De Khang Khang Sinh

Phn tch thc trng:
S dng khng sinh v khng khng sinh Vit Nam

GARP- Nhm nghin cu Quc gia ca Vit Nam
TS. Nguyn Vn Knh. Ch tch
Thng 10- 2010
Nhm nghin cu quc gia GARP-Vit Nam (NWG)

TS. BS. Nguyn Vn Knh. Ch tch. Gim c Bnh vin Bnh Nhit i Trung ng
TS. BS. Lng Ngc Khu. Cc trng Cc Qun l khm, cha bnh. B Y t
TS. DS. Trng Quc Cng. Cc trng Cc Qun l Dc. B Y t
TS. BS. L Ngc Knh. Cc Qun l khm, cha bnh. B Y t
ThS. DS. Ng Th Bch H. Chuyn vin chnh. Cc Qun l khm, cha bnh. B Y t
BS. Hong Thanh Mai. Phng Qun l thng tin v Qung co. Cc Qun l Dc. B Y t
ThS. BS. Nguyn Hng H. Ph Gim c NHTD. H Ni
PGS. TS. BS. Nguyn V Trung. Trng khoa xt nghim. NHTD
Ph Ch nhim B mn Vi sinh. i hc Y H Ni
PGS. TS. BS. Phm Vn Ca. Ph Trng khoa xt nghim. NHTD
PGS. TS. DS. Nguyn Th Kim Chc. Ging vin chnh. Ph Ch nhim B mn Y hc Gia nh. i
hc Y H Ni
TS. BS. on Mai Phng. Ph Trng khoa Vi sinh. BV Bch Mai. H Ni
TS. BSTY. Nguyn Quc n. Ph Trng phng Qun l Thuc. Cc th y. B Nng nghip v Pht
trin Nng thn
GS. TS. BS. Trn Tnh Hin. Ph Gim c Nghin cu Lm sng. n v Nghin cu lm sng i
hc Oxford. Thnh ph H Ch Minh
BS. Peter Horby. Gim c. n v Nghin cu Lm sng i hc Oxford
Cn b GARP- Vit Nam

TS. BS. Heiman Wertheim. GARP-Vit Nam gim st. Chuyn gia vi sinh lm sng. n v Nghin
cu Lm sng i hc Oxford
ThS. DS. Th Thu Nga. GARP-Vit Nam. iu phi vin Quc gia. n v Nghin cu Lm sng
i hc Oxford
Th k CDDEP/RFF GARP
TS. BS. Ramanan Laxminarayan. Sng lp GARP. Chuyn gia cp cao kim gim c. Trung tm
Nghin cu Bin ng Bnh dch, Kinh t v Chnh sch. T chc Ngun lc cho Tng lai
ThS. Hellen Gelband. iu phi vin chng trnh. Trung tm Nghin cu Bin ng Bnh dch,
Kinh t v Chnh sch. T chc Ngun lc cho Tng lai
GARP-VN Phn tch thc trng
Mc lc
Li ni u, TS. Nguyn Vn Knh ................................................................................................................. I
Tng kt .....................................................................................................................................................................III
I. Cc ch s c bn v kinh t v y t .............................................................................................................1
1.1. Gii thiu ......................................................................................................................................................1
1.2. Cu trc ca h thng chm sc sc kho ....................................................................................3
1.3. Chng nhim khun ................................................................................................................................9
1.4. Gnh nng bnh tt............................................................................................................................... 11
II. H thng cung ng v qun l khng sinh .......................................................................................... 17
2.1. C cu lp php chi phi s phn phi, lu thng khng sinh ........................................ 17
2.2. Chui cung ng ....................................................................................................................................... 20
2.3. S dng khng sinh ti cc tuyn c s ...................................................................................... 25
2.4. S dng khng sinh khng hp l ................................................................................................. 26
2.5 C ch khuyn khch ............................................................................................................................. 27
2.6. Cc v d v mc s dng khng sinh trn ngi .................................................................. 28
2.7. Chi ph cho khng sinh ti cc bnh vin ................................................................................... 31
2.8. Gim st khng khng sinh ............................................................................................................... 32
2.9. Khng sinh s dng trn ng vt ................................................................................................ 33
III. nh gi s b, xut chnh sch v gii php can thip ....................................................... 36
3.1. nh gi s b......................................................................................................................................... 36
3.2. Phn tch chnh sch ............................................................................................................................ 37
3.3. Cc c hi nghin cu ......................................................................................................................... 39
Ti liu tham kho ............................................................................................................................................... 41
Li ni u
Vn v thc trng khng khng sinh mang tnh ton cu v c bit ni tri cc nc ang
pht trin vi gnh nng ca cc bnh nhim khun v nhng chi ph bt buc cho vic thay th cc
khng sinh c bng cc khng sinh mi, t tin. Cc bnh nhim khun ng tiu ho, ng h
hp, cc bnh ly truyn qua ng tnh dc v nhim khun bnh vin l cc nguyn nhn hng u
c t l mc v t l t vong cao cc nc ang pht trin. Vic kim sot cc loi bnh ny v ang
chu s tc ng bt li ca s pht trin v lan truyn tnh trng khng khng sinh ca vi khun.
C th ni rng, vi khun cng phi nhim nhiu vi khng sinh th sc p v thuc cng lncc chng khng thuc cng c nhiu c hi pht trin v ly lan. Mc d khng khng sinh l vn
cn bn thuc v y t, trong sc p v thuc l yu t ni ti quan trng nht thc y s pht
trin v gia tng tnh trng khng khng sinh. Tuy nhin, vn ny cn chu s chi phi ca nhiu
lnh vc khc bao gm cc yu t v sinh thi hc, dch t hc, vn ho-x hi v kinh t. Ngi
bnh, cc nh lm sng, bc s th y, cc phng khm t, bnh vin v doanh nghip dc t qui m
nh n ln u c rt t ng thi (v mt kinh t hoc cc kha cnh khc) nhm nh gi nhng
nh hng bt li ca vic s dng khng sinh i vi cc i tng lin quan hoc hu qu ca
nhng nh hng i vi th h tng lai. Nhng hot ng nh tng cng gim st, cc chin
dch thng tin i chng v mi him ha ca tnh trng khng khng sinh l mt phn cn thit
trong k hoch i ph ton din c th em li tc ng rt hn ch. em li hiu qu cao, cc
gii php chnh sch cn c s thay i v mt cu trc cc bin php khuyn khch i vi bnh
nhn, cc nh lm sng v cc i tng khc trong h thng chm sc sc khe, ng thi cc
chnh sch ny phi c vn hnh trong mi quan tm cao nht ca x hi. nh gi cc gii php
chnh sch phi bao gm nhng hiu bit ca cng ng v bnh nhim khun. Trc ht cn
nghin cu, vch ra cc gii php chnh sch c th v trng tm c th em li cc tc ng c
ngha i vi tnh trng khng khng sinh. Tip theo , cn phi bin gii php chnh sch thnh
hnh ng.
Khng khng sinh khng nm trong danh sch cc vn c u tin ca mi quc gia cng
nh khng c c cc xut chin lc nhm thu ht cc mi quan tm t chnh ph. gii
quyt vn mt cch ng n, kim sot khng khng sinh nn tp trung vo mt s cc bin
php can thip trng im v mt y t c kh nng thc s em li hiu qu kinh t.
Bo co ny phn tch, nh gi mt cch chi tit v tnh hnh s dng khng sinh v thc trng
khng khng sinh ti Vit Nam. Bn bo co s dng cc ngun thng tin thu thp t cc bo co
trong v ngoi nc ng thi phn tch, tng hp cng nh tham kho kin ng gp ca cc
chuyn gia trong cc lnh vc lin quan nhm xy dng bn bo co phn tch mt cch tng quan
v chi tit. T xut cc gii php can thip nhm kim sot tnh hnh s dng thuc khng hp
l v thc trng khng khng sinh nh hin nay ti Vit Nam.
TS. Nguyn Vn Knh

Ch tch. i din Nhm nghin cu Quc gia. GARP Vit Nam
II
Tm tt
p tc ton cu v khng khng sinh (GARP) nhm hng ti gii quyt cc thch thc ca
tnh trng khng khng sinh bng cch xy dng cc xut chnh sch hnh ng ti Vit
Nam v bn nc c thu nhp thp v trung bnh nh: Trung Quc, n , Kenya v Nam
Phi. GARP s xy dng cc bng chng khoa hc cho chng trnh hnh ng khng khng sinh ti
Vit Nam v nhn bit cc chnh sch c tc ng mnh lm gim s pht trin v ly lan tnh trng
khng thuc.
K t sau i mi ca nn kinh t nm 1986, Vit Nam c nhiu chuyn bin ng k: tng thu
nhp bnh qun u ngi, tng tui th trung bnh, gim t l t vong tr em v ci thin kh nng
tip cn dch v chm sc sc khe v thuc k c thuc khng sinh. Vic ci thin kh nng tip cn
vi thuc khng sinh ng thi cng em li mt v khch khng mi m n: khng khng sinh.
Nh bn Phn tch thc trng cho thy, khng khng sinh gia tng, nhng cc c hi nhm bo
tn gi tr ca thuc khng sinh v ci thin trin vng iu tr i vi bnh nhn vn cn b ng.
Nm 1996, B Y t ban hnh chnh sch Quc gia v thuc, trong c nu r chnh sch v
thuc khng sinh nh sau: Thuc khng sinh c vai tr rt quan trng trong iu tr, c bit i
vi tnh hnh bnh tt ca mt s nc kh hu nhit i nh nc ta. Do , cn phi chn chnh
vic k n v s dng khng sinh, kim sot tnh trng khng khng sinh ca mt s vi khun gy
bnh thng gp, ng thi ci thin kh nng chun on ca cc phng xt nghim vi sinh lm
sng. Chnh sch ny thm ch cn ph hp hn vi tnh hnh hin nay, nm 2010.
Vn ton cu v khng khng sinh

Trn th gii, nhiu chng vi khun gy bnh tr nn ngy cng khng thuc khng sinh. Cc
khng sinh th h mt gn nh khng c la chn trong nhiu trng hp. Cc khng sinh th
h mi t tin, thm ch c mt s khng sinh thuc nhm la chn cui cng cng ang mt dn
hiu lc. Bng chng mi y nht l s ly lan ca chng vi khun khng carbapenem (ndm-1)
mt s quc gia Chu u v Chu . Hiu lc ca khng sinh nn c xem nh mt loi hng ha
c bit, cn c bo v v qu trng, khng nn lng ph vo cc trng hp khng cn thit. Mc
tiu lm th no khng sinh ch c s dng cho cc trng hp nhim khun l cc trng
hp c th iu tr bng thuc khng sinh, khng phi cho cc trng hp s khng c li t vic s
dng khng sinh.
III
Khng khng sinh Vit Nam

Tnh trng khng khng sinh Vit Nam mc cao. Trong nhng nm gn y, mt
s nghin cu cho thy:
Vit Nam, cc chng Streptococcus pneumoniae - mt trong nhng nguyn nhn thng
gp nht gy nhim khun h hp- khng penicillin (71.4%) v khng erythromycin
(92.1%) c t l ph bin cao nht trong s 11 nc trong mng li gim st cc cn
nguyn khng thuc Chu (ANSORP) nm 2000-2001.
75% cc chng pneumococci khng vi ba hoc trn ba loi khng sinh.
57% Haemophilus influenzae (mt cn nguyn vi khun ph bin khc) phn lp t bnh nhi
H Ni (2000-2002) khng vi ampicillin. T l tng t cng c bo co Nha Trang.
Vi khun phn lp t tr b tiu chy c t l khng cao. i vi hu ht cc trng hp, b
nc v in gii l bin php x tr hiu qu nht i vi bnh tiu chy, khong s tr
c ch nh khng sinh trc khi a n bnh vin.
Cc vi khun gram m a s l khng khng sinh (enterobacteriaceae): hn 25% s chng
phn lp ti mt bnh vin Thnh ph H Ch Minh khng vi khng sinh cephalosporin th
h 3, theo nghin cu nm 2000-2001. Theo bo co ca mt nghin cu khc nm 2009
cho thy, 42% cc chng vi khun gram m khng vi ceftazidime, 63% khng vi
gentamicin v 74% khng vi acid nalidixic ti c bnh vin v trong cng ng.
Xu hng gia tng ca tnh trng khng khng sinh cng th hin r rt. Nhng nm 1990,
ti thnh ph H Ch Minh, ch c 8% cc chng pneumococcus khng vi penicillin. n
nm1999-2000, t l ny tng ln 56%. Xu hng tng t cng c bo co ti cc tnh
pha bc Vit Nam.
Do t l khng khng sinh cao, nhiu liu php khng sinh c khuyn co trong cc ti liu
hng dn iu tr khng cn hiu lc. Do cc bnh nhim khun vn l cc bnh ph bin Vit
Nam, vic tip cn vi cc khng sinh c hiu lc gi vai tr rt quan trng. T l khng khng sinh
gia tng nh hin nay l mi him ha i vi hiu qu ca cc liu php iu tr bng khng sinh.
Cc nguyn nhn dn n tnh trng lm dng khng sinh v khng

khng sinh
C th ni rng, cng lm dng khng sinh, cc chng vi khun khng thuc cng c c hi pht
trin v ly lan. Khng sinh b lm dng c trong cng ng-do ngi dng t chn on v iu tr
hoc theo li khuyn ca ngi cung cp dch v y t- v trong bnh vin, ni m khng sinh c th
thay th kim sot nhim khun tt hn, ni cc khng sinh ph rng c s dng thay th cho
cc khng sinh ph hp, v cng l ni bnh nhn thng c cung cp cc loi bit dc mi, t
tin hn thay v cc thuc th h c.
IV
Cc nguyn nhn dn n vic s dng khng sinh khng hp l vn cn cha r, tuy nhin c
th xc nh mt s nhn t quan trng i vi thc trng ti Vit Nam. Cc nhn t ny c tho
lun di y.
Trong cng ng
Chi ph chm sc sc khe t tin ti ngi bnh: Vic p dng cc hnh thc chi tr t
ngi bnh ti cc bnh vin cng lp, m hnh chi tr bng bo him y t, thng mi ha ngnh
dc, v bi b qui nh v kinh doanh nh l i vi thuc em li nhiu ci thin ng k v
cht lng v kh nng tip cn cc dch v chm sc sc khe. Tuy nhin, cc yu t ny cng dn
n vic tng t trng chi ph y t t tin ti ngi bnh nhn trong tng chi ph y t. Chi ph t tin
ti ngi bnh cao khuyn khch ngi bnh mua thuc bao gm c thuc khng sinh trc tip,
m khng cn cc chn on ph hp. Tng doanh thu thuc gn nh tng gp ba v gi tr gia
nm 2001-2008, t 500 triu la M ln 1400 triu la M. Hin ti khng c s liu thng k
ring cho thuc khng sinh, tuy nhin y l nhm thuc c s dng rng ri nht, v thng
khng hp l.
Mua thuc khng c n: Mc d c qui nh v k n v bn thuc theo n, ngi bnh
vn c th mua thuc khng sinh v nhiu loi thuc khc trc tip t cc nh thuc v cc quy
thuc bn l. T iu tr l tnh trng kh ph bin, mc d t chn on thng rt thiu chnh xc.
Theo mt nghin cu cng ng nm 2007, 78% khng sinh c mua ti cc nh thuc t nhn m
khng cn n. Mua thuc trc tip l hnh thc tit kim c v kinh ph v thi gian so vi vic i
khm bc s.
Thiu kin thc v s dng khng sinh hp l: Theo bo co ca nghin cu thc hin nm
2007 nhm nh gi kin thc v s dng khng sinh khu vc nng thn Vit Nam cho thy, mc
d c cc ti liu hng dn, kin thc v s dng khng sinh vn cn rt hn ch v cc cn b
cung cp dch v chm sc sc khe thng cung cp khng sinh mt cch khng cn thit cho cc
trng hp cm cm thng thng. Khi khng sinh c s dng, loi, liu dng, thi gian iu tr
thng khng tun th theo hng dn.
Ti Bnh vin
Cng tc kim sot nhim khun cn yu v tnh trng qu ti: Kim sot nhim khun tt
l cng vic cn thit nhm ngn chn s ly lan ca vi khun khng thuc. Cc bnh vin lun trong
tnh trng qu ti, tnh trng ngi bnh phi nm ghp ging thng xuyn xy ra. Hn na, vic
qun l rc thi cng cn nhiu hn ch.
Thiu cc dch v v vi sinh: Hu ht cc bnh vin khng c phng xt nghim vi sinh. Ngay
c vi cc phng xt nghim hin c, cng khng c yu cu v vic nh gi cht lng. Hn na,
thiu i ng cc nh vi sinh lm sng c trnh nhm ci thin cht lng phng xt nghim. Do
, cc d liu v khng khng sinh cng khng th xem l chnh xc i vi Vit Nam.
Thiu Hi ng Thuc v iu tr hot ng c hiu qu: Nm 1997, B Y t yu cu tt c
cc bnh vin thnh lp Hi ng Thuc v iu tr nhm thc hin cc hng dn lin quan n
vic s dng thuc, a ra cc li khuyn v liu php khng sinh hp l, xy dng danh mc thuc
ch yu s dng trong bnh vin, thng bo cho cc cn b y t a phng v s dng thuc hp l
v t chc gim st, bo co v khng thuc khng sinh. Hin nay, hu ht cc bnh vin tuyn trung
ng u c hi ng ny, tuy nhin mt s bnh vin tuyn c s th vn cn thiu v yu. i
vi mt s bnh vin tuyn qun/huyn, thnh phn hi ng thng thiu dc s hoc chuyn
gia vi sinh v ngun lc cho hi ng hot ng.
Trong nng nghip

Khng sinh c s dng rng ri trong chn nui v nui trng thy sn vi mc ch kch
thch tng trng, phng bnh v iu tr. Chn nui ln v gia cm thng c b sung khng
sinh nh tetracycline v tylosin. Trong nui trng thy sn, tm, cua v c thng c nng d
lng khng sinh nhm quinolones v sulfonamides gp vi ln so vi cc quc gia khc. D lng
khng sinh cng thng c pht hin trong mu t v nc ng con ging, mc d hu ht cc
trng hp pht hin d lng ca cc khng sinh c php s dng v cng nm trong gii hn
cho php.
Tuy nhin, vn c nhiu trng hp d lng khng sinh vt qu gii hn. Mt nghin cu
gim st cho thy, thc phm, bao gm tht v c, pht hin nhim Salmonella a khng khng
sinh. Campylobacter phn lp t g tht cng c mc khng cao: 90% khng vi nalidixic acid, 89%
vi tetracycline v 82% vi ciprofloxacin.
Nghin cu ca GARP-Vit Nam

