l - c
vai tr quan trng trong iu tr v chm sc bnh trm cm).
Theo s liu kho st ton cu ca WHO, cc ngun ti chnh ch yu cho phng chng
BKLN ti cc quc gia trn th gii bao gm: NSNN, vin tr, BHYT v ngun thu thu dnh
ring cho phng chng BKLN nh thu tiu th thuc l (earmarked tax). Trong s ny, kinh
ph t NSNN l ngun c s dng nhiu quc gia nht, chim 84% cc quc gia kho st
[228]. BHYT c vai tr quan trng trong chi tr cc dch v chm sc v iu tr BKLN, c
bit ti cc nc c h thng BHYT quc gia. Kt qu kho st cng cho thy, BHYT l ngun
ti chnh cho iu tr cc BKLN ti 57% cc nc thnh vin ca WHO. T l ny ti chu u
ln ti 84% [228].
Ngun NSNN cho phng chng BKLN b ct gim, chm phn b, trong khi gnh nng
BKLN tng ln.
Trong khi gnh nng bnh tt ca BKLN ngy cng gia tng v chim t l ti 71% tng
gnh nng bnh tt v t vong quc gia th ngn sch ngn sch cho cc CTMTQG li b ct
gim. T nm 2013, cc CTMTQG b ct gim kinh ph truyn thng nn cng gy kh khn
cho hot ng ca cc chng trnh, d n. n nm 2014, hu ht cc CTMTQG u b ct
gim, trong cc chng trnh phng chng BKLN b ct gim rt ln, ti 68% nh chng
trnh phng chng ung th v phng chng hen v bnh VPTNMT. Trong khi , mc chi ngn
sch thng xuyn cho y t d phng kh thp (c tnh ngoi lng ch chi 13 triu ng/bin
ch) [49]. Nhiu kh nng nm 2015 s khng cn kinh ph cho CTMTQG. L do ch yu c
a ra theo mt s chuyn gia l ngun NSNN hn hp.
Bn cnh s thiu ht ngun ti chnh cho phng chng BKLN, kinh ph t NSNN cp
cho cc CTMTQG thng rt chm, gy kh khn cho vic trin khai cng nh hn ch hiu
qu cc chng trnh. Vic thm inh va ph duyt Chng trinh con keo dai va thm chi c
ph duyt mun hn chu ky k hoach 5 nm (ngay 04/9/2012 mi c ph duyt Chng trinh
giai oan 2012-2015) nn kho khn trong vic xy dng k hoach cua nhng nm u chu ky
[65]. Chng trnh phng chng i tho ng c ph duyt cng vi cc chng trnh mc
243

tiu Quc gia khc vo nm 2002 theo Quyt nh s 77/2002/TTg ngy 17/6/2002 Th tng
chnh ph. n nm 2008, Quyt nh s 172/2008/Q-TTg ngy 19/12/2008 ca Th Tng
Chnh Ph ph duyt b sung chng trnh phng chng i tho ng vo chng trnh
mc tiu y t quc gia. Tuy nhin, chng trnh phng chng i tho ng mi ch thc s bt
u c hot ng k t nm 2009 mc d chng trnh c xy dng mc tiu v k hoch
hot ng cho giai on 2006-2010. L do ch yu l kinh ph trong giai on 2006-2010 c
thc hin theo cng vn s 1298/ TTCP ngy 20/8/2009 v vic ph duyt kinh ph trin khai
cc hot ng, ng thi Thng t s 36/TTLB-BTC-BYT hng dn trin khai mun v ch
bt u c hiu lc t thng 4/2010. Chnh v vy, cc hot ng ca Chng trnh trong giai
on 2006-2010 mi thc hin t gia nm 2010.
Thi gian lp k hoach va phn b vn cho cac Chng trinh/D an cung nh phn b
vn cua Chng trinh/D an cho cac ia phng va cac B/Nganh trin khai Chng trinh/D
an thng rt gp va trong thi gian rt ngn. Do o, cha am bao c tinh hiu qua va y
u cua k hoach hang nm. Hn na, vic lp k hoach hang nm cua cac D an/Chng trinh
theo k hoach chung va muc tiu cua giai oan 5 nm a c Thu tng Chinh phu ph duyt.
Tuy nhin, ngn sach hang nm c Chinh phu va B K hoach va u t, B Tai chinh phn
b hang nm thp hn nhiu so vi k hoach nn rt kho khn trong vic trin khai va am bao
cac muc tiu cua D an/Chng trinh a c Thu tng Chinh phu ph duyt.
Mc d ngun ti chnh cn hn hp cho phng chng BKLN song cha c phn b,
s dng t hiu qu cao nht, do s tch bit ngun ti chnh cho y t d phng v iu tr,
phn b cho y t d phng cha cn xng, ch yu cho iu tr tuyn trn, cha u tin phn
b ti chnh cho cc can thip c hiu qu (best buy).
Trong khi ngun kinh ph cho phng chng cc BKLN kh hn hp v khng p ng
nhu cu, hiu qu trong phn b v s dng kinh ph ny cng cn nhiu hn ch. Trc ht,
vic chia ct trong phn b kinh ph gia cc chng trnh theo bnh cng nh phn tch kinh
ph theo cc hot ng d phng v iu tr nh hin nay l phng thc khng ph hp v
hiu qu. Mt trong cc chin lc hng u c WHO khuyn co cc nc thnh vin l
cc hot ng phng chng 4 BKLN ang l nguyn nhn t vong hng u ti cc nc c thu
nhp thp v trung bnh bao gm tim mch, ung th, bnh h hp mn tnh v i tho ng
cn phi c phi hp v iu phi chung [229]. Cc quc gia cn xy dng mt Chng trnh
hnh ng chung cp quc gia phng chng BKLN, theo cc hot ng v ngun lc c
iu phi, lng ghp mt cch hiu qu.
V tng th, phn b kinh ph y t hin vn tp trung ch yu cho lnh vc iu tr, cc
hot ng d phng v nng cao sc khe cha c ch trng v u t ng mc. Tng kinh
ph cho hot ng d phng v nng cao sc khe ni chung ch chim 25,9% tng chi ph y t
ton x hi. Nu phn tch ring cho cc BKLN, t l ny chc cn thp hn. Mt khc, trong
kinh ph cho iu tr cng ch yu tp trung cho cc bnh vin tuyn trn. S liu KCB BHYT
cho thy, hai phn ba kinh ph t BHYT chi tr cho cc bnh vin tnh v trung ng. Tuyn y
t c s bao gm bnh vin huyn v trm y t x vi hn 80% s ngi c BHYT ang ng
k KCB ban u song ch c s dng hn 30% tng kinh ph BHYT. Cc hot ng d phng
v qun l sc khe cng ng cha c quan tm v u t tha ng. Theo khuyn co ca
WHO, mt trong cc chin lc quan trng trong phng chng BKLN l phi lng ghp vo
cc hot ng CSSKB tng cng d phng, pht hin v iu tr sm cc BKLN [125].
Vic phn b v s dng kinh ph gia cc chng trnh v gia cc hot ng trong mi
chng trnh cha mang tnh chin lc, c bit l chin lc la chn cc can thip, dch v
244

c bng chng v hiu qu chi ph. Theo WHO, vic phng chng BKLN hon ton c th thc
hin thnh cng khng ph thuc vo mc pht trin kinh t ca cc quc gia [108]. WHO
cng b danh mc 10 can thip l la chn hng u u t cho phng chng BKLN
(Bng 23). Tt c cc can thip ny u l cc can thip d phng yu t nguy c v thc hin
trn quy m dn s.
Bn cnh 10 can thip ny WHO cng a ra danh sch cc can thip c hiu qu chi
ph cao cho phng chng BKLN cho cc quc gia la chn, bao gm c gi dch v thit yu
trong CSSKB phng chng BKLN vi ngun lc hn ch [230].(Xem bng 41 bn di)
Phng thc chi tr khng khuyn khch chn on pht hin sm v iu tr BKLN
giai on u.
Cc dch v d phng v iu tr BKLN vn c chi tr ch yu theo cc phng thc
truyn thng mang tnh th ng, khng khuyn khch cc dch v y t c cht lng v ph
hp vi mc tiu kim sot BKLN nh pht hin sm v qun l BKLN ti cng ng. Cho
n nay, chi tr theo ph dch v vn l phng thc ph bin ang c p dng. Phng thc
chi tr ny hin nay ang to s khuyn khch mnh m i vi cung ng dch v iu tr, ch
yu ti cc bnh vin tuyn trn, lm gia tng s chia ct gia cc tuyn iu tr. Tt c cc
yu t ny i ngc li vi cc chin lc hiu qu phng chng BKLN, trong phi u tin
d phng, nng cao sc khe, ch trng hot ng CSSKB, tng cng chm sc lin tc v
lng ghp i vi cc BKLN mn tnh. gim gnh nng bnh tt v t vong do BKLN gy
ra, cng tc d phng cn c c bit ch trng. Hu ht nguyn nhn ca cc BKLN u
c xc nh. 80% bnh tim mch, t qu v i tho ng tp 2 v 40% bnh ung th
c th phng trnh c nu cc yu t nguy c b loi tr [231]. Trong khi chi ph iu tr cc
BKLN thng kh cao, c bit khi pht hin mun, bi vy cn thc hin cc can thip d
phng c hiu qu chi ph cao [231].
Phng thc chi tr khng khuyn khch nhn vin y t
Hin nay, mc chi cho hot ng ca cc CTMTQG cha ph hp, rt hn ch v khng
khuyn khch c nhn vin y t. C th l theo Thng t lin tch s 30/2010/TTLT-BTCBYT v hng dn chi ph cho mt s chng trnh mc tiu Quc gia, trong c quy nh
chi cho chng trnh phng chng i tho ng c nhng khon mc cha hp l nh mc
chi h tr cng tc vin lp danh sch, chn mu, gi giy mi, n c i tng khm sng
lc: 50000 ng/x, phng/ngy; mi x, phng ti a 5 ngy/t khm sng lc, chi h
tr ngi thc hin khm sng lc pht hin bnh nhn i tho ng (ngoi ch cng tc
ph hin hnh). i vi ngi lm trc tip ch c 50000 ng/ngi/ngy nhng ti a ch
c 10 ngi/t khm sng lc). Hn na, quy nh cho php chi theo di nh k bnh nhn
i tho ng l 5000 ng/bnh nhn/thng nhng li ch cho php chi 200000 ng/c s
y t/thng l hon ton khng ph hp, khng khuyn khch c hot ng theo di qun l
bnh nhn. Cc mc chi khc nh chi xt nghim pht hin i tho ng, tng hp s liu,
vit bo co kt qu khm sng lc, chi thu bn, gh, phng, bt,.. phc v cng tc khm sng
lc. Chi qun l bnh nhn: Chi h tr c s y t trc tip qun l bnh nhn lp h s u
khng ph hp vi gi c th trng v nhiu khi cc cn b phi t b tin ti ra mua xng,
xe i cng tc.
Qua kho st ti mt s a phng cho thy vic chuyn kinh ph v hot ng truyn
thng ca cc chng trnh mc tiu quc gia v y t cho Trung tm Truyn thng Gio dc
sc khe trong khi cha c cc vn bn hng dn c th v vai tr, trch nhim v c ch phi
245

hp gia cc n v chuyn mn qun l chng trnh vi Trung tm Truyn thng Gio dc
sc khe c nhng tc ng khng mong mun ti hot ng truyn thng ca chng trnh.
C ch ti chnh hin hnh v thit k h thng cung ng dch v y t cha bo v c
ngi dn trc chi ph y t thm ha do BKLN
Cc BKLN ang v s to gnh nng kinh t to ln i vi cc quc gia cng nh nh
hng tiu cc ti qu trnh pht trin kinh t x hi ton cu. Theo c tnh, cc BKLN l
nguyn nhn ca 63% s ca t vong trn ton th gii, trong s 80% thuc v cc nc c
thu nhp trung bnh v thp. Theo tnh ton ca cc nh kinh t, trong vng 20 nm ti, cc
BKLN s gy tn tht kinh t l 47 000 t USD bng 75% tng GDP ton cu nm 2010 [119].
Cc nghin cu cho thy t l mc BKLN tng ln 10% s lm gim 0,5% tc tng trng
kinh t hng nm [108]. Gnh nng chi ph iu tr cc BKLN cng l nguyn nhn khin hng
triu h gia nh trn th gii ri vo tnh trng kh khn v ti chnh v thm ch ri vo cnh
i ngho. Ti Vit Nam, mt nghin cu v gnh nng ti chnh do BKLN i vi h gia nh
cho thy nh hng r rt ca chi ph iu tr BKLN i vi tnh trng mc chi ph y t thm
ha v ngho ha do chi ph y t. T l mc chi ph thm ha h gia nh c t nht 1 ngi
mc BKLN l 14,6% cao hn so vi h gia nh khng c ngi mc BKLN (4,2%). Tng
t, t l b ngho ha do chi ph y t h gia nh c t nht 1 ngi mc BKLN l 7,6% cao
hn so vi h gia nh khng c ngi mc BKLN (2,3%). Xc sut mc chi ph y t thm ha
v ngho ha do chi ph y t h gia nh c t nht 1 ngi mc BKLN cao hn so vi h gia
nh khng c ngi mc BKLN l 3,2 ln v 2,3 ln [232]. Nguyn nhn ca thc trng ny
c th k n mt s yu t nh sau:
Chi ph iu tr BKLN thng cao, c bit c th k n l thuc iu tr ung th, can
thip tim mch (Bng 38).
Cc BKLN thng l bnh mn tnh, thi gian iu tr ko di.
Chi ph gin tip ln: Do nng lc iu tr cc BKLN tuyn huyn, x hn ch nn ngi
bnh phi n cc bnh vin tuyn trn, n n chi ph i li, n cng nh chi ph y
t cao hn nhiu ln so vi iu tr ti tuyn di.
Vic pht hin sm cc BKLN cha t c kt qu mong i, do t l bnh nhn
pht hin bnh giai on mun khin chi ph iu tr cng ln v hiu qu hn ch.
Bng 38: Chi ph iu tr ung th v thc hin can thip tim mch ti Vit Nam
TT
Can thip/thuc
Chi ph/nm
Thuc chng thi ghp
31374000
1 ln t stent
60000000
Thuc iu tr ung th: Herceptin
503546000
Thuc iu tr ung th: Nevaxar
1416000960
Thuc iu tr ung th phi Erlotinib
480000000
Thuc iu tr ung th phi Gefitinib
432000000
Thuc iu tr ung th t bo Sorafenib
1416000000
246
Chi ph/t iu tr
TT
Can thip/thuc
Chi ph/nm
Chi ph/t iu tr
Thuc iu tr ung th i trc trng di cn v

ung th t bo vy vng u c Cetuximad
600000000
Thuc iu tr ung th d dy, v
800000000
3.3. Cc vn u tin
Phn tch thc trng ti chnh cho phng chng BKLN trn y thy ni ln mt s vn
u tin cn gii quyt h thng ti chnh y t p ng mt cch ph hp vi cc mc tiu
phng chng BKLN:
Phng chng BKLN cha c xc nh u tin tha ng trong phn b kinh ph, nht
l kinh ph cho kim sot cc yu t nguy c, sng lc chn on sm. Ngun ti chnh
khng p ng yu cu: t l mc BKLN tng cao so vi kh nng p ng ca h
thng y t v c nhn lc, c s vt cht v ngun ti chnh ng ph.
Cha c c ch ti chnh bn vng cho chm sc ngi bnh mc BKLN (cha t chc
chng BHYT ngi cao tui, cho ngi mc bnh mn tnh). Cha to ngun ti chnh
cho nng cao sc khe t thu thuc l, thu ru bia.
Vic phn b ngun ti chnh cha ph hp thc hin hiu qu cc mc tiu phng
chng BKLN (chia ct theo cc d n, tch ri gia d phng v iu tr, tp trung cho
dch v bnh vin). Cha c mt k hoch chin lc quc gia phng chng BKLN km
theo mt chin lc ti chnh ph hp.
Hiu qu s dng ngun ti chnh cho phng chng BKLN hn ch: cha c chin lc
la chn cc can thip c tnh hiu qu chi ph tt, cha xy dng c gi dch v thit
yu i vi BKLN.
Phng thc chi tr cha ph hp, da trn chi tr theo ph dch v: khuyn khch dch
v bnh vin, khng khuyn khch CSSKB, d phng v nng cao sc khe cng ng.
Din bao ph BHYT mi t 68,5% dn s, trong khi ngn sch t BHYT hn hp, phm
vi chi tr b gii hn. BHT khng chi tr mt s dch v phng chng BKLN - cha c
hng dn thanh ton BHYT cho sng lc mt s bnh theo Lut BHYT, khng thanh
ton chi ph t vn, chi ph iu tr t t, chi ph ca mt s phng php iu tr trong
lnh vc tm thn. Vng mc trong thanh ton BHYT i vi cc chi ph thuc khi
ngun t NSNN b ct gim.
3.4. Khuyn ngh
B Y t lm u mi xy dng k hoch hnh ng cp quc gia phng chng BKLN
bao gm k hoch v ti chnh thc hin K hoch ny.
Cn tng kinh ph cho hot ng phng chng BKLN: t NSNN, BHYT v Qu phng
chng tc hi ca thuc l
Cn sa i Lut BHYT v cc vn bn hng dn tng mc bao ph BHYT i
vi cc dch v p ng nhu cu phng chng KLN da trn cch tip cn da vo bng
chng.
247

Cn tng cng u tin trong phn b kinh ph cho lnh vc d phng, nng cao sc
khe, CSSKB, gim st BKLN.
Cn xc nh gi dch v c bn phng chng BKLN da trn bng chng v hiu qu
chi ph.
Tng cng u t cho nghin cu cung cp bng chng v hiu qu chi ph i vi cc
can thip lin quan n BKLN.
4. Dc v trang thit b y t
Tip cn c thuc thit yu v cng ngh y t c cht lng vi gi hp l l mt trong
nhng yu cu c bn trong d phng v kim sot BKLN. Cc chnh sch c hiu qu tip
cn thuc thit yu bao gm la chn thuc quc gia, hng dn iu tr chun da trn bng
chng v chnh sch khuyn khch s dng thuc thit yu [233].
Mt s la chn chnh sch lin quan ti dc v trang thit b y t trong phng chng
BKLN c WHO khuyn ngh nh sau:
Tng cng kh nng tip cn vi thuc, k thut chn on v cc cng ngh y t c
cht lng, an ton, hiu qu mc gi chp nhn c.
p dng chin lc quc gia da trn bng chng ci thin tip cn ca bnh nhn
vi cc thuc c gi c phi chng (bng cch chn cc loi thuc ph hp vo danh sch
thuc thit yu, tch bit k n v bn thuc, qun l gi thuc).
Thc y mua sm v s dng thuc (phng chng BKLN) an ton, cht lng, hiu
qu vi mc gi hp l, bao gm thuc generic, vc xin phng mt s loi ung th lin
quan n bnh ly nhim bng cc bin php qun l cht lng thuc, u tin trong
th tc ng k thuc, thay th thuc bng thuc generic, bt buc s dng tn INN
(international non-proprietary names) trong mua sm, c ch khuyn khch ti chnh,
gio dc ngi k n cng nh ngi bnh.
Tng tnh sn c ca cc trang b cp cu v thuc thit yu trong iu tr s cu, cp
cu BKLN.
bo m ngi dn c th tip cn thuc v trang thit b phng chng BKLN, WHO
khuyn co danh mc ti thiu cc thuc thit yu v trang thit b cho tuyn CSSKB ti cc
nc c thu nhp thp, bao gm 34 loi thuc v 21 thit b y t, trong c 11 thit b ti thiu
v 10 thit b b sung (Bng 39).
Di y s phn tch v p ng ca h thng y t Vit Nam i vi vic bo m tip
cn thuc thit yu v cng ngh y t trong phng chng BKLN, bao gm cc ni dung la
chn thuc thit yu, bo m s sn c ca thuc thit yu, hng dn iu tr chun, khuyn
khch s dng thuc thit yu, qun l gi thuc thit yu v cng ngh y t v xc nh cc vn
u u tin v khuyn ngh gii php khc phc.
4.1. Kt qu, tin b
4.1.1. V la chn thuc
248

