Read Tengiz verulava text version

Tengiz verulava medicinis mecnierebaTa doqtori saqarTvelos universiteti ambulatorul-poliklinikuri momsaxurebis dafinansebis meTodebi

samedicino momsaxurebis SemTxvevaTa meti wili ambulatorul-poliklinikur doneze xorcieldeba. igi mniSvnelovan gavlenas axdens Semdgom etapebze saWiro xarjebzec. ambulatorul-poliklinikuri samedicino momsaxureba warmoadgens momsaxurebis yvelaze masobriv saxes, romelsac mimarTavs qveynis mosaxleobis umetesi nawili. ambulatorul-poliklinikuri momsaxurebisas mkurnalobis dasrulebuli SemTxvevis Rirebuleba ar aris didi, amitom misi xarjebis anazRaurebam SesaZloa saerTo xarjebis mniSvnelovani nawili Seadginos. ambulatorul-poliklinikuri samedicino momsaxurebiT, rogorc wesi, iwyeba da mTavrdeba pacientis mimarTva jandacvis sistemaSi, mas gaaCnia finansuri resursebis efeqturad gamoyenebis mniSvnelovani SesaZleblobebi rogorc ambulatorul etapze, aseve jandacvis mTel sistemaSi. aqedan gamomdinare, samedicino daxmarebis aRniSnul doneze anazRaurebis meTodebis SerCevas gansakuTrebuli mniSvneloba eniWeba. ase magaliTad, kvlevebis mixedviT, saswrafo samedicino gamoZaxebis 40 %-ze meti xorcieldeba qronikul avadmyofebze, romlebic imyofebian dispanserul meTvalyureobaze. saswrafo samedicino daxmarebis gamoZaxeba ZviradRirebul momsaxurebas warmoadgens. aseTi saxis gamoZaxebaTa mniSvnelovani nawili SeiZleba Semcirdes zogadi praqtikis eqimis efeqturi muSaobis Sedegad. cnobilia, rom ambulatorul etapze samedicino momsaxurebis gaweva 8-10-jer ufro iafia, vidre stacionarSi Catarebuli momsaxureba. amave dros, mkvlevarebis mier gakeTebuli SefasebiT, hospitalizirebul pacientTa 30 %-ze mets SeeZlo xarisxiani samedicino momsaxureba ambulatorul pirobebSi mieRoT. ambulatoruli samedicino momsaxureba SeiZleba davyoT pirvelad samedicino momsaxurebad da specializebul samedicino momsaxurebad. pirvelad samedicino momsaxurebas saqarTveloSi axorcieleben ubnis eqimebi (Terapevtebi da pediatrebi), agreTve zogadi praqtikis eqimebi. bevr qveynebSi pirvelad samedicino daxmarebas umTavresad zogadi praqtikis eqimebi axorcieleben, romlebic SedarebiT met samuSaos asruleben, vidre Terapevtebi, an pediatrebi da nawilobriv moicaven eqim-specialistebis mier Sesasrulebel samuSaosac. specializebul ambulatorul daxmarebas axorcieleben eqimi-specialistebi (nevropaTologebi, otolaringologebi...). samedicino daxmarebis iseTi saxeebi, rogoricaa stomatologia da ginekologia, SesaZlebelia ganxorcieldes rogorc poliklinikebSi, aseve specializebul samedicino dawesebulebebSi (qalTa konsultacia, stomatologiuri poliklinika). sakonsultacio-diagnostikuri ambulatoruli samedicino daxmareba SesaZlebelia Catardes msxvili samedicino dawesebulebebis sakonsultacio da sadiagnostiko centrebSi. ambulatorul-poliklinikuri samedicino daxmarebis dafinansebis Semdegi ZiriTadi meTodebi gamoiyeneba: · suladobrivi anazRaurebis meTodi; · fiqsirebuli xelfasiT anazRaurebis meTodi; · Sesrulebuli samuSaos mixedviT anazRaurebis meTodi.

suladobrivi anazRaurebis meTodi

suladobrivi (kapitaciuri) anazRaureba gulisxmobs samedicino dawesebulebis dafinansebas suladobrivi ganakveTis (TiToeul pirze anazRaureba) mixedviT, romelic fiqsirebulia da damokidebulia im mosaxleobis raodenobaze, romelsac igi emsaxureba. aRniSnuli meTodi gansakuTrebiT efeqturia ambulatorul-poliklinikuri samedicino daxmarebis dasafinanseblad, radgan axdens samedicino momsaxurebis dafinansebis sistemis optimizacias.

1

suladobrivi (kapitaciuri) anazRaurebisas TiTo sulze dgindeba normativi, romelSic Sedis pacientis gamokvlevis, konsultaciis da mkurnalobis xarjebi, SesaZlebelia saswrafo da gadaudebeli samedicino daxmarebis xarjebis gaTvaliswinebac. suladobrivi anazRaurebisas samedicino daxmarebis mimwodeblis mier gaweuli muSaobis anazRaureba ar aris dakavSirebuli samedicino momsaxurebis moculobaze. suladobrivi dafinanseba SesaZlebelia dafuZnebuli iyos garkveul geografiul teritoriaze mcxovrebi mosaxleobis raodenobaze (daxuruli gawevrianeba) an samedicino daxmarebis mimwodebelTan registrirebuli mosaxleobis raodenobaze (Ria gawevrianeba). Ria saxis gawevrianeba samedicino daxmarebis mimwodebelTa Soris konkurenciis zrdas ganapirobebs, isini cdiloben rac SeiZleba meti da naklebi riskis pacientebi daazRvion. suladobrivi anazRaurebis ori forma arsebobs: martivi da rTuli. martivi formis dros, samedicino dawesebuleba yvela registrirebuli pacientis momsaxurebisaTvis erTsa da imave Tanxas iRebs. rTuli formis dros samedicino dawesbulebis momsaxureobis zonaSi myofi TiToeuli pacientis momsaxurebisaTvis gansxvavebuli Tanxa dgindeba. rTuli formis dros iTvaliswinebs aramarto pacientTa raodenobas, aramed iseT parametrebs, rogoricaa asaki, sqesi, socialuri statusi, sacxovreblis adgilmdebareoba, eTnikuri faqtori, ganaTlebis done, invalidoba, urbanizacia.., cnobili faqtia, rom bavSvebi, moxucebi, an reproduqciul asakSi myofi qalebi samedicino daxmarebas ufro metjer moiTxoven, vidre mosaxleobis sxva jgufebi, Sesabamisad mizanSewonilia maTze SedarebiT maRali suladobrivi anazRaurebis dadgena. dasavleT evropis bevr qveynebSi Rarib ubnebSi ganlagebuli samedicino dawesebulebebis dasafinanseblad gamoiyeneba kapitaciuri anazRaurebis rTuli saxe. am samedicino dawesebulebSi momuSave personalisTvis SedarebiT maRali xelfasia dadgenili. cxadia, anazRaurebis aseTi forma xels uwyobs samedicino personalis ufro aqtiur muSaobas mosaxleobis socialurad daucvel fenebTan. did britaneTSi pirveladi jandacvis eqimebs organizacias uweven pjd regionuli asociaciebi, romelTac pirveladi jandacvis trastebis pjd jgufebs (Primary Care Groups or Primary Care Trusts) uwodeben. aRniSnuli jgufebis anazRaureba xorcieldeba suladobrivi meTodiis gamoyenebiT, regionuli jandacvis organizaciis (Regional Health Authorities) meSveobiT. eqimTa Semosavlebis 60% suladobrivi meTodiT finansdeba. TiTo sulze gamoyofili Tanxa damokidebulia pacientis asakze, sqesze, xolo qveynis zogierT regionSi TiToeul pacientze damatebiTi saxsrebia gamoyofili. ase magaliTad, 1997 wels 65 wlamde asakis pacientebze dadgenili iyo 16,05 funti sterlingi, 65-dan 74 wlamde asakis pacientebze -21,2 funti sterlingi, 75 welze meti asakis pacientebze ­ 41 funti sterlingi. socialurad Rarib raionebSi pacientze gamoyofili damatebiTi Tanxa Seadgenda 6,45 funt strelings, mZime raionebSi ­ 8,4 funt sterlings, xolo ukiduresad umZimes raionebSi 11,2 funti sterlings. suladobrivi anazRaurebis analogiur, rTul formas iyeneben amerikis SeerTebul StatebSic (jandacvis mxardamWeri organizacia - HMO).

cxrili: suladobrivi meTodiT anazRaurebisas gamoyenebuli parametrebi qveyana parametrebi avstralia asaki, sqesi, eTnikuri faqtori, usaxlkaroba, sikvdilianobis done, ganaTlebis done. belgia asaki, sqesi, umuSevroba, invalidoba, sikvdilianoba, urbanizacia kanada asaki, sqesi, eTnikuri faqtori, socialuri mdgomareoba, adgilis siSore fineTi asaki, invalidoba, adgilis siSore. inglisi asaki, sikvdilianoba, daavadebianoba, umuSevroba, martoxela moxuci, eTnikuri faqtori, socialur-ekonomikuri statusi Sotlandia asaki, sqesi, sikvdilianoba uelsi asaki, sqesi, safrangeTi asaki, germania asaki, sqesi, israeli asaki

2

italia niderlandebi axali zelandia norvegia Svecia

asaki, sqesi, sikvdilianoba asaki, sqesi, socialuri/invalidobis statusi, urbanizacia asaki, sqesi, eTnikuri faqtori, socialuri statusi

asaki, sqesi, sikvdilianoba, martoxela moxuci, qorwinebis statusi asaki, martoxela, dasaqmebis statusi, sacxovrebeli pirobebi, diagnostikuri informacia. Sveicaria asaki, sqesi, regioni. brazilia adgilmdebareoba, Semosavlis done. a.S.S. asaki, sqesi, invalidoba/ socialuri statusi, diagnostikuri informacia. wyaro: Nigel Rice, Peter Smith, Approaches to capitation and risk adjustment in health care: an international survey, The University of York, Cenre for Health Economics, 1999. GV. 22-23

niderlandebSi samedicino daxmarebis pirveli donis dasafinanseblad sadazRvevo kompaniebi centraluri fondidan Rebuloben riskze gaTvlil suladobriv normativs, romelic warmoadgens erT sulze gaTvlil mosalodnel danaxarjebs im riskis jgufis CarCoebSi, romelsac ekuTvnis dazRveuli, gamoklebuli fiqsirebuli Tanxa. fiqsirebuli Tanxa warmoadgens erTidaigives yvela dazRveulisaTvis da Seadgens TiTo sulze mosalodneli saSualo savaldebulo samedicino danaxarjebis daaxloebiT 10%-s. deficiti ivseba minimaluri fiqsirebuli SenataniT, romelsac dazRveuli uSualod mis mier amorCeul sadazRvevo kompaniaSi ixdis. niderlandebSi 1993-1994 wlebSi riskze gaTvlili suladobrivi normativis gamosaTvleli formula dafuZnebuli iyo mxolod asakze da sqesze. 1995 wels riskis am or maCvenebels daemata "regioni" da "Sromisunarianoba". mecnierebma daadgines, rom riskis yvelaze perspeqtiul maCvenebels warmoadgens agreTve diagnostikuri informacia, romelic gviCvenebs winaT gaweul samedicino daxmarebas, invalidobis dones, janmrTelobis mdgomareobas, qronikul avadmyofobas. 1995 wels niderlandebis mTavrobam SemoiRo nawilobrivi suladobrivi normativi, romlis mixedviT sadazRvevo fondebi iReben pasuxismgeblobas faqtiuri da mosalodneli danaxarjebs Soris sxvaobis mxolod 3%-ze. savaldebulo samedicino dazRvevis fondebidan zogadi praqtikis eqimebis anazRaureba xorcieldeba suladobrivi (kapitaciuri) meTodiT. suladobrivi anazRaurebis zoma dgindeba sadazRvevo fondebis asociaciebisa da eqimTa asociaciebis urTierTSeTanxmebis safuZvelze. riskze gaTvlili suladobrivi normativi damzRvevebisaTvis warmoadgens resursebis efeqturi gamoyenebis stimuls. ZiriTad teqnikur problemas warmoadgens mis gasaangariSeblad formulis srulyofa. mkvlevarebis azriT, riskze gaTvlili suladobrivi normativi unda iTvaliswinebdes demografiul monacemebs (asaki da sqesi), eTnikur faqtors, Sromisunarianoba/invalidobis statuss, geografiul mdebareobas, (urbanizacia, mosaxleobis simWidrove, adgilis siSore, maRalmTiani regionebi,) daavadebianobisa da sikvdilobis maCveneblebi, socialuri faqtorebi (Semosavlis done, ganaTleba, umuSevroba...)

cxrili: suladobrivi anazRaurebis dadebiTi da uaryofiTi mxareebi dadebiTi mxareebi uaryofiTi mxareebi warmoiSvas momsaxurebis eqimi dainteresebulia pacientis SesaZlebelia dausabuTebeli Semcirebis janmrTelobis gaumjobesebiT, radganac rac moculobis (hospitalizaciaze uari, ufro naklebad avadmyofoben maTi mcdeloba pacientebi, miT meti saSualebebi darCebaT, konsultaciebi da a.S.) amgvarad izrdeba profilaqtikis, avadobis adreuli gamovlenis interesi eqimi dainteresebulia momsaxurebis yvela ambulatoruli momsaxurebis struqturis etapze racionalurad daxarjos finansuri Rrma analizisaTvis ar aris sakmarisi ekonomikuri informacia, saWiroa damatebiTi saSualebebi statistikuri informaciis Segroveba ambulatoruli momsaxurebis xarjebi mcirdeba eqimebis aqtiuroba (dafinanseba windawinaa SezRuduli, xolo saerTo windawinaa dadgenili) xarjebis kontroli xorcieldeba pirveladi jandacvis rgolis mier