Mt trong nhng mc tiu ca GARP-Vit Nam l nhm b p cc thiu ht v thng tin. Sau
y l mt s nghin cu m nhm nghin cu quc gia GARP-VN hin ang trin khai:
1. Xy dng mt mng li v s dng khng sinh v khng khng sinh: thit lp cc knh
chia s thng tin gia mt s bnh vin hng u ng thi hp tc vi Cc Qun l khm cha
bnh nhm xy dng v cng b cc bo co nh k v s dng khng sinh v khng khng sinh.
2. Nghin cu nh gi gnh nng ca tnh trng khng khng sinh: bng chng thuyt
phc nht i vi cc nh hoch nh chnh sch l ch ra c cc tn tht do khng
khng sinh gy ra v vic qun l khng sinh c th em li hiu qu kinh t ng thi cu
c mng sng ngi bnh. Nghin cu s tin hnh nh gi mc khng hin ti ca
mt s vi khun thng gp phn lp t bnh phm mu v dch no ty. nh gi gnh
VI
nng ca tnh trng khng thuc do cc cn nguyn ny gy ra trn c s so snh chi ph

iu tr bng khng sinh cho cc trng hp khng thuc v chi ph iu tr khng sinh
mc tiu chun cho cc trng hp cha khng thuc.
3. nh gi cu trc cc nhn t tc ng v kinh t: i vi vic bn khng sinh trong
cng ng ti cc c s bn l dc phm bng b cu hi v trc tip quan st vic bn
thuc ti 15 nh thuc khu vc ni thnh v 15 nh thuc ti khu vc ngoi thnh H
Ni. nh gi t trng li nhun do thuc khng sinh em li.
CC C HI NHM KIM SOT KHNG KHNG SINH

La chn chnh sch
Tng cng cng tc qun
l nh nc v khng
khng sinh
Thuc khng sinh l thuc
k n
Cc bnh vin cn c Hi
ng Thuc v iu tr hot
ng c hiu qu (D&TCs)
Cc bnh vin cn c hi
ng chng nhim khun
Chng trnh gim st
khng khng sinh quc gia
Chng trnh gim st v

s dng khng sinh ti cc
bnh vin
Chng trnh ging dy
trong cc trng y, dc
Hng dn iu tr
Trung tm cnh gic Dc
Chin lc gio dc truyn
thng cng ng
Cc
chng
trnh
tim
Hnh ng
Xy dng K hoch Hnh ng Quc gia v Khng Khng
sinh.
Hiu lc ha cc qui ch v qui nh hin hnh.
p ng yu cu ca Hi ng, xc nh cha nng v tiu
chun ca Hi ng, xy dng v thm tra c ch hot ng.
Cung cp cho Hi ng cc cng c/hng dn lm th no
xy dng Hng dn Qun l Khng sinh tt cho cc bnh
vin. ng thi bo co cho hi ng cc s liu cp nht v
ng tin cy v tnh hnh khng khng sinh.
Cung cp kinh ph hot ng cho cc hot ng ca hi ng
v nng cp c s h tng. Xy dng cc ch s chun nhm
gim st tin nh: t l nhim khun bnh vin theo tng
khoa v s tun th v sinh bn tay.
Chun ho d liu bng cch p dng trn ton quc cc ti
liu hng dn xt nghim bao gm c kim sot cht lng.
Cung cp kinh ph cho th nghim mc khng khng sinh,
kim sot cht lng, tp hun v bo co. Xy dng cc bo
co hng nm v tnh hnh s dng khng sinh v thc trng
khng khng sinh.
Chun ho cc ch s v mc s dng khng sinh theo n
v quc t, v d nh liu ch nh hng ngy (DDD) trn 100
ging-ngy. Xy dng cc bo co hng nm v s dng
khng sinh v khng khng sinh trong cng mt bn bo co.
Tng thi thi lng chng trnh ging dy v s dng
khng sinh v khng khng sinh.
m bo tnh chnh xc v cp nht ca cc ti liu hng
dn iu tr i vi cc bnh nhim khun.
Thu ht s tham gia ca trung tm cnh gic Dc vo vic
kim sot tnh trng k n khng sinh bt hp l.
Tng cng nhn thc v gio dc cho cng ng v s dng
khng sinh hp l v khng hp l bng cc chin dch lin
kt.
m bo t l tim chng cao cho cc bnh truyn nhim cn
VII
chng Quc gia

Chng trnh nng cao
nng lc phng xt nghim
vi sinh lm sng
Nng nghip
iu tr bng khng sinh.

m bo cht lng cc xt nghim vi sinh lm sng, Xem xt
vic xy dng mt trung tm chun quc gia v xt nghim
chn on vi sinh lm sng. Xy dng mng li nhm chia
s thng tin (d liu, hng dn, kin ca cc chuyn gia).
Hiu lc ho qui ch, qui nh hin hnh
Xy dng chng trnh gim st ton quc v s dng khng
sinh v khng khng sinh trn ng vt
Xy dng bo co hng nm v tnh hnh s dng khng sinh
v mc khng khng sinh trn ng vt
Qui nh v thi gian dng s dng thuc khng sinh trc khi
thu hoch sn phm t ng vt.
Vit Nam c rt nhiu con ng nhm kim sot v o chiu tnh trng khng khng sinh.
Cc c hi s c phn tch y trong bo co cui cng ca GARP-VN, d kin hon thnh vo
u nm 2011. Mt s cc la chn chnh sch c lit k di y. V l thuyt, tt c cc la
chn ny u c th kh thi, tuy nhin mt s c trin vng hn so vi cc la chn cn li. Nhm
nghin cu quc s phn tch nh gi tng la chn bng cch c lng v chi ph, ngun lc, v
cc iu kin thun li v mt k thut, khung thi gian thc hin, v quan trng hn c l tc ng
m la chn em li ( cc mc thnh cng khc nhau) trong bi cnh c th ca Vit Nam.
Danh sch c la chn s c xut cho cc la chn chnh sch c trin vng nhm xy dng
hnh ng.
Bn bo co u tin ny v phn tch thc trng khng khng sinh Vit Nam nhm chuyn
ti vn quan trng ny n tt c cc i tc c lin quan, bao gm chnh ph, dc s, bc s, cc
c s khm cha bnh, ngnh dc, v ngi bnh. Tt c chng ta u c trch nhim phi hp
hnh ng nhm duy tr hiu lc ca khng sinh ng thi m bo kh nng tip cn vi cc thuc
cu cha bnh bt c u v bt c khi no ngi bnh cn.
Thay mt Nhm nghin cu Quc gia,

TS. Nguyn Vn Knh. Ch tch
Gim c Bnh vin Bnh Nhit i Trung ng
H Ni, Vit Nam
VIII
I. Cc ch s c bn v kinh
t v y t
Hnh 1. Vit Nam
1.1. Gii thiu

Phn I phn tch khi qut v h thng
chm sc sc khe ca Vit Nam, t phn
tch, nh gi thc trng khng khng sinh
trong s chi phi ca bi cnh tng th. ng
thi, cng cp n cc vn c bn ca cc
chnh sch quc gia v y t, c cu t chc hot
ng ca h thng chm sc sc khe, c hi
tip cn vi cc dch v chm sc sc khe v
thuc cha bnh. Cc ch s v a l, y t cng
nh t l mc v t vong do nguyn nhn cc
bnh nhim khun cng c trnh by s lc
trong phn ny.
1.1.1. S lc v a l, dn s
Nm trn bn o ng dng, Vit Nam
c bin gii gip Trung Quc, Lo v
Campuchia, vi din tch khong 331.000 km.
Ngun: n v nghin cu lm sng H Oxford.

s dng phn mm AcrGIS
Tr em Vit Nam c tip cn tt vi gio
Vi hn 88 triu dn, Vit Nam l nc
dc, t l bit ch t 90%. Tnh n cui nm
ng th 13 v dn s trn th gii, vi mt
2005, 81% cc h gia nh c in. Mc tiu
dn s xp x 265 ngi/km. Dn s tng i
ca chnh ph l n nm 2010, 95% h gia
tr so vi cc nc pht trin vi tui trung
nh c s dng in1. Nm 2010, chnh ph
bnh l 27 tui trong khi cc nc Chu u l
hy vng 85% dn s c s dng nc sch.
39-41 tui. Tc tng dn s gim trong vng
Tuy nhin, qu trnh trin khai cn kh chm
20 nm qua vi t l trung bnh 1,98 tr/m
v khng th t mc tiu 70% nm 20102.
(Bng 1). Xp x 28% dn s sng ti thnh th

vi tc th ho khong 3,1% mi nm.
1.1.2. Tnh hnh pht trin kinh t

v t l ngho
Trong thp k qua, Vit Nam l mt trong
vc ngho nht m ch yu tp trung 2 khu
nhng nc trn th gii c s pht trin ng
vc chu th, ni m t l h ngho mc
k v kinh t. Tng sn phm quc ni GDP
trung bnh (Hnh 2).
bnh qun t 7,3% mi nm trong giai on

1995-2005 v thu nhp bnh qun u ngi
tng 6,2% mi nm. Vit Nam nhanh chng
Hnh 2. Tnh hnh phn b cc h ngho

Vit Nam4
hi phc v kinh t sau tc ng bt li ca 2

i dch SARS v cm gia cm. Thu nhp bnh
qun u ngi/nm tng t 260 USD trong
nm 1995 v t mc 835 USD vo nm 2007.
D tnh, n nm 2010, thu nhp bnh qun
u ngi/nm t 1000 USD v do Vit
Nam s tr thnh nc c mc thu nhp trung
bnh trn th gii3.
Vit Nam ang trong qu trnh cng
nghip ha. Gia giai on 1995-2005, t l
ng gp ca ngnh nng nghip vo tng sn
phm quc ni gim t 27% xung cn 21%,
trong khi , cng nghip tng t 29% ln
41%. Nm 2007, Vit Nam chnh thc tr
thnh thnh vin ca T chc Thng mi Th
gii.
Vit Nam cng thnh cng trong chin dch
xo i gim ngho. T l h ngho gim t
Ngun: Bn i ngho v an ton thc phm4
58,1% nm 1993 xung 22% nm 2007. Tc

tng trng kinh t cao v tc xo i gim
Vit Nam trin khai l trnh pht trin mt
ngho nhanh dn n s phn cp trong x hi.
s mc tiu pht trin thin nin k (MDGs). 5
T l cc h i ngho cao nht cc vng
trong s 10 mc tiu MDGs c ra cho giai
trung du v min ni pha Bc v thp nht
on n nm 2015 c hon thnh trong
ng nam v cc khu th ln. Tuy nhin,
k c mc tiu xo i gim ngho.
phn tch v mt cc h ngho ch ra

rng, hu ht dn ngho khng sng cc khu
1.1.3. Cc ch s c bn v y t
nm 2006. Tng t nh cc ch tiu khc,

dinh dng vn cn l vn kh ph bin
Tui th trung bnh ca Vit Nam kh cao

so vi cc quc gia ang pht trin, bnh qun
xp x 69 tui i vi nam v 74 tui n. Tui
th ny tng t Brazil v Hy Lp. Xu hng
bnh tt v t vong gim i vi cc nhm dn
s c bit nh ph n v tr em. T l t vong
vng su, vng xa v cc vng dn tc thiu s

ni m t l cc h ngho cn cao v cc iu
kin v kinh t cn rt thiu thn. Chnh ph
cn quan tm hn na v cng cuc ci thin
iu kin sng v tnh hnh y t vng su,
vng xa.
tr gim t 53 trn 1000 tr sng nm

1990 xung cn 22 trong nm 20085. T l m
Bng 1: Nhng ch s pht trin c bn v
t vong tng i thp vi khong 150 trn
cc ch s y t ca Vit Nam
100.000 tr sng nm 2005, so snh vi mt

s nc trong khu vc nh Campuchia, t l
ny ln ti 540/100.0006.
Ch s
Dn s (triu)
Tc tng dn s
(%)
Tc th ho (%)
Cc ch s khc v sc kho tr cn
cp gm c ch s v tim chng v dinh dng.
Chnh ph Vit Nam ti tr 88% cho chng
trnh tim chng m rng vi cc vc xin trong
chng trnh. Kt qu l, 90% tr c tim
chng cc vc xin trong chng trnh tim
chng m rng bao gm, lao, bch hu, ho g,
un vn, vc xin vim gan B, bi lit v si. Vc
xin Haemophilus influenzae B chnh thc c
trin khai v a vo chng trnh tim chng
m rng k t nm 2009. Tuy nhin t l tim
chng cn thp vng su, vng xa7. n nay,
Nm
2009
S lng
88,6
2009
1,14
20002008
2008
Tui th (Nam/N)
69/74
Bnh
qun
GDP
2008
2.600
(USD)
T sut cht s sinh
(trn 1.000 tr 2008
22,3
sng)
T sut cht m (trn
2005
150
100.000 tr sng)
T
l
ngho
2007
22
(%<1,25$/ng)
S dng nc sch
2006
92
(%)
iu kin v sinh (%)
2006
65
T l bit ch ngi 200390
ln (%)
2008
Ngun: Ngn hng th gii. CIA S kin th
gii. UNICEF Vit Nam6, 8, 9
vc xin phng bnh do ph cu vn cha c

a vo chng trnh tim chng m rng m
vn ang l sn phm thng mi ti Vit Nam.
Dinh dng l mt ch tiu sc khe quan
1.2. Cu trc ca h thng

chm sc sc kho
1.2.1. Gii thiu
trng khc. Mt trong cc ni dung trng im

ca MDGs l xo i n na u nm 2015,
25 nm trc, h thng chm sc sc kho
chng trnh ny vt mc ch tiu trc
Vit Nam ch c h tr bi chnh ph v cc
c s cng lp l n v duy nht cung cp cc
phi hp gia cc n v cng lp v t nhn,
dch v y t. Vo thi im , thuc men rt
trong hu ht cc loi thuc u sn c trn
khan him. Nhm to thm nhiu c hi tip
th trng vi mc gi tng i thp.
cn cc dch v chm sc sc khe, k t sau

1986, chnh ph thi hnh mt s bin php
1.2.2. T chc v phn b cc
nh: ngi bnh ng vin ph ti cc bnh
dch v y t
vin cng, p dng m hnh bo him y t, hp

H thng chm sc sc khe cng lp c
php ho ngnh cng nghip dc, bi b qui

nh v kinh doanh nh l i vi dc phm10.
iu gp phn chuyn i h thng chm
sc sc kho ca Vit Nam thnh mt h thng
chia thnh bn cp t trung ng n x

(Xem hnh 3). Mi cp li bao gm mt s
n v nh chu trch nhim v cc lnh vc
khc nhau trong h thng chm sc sc kho
bao gm: iu tr, phng bnh, o to, nghin
cu v phn phi thuc.
Hnh 3. H thng chm sc sc khe11

Tuyn
B Y t
B ngnh khc
Trung
Bnh vin tuyn trung ng
BV qun i
ng
Cc vin v sinh dch t
BV B cng an
Trng Y
BV B nng nghip
Trng Dc
BV Bu in
C s khm cha bnh
BV Giao thng-Vn ti
C s t nhn
Doanh nghip Dc
Tnh
Bnh vin tuyn tnh
Phng khm t
Trng cao ng Y
Nh thuc t
Trung tm v sinh phng dch
Bnh vin t
Qun/
Bnh vin tuyn qun/huyn
Huyn
Trm v sinh phng dch
Trm y t x
Bnh x (khu vc)
Ngun: Thun, N.T., Lofgren, C., Lindholm, L. &Chc, N.T.K. Choice of healthcare provider folloing
reform in Vietnam. BMC Health Serv Res 8, 162 (2008).
cng lp do ngi bnh khng khm bnh y
C s vt cht
t c s. Nghin cu ct ngang, thc hin ti

Mc d vi s pht trin nhanh chng ca
phng khm ngoi tr ti 6 bnh vin thnh
cc loi hnh chm sc sc kho t nhn, cc
ph H Ch Minh (TPHCM) trn 2.587 phiu
n v cng lp vn gi vai tr quan trng
iu tra t 2001 n 2006. Kt qu cho thy,
trong y t d phng, nghin cu v o to.
bnh nhn n khm ngoi tr ti cc bnh
Trong tng s 961 bnh vin trn ton quc,
vin chuyn khoa ngy cng tng v l do n
Vit Nam c 41 bnh vin cp trung ng, cn
khm a s l nhng bnh thng thng
li l cc bnh vin tuyn tnh, huyn. Hu ht
(44,0%-85,1%) trong khi tuyn y t c s c
cc bnh vin trung ng u nm trn a bn
th iu tr c (67,7%). Bnh nhn n bnh
th H Ni. Tuyn di, c 609 bnh vin
vin a s l vt tuyn hoc t n (85,5%)
tuyn huyn v 10.866 trm y t x12. Cc trm
dn n tnh trng qu ti bnh nhn cc
y t x v phng khm a khoa khu vc l c s
phng khm ngoi tr ti cc bnh vin tuyn
khm cha bnh ban u v cng l a ch u
trn, vt cng sut s dng ging (107,8%-
tin ngi bnh tip cn vi c s khm cha
130,0%) v vt ch tiu khm cha bnh
bnh cng lp, tr trng hp cp cu. Cc
ngoi tr (114,4%-145,0%). Mi ngy mt bc
n v ny cung cp cc dch v phng v cha
s c th khm t 50-100 bnh nhn, dn n
bnh cng nh chuyn ngi bnh ln tuyn
vic gim cht lng ca cng tc khm cha
trn trong trng hp iu kin c s tuyn
bnh14.
di khng p ng c yu cu chn on
v iu tr. Cc trm y t x/phng chu s
Ngoi ra, iu kin xt nghim chn on

ti cc c s khm cha bnh tuyn di cn
qun l ca trung tm y t huyn/qun.
rt hn ch, hoc nu c, ngi bnh phi t

Theo thng k ca B Y t, nm 2008, cng
chi tr cho chi ph ca cc xt nghim chn
sut s dng ging bnh ti cc bnh vin
on. Bnh vin a khoa c xu hng u t
cng lp l 128,52% i vi bnh vin tuyn
cho cc xt nghim chn on em li li
trung ng v 126,66% i vi cc bnh vin
nhun cao, cc xt nghim chn on bnh
tuyn tnh12. T l ny c th ln n trn 200%
nhim khun mt mt i hi u t trang
mt s bnh vin ln tuyn trung ng, nht
thit b t tin cng nh yu cu i vi c s
l trong thi im bng n dch bnh. in
h tng, mt khc li nhun thu c li khng
hnh nh, bnh vin Nhi ng I, thnh ph H
cao, do thng t c quan tm u t so
Ch Minh, t l ny c khi ln ti
285%13.
Qu
vi cc xt nghim chn on khc. Sc p v
ti cng vic l tnh trng kh ph bin i vi
mt thi gian v phng tin chn on l mt
cc cn b y t c bit l mt s bnh vin

trong nhng l do dn n vic k n khng
dn n cng trm trng hn tnh trng thiu
sinh mt cch thng xuyn.
nhn lc dc tuyn c s v vng su, vng
T khi chuyn i sang c ch th trng,
xa19.
gn 80 bnh vin t, 30.000 phng khm t v
Bng 2: Nhn lc ngnh y t nm 2005-
21.600 c s kinh doanh, phn phi dc
200816
phm t nhn c hnh thnh. Theo thng k
Phn loi
2005
Cn b ngnh Y
Bc s (k c TS.
48.215
ThS)
Y s
48.059
Y t (H. TH. SH)
49.536
N h sinh (H. TH.
17.610
SH)
KTV Y
8.771
Lng y
293
S bc s cho 10.000
5,88
dn
Cn
b
ngnh
Dc
Dc s (k c TS.
6.360
ThS)
Dc s TH v KTV
10.424
Dc
Dc t
8.298
S dc s cho
0,78
10.000 dn
Ngun: Thng k Y t 2008 (B Y t)
t cc bo co v Cc Qun l Khm cha bnh