Danh mc thuc thit yu v danh mc thuc c BHYT chi tr bao ph hu ht
cc thuc iu tr BKLN. Trong nhiu nm qua, B Y t xy dng v ban hnh Danh mc
Thuc thit yu, c tham kho Danh mc Thuc thit yu ca WHO. Nm 2013, B Y t
ban hnh Danh mc Thuc thit yu ln th VI, k tha Danh mc Thuc thit yu Vit Nam
ln th V, ng thi tham kho Danh mc Thuc thit yu hin hnh ca WHO, cc hng dn
iu tr ca B Y t Vit Nam. Cc tiu ch la chn thuc bao gm: (i) Bo m hiu qu, an
ton cho ngi s dng; (ii) Sn c vi s lng y , c dng bo ch ph hp vi iu kin
bo qun, cung ng v s dng; (iii) Ph hp vi m hnh bnh tt, phng tin k thut, trnh
ca thy thuc v nhn vin y t trong c s khm bnh, cha bnh; v (iv) Gi c hp l.
Danh mc Thuc thit yu ln th VI ca Vit Nam bao gm 466 thuc tn dc68, chia thnh
29 nhm thuc theo tc dng dc l.
Song song vi Danh mc thuc thit yu, B Y t ban hnh Danh mc thuc s dng ti
cc c s khm bnh, cha bnh c qu BHYT thanh ton. Phn ln thuc cn thit iu
tr BKLN hin c trong danh mc thuc ch yu, c BHYT chi tr69. Tt c 34 thuc trong
danh mc thuc ti thiu phng chng cc BKLN ti tuyn y t CSSKB theo khuyn co
ca WHO c trong danh mc thuc ch yu ni trn.
4.1.2. V chnh sch khuyn khch s dng thuc thit yu v hng dn iu tr chun
trong iu tr BKLN
B Y t ban hnh cc hng dn chn on v iu tr mt s BKLN, bao gm (i)

Hng dn chn on v iu tr tng huyt p (Quyt nh s 3192/Q-BYT ngy 31/8/2010);
(ii) Hng dn chn on v iu tr i tho ng tp 2 (Quyt nh s 3280/Q-BYT ngy
9/9/2011); 3) Hng dn chn on, iu tr hen ph qun c B Y t ban hnh t nm
2009 (Quyt nh s 4776/Q-BYT ngy 04/12/2009). Cc ti liu trn hng dn s dng
thuc generic trong iu tr BKLN, l ti liu o to nhn vin y t v c s dng rng ri
trn ton quc.
4.1.3. V qun l gi thuc
Kim sot gi thuc l mt trong nhng nhim v trng tm ca B Y t; mt s gii

php mi qun l chng tng gi thuc (trong c quy nh u thu thuc mi) c thc
hin, t c kt qu tt trong nm qua (xem chi tit ti chng II ca bo co ny). Nghin
cu gi thuc generic v bit dc theo phng php ca WHO cho thy gi trng thu Vit
Nam mc thp hn hoc trung bnh so vi s liu quc t [66]. Ti nhiu a phng, gi tr
thuc trng thu gim c 20-30% so vi gi k hoch ca cc gi thu[49].
4.1.4. V trang thit b y t thit yu phng chng BKLN
B Y t quy nh v danh mc trang thit b cho tng tuyn CSSK; hu ht cc trang

thit b y t cn thit cho chn on v iu tr BKLN c B Y t quy nh trong danh mc
trang thit b y t ca cc c s y t cng. Trm y t x c bc s c trang b my o huyt p,
my xt nghim sinh ha n gin, my xt nghim nc tiu n gin70, tuy nhin, nhiu thit
b cn thit cho qun l BKLN cha c trong danh mc (chi tit xem mc tip theo).
Thng t 45/2013/TT-BYT.
Thng t s 01/TTHN/BYT
70
Quyt nh s 1020/Q-BYT ngy 22/3/2004 ca B trng B Y t ban hnh Danh mc sa i trang thit b
y t trm y t x c bc s vo Danh mc trang thit b y t bnh vin a khoa tuyn tnh, huyn, phng khm a
khoa khu vc, trm y t x v ti y t thn bn ban hnh km theo Quyt nh s 437/Q-BYT ngy 20/2/2002 ca
B trng B Y t.
68
69
249

4.2. Kh khn, hn ch
4.2.1. Hn ch tip cn thuc thit yu iu tr BKLN ti tuyn y t c s
Mt s thuc iu tr BKLN khng sn c ti cc c s y t cng, c bit ti cc trm

y t x, phng. Tt c 34 thuc thit yu ti thiu phng chng BKLN theo khuyn co ca
WHO c trong danh mc thuc ch yu c qu BHYT thanh ton, tuy nhin, trong s 34
thuc ti thiu th c 11 loi thuc khng c trong danh mc thuc c s dng ti y t x,
phng (Bng 39). Ngoi ra, mt s thuc tuy c trong danh mc thuc thit yu s dng ti
TYT x, phng c qu BHYT thanh ton nhng khng sn c, do cp thuc chm, thiu,
khng p ng nhu cu iu tr [69].
Bng 39: So snh danh mc thuc ti thiu phng chng BKLN trong CSSKB ca
WHO v Danh mc thuc thit yu theo thng t s 31/2011/TT-BYT71
Danh mc thuc ti thiu phng
chng BKLN trong CSSKB
Danh mc thuc thit yu

(Thng t s 31/2011/TT-BYT)
Tuyn huyn
Tuyn x, phng
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
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+
+
Khng c
Khng c
+
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Khng c
+
Khng c
Khng c
Khng c
+
+
Khng c
+
Khng c (tr CC)
+
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+
Khng c
Thiazid
Amlodipin
Atenolol
Enalapril
Simvastatin (-)
Insulin (-)
Metformin
Glibenclamid
Isosorbide dinitrat
Glyceryl trinitrat
Furosemid (-)
Spironolacton
Salbutamol (-)
Prednisolon (-)
Beclometason (-)
Aspirin
Paracetamol
Ibuprofen (-)
Codein
Morphine (+/-)
Penicillin
Erythromycin
Amoxicillin
Hydrocortison
Epinephrin
Heparin (-)
Thng t s 31/2011/TT-BYT ngy 11/7/2011 ca B Y t ban hnh v hng dn thc hin danh mc thuc ch
yu s dng ti cc c s khm, cha bnh c qu BHYT thanh ton.
71
250
Danh mc thuc ti thiu phng

chng BKLN trong CSSKB
Danh mc thuc thit yu

(Thng t s 31/2011/TT-BYT)
Tuyn huyn
Tuyn x, phng
+
+
+
+
+
+
+
+
+
Khng c
Khng c
+
+
+
+
+
Diazepam
Magnesium sulphat (-)
Promethazin (-)
Senna
Dextrose
Glucose tim truyn
NaCl 0,9%
Oxy
Mt nghin cu v s dng thuc ti trm y t x ti 176 x thuc 48 huyn cho thy t

l thuc thit yu theo danh mc qui nh ca B Y t cho x c bc s ch t 12,5-20%[234].
Mt nghin cu khc cho thy ch c 57% cc nh thuc cc tnh pha nam c thuc chng
ng kinh [235]. Mt s thuc chng lon thn, thuc chng ng kinh c a vo k
hoch u thu (tnh Lai Chu) nhng do c gi thp nn khng c n v tham gia u thu,
dn ti tnh trng thiu thuc.
Mt s thuc cn thit cho iu tr BKLN cha c chi tr t qu BHYT. Mt s thuc
iu tr bnh phi tc nghn mn tnh v hen ph qun theo khuyn co ca Chng trnh Khi
ng ton cu v bnh phi tc nghn mn tnh (GOLD) cha c trong danh mc thuc c
BHYT chi tr tuyn x.
Qu BHYT cha p ng c nhu cu KCB cho ngi bnh mc cc BKLN tuyn
x, phng. Phn b qu BHYT hin hnh cho trm y t x theo quy nh hin hnh72 l khng
thp hn 10% qu KCB BHYT, nhng trn thc t cc trm y t x, phng thng ch c
giao 10%. Mc phn b ny khng p ng c yu cu chi ph trong trng hp cc trm y
t x c nhiu bnh nhn mc BKLN, cn s dng mt s thuc iu tr BKLN c gi cao, nh
mt s thuc iu tr iu tr bnh phi tc nghn mn tnh, hen ph qun.
Thiu thuc iu tr do thiu s phi hp kp thi gia cc d n phng chng BKLN
v BHXH. Thuc iu tr bnh tm thn phn lit, ng kinh c cp min ph bng ngun
ngn sch ca cc d n phng, chng BKLN v ngun vn i ng ca a phng, nhng
t nm 2014, ngun ngn sch cp cho D n bo v sc khe tm thn b ct gim ch cn
khong 35% so vi nm 2013. Nhiu a phng cha kp iu chnh ni dung thanh ton vi
qu BHYT, dn ti tnh trng gin on trong cp thuc iu tr.
S phn mnh, khng thng nht trong ch nh s dng thuc gia cc tuyn iu tr
to ra tnh trng thiu thuc gi to. Ti trm y t x, phng, trong iu tr ng kinh hoc
lon thn, ngi bnh c cp thuc min ph trong t CTMTQG, thng l phenobarbital
100mg (cha ng kinh), hoc clopromazin 100g; haloperidol 2mg (thuc chng lon thn).
Tuy nhin sau khi n khm, cha bnh ti c s chuyn khoa tm thn, c ch nh dng cc
thuc th h mi, ngi bnh thng t mua thuc theo ch nh ca bc s chuyn khoa tuyn
trn m khng dng cc loi thuc th h c do CTMTQG cp ti tuyn x.
Thng t lin tch 09/2009/TTLT-BYT-BTC ngy 14/8/2009 ca B Y t v B Ti chnh hng dn thc hin
BHYT.
72
251

Danh mc bnh mn tnh cha cp nht, khng c bnh tng huyt p v bnh phi tc
nghn mn tnh, gy kh khn trong tip cn thuc. C s y t tuyn tnh/thnh ph ch c
khm v cp thuc trong vng 15 ngy, tuyn qun/huyn l 7-10 ngy v tuyn x/phng ch
c 5 - 7 ngy cho ngi bnh tng huyt p. Vic cp thuc cho bnh mn tnh trong thi gian
ngn gy tn km cho ngi bnh, gim s tun th iu tr v gim hiu qu iu tr.
Chnh sch u tin s dng thuc generic cha hon thin. Lut Dc cha c cc quy
nh c th u tin s dng thuc generic, thuc thit yu v bo m s sn c thuc thit
yu. Thuc thit yu chim t trng thp trong danh mc thuc c BHYT thanh ton: ch
c 316 trong tng s 1143 thuc trong Danh mc thuc c BHYT thanh ton l thuc thuc
Danh mc thuc thit yu [68].
Gi thuc ngoi h thng y t cng vn cha c qun l tt. Lng thuc tiu th trn
th trng do h thng nh thuc t nhn phn phi chim 65-70% tng lng thuc s dng,
nhng cha c gii php qun l gi thuc c hiu qu khu vc ny; vic th im qun l gi
thuc bng thng s bn bun ton chng mi ch thc hin khu vc nh thuc bnh vin v
cha c nh gi.
4.2.2. Danh mc trang thit b y t ti y t x, phng cha p ng mc tiu phng
chng BKLN
Danh mc trang thit b y t ti TYT x, phng cha c cp nht p ng yu

cu phng chng BKLN. B Y t ban hnh danh mc tiu chun trang thit b ti trm y t
x, phng c bc s73 theo quyt nh s 1020/Q-BYT nm 2004, vi cc trang thit b tiu
chun ph hp vi cc mc tiu phng chng bnh dch, chm sc sc kho b m va tr em.
Tuy nhin, cc trang thit b theo danh mc trn cha p ng c yu cu thc hin cc
can thip thit yu phng, chng BKLN tuyn x. Danh mc ch c 5/11 thit b ti thiu, khi
i chiu vi danh mc thit b y t ti thiu phng chng BKLN trong CSSKB ca WHO
(Bng 40). Su thit b thiu l nhng thit b khng t tin, cn thit cho vic thc hin cc
can thip ti thiu phng chng bnh i tho ng v bnh phi tc nghn mn tnh.
Ngoi ra, c nhng trang thit b tuy c trong danh mc tiu chun (my xt nghim
sinh ho n gin) nhng cha th trang b c ti a s cc TYT x, do thiu ngun ti chnh,
thiu nhn lc c o to s dng thit b v do chi ph c hi ln (s lng xt nghim
qu t).
Bng 40: So snh danh mc thit b y t ti thiu phng chng BKLN trong CSSKB
theo khuyn co ca WHO [236].
Danh mc trang b ti thiu phng chng BKLN trong
CSSKB theo khuyn co ca WHO
Danh mc trang thit b trm y

t x - phng c bc s
Danh mc ti thiu
+
+
+
+
+
Nhit k
ng nghe
My o huyt p
Thc o
Cn
73
252
Thit b o tc th ra ti a (Peak ow meter)

Bnh m, bnh iu ho ca ng ht (spacers for inhalers)
My o ng huyt
Giy o ng huyt (Blood glucose test strips)
Giy o protein niu (Urine protein test strips)
Giy o x ton niu (Urine ketones test strips)
Khng c
Khng c
Khng c
Khng c
Khng c
Khng c
Danh mc b sung
My kh dung
Thit b o bo ho oxy trong mu (Pulse oximeter)
Thit b xc nh cholesterol mu (Blood cholesterol assay)
My o lipid mu
My o creatinin huyt thanh
Giy test Troponin
Giy test albumin niu
m thoa (Tuning folk)
My in tim
My kh rung tim
+
Khng c
+
+
+
Khng c
Khng c
Khng c
+
Khng c
Ngun: World Health Organization. Package of essential noncommunicable (PEN) disease interventions for
primary health care in low-resource settings. Geneva: WHO; 2010 [236].
Hnh 54: Thit b n gin o dung tch th ra ti a (Peak flow meter)
4.3. Cc vn u tin
Cha c chnh sch u tin s dng v bo m s sn c ca thuc gc, thuc thit yu.
Danh mc thuc thit yu cho BKLN ti y t x, phng cha y , c bit l thuc
iu tr i tho ng, bnh phi tc nghn mn tnh, iu tr gim nh cho ngi bnh
ung th;
Tip cn thuc iu tr BKLN cn c kh khn do thuc cha sn c trong mng li
cung ng dch v y t, c bit y t x phng, do chnh sch chi tr t qu BHYT cho
mt s thuc trc y c thanh ton t ngun NSNN, do bnh i tho ng, tng
huyt p cha c trong danh mc bnh mn tnh ca B Y t, do nh thu khng tham
gia u thu thuc thit yu c gi thp v do s phi hp iu tr gia cc tuyn iu tr;
Danh mc trang thit b tiu chun ca TYT x, phng c bc s thiu mt s thit b
n gin, cn thit cho vic thc hin cc can thip thit yu phng chng BKLN.
253

4.4. Khuyn ngh
Ngn hn
B sung chnh sch v vic tip cn, u tin s dng thuc gc, thuc thit yu trong
Lut Dc.
Di hn
Xy dng, chun ha danh mc thuc iu tr BKLN; Sa i danh mc thuc c qu

BHYT chi tr, b sung cc thuc iu tr BKLN vo danh mc thc hin c cc can
thip thit yu phng, chng BKLN y t c s c tham kho khuyn co ca WHO.
R sot li quy nh u thu thuc, c c ch u tin i vi thuc c th, gi thnh
thp to thun cho u thu hoc ch nh thu.
Cp nht danh mc bnh mn tnh, b sung mt s BKLN vo danh mc bnh mn tnh
thun li cho vic k n cp thuc cho ngi bnh THA, T v bnh phi tc
nghn mn tnh.
Sa i Thng t lin tch 09/2009/TTLT-BYT-BTC ngy 14/8/2009 hng dn thc
hin BHYT iu chnh mc phn b qu KCB BHYT ph hp vi nhu cu chm sc
iu tr cc BKLN ti y t x, phng.
Sa i, b sung danh mc trang thit b tiu chun ti trm y t x phng c bc s
p ng vic thc hin cc can thip thit yu phng chng BKLN y t c s c tham
kho khuyn co ca WHO.
5. H thng thng tin y t v gim st BKLN

Trong phng chng BKLN, theo khuyn co ca WHO i vi giai on 2008-2013, h
thng thng tin y t cc quc gia cn c tng cng thc hin nhng nhim v sau:
Theo di BKLN v cc yu t nguy c cung cp thng tin c bn cho qu trnh thuyt
phc, xy dng chnh sch phng chng BKLN; khng ch gii hn trong vic r sot
ghi nhn mc v xu hng ca bnh, m cn bao gm vic nh gi hiu qu, tc
ng ca cc can thip v tin thc hin cc d n.
Tng cng h thng gim st, thu thp s liu chun v cc yu t nguy c, tnh hnh
mc bnh, nguyn nhn t vong.
nh k v thng quy cung cp cc s liu v thng tin v xu hng BKLN v cc yu
t nguy c theo tui, gii, nhm dn c v tin thc hin k hoch quc gia.
Trong giai on 2013-2020, WHO xc nh chi tit hn cc nhim v theo di, ghi nhn
v gim st ca h thng thng tin y t trong phng chng BKLN nh sau:
Nhim v theo di: Cp nht cc vn bn quy phm php lut lin quan ti thu nhp s
liu thng k y t, tng cng h thng ng k h tch v nguyn nhn t vong, xc nh
mc tiu v b ch s nh gi. Lng ghp h thng theo di d phng kim sot BKLN
vo h thng thng k y t quc gia, bao gm mt s ch s v can thip nhm nh gi
mt cch c h thng xu hng thc hin c can thip v tc ng ca cc can thip.
254