3

ambulatorul momsaxurebaze sadazRvevo organizaciebis xarjebi minimaluria

dadebiTi mxareebi konkurenciis zrda. suladobrivi dafinansebis meTodis gamoyenebebisas eqimi cdilos maRali anazRaurebis miRebis mizniT gazardos masTan registrirebuli pacientebis raodenoba. aRniSnuli ganapirobebs eqimebs Soris konkurenciis gazrdas, rac Tavis mxriv samedicino daxmarebis maRali xarisxiT Catarebis stimuls iZleva. am garemoebas xels uwyobs dazRveulis ufleba, sakuTari surviliT airCios samedicino dawesebuleba da eqimi. xarjebis zrdis Sekaveba. dafinanseba samedicino daxmarebis moculobaze araa damokidebuli. samedicino dawesebulebas da personals ar gaaCnia dausabuTebeli, pacientisaTvis araaucilebeli samedicino daxmarebis gawevis stimuli, rac mkveTrad amcirebs jandacvis xarjebs. meTodis gamoyenebisas danaxarjebi advilad prognozirebadia. angariSsworebis simartive. suladobrivi anazRaurebisaTvis damaxasiaTebelia angariSsworebis simartive. igi ar moiTxovs samedicino daxmarebis TiToeuli SemTxvevisaTvis angariSis damuSavebas. Sesabamisad naklebia saqmis warmoebisaTvis saWiro xarjebi. suladobrivi anazRaureba naklebad moiTxovs ZviradRirebul sainformacio sistemebis gamoyenebas. mkveTrad mcirdeba didi raodenobiT safinansoekonomikuri personalis saWiroeba. prevenciuli RonisZiebebis gaaqtiureba. eqimi dainteresebulia droulad da xarisxianad ganaxorcielos daavadebaTa profilaqtika; vinaidan mwvave konkurentul brZolaSi igi cdilos damoukideblad gadawyvitos yvela warmoCenili problema. rac TavisTavd ufro gaadvilebulia naklebad dasnebovnebul kontigentSi. samedicino daxmarebis xarisxi. eqimi dainteresebulia masTan registrirebuli pacientebis janmrTelobis mdgomareobiT. igi cdilobs xangrZlivi kontaqti iqonios erTidaigive pacientTan, ukeTesad gaerkves daavadebis mimdinareobaSi, raTa uzrunvelyos saTanado samedicino daxmarebis gaweva. aseve dazRveuli piri dainteresebulia isargeblos erTi eqimis momsaxureobiT da urTierToba daamyaros im dawesebulebasTan, sadac misi avadmyofobis istoria inaxeba. meTodi gansakuTrebiT efeqturia qronikuli daavadebebis samkurnalod. eqimis, rogorc "meWiSkris" rolis gaZliereba. zogadi praqtikis eqimTan xangrZilivi kontaqtis gamo, pacienti cdilobs mxolod misi rCevis Semdeg mimarTos specialists. iseT qveynebSi, rogoricaa dania, irlandia, italia, niderlandebi, didi britaneTi, fineTi, norvegia, portugalia, espaneTi, specialistTan konsultaciis misaRebad aucilebelia zogadi praqtikis eqimis mimarTva. uaryofiTi mxareebi samedicino daxmarebis xarisxi. radgan yvela registrirebul pacientze eqims garantirebuli fiqsirebuli anazRaureba eZleva, mas uCndeba uaryofiTi stimuli, xarjebis Semcirebis mizniT Tavidan moiSoros pacienti, gaagzavnos specialisTan, an stacionarSi samkurnalod, Seamciros pacientTan konsultaciis dro, Casatarebeli gamokvelevebis moculoba. aRniSnuli negatiuri stimuli uaryofiTad moqmedebs samedicino daxmarebis maRali xarisxiT uzrunvelyofaze (Langenbrunner and Wiley 2002). aRniSnuli problemis gadaWris erT-erT gzas warmoadegns pacientisaTvis samedicino dawesebulebis Tavisufali arCevanis uflebis miniWeba. im SemTxvevaSi, rodesac pacientebs ar Cautareben saTanado xarisxis samedicino daxmarebas pacients ufleba aqvs airCios sxva samedicino dawesebuleba. amasTan, damfinansebelsac aqvs ufleba samedicino daxmarebis dabali xarisxiT gawevis, an gansazRvruli standartis darRvevis SemTxvevaSi dawesebulebasTan gawyvitos xelSekruleba da misTvis sasurvel sxva dawesebulebasTan gaaformos kontraqti. SesaZlebebelia agreTve suladobrivi anazRaurebisa da Sesrulebuli samuSaos meTodebis kombinirebuli gamoyeneba, romelic gulisxmobs momsaxurebis prioritetul saxeebze (mag; prevenciuli RonisZiebebi) Sesrulebuli samuSaos mixedviT anazraurebis meTodis gamoyenebas. ase, magaliTad did britaneTSi, zogadi praqtikis eqimis anazRaureba garda suladobrivi meTodisa, xorcieldeba fiqsirebuli xelfasis, Sesrulebuli samuSaos mixedviT da miznobrivi (imunizaciis maRali donis

4

misaRwevad) anazRaurebis meTodebiT. anazRaurebis kombinirebuli meTodebi gamoiyeneba iseT qveynebSi, rogoricaa: dania, didi britaneTi, norvegia, saberZneTi. konkurenciis xelSemSleli faqtorebi. konkurenciis efeqturad ganxorcielebas xels uSlis ori faqtori: erTi mxriv, pacientebi eqims afaseben ara samedicino daxmarebis xarisxis mixedviT, aramed iseTi martivi kriteriumebiT, rogoricaa: eqimTan rigebis arseboba an avadmyofobis furclis SedarebiT iolad gamowera. igi dakavSirebulia samedicino bazarze arsebul informaciis simetriasTan, sadac eqimi gvevlineba agentis rolSi, xolo pacients damoukideblad ar SeuZlia gadawyvitos Tu ra saxis samedicino daxmareba sWirdeba da rogor miiRos igi. meore mxriv, Tu mWidrod dasaxlebul adgilebSi eqimebs Soris konkurencia maRalia, naklebad dasaxlebul soflis pirobebSi igi SedarebiT dabalia. soflad SesaZlebelia mxolod erTi eqimi iyos dasaqmebuli, rac amcirebs konkurencias da Sesabamisad Tavisufali arCevanis principis ganxorcielebas. aRniSnuli problema kidev ufro Zlierdeba zogadi praqtikis eqimebis msxvil jgufad gaerTianebis SemTxvevaSi, romelic garkveulwilad efeqtur monopoliur kartels warmaodgens da Sesabamisad amcirebs pacientis mxridan arCevanis SesaZleblobas. am problemis mosagvareblad gamoiyeneba monitoringis iseTi meqanizmebi, rogoricaa: eqimTa samedicino auditi, licenzireba da akreditacia. maRali riskis pacientebis Tavidan moSoreba. suladobrivi anazraurebis erT-erT mTavar problemas warmodgens is garemoeba, rom zogadi praqtikis eqimebi cdiloben Tavidan moiSoron da maTTan ar daazRvion maRali riskis pacientebi (moxucebi, qronikuli avadmyofebi...) aRniSnuli problemis gadawyvetis erT-erT gzas warmoadgens suladobrivi anazRaurebis rTuli formis danergva, romelic samuSaos gazrdili moculobisa da Sesabamisad maRali xarjebis sakompensaciod iTvaliswinebs iseT risk faqtorebs, rogoricaa: pacientis sqesi, asaki, socialuri statusi... problemis gadawyvetis sxva gzas warmoadgens maRali riskis pacientebis garkveuli droiT eqimebSi gadanawilebis sqema. eqimebi SeTanxmdebian, garkveuli droiT erTmaneTSi gadainawilon marali riskis pacientebi. magaliTad, maRali riskis pacientebis pacientebis erTi nawili naxevari wliT erT eqimTanaa daregistrirebuli, Semdgom etapze sxva eqimTan da a. S. riskis dabali prognozireba. suladobrivi anazRaurebis meTodis gamoyenebisas riskis prognozireba dabalia, radgan dazRveulTa garkveulma nawilma SeiZleba saerTod ar isargeblos momsaxurebiT mocemul periodSi, mave dros, maRali riskis pacientebs SesaZlebelia drois imave periodSi ramdenjerme dasWirdeT ZviradRirebuli samedicino daxmareba. zemoaRniSnuli uaryofiTi mxareebis aRmosafxvrelad, saWiroa ambulatoruli dawesebulebebis sameurneo meqanizmebis SemuSaveba, romlebic moaxdenen efeqturi momsaxurebis stimulirebas. agreTve aucilebelia kompensatoruli meqanizmebis amoqmedeba, romlebic Seamcireben samedicino momsaxurebis dausabuTebel SezRudvas: · pacientebis mier samedicino personalis da dawesebulebis Tavisufali arCevani: · pacientTa momsaxurebis specialuri samsaxuri, sadac maT SeeZlebaT mimarTon samedicino momsaxurebaze uaris SemTxvevaSi; · samedicino momsaxurebis xarisxze kontroli; · samedicino dawesebulebebSi mimarTvaze da samedicino momsaxurebis gawevaze dausabuTebeli uaris Tqmis SemTxvevaSi sajarimo sanqciebis daweseba;

Sesrulebuli samuSaos mixedviT anazRaurebis meTodi

Sesrulebuli samuSaos mixedviT anazRaurebis meTodi warmoadgens samedicino daxmarebis TiToeuli erTeulis (Sesrulebuli procedurebis, diagnostikuri gamokvlevebis, namkurnalevi pacientebis raodenobis) mixedviT dafinansebas. Sesrulebuli samuSaos mixedviT anazRaureba yvelaze gavrcelebul sabazro meTods warmoadgens. igi ZiriTadad iseT qveynebSi gamoiyeneba, sadac dafinansebis

5

sadazRvevo sistemaa gavrcelebuli (germania, belgia, safrangeTi, luqsemburgi, holandia, Sveicaria, a.S.S., kanada). dafinanseba SesaZlebelia ganxorcieldes rogorc retrospeqtuli ise prospeqtuli principiT (samedicino daxmarebis mimwodebelsa da damfinansebels Soris momsaxurebis moculobasa da xarjebze winaswari SeTanxmebis Sesabamisad). igi gamoiyeneba rogorc samedicino dawesebulebis, aseve personalis mier Sesrulebuli samuSaos asanazRaureblad. dadebiTi da uaryofiTi mxareebi dadebiTi mxareebi eqimi dainteresebulia pacients maqsimaluri moculobiT gauwios samedicino momsaxureba Sesrulebuli samuSaos mixedviT anazRaurebis meTodis gamoyenebisas maRalia samedicino momsaxurebis xarisxi, radgan eqimi cdilobs rac SeiZleba mimzidveli gaxdes mis mier gaweuli samedicino daxmareba. pacients farTo saSualeba eZleva airCios eqimi, stacionarSi mkurnalobisas moiTxovos damatebiTi momsaxureba (calke palataSi ganTavseba, televizori, telefoni...). amgvarad, eqims stimuli aqvs pacients maqsimaluri moculobiT da xarisxiT gauwios samedicino daxmareba. im qveynebSi, sadac Sesrulebuli samuSaos mixedviT anazRaurebis meTodia gavrcelebuli, eqimTan mimarTvianobis maRali done SeiniSneba. ase magaliTad, SveicariaSi erT sul mosaxleze gaTvliT eqimTan mimarTvianoba Seadgens ­ 11-s, germaniaSi ­ 12,8-s, safrangeTSi ­ 6,3-s (1992 w.). uaryofiTi mxareebi xarjebis zrda. Sesrulebuli samuSaos mixedviT anazRaureba mniSvnelovnad zrdis jandacvis xarjebs. igi umTavresad gamowveulia samedicino personalis finansuri stimuliT, Semosavlebis momatebis mizniT gazardos momsaxurebis moculoba. eqimebi ar arian dainteresebuli efeqturad gamoiyenon finansuri resursebi. aRniSnulis gamo Sesrulebuli samuSaos mixedviT anazRaureba eqimebisaTvis yvelaze ufro sasurvel meTods warmoadgens. am mdgomareobas xels uwyobs samedicino bazarze arsebuli informaciis asimetria. pacientis naklebad informirebulobis gamo eqimi gansazRvravs samedicino daxmarebis moTxovnilebas. amasTan sayuradReboa, rom eqimis mxridan eTikuri saSiSroeba (Moral hazard) ufro metad Sesrulebuli samuSaos mixedviT anazRaurebis meTodis gamoyenebisas SeiniSneba. eqspertTa azriT, im qveynebSi, sadac aRniSnuli meTodia gavrcelebuli mniSvnelovnad maRalia rogorc diagnostikuri gamokvlevebis, aseve gamowerili medikamentebis raodenoba (Braham et al., 1990).

6

Catarebuli gamokvlevebis Sedegad dadginda, rom im qveynebSi, sadac gamoiyeneba Sesrulebuli samuSaos mixedviT anazRaurebis meTodi, weliwadSi saSualod 11 %-iT izrdeba jandacvis xarjebi (Gerdtham et al. 1992). hiqsonis mier Catarebuli kvlevis mixedviT, Sedarebul iqna 18 SerCeuli pediatri, romelTa anazRaureba xorcieldeboda an Sesrulebuli samuSaos mixedviT, an fiqsirebuli xelfasiT. kvlevam aCvena, rom im eqimebs romelTa anazRaureba xorcieldeboda Sesrulebuli samuSaos mixedviT, aReniSnebodaT 22 %-iT meti vizitebis raodenoba, vidre fiqsirebuli xelfasiT anazRaurebis SemTxvevaSi (18). CineTSi Sesrulebuli samuSaos mixedviT anazRaurebis meTodis danergvam jandacvis xarjebis mniSvnelovani zrda gamoiwvia (World Bank, 1995). analogiuri situacia SeiniSneboda saqarTveloSi jandacvis sistemis reorientaciis sawyis etapze, rodesac ambulatoruli samedicino daxmarebis asanazRaureblad aRniSnuli meTodi iqna SemoRebuli. meTodis danergvisas ar iqna gamoyenebuli samedicino daxmarebis moculobis zrdis Semakavebeli iseTi meqanizmebi, rac dasavleT evropis sxva qveynebSia gavrcelebuli. eqspertTa azriT, im qveynebSi, sadac qirurgebis anazRaureba Sesrulebuli samuSaos mixedviT xorcieldeba, qirurgiuli operaciebis raodenoba orjer aRemateba im qveynebTan SedarebiT, sadac qirurgebi fiqsirebul xelfass Rebuloben (d Intignano, 1992). mkvlevarebis erTmaneTs Seadares kanadaSi da did britaneTSi qirurgiuli samedicino daxmarebaze gaweuli xarjebi. did britaneTTan SedarebiT qirurgiul operaciaTa maRali sixSire kanadaSi da aSS-Si ganpirobebuli iyo aramarto daavadebaTa gavrcelebis sxvadasxvaobiT aRniSnul qveynebSi, an gansxvavebuli samedicino teqnologiebis arsebobisa da gamoyenebis gamo, aramed kanadaSi da aSS-Si TiToeul SemTxvevaze dafuZnebuli anazRaurebis meTodis arsebobiT (19).