- B Y t ca 731 bnh vin nm 2007, cng
sut s dng ging bnh ti cc bnh vin t
nhn l 67,8% nm 2006 v 74,7% nm 2007.
Ngi bnh iu tr ni tr ti cc bnh vin t
chim t l tng i nh trong tng s ngi
bnh iu tr ni tr ti cc bnh vin cng lp
(ch chim 1,9% nm 2006 v 2,2% nm
2007)15.
Nhn lc
Tnh trng thiu ht nhn lc trong ngnh
y t l kh ph bin vi t l kh thp t y t
n bc s, thiu cc chuyn gia v nhng nh
qun l c trnh , tnh trng thiu ht ny c
bit trm trng vng su v vng xa (Xem
bng
2)16.
2008
56.208
49.213
67.081
22.943
11.586
882
6,52
10.524
15.748
9.726
1,22
Ti chnh
Do c s chuyn i trong nn kinh t th
in hnh nh, khu vc chu th
trng, h thng ti chnh y t cng c thm
sng Mekong, t l nhn vin y t c trnh
nhiu ngun lc mi. Hu qu ca nhng hn
i hc (bc s-dc s) l 4,3 bc s/10.000
ch v mt ti chnh v nhu cu ci thin vic
dn v 0,2 dc s/ 10.000 dn17. Ngc li,
tip cn cc dch v chm sc sc kho. Chnh
cc thnh ph ln, con s ny cao hn r rt
ph quyt nh thi hnh mt s bin php
vi 9 bc s/10.000
dn18.
Theo thng k ca
bao gm: thu vin ph ti cc bnh vin cng
B Y t nm 2009, Vit Nam mi t t l 1,5
lp, m hnh bo him y t, hp php ho cng
dc s/10.000 dn. 52% s dc s tt
nghip dc v xo b cc qui nh i vi
nghip i hc ch yu tp trung hai thnh
kinh doanh dc phm nh l10. Nhng thay
ph ln l H Ni v thnh ph H Ch Minh
i ny c th em li nhng ci thin ng k
v cht lng v s tip cn cc dch v y t ti
chi ph cho y t nm 2006 (Hnh 4), mc chi ph
Vit Nam. Tuy nhin, ng thi cng dn n
ny tng i thp so vi cc nc c mc thu
vic tng chi ph ca ngi bnh, h phi t chi
nhp thp v trung bnh khc, vi t l xp x
tr cho cc dch v chm sc sc kho v chim
45%15. 69% ca tng chi ph y t c chi tr
t l kh cao trong tng chi ph v y t.
bi cc ngun t nhn, trong , 61% l chi ph
V tng s, chi ph cho y t Vit Nam,

tng v t mc xp x 5-6% tng sn phm
quc ni15. Con s ny tng i cao so vi mt
s nc trong khu vc nh Trung Quc (4,7%),
v Thi Lan (3,5%)20. Tuy nhin, chi ph t cc
ngun cng lp ch chim 31% trong tng s
t tin ti bnh nhn v 8% c h tr bi

cc t chc phi chnh ph (Xem hnh 4)21. Chi
ph t tin ti c nhn nh vy l kh cao so
vi cc nc ang pht trin trong khu vc,
nh
Trung
Quc
(38,8%)
Malaysia
(44,8%)15.
Hnh 4: C cu chi ph y t 200615.
8%
2%
11%
Out-of-pocket
Tin ti
MoH
budget
Ngn sch
nh nc
Bo him
y t
Health
insurance
18%
Phi chnh
ph
Non
governmental
61%
Vn ncaid
ngoi
Foreign
Ngun: B Y t. Ti khon Y t quc gia 2000-2006 (H Ni. 2008)
Bo him y t
dch v y t c min ph cho cc i tng
Ngn sch nh nc cng c dng
tr em di 6 tui c p dng k t nm
chi tr chi ph ca bo him y t i vi cc
2005. Trong cu trc cc ngun chi tr ca ph
nhm i tng c bit, v d nh cc i
bo him i vi nhm bo him y t bt buc
tng ngi ngho v ngi ngh hu. Cc
v bo him y t t nguyn cho thy, nh nc
chi tr phn ln nht cho bo him y t, chim
tr ngi bnh c thanh ton t bo him
64,5% trong tng s ngn sch ca bo him y
khng vt qu 20.000.000 VND15. Hin nay,
t. Cui nm 2007, xp x 42% dn s c bo
c mt s bnh vin t nhn ng k khm
him y t (Xem bng 4). Bo him y t l bt
bo him y t. Chnh ph chi tr 64,5% tng
buc i vi ngi lao ng. Mc ng bo
ngn sch ca bo him y t15.
him y t bt buc c qui nh tr gi 3%

mc lng c bn, trong , 1% c tr bi
ngi lao ng v 2% t ngi s dng lao
ng15. i vi nhng ngi khng c thu nhp
t lng, vic ng bo him y t l t nguyn
v mc ph tng ng 3% ca mc lng ti
thiu. Bo him y t yu cu ngi bnh ng
chi tr 20% chi ph (tr trng hp mc chi
di 100.000 VND i vi bnh nhn ngoi tr
v di 200.000 VND i vi bnh nhn ni
tr)22. i vi cc dch v k thut cao, mc chi
c hon tr cc chi ph cho cc dch

v chm sc sc kho, bnh nhn phi n
khm bnh ti c s y t ni h ng k khm
dch v bo him y t. Trong trng hp ngi
bnh chuyn vin, cn phi c giy chuyn vin
c hon tr mt phn vin ph trong
phm vi t 30% n 70% tu thuc vo cp
bnh vin. Ngi bnh s khng c hon tr
chi ph chm sc sc kho t bo him y t nu
ngi bnh chuyn vin m khng c giy
php t c s y t tuyn di22.
Bng 3. S ngi tham gia bo him y t trn ton quc, 2005-200715
Bt buc
Khng ngho
Ngho
T nguyn
Tng s
2005
Thnh vin
9.154.308
4.726.324
9.133.134
23.013.766
1.2.3. Tip cn dch v chm sc

sc kho v thuc
%
39,8
20,5
39,7
100
2007
Thnh vin
11.606.569
15.498.284
9.379.349
36.484.742
%
31,8
42,5
25,7
100
kin c s h tng v phng tin i li cn rt

kh khn. Hn na, i tng ngi ngho v
i tng khm bo him y t l hai i tng
Vit Nam c mt h thng trm y t rng
s dng loi hnh trm y t nhiu hn so vi
khp c nc vi t nht ba nhn vin y t
ngi c iu kin v kinh t. Cc h gia nh
mi c s. cc khu vc thuc vng su, vng
c iu kin tt hn v kinh t s dng cc dch
xa, s lng trm y t c php cao hn cc
v chm sc sc khe nhiu hn so vi cc h
khu vc khc v mt mt nhm tit kim
ngho v do mc ng gp ca h trong
thi gian di chuyn v nhng vng ny iu
tng chi tr t tin ti cng ln hn. V d nh,
cc h c iu kin v kinh t d dng tip cn

vi bnh vin ln cp trung ng23.
1.3. Chng nhim khun

Mi y, B Y t tin hnh vic sa i,
Cc dch v chm sc sc kho ngy cng
b sung qui ch c ban hnh nm 1997
phong ph, do vic tm kim v tip cn cc
v vic chng nhim khun vi h tr v mt
dch v y t cng thay i r rt: Nhiu c
k thut t T chc Y t th gii. Thng t
s khm cha bnh t nhn cung cp cho
Hng dn trin khai cng tc chng nhim
ngi bnh kh nng tip cn dch v y t cng
khun ti cc c s khm cha bnh c
nh cht lng dch v tt hn rt nhiu so
B Y t thng qua, v c hiu lc t thng 12
mt s c s khm cha bnh cng lp. Tuy
nm 200924. Thng t ny l mt n lc ca B
nhin nhiu ngi bnh t iu tr hoc tm
Y t nhm ci thin kh nng ca quc gia
n cc hiu thuc t nhn. T iu tr l bin
trong cng tc chng nhim khun v do
php r tin v tit kim thi gian hn nhiu so
tng cng cng tc bo v an ton cho ngi
vi vic i khm bnh ti cc c s y t. Mt
bnh cng nh cn b y t v ngi nh bnh
nghin cu ch ra rng, chi ph trung bnh ca
nhn. Cc hng dn ny c p dng c c
h gia nh cho mt t iu tr l 19.616 , i
s cng lp v t nhn trong bao gm rt
vi loi hnh chm sc sc kho t nhn l
nhiu mt ca cng tc chng nhim khun: v
35.206 , v vi loi hnh dch v cng lp l
sinh bn tay, kh khun, cc cnh bo chun,
95.795 . iu ny gii thch ti sao ngi bnh
cch ly, gim st nhim khun bnh vin, v
thng c xu hng la chn phng thc t
sinh mi trng, qun l cht thi, an ton thc
iu tr, kt qu l dn n tnh trng s dng
phm, git l, x l t thi. Mt nhm ch o
thuc khng hp l ngy cng ph bin. Theo
trin khai vic thc hin thng t theo hng
qui nh ca qui ch k n v bn thuc theo
dn c thnh lp nhm m bo vic hiu
n, tt c cc khng sinh u phi bn theo
v thc hin ng v ng b trn qui m ton
n nhng thc t th hu ht cc loi khng
quc v cng tc chng nhim khun. iu
sinh u mua c ti cc ca hng thuc m
ng ch theo Thng t ny l, vic gim
khng cn n. Mc d cc loi thuc khng
st nhim khun bnh vin tr thnh nhim
sinh b cm bn khi khng c n thuc, thc
v bt buc i vi cc c s y t. Hn na,
trng v vic bn thuc khng sinh khng n
cng tc ny c h tr bi T chc Y t th
ch r s khng tun th cc qui nh c
gii trong chng trnh: Nhng thch thc
ra10.
mang tnh ton cu v an ton cho ngi bnh,

nm 2009.
Mt nghin cu gn y ti 51 bnh vin
thuc khu vc Bc b, Vit Nam v cng tc
kim sot nhim khun ti bnh vin nm 2007
T l nhn vin y t nhn thc tt v v sinh
v so snh vi kt qu kho st nm 2003
bn tay l 41,2%. T l tun th VSBT tnh
c thc hin25. c mt s ci thin ng
chung l 13,4%26. T l tun th VSBT nhn
k, vi nhng khc bit r rt gia bnh vin
vin y t bnh vin trung ng l 17,7% cao
tuyn trung ng v tuyn a phng. cc
hn so vi nhn vin y t bnh vin tnh/TP:
bnh vin tuyn a phng, iu kin vt cht
10,7%26. Mt s yu t nh hng n thc
cn ngho nn v hn ch cc c hi o to
hnh VSBT ca nhn vin y t gm: thiu
lin tc cho cc cn b y t. Hu ht cc bnh
phng tin, khng c trang b cn kh
vin tuyn huyn c hi ng chng nhim
khun tay, nhn vin y t nhn thc khng tt
khun trc nm 2007, tuy nhin nhn lc cn
v VSBT, mt c hi cn VSBT/gi thp,
thiu v do hiu qu hot ng ca hi ng
khi
cha cao. Hn na, mt s hng dn thiu
NVYT/ging bnh<126. Mt nghin cu khc
tnh cp nht do khng cn ph hp v
tin hnh ti mt s bnh vin khu vc pha
mt ni dung25.
Bc Vit Nam cho thy phng tin v sinh bn
Thc trng ca cng tc chng nhim

khun c bit gp nhiu kh khn hu ht
cc bnh vin Vit Nam vi c s h tng
tr nn qu c v tnh trng qu ti ti cc
bnh vin ny. Cng sut s dng ging bnh
Ngoi
khoa,
hc
vin
tay cn thiu nh: nc, x phng, hoc khn

lau dng mt ln27. Ch c khong 1/3 bnh
vin t tiu chun v s v tr v sinh bn
tay27. Bung bnh c bn ra tay ch t cha
n 40%28.
c th vt qu 100%, c ngha l t nht 2
Vic qun l cht thi t bnh vin cng l
ngi bnh phi s dng chung mt ging.
vn ng ch Vit Nam. Mt d n v
Tnh trng ny thng xuyn xy ra trong cc
iu kin v sinh bnh vin v vic qun l
v dch nh t, st xut huyt, cm. Hn na,
cht thi c tin hnh 12 bnh vin khu
ngi nh bnh nhn cng cn cng gip
vc pha Bc (2006) cho thy, tnh trng kh
chm sc ngi bnh v v sinh v n ung,
ph bin khi nc thi t bnh vin c thi
dn n tnh trng qu ti cng nghim trng.
trc tip ra ng rung m khng c qua

qu trnh x l29. Mt kh khn nghim trng
Nghin cu v thc trng v sinh bn tay
khc l hu ht cc bnh vin thiu nc cho
c thc hin ti 29 khoa lm sng bao gm
cng tc v sinh. Cc theo di khc nh: cc loi
cc khoa Ngoi, Sn, Hi sc cp cu ca mt
rc thi bnh vin vt ba bi gn ngun nc,
bnh vin trung ng v 8 bnh vin tuyn
khng c hp ng xilanh qua s dng, iu
tnh/TP khu vc pha Bc26. Kt qu cho thy
kin v sinh ngho nn30. Theo bo co mi
s v tr VSBT/100 ging bnh rt thp: 10,3.
y, mi ngy, cc bnh vin trong khu vc
10
thnh ph H Ch Minh thi khong
Bng 4. Mt s nguyn nhn gy t l t
14.000m3 nc khng qua x l vo cc dng
vong cao nht ti Vit Nam12
sng v cng sinh hot31.
1.4. Gnh nng bnh tt

nhng nc m bnh truyn nhim
chim mt t l ln trong c cu bnh tt th
vic tip cn vi thuc khng sinh mt cch
hiu qu ng mt vai tr rt quan trng trong
Nguyn nhn t
vong
Chn thng s no
Hi chng suy gim
min dch mc phi
Vim phi
Xut huyt no
Tai nn giao thng
Nhi mu c tim cp
T l
(trn 100.000 dn)
2,53
2,43
2,34
1,27
1,10
0,85
Ngun: Thng k Y t 2008 (B Y t)
vic gim t l mc v t l t vong do cc bnh

nhim khun. Do , s gia tng ca tnh trng
1.4.2. Gnh nng bnh tt do
khng khng sinh c th c nh hng nghim
nguyn nhn vi khun
trng i vi sc kho ln kinh t ca ngi

dn cc nc ny. Phn ny nh gi mt
Cc bnh nhim khun vn l nguyn
cch tng quan gnh nng bnh tt Vit Nam
nhn ch yu gy t l mc v t l t vong
v cc cn nguyn vi khun ph bin gy nhim
cao Vit Nam. Hu ht d liu da trn
khun mc phi bnh vin.
cc nghin cu ca bnh vin, cha c d
1.4.1. Cc ch s trn ton quc
liu chung v t l mc v t vong ngoi

bnh vin ni thiu cc iu kin chn
T l t vong l mt ch s y t quan trng
on. Nhng hn ch v mt d liu i hi
nhm nh gi v tnh hnh sc kho ca ngi
cn c mt s hiu bit su sc v tc ng
dn v s pht trin ca mi quc gia. Vit

Nam, cha c s liu mang tnh h thng v
chnh xc v t l t vong. Theo thng k ca B
v dch t hc ca cc bnh nhim khun

phi iu tr bng khng sinh.
Y t, mt s nguyn nhn gy t l t vong cao
Gnh nng ca cc bnh truyn
nht ti Vit Nam c trnh by trong bng 5.
nhim c th phng bnh bng
Mt nghin cu ch ra rng, bnh l tim mch l
vc xin
nguyn nhn hng u gy t l t vong cao,

tip n l nguyn nhn bnh nhim khun.
Mi y theo thng k t UNICEF cho thy,
iu chng t Vit Nam c s pht trin
Streptococcus pneumoniae l nguyn nhn gy
ng k v mt dch t hc trong vic phng v
ra 50% cc ca t vong do vim phi tr trn
iu tr bnh nhim khun32.
ton th gii. Gim st cc trng hp tr nhp

vin c lin quan n cn nguyn ph cu
11
khun ti tnh Khnh Ho, Vit Nam (nm
trn 100.000 tr v 26 ca trn 100.000 tr tr
2005-2006) cho thy t l mc vim phi xm
di 2 tui36. Vim mng no do Hib tr di
ln (IPD) l 48,7/100.000 tr33. 69% cc ca tr
2 tui chim khong 88-94% s trng hp
nhp vin v vim phi do ph cu, v 11% v
vim mng no do vi khun tr di 5 tui35.
vim mng no do ph cu33. Mt nghin cu
Mt nghin cu khc tin hnh vi cc bnh
khc trn i tng bnh nhn l tr di 5
phm dch no tu thu thp t bnh nhn nhp
tui, vim ng h hp cp ti bnh vin Saint
vin vo vin Nhi trung ng t 2001 n
Paul, H Ni (2003), vi khun phn lp c
2005. Kt qu cho thy 129/529 (24%) cc
vi t l cao nht l S. pneumoniae (35,8%)34.
mu bnh phm dch no ty (CSF) nui cy
Hin ti cha c gim st da trn cng ng
dng tnh vi Hib, trong 59,7% (77/129)
v bnh vim phi xm ln v hin ti vn cha
cc chng khng vi amoxicillin37. Mt
c k hoch v vic a vc xin ph cu vo
nghin cu khc ch ra rng Hib l cn nguyn
Vit Nam.
ph bin th 2 gy ra t l mc bnh nhim
Trc khi trin khai vic a vc xin phi

hp Hemophilus influenza tup B (Hib) vo
chng trnh tim chng m rng, theo thng
k, trn th gii c khong 600.000 ca t vong
hng nm do cn nguyn Hib35. Mt vi nghin
cu c trin khai nhm nh gi tnh
hnh nhim Hib tr di 5 tui Vit Nam t
khun xm ln tr di 5 tui: 22,9/100.000.