Ghi nhn bnh (ung th): xy dng, duy tr v tng cng h thng ghi nhn bnh
ung th.
Gim st: xc nh b s liu, ngun s liu v lng ghp cc s liu vo h thng thng
tin y t quc gia. Thc hin nh k thu thp s liu v cc yu t nguy c v chuyn ha,
li sng (s dng ru bia, thiu vn ng, ht thuc l, dinh dng khng lnh mnh,
qu cn, bo ph, tng ng huyt v tng m mu), theo cc nhm tui, gii, hon
cnh kinh t x hi theo di xu hng v khc phc s bt bnh ng.
Ngoi ra, WHO cng khuyn co cn tng cng u tin phn b ngun ti chnh cho
h thng theo di, gim st BKLN.
Di y l nh gi v cng tc theo di, ghi nhn ung th v gim st phng chng
BKLN, c tham kho cc khuyn co ca WHO nu trn, xc nh cc vn u tin v khuyn
ngh.
5.1. Kt qu, tin b
5.1.1. V theo di bnh khng ly nhim
H thng thng tin thng k y t ca Vit Nam, bao gm cc tiu h thng thng tin y t
t cc bnh vin bt u thu thp d liu v BKLN t bnh vin. H thng thng tin thng
k y t do Cc Qun l KCB qun l, c cc tiu h thng thng tin y t ca cc bnh vin, thu
thp d liu v thng tin t cc bnh vin trn ton quc. Tiu h thng thng tin y t ca cc
bnh vin bt u vic thu thp v gim st d liu v cc BKLN v d liu v thng tch.
Phn mm chnh c p dng trong cc bnh vin l mt phin bn ca Medisoft. Cc gi
phn mm khc cho tng lnh vc c th nh khm cha bnh, iu tr v cc dch v ph tr
cng ang c s dng ti cc bnh vin tuyn tnh v trung ng, song kh nng tng thch
gia cc phn mm l rt hn ch hoc hu nh khng c.
Cc chng trnh mc tiu quc gia y t cng c cc tiu h thng, thu thp d liu
c lp: nh Chng trnh tng huyt p, i tho ng, bo v sc khe tm thn cng
ng... Cc thng tin y t ca cc D n ny do Trng ban qun l D n CTMTQG trin
khai thc hin.
5.1.2. V ghi nhn ung th
M hnh ghi nhn ung th cng da trn s liu bo co t bnh vin. S liu v tnh
hnh ung th c ghi nhn H Ni (1988-1990) v thnh ph H Ch Minh (1994) a ra
nhng con s v t l mc ung th v ln u tin tnh hnh mc ung th Vit Nam c cng
b. n nay, Vit Nam trin khai 9 trung tm ghi nhn ung th ti H Ni, thnh ph H Ch
Minh, Thi Nguyn, Hi Phng, Hu, Nng, thnh ph H Ch Minh, Cn Th, Kin Giang.
Vic ghi nhn c thc hin theo phng php ch ng (nhn vin ghi nhn ch ng ti cc
bnh vin tm kim ca ung th).
5.1.3. V gim st BKLN
Vit Nam thc hin c mt iu tra quc gia theo phng php STEPwise, tuy
nhin, do l do v ngun ti chnh, iu tra STEPwise ny cha thc hin nhc li theo nh k.
S liu v tnh hnh cc BKLN, nguyn nhn t vong, gnh nng bnh tt v cc yu t nguy
255

c c khai thc t cc nghin cu thuc D n VINE, do Vin Chin lc Chnh sch Y t,
Trng i hc Y H Ni v i hc Y t Cng cng thc hin.
5.2. Kh khn, hn ch
5.2.1. Theo di, gim st BKLN
Cc s liu v BKLN v cc yu t nguy c cha y , cha c tnh h thng. H thng

gim st BKLN c thit lp t nm 2009, thc hin c mt iu tra quc gia v yu t
nguy c ca BKLN, nhng khng duy tr hot ng sau khi kt thc d n v cha cung cp
c s liu thng k c bn v BKLN. Nm 2011, B Y t xy dng v ban hnh B ch
s theo di, nh gi hot ng phng chng BKLN74 nhng cha c s liu no c bo co
chnh thc theo b ch s, do phn ln cc ch s s c xc nh da trn kt qu iu tra quc
gia 5 nm mt ln. B ch s ny cha c lng ghp vo h thng thng k y t v cha c
cp nht, iu chnh c s thng nht vi B ch s gim st ton cu v BKLN ca WHO.
Cc d n phng chng BKLN thiu s lng ghp trong hot ng theo di, gim st.
Mi d n c cc biu mu bo co thng k ring v tnh hnh thc hin D n, bao gm cc
ch s v hot ng sng lc, ch s v tnh hnh qun l, iu tr bnh tuy nhin cha c hot
ng kim tra, gim st cht lng ca cc s liu thu thp. Mi d n thc hin mt biu mu
bo co ring, gy kh khn, to gnh nng cng vic cho cn b tuyn di. Mt s iu tra,
nghin cu c cc n v khc nhau thc hin, c s chng cho, thiu chun ha, gy kh
khn cho vic bo co s liu v cc ch s c bn.
H thng ng k h tch cha thng k v cha cung cp c d liu tin cy, y
v nguyn nhn t vong. Gim st v t vong, v t qu cng ch trin khai trong phm vi nh
ti H Ni v thnh ph H Ch Minh, cha kt ni c cc s liu ca cc lnh vc ni tit,
ung th, tim mch, bnh phi tc nghn mn tnh,... vo trong h thng.
5.2.2. Ghi nhn ung th
Gim st ung th: trong 9 trung tm ghi nhn ung th, mi ch c 2 trung tm (H Ni v
thnh ph H Ch Minh) c IARC (International Agency for Research on Cancer) cng nhn
cht lng. Nhn lc lm vic ti nhiu trung tm ghi nhn ung th khng n nh, ch ghi nhn
tnh hnh mi mc, cha ghi nhn t vong do ung th. Phn mm ghi nhn hin ang s dng
l phn mm CANREG 4, trong khi , cc nc trin khai phn mm mi CANREG 5.
Cha t chc c hot ng gim st cht lng ghi nhn ti cc trung tm ghi nhn ung th.
5.3. Cc vn u tin
Thiu thng tin cp nht, c h thng, da trn cng ng (population-based) v xu
hng din bin cc yu t nguy c (bao gm nhm nguy c t hnh vi, li sng v nguy
c trung gian), v tnh hnh mc bnh, t vong.
B ch s gim st nh gi hot ng phng chng BKLN cha c cp nht thng
nht vi khung theo di ton cu ca WHO (global monitoring framework); cc d liu,
ch s v BKLN c thng k nhiu ngun khc nhau, khng y . S liu thng
k v cc yu t nguy c cha c lng ghp vo h thng thng k y t.
74
256

H thng ng k h tch cha ghi nhn tt nguyn nhn t vong cng ng;
Thiu mng li thng tin v CSSK (HNIS) h tr chia s thng tin ca ngi BKLN
gia cc c s KCB.
5.4. Gii php
Ngn hn
Trin khai iu tra cc yu t nguy c ca BKLN theo phng php STEPwise vo nm 2015.
Di hn
Cng c hon thin h thng theo di, gim st phng chng BKLN v cc yu t nguy
c: (i) cp nht b ch s theo di, gim st phng chng BKLN v cc yu t nguy c
cho ph hp, trn c s khung theo di ton cu ca WHO, (ii) Cng c h thng bo co
thng k bnh vin, c bit v tnh hnh mc BKLN, phn theo tui, gii v (iii) o
to cn b v c chnh sch i ng thch hp nng cao cht lng ghi nhn ung th.
Nghin cu trin khai gim st t vong ti cng ng da trn thng k t vong ti trm
y t x (cng c li s A6/YTCS, biu mu, hng dn v quy trnh bo co t vong,
tng cng nng lc cn b thng k v cht lng ghi chp ti TYT x) trong khi cha
hon thin c h thng ghi nhn nguyn nhn t vong ti cng ng.
6. Cung ng dch v y t
BKLN l cc bnh mn tnh, i hi cc dch v khc bit v cch tip cn cung ng dch
v khc bit so vi cc bnh cp tnh. Dch v trong phng chng BKLN bao gm cc dch v
sng lc c hi (opportunistic case screening) hoc sng lc theo qun th (population-based)
xc nh yu t nguy c, pht hin sm bnh, xc nh mc nguy c, phi hp can thip
iu tr bng thuc v can thip thay i hnh vi li sng, k hoch chm sc di hn, thc hin
theo di v c v ngi bnh khng b chng trnh iu tr[237]. WHO khuyn co cung cp
cho ngi dn gi dch v thit yu phng chng BKLN, bao gm cc dch v v nng cao sc
kho, d phng, iu tr, phc hi chc nng v chm sc gim nh, bao gm 9 thnh phn c
th [125] (xem chi tit ti chng III, mc 1.6.4 bo co ny).
i vi cc nc ang pht trin, WHO khuyn co xy dng Gi can thip thit yu
phng chng BKLN (PEN - Package of Essential NCD interventions for PHC in low-resource
settings), bao gm cc can thip pht hin sm, d phng, iu tr, chm sc bnh tim mch
v cc yu t nguy c, i tho ng, bnh phi mn tnh v ung th[236].
i vi sc kho tm thn, cung cp dch v sc kho tm thn ton din, lng ghp,
c tnh p ng v dch v chm sc x hi ti cc c s y t da vo cng ng (to provide
comprehensive, integrated and responsive mental health and social care services in communitybased settings) c xc nh l mt trong cc mc tiu trong K hoch hnh ng ton cu v
sc khe tm thn 2013-2020 ca WHO.
Nh vy, m hnh cung ng dch v phng chng BKLN theo khuyn co ca WHO l
m hnh chm sc sc kho lng ghp, da trn mng li CSSK ban u c lin kt, lng ghp
gia cc c s y t cc tuyn.
257

Di y s phn tch nh gi thc trng cung ng dch v phng chng BKLN, i
chiu vi cc khuyn co ca WHO, t xc nh cc vn u tin v khuyn ngh gii php.
6.1. Kt qu, tin b
6.1.1. V h thng cung ng dch v
Mng li cc c s chn on v iu tr ung th, tim mch, ni tit, lao v bnh phi,
bo v sc kho tm thn tip tc pht trin, thc hin cc gii php nng cao nng lc cho y
t c s.
n 930 u t xy dng bnh vin a khoa tnh, bnh vin chuyn khoa ung bu,
nhi/sn nhi, tm thn v lao theo Ngh quyt s 18 ca Quc hi vi tng mc hn 45000 t
ng t ngun tri phiu Chnh ph, ngn sch a phng v vn ODA c ph duyt v
trin khai t nm 2009-2013.
i vi chuyn khoa ung th, mng li bnh vin v khoa ung bu c hnh
thnh cc vng, min. Cho ti nay, c ti 40/63 tnh thnh c bnh vin/trung tm/khoa/
n v ung bu, trong 2/3 s c s ang c hon thin. Mt s bnh vin, trung tm ung
bu c m rng nh Khoa Ung bu, Bnh vin Trung ng Hu, Bnh vin Ch Ry,
Bnh vin a khoa Ph Th, Bc Ninh, Bnh vin Nng pht trin thnh cc trung
tm, bnh vin ln vi cng sut ging bnh tng gp 2-5 ln. c bit l Bnh vin K t 1 c
s ti ph Qun S, vi cng sut 700 ging vo nm 2000, sau khi khnh thnh c s 3 ti
Tn Triu (8/2012) c 1560 ging.
Cc chuyn khoa khc: qua ngun vn tri phiu Chnh ph, hin c hn 50 tnh c
bnh vin lao v bnh phi v bnh vin tm thn, l iu kin thun li qun l iu tr bnh
phi tc nghn mn tnh v bnh l tm thn cn iu tr ni tr. n gim qu ti bnh vin
(Quyt nh s 92/Q-TTg) tp trung u t gim qu ti cho 5 chuyn khoa, bao gm ung
bu, nhi, sn, tim mch, chn thng.
Vin Tim mch c nng cp, mt s trung tm tim mch c thnh lp, xy mi
hoc ci to nhm ci thin nng lc can thip tim mch. Bnh vin Ni tit Trung ng c
xy mi vi 500 ging bnh i vo hot ng.
Song song vi vic u t xy dng cc bnh vin a khoa v chuyn khoa tuyn trn,
cc hot ng nng cao nng lc cung ng dch v phng chng BKLN ti y t c s c trin
khai qua cc chng trnh dc phng chng BKLN (xem chi tit ti chng V).
6.1.2. V truyn thng, gio dc sc kho
Cc hot ng t vn, truyn thng gio dc sc kho phng chng BKLN c trin
khai vi cc hnh thc phong ph. Sau khi Ngh nh s 77/2013/N-CP v cai nghin thuc
l c ban hnh, Cm nang hng dn cai nghin thuc l c bin son, mt s phng t
vn cai nghin thuc l c th im mt vi bnh vin ln nh Bnh vin Bch Mai, Bnh
vin K, Bnh vin Phi Trung ng, Bnh vin 74, Bnh vin i hc Y Dc thnh ph H
Ch Minh...
Hot ng t vn v dinh dng, ch n, ch luyn tp, phc hi chc nng
c trin khai ti mt s c s y t d phng. Cc hot ng truyn thng GDSK thng qua
258

truyn hnh, bo ch, dch v t vn trc tuyn trn mt s trang tin in t, dch v t vn cai
nghin thuc l qua in thoi75 c t chc thc hin.
Cc cu lc b hen ph qun76, cu lc b/hi bnh nhn i tho ng c hnh thnh
thng qua sng kin ca cc c s y t v ngi bnh ng gp mt phn quan trng trong
vic h tr, gip ngi bnh i tho ng, hen ph qun c thm kin thc, k nng v
bnh v t qun l iu tr bnh.
Cng tc truyn thng gio dc sc khe chung, trong c ni dung phng chng
BKLN c thc hin phi hp vi cc s kin y t, cc t tim chng [238] thng qua mng
li 63 trung tm truyn thng gio dc sc kho cc tnh/thnh ph, vi i ng 920 cn b
lm vic ti tuyn tnh, mi x c mt cn b ph trch v truyn thng gio dc sc kho v
320000 cng tc vin truyn thng thn, bn.
6.2. Kh khn, hn ch
Mng li y t c s cha kh nng cung cp cc dch v thit yu phng chng
BKLN. Mng li y t c s rng khp Vit Nam, vi trn 11000 trm y t x phng v trn
600 bnh vin a khoa tuyn huyn t c nhiu thnh tu trong phng chng cc bnh
dch, chm sc, bo v sc kho b m, tr em, iu tr cc bnh cp tnh. Tuy nhin, mng
li y t c s cha kp thch ng vi s chuyn i dch t t cc bnh cp tnh, ly truyn
sang BKLN, v nhn chung ngi dn vn cha tip cn c mt s can thip thit yu phng
chng BKLN trong mng li CSSKB, do nhn lc y t tuyn huyn, c bit l tuyn x,
phng thiu k nng, hiu bit, do thiu thuc v trang thit b cn thit, do mt s vng mc
trong chnh sch chi tr BHYT v cui cng do thiu s kt ni, lng ghp gia YTDP v iu tr,
cng nh s phn mnh trong cung ng dch v, khng bo m chm sc lin tc v ton din.
Nhiu dch v trong gi can thip thit yu phng chng BKLN ti cc c s CSSKB
cc nc ngho theo khuyn co ca WHO, cha th thc hin c ti y t x phng v ti
mt s bnh vin a khoa huyn (Bng 40). Ngi dn phi tm kim cc dch v trn cc
bnh vin chuyn khoa tuyn cui cng, hoc cc bnh vin a khoa, chuyn khoa cp tnh,
vi nhiu chi ph gin tip m nu khm cha bnh ti tuyn y t c s th khng phi chi tr.
V d thc hin cc can thip d phng cp I ti tuyn CSSKB i vi cn au tht
ngc v tai bin mch no vi theo khuyn co ca WHO, phn ln nhn vin y t tuyn x vn
cha c o to t vn cai thuc l, cha c k nng hng dn c th cch gim mui n
xung di 5 g/ngy, cha bit cch tnh mc nguy c mc bnh tim mch theo cc thang
im Euro hoc thang im Framingham. Phng t vn cai nghin thuc l mi ch trin khai
th im mt vi bnh vin ln. Cho ti nay, dch v t vn cha c lng ghp trong mng
li CSSKB mt cch c h thng, chi ph cho hot ng t vn cha c BHYT thanh ton.
Thiu trang thit b y t khin mt s can thip thit yu khng th thc hin c
TYT x phng. Mt trong nhng can thip c bn nht cn thc hin ti y t c s l kim sot
ng huyt, nhng thit b o ng huyt mao mch khng c ti trm y t x. Nhiu thit
b cn thit khc cng khng c ti trm y t x c th cung cp cc dch v ti thiu phng
chng BKLN (xem chi tit ti mc chng VI, mc v Dc v trang thit b y t).
Ngh nh s 77/2013/N-CP ca Chnh ph ngy 17/7/2013 quy nh chi tit thi hnh Lut Phng, chng tc hi
ca thuc lv mt s bin php phng, chng tc hi ca thuc l.
76
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75
259

Bng 41: Kh nng cung ng gi can thip thit yu phng chng BKLN trong mng
li y t c s Vit Nam
Cc can thip
1. D phng
cp mt au
tht ngc v tai
bin mch no
Cc dch v trong mi ni dung

can thip
Vng mc trong kh nng

cung ng ca cc TYT x, phng
Cai nghin thuc l.

Hot ng th lc 30 pht mi ngy.
Hn ch n mn, di 5 g mui/ngy.
Hoa qu v rau xanh ti thiu 400 g ngy.
Dng thuc aspirin, statin v thuc h
huyt p cho ngi c nguy c tim mch
trong 10 nm ti mc trn 30%.
iu tr tng huyt p cho ngi c HA
160/100 mmHg.
Dng thuc h huyt p cho ngi c
huyt p 160/90 mmHg v c nguy c
tim mch 10 nm ti trn 20%.
Phn ln cha c o to v k
nng t vn.
Cha c o to v cch tnh mc
nguy c bnh tim mch trong 10
nm ti, theo cc bng im thng
dng (Framingham hoc Euro).
Phn ln trang b ti TYT x phng
cha xc nh c cholesterol mu
v HDL cholesterol tnh t l nguy
c mc bnh tim mch trong 10 nm
ti ca ngi dn.
Hot ng t vn cha c chi tr t
qu BHYT.
2. Nhi mu
c tim
Ung aspirin
3. D phng
cp hai sau
nhi mu c
tim
Cai nghin thuc l, dinh dng lnh

mnh v hot ng th lc thng xuyn
Dng aspirin, c ch men chuyn angiotensin, chn beta, statin
Thiu k nng v t vn, thiu c ch

chi tr ph hp
Cai nghin thuc l, dinh dng lnh

mnh v hot ng th lc thng
xuyn.
Aspirin, thuc h p (thiazid liu thp, c
ch men chuyn angiotensin, statin).

chi tr ph hp.
4. D phng
cp hai sau tai
bin mch no
5. D phng
cp hai i vi
thp tim
6. i tho
ng tp 1
7. i tho
ng tp 2
Dng khng sinh nh k d phng

vim hng lin cu v st thp ti pht.
Tim insulin hng ngy
Insulin cha c trong danh mc thuc

ch yu ti trm y t x, phng.
Phn ln TYT x cha c thit b
theo di ng huyt.
Ung thuc gim ng huyt nu thay

i ch dinh dng, gim cn, hot
ng th lc khng t c mc tiu
ng huyt.
Bt u s dng metformin i vi ngi
qu cn.
Dng cc thuc gim ng huyt khc
nu khng t mc tiu ng huyt.
Gim nguy c bnh tim ngi T c
mc nguy c bnh tim 10 nm mc
trn 20% bng aspirin, thuc c ch men
chuyn angiotensin v statin.
Phn ln TYT x, phng cha c

my xt nghim ng huyt (glucometer).
Mt s thuc iu tri khng sn c
TYT x phng.
Cha c k nng v iu kin xc nh
mc nguy c bnh tim 10 nm.
260
Cc can thip
Cc dch v trong mi ni dung

can thip
Vng mc trong kh nng

cung ng ca cc TYT x, phng
8. D phng
bin chng
chn (do T)
Khm chn tm du hiu nguy c lot

v chuyn tuyn trn nu c nguy c
lot.
Phn ln TYT cha c o to

thc hin dch v ny.
9. D phng
s xut hin v
tin trin ca
bnh thn mn
tnh (T)
Kim sot ng huyt ti u.
Phn ln TYT khng c kh nng xc

nh ng huyt.
10. D phng
xut hin v
lm chm tin
trin ca bnh
l vng mc
T
Chuyn tuyn sng lc v nh gi,

iu tr bng laser tn thng vng mc
Kim sot ng huyt v huyt p.

nh ng huyt.
11. D phng
xut hin v
lm
chm
tin trin tn
thng
thn
kinh do T
Kim sot ng huyt.

nh ng huyt.
iu tr triu chng bng thuc khng 2

tc dng nhanh, dng ung hoc ht.
Dng steroids dng ht trong trng hp
kh th mc trung bnh hoc nng
h tr chc nng h hp, gim t l t
vong, gim tn sut v mc cn hen
ti pht.
Thiu ng ni cho bnh xt.

Thuc iu tr khng c sn nhiu
TYT x.
Thiu thit b o dung tch th ra ti a
(peak flow meter).
13. D phng
ti pht COPD
v tin trin
ca bnh
Cai nghin thuc l.

chi tr ph hp.
14. Gim kh
th v ci thin
kh nng chu
ng tp th
dc (exercise
tolerance)
Thuc gin ph qun tc dng nhanh.
Thuc khng sn c nhiu TYT.
15. Ci thin
chc nng h
hp
Ht cortisteroid khi FEV1 < 50%.

Dng thuc gin ph qun tc dng
chm, nu vn kh th sau khi dng
thuc tc dng nhanh.
Thuc khng sn c nhiu TYT.