eqimebma pacientebs SeiZleba gauwion arasaWiro samedicino momsaxureba Sesrulebuli samuSaos mixedviT anazRaurebisas eqimebs SeiZleba gauCndeT negatiuri stimuli, moaxdinon dadgenili preiskurantis garkveuli manipulireba. samedicino momsaxurebis zogierTi saxe maTTvis ufro Semosavliani xdeba. ase magaliTad, braziliaSi, sadac Sesrulebuli samuSaos mixedviT anazRaurebis meTodia gavrcelebuli, mkveTrad gaizarda sakeisro kveTebis raodenoba (20). moTxovnilebis provicirebis erT-erT gavrcelebul formas warmoadgens eqimis mier pacientisaTvis dausabuTeblad ganmeorebiTi vizitis daniSvna.

germania eqimTan mimarTvianobis yvelaze maRali maCvenebliT xasiaTdeba. germaneli zogadi praqtikis eqimi kviraSi saSualod 220 vizits axorcielebs (maTgan 35 binazea). dReSi eqimi saSualod 44 pacients naxulobs (37 ofisSi da 7 binaze), wliurad ki erT pacientze 10-12 konsultacia tardeba. igi ganpirobebulia im garemoebiT, rom yoveli pacientis viziti eqimis Semosavals saSualod 50-70 markiT zrdis. amis gamo, germaniaSi sadazRvevo kompaniebis mier yovelwliurad 5-7 miliardi marka ixarjeba usafuZvlod. aqve aRsaniSnavia, profesiuli asociaciebis roli, romlebic aqtiur winaaRmdegobas uweven eqimis Sromis anazRaurebis wesis Secvlas.

eqims ar aqvs pacientis janmrTelobis gaumjobesebis ekonomikuri stimuli, prevenciul RonisZiebebze naklebi yuradReba. aRniSnuli meTodis gamoyenebisas ufro meti yuradReba eqceva pacientis mkurnalobas vidre profilaqtikuri RonisZiebebis Catarebas. igi gamowveulia eqimis mcire ekonomikuri stimuliT, hyavdes janmrTeli pacienti, radgan misi yoveli viziti

7

da sadiagnostiko saSualebas aZlevs.

samkurnalo

RonisZieba

eqims

damatebiTi

Semosavlis

miRebis

ar aris ekonomikuri kavSiri samedicino momsaxurebis sxva etapebTan. mcirdeba zogadi praqtikis eqimis makoordinirebeli, rogorc "mekaribWis" funqcia. igi naklebadaa dainteresebuli racionalurad airCios mkurnalobis Semdgomi etapebi da am etapebze meTvalyureoba gauwios pacients, Seafasos sxva eqimebis mier gaweuli samedicino daxmarebis xarisxi. angariSsworebis sirTule. aRniSnuli meTodisaTvis damaxasiaTebelia angariSsworebis sirTule. igi moiTxovs samedicino daxmarebis TiToeuli SemTxvevisaTvis angariSsworebis damuSavebas. Sesabamisad izrdeba saqmis warmoebisaTvis saWiro xarjebi. meTodis danergva moiTxovs ZviradRirebul sainformacio sistemebis gamoyenebas, centralizebul monacemTa bazis Camoyalibebas, rac aucilebelia gaTvlebis sawarmoeblad. mkveTrad izrdeba didi raodenobiT safinanso-ekonomikuri personalis saWiroeba. maRali administraciuli xarjebi. Sesrulebuli samuSaos mixedviT anazRaurebisas maRalia administraciuli xarjebi, vinaidan igi ZviradRirebuli ekonomikuri kontrolis (miwerebis gamovlena, saavadmyofoSi mimarTvis adeqvaturobis Seswavla da a. S.) sistemis Seqmnas moiTxovs.

Sesrulebuli samuSaos mixedviT anazRaurebis meTodis Taviseburebebi qveyana Tavisebureba wyaro ganviTarebuli xarjebi 11 %-iT izrdeba Gerdtham et al., meTodis mTavari qveynebi Tavisebureba sxva 1992 meTodebTan SedarebiT diagnostikur RonisZiebebze CineTi izrdeba diagnostikur Gellert, 1995 zemoqmedeba proceduraTa raodenoba da ZviradRirebuli diagnostikuri mowyobilobebis gamoyeneba qirurgiuli operaciebis brazilia izrdeba sakeisro Barrors et al., raodenoba kveTaTa raodenoba im 1986 qveynebTan SedarebiT, sadac aRniSnuli meTodi ar gamoiyeneba gavlena samedicino samxreT korea xarjebis zrda Barnum et al., dawesebulebaze 1995 utilizaciaze gavlena vietnami utilizaciis zrda Ensor, 1995 izrdeba qirurgiuli aSS, didi Sesrulebuli samuSaos Mc. Pherson, operaciebis raodenoba 1981 britaneTi, mixedviT anazRaurebis kanada Sedareba fiqsirebul xelfasTan wyaro: s. vitteri, t. enzori, m. ioveti, r. Tompsoni. jandacvis ekonomika. iorkis universiteti, jandacvis ekonomikis centri, 2000 w. gv. 221.

8

Sesrulebuli samuSaos mixedviT anazRaurebis meTodis saxeebi Sesrulebuli samuSaos mixedviT anazRaurebis meTodis Semdegi saxeebi arsebobs: · detaluri samedicino momsaxurebis (eqimTan vizitebi, receptebis gamowera, laboratoriuli gamokvlevebi, procedurebi) anazRaureba; · detaluri samedicino momsaxurebis anazraureba tarifebis erTiani sistemis saSualebiT, sadac momsaxurebis Rirebuleba gamoixateba qulebSi; · mkurnalobis (dispanserizaciis) dasrulebuli SemTxvevebis anazRaureba, romlebic windawin arian klasificirebuli zogierTi niSnis mixedviT (SemTxvevis simZime, saerTo xarjebi). detaluri samedicino momsaxurebis (eqimTan vizitebi, laboratoriuli gamokvlevebi, procedurebi) anazRaureba receptebis gamowera,

cxrili: detaluri samedicino momsaxurebis anazRaurebis dadebiTi da uaryofiTi mxareebi dadebiTi mxareebi uaryofiTi mxareebi eqims ar aqvs pacientis janmrTelobis gaumjobesebis ekonomikuri stimuli, prevenciul RonisZiebebze naklebi yuradReba. eqimi dainteresebulia pacients maqsimaluri moculobiT gauwios eqimebma pacientebs SeiZleba gauwion samedicino momsaxureba arasaWiro samedicino momsaxureba Znelia windawin ganWvrito dafinansebis moculoba eqimebi ar arian dainteresebuli efeqturad gamoiyenon finansuri resursebi ar aris ekonomikuri kavSiri samedicino momsaxurebis sxva etapebTan maRali administraciuli xarjebi Znelia miwerebis sruli gamovlena

SesaZlebelia Segrovdes gaweuli momsaxurebis struqturis detaluri monacemebi

detaluri samedicino momsaxurebis anazRaureba SeiZleba gamoyenebul iqnes im SemTxvevaSi, rodesac sadazRvevo organizaciebs farTo saSualeba aqvT SearCion ambulatoruli momsaxurebis iseTi rgolebi, romlebic muSaoben ufro efeqturad da amave dros, gaiTvaliswineben sadazRvevo organizaciis ekonomikur interesebs. meTodi SeiZleba gamoyenebul iqnes rogorc momsaxurebis anazRaurebis ZiriTadi meTodis damateba. detaluri samedicino momsaxurebis anazraureba tarifebis saSualebiT, sadac momsaxurebis Rirebuleba gamoixateba qulebSi erTiani sistemis

ambulatorul momsaxurebaze sadazRvevo organizaciis saerTo xarjebi windawinaa gansazRvruli. qulis Rirebuleba ganisazRvreba aRniSnuli Tanxis gayofiT mocemul periodSi yvela ambulatoruli dawesebulebis mier mogrovil qulaTa saerTo raodenobaze. cxrili: detaluri samedicino momsaxurebis anazraureba tarifebis erTiani sistemis saSualebiT, dadebiTi da uaryofiTi mxareebi dadebiTi mxareebi uaryofiTi mxareebi eqims ar aqvs pacientis janmrTelobis eqimi dainteresebulia TiToeul pacients gaumjobesebis ekonomikuri stimuli, maqsimaluri moculobiT gauwios prevenciul RonisZiebebze naklebi samedicino momsaxureba yuradReba.

9

ambulatorul momsaxurebaze windawinaa gansazRvruli

xarjebi

SesaZlebelia Segrovdes gaweuli momsaxurebis struqturis detaluri monacemebi

eqimebma pacientebs SeiZleba gauwion arasaWiro samedicino momsaxureba Znelia windawin ganWvrito dafinansebis moculoba eqimebi ar arian dainteresebuli efeqturad gamoiyenon finansuri resursebi ar aris ekonomikuri kavSiri samedicino momsaxurebis sxva etapebTan maRali administraciuli xarjebi Znelia miwerebis sruli gamovlena

aRniSnuli meTodic SeiZleba gamoyenebul iqnes im SemTxvevaSi, rodesac sadazRvevo organizaciebs farTo saSualeba aqvT SearCion ambulatoruli momsaxurebis iseTi rgolebi, romlebic muSaoben ufro efeqturad da amave dros, gaiTvaliswineben sadazRvevo organizaciis ekonomikur interesebs. meTodi SeiZleba gamoyenebul iqnes rogorc momsaxurebis anazRaurebis ZiriTadi meTodis damateba. kontrolis xarjebi SesaZlebelia nawilobriv daekisros eqimTa asociaciebs, radganac xorcieldeba mxolod ambulatoriis SigniT saxsrebis samarTliani ganawilebis kontroli. yvela dagrovili qulebis gamosaTvlelad aucilebelia kompiuteruli programis arseboba. aRniSnuli meTodi gamoiyeneba germaniaSi ambulatoruli momsaxurebis dasafinanseblad. germaniaSi eqimebi romelTac gaaCniaT Sesabamisi licenzia da xelSekruleba aqvT gaformebuli savaldebulo samedicino sadazRvevo fondebTan, warmoadgenen sadazRvevo salaroebis eqimTa asociaciis sruluflebian wevrebs. gaweuli samedicino daxmarebis xarjebi waredgineba ara sadazRvevo salaroebs, aramed eqimTa asociacias. federalur doneze ganisazRvreba licenzirebuli samedicino momsaxurebis saxeTa CamonaTvali punqtebis saxiT (dReisaTvis moqmedebs 250 saxe). momsaxurebis ZiriTad 147 saxesTan (konsultacia, vizitebi, gamokvlevebi da a. S.) erTad arsebobs sxvadasxva specialobebis mixedviT momsaxurebis saxeebi (22). ase magaliTad, qirurgiuli da orTopediuli qirurgiis CamonaTvali moicavs momsaxurebis 355 saxes, otolaringologia 97-s, Sinagani daavadebebi ­ 87-s da a. S (22). momsaxurebis TiToeul saxeze miniWebulia gansazRvruli kodi da qula. regionalur doneze dgindeba TiToeuli punqtis Rirebuleba (tarifebi). tarifs adgens saerTo federaluri sabWos ambulatoruli daxmarebis komisia. tarifis dadgenaSi jandacvis saministrosTan erTad monawileoben sadazRvevo salaroebi da eqimTa asociaciebi. eqimTa asociaciebsa da sadazRvevo salaros Soris dadebuli xelSekrulebiT (5 wlis vadiT formdeba) dgindeba samedicino dawesebulebisa da personalis anazRaurebis forma da zoma, kontrolis meqanizmebi, TiToeuli qulis fasi. sadazRvevo salaroebi regionul eqimTa asociaciebs yovelkvartalurad uricxaven mocemuli regionis yvela eqimebis dafinansebisaTvis saWiro saerTo regionul biujets. regionul eqimTa asociaciebi regionul biujets gansazRvraven suladobrivi meTodiT, anu igi damokidebulia damokidebulia mocemuli regionis dazRveulTa raodenobaze da moicavs sxvadasxva specialobis eqimis mier gaweuli momsaxurebis yvela saxes. TiToeul dazRveulze gamoyofili Tanxa gansxvavebulia aramarto federaluri mxareebis mixedviT, aramed erTidaigive mxareSi sadazRvevo salaroebis mixedviTac. sqema: fondebsa, dazRveulebsa da eqimebs Soris urTierToba germaniis samedicino sadazRvevo sistemaSi

10

saxelmwifo samedicino sadazRvevo fondi S C dazRveuli pacientebi C QI saavadmyofo salaroTa eqimTa asociacia G

MS

QI

saavadmyofo salaros eqimebi

I

_____ naturiT gadaxdis nakadebi; C - samedicino dazRvevis serTifikati an baraTi; fuladi gadaxdis nakadebi; MS ­ samedicino momsaxureba; G - saerTo anazRaureba; QI - yovelkvartaluri angariSebi; S - mkurnalobis xarjebi; I - individualuri anazRaureba

eqimi kvartalSi erTjer eqimTa asociacias awvdis angariSs, sadac miTiTebulia mis mier Catarebul momsaxurebaze qulaTa saerTo raodenoba. eqimTa asociacia specialuri kompiuteruli programiT amuSavebs warmodgenil informacias. eqims eZleva yovelTviuri anazRaureba wina kvartalis monacemebis mixedviT, magram faqtiuri Semosavali damokidebulia Semdeg faqtorebze: · gamoiTvleba yvela eqimis mier gamomuSavebul qulaTa saerTo raodenoba. asociacia masTan gawevrianebuli eqimebs Soris axdens saerTo biujetis ganawilebas, maT mier gamomuSavebuli qulebis raodenobis mixedviT. saerTo regionuli biujeti iyofa qulaTa raodenobaze da Sesabamisad dgindeba TiToeuli qulis Rirebuleba. ase rom TiToeuli qulis Rirebulebis winaswar ganWvreta Znelia, igi damokidebulia qulebis saerTo raodenobaze. eqimebis mier biujetiT gaTvaliswinebulze meti moculobis samuSaos Catarebisas mcirdeba TiToeuli qulis Rirebuleba da Sesabamisad, samedicino daxmarebis Rirebuleba SedarebiT dabali fasiT anazRaurdeba. eqimis kvartaluri Semosavali ganisazRvreba miRebuli TiToeuli qulis Rirebulebis gadamravlebiT mis mier Sesrulebul samedicino daxmarebis procedurebis saerTo raodenobaze. · axdenen anazRaurebis koreqtirebas anazRaurebis ganawilebis sqemis mixedviT. TiToeul asociacias anazRaurebis ganawilebis Tavisi sqema aqvs. swored am RonisZiebis Sedegad xorcieldeba momsaxurebis sxvadasxva saxeobebs Soris gansvavebis da Sesabamisad sxvadasxva kategoriis momsaxurebaze qulebis Sefasebis sididis koreqtireba. · 1997-2003 wlebSi limitirebuli iyo TiToeul pacientze qulaTa raodenoba. limiti gansxvavebuli iyo aramarto daavadebebis mixedviT, aramed federaluri mxareebis mixedviT. igi Semdgom gauqmebul iqna federaluri sasamarTlos mier. cxrili: saxelmwifo samedicino dazRvevis sistemaSi dasaqmebul eqimTa anazRaureba: momsaxurebis 20 saxeze, romlebzec yvelaze meti Tanxebi ixarjeba yvela eqimis momsaxurebis saxe qulaTa raodenoba saerTo Semosavlidan % ZiriTadi kvartaluri anazRaureba erT ojaxis eqimebi: 265 1 20,8 avadmyofze (dazRveul