T l mc Hib c bo co trong nghin cu
ny cao hn t l mc c bo co trc
vi t l t 12 n 18/100.000 trong 2 phn
tch khc33. Vic a vc xin Hib vo chng
trnh tim chng s gip gim t l mc bnh
nhim khun xm ln tr.
cc ca vim mng no. Trn ton quc, mi
Trong mt thi gian di, Salmonella typhi
nm c 5.107 ca nhp vin v vim phi do H.
thng c phn lp t bnh phm mu ca
influenzae tr di 5 tui36. Mt nghin cu
bnh nhn c triu chng st. Chng trnh
khc ch ra rng, Hib l cn nguyn gy t l
tim chng cng vi cng tc ci thin iu
vim mng no xm ln do vi khun tr di
kin v sinh em li nhng thay i ng k
5 tui: 22,9 ca trn 100.000 tr33. Nhm tui c
v mt dch t hc ca S. typhi Vit Nam. Vit
t l mc bnh do Hib cao nht l tr s sinh
Nam v ang s dng vc xin cha Vi
(87,9/100.000 tr) v tr di 2 tui
polysaccharide chng li st thng hn
(32,9/100.000)33.
cc vng c t l mc cao vi i tng tr t 3
Nghin cu dch t hc vim mng no

xm ln do Hib ti H Ni t 2000-2002, t l
n 10 tui38.
Vim mng no
vim mng no do Hib tr 5 tui l 12 ca

12
Vit Nam, nguyn nhn gy bnh vim
16,2%; E. coli ESBL (+) 21,5%; S. aureus
mng no vi khun ch yu do H. influenzae v
(MRSA) khng methicillin 13,6%; S. aureus
S. pneumoniae nh c cp trn y.
khng trung gian vancomycin (VISA) v S.
ngi ln, yu t dch t hc c s khc bit. V
aureus khng vancomycin (VRSA) 6,1%42. Theo
d, Streptococcus suis l nguyn nhn gy vim
bo co ca Bnh vin Bnh Nhit i Trung
mng no do vi khun ph bin nht: 26% tt
ng, cc cn nguyn vi khun gy bnh
c cc chng vi khun nui cy39.
thng gp t 2008 n 2009 l: E. coli
S. suis l mt vi khun t ln truyn nhim

sang ngi do tip xc v n cc sn phm t
tht ln khng m bo an ton thc phm. Cn
nguyn vi khun quan trng khc gm S.
pneumoniae (11,1%), N. meningitidis (2,4%),
Klebsiella (2,7%), E. coli (1,8%), S. aureus
(0,7%) v Haemophilus influenzae (0.9%)39.
Ceftriaxone c s dng ph bin trong iu
tr vim mng no ti Vit Nam, nghin cu
nh gi mc khng khng sinh i vi
khng sinh ny (t nm 1996 n nm 2005)
cho thy: Trong s 55 chng S. pneumoniae, 50
(90,9%) chng nhy cm vi ceftriaxone v 5
(9,1%) chng khng trung gian vi khng sinh
ny40.
(19,3%), K. pneumoniae (15,2%), S. aureus

(13,8%), v S. suis (9,7%)43. Ti thnh ph H
Ch Minh, cc cn nguyn vi khun thng
phn lp c l: E. coli, S. typhi, Klebsiella
pneumoniae v Streptococcus spp44. Cc cn
nguyn gy bnh quan trng khc nui cy
phn lp t mu Vit Nam l: Burkholderia
pseudomallei, nguyn nhn gy melioidosis,
nm Penicillium marneffei v Cryptococcus
neoformans bnh nhn nhim HIV.
Vim ng h hp cp (ARI)
ARI l mt trong nhng nguyn nhn ch
yu nht gp phn gy ra gnh nng v bnh
truyn nhim. Vim phi l nguyn nhn ph
bin th hai gy t l t vong. Theo bo co t
Nhim khun huyt
cc trm y t x, ARI l bnh ph bin nht ti

cc c s ny v khng sinh thng c ch
Phn lp cc tc nhn gy nhim khun
nh trong iu tr45. Mt iu tra nghin cu
huyt ti mt bnh vin tuyn trung ng: t l
ch ra rng, s dng khng sinh khng y
dng tnh l 8% nm
200941.
Cc vi khun
trong trng hp kh th (mt trong nhng
thng gp l: K. pneumonia (18,3%), E. coli
triu chng in hnh ca vim phi), v vic
(17,6%),
lm dng khng sinh iu tr cm lnh v ho
Staphylococcus
Pseudomonas
aureus
aeruginosa
(11,9%),
v
ca cn b y t, cc b m v cc i tng
Acinetobacter baumannii (4,4%). Mc khng
hnh ngh y dc t nhn l kh ph bin11.
khng sinh ln lt l: K. pneumoniae ESBL (+)
Cc nguyn nhn chnh ca ARI v bn cht l
(5,9%)
13
vi rt nh rhinovirus, vi rt RS, influenza, v
nhp vin, 162/587 (27,6%) tr dng khng
cc cn nguyn khc [s liu cha cng b,
sinh. Hu ht cc ca tiu chy c bn t cc h
OUCRU]. Cn nguyn vi khun bao gm:
gia nh c iu kin v sinh km47.
S.pneumoniae, K. pneumonia, H. infuenzae,

Moraxella catarrhalis, v S. aureus. ng ch
l, K. pneumoniae l mt nguyn nhn ch yu
gy vim phi mc phi cng ng ngi ln
[S liu cha cng b OUCRU-NHTD].
Sau ca nhim HIV u tin c bo co
HIV v AIDS gia tng nhanh chng tt c
Gnh nng ca bnh tiu chy Vit Nam

gim ng k nh vic ci thin iu kin
sng, nh s dng nc sch v h thng v
sinh m bo. Mc d vy, trong nm 2007 vn
xy ra v dch t cc tnh pha Bc Vit Nam46.
Nghin cu H Ni t 3/2001 n 4/2002,
trn 587 tr b tiu chy, cn nguyn vi khun
gy bnh phn lp c vi t l 67,3%, bao
gm: rotavirus (47%), E. coli (23%), Shigella
spp. (5%), v Bacteroides fragilis (7%). Khng
phn lp c Salmonella spp hoc phy khun
t47. E. coli v Shigella spp. c mc khng khng
sinh cao vi ampicillin, chloramphenicol, v
trimethoprim/ sulfamethoxazole. E. coli khng
cao vi ampicillin (AMP), chloramphenicol
v
tnh dc (STI)
Vit Nam vo nm 1990, con s cc ca nhim
Bnh tiu chy
(CHL),
Bnh truyn nhim qua ng
trimethoprim/sulfamethoxazole
(SXT), vi t l khng tng ng l 86.4%,

77.2%, v 88.3%. Khong 89% cc chng
cc tnh/thnh ph48. Tng s trng hp

nhim HIV tnh n cui nm 2008 l 179.735
ngi12. Tnh hnh nhim HIV Vit Nam vn
gia tng v din bin phc tp, ch yu tp
trung nhm i tng s dng ma ty, gi
mi dm v quan h tnh dc ng tnh nam
gii49. Cc nhm i tng khc chim khong
0,53%49. Tnh n nay, c nc c khong
15.007 trng hp t vong do AIDS49. 63
tnh/thnh trn ton quc u c ngi nhim
HIV, t l nhim 96% ti 659 qun v hn 66%
10.732 trm y t phng/x49. Nhim HIV
ch yu tp trung nhm i tng t 20-39
tui chim 78.9%, trong nam gii chim
85.2%49. T l nhim HIV nhm i tng tr
tui v quan h tnh dc ng gii ngy cng
gia tng49.
Trong mt nghin cu vng nng thn
vi
Vit Nam, 37% gi mi dm mc bnh truyn
trimethoprim/sulfamethoxazole, 75% khng
nhim qua ng tnh dc hoc mc bnh vim
ampicillin, v 53.6% khng chloramphenicol47.
ng sinh dc50. Cc nhim khun thng gp
Tr nhp vin vi cc triu chng st (43,6%),
l candidiasis (26%), vi khun m o (11%),
nn (53,8%), v mt nc (82,6%). Trc khi
tip n l vim gan B (8,3%), Chlamydia
Shigella
khng
14
trachomatis (4,3%), trng roi m o (1%),
Nghin cu 36 bnh vin cc tnh pha
Neisseria gonorrhoeae (0,7%), v mn cc m
Bc Vit Nam trong nm 2006-2007 bao gm 2
o (0,2%)50. Khng pht hin trng hp no
bnh vin trung ng, 17 bnh vin tuyn tnh
nhim HIV v giang mai, 50% cc ca STI khng
v 17 bnh vin tuyn huyn cho thy
c triu chng50. Yu t lin quan n
553/7571 (7,8%) bnh nhn mc nhim trng
chlamydia STI l nhm i tng c iu kin
bnh vin (HAIs)27. Cn nguyn gy nhim
kinh t cao50.
khun bnh vin thng gp l: vim phi
Nhim khun bnh vin
(41,9%), nhim khun vt m (27,5%), nhim

khun tiu ho (13,1%). Cc vi khun thng
Hin nay c rt t s liu v gnh nng ca
gp l Pseudomonas aeruginosa (31,5%),
nhim khun bnh vin Vit Nam. Nh
Acinetobacter baumanii (23,3%), v Candida
trnh by phn trn, cng tc chng nhim
spp (14,4%). Ch yu, HAIs xy ra khoa phu
khun bnh vin Vit Nam gp nhiu tr ngi
thut27.
do thiu iu kin v sinh (x phng, nc sch
Mt nghin cu ct ngang Bnh vin
hp ng cht thi sc nhn, h thng qun l
Bch Mai nm 2006 cho thy, t l cc trng
cht thi), v sinh bn tay khng y , tnh
hp nhim khun bnh vin tng i thp:
trng qu ti v thiu nhn lc. Hin ti, khng
5.9%. C 3 loi nhim khun chnh: nhim
c s liu ton quc v t l mc v gnh nng
khun h hp (75%), nhim khun tit niu
ca nhim khun bnh vin Vit Nam. Ti
(10%) v nhim khun tiu ho (5%). Cn
liu hng dn mi ca B Y t yu cu tt c
nguyn chnh l P. aeruginosa (28,6%), A.
cc c s y t phi ghi li cc s liu v nhim
baumanii (23,8%), K. pneumoniae (19%) v
khun bnh vin trong thi gian sp ti.
Candida spp (14,3%)52. 48,5% bnh nhn c
Mt s nghin cu v nhim khun bnh
iu tra s dng khng sinh trc khi chn
vin Vit Nam, ch yu c thc hin
on mc HAIs53. Nghin cu khc bnh vin
bnh vin Bch Mai v bnh vin Ch Ry.
Ch Ry cng ch ra rng, cn nguyn thng
Gim st c tin hnh bnh vin Bch Mai
gy HAIs l trc khun Gram m bao gm: K.
v hiu qu iu tr v chi ph cho nhim khun
pneumoniae (25%), P. aeruginosa (24%), A.
bnh vin do nhim khun vt m (SSI). Kt
baumani (18%). v E. coli (19%)54. HAIs do S.
qu cho thy nhim khun vt m lm tng chi
aureus khng ng vai tr quan trng Vit
ph iu tr v tng thi gian nm vin. C th
Nam.
l tng thi gian nm vin ln 8,2 ngy, chi ph

iu tr khong 110 USD
51.
Mt nghin cu khc khoa cp cu hi

sc, khoa phu thut v khoa sn ca 3 bnh
15
vin tnh bao gm Qung Ninh, Ha Bnh, in
bin nht l nhim khun vt m (55%), nhim
Bin nm 2004 cho thy, t l mc nhim khun
khun tit niu (21%) v vim ng h hp
bnh vin tng i cao: 17,3%55. T l cao
di (17%)55.
nht khoa cp cu hi sc. Nhim khun ph
16
II. H thng cung ng v

qun l khng sinh
Ni dung phn II trnh by v h thng
qun l v phn phi khng sinh Vit Nam,
ng thi cung cp cc thng tin lin quan n
cc chnh sch qui ch quc gia lin quan n
php xut nhp khu thuc v cc lnh vc

qun l khc c lin quan. Cc Qun l Khm,
cha bnh tham mu gip B trng B Y t
qun l nh nc v lnh vc khm, cha bnh;
qun l bnh vin; iu dng; phc hi chc
nng; gim nh (bao gm gim nh y khoa,
s cung cp v phn phi thuc, tm quan
gim nh y php) i vi ton b h thng y t
trng ca khng sinh trong cc ti liu hng
nh nc, bn cng v t nhn trong phm vi
dn iu tr, qui nh phn b v thc trng

qun l dc phm.
c nc; Ch o, hng dn s dng thuc an

ton, hp l, hiu qu. Chm sc v bo v sc
kho cn b. Ch o cc c s y t thc hin
2.1. C cu lp php chi phi

s phn phi, lu thng
khng sinh
Mt s V, Cc trc thuc B Y t c chc
nng, nhim v iu hnh cc hot ng ca
cc c s y dc cng lp v t nhn. C th l,
Cc Qun l Dc gip B trng B Y t thc
hin chc nng qun l Nh nc v thc thi
php lut, iu hnh cc hot ng chuyn
mn, nghip v v lnh vc dc v m phm
trong phm vi c nc. Nhim v: Xy dng
chin lc, chnh sch, quy hoch, k hoch
pht trin ngnh Dc Vit Nam; Ch o,
hng dn, kim tra vic thc hin cc vn bn
quy phm php lut, quy ch, ch qun l v
dc, m phm trong phm vi c nc; Ch tr
hoc phi hp vi cc c quan lin quan trong
khm cha bnh, iu dng, phc hi chc

nng cho ngi bnh c th bo him y t.
Thanh tra B Y t c chc nng thc hin thanh
tra chuyn ngnh y t trong phm vi c nc
trong bao gm: T chc thanh tra vic chp
hnh nhng quy nh ca php lut, cc quy
ch, quy trnh chuyn mn, k thut trong
khm cha bnh, iu dng, phc hi chc
nng trong phm vi c nc bao gm c t
chc v c nhn nc ngoi ti Vit Nam; T
chc thanh tra vic chp hnh nhng quy nh
ca php lut v dc trong phm vi c nc
bao gm c t chc v c nhn nc ngoi ti
Vit Nam. n nm 2006, c nc c 230 thanh
tra y, vi s h tr ca khong 1000 cng tc
vin trong tng khu vc c th v 30 cn b
tuyn trung ng56.
vic qun l thng tin, qung co thuc, m
Trc thuc B Nng nghip v Pht trin
phm; T chc thc hin v quyt nh theo
Nng thn, Cc Th y gip B trng thc hin
thm quyn vic cp, nh ch, thu hi giy
chc nng qun l Nh nc v cng tc phng
chng nhn t tiu chun thc hnh tt v
chng dch bnh cho ng vt, kim dch v
lnh vc dc, s ng k lu hnh thuc; giy
kim sot thuc th y trong phm vi c nc.
17
Ngoi ra, Cc Qun l Cht lng Nng lm
cc xt nghim vi sinh. Trong chng trnh
Thu sn gip B thc hin chc nng qun l
ASTS (Nghin cu th nghim nhy cm khng
nh nc v cht lng, v sinh an ton thc
sinh) cht lng v tin cy ca cc xt
phm i vi nng, lm, thy sn trong qu
nghim vi sinh l mt vn . V d,
trnh sn xut n khi thc phm c a ra
Pseudomonas aeruginosa trong mt s bo co
th trng ni a hoc xut khu, trong
cho thy kt qu nhy cm vi cotrimoxazole,
phi k n chng trnh gim st d lng
trong khi vi khun ny v bn cht khng
cc cht b hn ch hoc cm s dng trong
vi cc khng sinh ny.
chn nui v nui trng thu sn, k c thuc

khng sinh.
Nm 1996, B Y t ban hnh chnh sch
Quc gia v thuc, trong c nu r chnh
sch v thuc khng sinh nh sau: Thuc
khng sinh c vai tr rt quan trng trong iu
tr, c bit i vi tnh hnh bnh tt ca mt
s nc kh hu nhit i nh nc ta. Chn
chnh vic k n v s dng khng sinh, xc
nh tnh khng khng sinh ca mt s vi
khun gy bnh, to iu kin cc c s iu
tr c kh nng lm khng sinh . Ngnh y t
cng vi B Nng nghip v Pht trin Nng
thn ban hnh quy nh s dng khng sinh
cho sc vt nhm trnh s gia tng tnh khng
khng sinh i vi mt s vi khun gy bnh
cho ngi.
Nm 1997, B Y t c vn bn yu cu cc
bnh vin thnh lp Hi ng Thuc v iu
tr. Thnh vin ca Hi ng gm c bc s lm
sng, dc s v chuyn gia vi sinh. Mt trong
nhng nhim v ca HT&T l thc hin cc
hng dn ca B Y t v vic s dng thuc,
a ra cc li khuyn v mt chuyn mn
nhm gip ci thin vic s dng thuc hp l,
an ton v hiu qu. Ngoi ra, Hi ng cn c
nhim v tham vn gip xy dng danh mc
thuc ch yu s dng ti n v ca h. Mt s
loi thuc khng sinh nht nh, v d nh
meropenem, trc khi s dng trong iu tr
phi tham kho kin t vn ca Hi ng.
Mt nhim v khc ca Hi ng l ch o
tuyn cho cc cn b y t a phng v vic s
dng thuc hp l v t chc cc hot ng
gim st v bo co v tnh trng khng khng
Hin nay, ch c cc bnh vin tuyn trung
sinh khng sinh. Hin ti, gn 100% cc bnh
ng hoc cc bnh vin ln tuyn tnh c kh
vin c hi ng thuc v iu tr. Cc bnh
nng tin hnh nui cy vi khun, nh danh v
vin tuyn huyn tn ti tnh trng thiu nhiu
xc nh mc nhy cm khng sinh. Cho n
nhn lc dc c trnh v cc chuyn gia vi
nay, hu ht cc phng xt nghim vi sinh lm
sinh. B Y t trin khai nhiu hot ng
sng ti cc bnh vin khng t tiu chun
nhm tip tc thc hin ch th 05/2004/CT-
c th tin hnh v cho kt qu ng tin cy ca
BYT v vic chn chnh cng tc cung ng, s
18
dng thuc trong bnh vin. C th nh sau:
dng i vi cc c s kinh doanh dc phm
Xy dng hng dn s dng thuc hp l, an
khng tun th theo qui nh.
ton; Tp hun tng cng s dng thuc hp
Quy ch K n thuc trong iu tr ngoi
l; Kim tra hot ng ca Hi ng thuc v
tr (ban hnh km theo Quyt inh s
iu tr; Hot ng h tr s dng khng sinh
04/2008/Q- BYT ngy 1 thng 2 nm 2008
hp l; Cung ng qun l thuc; s dng thuc
ca B trng B Y t :Quy nh thuc phi k
trong bnh vin; Hot ng s dng thuc hp
n: Theo quy nh ti Danh mc thuc phi k
l trong bnh vin v tng cng hot ng ca
n do B Y t ban hnh; iu kin i vi
nh thuc bnh vin57. Tuy nhin, nhng thnh
ngi k n thuc phi l ngi c bng i
tu v tc ng do Ch th ny em li cha
hc y ang lm vic ti c s khm cha bnh
c nhn bit r rng.
hp php hoc i vi cc tnh vng su vng
Trong quy nh ca Lut Dc c ban