Thiu thit b o chc nng h hp.
16. Ung th
Khm pht hin triu chng, chuyn

tuyn trn chn on xc nh.
12. Hen ph
qun
Gi can thip thit yu phng chng BKLN cha c xy dng v p dng trong mng
li y t c s. xy dng danh mc cc can thip thit yu, hiu qu v kh thi, cn la chn
dch v thit yu i vi cc nhm BKLN chnh c hiu qu chi ph tt (di 3 ln GDP bnh
qun u ngi cho 1 nm DALY) hoc rt tt (di 1 ln GDP bnh qun cho 1 nm DALY)
261

v chi ph trin khai thp (t hn 1 USD/1 ln), thc hin c y t c s, ph hp vi hon
cnh Vit Nam. Cho ti nay, h thng cung ng dch v cha c danh mc cc dch v hiu qu
nht (best buy) trong pht hin sm, chn on, iu tr v qun l BKLN trin khai trong
ton h thng.
Chm sc lin tc, cung ng dch v theo nguyn tc ly ngi dn lm trung tm kh
thc hin trong hon cnh h thng cung ng dch v ang b phn mnh. Trong phng chng
BKLN, ngi dn cn c chm sc, s dng cc dch v sut vng i, tip cn cc dch v
thit yu gn nh ti tuyn y t c s v dch v chuyn su tuyn trn, trong mt qu trnh
phi hp, lng ghp gia cc tuyn iu tr thc hin chm sc lin tc. Tuy nhin, hin nay
cc trm y t x phng hot ng tng i c lp vi cc bnh vin tuyn trn; thng tin
v ngi bnh t c trao i, chia s. Thay v TYT x, phng, bnh vin huyn, cc phng
khm chuyn khoa v cc bnh vin tnh, bnh vin trung ng phi hp cht ch vi nhau
chm sc ngi dn v tr trung tm, th ngi dn phi t tm kim dch v ca cc c s
y t tch bit vi nhau. Ngi bnh mc BKLN khng c h s theo di sc kho TYT x,
phng, thng tin v sc kho ngi bnh s dng dch v cc c s y t khc nhau khng
c lu tr v chia s mt cch c h thng. Cha t chc mng li thng tin CSSK (HNIS healthcare networking information system). S phi hp lin ngnh v cc hot ng chm sc
da vo cng ng trong phng chng cc BKLN cha c thc hin tt tuyn c s.
Chm sc gim nh cha c t chc thc hin mt cch c h thng trong cng ng.
Tuy B Y t ban hnh Hng dn quc gia v chm sc gim nh i vi ngi bnh ung
th v HIV/AIDS77, thuc morphin sulfat dng ung c k n rng ri hn, chm sc
gim nh mi c thc hin ch yu cc trung tm iu tr gim au v chm sc gim nh
ti mt s bnh vin trung ng v trung tm ung bu. Chm sc gim nh cha c thc
hin rng ri ti tuyn y t c s v mi thc hin th im ti nh. Theo mt nghin cu nm
2010, tnh sn c ca dch v chm sc gim nh ti bnh vin huyn l 5,3% v ti TYT x l
10%. Cng theo nghin cu trn, s cn b y t bit v ti liu Hng dn chm sc gim nh
i vi ngi bnh ung th v HIV/AIDS huyn l 15,8%, TYT x l 6,7% [208].
Cui cng, mc d ngun lc hn ch, vn ang c xu hng xy dng thm cc bnh
vin chuyn khoa tuyn tnh (bnh vin tm thn), 12 bnh vin chuyn khoa vng (phng
chng ung th). Vic xy dng cc bnh vin chuyn khoa tuyn tnh khng khuyn khch
s lng ghp cn thit trong qun l BKLN, ng thi khng s dng ngun lc mt cch c
hiu qu.
6.3. Vn u tin
Mng li cung ng dch v b phn mnh, thiu s lng ghp gia d phng v iu tr,
gia y t c s, c bit l y t x, phng vi cc c s y t tuyn trn, t chia s thng
tin v ngi bnh gia cc c s y t, cha thc hin c chm sc lin tc, cha bo
m c cch tip cn ly ngi dn lm trung tm trong phng chng BKLN.
Cha xc nh c gi dch v thit yu, hiu qu v kh thi v t vn, d phng, pht
hin sm, iu tr, chm sc trong phng chng BKLN cho y t c s v cha c s phn
nh trch nhim thc hin gi dch v trn cho y t x, phng v y t huyn .
Quyt nh s 3483/Q-BYT ngy 19/5/2006 ca B Y t ban hnh Hng dn Chm sc gim nh i vi bnh
nhn ung th v AIDS.
77
262

Y t c s cha nng lc cung cp cc dch v thit yu phng chng BKLN, do hn
ch v nng lc chuyn mn, thuc, trang thit b v ngun ti chnh.
Chm sc gim nh cha c thc hin y t c s v trong cng ng.
Ngun lc vn hn ch ca ngnh y t mt s tnh, thnh ph c nguy c tip tc b
phn tn do xu hng tip tc xy dng mi cc bnh vin chuyn khoa iu tr cc
BKLN, nh bnh vin tm thn, bnh vin ung th, bnh vin lao v bnh phi.
6.4. Khuyn ngh
Ngn hn
Xy dng v thc hin D n i mi cung ng dch v y t tuyn c s (t huyn tr

xung) theo hng ly CSSKB lm nn tng, thc hin phi hp, lng ghp YTDP,
nng cao sc khe, KCB, phc hi chc nng, bo m s kt ni v h tr gia cc
tuyn y t.
Xy dng gi cc dch v thit yu phng chng BKLN, trong c dch v thit yu
chm sc sc kho tm thn cho y t x, phng v y t huyn cho giai on 2015-2020,
c tham kho khuyn co ca WHO.
Di hn
Xy dng quy ch v qun l, cp nht, trao i v lu tr thng tin sc kho ca bnh

nhn BKLN trong mng li KCB v gia cc c s KCB gp phn thc hin yu
cu chm sc lin tc BKLN.
Bo m cc iu kin cung cp c cc dch v thit yu phng chng BKLN, bao
gm c chm sc gim nh: (i) xy dng v thc hin k hoch o to lin tc nng cao
nng lc cho nhn lc y t x, phng, y t huyn trong t vn, khm, cha BKLN; (ii)
iu chnh danh mc thuc v danh mc trang b y t p ng yu cu cung cp cc dch
v thit yu phng chng BKLN ti y t c s v (iii) sa i quy nh v ngun chi tr
cho cc dch v thit yu phng chng BKLN theo nguyn tc ca bao ph CSSK ton
dn.
Tng cng nng lc ca cc bnh vin a khoa v lng ghp hot ng phng chng
BKLN trong bnh vin a khoa tuyn tnh, thay v xy dng thm cc bnh vin chuyn
khoa mi.
263
PHN BA: KT LUN V KHUYN NGH
264
Chng VII: Kt lun
Chng VII: Kt lun

Bo co JAHR 2014, c xy dng vo nm th t trin khai thc hin Ngh quyt i
hi i biu ton quc ln th XI ca ng v K hoch 5 nm v Bo v, chm sc v nng cao
sc khe nhn dn 2011-2015, (i) cp nht v phn tch su tnh hnh sc khe v cc yu t
nh hng; (ii) cp nht thc trng h thng y t, bao gm cp nht cc chnh sch mi v tnh
hnh thc hin cc mc tiu, nhim v ra trong K hoch 5 nm 2011-2015 ca ngnh y t;
tin thc hin cc mc tiu Pht trin Thin nin k lin quan n y t v mc tiu sc khe
ca Vit Nam; v (iii) phn tch su ch Tng cng d phng v kim sot bnh khng ly
nhim - mt ch ang c cc nh hoch nh chnh sch y t c bit quan tm.
Nhng kt qu chnh ca Bo co c th hin cc ni dung di y.
1. Tnh trng sc khe v cc yu t nh hng ti sc khe

Ch s sc khe c bn: nhng nm gn y, tnh trng sc khe ngi dn Vit Nam
c ci thin ng k, trong c tui th, t vong tr em di 1 tui, t vong tr em di
5 tui, t l suy dinh dng, t tt hn so vi cc nc ang pht trin chu . Tuy nhin, s
chnh lch ng k trong cc ch s ny gia cc vng, min v gia cc nhm dn c, l mt
vn ln rt ng quan tm hin nay, c bit l tnh trng sc khe km hn 2 vng Ty
Nguyn, Trung du v min ni pha Bc, l 2 vng ngho, kh khn.
Gnh nng bnh tt: Vit Nam, t nm 1990 n nm 2010, gnh nng bnh tt (tnh
bng DALY) do cc bnh truyn nhim, cc vn sc khe ca b m, tr chu sinh v ri lon
dinh dng gim t 45,6% xung 20,8%. ng thi gnh nng bnh tt do cc BKLN tng t
42% ln 66% tng s DALY. Trong nhm cc bnh truyn nhim (gm c vn sc khe b
m, tr chu sinh v ri lon dinh dng), gnh nng bnh tt quan trng nht l do HIV, nhim
khun ng h hp di, lao, bin chng do sinh non, giun sn. Trong nhm cc BKLN, gnh
nng bnh tt ch yu do ung th, bnh tim mch (gnh nng ch yu do gy t vong sm) sau
l ri lon tm thn v hnh vi, bnh xng khp (gnh nng ch yu do gy nm sng tn
tt). Nhm tai nn, chn thng c ba nguyn nhn gnh nng bnh tt quan trng nht l tai
nn giao thng, ui nc v ng. i vi nam gii, 4 nguyn nhn quan trng nht gy gnh
nng bnh tt l tai bin mch mu no do xut huyt, chn thng do tai nn ng b, HIV/
AIDS v au vng lng di. i vi n gii, 4 nguyn nhn quan trng nht l trm cm, tai
bin mch mu no do xut huyt, au vng lng di v bnh phi tc nghn mn tnh.
Mt s bnh c c bit quan tm: nhiu dch bnh nguy him khng th hin trong
s liu v gnh nng bnh tt do s mc v t vong khng ln, hoc do bnh ang c phng
hiu qu bng vc xin v bin php y t d phng khc. Dch cm nh A(H1N1), A(H5N1), mt
s bnh mi ni nh vi rt Ebola, MERS-CoV, cm A(H7N9) v cm A(H5N6) c tim nng
gy dch ln. D Vit Nam thc hin tim chng hiu qu, nhng gnh nng bnh tt ca cc
bnh c th phng bng vc xin nh rubella (cha c trong chng trnh TCMR), si (do yu
km truyn thng v an ton tim chng), hoc vi rt Rota, ph cu khun v mng no cu (do
vc xin t cha a vo chng trnh TCMR) vn cn ng k. Vit Nam thnh cng trong
vic loi tr bi lit v un vn s sinh, v ang n lc tip tc loi tr cc bnh phong, vim
no Nht Bn, bnh si, bnh di v bnh st rt, v tin ti loi tr bnh st xut huyt. Bnh
HIV/AIDS v lao l hai bnh c t l mc v t vong cao. Mt s bnh truyn nhim khc c t
l mc cao nh giun sn, nhim khun ng h hp di v vim gan (A, B, C) hoc c t l
265

cht trn mc cao nh chn tay ming. T vong tr em Vit Nam giai on di 7 ngy tui
ch yu l bin chng do sinh non, di tt bm sinh, ngt th v sang chn lc sinh, trong khi
tui t 7 ngy n 5 tui cc nguyn nhn t vong chnh l nhim khun h hp di, tiu chy
v ui nc. Tai nn ng b v ui nc l hai nguyn nhn gnh nng bnh tt cha gim
ng k trong thi gian qua, cn s can thip t ngoi ngnh y t mi gii quyt c.
Cc yu t v dn s, hon cnh kinh t-x hi nh hng sc khe gin tip. C
cu tui gii, c bit gi ha dn s, tc ng ti gnh nng bnh tt do m hnh bnh tt v
nhu cu CSSK tng nhm tui khc nhau. Ph n trong tui sinh (27,0% dn s) v s tr
em (8,5% dn s) to ra nhu cu rt ln i vi cc dch v phng bnh bng vc xin, chm sc
sc khe sinh sn v chu sinh. Nhm thanh thiu nin (10-24 tui chim 24% dn s) l nhm
tui thng khe mnh, nhng cn s quan tm c bit to ra li sng lnh mnh, trnh tai
nn v chm sc sc khe tnh dc. Tui cao l yu t nguy c ca nhiu BKLN nh bnh tim
mch, i tho ng v ung th, nn t l dn s 65 tui tr ln cng ln, gnh nng bnh tt
do cc bnh ny cng ln. S pht trin kinh t-x hi tc ng tch cc ti sc khe do ci thin
dinh dng, tip cn vi thng tin v dch v y t. Nhng, pht trin cng to ra nhiu tc nhn
gy nhim, li sng khng lnh mnh v yu t khc c hi cho sc khe. Nhng s khc bit
v sc khe lin quan phn b dn c gia cc vng/khu vc c mc pht trin kinh t khc
nhau v bt bnh ng trong kh nng tip cn vi dch v y t (gm c YTDP) c cht lng.
Cc yu t mi trng, li sng, sinh chuyn ho, ngh nghip v bo lc l cc
nguy c trc tip gy gnh nng bnh tt. Trong , yu t nguy c quan trng nht Vit
Nam l ch n khng hp l: thiu nhng thnh phn c li cho sc khe nh rau qu v tha
nhng cht c hi cho sc khe nh tht ch bin hoc ung ngt. Yu t quan trng th hai
l yu t sinh chuyn ho nh tng huyt p, tng cholesterol mu. Tip theo cc nguy c i
vi gnh nng bnh tt l ht thuc l, nhim khng kh v s dng ru/ma ty.
Cc thch thc i vi h thng y t bao gm:
Cc vn sc khe u tin:
Cc bnh hin nay hoc trong tng lai c tim nng ly lan rng trong x hi nh
cc bnh ly t ng vt sang ngi, HIV/AIDS, bnh lao.
Cc bnh dch nguy him c kh nng loi tr nh bnh st rt, vim no Nht Bn,
si, di, phong,
Cc bnh gy t vong v gnh nng bnh tt tr em nh vim phi, tiu chy, ui
nc, d tt bm sinh, ngt th v sang chn lc sinh.
Cc nguyn nhn gy t vong v gnh nng bnh tt ln nhm tui lao ng nh
tai nn giao thng, HIV/AIDS, BKLN.
Cc bnh c gnh nng bnh tt ln c th phng c trnh chi ph iu tr gy
gnh nng ti chnh qu ln cho x hi, c bit l BKLN. Vit Nam, BKLN
chim t l ln gnh nng bnh tt ln l bnh tim mch, ung th, bnh phi mn
tnh, i tho ng, x gan, bnh thn mn tnh, bnh c xng, bnh tm thn,
thn kinh.
S khc bit trong nhu cu CSSK gia cc vng v nhm dn c:
266
Chng VII: Kt lun

Chnh lch gia cc vng a l khng gim trong giai on 2010-2013 i vi cc
ch s c bn nh tui th, t sut t vong tr em, b m, t l suy dinh dng. S
khc bit theo vng trong m hnh bnh tt, trong mc phi nhim yu t nguy c
v trong kh nng tip cn dch v y t c cht lng gia cc vng a l i hi
s khc nhau trong p ng ca h thng y t theo vng c iu kin kinh t-x hi
khc nhau.
Gi ha dn s km theo t l mc bnh nng, ko di, lm gia tng gnh nng i
vi h gia nh, c s cung cp dch v y t v ngun ti chnh y t. Nhu cu i vi
h thng y t mt phn l i ph vi gnh nng CSSK ca ngi cao tui, mt
phn l d phng yu t nguy c ngi tr sng khe mnh khi n tui cao.
Gia tng cc yu t nguy c do tc ng ca cng nghip ha, hin i ha, th
ha: nhim khng kh; cc vn v li sng c hi (ht thuc l, ung ru bia, lm
dng ma ty, c bit i vi tui thanh thiu nin), thiu hot ng th lc; ch n
ung cha hp l; cng nghip ha tc ng ti bnh ngh nghip v tai nn lao ng;
cc yu t gy cng thng, gim yu t bo v sc khe tm thn, bo lc gia nh.
H thng cung ng dch v cn nhiu hn ch: h thng YTDP v dch v c bn
CSSK b m tr em, hin nay ang phn mnh, chia ct gia cc tuyn gia YTDP v
KCB; dch v CSSK p ng nhu cu c bit ca thanh thiu nin (truyn thng
gio dc v li sng lnh mnh v CSSK tnh dc v sinh sn) cha c quan tm ng
mc; s khc bit trong kh nng tip cn dch v c cht lng (k c dch v truyn
thng gio dc sc khe, YTDP, KCB) dn n s khc bit trong cc ch s t vong,
sc khe v hiu bit v gim nguy c bnh tt theo vng v nhm dn c; mng li
y t t tuyn huyn tr xung cn yu, cht lng cha c kim sot y nn kh
p ng nhu cu rt ln ca dn s.
2. Cp nht tnh hnh h thng y t

Nhm gim st vic thc hin k hoch 5 nm ca ngnh y t Chng II cp nht kt
qu thc hin nhim v v nu ra nhng kh khn, hn ch cn phi gii quyt hon thnh
mc tiu ca k hoch 5 nm ca ngnh y t giai on 2011-2015.
2.1. Tng cng nng lc qun l v y t
B Y t phi hp vi cc b, ngnh lin quan xy dng, trnh Chnh ph v Quc

hi ban hnh nhiu vn bn php quy, n quan trng. B Y t tin hnh kin ton t chc
cc n v ca B Y t theo Ngh nh 63 (2012) v tip tc xy dng thng t ca B Y t quy
nh chc nng, nhim v, quyn hn v c cu t chc ca trung tm y t tuyn huyn, v d
tho Ngh nh quy nh t chc b my v ch chnh sch i vi cn b y t tuyn x. B
Y t nghim thu v cng nhn ti liu Khung k hoch v Hng dn xy dng K hoch y
t tuyn tnh v tip tc t chc cc lp tp hun v nng cao nng lc qun l, lp k hoch y
t. Mt s a phng bt u xy dng K hoch y t tuyn tnh theo cc khung, biu mu
mi tp hun. B Y t xy dng v trin khai k hoch thanh tra y t, qua cng tc thanh tra,
kim tra kin ngh khc phc cc s h trong c ch chnh sch v php lut, xut cc gii
php chnh sch. B Y t cng tng cng cng tc kim tra pht hin nhng tn ti trong
267

x hi ha, ban hnh Ch th s 05/CT- BYT ngy 22/5/2014 v tng cng kim tra, chn chnh
cng tc x hi ha, khm cha bnh theo yu cu.
2.1.2. Kh khn, hn ch
Xy dng vn bn quy phm php lut vn chm so vi k hoch. C cu t chc b my

v chc nng, nhim v ca cc c s y t, c bit tuyn y t c s cha c chnh sa ph
hp p ng vi s thay i ca m hnh bnh tt, nhu cu chm sc sc khe ca ngi dn.
Y t c s v CSSK ban u cn yu, cha c quan tm ng mc. Thiu s gn kt, phi
hp gia YTDP v KCB, gia y t cc tuyn x, huyn, tnh v trung ng. Thiu ng lc i
mi phng php lp k hoch. Cc hot ng thanh tra, kim tra vn ch yu c thc hin
sau khi c cc s vic xy ra, mang tnh cht b ng, thiu lc lng thanh tra. Vn cn nhiu
tn ti trong cc quy nh qun l nh nc v x hi ha, cung cp dch v y t theo yu cu.
2.2. Nhn lc y t
S lng nhn lc y t cc loi tng qua cc nm, t 7,5 bc s trn mt vn dn v 2,1