11

2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

ganmarteba, dagegmva da SeTanxmeba anazRaureba konsultaciaze ojaxis eqimis ZiriTadi kvartaluri anazRaureba daavadebis Sedegebze da mis mkurnalobaze gaRrmavebuli konsultacia pacientis binaze viziti finansurad dasabuTebuli laboratoriuli gamokvlevis daniSvna pacientis zogadi gasinjva Tavis, kidurebisa da saxsrebis rentgenologiuri gamokvleva RamiT, dasvenebis dReebSi da dResaswaulebze momsaxurebis anazRaureba Sardsasqeso organoebis eqoskopia sxeulis sxvadasxva organoebis rentgenologiuri gamokvleva (garda Tavisa da kidurebisa) muclis Rrus eqoskopia sxeulis sxvadasxva organoebis kompiuteruli tomografia (garda Tavisa da kidurebisa) ekg minimaluri laboratoriuli gamokvlevis anazRaureba fsiqoTerapia (xangrZlivi, individualuri) onkologiuri gamokvleva

pensionerebze 475), specialistebi ­ 40420 180 50 90 300 (Tu konsultacia grZeldeba 30 wT-ze met xans ­ 600) 300 (saswrafo gamoZaxebisas 600) 5-240 specialobis mixedviT 320 1150 200-300 400 1150 520 80 100-250 5-110 1450 qalebi ­ 310 kacebi ­ 260 + 140 citologiuri gamokvlevisaTvis 1850

5 4,8 2,9 2,2 1,9 1,9 1,6 1,5 1,4 1,2 1,1 1,1 0,9 0,8 0,8 0,8

18 19

0,8

orsulTa meTvalyureoba 0,8 bazisuri klinikur-nevrologiuri 20 170 0,7 gamokvleva wyaro: Busse R, Reisberg A. Health Care System in Transition: Germany, Copenhagen, WHO. Regional Office on behalf of the European Observatory on Health Systems and Policies, 2004. amgvarad, germanuli sistemis mixedviT, eqimebs ar SeuZliaT gamoyofil biujetze metis xarjva. koleqtiuri SezRudvis aseTi meqanizmi mniSvnelovnad amcirebs eqimis dainteresebas gazardos momsaxurebis moculoba. garda amisa, eqimebis anazRaureba gansxvavebulia aramarto federaluri mxareebis mixedviT, aramed yovelkvartalurad da momsaxurebis specialobebis mixeviT. rogorc qvemoT moyvanil cxrilSia naCvenebi, 1995-2001 wlebSi eqimTa dafinansebis analizi gviCvenebs, rom miuxedavad momsaxurebis moculobis zrdisa, windawin dadgenili biujetis saSualebiT TiTo eqimze gamoyofili Tanxa TiTqmis ar Secvlila. igi ganpirobebuli iyo TiToeul pacientze qulaTa raodenobis zvaris dawesebiT.

12

cxrili: saxelmwifo samedicino dazRvevis sistemaSi ambulatorul-poliklinikuri seqtoris muSaobis maCveneblebi, eqimTa raodenobis, momsaxurebis moculobis da anazRaurebis cvlilebebi 1980-2001 wlebSi xelfasi, TiTo TiTo saxelmwifo saerTo TiTo eqimze samedicino dazRveulze mkurnalobis mkurnalobis Tanxa dazRveul TiTo dazRvevaSi gaTvlili SemTxvevaTa mkurnalobis yvela ze wlebi SemTxvevaze raodenoba, momuSave saSualo SemTxvevaTa eqimze, xarjebi, xarjebi mln eqimTa xelfasi, ricxvi mlrd evro raodenoba (weliwadSi) evro evro 1980 a 55743 7,4 132932 252,1 29,4 4,6 209,8 1085 a 83056 9,6 152404 268,3 35,7 4,8 264,9 1990 a 71218 12,5 175237 320,8 38,9 5,5 329 a 1995 88165 16,7 189644 400,8 41,7 6,7 412,4 1996 b 107071 20,1 188100 508,8 39,6 7,1 396,3 1997 b 108734 20,5 188074 523,2 39 7,3 401,9 1998 b 110339 20,8 186788 532,2 38,7 7,5 406,7 1999 b 122604 21,7 176830 551,3 39,3 7,7 425,7 b 2000 128670 22,5 174866 558,1 40,3 7,8 440,7 2001 b 128333 23,2 180780 564,8 41,1 8 455,5 cvlilebe bi, % 1996+ 20 + 15 - 4 + 9 + 4 + 13 + 15 2001 ww. wyaro: Busse R, Reisberg A. Health Care System in Transition: Germany, Copenhagen, WHO. Regional Office on behalf of the European Observatory on Health Systems and Policies, 2004. SeniSvna: a ­ dasavleT germania, b ­ fsiqologebisa da fsiqoTerapevtebis CaTvliT (moicavs aRm. da dasavleT germanias) v ­ pacientis erTi an ramdenime kontaqti erT eqimTan kvartalSi. saSualo wliuri Semosavali meryeobs 64 aTasi evrodan (dermatologebi da qirurgebi) 96 aTas evromde (Terapevtebi). Tumca, miuxedavad saxelmwifo samedicino dazRvevis sistemaSi eqimTa anazRaurebis zomieri matebisa, kerZo praqtikis eqimis anazRaurebis matebis tempebi ufro maRalia. gansakuTrebiT gaizarda kerZo sadazRvevo kompaniaSi momuSave eqimTa xelfasebi. amgvarad, eqimebis Semosavali 3-5jer aRemateba muSebis saSualo xelfass da 2-3-jer - mosamsaxure personalis xelfass. cxrili: saxelmwifo samedicino dazRvevis sistemaSi dasaqmebul eqimTa*Axelfasi, xarjebi da Semosavali (ambulatoruli seqtori) 2001 w. Semosavali xarjebi (pirvel or eqimis personalze, specialoba maCveneblebs mowyobilobaze, xelfasi, evro Soris sxvaoba), evro evro dermatologebi 171100 106766 64334 otolaringologebi 192900 111882 81018 ginekologebi 190600 110357 80243 Terapevtebi 236900 140956 95944 nevropaTologebi da 151300 80643 70657 fsiqiatrebi ofTalmologebi 203300 120964 82336 orTopedebi 241700 148162 93538 pediatrebi 188100 102138 85962 radiologebi 421200 347068 74132 qirurgebi 194300 129987 64131 urologebi 204900 126014 78886 yvela specialistebi (sxva 205200 124556 80644 specialistebis CaTvliT)

13

zogadi praqtikis eqimebi 171700 94435 77265 (diplomianebi da mis gareSe) sul 192500 113190 79310 wyaro: Busse R, Reisberg A. Health Care System in Transition: Germany, Copenhagen, WHO. Regional Office on behalf of the European Observatory on Health Systems and Policies, 2004. SeniSvna: * ­ im eqimTa gamoklebiT, romlebic erToblivad muSaoben sxva specialobis eqimebTan. 2005 wlis aprilidan ZalaSi Sevida samedicino daxmarebis saxeebze dawesebuli tarifebis erTiani sqemis axali varianti, romelic iTvaliswinebs zogadi praqtikis eqimebisa da specialistebis momsaxurebas Soris mkveTri zRvaris gavlebas (22). siaxle mdgomareobs imaSi, rom momsaxurebis anazRaureba iTvaliswinebs masze daxarjul dros (dasabuTebuli momsaxurebis ufro meti kontrolis mizniT). 2003 wlis dekemberSi specialuri komisiis mier dadgenili momsaxurebis samedicino nawilis drois Rirebuleba (wuTze 0,77 evro) mravldeba samedicino daxmarebis gasawevad saWiro droze. mas emateba momsaxurebis teqnikur mxareze dawesebuli Rirebuleba (evro/wuTSi). meore sidide kapitaldabandebebis amortizaciis saSualebas iZleva, garda amisa, igi teqnikurad ufro rTuli momsaxurebis Catarebis Zlier stimuls iZleva (22). samedicino daxmarebis tarifi yovelwliurad icvleba. ase magaliTad, ukanasknel wlebSi laboratoriuli gamokvlevebis raodenobis matebis gamo, ramdenjerme Semcirebul iqna misi tarifi. germaniaSi 80-iani wlebis dasawyisSi eqims pacientTan binaze vizitisaTvis SedarebiT mcire anazRaureba eZleoda, ris gamoc igi naklebad iyo dainteresebuli misi SesrulebiT. amis gaTvaliswinebiT mniSvnelovnad iqna momatebuli eqimis pacientTan binaze vizitis fasi. tarifis gadasinjvas axorcielebs specialuri komisia, romelSic Sedian eqimTa asociaciebisa da sadazRvevo organizaciebis warmomadgenlebi (21). saxelmwifo samedicino dazRvevis sistemis modernizaciis kanonis mixedviT, 2007 wlidan eqimTa asociaciebi sadazRvevo salaroebTan dadeben xelSekrulebas momsaxurebis moculobis mixedviT, romelSic gaTvaliswinebuli iqneba daavadebianobis maCvenebeli (21). ase rom, rac ufro meti iqneba daavadebianobis maCvenebeli, miT meti iqneba asanazRaurebeli Tanxa, rac Sesabamisad gazrdis sxvadasxva specialobis eqimTa Semosavals. xarjebis zrdis Sekavebis mizniT kanadaSi samedicino momsaxurebis 7000 saxeze garkveuli tarifia dadgenili. safrangeTSi 1991 wlidan ganxorcielda samedicino daxmarebis garkveuli saxeebis erT msxvil jgufSi gaerTianeba, romelzedac erTiani tarifi dawesda. xarjebis zrdis Sekavebis erT-erT gzas warmoadgens agreTve e. w. "konusisebri" anazRaurebis meTodis SemoReba, romelic gavrcelebulia kanadaSi. igi gulisxmobs samedicino personalis anazRaurebis zeda zRvaris dadgenas, romlis gadaWarbebis SemTxvevaSi Sesrulebuli samuSaos mixedviT anazRaureba mcirdeba. germaniis magaliTze Cven ganvixileT, Tu rogor SeiZleba xarjebis Sekaveba ganxorcieldes makrodoneze saerTo regionuli biujetis dawesebiT, magram mniSvnelovania, xarixsis TvalsazrisiT Tu ra Sedegebi mohyveba aseTi regulirebas makrodoneze. xarjebis Sekaveba SesaZlebelia arasamarTliani da araefeqturi aRmoCndes makrodoneze. am TvalsazrisiT, germaniaSi awarmoeben analizs mikrodoneze, eqimis muSaobis racionalurobis SefasebisaTvis. eqimis muSaobis racionalurobis Sesafaseblad gamoiyeneben Semdeg monacemebs: gaweuli momsaxurebis moculoba, ZviradRirebuli medikamentebis gamowera, sadiagnostiko RonisZiebaTa, specialistebTan gagzavnis SemTxvevaTa da hospitalizebul pacientTa raodenoba. aRniSnuli monacemebis analiziT fasdeba eqimis mier Sesrulebuli samuSao. Sefasebis Sedegebi miewodeba eqims, sadac aRniSnulia misi muSaobis SesaZlebeli koreqciisaTvis saWiro rekomendaciebi. informacia konfidencialur xasiaTs atarebs da gankuTvnilia ara misi dasjisaTvis, aramed eqimis saorientaciod. ukidures SemTxvevaSi SesaZlebelia masTan dadebuli xelSekrulebis gawyveta. germaniaSi saavadmyofoebis salaroebi yovelwliurad aanalizeben da aqveyneben monacemebs eqimTa mier Sesrulebuli samuSaoebis Sesaxeb. es monacemebi mTlianobaSi warmoadgenen im saorientacio maCveneblebs, romliTac sargeblobs rogorc eqimi,

14

aseve damfinansebeli mxare, romelsac am monacemebze dayrdnobiT SeuZlia aiZulos eqimi ganaxorcielos Sesabamisi koreqtivebi Tavis muSaobaSi. mkurnalobis (dispanserizaciis) dasrulebuli SemTxvevebis anazRaureba, romlebic windawin arian klasificirebuli zogierTi niSnis mixedviT (SemTxvevis simZime, saerTo xarjebi) cxrili: mkurnalobis dasrulebuli SemTxvevebis anazRaureba, romlebic windawin arian klasificirebuli zogierTi niSnis mixedviT, dadebiTi da uaryofiTi mxareebi dadebiTi mxareebi uaryofiTi mxareebi eqims ar aqvs pacientis janmrTelobis gaumjobesebis ekonomikuri stimuli, prevenciul RonisZiebebze naklebi yuradReba. garkveuli zomiT mcirdeba ambulatoruli momsaxurebis saerTo xarjebi SeiZleba warmoiqmnas dausabuTebeli ekonomiis mcdeloba detaluri momsaxurebis (gamokvlevebi, analizebi) gawevisas eqimebi dainteresebuli arian Seamciron Znelia windawin ganWvrito dafinansebis mkurnalobis vadebi moculoba eqimebi ar arian dainteresebuli efeqturad gamoiyenon finansuri resursebi mcirdeba dasamuSavebeli angariSebis moculoba ar aris ekonomikuri kavSiri samedicino momsaxurebis sxva etapebTan adgili aqvs SemTxvevis damZimebas aRniSnuli meTodi gamoiyeneba samedicino momsaxurebis mimwodeblebs Soris konkurenciis arsebobisas, magram mizanSewonilia sadazRvevo organizaciebis mxridan qmediTi kontroli, rTuli da araxelsayreli SemTxvevebis momsaxurebis ZviradRirebul etapebze gadamisamarTebis aRmosafxvrelad. SeiZleba gamoyenebul iqnes dawesebulebis SigniT eqim-specialistebis momsaxurebis dasafinanseblad, agreTve specializebuli ambulatoruli dawesebulebebis momsaxurebis dasafinanseblad (saswrafo samedicino momsaxureba, qalTa konsultaciebi, stomatologiuri poliklinikebi, kabinetebi).

miznobrivi anazRaureba

Sesrulebuli samuSaos mixedviT anazRaurebis erT-erT saxes warmoadgens miznobrivi dafinansebis (Target payment) meTodi. igi gamoiyeneba samedicino daxmarebis garkveuli, specifikuri saxeebis (mag., imunizacia, profilaqtikuri Semowmebis Catareba da a. S.) dasafinanseblad. miznobrivi dafinansebis meTodi warmoadgens zogadi praqtikis eqimis dafinansebis damatebiT meTods. miznobrivi dafinansebis meTodi umTavresad gamoiyeneba didi moculobis samedicino momsaxurebis (mag., profilaqtikuri acrebis) Catarebisas. eqims stimuli eZleva rac SeiZleba met pacients Cautaros profilaqtikuri acrebi, radgan miznobrivi dafinansebis SemTxvevaSi ufro met anazRaurebas miiRebs. miznobrivi meTodiT anazRaureba SeiZleba gamoyenebul iqnes zogierTi daavadebis skriningisaTvis (mag., saSvilosnos yelis an mkerdis jirkvlis kibo). did britaneTSi miznobrivi anazRaurebis meTodis SemoRebam mniSvnelovnad gaaumjobesa profilaqtikuri programebis ganxorcieleba. infeqciuri daavadebebis saprofilaqtikod miznobriv anazRaureba gamoiyeneboda mosaxleobis 95 %-is vaqcinaciis Catarebisas.