hnh nm 2005 c ghi r: nghim cm: Bn l
thuc k n khng c n thuc; Khi s dng
thuc theo n thuc, ngi s dng thuc
phi thc hin theo ng hng dn ghi trong
n thuc; Khi s dng thuc, nu c th c
nhng du hiu khng bnh thng, ngi s
dng thuc cn thng bo ngay cho c s y t
gn nht, ngi k n thuc hoc ngi bn
l thuc bit c bin php x l kp thi;
Ngi k n thuc, ch c s bn l thuc c
trch nhim thng bo vi c quan y t c
thm quyn v nhng du hiu khng bnh
thng ca ngi s dng thuc. Ngi k n
phi chu trch nhim v n thuc k;
Thuc k n khng c qung co cho cng
chng di mi hnh thc. Mc d vy, hu ht
cc hiu thuc vn bn thuc khng n mt
cch t do m khng phi chu bt k hnh pht
no58. L do dn n tnh trng ny c th l v
cho n nay, vn cha c cc ch ti c th p
xa. Y s c th c ch nh thay th bc s.
ng ch l, trong qui ch ny cng qui nh
v vic khng c k n theo yu cu khng
hp l ca ngi bnh. n thuc c gi tr
mua thuc trong thi hn 05 ngy k t ngy
k n v c mua ti tt c cc c s bn
thuc hp php trong c nc.
Quyt nh s 11/2007 ca B Y t va
ban hnh v vic thc hnh tt qun l nh
thuc (Good Pharmacy Practice - GPP) a ra
cc nguyn tc, tiu chun c bn trong thc
hnh ngh nghip ti nh thuc ca dc s v
nhn s dc trn c s t nguyn tun th
cc tiu chun o c v chuyn mn mc
cao hn nhng yu cu php l ti thiu.
GPP bo m thc hin cc nguyn tc
sau: t li ch ca ngi bnh v sc kho ca
cng ng ln trn ht; Cung cp thuc bo
m cht lng km theo thng tin v thuc, t
vn thch hp cho ngi s dng v theo di
vic s dng thuc ca h; Tham gia vo hot
ng t iu tr, bao gm cung cp thuc v t
19
vn dng thuc, t iu tr triu chng ca cc
quan trng trong vic tip cn cc chnh sch
bnh n gin; Gp phn y mnh vic k n
v thc hnh k n trong h thng y t.
ph hp, kinh t v vic s dng thuc an ton,
Cho n nay, Vit Nam s dng 2 danh mc
hp l, c hiu qu. Theo bo co ca 37 tnh,
thuc l danh mc thuc thit yu v danh mc
thnh ph (tnh n 31.3.2009) c 5% nh
thuc ch yu. Danh mc thuc thit yu l
thuc t nh thuc t GPP59.
danh mc gm c s thuc cn c ti cc c s
Tp trung trin khai vi i tng cc nh
khm cha bnh. Danh mc thuc ch yu
thuc bnh vin. Khuyn khch cc doanh
c xy dng da trn danh mc thuc thit
nghip t chc chui nh thuc t GPP vi
yu v bao gm cc thuc c th c Bo
nhiu chnh sch u i nh chnh sch v
him y t chi tr. Danh mc ny c th iu
thu, trc tip nhp khu, cung ng thuc cho
chnh cho ph hp vi iu kin ca tng bnh
bnh vin. Theo d kin cc nh thuc khng
vin. Hin nay, cc bnh vin s dng danh
trin khai thc hin l trnh s ch c php
mc thuc ch yu (ban hnh nm 2008 vi
bn thuc OTC.
hn 750 thuc trong c 141 thuc khng
Nhm tng cng hiu qu trong s dng
sinh) c xy dng da trn danh mc thuc
thuc Vit Nam, mi y B Y t chnh
thit yu quc gia. Danh mc ny l c s
thc thnh lp Trung tm Quc gia v thng tin
cc c s khm cha bnh la chn, m bo
thuc quc gia v theo di phn ng c hi ca
nhu cu iu tr v thanh ton cho cc i
thuc (DI&PV). Mc tiu ca trung tm l nhm
tng ngi bnh, bao gm c ngi bnh c
xy dng mt h thng DI&PV ton din nhm
bo him y t. Trong danh mc ny, c 44
m bo an ton thuc Vit Nam. Mc tiu c
khng sinh ch c s dng cc bnh vin
th bao gm, xy dng mt c s d liu thng
hng hai tr ln, 16 loi khng sinh cn phi
tin v thuc k c thng tin v cnh gic Dc;
c Hi ng thuc v iu tr thng qua
h tr cc c quan qun l nh nc trong vic
trc khi k n. Mt s loi khng sinh nn
nh gi, thng tin v nhng nguy c v li ch
hn ch s dng bao gm cephalosporins th
ca cc loi thuc trn th trng; cung cp t
h 3, 4 (cefepim, cefoperazon, cefotiam, v
vn v ph bin cc thng tin v thuc, cnh
ceftriaxone),
carbapenems
gic Dc cho cc c s y t, cn b y t v
ertapenem),
piptazobactam,
cng ng; xy dng mng li thng tin thuc
azithromycin, fluorquinolones (levofloxacin,
v cnh gic Dc trn ton quc v thit lp
lomefloxacin, v moxifloxacin), v vancomycin.
(khng
netilmicin,
mi quan h vi cc trung tm thng tin thuc

v cnh gic dc khu vc v trn th gii.
2.2. Chui cung ng
Trung tm ny c th ng gp mt vai tr
2.2.1. Nh sn xut
20
Hin nay, c 93 doanh nghip trong nc

sn xut dc phm. Trong s , 53 c s t
tiu chun thc hnh tt sn xut thuc ca T
chc Y t th gii (GMP WHO) v 24 c s t
tiu chun GMP ASEAN. Hu ht cc c s sn
xut trong nc v c bn ch yu nhp bn
thnh phm v ng gi mt s loi thuc bao
gm c mt s thuc khng sinh thng thng
y t cng c khuyn khch s dng cc thuc

sn xut trong nc nu c th.
Hnh 5. Doanh thu ca thuc sn xut
trong nc v thuc ni chung ti Vit
Nam (triu la M) t 2001 n 200861.
la
M
Tng doanh thu

DT thuc ni
nh beta-lactams, tetracycline, chloramphenicol

v gentamicin, t bn thnh phm nhp khu.
Cc nguyn liu sn xut ch yu nhp khu t
Trung Quc, Singapore v n . Mt s doanh
nghip sn xut ni a cng tham gia vo qu
trnh cung ng thuc cho cc bnh vin v cc
c s bn bun (c bit n nh mt s
ch thuc ln) hoc thm ch cc doanh
nghip ny cng s hu cc nh thuc hot
ng trong lnh vc kinh doanh. C 4 doanh
Nm
nghip dc phm ln chi phi hot ng sn

xut, nhp khu, cung ng thuc v chim lnh
Ngun: Cc Qun l Dc (B Y t)
th trng. Cc doanh nghip ny trc y l

doanh nghip c 100% vn nh nc, hin nay
tr thnh cc cng ty c phn vi vn nh
nc chim khong 46,5% tng s vn iu l,
nhn vin ca doanh nghip gi 38,1% v
thnh phn ngoi doanh nghip gi 15,4%60.
2.2.2. Nh phn phi

Knh phn phi dc phm trn th
trng Vit Nam c chia lm 2 th phn:
iu tr (37%) v thng mi (63%)62. u
thu v bn thuc qua h thng bnh vin
S liu nm 2008 cho thy, sn phm
thuc v knh iu tr, trong khi vic kinh
thuc ni a chim 50,2% trong tng s tt c
doanh qua h thng nh thuc c hiu l
cc thuc trn th trng Vit Nam (Ngun: B
knh thng mi. Li nhun trong knh iu
Y t). Tng gi tr thuc sn xut trong nc
tr thp hn knh thng mi do gi thuc
nm 2008 l 715.435 triu la M, tng ng
trong bnh vin thng thp hn gi th
k so vi nm 2007 (600.630 triu la M
trng.
USD, xem hnh 1, s liu t B Y t). Cc cn b

21
Hn 370 doanh nghip nc ngoi v 93
cht lng thuc, uy tn ca cng ty phn phi
doanh nghip sn xut trong nc cung ng
v li ch bnh vin nhn c. Theo kt qu
thuc khng sinh cho th trng thuc Vit
thanh tra mi y ca Cc Qun l Dc ti 6
Nam qua mt h thng phn phi phc tp,
nh thuc bnh vin v 8 nh thuc khu vc
trong ring doanh s ca mt vi cng ty
gn bnh vin cho thy, gn 98% cc loi thuc
phn phi nc ngoi chim gn 50% th
ti nh thuc bnh vin c bn vi gi thp
trng. Trong h thng cung ng thuc Vit
hn so vi cc nh thuc ngoi bnh vin58.
Nam c khong 800 cng ty phn phi dc
Tuy nhin, mt s nghin cu khc li chng
phm v 39.016 i l (nh thuc, hiu thuc,
minh kt qu ngc li, gi thuc ti nh thuc
quy thuc) nm 200863. Qun l gi v cht
trong bnh vin t hn gi bn l bn ngoi.
lng thuc trong chui cung ng cn rt yu.
Bo co mi y ca T chc y t th gii v
V d, khng sinh phi qua rt nhiu khu trung
gi thuc ti Vit Nam cng nhn nh rng, gi
gian mi n c tay ngi bnh dn n
thuc ti khu vc cng lp cao hn so vi khu
tnh trng tng gi thuc gi to.
vc t nhn64.
Mc d tp trung ch yu ti TP. H Ch
2.2.4. Hiu thuc
Minh v H Ni, cc ca hng bn bun v cng

ty trch nhim hu hn chi phi kh ln vo
y l a ch u tin ngi bnh tm n
cc khu vc phn phi thuc trn ton quc.
khi au m vi mc tiu tit kim thi gian v
Cc doanh nghip ny c u th l rt linh hot
chi ph. Hin nay, trn th trng Vit Nam c
tm ngun hng cung ng, giao nhn hng v
hn 39.000 hiu thuc.
thanh ton.
c bn khng c n thuc km theo65.
Hu ht cc thuc
Ngi bnh m t triu chng bnh, v ngi
2.2.3. Bnh vin

Tt c cc bnh vin u c nh thuc chu
trch nhim vic cung ng v phn phi thuc
trong bao gm thuc khng sinh cho cc i
tng bnh nhn ni tr v ngoi tr c n
thuc. Mi nm khoa dc bnh vin d tr
danh mc v s lng thuc thit yu s dng
cho mt nm, t chc u thu cho cc cng ty
phn phi dc phm. Cc tiu chun la
chn nh phn phi ch yu da trn gi c,
bn thuc vi kin thc hn ch v y, dc, s

a ra cc hng dn la chn. Sau thi gian 5
nm thc hnh ti c s Dc, dc s c
quyn xin cp giy php hnh ngh Dc t
nhn, v phi c mt ti c s kinh doanh dc
m h ng tn, tuy nhin tnh trng cc dc
s cho thu bng l kh ph bin trong khi vn
lm vic ton b thi gian c s khc. Hu
ht bnh nhn mua thuc khng sinh iu tr
trong mt thi gian ngn, khong 3 ngy.
Khng sinh thng c bn km vi vitamin,
22
thuc h st v mt s thuc nhm steroids [S
tng gi tr67. Do li nhun t khng sinh
liu cha cng b OUCRU-HMU].
em li chim t trng kh ln trong tng s li
2.2.5. Gi thuc cc cp khc

nhau trong knh phn phi
Mt kho st nh ti ch thuc H Ni v
mt s nh thuc ti a bn xung quanh bnh
vin Bch Mai cho thy, gi thuc khng sinh
bn l thng cao hn gi bn bun khong
15-20% (Xem bng 5). Gi thuc trong bnh
vin thng thp hn gi thuc bn bun
khong 15-20% do gi thuc trong bnh vin l
gi thuc trng thu, c n nh vo u
nm, khi cc hp ng u thu c k kt.
nhun m c s kinh doanh thu c68.
2.2.6 Kim sot gi thuc

Cc Qun l Dc phi hp vi B Ti
chnh chu trch nhim thi hnh v thit lp h
thng kim sot gi thuc. Hi ng ny cn
hoch nh cc hot ng v t chc hp nh
k. Cc Qun l Dc cn thiu bng chng y
thit lp h thng gi thuc. T chc y t
th gii h tr trong vic thu thp d liu v
tin hnh cc nghin cu gim st v gi thuc
cng nh cc cu thnh ca gi thuc.
Trong khi , gi thuc bn bun c th tng do
C ch hin ti vn cha t c cc mc
c ch th trng. Gi thuc trong bnh vin
tiu mong mun v gi thuc Vit Nam vn
ch p dng cho bnh nhn ni tr. i vi
cao hn gi thuc th gii64. Hin ti, Cc Qun
bnh nhn ngoi tr, c th mua thuc t nh
l dc thu thp gi CIF ca tt c cc thuc
thuc bnh vin, vi gi bn l c qui nh
nhp khu v yu cu cc nh sn xut cng b
bi B Y t (Xem bng
6)66.
Hin cha c s liu
gi bn bun trc khi cp s ng k. Tuy
ng tin cy v tng chi ph cho khng sinh trn
nhin, khng c gii hn trn i vi gi bn
ton quc Vit Nam. cc c s cng lp,
bun. Chnh ph cng khng c bin php no
khng sinh chim khong 40-50% tng chi ph
thng lng v gi bn bun. Thm ch c
cho thuc ni chung. Trong s 100 dc phm
so snh gi CIF vi gi bn bun th gi bn
c doanh thu cao nht ti th trng Vit Nam
bun vn c php cao hn gi CIF. Cc bnh
nm 2002, 21 thuc l khng sinh, chim 29%
vin c yu cu mua thuc qua qu trnh
23
Bng 5: Gi ca mt s khng sinh cc cp khc nhau

Khng sinh
Cng ty
n v
Bnh
vin
Gi bn
bun (USD)
Gi bn
l
(USD)
Augmentin 625mg (Amoxicillin

+ Acid Clavulanic)
Unasyn
(Ampicillin+Sulbactam)
GSKEngland
vin
0,58
0,79
0,89
Pfizer-Italy
3,56
4,26
4,96
Traphacovin
0,025
0,035
0,042
Vietnam
MekofarmCefaclor 125mg
vin
0,36
0,48
0,55
America
RotexCefuroxim 750mg
l
2,43
2,81
3,24
Germany
BayerCiprofloxacin 500mg
vin
0,67
0,76
0,89
Germany
Ngun: kho st ti ch thuc Ngc Khnh. H Ni v mt s hiu thuc xung quanh bnh vin Bch Mai.
Cefalexine 500mg
u thu theo gi bn bun. Gi bn bun
Ngun: Qui nh v t chc v hot ng ca
cao, kt hp vi vic cc nh thu y gi cao
Nh thuc bnh vin (Ban hnh km theo Quyt
n mc ti a dn n gi thuc cao ti khu
nh s: 24/2008/Q-BYT. ngy 11/7/2008 ca
vc cng lp. Gi bn l c th trng qui
B trng B Y t)
nh, tuy nhin th trng c xu hng bn

thuc bit dc hn l thuc gc gi r64. Vi
cc chnh sch hin nay, cc nh cung cp d
dng iu chnh tng gi v chnh ph khng
th kim sot. Mt s quc gia c c ch kim
sot gi c cht ch hn, vi chnh sch thuc
gc mnh m, phi hp vi h thng mua bn
hp l nhm h gi thnh ca thuc.
2.2.7. Thuc gi
Mt s khng sinh gi thng gp th
trng
Vit
Nam
gm
c:
ampicillin.
Amoxicillin, chloramphenicol, erythromycin

and tetracycline69. Hu ht cc loi thuc ny
c bn ti cc c s kinh doanh khng c
giy php. Cc bo co v thuc b thu hi cho
Bng 6. Gi thuc bn l v nh nc qui
thy trong 5 nm tr li y s lng thuc b
nh mc gi thng d cho nh thuc
thu hi gim ng k, v c th s tip tc gim
bnh vin
trong thi gian sp ti, khi m l trnh GPP
STT
1
2
3
4
5
Gi gc/n v
(USD)
0,054
0,054-0,27
0,27-5,41
5,41-54,05
>54,05
Thng d
ti a (%)
20
15
10
7
5
c trin khai vi tt c cc c s kinh doanh

dc phm hp php. ngi dn s khng phi
mua thuc t cc c s khng ng k cp giy
php kinh doanh69. Theo B Y t, nm 2008, 25
l thuc khng sinh trong tng s 94 thuc b
24
thu hi do khng t tiu chun v cht
st v s phi hp gia cc ban ngnh (Bng
lng70.
7)71.
Nm 2008, c s gia tng t l thuc gi

c pht hin do tng cng hot ng gim
Bng 7. Thuc gi c pht hin qua cc nm71

Nm
2000
2001
2002
2003
T l (%)
0.06
0.05
0.03
0.06
Ngun: Cc Qun l Dc B Y t Vit Nam71
2.3. S dng khng sinh ti

cc tuyn c s
Vi s h tr ca T chc Y t Th gii
WHO v UNICEF, B Y t xy dng cc
hng dn iu tr i vi cc bnh thng
gp tr bao gm bnh vim ng h hp
cp (ARIs), vim mng no, tiu chy, cm,
vim phi mc phi cng ng, v tiu chy
do l trc khun72. Hng dn iu tr cc bnh
nhim khun thng gp (B y t, 2006) bao
gm cc hng dn c th v liu php khng
sinh (tn, liu, thi gian iu tr) da trn cp
ca c s khm cha bnh, triu chng, tnh
trng bnh, cn nng v la tui, v la chn
theo cn nguyn gy bnh73. ng thi, hng
2004
0.06
2005
0.09
2006
0.13
2007
0.17
2008
0.21
khng sinh cephalosporin th h 2, 3 c th