dc s i hc trn mt vn dn. S nhn lc tuyn huyn v tuyn x cng c ci thin,
nm 2013 t 76,9% trm y t x c bc s lm vic. B Y t tip tc trin khai cc gii php
ci thin cht lng nhn lc. S lng c s o to v quy m o to ca cc trng tip
tc tng. Cc chnh sch qun l v nng cao cht lng nhn lc ang c thc hin nh cp
chng ch hnh ngh v xy dng cc chun nng lc. Nhm ci thin giao tip ca cn b y t
vi bnh nhn, B Y t t chc cc lp tp hun v k nng giao tip, ng x, nng cao o
c ngh nghip. Mt s chnh sch c ban hnh v thc hin tng cng nng lc cho
tuyn di v phn b nhn lc y t hp l gia cc vng min v chuyn khoa nh n 1816
(ch lun phin c thi hn) v n Bnh vin v tinh c cc hot ng chuyn giao k
thut; n khuyn khch o to v pht trin nhn lc y t mt s chuyn ngnh thiu nhn
lc; D n th im a bc s tr tnh nguyn v cng tc min ni. Ngh nh ca Chnh ph
quy nh t chc v ch chnh sch i vi cn b y t x, phng, th trn c chun b
v d nh s c ban hnh trong nm 2014.
Mt cn bng trnh ca nhn lc y t hin nay theo vng, v lnh vc chuyn mn.
Nhn lc y t c trnh cao tp trung ch yu cc thnh ph ln v khu vc kinh t pht
trin. tuyn y t c s v vng kh khn thiu nhn lc y t c trnh i hc tr ln. D n
th im a bc s tnh nguyn v vng kh khn kh gii quyt c bn vng tnh trng thiu
cn b y t vng kh khn. Cha c s thay i ng k no trong c ch s dng, tuyn dng
nhn lc y t ca cc a phng, chnh sch tin lng v ch i ng cha hp dn
thu ht nhn lc y t lm vic vng su, vng xa. Trin khai cc n tng cng nng lc
tuyn di vn cn kh khn v cha xc nh c c th cc k thut cn chuyn giao, cha
da trn iu kin c s vt cht sn c ti tuyn y t c s. Mi trng lm vic ti vng kh
khn khng p ng c vi yu cu cng vic.
Qun l nhn lc y t cha p ng nhu cu ca x hi. ng x ca cn b y t vn
gy phn ng ca x hi, bnh nhn trong thi gian qua. C ch qun l c s y t v s dng
cn b lnh o, qun l cc cp gp phn lm gim s lng, gim thi gian nhn lc y t lm
268
Chng VII: Kt lun

cng tc chuyn mn. S iu dng bnh qun mt bc s vn rt thp, mc d hng nm vn
o to ra nhiu iu dng. Chng ch hnh ngh cp mt ln, khng thi st hch nn cha c
gi tr trong vic bo m mt mt bng cht lng c bn.
2.3. Ti chnh y t
Vi bi cnh kinh t v m ang gp nhiu kh khn, Chnh ph ch trng tht cht chi
tiu, song NSNN vn c b tr theo cc nhim v chi thng xuyn cho y t (chi cho KCB,
YTDP, ci cch tin lng, kinh ph thc hin CTMTQG, chi mua BHYT cho cc i tng
c h tr theo Lut BHYT). Trong giai on t 2010-2013, d ton chi NSNN cho y t tng
chm hn chi NSNN chung, nhng n 2014 d ton chi NSNN cho y t tng nhanh hn. Tng
gi tr ODA vn duy tr n nh. T l chi cho YTDP v nng cao sc khe tng ln qua cc
nm do chi a phng tng mnh, n nm 2011 chi cho YTDP chim 69,8% tng NSNN chi
cho y t78. Lut sa i, b sung mt s iu ca Lut BHYT c Quc hi thng qua ngy
13/6/2014; B Y t ban hnh mt s thng t hng dn thc hin Lut BHYT sa i. T
l bao ph BHYT t 68,5% dn s. Qu BHYT vn cn i. B Y t ang tp trung xy dng
cc vn bn hng dn thc hin Ngh nh 85 v i mi c ch hot ng v ti chnh trong
ngnh y t.
Trn c s kho st nh gi thc trng v tham kho cc kin t vn trong nc v
quc t, B Y t ban hnh Quyt nh 5380 ph duyt n trin khai th im sa i thanh
ton chi ph khm cha bnh BHYT theo nh sut. D n nghin cu th im chi tr theo
trng hp bnh vn ang c trin khai vi cc hot ng nng cao nng lc cn b v thanh
ton theo trng hp bnh, xy dng quy trnh chuyn mn v tiu chun cht lng lm sng.
Kh khn v kinh t v m lm gim tc tng chi t NSNN cho y t. Mt s hot ng

qun l nh nc v y t nh thanh tra, kim tra, thng k thng tin y t, hot ng truyn thng
gio dc sc khe, can thip phng, chng BKLN ti cng ng thiu kinh ph thc hin. T
l chi tin ti ca h gia nh so vi tng chi y t tng ln mc gn 49% nm 2012, trong khi
mc tiu cho n nm 2020 phi gim xung cn di 40%. Trong khi , t l chi cng cho y
t gim xung cn 42,6%, cn kh xa so vi mc phn u ti thiu 50%. Mt s a phng
cha b tr chi s nghip y t theo nh mc quy nh. u t cho y t c s cn hn ch,
cha c ngun chc chn. Nm 2014 cc CTMTQG b ct gim kinh ph, gy kh khn cho hot
ng cc chng trnh, d n, c bit cc d n phng, chng BKLN. Tin m rng BHYT
ang b chm li, s dng qu BHYT cn hn ch v tnh bn vng v hiu qu, h thng qun
l thng tin yu, c tnh trng lm dng qu BHYT.
i mi phng thc thanh ton tin trin chm, gp nhiu kh khn do lin quan trc
tip ti li ch cc bnh vin, i hi phi hp tc, phi hp v ng thun ca cc bn lin
quan mi thc hin c. Cc iu kin trin khai m hnh phng thc thanh ton mi rt
hn ch.
Vic ban hnh cc vn bn hng dn thc hin Ngh nh 85 vng mc vi vic thc
hin cc chnh sch khc nh x hi ha, qun l gi dch v cng ch. Nhiu vn hn ch
Nu tnh t l chi cho y t d phng so vi tng ngn sch y t bao gm c cc khon BHYT thanh ton v ngi
dn np vin ph th t l ny l 43,9%, v so vi tng chi y t ton x hi l 27,9%.
78
269

hiu sut s dng cc ngun lc ti cc n v y t cng lp nh kim sot lng ph, hn ch
trong kim sot ch nh thuc, Vic thc hin t ch ti chnh ca cc n v cng lp gp
kh khn do khng bo m ngun cn i ti chnh, c bit i vi chi ph lao ng.
Nhim v bo m cung ng thuc thit yu c thc hin tt. Mc chi tin thuc
bnh qun u ngi tng t 22 USD nm 2010 ln 31,2 USD nm 2013. Gi tr thuc sn
xut trong nc nm 2012 chim t trng 46,2% tng gi tr thuc s dng ti Vit Nam, p
ng hai phn ba hot cht trong Danh mc Thuc thit yu ca Vit Nam ln th V. Mng li
cung ng thuc khu vc kh khn ang pht trin. Vit Nam sn xut c 10/11 vc xin
trong chng trnh TCMR. Thuc ng y v thuc t dc liu c y mnh s dng thng
qua ban hnh Danh mc thuc ng y thit yu, ph duyt v trin khai quy hoch tng th pht
trin dc liu, xy dng cc vng nui, trng dc liu theo tiu chun thc hnh tt v tng
cng qun l ngun gc v cht lng dc liu.
Th trng thuc c bn bnh n, ch s gi thuc tng chm hn ch s gi tiu dng
chung, mc gi thuc Vit Nam thp hn thuc Thi Lan v Trung Quc. Vic trin khai
cc vn bn quy phm php lut v qun l gi thuc v u thu thuc bc u pht huy
tc dng.
B Y t v ang tch cc trin khai thc hin ch trng qun l ton din cht lng
thuc thng qua vic trin khai p dng cc nguyn tc Thc hnh tt (GPs) v tng cng
nng lc kim nghim thuc. tng cng s dng thuc an ton, hp l, B Y t cng c
hot ng ca Hi ng Thuc v iu tr trong bnh vin, thc hin k hoch hnh ng quc
gia v chng khng thuc, cng c h thng theo di, gim st phn ng c hi ca thuc v
xy dng c s d liu tra cu thng tin thuc.
B Y t phi hp vi B Ti chnh kim tra v nghin cu xut gii php h tr chnh
sch thu i vi n v sn xut trang thit b y t trong nc. Hin nay c khong 600 chng
loi c B Y t thm nh v cp php lu hnh trong nc. Mng li KCB cc tuyn tip
tc c cng c v hon thin trong cc n 47, n 930 xy mi, nng cp nhiu bnh
vin a khoa tuyn tnh, khu vc, huyn v mt s bnh vin chuyn khoa.
Nhiu thuc thit yu vn cha c trong danh mc thuc c BHYT thanh ton, trong
c cc loi thuc ca CTMTQG nh thuc iu tr HIV v thuc iu tr bnh lao. Ngoi
ra, mt s trm y t x c tnh trng cp thuc chm, thiu v c cu thuc khng p ng nhu
cu iu tr.
Vic qun l gi thuc ti cc n v bn l thuc khng thuc c s y t cn gp kh
khn do cha c c ch hu hiu nh gi tnh hp l ca gi thuc. D kim sot c gi
thuc ti c s y t thng qua u thu thuc, nhng cha c bin ph khuyn khch bc s quan
tm n hiu qu chi ph khi ch nh thuc. Cha t c s ng thun v t chc v phn
cng trch nhim n v u mi trong qun l nh nc gi thuc.
270
Chng VII: Kt lun

Lin quan s dng thuc an ton hp l, vn cn kh khn trong s dng thng tin v
cc mt hng thuc b nh ch lu hnh, cha gim st tnh hnh s dng thuc an ton hp l,
thiu dc s i hc ti cc a phng kh khn. Thiu cc quy nh v pht trin m hnh
phn phi thuc c kh nng bo m cht lng thuc. Qun l cht lng thuc ng y gp
kh khn do kh gim st ngun gc v cht lng ng dc v dc liu, nhiu c s sn
xut l h c th, thiu trang thit b hin i.
Vic ct gim kinh ph t tri phiu Chnh ph dn n s chm tin nng cp bnh
vin huyn; mt s d n phi tm dng u t sau nm 2015 hoc chuyn i hnh thc u
t, dn n hn ch trong cung ng dch v.
2.5. Thng tin y t
Trong hai nm gn y, mt lot cc vn bn quy phm php lut c Chnh ph v

B Y t ban hnh, c bit v cng c ch bo co thng k tng hp i vi h thng cng
lp v ngoi cng lp v ng dng cng ngh thng tin ngnh y t. Ngoi ra, Chnh ph ban
hnh quy nh x pht vi phm hnh chnh trong lnh vc thng k trong khi B Y t ch th
v tng cng cng tc thng tin thng k y t v ban hnh Bn k hoch pht trin H thng
thng tin n nm 2020 tm nhn 2030. Ngnh y t tip tc ci tin v a dng ha hnh thc
ph bin thng tin di nhiu hnh thc khc nhau, vi nhiu hnh thc ph bin a dng. Ti
liu o to ging vin v thng tin y t c bn ang c chun ha. Cc a phng s
dng tin ngn sch v h tr t mt s nh ti tr trin khai o to cho cn b thng k
tuyn di v thng tin thng k c bn. Ngnh y t ang xy dng c s d liu ngi hnh
ngh trn ton quc.
Thng tin phc v theo di, nh gi, nghin cu hin nay cha p ng nhu cu. Thiu
cc quy nh lin quan nhim v ph bin thng tin v c s d liu, thng tin cung cp cha
kp thi, cha y , thiu thng tin t cc c s y t t nhn, c s y t thuc cc b ngnh
khc. Cc cuc iu tra do Chnh ph phn cng cho ngnh y t cha c tin hnh do kinh ph
ca ngnh cn hn ch. Thiu c s d liu thng tin thng k, c s d liu quc gia v y t.
Cha quy nh v tr, chc danh, nh mc thng k i vi cc n v trong ngnh y t.
Trnh ca cn b thng k v cn b k hoch v tng hp bo co, s dng, phn tch s
liu v cng tc d bo thng k cn yu.
Ti tuyn y t c s ch yu x l v tng hp s liu th cng, vic ng dng cng ngh
thng tin cn hn ch. Cha c phn mm tng hp s liu trc tuyn p dng t trm y t x
bo co ln tuyn trn. Vic m ha c s y t v cc chun i vi lnh vc chuyn mn cn
hon thin to iu kin trin khai ng dng cng ngh thng tin thng nht, ng b.
Cc hot ng YTDP v CSSKB c thc hin quy m rng. Gn y, ngnh y t

tp trung cng c mng li y t ti vng bin, o. Cc hot ng DS-KHHG thc hin
271

hiu qu, t mc sinh thay th nhiu a phng, lm chm li gia tng dn s, v thc hin
an ton sinh nhm gim t vong b m v tr s sinh. S c s y t cung cp dch v v t l
bnh nhn s dng dch v YHCT tng ng k. B Y t cp nht b sung nhiu quy trnh
k thut mi, m rng s k thut c th thc hin ti tuyn y t c s, c BHYT thanh ton,
ang trin khai mt s m hnh qun l bnh mn tnh, hng dn th im m hnh bc s gia
nh v m hnh CSSK ngi cao tui.
Nhiu vn bn chnh sch hng dn vic qun l cht lng cc dch v y t v gim
qu ti bnh vin c xy dng v trin khai nh hng dn qun l cht lng xt nghim,
dch v KCB ti bnh vin v ti trm y t x, phng, n gim qu ti bnh vin, n
bnh vin v tinh, bc s gia nh, v n 1816. Thng 5/2014 v c bn khng c tnh trng
qu ti bnh vin tuyn tnh, huyn, ch cn mt s bnh vin trc thuc B Y t vn c bnh
nhn nm ghp. Cng c gim st cht lng c xy dng v trin khai th im. Cc trng
v trung tm o to v qun l bnh vin c thnh lp v hng nghn cn b qun l bnh
vin c o to.
Kim sot mt s bnh truyn nhim cha t mc tiu mong mun, nh y li bnh
lao, chn ng i dch HIV/AIDS. Cng tc v sinh an ton thc phm cha bn vng v cng
tc y t hc ng thiu kinh ph v nhn lc trin khai hiu qu. T l bnh nhn c khm
bnh bng YHCT cha cao, mt phn do vng mc trong cc quy nh. V DS-KHHG vn
c vng ngho c mc sinh cao, CSSKSS cha t cc ch tiu, t s gii tnh khi sinh vn cha
c kim sot.
Cht lng dch v y t vn cha t yu cu. Tnh trng qu ti bnh vin tuyn cui
(ch yu bnh vin trung ng) cha c gii quyt v ngi bnh cha tin tng vo cht
lng iu tr tuyn di. Cn nhiu bt cp trong chnh sch bnh vin cng cung cp dch v
theo yu cu v trong cc bnh vin lin doanh lin kt gia bnh vin cng v bnh vin t
nhn v lm dng thuc, xt nghim v dch v k thut cao. Thiu s lng ghp gia chng
trnh YTDP v KCB. Cung ng dch v KCB mt cn i gia cc tuyn, thiu kt ni v chm
sc lin tc. Nng lc thc hin ti cc c s y t tuyn huyn v x cn hn ch, c bit i
vi qun l bnh mn tnh. B Y t cha thnh lp c T chc chng nhn cht lng c
lp cha c c quan c lp chu trch nhim kim nh cht lng KCB. Quy ch bnh vin
cha c cp nht t nm 1997 n nay v nhiu dch v k thut cha c hng dn chuyn
mn chnh thc ca B Y t. Cha p ng c nhu cu o to v qun l bnh vin, qun
l cht lng.
2.7. Tnh hnh thc hin Mc tiu Thin nin k trong lnh vc y t
Vit Nam t hoc c kh nng t hu ht cc MDG, nhng vn cn mt s mc
tiu cn n lc mi t c. n ht nm 2013, cc MDG t bao gm gim t l suy dinh
dng tr em, gim t l mc v t l t vong do st rt v t l tip cn vi nc sch, h x
hp v sinh. Mt s mc tiu c kh nng t nu tip tc tin hin nay nh t sut t vong
tr em di 1 tui, tng t l ngi nhim HIV/AIDS cn iu tr c tip cn vi thuc khng
vi rt v t l hin mc bnh lao. Mt s ch s c xu hng ci thin nh tng kh nng tip cn
ton din vi chm sc sc khe sinh sn (th hin cc ch s v t l khm thai, t l ph n
sinh con c cn b y t , t l s dng bin php trnh thai v t sut sinh v thnh nin)
272
Chng VII: Kt lun

v tng t l ph n bn dm s dng bao cao su khi quan h vi khch. ng lo ngi l mt s
mc tiu kh t vo nm 2015 hoc ch s theo xu hng khng tch cc nh mc tiu gim t
sut t vong tr em di 5 tui v t s t vong m. Mt s mc tiu cng ng cn quan tm
nh mc tiu tng t l s dng bao cao su ngi nghin chch ma ty v gn y s suy gim
trong t l iu tr ARV i vi tr em c nhu cu.
3. Kim sot cc yu t nguy c chung ca cc BKLN

Kim sot cc yu t nguy c l mt trong ba nhm gii php chnh c WHO khuyn
co phng chng BKLN ton cu, trong 4 yu t nguy c c c bit quan tm l ht
thuc l, s dng ru, bia mc c hi, ch dinh dng khng lnh mnh v li sng t vn
ng. Vit Nam c nhiu can thip lin quan cc yu t ny nhng mc hiu qu khc nhau.
H thng chnh sch v PCTHTL tng i y , bao gm c Lut PCTHTL v Chin
lc quc gia phng, chng tc hi ca thuc l n nm 2020 cng cc vn bn hng dn
thc hin. Chnh sch PCTHTL bao gm bn can thip ti u theo khuyn co ca WHO l:
(i) tng thu thuc l, p dng thu tiu th c bit vi thuc l; (ii) cm ton din vic qung
co, khuyn mi v ti tr thuc l; (iii) cnh bo tc hi ca thuc l; v (iv) bo v ngi dn
trc khi thuc. Cc chnh sch khc: cm mua bn thuc l ngi di 18 tui; thnh lp
qu phng chng tc hi ca thuc l; xy dng hng dn v cai nghin thuc l.
Chnh sch quc gia phng chng tc hi ca lm dng ung c cn n nm 2020
c ban hnh v Lut phng chng tc hi ca lm dng ru, bia ang c son tho. Chnh
sch kim sot tc hi ca s dng ru, bia cp n ba can thip ti u theo khuyn co
ca WHO: (i) tng thu ru, bia; (ii) hn ch tip cn vi bn l ru, bia; v (iii) cm qung
co cc sn phm ru, bia. Chnh sch khc: quy hoch sn xut ru, bia; kim sot nhp
khu sn phm ru, bia; xy dng tiu chun ru, bia; quy nh v x pht vi phm; y
mnh tuyn truyn; hng dn iu tr cai nghin ru, bia.
xy dng Chin lc quc gia v dinh dng giai on 2011-2020 v tm nhn 2030,
trong cp mt s mc tiu lin quan n dinh dng lnh mnh phng chng BKLN nh
kim sot tnh trng tha cn, bo ph v khng ch cholesterol trong mu. B Y t ban hnh
v thc hin tuyn truyn v Mi li khuyn dinh dng hp l, thnh lp khoa dinh dng
lm sng ti cc bnh vin, tin hnh o to nhn lc v dinh dng. B Gio dc v o to
a ni dung gio dc dinh dng sc khe vo chng trnh chm sc gio dc tr em nh
tr mu gio. Mt s thnh ph ln xy dng n sn xut v tiu th rau an ton. B Ti
chnh ang a ra xut nh thu tiu th c bit ln nc gii kht c ga khng cn.
xy dng mt s chnh sch, hot ng lin quan n khuyn khch hot ng th
lc nh pht ng cuc vn ng Ton dn rn luyn thn th theo gng Bc H v i trn
phm vi ton quc; xy dng n 614 nng cao tm vc ngi Vit Nam. Nhiu b, ngnh,
a phng xy dng cc k hoch, n khuyn khch rn luyn th lc, luyn tp th dc
th thao qun chng trong ngnh gio dc, i tng thanh nin, cng on. Cc chng trnh
tuyn truyn, gio dc sc khe trn O2TV c cc thng ip quan trng v khuyn khch
hot ng th lc, nng cao sc kho. Mt s khu th mi c quy hoch bo m tun th
t l xy xanh, cng vin, khu gii tr, tp luyn th dc th thao. Nhiu c s tp th dc th
thao t nhn c thnh lp.
273