15

fiqsirebuli xelfasiT anazRaurebis meTodi

fiqsirebuli xelfasiT anazRaureba warmoadgens samedicino personalis saerTo da ara konkretuli samuSaoebis SesrulebisaTvis fiqsirebul dafinansebas drois SeTanxmebuli periodis ganmavlobaSi. fiqsirebuli anazRaurebisas eqimis Semosavali damokidebuli ar aris gaweuli samedicino daxmarebis moculobaze. xelfasis zomas adgens damfinansebeli mxare, zog qveynebSi igi SeTanxmebulia profkavSirebTan, eqimTa asociaciebTan. xelfasis zoma SeiZleba damokidebuli iyos personalis asakze, specialobasa da gamocdilebaze, an ar iTvaliswinebdes aRniSnul kriteriumebs (saerToerovnuli Tanrigobrivi xelfasi). samedicino personalTan xelSekruleba ideba sruli an arasruli droiT. arasruli droiT dadebuli xelSekruleba eqims saSualebas aZlevs damatebiT sxva samuSaoebi Caataros (mag., kerZo konsultaciebi). xelSekruleba SeiZleba ganaxldes personalis mier Sesrulebuli samuSaos mravalmxrivi Sefasebis safuZvelze. xelSekrulebaSi zogjer iTvaliswineben personalis damatebiTi anazRaurebis saxiT waxalisebas (magaliTad, vaqcinaciis maRali mocvis miRwevisas). SesaZlebelia personalis stimulireba damatebiTi Svebulebisa da satransporto SeRavaTebis saxiT, an damatebiTi waxaliseba iseTi samuSaoebis CatarebisaTvis, rogoricaa: samecnierokvleviTi muSaoba, samecniero konferenciebze monawileoba sazRvargareT. fiqsirebuli xelfasiT anazRaurebis meTodi farTod gamoiyeneba mravali qveynis rogorc saavadmyofos, aseve ambulatorul dawesebulebebSi samedicino personalis Sromis asanazRaureblad (fineTi, Svecia, portugalia, saberZneTi, espaneTi, TurqeTi, israeli, aRmosavleT evropisa da yofili sabWoTa kavSiris qveynebi). yofili sabWoTa kavSiris qveynebSi sxvadasxva specialobis samedicino personalis Semosavlebs Soris mcire gansxvaveba aRiniSneboda, rac materialuri mdgomareobis gaumjobesebis nakleb SesaZleblobas iZleoda. amasTan, sabWoTa sistema farTod iyenebda zogierTi saxis wamaxalisebel saSualebebs: medlebi, biniT uzrunvelyofa, saswavlo turebi sazRvargareT. sabWoTa kavSiris daSlis Semdeg aseTi wamaxalisebeli saSualebebi gauqmda da mcire xelfasis sakompensaciod eqimebi ewevian araoficialur, kerZo praqtikas. aRmosavleT evropisa da yofili sabWoTa kavSiris qveynebSi, sadac moqmedebs Sromis anazRaurebis arsebuli wesi, arc kanonmdebloba da arc mosaxleobis TviTSegneba ar iZleva saTanado kontrolis dawesebis saSualebas. aRniSnuli mdgomareoba xels uwyobs samedicino personalis mier aralegaluri Semosavlebis miRebas. eqspertTa SefasebiT, im qveynebSi, sadac samedicino personalis xelfasi dabalia, aralegaluri anazRaureba gacilebiT aRemateba kanoniT dadgenil anazRaurebas. arsebuli situacia gamoxatul gavlenas axdens socialurad daucveli mosaxleobisadmi samedicino daxmarebis xelmisawvdomobis principis ganxorcielebaze. aRniSnulis gamo, mniSvneloba eniWeba personalis anazRaurebis dones. Tu eqims SeuZlia aralegaluri Semosavlebis xarjze gaaormagos xelSekrulebiT gansazRvruli xelfasi, maSin garkveuli miznis misaRwevad (mag., vaqcinaciis maRali mocvis miRweva) gamoyofili mcire oficialuri damatebiTi anazRaureba misTvis aRar iqneba mimzidveli. ase magaliTad, britaneTis jandacvis sistemaSi mimdinare reformebis periodSi, eqimebisaTvis zogadi praqtikis eqimi-fondis mesakuTred gaxdomis yvelaze damajerebel motivs warmoadgenda ara suladobrivi dafinanseba, aramed damatebiTi waxalisebis mniSvnelovnad gazrda. aRsaniSnavia, rom did britaneTSi, personalis muSaobis stimulirebis mizniT, iyeneben damatebiT wamaxalisebel anazRaurebas, romelic meryeobs 790 funti sterlingidan 20 550 funt sterlingamde weliwadSi. fiqsirebuli anazRaurebis meTodis efeqturobis gazrdis TvalsazrisiT, zogierT qveynebSi SemoRebulia dafinansebis ramdenime meTodis kombinacia. magaliTad, norvegiaSi eqimis Semosavlebis 35 %-s fiqsirebuli xelfasi Seadgens, xolo danarCeni 65 %-is anazRaureba Sesrulebuli samuSaos mixedviT xorcieldeba. dadebiTi mxareebi: · jandacvis sistemis advili dagegmareba da stabiluroba, radganac samedicino daxmarebis xarjebi winaswar gansazRvrulia;

16

· fiqsirebuli xelfasiT anazRaurebis gamo, eqimi ar aris dainteresebuli araaucilebeli samedicino daxmarebis ganxorcielebiT; · dabalia administraciuli da saqmis warmoebisaTvis saWiro xarjebi; · advilia samedicino dawesebulebis safinanso muSaobis monitoringi; · xels uwyobs personalis gadanawilebas centrisagan moSorebul regionebSi, raionebSi, an soflebSi; · izrdeba samedicino daxmarebis xelmisawvdomoba. uaryofiTi mxareebi: · eqimebs Soris konkurenciis dabali done; · dabalia samedicino daxmarebis xarisxi, radgan eqimis anazRaureba mciredaa damokidebuli mis kvalificiurobaze; · eqimi naklebadaa dainteresebuli imuSaos maqsimaluri datvirTviT. igi Tavidan iSorebs mZime avadmyofebs da saavadmyofoSi an sxva ganyofilebebSi agzavnis samkurnalod, rac mniSvnelovnad aZvirebs samedicino daxmarebis Rirebulebas; · meTodi stimuls aZlevs samedicino dawesebulebas biurokratiuli aparatis zrdas, formalizms, mouqnelobas da amiT aiZulebs damfinansebels gazardos sabiujeto xarjebi; · Tu anazRaurebis zoma dabalia, xels uwyobs samedicino personalis mier aralegaluri Semosavlebis miRebas.

ambulatorul-poliklinikuri daxmarebis dafinansebis meTodebi dasavleT evropis qveynebSi

qvemoT moyvanil cxrilSi naCvenebia dasavleT evropis qveynebSi gamoyenebuli ambulatorul-poliklinikuri samedicino daxmarebis dafinansebis meTodebi. mocemulia agreTve anazRaurebis meTodsa da sxva mniSvnelovan faqtorebs (eqimTan mimarTvianoba wlis ganmavlobaSi erT sul mosaxleze gaTvliT, TanagadaxdaSi monawileoba, Tu vin sazRvravs specialistTan gagzavnas) Soris damokidebuleba. im qveynebSi, sadac eqimi daqiravebulia dawesebulebis mier ZiriTadad gamoiyeneba fiqsirebuli xelfasiT anazRaurebis meTodi. im qveynebSi, sadac sadazRvevo sistemaa ganviTarebuli da eqimi xelSekrulebis safuZvelze muSaobs, ZiriTadad Sesrulebuli samuSaos mixedviT anazRaurebis meTodi gamoiyeneba (15. gv. 236). im qveynebSi sadac jandacvis saxelmwifo sistemaa ganviTarebuli, romelSic eqimebi daqiravebulia saxelmwifos mier, gamoiyeneba fiqsirebuli xelfasiT anazRaurebis meTodi. magram, am SemTxvevaSi, gamonaklis warmoadgens zogierTi qveyana (dania, italia, didi britaneTi), sadac pirvelad jandacvaSi momuSave eqimebis anazRaureba damokidebulia mis meTvalyureobis qveS myofi mosaxleobis saerTo raodenobaze, an maT asanazRaureblad gamoiyeneba Sereuli meTodi - fiqsirebuli xelfasi, mis meTvalyureobis qveS myofi mosaxleobis saerTo raodenoba da TiToeul SemTxvevaze Sesrulebuli samuSaos mixedviT anazRaurebis meTodi (15. gv. 236). cxrili: eqimTa anazRaureba dasavleT evropis qveynebSi qveyana fiqsirebuli kapitacia Sesr. sam. mixedviT kombinacia xelfasi jandacvis erovnuli servisis modeli/saSemosavlo gadasaxadebis jandacvis sistemebi dania X (kapitacia FFS) inglisi X (saavadmyofo) X (sazogadoebrivi) X (kerZo) fineTi X irlandia X (saavadmyofos X (sazogadoebrivi X (kerZo konsultantebi pacientebisaTvis) pacientebisaTvis) sazogadoebrivi praqtikisaTvis) norvegia X Svecia X X (kerZo) (sazogadoebrivi)

+

17

italia portugalia espaneTi

X X X (fiqs. xelfasi + kapitacia)

socialuri samedicino dazRvevis jandacvis sistemebi avstria X (fiqs + FFS) belgia X (kerZo) safrangeTi X germania X wyaro: J. Figueras, R. Robinson, E. Jakubowski Purchasing to improve health systems performance, World Health Organization Regional Office for Europe, 2006 aRsaniSnavia, rom im qveynebSi, sadac gabatonebulia Sesrulebuli samuSaos mixedviT anazRaurebis meTodi, ZiriTadad ar gamoiyeneba anazRaurebis kombinirebuli meTodi. im qveynebSi ki, sadac eqimebis anazRaureba damokidebulia mis meTvalyureobis qveS myofi mosaxleobis saerTo raodenobaze, maT aerTianeben pacientis ekonomikuri mdgomareobis mixedviT (irlandia da niderlandebi), an momsaxurebis xasiaTis mixedviT (15. gv. 236). magaliTad, daniaSi da did britaneTSi zogadi praqtikis eqimebis anazRaureba momsaxurebis garkveul saxeebze xorcieldeba Sesrulebuli samuSaos mixedviT. aseT SemTxvevaSi koordinatoris funqcia dakavSirebulia an suladobrivi anazRaurebis sistemasTan, an fiqsirebuli xelfasiT anazRaurebis sistemasTan da arasodes Sesrulebuli samuSaos mixedviT anazRaurebis sistemasTan (15. gv. 236). aqve aRsaniSnavia, rom aseT qveynebSi ar aris gavrcelebuli Tanagadaxdis principi, da Tu igi gamoiyeneba, mxolod umniSvnelo zomiT. sapirispiro mdgomareobasTan gvaqvs saqme im SemTxvevaSi, rodesac Sesrulebuli samuSaos mixedviT anazRaurebis meTodia gabatonebuli. am dros, momsaxurebis Warbad gamoyenebis Tavidan asacileblad farTodaa gavrcelebuli pacientis mier Tanagadaxda. franguli termini ­ ticket moderateur, romelic niSnavs xarjebis garkveuli wilis pacientis mxridan gadaxdas, naTlad migviTiTebs pacientis pasuxismgeblobaze samedicino momsaxurebis xarjebSi. aqve aRsaniSnavia, rom safrangeTSi da agreTve zog qveynebSi pacientis pirdapir xarjebs mTlianad faravs kerZo sadazRvevo kompaniebi, rac cxadia, uaryofiT gavlenas axdens momsaxurebis Warbad gamoyenebis Tavidan asacileblad mimarTul RonisZiebebze (15. gv. 236). ufro metic, Tanagadaxdis principi, zog SemTxvevaSi, momsaxurebis moTxovnis arasrulyofil regulatorad gvevlineba (15. gv. 236). cxrili: dasavleT evropis qveynebSi gamoyenebuli ambulatorul-poliklinikuri samedicino daxmarebis dafinansebis meTodebi eqimTan specialistTan pacientis vizitebis qveyana dafinansebis meTodi gagzavnas Tanagadaxdis saSualo gansazRvravs: principi ricxvi xelSekrulebiT momuSave eqimi mosaxleobis 20 % Sesrulebuli samuSaos ixdis calkeuli avstria 5.11 TviTon pacienti mixedviT daxmarebis 10 an 20 %-s Sesrulebuli samuSaos TviTdasaqmebulebi belgia 81 TviTon pacienti mixedviT ixdian srulad 28 % suladobrivi, 63 % zogadi 4.42 ara dania Sesr. samuSaos mixedviT, praqtikis eqimi 9 % subsidia Sesrulebuli samuSaos 6.31 TviTon pacienti safrangeTi 25 % mixedviT Sesrulebuli samuSaos 12.83 TviTon pacienti germania ara mixedviT