dng thay th. i vi trng hp nghi vim
phi khng in hnh, khng sinh nhm
macrolide c th c la chn b sung trong
liu php iu tr. Vi tnh trng khng khng
sinh hin ti ca S. pneumoniae v H.
influenzae, khuyn co s dng penicillin hoc
amoxicillin c th khng hiu qu74. Thc t,
ampicillin hoc cephalexin (cephalosporin th
h 1) thng c ch nh trm y t x. Ti
cc tuyn bnh vin, bnh nhn mc vim phi
cng ng c ch nh amoxicillin (n hoc
phi
hp
vi
axit
clavulanic)
hoc
cephalosporin th h 2, 3 v mt khng sinh

nhm macrolide.
dn cng a ra nhng khuyn co v vic
i vi vim mng no, hng dn khuyn
gim st c tnh ca thuc trn bnh nhn (v
co dng khng sinh ng tim vi la chn
d theo di c tnh trn thn vi khng sinh
ban u l ceftriaxon. Ch nh ph thuc vo
nhm aminoglycosides).
i tng tr em hoc ngi ln v cn nguyn
Ti cng ng, hng dn ca B Y t
gy bnh. ng ch l, mt cn nguyn quan
khuyn co dng penicillin hoc amoxicillin
trng gy vim mng no ngi ln thng
cho trng hp vim phi cha r nguyn
gp Vit Nam, Streptococcus suis, khng c
nhn. Amoxicillin phi hp axit clavulanic hoc
cp trong hng dn. Hn na, hng dn
25
cng khuyn co dng penicillin ng tnh
chloramphenicol v sau a tr i bnh
mch i vi vim mng no do ph cu, mc
vin.
d trn thc t mc khng vi khng sinh

ny tng i cao. Trovafloxacin cng c
khuyn co s dng trong iu tr vim mng
no trong khi thuc ny b cm s dng
trong nhiu nm do c tnh cao vi gan. i
vi l trc khun gy tiu chy c ln mu
tr, hng dn khuyn co b sung nc v
in gii phi hp vi amoxicillin hoc
cotrimoxazole. i vi ngi ln, khuyn co
dng ORS phi hp vi mt khng sinh nhm
fluorquinolone (v d ciprofloxacin). Hn na,
cc bnh vin tuyn di khng c php ch
nh khng sinh cho cc bnh nhn nghi vim
mng no vi khun. n v c nhim v thc
hin vic chuyn bnh nhn ln tuyn trn
chn on v iu
tr73.
Mt nghin cu c tin hnh nm 2007

nhm nh gi kin thc s dng khng sinh
khu vc nng thn Vit Nam cho thy mc d
c cc ti liu hng dn iu tr, mt nghin
cu cng ng ti khu vc nng thn Vit Nam
cho thy, kin thc v s dng khng sinh
khng tun th theo cc hng dn ny dn
n tnh trng x l vim ng h hp cp
khng hp l ca cc cn b y t74. Khng sinh
thng c ch nh iu tr cm lnh v
ho thng thng. Ngoi ra, liu dng v qu
trnh iu tr cng thng khng tun th theo
hng dn75.
2.4. S dng khng sinh

khng hp l
Hng dn x l lng ghp cc bnh
Trong chng trnh o to ti cc trng
thng gp tr (B Y t, 2006) ch yu
Y, dc, thi lng ging dy v khng sinh,
hng dn cc b m chm sc tr ti nh hoc
khng khng sinh v cch k n chim t l rt
a tr n trung tm y t trong trng hp
nh. Mt nghin cu da trn cng ng c
bnh nng. Trong ti liu ny, khi qut nh
tin hnh nm 2003 bo co rng, 78% khng
gi, phn loi v iu tr bnh thng gp tr
sinh c mua ti cc nh thuc t nhn m
bao gm vim phi v tiu chy. Hng dn
khng c n67, 67% tham kho t vn dc s
khuyn co dng cotrimoxazole, amoxicillin,
trc khi s dng v 11% t quyt nh v vic
hoc erythromycin i vi cc trng hp
dng thuc; ch c 27% nhn vin dc c kin
vim ng h hp nng. ng cng khuyn
thc ng v khng sinh v khng khng sinh.
co khng s dng khng sinh trong trng
c cc qui ch v vic cm bn thuc khng
hp tr ho hoc cm lnh khng c triu chng
sinh khng c n, tuy nhin cc qui ch ny
vim phi. Tr c du hiu tin lng bnh
n nay vn cha c hiu lc.
nng,
phi
tim
bp
mt
liu
26
i vi tr bnh, cc b m thng t k
2.5 C ch khuyn khch
n, 82% tr c t nht mt triu chng vim
Nh bo co ca Cc Qun l Khm Cha
ng h hp cp (ARI) c iu tr vi
bnh nm 2009, chi ph cho khng sinh chim
khng sinh. Nm 1999 khng sinh c s
trn 30% tng chi ph ca bnh vin cho thuc
dng ph bin nht bao gm: ampicillin hoc
v ho cht. Mt phn ln kinh ph c chi
amoxicillin
cho cephalosporins th h 3 (ceftriaxone.
erythromycin
(86%),
tetracyclin
(12%),
v
cefoperazone), quinolones (levofloxacine) v
streptomycin (2%). Khng sinh c dng
carbapenem (imipenem). Bng 8 lit k mt s
khong 3 ngy, qu ngn cho iu tr vim phi
li ch vt cht c s dng nhm khch l
do vi khun vi thi gian iu tr ti thiu c
vic k n v s dng thuc khng sinh t cc
khuyn co l 5 ngy. Nm 2007, xu hng s
bo co c trnh by ti hi tho nm 2009
dng khng sinh thay i, cephalosporins
[Ngun: Bo co hi tho khoa hc ln th nht
ng ung c dng ph bin i vi cc
ca GARP]. bnh vin tuyn di, c bit
bnh c triu chng nng. Cc khng sinh
i vi bnh nhn khm bo him y t, cc
thng dng l: ampicillin hoc amoxillin
khng sinh r thng c la chn v d nh
(49%), cephalosporin th h 1, ng ung
amoxicillin. Trong khi , cc phng khm t
(27%), cotrimoxazol (11%), macolides (3%),
nhn, bc s thng c xu hng chn cc
loi khc (2%)
(5%),
penicillin
(4%)
76.
khng sinh mnh nh cephalexin, zinnat, hoc
Cng ging nh mt s nc khc, mt
augmentin. Hn na, cc cng ty dc phm
trong nhng nguyn nhn ca tnh trng s
thc y vic tiu th sn phm bng cc chnh
dng khng sinh khng hp l l do ngh ca
sch khuyn khch bc s k n.
bnh nhn, p lc v thi gian thm khm,

thiu kin thc, thiu kh nng chn on, li
Bng 8. Khuyn khch cho vic s dng
nhun kinh t i vi ngi k n [Ngun:
khng sinh
Bo co hi tho khoa hc ln th nht ca

GARP]. Mt thch thc ln l xc nh v thay
i cu trc khuyn khch i vi vic k n
khng hp l. Hn na, chi ph m ngi bnh
phi t chi tr chim t trng ln trong tng chi
ph y t, do ngi dn c xu hng tm kim
cch thc r nht cho vic chm sc sc kho.
Phn loi
Khuyn khch
Bc s c Chia s gi thuc, tham
s cng lp
gia hi tho, qu tng
Tho mn mong i ca
bnh nhn
C th tit kim thi
gian
Bc s c Chia s gi thuc
s t nhn
Tho mn mong i ca
bnh nhn
Phng khm H tr v c s vt
t
cht, v d nh iu ho
nhit nh, TV, vv,
27
Bnh vin
Nh
thuc/Hiu
thuc
Bnh nhn
Chia s gi tr hp ng
u thu thuc, h tr
v c s vt cht
Cc
chng
trnh
khuyn mi, gim gi
Chia s li nhun da
trn chnh sch gi
Mong mun c ch
nh thuc mnh nh
khng sinh
Cn tc v y ny, v
khng kh nng chn
on xc nh cn
nguyn vi khun gy
bnh
T iu tr r hn v
thun tin hn l i
khm bc s
2.6. Cc v d v mc s
dng khng sinh trn ngi
IMS l mt t chc thng mi nghin cu
v th trng dc phm Vit Nam theo 2 knh
chnh: nh thuc bn l v nh thuc bnh vin.
S liu ca nh thuc bn l s dng y
c thng k t 439 nh thuc khng bao
gm cc c s bn bun. S liu v nh thuc
bnh vin c thng k t 62 bnh vin trong
ng k gia nh thuc v bnh vin l cc

khng sinh tim ch yu c dng bnh
vin hn l bn l nh thuc. Do , cc
khng sinh aminoglycosides v carbapenems
tim thng c dng ch yu bnh vin,
him khi bn nh thuc bn l. Cc khng
sinh th h c nh chloramphenicol ch yu
c bn hiu thuc bn l v t dng bnh
vin. Doanh s ca polymyxins (v d colistin)
rt thp v nhng thuc ny cha c ng k
Vit Nam trong iu tr cc cn nguyn
nhim trng khng khng sinh, mc d vy, cc
khng sinh ny vn c lit k trong danh
mc thuc ch yu s dng trong bnh vin.
S liu tng t ti M cho thy, khng
sinh tim cng c chim t trng ln trong kinh
ph iu tr. Cephalosporins tim c doanh thu
cao nht trong bnh vin, tip theo l
carbapenems. hiu thuc bn l, cc khng
sinh cephalosporins tim cng tr nn ngy
cng quan trng.
khu vc 5 thnh ph: H Ni, thnh ph H Ch
Mt nghin cu th im ti NHTD (2008-
Minh, Hi Phng, Nng v Cn Th. S liu
2009) nh gi mc s dng khng sinh
v doanh thu trong vng 1 nm: t u qu 4
thng qua liu xc nh hng ngy trn 100
nm 2008 n ht qu 3 nm 2009.
ging-ngy (DDD/100 ging-ngy). S liu
Con s thng k cho thy, cc khng sinh
ca khoa Dc cho thy, c 44 loi khng sinh
c doanh thu cao tng t nh nhau gia nh
c s dng [s liu cha cng b NHTD]. Cc
thuc bn
l v bnh vin (Hnh 1).
khng sinh c gi tr DDD /100 ging-ngy
Cephalosporins ung (J01D01) l khng sinh
cao nht trong nm 2009 ln lt l
ph bin nht c 2 c s y t ni trn, tip
levofloxacine (104,73), ceftriaxone (85,93),
(J01C01),
doxycyclin (62,58), ampicillin (sulbactam)
macrolides v fluoroquinolones. S khc bit
(tng ng l 48,86 v 45,36), azithromycine
penicillins
ph
rng
28
(42,59),
imipenem
(22,58),
cefoperazone
DDD/100
ging-ngy.
ng
ch
l,
(22,14) v streptomycine (21,9). Mc tiu th
meropenem tng khong 8 ln nm 2009 (7,8
ca levofloxacin l cao nht tip theo l
DDD/100 ging-ngy) so vi nm 2008
ceftriaxone, azithromycin v doxycyclin (Xem
(0,9/100 ging-ngy). Cc khng sinh th h
hnh). 7 khng sinh c mc tiu th cao nht
c nh amphenicols v cephalosporins th h 1
tng gn gp i trong nm 2009 so vi s liu
hoc 2, t c s dng trong iu tr (Xem
nm 2008. V d, fluoroquinolones tng t 76,5
hnh 3). Hnh 4 ch ra khng sinh s dng nhiu
DDD/100
nht vo cc thng 6, 7 v 11 nm 2009.
ging-ngy
125,6
cephalosporins th h 3 t 63,4 n 124,5

Hnh 6. S liu v doanh thu ca khng sinh ti Vit Nam.
Doanh thu trung bnh hng

nm/nh thuc ( la M)
Doanh thu trung bnh hng

nm/bnh vin ( la M)
S lng tiu th hng

nm/nh thuc
S lng tiu th hng

nm/bnh vin
S lng trung bnh thuc khng sinh c bn ca nh thuc t (trn) v bnh vin (di). Doanh thu
trung bnh hng nm tnh theo la M t khng sinh ca nh thuc t (trn) v bnh vin (di).
29
Hnh 7: DDD trn 100 ging ngy ca cc loi khng sinh nm 2008-2009
J01A-Tetracyclines
J01B-Amphenicols
J01CA-Penicillins with expanded spectrum
J01CE-Beta lactam sensitive Penicillines
J01CF-Beta lactam resistance Penicillines
J01CG-Sulbactam
Khng sinh
J01CR-Beta-lactam and Inhibitors

J01DB-First gen. Cephalosporins
Nm
2009
Series2
J01DC-Second gen. Cephalosporins
Nm
2008
Series1
J01DD-Third gen. Cephalosporins

J01DE-Forth gen. Cephalosporins
J01DH-Carbapenem
J01FA-Macrolides
J01FF-Lincosamides
J01G-Aminoglycosides
J01M-Fluoroquinolones
J01X-Others
0
20
40
60
80
100
120
140
DDD trn 100 ging-ngy
Ch : Khng sinh khc bao gm Vancomycin, Fosfomycin, Rifampicin, Metronidazole, Tinidazole.
30
Hnh 8: DDD trn 100 ging-ngy theo thng ca 7 loi khng sinh c mc tiu
th cao nht nm 2009
DDD trn 100 ging-ngy
25
20
Doxycylin J01AA02
Ampicilline J01CA01
15
Ceftriaxone J01DD04
Cefoperazone J01DD12
Azithromycin J01FA10
10
Streptomycin J01GA01
Levofloxacin J01MA12
0
1
10
11
12
Thng
2.7. Chi ph cho khng sinh

ti cc bnh vin
B Y t thu thp cc bo co v tnh hnh
thuc khng sinh. Trong s 4 nhm bnh vin,

th bnh vin a khoa tuyn tnh/thnh ph c
mc chi trung bnh cho khng sinh l cao nht
(43%)77.
s dng thuc ti bnh vin. Theo thng k t

cc bo co ny, khng sinh chim khong 36%
tng chi ph cho thuc v ho cht (khong gii
Bng 9. Chi ph bnh vin cho khng sinh

nm 2009 (s liu: B Y t)
Khng
hn t 3% n 89%, xem bng 9). Trong s

S
sinh
lng
/Tng
Trung
tuyn trung ng (12%) chi khong 26% (gii
Phn loi
bnh vin
bnh
chi ph
bnh
hn 10-45%) cho thuc khng sinh trong tng
vin
cho
(%)
100 bnh vin chn ngu nhin, bnh vin
kinh ph cho thuc ni chung. Bnh vin tm
thuc
thn c mc chi ph cho khng sinh thp nht
(%)
(3%). T l cao nht c bo co ti bnh vin

nhi thnh ph H Ch Minh (89%). Bnh vin
bnh nhit i trung ng, bnh vin u
ngnh v bnh truyn nhim, chi 35% cho
Bnh vin a
khoa tuyn
trung ng
Bnh vin
chuyn khoa
12
10-45
26
21
5-89
28
31
tuyn trung
ng
Bnh vin a
khoa tuyn
tnh
Bnh vin
chuyn khoa
tuyn tnh
Ngun: B Y t
Di y l mt s bo co v khng
khng sinh c cng b, thng tin tham
52
6-88
43
15
3-66
34
kho xem thm phn ph lc A.
Streptococcus pneumoniae
Mc khng penicillin ca S. pneumoniae
tng ng k. Mt nghin cu TP H Ch Minh
2.8. Gim st khng khng

sinh
cho thy, trong 10 nm, t l cc chng
Hin nay, Vit Nam cha c chng trnh
mu v dch no ty tng t 8% (1993-1995)
gim st quc gia v khng khng sinh qui
ln 56% (giai on 1999-2002)78. Nm 2000-
m ton quc. C quan hp tc pht trin quc
2001, Vit Nam c t l khng penicillin cao
t Thy in (SIDA) v B Y t phi hp h tr
nht trong 11 nc khu vc Chu (71.4%)79.
chng trnh gim st khng khng sinh trong
Mc khng penicillin ca tr thnh th cao
vng hn 10 nm tnh n nm 2006, c
gp 22 ln so vi tr nng thn80. Trong
bit n vi tn gi Chng trnh gim st mc
chng trnh nghin cu quc gia v khng
nhy cm vi khng sinh (ASTS). Cc bnh
khng sinh (ANSORP), Vit Nam c mc
vin trng im trn ton quc tham gia vo
khng
chng trnh ny xy dng c cc bo
erythromycin (92,1%)79. Hn na, 75% ph
co hng nm. Tuy nhin, tc ng ca cc bo
cu khun khng vi t nht 3 loi khng sinh
co ny, cng nh thnh tu ca ton b
tr ln. Hu ht cc chng ph cu vn nhy
chng trnh vn cha c nh gi mt cch
cm vi ceftriaxon44.
ton din v r rng. n nay, c 8 bnh vin

tip tc ng ti d liu WHO-NET ln trung
pneumococcus khng penicillin phn lp t
cao
vi
penicillin
(71,4%)
Haemophilus influenza
tm d liu do Khoa vi sinh Bnh vin Bch
Hib phn lp t tr vim mng no m
Mai- l mt trong nhng bnh vin a khoa u
H Ni (2000-2002) cho thy 57% cc chng
ngnh tuyn trung ng. Mi y, B Y t cng
sinh
mi xy dng chng trnh gim st khng
ampicillin81. Mc khng tng t cng c
khng sinh mi nhm thu thp cc bo co v
ghi nhn tr vim ng h hp trn Nha
tnh hnh s dng thuc cng nh khng khng
Trang82.
men
-lactamase
dn
khng
sinh t 20 bnh vin khc nhau c cc phng

xt nghim vi sinh lm sng.
32
vi khong 50% nm 2004. Mc khng axit
Enterobacteriaceae
nalidixic tng r rt trong vng 12 nm, t 4%