3.1. Kh khn, hn ch
3.1.1. Cc chnh sch vn thiu, cha hon chnh hoc cn bt cp
Cha c cc chnh sch, chin lc tm quc gia v khuyn khch ch dinh dng
lnh mnh v tng cng hot ng th lc, c bit l cho mc tiu kim sot cc yu t nguy
c chung BKLN. Mt s chnh sch hin c ch yu phc v mc tiu ca n v iu phi
nh chnh sch v dinh dng vn ang ch trng nhiu hn cho phng chng suy dinh dng;
chnh sch v hot ng th lc vn ch trng nhiu hn cho th dc, th thao.
Cha c Lut kim sot tc hi ca lm dng ru, bia m ch mi c Chin lc kim
sot tc hi ca lm dng ung c cn n nm 2020 vi phm vi iu chnh hn ch hn.
Cha c cc quy nh gii hn thi gian v a im bn ru, bia; cha c chnh sch cm bn
ru, bia cho ngi say,
Chnh sch v PCTHTL vn cn mt s im bt cp nh mc thu cn thp dn n gi
thuc l bn l thp nn chnh sch thu cha pht huy hiu qu tch cc trong gim t l ht
thuc. Cc quy nh v x pht vi phm trong PCTHTL vn kh thc thi.
Vic phi hp gia cc b, ngnh trong vn ng xy dng chnh sch nh tng thu
tiu th c bit i vi ru, bia, thuc l; xy dng quy hoch sn xut, kinh doanh thuc l,
ru, bia; quy hoch giao thng, trng hc v cc khu th phc v mc tiu phng chng
BKLN,. vn cn gp nhiu kh khn.
3.1.2. Phi hp trin khai thc hin cc chnh sch cha t hiu qu cao
Hot ng ca cc b, ngnh, on th, a phng ch yu ch mi dng mc xy

dng k hoch, t chc tuyn truyn, cha quan tm n cng tc theo di, gim st, nh gi
kt qu thc hin cng nh lng ghp, phi hp hnh ng gia cc n v. Nguyn nhn ca
tnh trng ny l do cha c mt u mi t chc thng nht c nng lc v thm quyn iu
phi cc hot ng lin ngnh trong lng ghp cc hot ng d phng, kim sot cc yu t
nguy c chung ca BKLN. Bn cnh , cha c c ch huy ng s tham gia tch cc v s
phi hp cht ch gia cc b, ngnh, a phng, cc on th, t chc qun chng trong d
phng v kim sot cc yu t nguy c BKLN.
Vi phm cc quy nh v kim sot cc yu t nguy c chung ca cc BKLN vn cn din
ra kh ph bin nh: vi phm v qung co thuc l ti cc im bn l; vi phm v ht thuc ti
c quan, cc a im cng cng cm ht thuc; vi phm v bn thuc l v ru, bia cho ngi
di 18 tui, th ni cht lng ru th cng, s dng ru, bia trong gi lm vic, Nguyn
nhn ca vn ny l do nhn thc v tc hi ca cc yu t nguy c, hiu bit v cc chnh
sch kim sot cc yu t nguy c cng nh thc tun th cc quy nh ca ngi dn vn
cn hn ch trong khi , vic phi hp trong kim tra, gim st, x pht cc hnh vi vi phm
vn cha c thc hin nghim.
Cha c mt h thng lng ghp gim st cc yu t nguy c chung ca cc bnh BKLN:
thiu mt n v u mi gim st, cha c mt h thng bo co nh k vi b ch s gim
st y , thiu kinh ph thc hin cc cuc iu tra, kho st nh k. Mc d vy, kt qu
mt s cuc iu tra, kho st cc quy m khc nhau cho thy t l thc hnh cc kim sot
cc yu t nguy c cn hn ch (xem thm chng III v IV).
274
Chng VII: Kt lun

3.2. Cc vn u tin
Chnh sch kim sot cc yu t nguy c BKLN vn cha hon chnh v cn nhiu im
bt cp.
Thiu mt u mi v mt c ch hiu qu trong huy ng v phi hp lin ngnh trin
khai cc chnh sch kim sot cc yu t nguy c BKLN.
Thiu mt h thng theo di, gim st, nh gi y v cc yu t nguy c v kt qu
thc hin phng chng cc yu t nguy c BKLN.
Nhn thc v thc hnh ca ngi dn trong kim sot cc yu t nguy c BKLN vn
cn hn ch.
4. Tnh hnh thc hin cc chng trnh, d n phng chng bnh

khng ly nhim
4.1. Kt qu thc hin
C bn d n phng chng BKLN, bao gm bnh tng huyt p, i tho ng, ung
th, bnh phi tc nghn mn tnh v hen ph qun, cng vi D n bo v sc khe tm thn
cng ng v tr em ang c trin khai trong chng trnh mc tiu quc gia n nm 2015.
Trong nhng nm qua, cc d n ny t c mt s kt qu chnh:
a bn trin khai d n ngy cng c m rng c 3 cp tnh, huyn v x.
Hot ng truyn thng gio dc sc kho c trin khai ngy cng rng ri vi nhiu
hnh thc a dng v phong ph.
T chc tp hun, o to nng cao nng lc chuyn mn, nghip v cho mt i ng
ng k cn b y t cc tuyn.
T chc sng lc th ng cho cc i tng nguy c ti cng ng cc quy m khc
nhau.
Xy dng v cng c mng li sng lc, chn on, qun l iu tr bnh cc tuyn.
Chi tit xin xem chng V.
4.2. Kh khn, vng mc
Thiu mt m hnh, mt u mi v c ch phi hp, lng ghp hot ng ca cc d
n. Cc d n c trin khai theo ngnh dc, thiu s gn kt, cha huy ng c s
tham gia ca cc b, ngnh, t chc khc ngoi ngnh y t. Cha c mt h thng gim
st cht ch vi hot ng phng chng cc BKLN.
Quy m (a bn trin khai v mc bao ph dn s) ca cc d n vn cn hp v
chm c m rng. D n phng chng BPTNMT v hen ph qun mi ch trin
khai 25 tnh, thnh ph. Ghi nhn ung th mi c tin hnh 9 tnh, mi bao ph
c 20% dn s. Cc d n khc bao ph 63 tnh thnh ph song t l cc huyn
x tham gia vn cn hn ch. Phn b mng li cha hp l, ch yu tp trung cc
thnh ph ln.
275

Nng lc trin khai d n vn cn hn ch do thiu ht nhn lc tt c cc tuyn, nht
l tuyn y t c s. Hot ng t vn, sng lc, chn on, qun l iu tr ch yu mi
ch trin khai n tuyn tnh. Cc n v chuyn mn hoc c t chc cha hon chnh
(vi cc khoa ung bu) hoc cn thiu cc trang thit b cn thit (vi cc n v qun
l iu tr BPTNMT v hen ph qun).
Hu ht cc d n vn quan tm nhiu hn n cng tc iu tr, cha coi trng ng
mc cng tc d phng. Vic sng lc theo hnh thc th ng tn km, khng hiu qu
v kh thc hin quy m ln trong khi sng lc ch ng v sng lc c hi thng qua
khm cha bnh thng xuyn cha c trin khai. Cc hot ng t vn, khm sng
lc vn cha c BHYT thanh ton.
Thiu ngun kinh ph n nh, bn vng cho vic trin khai cc d n. c bit, nhng
nm gn y, kinh ph cho trin khai cc d n b ct gim mnh, khin cho cc d n
phi ct gim hot ng, gim quy m trin khai hoc hot ng cm chng. C kh
nng t nm ti khng cn kinh ph t NSNN cho vic trin khai cc d n ny.
Vic tip cn thuc iu tr cn gp kh khn do nhiu d n ngng vic cung cp
thuc trong khi BHYT cha thanh ton tin thuc cho cc bnh c d n (tng huyt
p, BPTNMT), vic la chn danh mc thuc tuyn c s cha hp l hoc quy nh
cp thuc cha ph hp do bnh cha c a vo danh mc bnh mn tnh (v d vi
d n phng chng tng huyt p), thuc khng sn c thng xuyn do kh u thu
(thuc iu tr tm thn).
Thiu ngun kinh ph n nh, bn vng cho vic trin khai cc d n. c bit, nhng
nm gn y, kinh ph cho trin khai cc d n b ct gim mnh, khin cho cc d n
phi ct gim hot ng, gim quy m trin khai hoc hot ng cm chng. Cc d n
c nguy c b ct ton b kinh ph t NSNN t nm ti.
Vn sc kho tm thn cha c quan tm lng ghp trong phng chng cc BKLN.
Cha c Lut v sc kho tm thn.
Ni dung t vn, truyn thng cn ngho nn, km hp dn, cha c th kh thc hin.
4.3. Cc vn u tin
Kinh ph trin khai b gim mnh, thm ch c nguy c b ct, dn n chng trnh dc
b loi b trong khi cha kp lng ghp cc hot ng vo hot ng thng xuyn
ca h thng y t.
Cha xc nh c m hnh cho vic t chc, ch o trin khai cc hot ng phng
chng cc BKLN trong thi gian ti theo hng lng ghp cc d n, u tin cho d
phng v huy ng s tham gia lin ngnh.
Nng lc trin khai cc hot ng vn cn hn ch, nht l tuyn c s. Kinh ph thc
hin m hnh sng lc trong cng ng b ct, nhng iu kin thc hin khm sng lc
BKLN trong hot ng thng xuyn ti cc c s y t cha bo m c v nhn lc,
nh trang thit b, chin lc truyn thng.
Mt s quy nh ca BHYT cha ph hp vi nhu cu c bit ca khm v iu tr bnh
mn tnh, v d nh cc hot ng t vn, khm sng lc cc BKLN cha c a vo
276
Chng VII: Kt lun

danh mc dch v c BHYT thanh ton, mt s loi thuc thit yu iu tr cc BKLN
cha c trong danh mc thuc c BHYT thanh ton, v mt s loi thuc c bn
qun l BKLN cha c ti tuyn y t c s theo danh mc thuc thit yu.
5. Tng cng h thng y t trong phng chng BKLN

5.1. Qun l, iu hnh
Vit Nam xy dng, ban hnh v trin khai, thc hin cc chnh sch v chng trnh
y t phng chng BKLN ni chung; cc d n c th i vi 5 nhm bnh tng huyt p, ung
th, i tho ng, bnh phi tc nghn mn tnh v d n bo v sc kho tm thn.
Tuy nhin, phng chng BKLN vn cha c c mc u tin v cam kt chnh tr
tng xng vi gnh nng bnh tt do BKLN; Phng chng BKLN cha tr thnh mt u tin
cao trong k hoch pht trin kinh t x hi ca ng v Nh nc. Cha c chin lc quc gia
phng chng BKLN mang tnh ton din, di hn, yu cu s tham gia ca ton chnh ph, ton
x hi. T chc b my ch o phng chng BKLN cha bo m s tham gia, hnh ng a
ngnh v cha bo m s lng ghp gia cc chng trnh phng chng BKLN v lng ghp
vi vic thc hin cc nhim v CSSK khc.
Do cha c mt k hoch chin lc phng chng v kim sot BKLN ton din nn
cc chnh sch kim sot yu t nguy c cha c xy dng y . Cc chng trnh phng
chng BKLN mi ch bao ph 5 nhm BKLN, gnh nng bnh tt ca 5 nhm bnh ny mi
ch chim gn 1/3 tng gnh nng bnh tt ca cc BKLN Vit Nam.
T chc ch o, qun l phng, chng BKLN hin nay cha ph hp vi nguyn tc
tip cn ton chnh ph, ton x hi v a ngnh. Cc chng trnh, d n phng chng BKLN
hot ng ring r, thiu s lng ghp gia cc chng trnh cng nh thiu lng ghp trong
hot ng ca h thng y t ni chung.
u t cho hot ng nghin cu phng chng BKLN cha tng xng vi gnh nng
ca cc BKLN. Thiu cc nghin cu v BKLN p ng c nhu cu xy dng, la chn
chnh sch phng chng BKLN da trn bng chng.
5.2. Nhn lc
i ng nhn lc y t, trong c nhn lc trong lnh vc BKLN, lin tc pht trin
v s lng v khng cn tnh trng thiu trm trng, ngoi tr i vi chuyn khoa tm thn.
Nhn lc trong lnh vc cc BKLN c hng cc ch , chnh sch i ng chung
cho nhn lc ca ngnh y t v cho mt s lnh vc c bit. Ring nhn lc y t thuc chuyn
khoa tm thn c xp vo nhm u tin cao nht.
Chng trnh o to cp bng bc s, iu dng hin nay bao gm cc ni dung
quan trng lin quan n BKLN. Chng trnh khung gio dc i hc cho ngnh iu dng,
bn cnh cc mn iu dng c s chung, cn c cc mn hc quan trng lin quan nhiu n
chm sc ngi b BKLN. Nhiu chng trnh o to sau i hc ti cc trng i hc, vin,
bnh vin, cung cp kin thc, k nng chuyn su hn v BKLN. Cng tc o to lin tc
c trin khai trong tt c cc d n, chng trnh mc tiu quc gia phng chng cc BKLN.
277

Nhn lc y t cng tc trong lnh vc BKLN c nh gi l cn yu, thiu v khng
ng b. Nng lc ca i ng cn b y t tuyn x khng p ng c nhim v qun l
cc BKLN, bnh mn tnh. S dng nhn lc y t trong phng chng v qun l BKLN cn
lng ph, khng c s lng ghp nhim v ca nhn lc cc tuyn v gia cc c s trong mt
tuyn, c bit l tuyn di. Cc ch chnh sch u tin cho cn b y t ni chung v cho
cc khu vc, lnh vc kh khn c ban hnh, nhng vn bt cp. Cha c c ch bo m
mt bng chung v cht lng ca cc chng trnh o to i hc, o to theo a ch v
o to sau i hc khi ngnh khoa hc sc kho dn n cht lng nhn lc mi ra trng
cha ng u. Hiu qu o to trong cc d n, chng trnh mc tiu quc gia phng, chng
BKLN khng cao. o to lin tc cho cc tuyn di c t chc ring r cho tng loi bnh,
cha c s lng ghp trong o to. Hot ng o to ca mt s trung tm o to trong bnh
vin dn tri, cha c nh hng r rng.
5.3. Ti chnh y t cho phng chng BKLN
Chnh ph b tr kinh ph u t xy mi, nng cp, m rng cc bnh vin chuyn
khoa ung bu, tim mch t NSNN, tri phiu chnh ph v x hi ha. NSNN vn l ngun
ti chnh bo m cc hot ng o to nng lc, khm sng lc, xy dng m hnh qun l
BKLN, truyn thng v theo di nh gi. BHYT l ngun quan trong cho KCB cho cc BKLN,
bao gm c cc dch v k thut cao nh can thip tim mch, iu tr ung th bng thuc phng
x. Ngoi ra kinh ph cho phng chng BKLN cn c huy ng t ngun x hi ha, vn vay,
vin tr, v tin chi tr gi dch v y t ca ngi bnh.
Ti chnh cho phng chng BKLN s dng t nhiu ngun, thiu lng ghp. Nhiu hot
ng phng chng BKLN khng c chi tr t qu BHYT, do y t d phng khng nm trong
phm vi quyn li BHYT; cha c hng dn chi tr i vi cc dch v sng lc chn on
sm, hn ch nng lc ca y t c s v s hn ch trong danh mc thuc c BHYT chi tr
y t c s. Ngun NSNN cho cc d n phng chng BKLN b ct gim, chm phn b, trong
khi gnh nng BKLN tng ln. Mc d ngun ti chnh cn hn hp cho phng chng BKLN
song cha c phn b, s dng t hiu qu cao nht, do s tch bit ngun ti chnh cho
y t d phng v iu tr, phn b cho y t d phng cha cn xng, ch yu cho iu tr
tuyn trn, cha u tin phn b ti chnh cho cc can thip c hiu qu (best buy). Phng thc
chi tr khng khuyn khch chn on pht hin sm v iu tr BKLN giai on u, khng
khuyn khch nhn vin y t. C ch ti chnh hin hnh v thit k h thng cung ng dch v
y t cha bo v c ngi dn trc chi ph y t thm ha do BKLN.
5.4. Thuc v trang thit b y t
Danh mc thuc thit yu v danh mc thuc c BHYT chi tr bao ph hu ht
cc thuc iu tr BKLN. Kim sot gi thuc thc hin hiu qu qua u thu thuc ti cc
c s y t cng lp. Danh mc trang thit b y t ti cc tuyn bao gm nhiu trang thit b cn
thit chn on v iu tr BKLN. B Y t ban hnh cc hng dn chn on v iu tr
mt s BKLN.
Cha c chnh sch u tin s dng v bo m s sn c ca thuc generic, thuc thit
yu. Danh mc thuc thit yu cho BKLN ti y t x, phng cha y , c bit l thuc
iu tr i tho ng, bnh phi tc nghn mn tnh, iu tr gim nh cho ngi bnh ung
th. Tip cn thuc iu tr BKLN cn c kh khn do thuc cha sn c trong mng li cung
278
Chng VII: Kt lun

ng dch v y t, c bit y t x phng, do chnh sch chi tr t qu BHYT cho mt s
thuc trc y c thanh ton t ngun NSNN, do bnh i tho ng, tng huyt p cha
c trong danh mc bnh mn tnh ca B Y t, do nh thu khng tham gia u thu thuc thit
yu c gi thp v do s phi hp iu tr gia cc tuyn iu tr. Danh mc trang thit b tiu
chun ca TYT x, phng c bc s thiu mt s thit b n gin, cn thit cho vic thc hin
cc can thip thit yu phng chng BKLN.
5.5. Thng tin v gim st phng chng BKLN
H thng thng tin thng k y t ca Vit Nam, vi cc tiu h thng thng tin y t t cc
bnh vin bt u thu thp d liu v BKLN t bnh vin. M hnh ghi nhn ung th cng
da trn s liu bo co t bnh vin. Vit Nam thc hin c mt iu tra quc gia theo
phng php STEPwise.
Thiu thng tin cp nht, c h thng, da trn cng ng v xu hng din bin cc yu
t nguy c (bao gm nhm nguy c t hnh vi, li sng v nguy c trung gian), v tnh hnh mc
bnh, t vong. B ch s gim st nh gi hot ng phng chng BKLN cha c cp nht
thng nht vi khung theo di ton cu ca WHO (global monitoring framework); cc d
liu, ch s v BKLN c thng k nhiu ngun khc nhau, khng y . S liu thng k
v cc yu t nguy c cha c lng ghp vo h thng thng k y t. H thng ng k h tch
cha ghi nhn tt nguyn nhn t vong cng ng; Cht lng ghi nhn ung th cn hn ch.
5.6. Mng li cung ng dch v y t trong phng chng BKLN
Mng li cc c s chn on v iu tr ung th, tim mch, ni tit, lao v bnh phi,
bo v sc kho tm thn tip tc pht trin, thc hin cc gii php nng cao nng lc cho y t
c s. Cc hot ng t vn, truyn thng gio dc sc kho phng chng BKLN c trin
khai vi cc hnh thc phong ph.
Mng li cung ng dch v b phn mnh, thiu s lng ghp gia d phng v iu
tr, gia y t c s, c bit l y t x, phng vi cc c s y t tuyn trn, t chia s thng tin
v ngi bnh gia cc c s y t, cha thc hin c chm sc lin tc, cha bo m c
cch tip cn ly ngi dn lm trung tm trong phng chng BKLN.
Cha xc nh c gi dch v thit yu, hiu qu v kh thi v t vn, d phng, pht
hin sm, iu tr, chm sc trong phng chng BKLN cho y t c s v cha c s phn nh
trch nhim thc hin gi dch v trn cho y t x, phng v y t huyn.
Y t c s cha nng lc cung cp cc dch v thit yu phng chng BKLN, do hn
ch v nng lc chuyn mn, thuc, trang thit b v ngun ti chnh. Chm sc gim nh cha
c thc hin y t c s v trong cng ng.
Ngun lc vn hn ch ca ngnh y t mt s tnh, thnh ph c nguy c tip tc b
phn tn do xu hng tip tc xy dng mi cc bnh vin chuyn khoa iu tr cc BKLN, nh
bnh vin tm thn, bnh vin ung th, bnh vin lao v bnh phi.
279
Chng VIII: Khuyn ngh