18

Sesrulebuli samuSaos mixedviT maRali Semosavlis SemTxvevaSi; dabalSemosavliani zogadi dabali Semosavlis irlandia 6.64 pacientebi ar SemTxvevaSi praqtikis eqimi ixdian suladobrivi (asakis mixedviT diferencirebuli) suladobrivi meTodi zogadi italia (asakis mixedviT 113 ara praqtikis eqimi diferencirebuli) Sesrulebuli samuSaos luqsemburgi TviTon pacienti 5 % mixedviT Sesrulebuli samuSaos mixedviT maRali Semosavlis SemTxvevaSi; dabalSemosavliani zogadi dabali Semosavlis holandia 5.85 pacientebi ar SemTxvevaSi praqtikis eqimi ixdian suladobrivi (asakis mixedviT diferencirebuli) Sesrulebuli samuSaos Sveicaria 115 TviTon pacienti 10 % mixedviT suladobrivi meTodi (asakis mixedviT didi diferencirebuli); Sesr. zogadi 5.83 ara britaneTi samuSaos mixedviT, praqtikis eqimi subsidiebi, miznobrivi anazRaureba eqimi rogorc daqiravebuli personali TiTo vizitze 0,17 zogadi fineTi fiqsirebuli xelfasi 3.32 praqtikis eqimi $ saberZneTi fiqsirebuli xelfasi 5.36 TviTon pacienti Aara 35 % fiqsirebuli zogadi TiToeul punqtze norvegia xelfasi, 65 % Sesr. praqtikis eqimi 30 % samuSaos mixedviT zogadi portugalia fiqsirebuli xelfasi 3.11 ara praqtikis eqimi fiqsirebuli xelfasi, zogadi suladobrivi meTodi espaneTi 6.27 ara (asakis mixedviT praqtikis eqimi diferencirebuli) Svecia fiqsirebuli xelfasi 31 TviTon pacienti TiTo vizitze 6-9 $ 1 2 3 4 5 6 7 1993; 1991; 1992; 1998; 1994; 1982; 1989. wyaro: OECD. The reform of health care systems: Review of seventeen OECD countries. Health studies N 5 1994. Paris 1994. Abel-Smith B., et al., Choices in health policy. An agenda for the European Union, 1995. sainteresoa aRmosavleT germaniis poliklinikur dawesebulebaTa damoukidebel saeqimo praqtikis erTeulebad gardaqmnis gamocdilebis Seswavla. germaniis gareTianebis Semdeg aRmosavleT regionebSi amoqmedda federaciuli germaniis kanonebi. samedicino dazRvevis Sesaxeb kanonmdeblobis mixedviT ambulatoruli daxmarebis ZiriTad formas kerZo saeqimo praqtika warmoadgenda. 1991 wlis dasawyisSi mwvave debatebis Semdeg poliklinikuri qselis damoukidebel saeqimo praqtikad gardaqmnis saxelmwifo programa gamocxadda. axali modelis ganviTarebisaTvis ganzraxul iqna Semdegi xelSemwyobi RonisZiebebis ganxorcieleba: § kreditis gamoyofa; § kerZo praqtikis momsaxurebaze maRali tarifebis daweseba; § sagadasaxado SeRavaTebi;

19

§ eqimTa gaerTianebebis mxridan sakonsultacio daxmareba; § yofili poliklinikebis administraciasTan konfliqtSi kerZo praqtikis pretendentTa xelSewyoba adgilobivi xelisuflebis mxridan kerZo praqtikis gaxsnis eqimebisaTvis gamoyofil iqna 18 wlamde sabanko kreditebi adgilobrivi xelisuflebis garantiiT. kreditebi gaicemoda SeRavaTiani pirobebiT ­ 8,5% vadis pirvel naxevarze, da uprocento ­ meore naxevarze. kreditis gacemis mTavar kriteriums warmoadgenda eqimis asaki. umravles SemTxvevaSi krediti mxolod 42 wlamde eqimebze gaicemoda, Tumca asakobrivi SezRudva gansxvavdeboda specialobebis mixedviT (ufro deficituri specialobebis SemTxvevaSi adgili hqonda ufro dabal asakobriv cenzs). kreditebis moculoba damokidebuli iyo specialobebze. magaliTad, orTopediaSi, romelic samedicino mowyobilobebis ufro met aRWurvilobas moiTxovs, Sesabamisad meti Tanxebi iyo gansazRvruli. kreditis gacemisas eqimebs SesTavazes ori varianti: ijariT aeRoT samuSao farTi an miRebuli kreditis meSveobiT gamoesyidaT. germaniis gaerTianebis Semdeg poliklinikebis ZiriTadi nawili adgilobrivi xelisuflebis sakuTrebaSi darCa. kanonmdeblobiT dafiqsirda poliklinikebis farTis miRebaze eqimTaTvis prioritetis miniWebis principi. damoukidebeli praqtikebis umravlesoba poliklinikebis SenobebSi ganTavsdnen. maT Soris zogierTma ijariT aiRo samuSao farTi an kreditebis saSualebiT gamoisyida Tavisi yofili kabinetebi, zogierTma ki - sxva poliklinikebSi SearCies adgilebi. aRsaniSnavia, rom kreditebi ijaris gadaxdis SesaZleblobas iZleoda. garda amisa, eqimebs saijaro gadasaxadebze garkveuli SeRavaTebi dauwesdaT, xolo ijarasTan dakavSirebuli xarjebi Cadebul iqna momsaxurebis tarifebis SemadgenlobaSi. eqimTa umravlesobam upiratesoba arendas mianiWes, Tumca zogierTebi jgufebad gaerTiandnen (6-dan 10 kacamde), riTac SeZles gamoesyidaT samuSao farTi da gamxdariyvnen sruluflebiani mesakuTreebi. kreditebi gaicemoda samuSao farTis kapitalur remontze da axali samedicino teqnikis SeZenazec. saeqimo praqtikis SemoRebis programis Sesabamisad, eqim-mewarmeebs saxelmwifom sagadasaxado SeRavaTebi dauwesa, rac gulisxmobda gadasaxadebis gadaxdis 5 wlamde gadavadebis uflebas. kerZo praqtikebis anazRaureba Sesrulebuli samuSaos meTodiT xorcieldeba. kanoniT nebadarTulia poliklinikebis funqcionireba. Tumca umravles regionSi isini Zalian mcire raodenobas Seadgenen. mag., tiuringiaSi (2.33 mln mosaxleoba), mxolod 20 mcire poliklinika funqcionirebs, sadac sul 80 eqimi muSaobs (amave regionSi, SedarebisaTvis, 3500 kerZo praqtikis eqimia dasaqmebuli). maT "narCen poliklinikebs" uwodeben, radgan isini Zveli sistemis naSTebs warmoadgenen. aseT poliklinikebSi eqimTa anazRaureba fiqsirebuli xelfasiT xorcieldeba. maT umravlesobas ZiriTadad is eqimebi warmoadgenen, vinc ver SeZlo kerZo praqtikis miRebis ufleba. Sesabamisad maTi zogadi kvalifikaciis done mniSvnelovnad dabalia. aqve aRsaniSnavia, rom eqimebi valdebulni arian Seasrulon pacientTa miRebis dadgenili normebi, romelTa Seusruleblobis SemTxvevaSi, eqims Tavisi saganakveTo xelfasis meoTxedis an sulac naxevris dakargva emuqreba. axali modelis naklovanebebi § kerZo praqtikis eqimebis Sesrulebuli samuSaos mixedviT anazRaurebis gamo, maTTvis ufro momgebiania iseTi samuSaos Sesruleba, romelic ufro meti Rierbulebisaa, kerZod maRalteqnologiuri momsaxurebis gaweva; § eqimebs gaaCniaT profilaqtikuri daxmarebis gawevis naklebi ekonomikuri stimuli, isini ar arian dainteresebulni, hyavdeT janmrTeli pacienti. § wina sistemisagan gansxvavebiT ambulatoruli rgoli srulebiT gancalkevda stacionarisagan. amitom am or seqtors Soris koordinacia sustad aris gamoxatuli. Sedegad, dabalia samedicino daxmarebis struqturis optimizacia. samedicino daxmarebis bevri saxeebi stacionarSia warmodgenili; § miuxedavad eqimTa jgufebad gaerTianebisa, klinikuri sakiTxebis gadawyvetisas, an damxmare personalis Tu samedicino teqnikis gamoyenebis TvalsazrisiT, kooperireba ar aris sakmarisad Zlieri, rac amcirebs resursebis gamoyenebis efeqturobas. § reformis radikalzmma gamoiwvia eqimTa da sxva samedicino personalis umuSevrobis zrda.

20

§ poliklinikebi naklebad sicocxlisunariani aRmoCndnen. maTi umravlesoba an saerTod ar moqmedebs an umZimes pirobebSi fumqcionirebs. faqtiurad, ganxorcielda poliklinikis institutis dangreva.

modelis dadebiTi mxareebi § administraciul-mmarTvelobiTi personalis Semcireba. reformis Sedegad ganxorcielda adamianuri resursebis optimizacia, ufunqciod darCenili xelmZRvaneli pirebis, finansistebis, saregistracio samsaxuris personalis Semcirebis TvalsazrisiT. § muSaobis moculobis gazrdiT daintereseba. mkveTrad gaizarda ufro meti moculobiT da intensiurad muSaobis daintereseba. eqimebis muSaobis miaxloebiTi grafiki Semdegnairi gaxda: 8:00-dan 18:00-mde kviraSi xuTi dRe, yoveldRiuri viziti pacientTan binaze (xSirad muSaoba SabaT-kviris ganmavlobaSic xdeba). gansakuTrebiT maRalia zogadi praqtikis eqimTa datvirTva, isini diliT miRebas awarmoeben, saRamos ki - binaze vizitebs. aseTi eqimi dRis ganmavlobaSi saSualod 35 pacients naxulobs, maT Soris 7-s - binaze. yvela kategoriis eqimTa saSualo samuSao kvira xSirad 50 saaTs aWarbebs. § zogadi praqtikis eqimTa daintereseba gazardon Tavisi funqciebi. eqimebi cdiloben itvirTon yel-yur-cxviris, nevropaTologis, zogjer qirurgis da pediatris movaleobebi. § eqimis damoukidebeli statusi. eqimebi axali sistemis erT-erT dadebiT Tvisebad administraciisagan damoukideblobas, agreTve, TavianTi droisa da resursebis gankargvaSi Tavisuflebas aRniSnaven. § pacientis interesTa mimarT yuradReba. Semosavali damokidebulia gaweuli saSuSaos raodenobaze, ris gamoc eqimebi cdiloben pacientTa moTxovnilebis dakmayofilebas. § susti specialistebis gacxrilva. zogierTma eqimma reformis periodSi ver SeZlo kerZo praqtikis miRebis uflebis mopoveba, amitomac isini iZulebulni gaxdnen gasuliyvnen pensiaze an saerTod SeecvalaT samsaxuri. dasavleT germaniis modelis saqarTveloSi gasaTvaliswinebeli dadebiTi mxareebi ra SeiZleba gamoyenebul iqnas saeqimo praqtikis Seqmnaze aRebuli kursis realizaciaSi yofili gdr-is magaliTidan:

· gasaTvaliswinebelia im eqimze SeRavaTiani grZelvadiani kreditebis gacemis magaliTi, visac gaaCnia Sesabamisi kvalifikacia da survili aqvs gamoeyos poliklinikas da gaxsnas sakuTari praqtika. kreditis pirobad savaldebulo samedicino dazRvevis teritoriuli programebis realizaciaSi eqimTa mkacri saxelSekrulebo valdebulebebi da aseve saeqimo praqtikaze da momsaxurebaTa gansazRvrul paketze licenziis miReba unda gaxdes. · mizanSewonilia kerZo praqtikis eqimTa sul cota xuTi wliT ganTavisufleba gadasaxadebisagan maTi savaldebulo samedicino dazRvevaSi monawileobisas; · finansuri politika unda iTvaliswinebdes zogadi saeqimo praqtikis upiratesi ganviTarebis xelSewyobas. kerZod, mizanSewonilia, rom suladobriv meTodTan erTad Sesrulebuli samuSaos meTodiT anazRaurebis principis gamoyeneba. · ambulatoruli rgolis efeqturobis gazrda. SromiTi resursebis restruqturizacia. zogadi praqtikis eqimebis wilis gazrda specialistebis wilTan SedarebiT. · eqimebisaTvis kerZo praqtikis gaxsnis uflebis xelSewyoba kanonmdeblobiTi safuZvlebis uzrunvelyofiT, romelic mxolod eqimis mier profesionaluri moTxovnilebebis dakmayofilebaze iqneba damokidebuli. · mosaxleobas unda mieces eqimis Tavisufali arCevis da naxevarweliwadSi erTxel misi gadarCevis ufleba. aRmosavleT germaniis gamocdilebis bevri aspeqti amtkicebs sabazro ekonomikis pirobebSi damoukidebel saeqimo praqtikaze gadasvlis upiratesobas poliklinikur sistemasTan SedarebiT. rac mTavaria, is SesaZleblobas gvaZlevs kritikuli TvaliT SevxedoT am reformis warmatebebsa da naklovanebebs da Cvens qveyanaSi mimdinare jandacvis seqtoris reformaSi gaviTvaliswinoT yoveli aseTi dadebiTi Tu

21

uaryofiTi gakveTili. germaniis magaliTma daadastura pirveladi jandacvis swrafi da efeqturi reformirebis SesaZlebloba da am procesSi kompleqsuri midgomisa da resursebis swori dagegmvisa da warmarTvis aucilebloba.