Theo bo co ca Bnh vin chn thng
ln 97% nm 2005
89.
Mt bo co khc cho
chnh hnh thnh ph H Ch Minh (2004) cho
thy hn 80% cc chng S. typhi phn lp
thy, trong s cc chng Gram m phn lp
c khng vi khng sinh axit nalidixic 90.
c, 14,7% sinh ESBL. Trong s cc chng

sinh ESBL, 70% khng gentamicin v 72,5%
khng
ciprofloxacin83.
Tnh
trng
khng
cephalosporins ph rng l kh ph bin trong

s cc chng E. coli, K. pneumoniae v Proteus
2.9. Khng sinh s dng trn

ng vt
2.9.1. Xu hng s dng
mirabilis t 2000-2001 thnh ph H Ch
Mt lng ln dc phm c s dng
Minh: hn 25% khng vi cephalosporins th
trn ng vt bao gm khng sinh, vitamin v
h 3 v 16% khng vi cefoperazone84. Mt
cc thuc dit k sinh trng. Trong , khng
nghin cu khc cng thnh ph H Ch Minh
sinh chim phn ln nht (70% trong tng s
cho thy 42% cc chng Enterobacteriaceae
thuc) c s dng trn ng vt91. 77% cc
khng ceftazidime, 63% khng vi gentamicin
thuc dng cho ng vt l thuc sn xut
v 74% khng axit nalidixic. T l khng cao
trong nc v 23% l thuc nhp khu. Cha
cng c ghi nhn ngi kho mnh trong
c s liu chnh thc v lng khng sinh s
cng ng85.
dng trong nui trng thu sn, tuy nhin vic

s dng ngy cng rng ri trong lnh vc ny
Shigella
cng c nhn thc r rng. Theo bo co t
T l khng cao cng c ghi nhn, c th

l:
trimethoprim-sulfamethoxazole
tetracycline
(74%),
ampicillin
chnh ph H Lan c khong 700 g khng sinh
(81%),
c s dng trn mi tn c trong nui trng
(53%),
thu sn Vit Nam, cao gp 7 ln so vi cc
ciprofloxacin (10%), v ceftriaxone (5%)
86.
quc gia khc [Bo co t Cc Qun l Thc
Hn 75% cc chng a khng khng sinh
87.
phm,
Lan,
2009,
Mt nghin cu khc ti khu vc pha Nam Vit
VWA/BuR/2009/13186]. C 11 nhm khng
Nam (2006-2008) ch ra rng 15,3% khng
sinh c s dng trong nui trng thu sn
ceftriaxone88.
trong bao gm c cc loi khng sinh c
Salmonella typhi
Vit Nam, t l cc chng S. typhi a
khng khng sinh vn chim t l tng i cao
s dng trong iu tr bnh nhim khun trn

ngi. Cc khng sinh c s dng gm: lactams,
tetracycline,
aminoglycosides,
(fluoro)quinolones,
macrolides,
Phenicols,
33
polymyxins
(colistin),
pleuromutilins,
lincosamides, sulfamides, diaminopyrimidine

(trimethoprim)91.
nhim chlotetracyclin. Mt s mu cng vt

qu ngng gii hn cho php91.
Quinolone v sulfonamide c s dng
Gim st c hai lnh vc chn nui v nui
rng ri trong nui trng thu sn. Theo bo
trng thu sn cho thy, tt c cc trang tri
co hng nm ca Cc Qun l Cht lng Nng
chn nui u s dng khng sinh. Cc khng
lm Thu sn cho thy, d lng ca mt s
sinh c
tylosin
(16%),
khng sinh hn ch s dng c pht hin
gentamicin
(9%),
trong nui trng thu sn: quinolone v
enrofloxacin (7%), penicillin (6%), lincomycin
sulfonamide. Hu ht cc mu pht hin d
(6%),
amoxicillin
dng
(12%),
tiamulin
l:
colistin
(5%),
lng u nm trong gii hn cho php. Tuy
norfloxacin
(5%),
nhin, c mt s mu thu sn pht hin
quinolone vt qu gii hn cho php 18 ln92.
florphenicol (3%). Theo bo co ca B Nng
Cc khng sinh b cm s dng trong nui
nghip, tnh hnh s dng khng sinh trong
trng thu sn t b pht hin d lng, iu
chn nui cha hp l. Vic la chn khng
chng t, cc qui nh v xut khu to ra
sinh v liu dng c quyt nh ch yu da
nhng khuyn khch ng k trong vic s
trn kinh nghim ca ch h (44%), 33% theo
dng khng sinh. Tuy nhin, chloramphenicol
hng dn ca bc s th y, 17% theo hng
vn pht hin c s dng trong nui trng
dn ca nh sn xut. Cc ch h chn nui
thu sn. Mt nghin cu cho thy, t l cao ca
khng tun th theo qui ch v vic ngng s
cc mu nc ng nhim chloramphenicol,
dng khng sinh trc khi thu hoch sn phm
chng t khng sinh ny vn c s dng
t ng vt92.
mc d b cm s dng trn ng vt91. Xem
streptomycin
tetracyclin
(6%),
(5%),
(4%),
ampicillin
(4%)
Gim st tnh hnh s dng khng sinh ti

30 tri ln tht v 30 tri nui g tht trn a
ph lc C (Bng 12).
mu ln tht v 70% mu g tht nhim
2.9.2. L do/khuyn khch i

vi vic s dng khng sinh
trong nng nghip
tetracyclins hoc tylosins91. Mt s mu vt
Trong nng nghip, khng sinh c s
qu nng cho php. Gim st 55 trang tri
dng rng ri vi mc ch kch thch tng
nui ln tht tnh ng Nai v Bnh Dng
trng, hoc phng bnh v iu tr. Khng
cho thy tnh trng nhim khng sinh kh ph
sinh c s dng vi mc ch kch thch tng
bin:
nhim
trng theo khuyn co ca FDA. Theo Cc th
tetracycline, 7% nhim oxytetracycline v 2%
y quc gia (NOAH, 2001), khng sinh c s
bn tnh Hng Yn v H Ty cho thy 60%
52%
nhim
tylosin,
41%
34
dng vi mc ch kch thch tng trng

nhm gip ng vt tiu ho thc n d dng,
gip pht trin khe mnh93. Thc n chn
nui ln v g tht c b sung khng sinh
tetracycline v tylosin91. Tm, cua v c cng
phi nhim vi quinolone v sulfonamide92.
- Tun th cc qui
nh ca th trng
M v Chu u
- Kim sot bnh dch - Khng phi gim
st d lng
khng sinh
- Tit kim v mt kinh - Quan tm v sc
khe
t
- Tng kim ngch xut
khu
trng thu sn ang ngy cng tr thnh mt
2.9.3. Khng khng sinh trong

cng nghip thc phm
ngnh cng nghip quan trng Vit Nam v
Cc bnh lin quan n thc phm l mt
khng sinh c s dng rng ri. T khi Vit
trong nhng nguyn nhn quan trng dn n
Nam gia nhp T chc thng mi th gii, cc
t l mc v t vong trn th gii. Thc n
qui nh v s dng khng sinh trn ng vt
nhim vi khun khng khng sinh c th l mi
cng cht ch hn v mt s khng sinh b cm
him ho ln i vi sc kho cng ng.
s dng. Tuy nhin, gim st d lng khng
Trong mt nghin cu kho st mc ph
sinh tht v c cho thy nhng vi phm
bin ca tht nhim Salmonella spp v E. coli ti
trong vic tun th qui ch v s dng khng
cc ch khu vc thnh ph H Ch Minh (2004)
sinh. Cc trang tri b pht hin d lng ca
cho thy t l nhim kh cao (Salmonella spp:
khng sinh cm vt qu gii hn cho php s
60,8% sn phm tht v 18,0% mu c v hn
b cm thu hoch, ch bin v xut khu sn
90% tt c cc mu thc phm nhim E. coli.
phm cho n khi khng pht hin vi phm.
Khong 50% cc chng Salmonella v 84% E.
Bng 10 trnh by cc bin php khuyn khch
coli phn lp c l khng vi t nht mt
vic s dng khng sinh trong nng nghip.
khng sinh, v Salmonella a khng khng sinh
Trong nng nghip, chn nui v nui
Bng 10: Cc khuyn khch i vi vic

s dng khng sinh trong nng nghip
cng c phn lp tt c cc mu94, 95. Mt

nghin cu Bc Ninh cho thy tt c cc
chng campylobacter phn lp t g tht khng
Khuyn khch
S dng
Khng s dng
- p dng cc bin
- Kch thch tng
php thay th
trng (tng sn
tng sn lng
lng)
- Ci thin cht lng - Gim p lc v
khng khng sinh
sn phm
i vi c ngi v
ng vt
vi
cephalothin,
axit
nalidixic
(89,9%),
tetracyclin (88,6%) v ciprofloxacin (82,3%)96.

Mc khng ca Salmonella t thc n ti
khu vc ng bng Nam b, Vit Nam c
iu tra tnh khng khng sinh vi 10 loi
khng sinh, 21,3% khng khng sinh97.
35
III. nh gi s b, xut
chnh sch v gii php can
thip
bi trong cng ng. Mt khc, vic s dng
3.1. nh gi s b
i vi tnh trng khng khng sinh ca cc cn
khng sinh trn ng vt cng ngy cng rng

ri, l mt trong nhng nguyn nhn quan
trng vn cha b pht hin v vai tr ca n
T khi Vit Nam chuyn sang nn kinh t
nguyn gy bnh trn ngi. Hu qu tt yu
th trng, th trng dc phm tr nn
ca tnh trng khng khng sinh gia tng l
phong ph v sn c ng ngha vi vic tng
nhiu khng sinh vn c khuyn co s
c hi tip cn thuc qua h thng nh thuc.
dng trong cc ti liu hng dn iu tr
Kh nng v c hi tip cn vi khng sinh gp
nhng thc t khng cn hiu qu trn lm
phn tng hiu qu iu tr bnh nhim khun
sng. Mc d c nhiu n lc trong vn v
ng thi cng dn n gia tng tnh trng s
khng khng sinh, thc trng ny vn gy ra
dng thuc khng hp l. Kin thc gii hn
nhng nh hng tiu cc v y t v kinh t
ca ngi dng, ngi bn v dc s v gi tr
quc gia.
v nguy c ca khng sinh l mt phn ca vn
Bng 11. Thch thc v c hi trong kim

sot khng khng sinh
C hi
Thch thc
Cng ng
Cng ng
Thnh vng hn
Thun tin hn khi
Truyn thng tt hn n hiu thuc
(internet v in thoi Kin thc ngho
di ng c s nn
dng rng ri)
C hi tip cn
Yu cu cao hn i thng tin cn hn
vi vic chm sc ch
sc kho
H thng Dc
H thng dc
Thay i thi lng Khch l i vi
ging dy v khng cung ng
sinh v khng khng Kin thc hn ch
sinh trong cc trng C hi tip cn
chuyn ngnh
thng tin cn hn
Trin khai GPP
ch
Trung tm cnh gic Thi lng ging
dc
dy v khng sinh
v khng khng
sinh trong trng
qu hn ch
H thng y t
H thng y t
Tng gi ging trong Khch l i vi
trng
ngi k n
Tng kh nng chn Kinh ph cho gim
, tuy nhin c nhng khuyn khch v ti

chnh i vi vic bn khng sinh v li ch
gin tip trong vic s dng khng sinh l gnh
nng i vi x hi. Thm ch trong lnh vc
chm sc sc kho, nhng hn ch v kin thc
trong vic s dng khng sinh trong iu tr, v
kh nng chn on phng xt nghim xc
nh cn nguyn gy bnh v cc khuyn khch
i vi vic k n dn n s gia tng tnh
trng s dng khng sinh khng hp l. Hin
nay c cc qui nh v kim sot s dng
khng sinh tuy nhin s tun th cc qui ch
ny vn cn cha hiu lc do cha c cc ch
ti c th.
Tnh trng ph bin ca vi khun khng
khng sinh Vit Nam mc bo ng.
l kt qu ca vic s dng khng sinh ba
36
on
Trin
khai
chng
nhim khun
Sn sng ci tin
Chng trnh tng
cng
nng
lc
phng th nghim
st rt hn ch
Nng lc chn
on yu
Kin thc hn ch
C hi tip cn
thng tin hn ch
Cc hng dn
khng cp nht
Thi lng ging
dy v khng sinh
v khng khng
sinh trong trng
qu hn ch
3.2. Phn tch chnh sch
hnh s dng khng sinh v chng nhim

khun (v d nh. thiu ht v kinh ph, thiu
nhn lc v cc khuyn khch v mt ti chnh).
ng thi, tin lng hu qu ca vic hiu lc
ho cc chnh sch ny s c th dn n nhng
bt li v mt li nhun i vi cc c s y
dc cng nh c hi tip cn cc dch v
chm sc sc kho. Nm bt c iu ny s
c th ci thin vic thi hnh cc chnh sch
mt cch hiu qu. Hn na, cn nhn nh r
S cn thit ca cc chnh sch lin quan
qui m p dng trng im ca cc qui ch, nu
n vic s dng khng sinh c cc nh lnh
khng cc mc tiu s b phn tn v km kh thi.
o v hoch nh chnh sch trong lnh vc y

t nhn thc mt cch r rng, v thc t c
rt nhiu iu lut v chnh sch c ban
hnh nhm gim thiu vic s dng khng sinh
khng hp l (Xem bng 12). Tuy nhin, thc
t cho thy vic thc hin cc iu lut v qui
nh vn cha thc s em li hiu qu. Vic
ngi dn t do mua thuc khng sinh khi au
m l tnh trng kh ph bin, t l s dng
khng sinh trong bnh vin cao v tnh trng
khng khng sinh ngy cng gia tng r rt.
Mc d c khng t cc chnh sch c ban
hnh, thc trng khng khng sinh Vit Nam
vn ngy cng nghim trng.
Phn ln cc xut chnh sch hng ti
Mt trong nhng nguyn nhn dn n s

thiu hiu qa ca cc qui ch c th l do vic
bi b cc qui ch ca cc c s chm sc sc
khe, dn n vic lm mt hiu lc ca cc qui
ch i vi vic kim sot tnh hnh s dng
khng sinh. Bn cnh , chi ph t tin ti
bnh nhn ng mt phn ln trong tng chi
ph y t c th l nguyn nhn dn n tng
nhu cu ca ngi bnh i vi cc dch v
chm sc sc kho v suy gim quyn hn ca
nh nc i vi th trng y, dc. Cc chnh
sch gim chi ph t tin ti bnh nhn qua h
thng bo him y t c th gim vai tr ca
khch hng i vi th trng y, dc v do
c th tng cng vai tr ca nh nc.
vic ban hnh cc qui ch, trong khi th
Ngoi cc php ch trc tip tn ti, cc
trng y, dc lun tm cch bi b hiu lc
cng c chnh sch khc c th em li hiu
ca cc qui ch ny. Quan trng l cn phi xc
qu. Nhng bin php iu chnh mt cch
nh c ro cn no dn n s km hiu lc
mm do v linh hot c th em li hiu qu,
ca cc qui ch lin quan n vic ci thin tnh
v d nh. khuyn khch c ch th trng t
37
iu ho phi hp vi cc qui tc thc hnh.
tng cung cp dch v y t. nh hng t pha
Cc cng c kinh t, v d nh chnh sch tr
cc nh lnh o v cc chuyn gia trong lnh
cp v thuc, v ang c p dng rng ri
vc y, dc cng c th em li thay i nh
nhm ci thin chnh sch gi v cc u i ca
vo cc bng chng in hnh trong thc tin.
thuc, to thun li i vi ngi tiu dng,
Ch trng hn na vic ghi nhn cc sn phm
ng thi khng gy ra nhng cn tr v mt
thuc bt buc bn theo n c th s em li
th trng i vi cc mt hng dc phm ,
nhng hiu qu tim nng i vi cc c nhn
v d nh, p thu i vi a s cc khng sinh
v ton x hi v vic s dng khng sinh
ph rng, ngc li, chnh sch tr cp ch p
khng hp l.
dng i vi mt s lng gii hn cc khng

sinh c th.
Tt c cc xut v chnh sch ny cn

c xem xt ht sc cn thn v tnh kh thi,
H thng thng tin, gio dc v cc bng
kh nng cng nh nhng tc ng bt li m
chng in hnh cng c th l cng c hu
cc chnh sch ny c th em li. s l
hiu gip em li nhng thay i v mt quan
ti nghin cu trong giai on tip theo trong
im. Cc phng php qung co tng em
chng trnh hot ng ca GARP-Vit Nam.
li nhng thay i trong thi ca cc i

Bng 12. Danh sch cc chnh sch hin c lin quan n vic s dng khng sinh v
thc trng khng khng sinh ti Vit Nam v nhng xut
Lut/Chnh sch
xut
Thuc khng sinh l thuc k Hiu lc ho qui ch
n
Thnh lp Hi ng Thuc v Cung cp cho hi ng cc cng c/quyn ch o nhm
iu tr ti tt c cc bnh xy dng cc hng dn kim sot khng sinh hiu qu ti
vin t tuyn trung ng n cc bnh vin. ng thi bo co cho hi ng cc s liu
c s
cp nht v ng tin cy v tnh hnh khng khng sinh,
Thnh lp Hi ng chng Cung cp kinh ph hot ng cho cc hot ng ca hi
nhim khun ti tt c cc ng v nng cp c s h tng. Xy dng cc ch s chun
bnh vin t tuyn trung nhm gim st tin nh: t l nhim khun bnh vin theo
tng khoa v s tun th v sinh bn tay,
ng n c s
Chng trnh gim st khng Chun ho d liu bng cch p dng trn ton quc cc ti
khng sinh quc gia
liu hng dn xt nghim bao gm c kim sot cht
lng. Cung cp kinh ph cho th nghim mc khng
khng sinh, kim sot cht lng, tp hun v bo co. Xy
dng cc bo co hng nm v tnh hnh s dng khng
sinh v thc trng khng khng sinh.
Chng trnh gim st v s Chun ho cc ch s v mc s dng khng sinh theo
dng khng sinh ti cc bnh n v quc t, v d nh liu ch nh hng ngy (DDD) trn
100 ging-ngy. Xy dng cc bo co hng nm v s
vin
dng khng sinh v khng khng sinh trong cng mt bn
bo co.
Chng trnh ging dy trong Tng thi lng chng trnh ging dy v s dng khng
38
cc trng y, dc
Hng dn iu tr
Trung tm cnh gic Dc
Chng trnh nng cao nng
lc phng xt nghim vi sinh
lm sng
Nng nghip: Qui ch v vic

ngng s dng khng sinh
trc khi thu hoch sn phm
t ng vt
sinh v khng khng sinh,

m bo tnh chnh xc v cp nht ca cc ti liu hng
dn iu tr i vi cc bnh nhim khun.
Thu ht s tham gia ca trung tm cnh gic Dc vo vic
kim sot tnh trng k n khng sinh bt hp l.
m bo cht lng cc xt nghim vi sinh lm sng. Xem
xt vic xy dng mt trung tm chun quc gia v xt
nghim chn on vi sinh lm sng. Xy dng mng li
nhm chia s thng tin (d liu, hng dn, kin ca cc
chuyn gia).
Hiu lc ho qui ch.
Xy dng chng trnh gim st ton quc v s dng
khng sinh v khng khng sinh trn ng vt
Xy dng bo co hng nm v tnh hnh s dng khng
sinh v mc khng khng sinh trn ng vt
3.3. Cc c hi nghin cu
biu nh Bnh vin Bch Mai, Bnh
c cc d liu y c th kt lun
vin Bnh Nhit i Trung ng, Bnh
v mc ng bo ng ca tnh hnh s
vin Nhit i TP H Ch Minh v Bnh
dng khng sinh v thc trng khng khng
vin Ch Ry. Cng vi s hp tc ca
sinh. Tuy nhin, cc thng tin hin c khng
Trung tm Quc gia v Thng tin thuc
c so snh v tuyn truyn rng ri. Cn
v theo di phn ng c hi ca thuc,
phi c ting ni mnh ng h cho chin
mng thng tin s xy dng v cng b
dch i ph vi tnh trng s dng khng sinh
cc bo co nh k v s dng khng
khng hp l hin nay. Thiu cc d liu v
sinh v tnh hnh khng khng sinh.
gnh nng y t v kinh t dn n cha kh
Hn na, cc hng dn cp nht cng
nng thuyt phc cc nh hoch nh chnh
nh cc ti liu lin quan s c lu
sch. Cn xc nh r c ch khuyn khch cho
hnh rng ri trn mng ni b.
vic k n khng sinh s gp phn h tr thit