T kt qu nh gi tnh trng sc kho nhn dn v cc yu t nh hng ti sc kho,
cp nht thc trng h thng y t v phn tch su chuyn Tng cng d phng v kim sot
cc BKLN, bo co khuyn ngh cc gii php nhm p ng nhu cu chm sc sc kho nhn
dn, ng ph vi cc yu t nh hng ti sc kho (xem chi tit Chng I), thc hin tt hn
cc nhim v ra trong K hoch 5 nm v Mc tiu thin nin k (xem chi tit Chng
II), gii php nhm tng cng kim sot cc yu t nguy c chung (xem chi tit Chng
IV), thc hin tt hn cc chng trnh mc tiu quc gia phng chng BKLN (xem chi tit
Chng V) v tng cng p ng ca h thng y t trong d phng, kim sot cc bnh khng
ly nhim (xem chi tit Chng VI). Di y l tng hp cc khuyn ngh chung ca bo
co. Khuyn ngh chi tit c trnh by cui mi chng.
1. nh hng h thng y t p ng vi tnh hnh bnh tt, yu

t nguy c hin nay ca Vit Nam
1.1. Xy dng chin lc ph hp i vi cc nhm bnh u tin
i vi bnh truyn nhim c cc can thip vc xin, gim st dch bnh, tuyn truyn
gio dc sc khe, khm sng lc sm, iu tr bnh truyn nhim trnh ly lan, x l
cc yu t mi trng (nc sch, v sinh, mi trng sinh sn mui,).
i vi tai nn, thng tch thc hin cc can thip ngi tham gia giao thng tun
th Lut giao thng, i m bo him, khng li xe khi say ru. Tng cng hiu qu
ca dch v cp cu ng b.
i vi BKLN, tp trung vo phng chng cc yu t nguy c v khm sng lc pht
hin sm v qun l bnh hiu qu.
1.2. Gim s khc bit gia cc vng min
Xy dng chin lc ph hp gim s khc bit i vi cc ch s sc khe c bn
bao gm tui th, t vong tr em, t vong m, suy dinh dng tr em. Trong chin lc,
bo m u tin trong phn b ngn sch, xy dng can thip hiu qu chi ph ph hp
vi vng kh khn, v theo di, gim st cht ch trong cc bo co ln lnh o cao cp
bo m trch nhim gii trnh.
1.3. Gim tc hi ca cc yu t nh hng sc khe
Xy dng c s bng chng v tc hi ca cc yu t, vn ng cc b, ngnh tng
cng u t thc hin cc can thip gim yu t nguy c.
Tng cng gim st tnh hnh cc yu t nguy c i vi sc khe (v d nh ht thuc
l, s dng ru/bia, ch n, hot ng th lc, nhim mi trng, thin tai). Gim
st tc ng ca cc can thip ti cc yu t nguy c.
Xy dng, iu chnh v thc hin cc k hoch i ph vi cc yu t nguy c da trn
thng tin gim st, nh gi tc ng ca cc hot ng ang thc hin.
Tng cng tuyn truyn tng thc v kin thc ca ngi dn i vi cc yu t nguy
280

c v cc i ph. Thc hin cc can thip to iu kin thun li cho ngi dn thc
hin hnh vi c li cho sc khe.
Xy dng v ban hnh nhng chnh sch bo m cc n v sn xut quan tm nhiu
hn na ti mi trng lao ng, sc khe ca ngi lao ng.
2. Thc hin nhim v ca K hoch 5 nm v Mc tiu Thin nin

k v y t
2.1. Tng cng nng lc qun l ca ngnh y t
Ci thin nng lc v nng cao cht lng chin lc, chnh sch, quy hoch y t.
Nng cao vai tr v nng lc qun l, lp k hoch y t.
Cng c, hon thin v n nh b my t chc ngnh y t t trung ng n a phng.
Tng cng cng tc thanh tra, kim tra, gim st.
Tng cng s tham gia cc bn lin quan trong qu trnh hoch nh chnh sch, xy
dng v trin khai k hoch y t.
y mnh cc hot ng x hi ha mt cch hp l; Khuyn khch cc thnh phn kinh
t u t pht trin cc dch v y t.
2.2. Nhn lc y t
Xy dng i ng nhn lc y t v s lng v bo m v cht lng, cn i v c
cu v phn b hp l, p ng nhim v bo v v chm sc sc khe nhn dn.
Tip tc cc n lc, chin lc trong s dng ngun nhn lc y t.
Tip tc ci thin cht lng o to ti cc c s o to nhn lc y t.
Tip tc ci thin cng tc qun l o to lin tc nhn lc y t.
2.3. Ti chnh y t
Tng chi NSNN cho y t, tng t l chi cng cho y t, gim t l chi tin ti cho y t.
u tin phn b NSNN cho y t d phng, y t c s, CSSKB, thc hin chnh sch
x hi v y t.
Pht trin BHYT ton dn bn vng.
Tip tc i mi c ch hot ng, c ch ti chnh trong cc n v s nghip y t
cng lp.
i mi phng thc chi tr dch v khm cha bnh.
Bo m thuc thit yu phc v cng tc iu tr.
281

Kim sot cht ch gi thuc.
Tng cng qun l cht lng thuc v s dng thuc an ton hp l.
y mnh pht trin thuc ng y v thuc t dc liu.
Tng cng sn xut trang thit b y t trong nc.
Tng cng c s vt cht ca cc n v s nghip y t.
2.5. Thng tin y t
Hon thin chnh sch, k hoch tng th pht trin h thng thng tin.
Hon thin h thng ch s, s sch ghi chp v bo co thng k y t cho khu vc y t
nh nc v t nhn.
Tng cng kh nng p ng nhu cu s dng thng tin, s liu.
p dng cng ngh thng tin trong thng tin y t.
2.6. Cung ng dch v
Kin ton v cng c mng li y t c s.
y mnh cc hot ng YTDP, trin khai hiu qu cc d n ca chng trnh mc tiu
quc gia v y t.
Hon thin h thng chnh sch, cng c mng li v thc hin tt cc hot ng dn
s-KHHG v chm sc sc khe sinh sn.
Nng cao cht lng dch v KCB.
Chng qu ti bnh vin.
Nng cao nng lc qun l bnh vin.
Tng cng kim sot cht lng dch v YHCT.
2.7. Thc hin Mc tiu Pht trin Thin nin k
N lc trin khai thc hin 6 nhm gii php trong Ngh quyt s 05/NQ-CP ca Chnh
ph v vic y mnh thc hin cc Mc tiu pht trin Thin nin k ca Lin Hp Quc trong
lnh vc y t, bao gm:
Nng cao nhn thc, tng cng lnh o, ch o ca cp y ng, chnh quyn cc cp
v thc hin cc Mc tiu thin nin k trong lnh vc y t.
Tng cng huy ng cc ngun ti chnh.
Tng cng hp tc quc t.
Phi hp lin ngnh trong thc hin cc Mc tiu Thin nin k v y t.
Trin khai tt cc gii php chuyn mn k thut.
282

Cng c, nng cao nng lc h thng y t, c bit l y t c s, y t min ni, vng su,
vng xa trong thc hin cc Mc tiu Thin nin k v y t.
3. Tng cng kim sot cc yu t nguy c chung

3.1. Hon thin h thng php lut
Nng cao nng lc vn ng xy dng chnh sch.
Tng bc hon thin cc chnh sch kim sot cc yu t nguy c chung ca cc BKLN.
3.2. Tng cng t chc, ch o, iu phi hot ng
i vi c quan ch o: xy dng mt m hnh t chc thng nht qun l hot ng
kim sot cc yu t nguy c trong khun kh mt u mi t chc, ch o phng
chng BKLN c nng lc, thm quyn huy ng lin ngnh v s tham gia ca
ton x hi.
i vi c quan iu phi: xy dng m hnh t chc ph hp v nng cao nng lc
ca c quan iu phi trong ch o, iu phi cc hot ng d phng, kim sot cc
yu t nguy c.
3.3. Theo di, gim st v nh gi cc yu t nguy c
Thit lp h thng gim st c hiu qu v cc yu t nguy c v cc hot ng kim sot
cc yu t nguy c chung ca cc BKLN.
Tng cng hot ng kim tra, nh gi kt qu hot ng kim sot cc yu t
nguy c.
3.4. Kim tra thi hnh cc quy nh kim sot yu t nguy c
Tng cng cng tc tuyn truyn, gio dc sc kho, ph bin php lut (v d cc quy
nh v chng tc hi ca thuc l).
Tng cng phi hp lin ngnh trong kim tra, x pht nghim cc vi phm nhm nng
cao nhn thc v thc hnh ca ngi dn v kim sot cc yu t nguy c.
4. Thc hin cc chng trnh mc tiu quc gia phng chng bnh
khng ly nhim
4.1. Lng ghp vo h thng y t
Tng cng v lng ghp cc hot ng truyn thng, gio dc phng chng cc BKLN
vi cc chng trnh truyn thng gio dc sc kho khc.
Lng ghp cc dch v qun l, iu tr BKLN vo h thng cung ng dch v, c bit
l mng li y t c s.
B sung mt s dch v lin quan ti phng chng BKLN vo danh mc cc dch v KCB
c BHYT chi tr, nh dch v t vn, mt s dch v sng lc, pht hin sm BKLN.
283

o to, pht trin nhn lc phng chng BKLN. Tng cng v m rng cc hnh thc
o to tng kin thc v phng chng BKLN cho bc s a khoa, iu dng, k thut
vin v dc s cc tuyn, c bit tuyn y t c s. o to chuyn ngnh tim mch,
ung bu, ni tit chuyn ha, bnh phi, tm thn.
4.2. D n phng chng tng huyt p
Th im m hnh ghp khm sng lc tng huyt p trong qu trnh khm cha bnh
thng thng i vi i tng t 40 tui tr ln.
T chc iu tr tng huyt p ti cc tuyn c s, ch yu l cc trm y t x, da vo
Hng dn chn on v iu tr tng huyt p ca B Y t 2010 i vi ngi khng c
bin chng. Xy dng quy chun v pht hin, qun l, iu tr tng huyt p ti trm y
t x, lng ghp vo tiu ch quc gia v y t x.
Nhn mnh qun l tng huyt p bng thay i li sng, c th l gim cn nu tha
cn, bo ph; b ht thuc; n nhiu hoa qu, rau, sn phm t sa, t cht bo, c bit t
cht bo bo ha; gim tiu th mui; tng tiu th kali, hot ng th lc thng xuyn;
hn ch lng ru, bia c tiu th [205].
Xem xt iu chnh danh mc thuc iu tr tng huyt p trong danh mc thuc c
BHYT thanh ton ti tuyn x. La chn thuc da trn bng chng v hiu qu v an
ton, cng vi cc quy nh lin quan n thi gian cp thuc nh k ph hp vi vic
iu tr bnh mn tnh.
4.3. D n phng chng ung th
Tng cng nng lc ghi nhn v qun l ung th, nh gi hiu qu ca k hoch hot
ng phng chng ung th. y mnh nghin cu dch t trong phng chng ung th v
hon thin h thng d liu quc gia v ung th.
Tip tc u t xy dng cc c s chn on, iu tr ung bu tuyn trung ng v
tuyn tnh; Nng cao chuyn mn nghip v thng qua n Bnh vin v tinh, chuyn
giao k thut.
Thc hin khm sng lc pht hin sm ung th trn din rng i vi mt s loi ung
th c th pht hin sm (v d ung th v, c t cung). Xy dng hng dn, o to
nhn lc v xem xt cc iu kin cn thit a khm sng lc ung th vo nhm dch
v c BHYT thanh ton.
Nhn mnh cc hot ng d phng ung th nh b ht thuc, tiu th ru, bia mc
hp l, hn ch dng cht t nu n trong nh, gim cn, thc hin ch n nhiu
rau qu, cht x, calxi v t tht b, tht ch bin, ung ngt, mui, v khi lm vic
trong iu kin c hi, phi tun th cc quy nh bo h lao ng.
Thnh lp v a vo hot ng cc n v iu tr au v chm sc gim nh ti cc c
s phng chng ung th hin c. Xy dng m hnh chm sc ngi bnh ung th giai
on cui ti c s.
284

4.4. D n phng chng i tho ng
Nhn mnh cc hot ng d phng i tho ng nh b ht thuc, tiu th t ru,
bia, gim cn, thc hin ch n nhiu ng cc nguyn ht, t tht b, t tht ch bin,
t ung ngt.
Chuyn i hot ng sng lc bnh i tho ng sang m hnh sng lc ch ng v
sng lc c hi lng ghp trong qu trnh khm cha bnh thng thng. Thc hin sng
lc ti cc trm y t c nng lc tin hnh xt nghim glucose mu.
Hon thin mng li phng chng i tho ng bao gm cc c s iu tr v cc c
s phng chng i tho ng ti cng ng.
Xy dng v m rng cc phng t vn dinh dng cho ngi i tho ng, ti phng
khm ca cc bnh vin v trm y t x.
4.5. D n phng chng bnh phi tc nghn mn tnh v hen ph qun
Tng cng cc hot ng d phng v qun l iu tr bnh ti tuyn huyn, x. Nhn
mnh cc hot ng d phng bnh nh b ht thuc, hn ch s dng cht t nu
n, s dng phng tin bo h lao ng nu lm vic trong iu kin tip xc vi ht
tri ni (particulates).
B sung, iu chnh danh mc thuc iu tr bnh phi tc nghn mn tnh v hen ph
qun c qu BHYT chi tr trong iu tr ngoi tr cho tt c cc tuyn.
Trang b cho tuyn y t c s my o chc nng h hp t chun v dng c filter lc
khun gip chn on chnh xc v qun l theo di bnh nhn c tt. Trang b
thm my th khng xm nhp, my th xm nhp cho tuyn tnh v mt s bnh vin
a khoa khu vc iu tr bnh nhn b suy h hp.
4.6. D n bo v sc kho tm thn
Xy dng Chin lc quc gia v sc khe tm thn giai on 2015-2020. B Y t
xut Chnh ph v Quc hi v vic xy dng d n Lut Sc khe tm thn. Trong
nhn mnh vo tng cng yu t bo v v gim yu t nguy c trong cng ng,
trng hc, h gia nh, ni lm vic.
Thit lp Ban ch o quc gia v sc khe tm thn tng cng lnh o, qun l,
hp tc lin ngnh hiu qu v sc khe tm thn.
Xy dng, chun ha cc ti liu o to, gio trnh o to v chm sc sc khe tm
thn v chm sc x hi. Hon thin cc quy trnh chuyn mn, k thut trong khm
sng lc, chn on, iu tr ri lon tm thn.
R sot c ch ti chnh hin hnh, bo m ngun ti chnh bn vng cho CSSK tm
thn t ngun BHYT v NSNN.
Cung cp dch v sc khe tm thn v chm sc x hi ton din, lng ghp v da
vo cng ng. c bit, CSSK tm thn cho tr em, ph n, ngi ngho, sau thin tai,
thm ha.
285

Xy dng, hon thin chnh sch nhm dch chuyn cc cng tc chm sc, iu tr i
vi mt s bnh l tm thn t cc c s iu tr di ngy chuyn khoa tm thn sang
cc c s y t khng chuyn khoa v chm sc ti cng ng.
Pht trin mng li nhn vin cng tc x hi (social workers), tm l lm sng p ng
nhu cu CSSK tm thn v chm sc x hi.
Thc hin nghin cu, iu tra dch t hc v cc ri lon tm thn Vit Nam. Tng
cng h thng thng tin, bng chng v nghin cu v sc khe tm thn. Xy dng v
trin khai khung theo di, nh gi thc hin chin lc.
5. Tng cng h thng y t trong d phng v kim sot BKLN

5.1. Qun l, iu hnh
Hon thin m hnh t chc ch o phng chng BKLN c s tham gia ca i din
cc b, ngnh, t chc x hi cng c phi hp lin ngnh, v phn b kinh ph v
giao trch nhim cho mt s cn b chuyn trch ch o, iu hnh hot ng phng,
chng BKLN.
Lng ghp cc hot ng phng, chng BKLN vo cc hot ng y t ti tuyn y t c
s. Trong giai on u, song song vi vic lng ghp mt phn hot ng gia cc
chng trnh dc, cn trin khai thc hin k hoch chin lc nng cao nng lc ca h
thng cung ng dch v y t ly CSSKB lm nn tng.
Nhng hot ng c th lng ghp gia cc chng trnh phng chng BKLN trong giai
on u l cc hot ng truyn thng, o to lin tc nng cao nng lc, sng lc
pht hin sm.
5.2. Nhn lc
S dng hp l nhn lc y t trong phng chng BKLN, trong , tuyn y t c s thc
hin tt CSSKB trong phng chng v qun l BKLN, cc tuyn trn c nhim v
trong h tr chuyn mn, o to, theo di gim st v iu tr chuyn su. Tng cng
i ng, khuyn khch nhn lc cng tc y t c s.
Tng cng hot ng o to lin tc c lng ghp gia cc CTMTQG, cc d n v
cc c quan, ph hp vi nhu cu ca tng tuyn CSSK, c gim st cht lng o to,
xc nh mc tiu u ra. u tin o to nhn lc y t c s, phi hp o to vi h
tr, gim st chuyn mn sau o to.
Xy dng chnh sch, ch h tr khuyn khch cn b y t c s tham gia o to
lin tc, tng cng hnh thc o to v h tr lin tc ti ni lm vic cho cn b y t
x. Thc hin gii php bt buc tham gia o to lin tc nh cp chng ch hnh ngh
c thi hn, vic cp v cp li chng ch i hi thi kim tra trnh tay ngh chuyn
mn v tham gia cc chng trnh o to lin tc.
T chc h tr pht trin ngh nghip cho cc nhn vin y t trong lnh vc BKLN ngay
ti ni lm vic, nh trong hot ng chuyn giao cng ngh v bnh vin v tinh.
286

5.3. Ti chnh
Tng kinh ph cho hot ng phng chng BKLN t NSNN, BHYT v Qu phng
chng tc hi ca thuc l.
Sa i Thng t lin tch 09/2009/TTLT-BYT-BTC ngy 14/8/2009 hng dn thc
hin BHYT iu chnh mc phn b qu KCB BHYT ph hp vi nhu cu chm sc
iu tr cc BKLN ti y t x, phng.
Tng cng u tin trong phn b kinh ph cho lnh vc d phng/nng cao sc khe,
CSSKB, gim st BKLN.
Sa i Lut BHYT v cc vn bn hng dn tng mc bao ph BHYT i vi
cc dch v p ng nhu cu phng chng BKLN. Xc nh gi dch v c bn phng
chng BKLN da trn bng chng v chi ph hiu qu.
5.4. Thuc v trang thit b y t
Xy dng, chun ha danh mc thuc iu tr BKLN sa i Danh mc thuc c
qu BHYT chi tr, b sung cc thuc iu tr BKLN vo danh mc thc hin c
cc can thip thit yu phng, chng BKLN y t c s c tham kho khuyn co ca
WHO.
R sot li quy nh u thu thuc, c c ch u tin i vi thuc c th, gi thnh
thp to thun li cho u thu hoc ch nh thu.
Cp nht danh mc bnh mn tnh, b sung mt s BKLN vo danh mc bnh mn tnh
thun li cho vic k n cp thuc cho ngi bnh tng huyt p, i tho ng v
bnh phi tc nghn mn tnh.
Sa i, b sung danh mc trang thit b tiu chun ti trm y t x phng c bc s
p ng vic thc hin cc can thip thit yu phng chng BKLN y t c s c tham
kho khuyn co ca WHO.
B sung chnh sch v vic tip cn, u tin s dng thuc gc, thuc thit yu trong
Lut Dc.
5.5. Thng tin v gim st phng chng BKLN
Cng c hon thin h thng theo di, gim st phng chng BKLN v cc yu t nguy
c: (i) cp nht b ch s theo di, gim st phng chng BKLN v cc yu t nguy c
cho ph hp, trn c s khung theo di ton cu ca WHO, (ii) cng c h thng bo co
thng k bnh vin, c bit v tnh hnh mc BKLN, phn theo tui, gii, v (iii) o
to cn b v c chnh sch i ng thch hp nng cao cht lng ghi nhn ung th.
Nghin cu trin khai gim st t vong ti cng ng da trn thng k t vong ti trm
y t x (Cng c li s A6/YTCS, biu mu, hng dn v quy trnh bo co t vong,
tng cng nng lc cn b thng k v cht lng ghi chp ti TYT x) trong khi cha
hon thin c h thng ghi nhn nguyn nhn t vong ti cng ng.
Trin khai iu tra cc yu t nguy c ca BKLN theo phng php STEPwise vo
nm 2015.
287