ambulatorul-poliklinikuri momsaxurebis dafinansebis meTodebi aRmosavleT evropisa da postsabWoTa qveynebSi

gasuli saukunis ukanasknel aTwleulSi mnivnelovani cvlilebebi ganxorcielda aRmosavleT evropisa da postsabWoTa qveynebSi. kerZod, personalis saxelmwifos mier daqiravebisa da fiqsirebuli xelfasiT anazRaurebis modeli Seicvala xelSekrulebiT urTierTobebze damyarebuli modeliT, sadac gamoiyeneba eqimis anazRaurebis sxvadasxva meTodebi (suladobrivi, fiqsirebuli xelfasiT, Sesrulebuli samuSaos mixedviT anazRaurebis meTodebi). cxrili: aRmosavleT evropis qveynebSi gamoyenebuli ambulatorul-poliklinikuri samedicino daxmarebis dafinansebis meTodebi qveyana anazRaurebis meTodi albaneTi suladobrivi bulgareTi globaluri biujeti da fiqsirebuli xelfasi CexeTi Sesrulebuli samuSaos mixedviT, gamiznulia suladobrivis danergva xorvatia Sesrulebuli samuSaos mixedviT, suladobrivi ungreTi suladobrivi makedonia suladobrivi globaluri biujeti da fiqsirebuli xelfasi, 1999 wlidan suladobrivi, poloneTi Sesrulebuli samuSaos mixedviT globaluri biujeti da fiqsirebuli xelfasi, 1999 wlidan suladobrivi, rumineTi Sesrulebuli samuSaos mixedviT slovakia Sesrulebuli samuSaos mixedviT, eqsperimentiT suladobrivTan erTad slovenia suladobrivi da Sesrulebuli samuSaos mixedviT estoneTi suladobrivi da Sesrulebuli samuSaos mixedviT somxeTi suladobrivi da Sesrulebuli samuSaos mixedviT ruseTi fiqsirebuli xelfasi wyaro: PHARE, Recent reforms (Annex); WHO, Health Care Systems in Tranzition, 2000. estoneTis jandacvis sistemaSi ganxorcielebuli reformebis Sedegad pirveladi jandacvis sistemis dasafinanseblad SemoRebul iqna Sesrulebuli samuSaos mixedviT anazRaurebis meTodi. Semosavlebis gazrdis mizniT mniSvnelovnad gaizarda momsaxurebis moculoba, ramac jandacvis xarjebis zrda ganapiroba. amis aRmosafxvrelad saavadmyofos salaroebma jandacvis yoveli centrisaTvis SeimuSaves limitebi, romelic ganisazRvreboda mosaxleobisa da eqimebis raodenobis, agreTve jandacvis TiToeuli centris mier ukanasknel wlebSi Sesrulebuli samuSaos moculobis mixedviT. anazRaurdeba ara calkeuli viziti, aramed TiToeuli SemTxveva. sakonsultacio vizitSi Sedis daavadebis aRwera, gamokvleva, diagnozi, mkurnalobis sawyisi etapi, receptis gamowera, janmrTelobis gaumjobesebisa da daavadebis profilaqtikisaTvis saWiro rekomendaciebi. samedicino dokumentaciis Sevseba, mkurnalobis martivi saxeebi (mag. ineqciebi), laboratoriuli gamokvlevebi. sxva saxis laboratoriuli gamokvlevebisa da nkurnalobis meTodebis saWiroebis SemTxvevaSi anazRaureba xorcieldeba winaswar dadgenili tarifebis Sesabamisad. reformebis Sedegad SemuSavebul iqna ojaxis eqimze dafuZnebuli pirveladi jandacvis sistemis modeli. ojaxis eqims samedicino sadazRvevo fondTan aqvs dadebuli xelSekruleba, ojaxis eqimi jandacvis sistemaSi mTavar meWiSkres Warmoadgens, specialistebTan konsultacia mxolod misi mimarTvis Semdegaa SesaZlebeli. Tumca, zog SemTxvevaSi (ofTalmologTan, dermato-venerologTan, ginekologTan, fsiqiatrTan, fTiziatrTan, stomatologTan da travmis dros qirurgTan vizitebi) igi ar atarebs savaldebulo xasiaTs. ojaxis eqimebma rom ar gaarTulon pacientis specialistebTan mimarTvianobis procesi, saavadmyofos salaro calke afinansebs specialistebTan vizitebs.

22

ministris mier gamocemuli dekretis Sesabamisad reforma daiwyo 1997 wels. igi Semdeg etapepad daigegma: · ojaxis eqimebis SerCeva · mosaxleobis registraciis ganxorcieleba ojaxis eqimebTan · dafinansebis axali meTodis danergva, romelic gulisxmobs ojaxis eqimebis mier samedicino sadazRvevo fondTan xelSekrulebas gaaformebas. dadginda erT eqimTan registraciisaTvis saWiro mosaxleobis raodenoba. igi Seadgenda 1500 ­ 2300 mosaxles erT eqimTan, gamonakliss warmoadgendnen Soreuli raionebi da mcire kunZulebi. 1997 wlis oqtomberSi ministris dekretiT damtkicda ojaxis eqimis mier Sesasrulebeli samuSaos moculoba (CamonaTvali) da dafinansebis wesi. gamoTvlil iqna, rom qveynis mastabiT pirveladi samedicino momsaxurebisaTvis sakmarisi iyo 808 ojaxis eqimi. 1998 wels 391 ojaxis eqimi da pediatri Seudga saqmianobas dafinansebis axali wesiT. 1999 wlisaTvis maT ricxvma 493-s miaRwia. Tavdapirvelad mosaxleobis registracia Senelebuli tempebiT mimdinareobda, 1997 wlis noembrisaTvis zogierT mxareSi mosaxleobis mocvam 80 %-s miaRwia. eqimTan registrirebuli pacientTa siebis analizisaTvis saavadmyofos salaroebSi dainerga sainformacio teqnologiebi. aRsaniSnavia, rom reforma yvelaze efeqturad da droulad soflad da samxareo centrebSi ganxorcielda. reformas yvelze ufro konservatiulad da kritikulad talini Sexvda, rac gasagebia, radgan talinSi bevri specialistia dasaqmebuli da SeiniSneba msxvili poliklinikebi didi raodenoba. ojaxis eqimis anazRaureba xorcieldeba Sereuli meTodiT, romelic moicavs dafinansebis Semdeg meTodebs: · yovelTviuri suladobrivi anazRaureba TiToeuli daregistrirebuli pirisaTvis, romelic faravs momsaxurebis umravles saxes; · Sesrulebeli samuSaos mixedviT anazraureba; · fiqsirebuli yovelTviuri dafinanseba infrastruqturis ganviTarebisaTvis (mowyobilobebi); · yovelTviuri danamatebi (ojaxis eqimis ganaTlebis donis amaRlebisaTvis saWiro xarjebi, geografiulad moSorebul raionebSi momuSave ojaxis eqimebisaTvis damatebiTi anazRaureba). 1998 wlamde suladobrivi anazRaurebis martivi forma iyo gavrcelebuli, anu igi erTnairi iyo mTeli qveynis masStabiT, 1998 wlidan SemoRebul iqna rTuli forma, romelic iTvaliswinebda dafinansebis diferencirebas asakobrivi jgufebis mixedviT (0-dan 2 wlamde; 2-70 wlamde; 70 wels zeviT). damatebiTi momsaxurebis anazRaureba xorcieldeba Sesrulebuli samuSaos mixedviT, romelic limitirebulia da Seadgens maqsimaluri suladobrivi anazRaurebis 18,4 %-s. ojaxis eqimebis kavSirisa da samedicino sadazRvevo fondebis SeTanxmebiT windawinaa dadgenili damatebiTi momsaxurebis CamonaTvali (preiskuranti). garda amisa eqimebs eZlevaT yovelTviuri danamati samedicino dawesebulebidan geografiulad moSorebul adgilebSi muSaobisaTvis, ganaTlebis donis amaRlebisaTvis, muSaobis warmoebisaTvis saWiro fiqsirebuli Tanxa. amgvarad, ojaxis eqimis anazRaureba damokidebulia aramarto masTan registrirebuli pacientebis raodenobaze, aramed Tu rogor muSaobs igi, radgan damatebiTi momsaxureba Sesrulebuli samuSaos mixedviT finansdeba. eqimebi dainteresebuli arian gaafarTovon diagnostikuri da samkurnalo momsaxurebis speqtri, uzrunvelyon samedicino daxmarebis uwyvetoba, xandazmuli asakis pirTa mkurnalobasTan dakavSirebuli xarjebis riski kompensirebulia suladobrivi dafinansebis rTuli formis dawesebiT, romelic diferencirebulia asakobrivi jgufebis mixedviT, waxalisebulia soflad muSaoba. specializebul ambulatorul momsaxurebas uweven poliklinikebi da samedicino centrebi, saavadmyofoebis ambulatoruli ganyofilebebi da damoukidebeli eqimispecialistebi. damoukidebel eqimi-specialistebs xelSekruleba aqvT gaformebuli samedicino sadazRvevo fondTan da anazRaurebas Rebuloben Sesrulebuli samuSaos mixedviT. xelfasis saerTo done limitirebulia xelSekrulebiT.

23

cxrili: ojaxis eqimebis yovelTviuri anazRaureba estoneTSi (1998-2003 ww) 19992001 2002 1998* dafinansebis meTodi 2000 EUR EUR $ EUR 1,0 yovelTviuri suladobrivi Aaradiferencirebuli anazRaureba TiToeuli 0-2 wl 1,28 1,33 1,53 daregistrirebuli 2-70 wl 1,02 1,06 1,22 pirisaTvis 70 wels zeviT 1,15 1,2 1,37 Sesrulebuli samuSaos 18,4 mixedviT (maqsimum 18 % 18 % 18 % % suladobrivi anazRaurebis % fiqsirebuli yovelTviuri Tanxa infrastruqturis 342,5 319,6 319,6 338,1 ganviTarebisaTvis (mowyobilobebi) samedicino dawesebulebidan 34,2 44,7 44,7 44,7 20-40 km-is moSorebiT samedicino dawesebulebidan 68,5 89,5 89,5 89,5 yovelTviuri danamatebi 40 km-ze meti moSorebiT ojaxis eqimis ganaTlebis donis amaRlebisaTvis 63,9 63,9 63,9 saWiro xarjebi wyaro: Eesti Haigekassa: Estonian Health Insurance Fund, Tallinn, Estonian Health Insurance Fund, 2004; *, 1992 ­ 1999 , , , 2004.

2003 EUR 1,76 1,35 1,57 18,4 %

338,1

44,7 89,5 63,9

24

stacionaruli samedicino momsaxurebis dafinansebis meTodebi stacionaruli samedicino daxmarebis dafinansebis meTodebis klasifikacia

stacionaruli samedicino momsaxureba yvelaze ZviradRirebul saxes warmoadgens, amitom stacionaris dafinansebis sistemam SesaZlebelia moaxdinos jandacvis xarjebis mkveTri zrda. aseTi mdgomareoba Seiqmna CexeTSi, sadac savaldebulo samedicino dazRvevis konkurentuli modelis SemoRebisas stacionaris dafinanseba xorcieldeboda pacientis faqtiurad gatarebuli sawol-dReebis mixedviT (retrospeqtuli anazRaureba) da faqtiurad Catarebuli gamokvlevebis, procedurebis da gamoyenebuli medikamentebis mixedviT (ambulatorul-poliklinikuri momsaxurebac finansdeboda Sesrulebuli samuSaos mixedviT). jandacvaze mimarTuli Tanxebis gaormagebis (savaldebulo samedicino dazRvevis Senatani Seadgenda Sromis anazRaurebis 13,5 %-s) miuxedavad sadazRvevo organizaciebi gakotrebis winaSe dadgnen, rasac mohyva samedicino personalis gaficvebi. amgvarad, araadeqvaturi dafinanseba ganapirobebs jandacvis dafinansebis da organizaciuli sistemis moSlas. ganviTarebuli qveynebi globaluri biujetiT dafinansebaze gadavidnen stacionarul samedicino momsaxurebaze mosaxleobis moTxovnis da misi Rirebulebis Rrma analizis Sedegad. aRniSnuli SesaZlebeli gaxda winaT gamoyenebuli stacionaruli samedicino momsaxurebis Sesrulebuli samuSaos mixedviT anazRaurebis meTodis Sedegad. saqarTveloSi, sadac reformamde saavadmyofoebi finansdeboda biujetur-muxlobrivi anazRaurebis meTodiT da ar iyvnen dainteresebuli pacientTa intensiuri mkurnalobiT, globaluri biujetiT dafinansebis meTodis gamoyenebam SesaZloa ganapirobos arsebuli disproporciis SenarCuneba. globaluri biujetis efeqturad gamoyenebisaTvis, aucilebelia stacionaruli samedicino momsaxurebaze dasabuTebuli moTxovnis codna profilebis, simZimis, intensiurobis mixedviT, agreTve misi Rirebulebisa da stacionarebis sarezervo SesaZleblobebis Sesaxeb informaciis qona. rezervebis gamovlenas xels uwyobs mkurnalobis dasrulebuli SemTxvevebis anazRaureba winaswar dadgenili tarifebis mixedviT (prospeqtuli anazRaureba): samedicino ekonomikuri standartebiT anazRaureba. aRniSnuli meTodi stacionaruli samedicino momsaxurebaze moTxovnis struqturis analizis Casatareblad saWiro informaciis Segrovebis saSualebas iZleva, romelic aucilebelia saavadmyofoebis restruqturizaciisaTvis. aqve aRsaniSnavia, rom Tu poliklinikebs ar miecemaT hospitalizaciis Sesakaveblad aucilebeli stimulebi, stacionaruli samedicino momsaxurebis dasafinanseblad prospeqtuli meTodis gamoyeneba stacionarul momsaxurebaze xarjebis gazrdas ganapirobebs, xolo finansuri saSualebebis deficitis pirobebSi ­ ambulatorul-poliklinikuri momsaxurebis mwiri saxiT dafinansebas. aseT pirobebSi stacionaruli momsaxureba finansdeba poliklinikebis sazianod. igive mdgomareoba aRiniSneba saqarTveloSi, sadac saavadmyofoebi gadavidnen mkurnalobis dasrulebuli SemTxvevebis anazRaurebis meTodze. stacionaruli samedicino momsaxurebis dasafinanseblad SeiZleba gamoyenebul iqnes iseTive meTodebi rac ambulatoruli samedicino daxmarebis dros. ase magaliTad, suladobrivi anazRaurebis meTodis gamoyenebisas saavadmyofos biujeti dgindeba garkveul teritoriul arealSi mcxovrebi mosaxleobis raodenobis mixedviT. Tumca aRniSnuli meTodis gamoyenebisas mniSvnelovan problemas warmoadgens geografiuli arealis gareT mcxovrebi mosaxleobisaTvis samedicino daxmarebis gaweva. stacionaruli samedicino daxmarebis dasafinanseblad umTavresad Sesrulebuli samusaos mixedviT dafinansebis meTodi gamoiyeneba. stacionaruli samedicino daxmarebis Sesrulebuli samuSaos meTodiT anazRaurebis sxvadasxva saxe arsebobs: · anazRaureba faqtiurad Catarebuli detaluri procedurebis mixedviT; · stacionarSi dayovnebis xangrZlivobis mixedviT anazRaureba; · samedicino ekonomikuri standartebis mixedviT anazRaureba; · anazRaureba SemTxvevis saSualo Rirebulebis gansazRvris mixedviT; · miznobrivi anazRaurebis meTodi.