k cc can thip mt cch hiu qu.
Da trn bn phn tch thc trng v nhng
thiu ht v thng tin quan trng c xc
nh, 3 nghin cu c xut nh sau:
2. Nghin cu v gnh nng ca khng

khng sinh: xc nh c cc c
im c bn ca cc cn nguyn gy
bnh thng gp ti mt s bnh vin
tiu biu v nh gi gnh nng ca
khng khng sinh. Cn thuyt phc cc
1. Xy dng mng li thng tin v vic
nh hoch nh chnh sch ch ra
s dng khng sinh v tnh hnh khng
nhng tn tht v kinh t v y t m
khng sinh: thit lp cc knh chia s
vn khng khng sinh gy ra, ng
thng tin gia mt s bnh vin tiu
thi vic qun l khng sinh v kim
39
sot khng khng sinh c th gip gim
Cc thiu ht khc c lit k di y.
thiu nhng tn tht ny. Do , nghin
Ngn sch hin c khng tin hnh cc
cu nh gi gnh nng ca khng khng
nghin cu gip b p cc thiu ht.
sinh l ht sc cn thit Vit Nam.
1. Lng ln khng sinh s dng Vit
Nghin cu xut: nh gi mc khng
Nam khng phi trn ngi m c th
khng sinh ca 5 cn nguyn vi khun thng
l trn ng vt. Cn c nhng thng
gp nht t cc bnh phm: mu, dch no ty,
tin ng tin cy xy dng chnh sch.
v dch h hp, ng thi nh gi mc ph

hp ca cc hng dn iu tr. nh gi s
khc bit v gi ca cc thuc c th s dng theo
hng dn iu tr v chi ph cc thuc thay th
dng trong iu tr i vi bnh nhn khng
khng sinh.
Nghin cu xut: nh gi thc trng s

dng khng sinh ti cc trang tri chn nui:
ln, g v nui trng thy sn c/tm, mi lin
quan n khng khng sinh trn ngi v sn
phm tiu th trn th trng.
3. Cu trc khuyn khch v kinh t, can
2. Thi lng chng trnh ging dy v
thip da trn cng ng, ti cc hiu
khng sinh cho bc s v dc s trong
thuc bn l c cung ng thuc khng
trng cn rt thiu ht.
sinh. thnh cng trong vic thay i
Nghin cu xut: nh gi chng trnh
thi quen ca ngi bn thuc, trc
o to cho bc s/dc s v khng sinh, s
tin phi hiu cu trc khuyn khch.
gi, ni dung. So snh vi cc nc khc, bc s
Li nhun mang li t khng sinh
v dc s thc s hiu v khng sinh nh th
chim t l cao, do nu cc i tng
no.
kinh doanh dc phm t nhn thc

hin vic bn khng sinh mt cch hp l
3. Bnh nhn-i tng quan trng nht
th s gim ng k li nhun thu c.
trong vic s dng khng sinh: c thc
Lm th no c th to ra thay i?
s mun dng khng sinh khng?, nu
Nghin cu xut: nh gi doanh thu do

khng sinh mang li ti mt s hiu thuc. T
chc cc cuc tho lun nhm vi dc s,
nhn vin bn thuc tm ra nguyn nhn
thc y vic bn khng sinh ngoi yu t li
c, ti sao mun dng khng sinh, hiu

bit v khng sinh. Xc nh r ngha
ca triu chng Vim. Cn thng tin g
thuyt phc ngi bnh khng dng
khng sinh?
nhun. nh gi cu trc khuyn khch, kin
Nghin cu xut: kho st cng ng v
thc h c th cn h tr to ra thay i.
tho lun trng tm nhm.
40
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78. Parry, C.M. et al. Emergence in Vietnam of Streptococcus pneumoniae resistant to multiple
antimicrobial agents as a result of dissemination of the multiresistant Spain(23F)-1 clone.
Antimicrob Agents Chemother 46, 3512-3517 (2002).
79. Song, J.H. et al. High prevalence of antimicrobial resistance among clinical Streptococcus
pneumoniae isolates in Asia (an ANSORP study). Antimicrob Agents Chemother 48, 21012107 (2004).
80. Parry, C.M. et al. Nasal carriage in Vietnamese children of Streptococcus pneumoniae
resistant to multiple antimicrobial agents. Antimicrob Agents Chemother 44, 484-488
(2000).
81. Phan, L.T. et al. Genetic and phenotypic characterization of Haemophilus influenzae type b
isolated from children with meningitis and their family members in Vietnam. Jpn J Infect Dis
59, 111-116 (2006).
82. Gotoh, K. et al. Prevalence of Haemophilus influenzae with resistant genes isolated from
young children with acute lower respiratory tract infections in Nha Trang, Vietnam. J Infect
Chemother 14, 349-353 (2008).
83. Jones, S.L., Nguyen, V.K., Nguyen, T.M. & Athan, E. Prevalence of multiresistant Gramnegative organisms in a surgical hospital in Ho Chi Minh City, Vietnam. Trop Med Int Health
11, 1725-1730 (2006).
84. Cao, V. et al. Distribution of extended-spectrum beta-lactamases in clinical isolates of
Enterobacteriaceae in Vietnam. Antimicrob Agents Chemother 46, 3739-3743 (2002).
85. Le, T.M. et al. High prevalence of plasmid-mediated quinolone resistance determinants in
commensal members of the Enterobacteriaceae in Ho Chi Minh City, Vietnam. J Med
Microbiol 58, 1585-1592 (2009).
86. Kuo, C.Y. et al. Antimicrobial susceptibility of Shigella isolates in eight Asian countries,
2001-2004. J Microbiol Immunol Infect 41, 107-111 (2008).
87. Nguyen, T.V., Le, P.V., Le, C.H. & Weintraub, A. Antibiotic resistance in diarrheagenic
Escherichia coli and Shigella strains isolated from children in Hanoi, Vietnam. Antimicrob
Agents Chemother 49, 816-819 (2005).
44
88. Vinh, H. et al. Rapid emergence of third generation cephalosporin resistant Shigella spp. in
Southern Vietnam. J Med Microbiol 58, 281-283 (2009).
89. Chau, T.T. et al. Antimicrobial drug resistance of Salmonella enterica serovar typhi in asia
and molecular mechanism of reduced susceptibility to the fluoroquinolones. Antimicrob
Agents Chemother 51, 4315-4323 (2007).
90. Le, T.A. et al. Clonal expansion and microevolution of quinolone-resistant Salmonella
enterica serotype typhi in Vietnam from 1996 to 2004. J Clin Microbiol 45, 3485-3492
(2007).
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workshop). (2009).
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Quality Assurance Department). http://www.nafiqad.gov.vn/d-chuong-trinh-giam-sat/a-duluong/. (2009).
93. Hughes, P. & Heritage, J. Antibiotic Growth-Promoters in Food Animals
(http://www.fao.org/DOCREP/ARTICLE/AGRIPPA/555_EN.HTM). (2002).
94. Van, T.T., Moutafis, G., Tran, L.T. & Coloe, P.J. Antibiotic resistance in food-borne bacterial
contaminants in Vietnam. Appl Environ Microbiol 73, 7906-7911 (2007).
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retail raw food samples from Vietnam and characterization of their antibiotic resistance.
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spp. from chicken carcass in Bac Ninh province (unpublished).
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45
Danh sch cc bng

Bng 1: Nhng ch s pht trin c bn v cc ch s y t ca Vit Nam
Bng 2: Nhn lc ngnh y t nm 2005-2008
Bng 3. S ngi tham gia bo him y t trn ton quc, 2005-2007
Bng 4. Mt s nguyn nhn gy t l t vong cao nht ti Vit Nam
Bng 5: Gi ca mt s khng sinh cc cp khc nhau
Bng 6. Gi thuc bn l v nh nc qui nh mc gi thng d cho nh thuc bnh vin
Bng 7. Thuc gi c pht hin qua cc nm
Bng 8. Khuyn khch cho vic s dng khng sinh
Bng 9. Chi ph bnh vin cho khng sinh nm 2009 (s liu: B Y t)
Bng 10: Cc khuyn khch i vi vic s dng khng sinh trong nng nghip
Bng 11. Thch thc v c hi trong kim sot khng khng sinh
Bng 12. Danh sch cc chnh sch hin c lin quan n vic s dng khng sinh v thc
trng khng khng sinh ti Vit Nam v nhng xut
Bng 13. T l E. coli v K. pneumoniae sinh ESBL mt s bnh vin
Bng 14. Mc khng Carbapenem ca P. aeruginosa v A. baumannii 6 bnh vin nm
2008
Bng 15. Gi tr MIC i vi Vancomycin ca Staphylococcus aureus phn lp Bch Mai v
Ch Ry nm 2008
Bng 16: D lng khng sinh trong nui trng thu sn
Danh sch cc hnh

Hnh 1. Vit Nam
Hnh 2. Tnh hnh phn b cc h ngho Vit Nam
Hnh 3. H thng chm sc sc khe
Hnh 4: C cu chi ph y t 2006
Hnh 5. Doanh thu ca thuc sn xut trong nc v thuc ni chung ti Vit Nam (triu la
M) t 2001 n 2008
Hnh 6. S liu v doanh thu ca khng sinh ti Vit Nam
Hnh 7: DDD trn 100 ging ngy ca cc loi khng sinh nm 2008-2009
Hnh 8: DDD trn 100 ging-ngy theo thng ca 7 loi khng sinh c mc tiu th cao nht
nm 2009
46
Ph lc A
nhm vi khun Gram m c bnh vin a
Bch Mai
(77/359)
(2006)
Bnh vin
32,5
41,2
Bch Mai
(105/323)
(136/330)
(2007)
Bnh vin
42,2
Bch Mai
33,6 (85/253)
(97/231)
(2008)
Ngun: Bo co hi tho khoa hc ln th nht
khoa v chuyn khoa tuyn trung ng bao
GARP-Vit Nam42
S liu v khng khng sinh

Vit Nam: bnh vin
Kho st 4 cn nguyn thng gp thuc
gm E. coli, K. pneumonia, P. aeruginosa v A.

baumannii cho thy tnh trng khng khng
Hai cn nguyn gy nhim khun bnh
sinh ngy cng gia tng. Mc sinh ESBL
vin thng gp l: P. aeruginosa v A.
cc chng E. coli v K. pneumonia nm 2005 l
baumannii, c nh gi mc khng
khong 34% i vi c 2 loi cn nguyn ny.
carbapenem nm 2008. 20% cc chng P.
bnh vin Bch Mai, t l K. pneumonia v E.
aeruginosa v gn 50% cc chng A. baumanii
coli tng t 20% nm 2005 n 34% nm
khng carbapenem (Xem bng 14)42.
2008, v t 18% nm 2005 n 42% nm
Bng 14. Mc khng Carbapenem ca

P. aeruginosa v A. baumannii 6 bnh
vin nm 2008
P.aeruginosa A.baumannii
(%)
(%)
Meropenem
18
46,2
Imipenem
25
47,1
Ngun: Bo co hi tho khoa hc ln th nht
2008, tng ng vi 2 loi vi khun (Xem bng

13)42.
Bng 13. T l E. coli v K. pneumoniae sinh
ESBL mt s bnh vin
K.pneumoniae
E. coli
ASTS
program 7,7
23,7 (n = 485)
MOH
(n = 548)
(2004)
Bnh vin
51,6
Ch Ry
61,7 (87/141)
(145/281)
(2005)
Bnh vin
34,2
Vit c
39,3 (55/140)
(66/193)
(2005)
Bnh vin
36,2
Bnh nh
19,6 (29/148)
(51/141)
(2005)
Bnh vin
36,1
Vit Tip
25,7 (09/35)
(22/61)
(2005)
Bnh vin
18,5
Bch Mai
20,1 (37/184)
(28/151)
(2005)
Bnh vin
28,7 (99/347)
21,5
GARP-Vit Nam42
nh gi tnh ph bin ca cc chng S.
aureus mt trong nhng cn nguyn Gramdng gim nhy cm vi vancomycin trong s
cc chng khng methicillin S. aureus (MRSA)
v S. aureus nhy cm methicillin (MSSA)
Vit Nam. 200 chng phn lp t lm sng
MSSA v MRSA thu thp t 2 bnh vin trung
ng nm 2008 c th nghim xc nh gi
tr MIC ca Vancomycin. Kt qu cho thy
bt u ni ln tnh khng trung gian v/hoc
khng vancomycin ca cc chng S. aureus c
47
2 nhm MSSR v MRSA vi t l 3% ca MSSA
2004 bao gm S. aureus, E. coli, Salmonella,
v 5% ca MRSA (Xem bng 15)42.
Shigella, Enterobacteriaceae, S. pyogenes, S.

pneumoniae,
S liu ASTS
H.
influenzae,
Enterococcus,
Klebsiella pneumonia, P. aeruginosa v A.
Chng trnh ASTS v gim st tnh khng
baumannii. V tnh thiu chc chn ca s liu
khng sinh ca mt s cn nguyn thng gp
nn cc t l khng khng sinh khng c
phn lp t bnh nhn ni tr v ngoi tr t
cp trong bn bo co ny.
22 bnh vin trn ton quc t nm 1988 n
Bng 15. Gi tr MIC i vi Vancomycin ca Staphylococcus aureus phn lp

Bch Mai v Ch Ry nm 2008
Chng
Mean
SD
Geometric mean
S. aureus
200
1,63
0,41
MSSA
100
1,55
0,44
MRSA
100
1,72
0,36
S. aureus
BV Bch Mai
100
1,47
0,43
MSSA
57
1,34
0,42
MRSA
42
1,63
0,39
S. aureus
BV Ch Ry
100
1,80
0,32
MSSA
43
1,81
0,31
MRSA
57
1,78
0,33
Ngun: Bo co hi tho khoa hc ln th nht GARP-Vit Nam42
Tng s
1,57
1,47
1,67
1,39
1,27
1,57
1,77
1,79
1,75
% VSSA
(MIC 2mg/L)
96%
97%
95%
100%
100%
100%
92%
93%
91%
Ch : MSSA: S. aureus nhy cm Methicillin ; MRSA: S. aureus khng Methicillin
48
Ph lc B
Bng 16: D lng khng sinh trong nui trng thu sn
2007
2008
Sn
Sn
Nc
Nc
phm
phm
(%)
(%)
(%)
(%)
Khng
sinh cm
Chloramphenicol
0,9000
Semicarbazide
Malachite Green
Tetracyclin
0,7000
0,3000
0,0038
0,0035
(vt
qu gii
hn:
0,0017)
0,1250
0,1163
(vt
qu gii
hn:
0,007)
Sulfonamide
Khng
sinh gii
hn s
dng
Quinolone
Enrofloxacin
/Ciprofloxacin
Trimethoprim
0,0004
19
0,5
0,4
0,3
0,000
14,430
2009
Sn phm
(%)
Khng c
s liu
0,002
no data
no data
1,460
Khng c
s liu
0,120
0,011
0,094
0,09 (vt
qu gii
hn:
0,009)
1,850
Khng c
s liu
Nc
(%)
2 mu
Ngun: Bo co hi tho khoa hc ln th nht GARP-Vit Nam91
49

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Phn tch thc trng:

S dng khng sinh v khng khng sinh Vit Nam

Thng 10- 2010

Nhm nghin cu quc gia GARP-Vit Nam (NWG)

Cn b GARP- Vit Nam

GARP-VN Phn tch thc trng

GARP-VN Phn tch thc trng

TS. Nguyn Vn Knh

GARP-VN Phn tch thc trng

Vn ton cu v khng khng sinh

GARP-VN Phn tch thc trng

Khng khng sinh Vit Nam

Cc nguyn nhn dn n tnh trng lm dng khng sinh v khng

Trong nng nghip

Nghin cu ca GARP-Vit Nam

nng ca tnh trng khng thuc do cc cn nguyn ny gy ra trn c s so snh chi ph

CC C HI NHM KIM SOT KHNG KHNG SINH

Chng trnh gim st v

GARP-VN Phn tch thc trng

chng Quc gia

iu tr bng khng sinh.

Thay mt Nhm nghin cu Quc gia,

GARP-VN Phn tch thc trng

Hnh 1. Vit Nam

1.1. Gii thiu

Ngun: n v nghin cu lm sng H Oxford.

Vi hn 88 triu dn, Vit Nam l nc

dc, t l bit ch t 90%. Tnh n cui nm

2005, 81% cc h gia nh c in. Mc tiu

dn s xp x 265 ngi/km. Dn s tng i

ca chnh ph l n nm 2010, 95% h gia

tr so vi cc nc pht trin vi tui trung

nh c s dng in1. Nm 2010, chnh ph

bnh l 27 tui trong khi cc nc Chu u l

hy vng 85% dn s c s dng nc sch.

39-41 tui. Tc tng dn s gim trong vng

Tuy nhin, qu trnh trin khai cn kh chm

20 nm qua vi t l trung bnh 1,98 tr/m

v khng th t mc tiu 70% nm 20102.

(Bng 1). Xp x 28% dn s sng ti thnh th

1.1.2. Tnh hnh pht trin kinh t

GARP-VN Phn tch thc trng

Trong thp k qua, Vit Nam l mt trong

vc ngho nht m ch yu tp trung 2 khu

nhng nc trn th gii c s pht trin ng

vc chu th, ni m t l h ngho mc

k v kinh t. Tng sn phm quc ni GDP

trung bnh (Hnh 2).

bnh qun t 7,3% mi nm trong giai on

Hnh 2. Tnh hnh phn b cc h ngho

hi phc v kinh t sau tc ng bt li ca 2

Ngun: Bn i ngho v an ton thc phm4

58,1% nm 1993 xung 22% nm 2007. Tc

Vit Nam trin khai l trnh pht trin mt

ngho nhanh dn n s phn cp trong x hi.

s mc tiu pht trin thin nin k (MDGs). 5

T l cc h i ngho cao nht cc vng

trong s 10 mc tiu MDGs c ra cho giai

trung du v min ni pha Bc v thp nht

on n nm 2015 c hon thnh trong

ng nam v cc khu th ln. Tuy nhin,

k c mc tiu xo i gim ngho.

phn tch v mt cc h ngho ch ra

nm 2006. Tng t nh cc ch tiu khc,