Xy dng quy ch v qun l, cp nht, trao i v lu tr thng tin sc kho ca ngi
mc BKLN trong mng li KCB v gia cc c s KCB gp phn thc hin yu cu
chm sc lin tc BKLN.
Bo m cc iu kin (nhn lc, thuc, trang thit b, ti chnh) cung cp c cc
dch v thit yu phng chng BKLN, bao gm c chm sc gim nh.
Tng cng nng lc ca cc bnh vin a khoa v lng ghp hot ng phng chng
BKLN trong bnh vin a khoa tuyn tnh, thay v xy dng thm cc bnh vin chuyn
khoa mi.
Xy dng v thc hin D n i mi cung ng dch v y t tuyn c s (t huyn tr
xung) theo hng ly CSSKB lm nn tng, thc hin phi hp, lng ghp YTDP,
nng cao sc khe, KCB, phc hi chc nng, bo m s kt ni v h tr gia cc
tuyn y t.
Xy dng gi cc dch v thit yu phng chng BKLN, trong c dch v thit yu
chm sc sc kho tm thn cho y t x, phng v y t huyn cho giai on 2015-2020,
c tham kho khuyn co ca WHO.
288
289
n v
Phn t
Ton quc
Ton quc
Ton quc
1000
VND
Trn
10 000
dn
Trn
10000
dn
Tng chi y t bnh qun

u ngi hng nm
(gi hin hnh)
T l chi trc tip t tin

ti ca h gia nh cho
chm sc y t trong tng
chi tiu y t
S bc s trn 10 000
dn
S dc s i hc trn
10 000 dn
939,6
741,6
ng Nam B
ng bng sng Cu
Long
1,77
6,59
656,4
Ty Nguyn
1,8
7,2
44,84
642,0
Bc Trung B v duyn
hi min Trung
50,5
454,8
Trung du v min ni
pha Bc
1,579
890,4
1,263
Ton quc
46,55
6,36
2010
ng bng sng Hng
42,2
6,6
2009
Ton quc
T l chi tiu cng cho y

t trong tng chi y t
Ton quc
Tng chi cho y t so vi

GDP
Ti chnh y t, nhn lc y t v c s h tng y t
Cc ch s u vo v qu trnh
Cc ch s
gim st
1,9
7,33
45,58
1,963
45,23
6,20
2011
1,96
7,46
48,83
1003,2
981,6
789,6
808,8
684,0
1162,8
2,184
42,56
5,97
2012
Nm
2,01
7,5
2013
1,8
8,0
50%
2015
Ph lc: Cc ch s gim st v nh gi
KH 5 nm
KH 5 nm
Loi
ch s
B Y tNGTKYT
B Y tNGTKYT
B Y tTKYTQG
TKYTQG
B Y tTKYTQG
B Y tTKYTQG
Ngun
thng tin
290
T l trm y t x/
phng c h sinh hoc
y s sn nhi
Trn
10000
dn
S ging bnh ni tr
trn 10 000 dn (khng
bao gm TYT x)
T l trm y t x/
phng c bc s
n v
Cc ch s
gim st
78,4
80,1
95,7
96,3
94
96,2
95,4
97,2
96,1
ng Nam B
ng bng sng Cu
Long
Ton quc
ng bng sng Hng
Trung du v min ni
pha Bc
Bc Trung B v duyn
hi min Trung
Ty Nguyn
ng Nam B
ng bng sng Cu
Long
58,2
Trung du v min ni
pha Bc
49,5
73,2
ng bng sng Hng
Ty Nguyn
67,7
Ton quc
65,9
0,68
T nhn
Bc Trung B v duyn
hi min Trung
20,8
2009
Cng lp
Phn t
97,3
97,5
96,7
96,6
95,3
92,5
95,6
80,7
80,5
57,8
66,2
61,9
75,7
70,0
21,7
2010
99,1
100
99,2
90,5
89,7
95,3
95,3
82,2
85
66,5
66
63,5
77,5
71,9
22,5
2011
96,7
99,1
97
94,5
95,1
92,2
96,4
87,2
83,4
69,7
68,8
66,4
78,7
73,5
1,1
23,5
2012
Nm
100
99,2
99,6
96,1
91,3
93,3
97,3
84
84,3
75,7
69
67,3
82,5
76,9
1,1
24,2
2013
>95
80
23
2015
KH 5 nm
KH 5 nm
KH 5 nm
Loi
ch s
B Y tNGTKYT
B Y tNGTKYT
Cc QL KCB
B Y tNGTKYT
Ngun
thng tin
291
S c s bn l thuc
trn 10 000 dn
Trn
10000
dn
T l thn, bn c nhn
vin y t thn bn hot
ng (nng thn)
T l x t Tiu ch
quc gia v y t (Tiu
ch mi p dng t nm
2011 nhng s liu nm
2011-2012 ln ln tiu
ch c v mi)
n v
Cc ch s
gim st
92,2
65,4
(20012010)
78,6
55,4
61
48,1
ng bng sng Cu
Long
Ton quc
ng bng sng Hng
Trung du v min ni
pha Bc
Bc Trung B v duyn
hi min Trung
Ty Nguyn
Ton quc
4,9
72,7
99,9
ng Nam B
ng bng sng Cu
Long
97,8
Ty Nguyn
72,5
80,1
(20012010)
96
Bc Trung B v duyn
hi min Trung
ng Nam B
92,4
97,1
Trung du v min ni
pha Bc
86,5
87,5
64,7
73,8
74,3
91,1
99,9
97,2
98,2
97,8
98,4
97,8
ng bng sng Hng
97,5
2010
96,6
2009
Ton quc
Phn t
4,6
88,6
90,2
61,1
72,5
61,9
89,6
76,8
92,5
99,9
98
98
96,2
97,9
96,9
2011
4,4
87,1
90,7
61,9
68,5
53
90,3
73,4
90,8
96,6
98,1
97,9
96,3
98
96,6
2012
Nm
4,5
43,1
66,9
37,2
36,8
29,2
36,6
42
81,9
100
92,1
88,9
94
96,1
91,5
2013
60
(20112020)
90
2015
KH 5 nm
KH 5 nm
Loi
ch s
Cc Qun l
Dc
B Y tNGTKYT
B Y tNGTKYT
Ngun
thng tin
292
n v
Phn t
S ngy
S ngy iu tr trung
bnh ca 1 t iu tr
ni tr
6,9
10,8
11
6,7
Ton quc
Trung ng
Ngnh
Tnh v huyn
Ton quc
1330
3770
Ton quc
Ton quc
2009
T l ph n c
khm thai t nht 3 ln,
mi k mt ln
T l ph n c thai
c tim phng mi
vc xin un vn
Ton quc
Ton quc
93,7
bao ph, tc ng ca can thip, yu t v hnh vi nguy c
Ch s u ra
Trn
10000
dn
S lt ngi bnh iu
tr ni tr trn 10000
dn
T l dn s KCB trong
12 thng qua
Trn
10000
dn
S lt khm bnh trn

10 000 dn
Tip cn dch v; dch v an ton c cht lng
Ch s u ra
Cc ch s
gim st
93,5
79,2
40,9
7,1
11
10,3
7,35
1370
3980
2010
94,6
86,7
6,61
6,55
9,41
6,83
1374
3988
2011
95,5
89,4
39,2
6,57
8,53
9,51
6,89
2012
Nm
95,7
84,5
2013
Loi
ch s
MDG, CTMTQG, KH
80 (87*)
Hnh ng
quc gia*
2015
B Y tCTMTQG
B Y tCTMTQG
Ring nm
2013: GSOTBDS
TCTK-KSMS
B Y tNGTKYT
B Y tNGTKYT
B Y tNGTKYT
Ngun
thng tin
293
n v
Cc ch s
gim st
T l tr em di 1 tui
c tim chng y
(7 loi vc xin nm
2010 v 8 loi vc xin t
2011-2013)
T l ph n c
cn b y t
T l b m v tr s
sinh c chm sc sau
sinh
T l ph n trong nhm
tui 15-49 p dng bin
php trnh thai
T l ngi dn c
BHYT
T l ngi iu tr ni
tr, ngoi tr c BHYT
hoc th min ph
74,1
61,2
60,4
66,6
70,9
Ngho nht
Cn ngho
Trung bnh
Trn trung bnh
Kh, giu
60,3
78
87,8
66,7
58,2
89,2
97,1
Ton quc
Ton quc
Ton quc
Ton quc
94,4
96,1
Ton quc
94,1
95,9
ng Nam B
ng bng sng Cu
Long
88,1
93,8
96,2
97,3
94,5
Ty Nguyn
94,3
Trung du v min ni
pha Bc
98,6
95,8
98,5
ng bng sng Hng
94,6
2010
Bc Trung B v duyn
hi min Trung
96,3
2009
Ton quc
Phn t
65,0
78,2
87,2
97,2
94,8
96,8
95,4
95
94,5
98,2
96,0
2011
75,3
69,4
66,6
67,7
81,5
72,1
66,4
76,2
87,3
97,9
95,0
93,3
96,5
97,1
95,5
97,7
95,9
2012
Nm
68,5
77,2
87,9
97,8
91,6
93,0
81,8
90,9
90,6
94,0
91,4
2013
B Y tCTMTQG
MDG, KH
5 nm
70
70,1
85
CTMTQG
CTMTQG
TCTK-KSMS
B Y t
TCTK-DTBDS
B Y tCTMTQG
B Y tCTMTQG
Ngun
thng tin
Loi
ch s
MDG, CTMTQG, KH
96 (98*)
Hnh ng
quc gia*
>90
>90
>90
>95
>90
>95
>90
2015
294
2,24
2,21
2,65
1,69
1,84
Trung du v min ni
pha Bc
Bc Trung B v duyn
hi min Trung
Ty Nguyn
ng Nam B
ng bng sng Cu
Long
69
2,11
ng bng sng Hng
Trn
100000
Ton quc
tr
sng
2,03
Ton quc
T s t vong m
(MMR)
Tng
0,9
Ton quc
75,6
S con
Mc gim t l sinh
hng nm
70,2
72,8
2009
Nam
Ton quc
Phn t
Tng t sut sinh (TFR):

S con bnh qun mt
ph n tui sinh da
trn t sut sinh c
trng theo tui
Tui
n v
Tui th trung bnh
Tnh trng sc khe
Ch s tc ng
Cc ch s
gim st
1,8
1,68
2,63
2,21
2,22
2,04
Gim
0,5
75,7
70,3
72,9
2010
1,8
1,59
2,58
2,21
2,21
2,06
1,99
Gim
0,5
75,8
70,4
73,0
2011
1,92
1,57
2,43
2,32
2,31
2,11
2,05
Tng
0,3
75,8
70,4
73,0
2012
Nm
1,92
1,83
2,49
2,37
2,11
2,18
2,10
Tng
0,1
75,9
70,5
73,1
2013
58,3
1,86
Gim
0,1
74
2015
MDG, KH
5 nm
KH 5 nm
KH 5 nm
Loi
ch s
TCTK, TDTDS
TCTK, TDTDS
v TBDS
TCTK, DTBDS
TCTK, TDTDS
v TBDS
Ngun
thng tin
295
Ton quc
Ton quc
Ton quc
Trn
1000 tr
sng
Trn
100000
dn
Trn
100000
dn
Trn
100000
dn
T sut t vong tr em
di 5 tui (U5MR)
T l pht hin bnh lao

(cc th)
T l pht hin lao phi

(AFB+)
T l iu tr khi lao
phi AFB+ mi (DOTS)
T l ngi ht thuc l
(trn 18 tui)
T l h gia nh nng
thn c nh tiu hp v
sinh
T l h gia nh nng
thn s dng nc hp
v sinh
10,0
13,3
ng Nam B
ng bng sng Cu
Long
Ton quc
Ton quc
Ton quc
79
48
90,6
52,2
(59,6)
114,1
24,1
27,3
Ty Nguyn
Ton quc
17,2
Bc Trung B v duyn
hi min Trung
24,5
Trung du v min ni
pha Bc
T sut t vong tr em
di 1 tui (IMR)
12,4
ng bng sng Hng
Trn
1000 tr
sng
16,0
2009
Ton quc
Phn t
n v
Cc ch s
gim st
75
51,4
47,4
90,5
52,7
(60,0)
113,9
23,8
12,6
9,6
26,8
17,1
24,3
12,3
15,8
2010
89,4
(90%)
71,4
(63%)
90,8
57,7
114
23,3
12,2
9,3
24,3
17,1
23
12,5
15,5
2011
91,1
57,5
113,9
23,2
12
9,2
26,4
17,1
23,5
12,3
15,4
2012
Nm
94
67
23,1
12,0
9,1
26,1
17,0
23,2
12,2
15,3
2013
85
65
19,3
14,8
2015
MDG
MDG
MDG, KH
5 nm
MDG, KH
5 nm
Loi
ch s
B Y tCTMTQG (JMP)
B Y tCTMTQG (JMP)
B Y t
B Y tCTMTQG
B Y tCTMTQG (NGTKYT 2011)
B Y tNGTKYT
TCTK-DTBDS
TCTK-DTBDS
Ngun
thng tin
296
Ton quc
Trn
100000
dn
Trn
100000
dn
Trn
100000
dn
T l pht hin mc st
rt trong nm
T l mc bnh phong
T l pht hin mc
bnh phong trong nm
T l tng trng dn s
Triu
ngi
Ton quc
Trn
100000
dn
S trng hp SXH
trong nm trn 100000
dn
Dn s
Ton quc
T l ph n t 15-49
tui c nhu cu KHHG
cha c p ng
86,9
5,2
14,6
19,6
11,1
18,9
5,1
14,1
17,2
25,5
Trung du v min ni
pha Bc
Bc Trung B v duyn
hi min Trung
Ty Nguyn
ng Nam B
ng bng sng Cu
Long
Thnh th
26,5
17,3
18,9
11,2
19,8
86,02
Ton quc
ng bng sng Hng
0,41
0,04
62
14,8
2010
1,05
0,41
0,04
70,8
12,2
74
2009
1,06
Ton quc
Ton quc
Ton quc
Ton quc
T l cc c s KCB x
l cht thi y t theo quy
nh
Phn t
n v
Cc ch s
gim st
27,8
17,3
14,9
5,3
19,0
11,3
20,0
87,84
1,04
0,43
0,04
51,6
16,1
4,3
2011
28,6
17,4
15,2
5,4
19,2
11,4
20,2
88,77
1,06
0,34
0,03
49
2012
Nm
28,9
17,4
15,4
5,5
19,3
11,5
20,4
89,71
1,05
2013
<93,0
0,93
0,3
0,2
<15
(2020)
80
2015
KH 5 nm
KH 5 nm
CTMTQG
CTMTQG
Chin lc
quc gia
MDG
Loi
ch s
TCTK, TTDS,
TBDS
TCTK, TTDS,
TBDS
B Y tCTMTQG
B Y tCTMTQG
B Y tCTMTQG
B Y tCTMTQG
TCTK-MICS
B Y t
Ngun
thng tin
297
T l suy dinh dng

th thiu cn tr em
di 5 tui (cn nng
theo tui)
20,8
26,5
14,4
18,3
Bc Trung B v duyn
hi min Trung
Ty Nguyn
ng Nam B
ng bng sng Cu
Long
17,5
ng bng sng Hng

24
18,9
Ton quc
Trung du v min ni
pha Bc
35
Ton quc
S t
vong
152
5212
Ton quc
Ton quc
S mc
187
16,1
2009
S v
Ton quc
Trn
100000
dn
T l hin nhim HIV/

AIDS trong cng ng
Ng c thc phm
Ton quc
Trn
100000
dn
T l pht hin bnh HIV

trong nm
Phn t
n v
Cc ch s
gim st
16,8
10,7
24,7
19,8
22,1
14,6
17,5
49
173
5397
211,3
15,9
2010
15,4
11,3
23,8
17,8
21,2
14,2
16,8
27
148
4700
224,4
16,1
2011
14,8
11,3
25
19,5
20,9
11,8
16,2
34
168
5541
237,5
15,9
2012
Nm
13,8
8,0
21,8
16,5
19,5
10,9
15,3
28
167
5558
242,2
2013
15
<300,0
2015
KH 5 nm
KH 5 nm
CTMTQG
Loi
ch s
VDD
B Y tCTMTQG
B Y tCTMTQG
(c tnh)
B Y tCTMTQG
Ngun
thng tin
298
T l dn s chu mc
chi ph y t thm ha
(tng s chi ph tin ti
cho y t bng hoc cao
hn 40% kh nng chi
tr ca h gia nh)
Bo v ti chnh
T s gii tnh khi sinh
T l suy dinh dng

th thp ci tr em
di 5 tui (chiu cao
theo tui)
Cc ch s
gim st
S con
trai so
vi 100
con gi
n v
34,8
31,9
37
25,9
29,4
111
115,3
108,5
109,7
105,6
109,9
109,9
Trung du v min ni
pha Bc
Bc Trung B v duyn
hi min Trung
Ty Nguyn
ng Nam B
ng bng sng Cu
Long
Ton quc
ng bng sng Hng
Trung du v min ni
pha Bc
Bc Trung B v duyn
hi min Trung
Ty Nguyn
ng Nam B
ng bng sng Cu
Long
5,5
(2008)
28,1
ng bng sng Hng
Ton quc
31,9
2009
Ton quc
Phn t
3,9
108,3
105,9
108,2
114,3
109,9
116,2
111,2
28,2
19,2
35,2
31,4
33,7
25,5
29,3
2010
114,9
108,8
104,3
103,3
110,4
122,4
111,9
26,8
21,5
35
29,7
32,4
24,8
27,5
2011
4,2
111,5
111,9
98,4
112,1
108,2
120,9
112,3
26
20,7
36,8
31,2
31,9
21,9
26,7
2012
Nm
103,8
114,2
114,1
112,3
112,4
124,6
113,8
24,5
16,5
32,9
27,7
30,6
20,8
25,9
2013
113
26
2015
KH 5 nm
CTMTQG
Loi
ch s
Trng i hc
Y H Ni v
WHO phn tch
s liu iu tra
mc sng dn
c
TCTK, TTDS,
TBDS
VDD
Ngun
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B Y t Vit Nam

Cc chuyn gia tham gia bin son

5. H thng thng tin y t v gim st BKLN . ................................................................. 254

Bng 37: Kt qu thc hin D n Bo v sc khe tm thn cng ng

Hnh 35: T l ph n sinh con cha c p ng nhu cu khm thai,

Bnh khng ly nhim

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Phi on Lin minh chu u ti Vit Nam

Lin minh ton cu v vc xin v tim chng

Tng sn phm trong nc (Gross Domestic Production)

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Thc hnh tt bo qun thuc

Vin nh gi v o lng sc khe

T sut t vong tr em di 1 tui

Bo co chung tng quan ngnh y t

Khm cha bnh

Mc tiu Pht trin Thin nin k

H tr pht trin chnh thc

Sc mua tng ng ( la quc t)

Tim chng m rng

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Chng trnh phng, chng AIDS ca Lin Hp Quc

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Trung Quc (2010)

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Chng I: Tnh trng sc khe v cc yu t nh hng

T l hin nhim nam gii

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