25

cxrili: saavadmyofos anazRaurebis meTodebi dasavleT evropis qveynebSi qveyana muxlobrivi SemTxvevis globaluri kombinacia globaluri mixedviT biujeti biujetis DRG-iT/ SemTxvevis mixedviT dania X X inglisi X fineTi X irlandia X norvegia X Svecia X italia X portugalia X espaneTi X avstria X belgia X safrangeTi X germania X wyaro: J. Figueras, R. Robinson, E. Jakubowski Purchasing to improve health systems performance, World Health Organization Regional Office for Europe, 2006

cxrili: saavadmyofos anazRaurebis meTodebi aRm. evropis da qveyana muxlobrivi per - diemi SemTxvevis mixedviT albaneTi somxeTi X azerbaijani X bosnia da hercegovina bulgareTi X xorvatia X CexeTi X estoneTi X X saqarTvelo X ungreTi X yazaxeTi X X nawilobriv yirgizeTi X latvia X X litva X poloneTi X moldaveTi X rumineTi X ruseTi X X slovakeTi X slovenia X tajikeTi X TurqmeneTi X X TurqeTi X ukraina X uzbekeTi X Camoyalibebis procesSi wyaro: Langenbrunner et al; Dixon et al. (2004).

yofili ssrk qveynebSi globaluri biujeti X X X X X X X

X X Camoyalibebis procesSi ? Camoyalibebis procesSi Camoyalibebis procesSi

26

cxrili: Sesrulebuli samuSaos mixedviT anazRaurebis meTodis sxva meTodebTan Sedareba qveyana Tavisebureba wyaro a.S.S. sawolze dayovneba Semcirda 9 Rosko and DRG-is sistemis danergvisas %-iT, TiToeul mimarTvaze Broyles, 1987 xarjebi 14 %-iT Semcirda brazilia SemTxvevis mixedviT Semcirda hospitalizaciisa da Rodrigues, sawolze dayovnebis 1989 anazRaurebis Sedareba Per diemmaCvenebeliE Tan suladobrivi meTodis Sedareba a.S.S. hospitalizaciis da sawolze Robinson and Sesrulebuli samuSaos dayovnebis dabali done; mcire Steiner, 1998 mixedviT anazRaurebis gansxvaveba samedicino meTodTan daxmarebis xarisxis TvalsazrisiT fiqsirebuli xelfasis samxreT samedicino personalis didi Boomberg and meTodTan Sedareba afrika raodenoba, samedicino Price, 1990 daxmarebis maRali xarisxi suladobriv meTodTan Sedareba ruseTi didi xarjebi Barr and Frield. 1996 TiToeul pacientze gaTvlil CineTi TiToeul pacientze gaTvlili World Bank, saSualo xarjTan Sedareba saSualo xarjiTanazRaurebisas 1995 xarjebi mcirdeba wyaro: s. vitteri, t. enzori, m. ioveti, r. Tompsoni. jandacvis ekonomika. iorkis universiteti, jandacvis ekonomikis centri, 2000 w. gv. 221. cxrili: provaiderebis anazRaurebis meTodebi da provaiderebis qcevis stimulebi provaiderebis qcevis stimulebi meTodi prevencia servisebis xarjebis Sekaveba warmoeba/miwodeba muxlobrivi biujeti +/_ +++ Sesrulebuli samuSaos mixedviT +/+++ _ _ _ per diemi +/+++ _ _ _ +/++ ++ SemTxvevis mixedviT (DRG) globaluri biujeti ++ _ _ +++ kapitaciuri +++ _ _ +++ wyaro: WHO (2000); Jegers et al. (2002).

27

anazRaureba konkretul pacientze faqtiurad Catarebuli detaluri procedurebis mixedviT samedicino dawesebulebis anazRaureba xdeba TiToeuli proceduris fasis gansazRvris safuZvelze. gasaTvaliswinebelia, rom anazRaurebis aseTi formiT moqmedebis SemTxvevaSi samedicino dawesebuleba dainteresebulia meti gamokvlevebi da samkurnalo RonisZiebebi Cautaros pacients, rac Tavis mxriv, ganapirobebs, rogorc mkurnalobisa da diagnostikis fasis zrdas, aseve araiSviaTad, naklebad saWiro, magram ZviradRirebuli procedurebis Catarebas. samedicino momsaxurebis TiToeul saxeze (gamokvlevebi, manipulaciebi, operaciebi) centralizebulad dgindeba tarifebi. medikamentebi, kveba, sastumros xarjebi (ukanaskneli ori komponenti Cveulebriv winanswar dadgenili fasiT anazRaurdeba) damatebiT anazRaurdeba.

dadebiTi mxareebi: · samedicino personali dainteresebulia TiToeul pacients Cautaros samedicino momsaxurebis maqsimaluri raodenoba; · SesaZleblobas iZleva Segrovdes gaweuli samedicino momsaxurebis struqturis detaluri monacemebi; uaryofiTi mxareebi: · xarjebis moculoba araprognozirebadia; · pacientebs SesaZloa CautardeT arasaWiro samedicino momsaxureba; · samedicino personali finansuri saSualebebis efeqturi gamoyenebiT ar aris dainteresebuli; · gaweuli momsaxurebis didi moculoba ganapirobebs maTi damuSavebisaTvis saWiro maRal xarjebs.

anazRaurebis aRniSnuli meTodi, araprognozirebadi xarjebis gamo, moiTxovs didi raodenobiT finansur saSualebebs. ase magaliTad, iaponiaSi, sadac aRniSnuli meTodi gamoiyeneba, socialur samedicino dazRvevis sistemas finansuri saSualebebis samTviani Seumcirebeli maragi gaaCnia (TiTqmis nulovani inflaciis pirobebSi).

anazRaureba stacionarSi dayovnebis xangrZlivobis (faqtiurad gatarebuli sawol-dReebis) mixedviT stacionarSi dayovnebis xangrZlivobis mixedviT anazRaureba gulisxmobs pacientis stacionarSi gatarebuli sawol-dReebis mixedviT dafinansebas. 1980-ian wlamde kanadaSi, iaponiaSi da dasavleT evropis bevr qveynebSi samedicino dawesebulebebis dafinanseba ZiriTadad sawol-dReebis mixedviT xorcieldeboda. ukanasknel wlebSi sawol-dRis Rirebuleba gamoiyeneba, rogorc globaluri biujetis gamoTvlis erTeuli. amisaTvis, stacionarSi gatarebuli sawol-dReebis raodenoba mravldeba TiToeuli dRis standartiT gansazRvrul Rirebulebaze. damfinansebeli aanalizebs samedicino dawesebulebis datvirTvis maCvenebels, pacientis stacionarSi dayovnebis xangrZlivobas, gatarebul sawol-dReTa raodenobas. Semdgom etapze damfinansebelsa da samedicino dawesebulebas Soris urTierTSeTanxmebis safuZvelze dgindeba biujeti. sxvadasxva profilis (qirurgiuli, Terapiuli, onkologiuri) daavadebebze SesaZlebelia dadgindes sawol-dRis rogorc erTnairi aseve gansxvavebuli saSualo Rirebuleba. cxadia, erTnairi Rirebuleba naklebad iTvaliswinebs sxvadasxva daavadebebis specifikur niSnebs. ase magaliTad, cnobili faqtia, rom qirurgiuli daavadebebis sawol-dRis Rirebuleba ufro Zviria, vidre Terapiuli profilis. sawol-dReebis mixedviT anazRaurebis Semdegi saxeebi arsebobs: · sawol-dReebis saSualo raodenobis mixedviT. Rirebuleba mkurnalobis yvela komponents Seicavs;

28

sawolis profilis mixedviT (qirurgiuli, Terapiuli...) gansazRvruli sawoldReebis saSualo raodenoba, romlis Rirebuleba mkurnalobis yvela komponents Seicavs; · saSualo da saSualoprofiluri sawol-dReebi, romlis Rirebuleba ar Seicavs samedicino daxmarebis zogierT saxes (mag., rTuli qirurgiuli operaciebi, paraklinikuri procedurebi), romlebic calke anazRaurdeba; · saSualo da saSualoprofiluri sawol-dReebi, romlis Rirebuleba ar Seicavs mkurnali eqimebis Sromis anazRaurebas (igi Sesrulebuli samuSaos mixedviT anazRaurdeba). sxvadasxva qveynebSi sawol-dRis Rirebulebis gansazRvrisadmi gansxvavebuli midgoma arsebobs. magaliTad, ruseTSi sawol-dRis Rirebuleba saavadmyofos ganyofilebebis profilis mixedviT dgindeba (i. Seimani, 2001 w.). evropis bevr qveynebSi sawol-dRis RirebulebaSi ar Sedis qirurgiuli operaciebis Rirebuleba, romelic calke anazRaurdeba. zog qveynebSi sawol-dRis RirebulebaSi ar Sedis mkurnali eqimis xelfasi, romelic calke, Sesrulebuli samuSaos mixedviT anazRaurdeba

·

dadebiTi mxareebi anazRaurebis aRniSnuli meTodisaTvis damaxasiaTebelia angariSsworebis simartive, radgan mcirdeba dasamuSavebeli angariSebis moculoba. saavadmyofoebis dasafinanseblad xorcieldeba pacientis mier stacionarSi gatarebul dReTa daTvla, romelic TiToeuli dRis gansazRvrul Rirebulebaze mravldeba. aseTi saxis angariSsworeba SedarebiT iol samuSaos warmoadgens. uaryofiTi mxareebi meTodis uaryofiT mxares warmoadgens samedicino dawesebulebis daintereseba, gaaxangrZlivos pacientis stacionarSi dayovneba da Sesabamisad gatarebul sawoldReTa raodenoba. cxadia, saavadmyofos ZiriTadi datvirTva pacientis mkurnalobis pirvel dReebze modis, radgan igi dakavSirebulia mravali sadiagnozo procedurebis CatarebasTan da araiSviaT SemTxvevaSi intensiuri Terapiis ganxorcielebasTan, rac mkurnalobis bolo dReebisagan gansxvavebiT SedarebiT Zviri jdeba. aRniSnulis gamo saavadmyofo dainteresebulia gazardos mkurnalobis SedarebiT iafi dReebis raodenoba. magaliTad, qirurgiuli operaciebis Catarebis Semdgom samedicino dawesebuleba cdilobs gaaxangrZlivos pacientis stacionarSi dayovneba, Tumca SeiZleboda misi droze adre gawera da mkurnalobis ambulatorul pirobebSi gagrZeleba. stacionarSi dayovnebis xelovnurad gaxangrZlivebis winaaRmdeg zogierT qveyanaSi SemoRebulia nozologiuri standartebi, romlis zeviT gatarebuli sawol-dReebis Rirebulebis anazRaureba SedarebiT dabali fasebiT xorcieldeba. zogierT qveyanaSi standarts zeviT gatarebuli sawol-dReebi saerTod ar anazRaurdeba. magaliTad, safrangeTSi stacionarSi 20 dReze meti dayovnebis SemTxvevaSi aucilebelia damfinanseblis (sadazRvevo fondis) Tanxmoba. garda zemoaRniSnulisa, uaryofiTi mxareebis gamosasworeblad gamoiyeneba Semdegi RonisZiebebi: · pacientis stacionarSi gatarebul pirvel da Semdgom dReebze diferencirebuli fasia dadgenili (pirveli sami dRe ufro Zviri Rirs vidre sxva dReebi); · TiToeuli nozologiis mixedviT hospitalizaciis savaraudo vadebi windawin dadgenilia. stacionarSi standarts zeviT dayovnebis SemTxvevaSi aucilebelia damfinanseblis Tanxmoba; · mizanSewonilia hospitalizaciis xangrZlivobis dasabuTeba specialuri eqspertizis saSualebiT; · damfinansebeli (sadazRvevo fondi) samedicino dawesebulebasTan SeTanxmebis safuZvelze adgens gasatarebel sawol-dReTa raodenobas da Sesabamisad asanazRaurebel Tanxas, romlis farglebSi xorcieldeba calkeuli pacientis stacionaruli mkurnalobis Rirebulebis dafinanseba (globaluri biujetis principi). am SemTxvevaSi sawol-dRe gvevlineba, rogorc globaluri biujetis gansazRvris erTeuli. amJamad, dasavleT evropis bevr qveynebSi, swored aseTi midgomaa gavrcelebuli.

29

pirvel SemTxvevaSi stacionarSi gatarebul pirvel da Semdgom dReebze diferencirebuli fasia dadgenili (mag., estoneTSi). pirveli sami, ufro ZviradRirebuli dRe saSualo maCvenebelTan SedarebiT ormagad anazRaurdeba. am meTodiT SesaZlebelia stacionarSi pacientis dayovnebis Semcireba, magram amave dros, Tu saavadmyofo sawolTa fondis datvirTviTaa dainteresebuli (magaliTad, sakmaod didi mudmivi xarjebis gasamarTleblad), maSin gatarebul sawol-dReTa raodenoba mainc gaizrdeba (isakova, Seimani, 1994). meore SemTxvevaSic aRiniSneba uaryofiTi movlenebis ganviTareba. kerZod, saavadmyofo dainteresebulia pacientis stacionarSi dayovneba standartiT gansazRvrul donemde gazardos, Tumca stacionaruli mkurnalobis kursi dasrulebulia da mkurnalobis gagrZeleba SesaZlebelia ambulatorul pirobebSi. magaliTad, rodesac apendeqtomiis dros stacionaruli mkurnalobis xangrZlivoba 8 dRes Seadgens, xolo konkretul SemTxvevaSi stacionaruli mkurnaloba 6 dReze mets ar moiTxovs, saavadmyofo cdilobs 8 dRemde gaaxangrZlivos pacientis stacionarSi dayovneba (i. Seimani, 2001 w.). aRniSnulis gamo, am meTodis gamoyenebisas stacionarebi SesaZlebelia gadaiqces minimaluri samedicino momsaxurebis sastumroebad, radganac rac ufro didxansaa pacienti saavadmyofoSi ganTavsebuli, miT mcirea masze xarjebi. aRniSnuli moiTxovs sadazRvevo organizaciis mxridan gansakuTrebiT safuZvlian samedicino da ekonomikur kontrols. eqspertizis saSualebiT hospitalizaciis xangrZlivobis dasabuTeba mxolod aSkarad gamoxatul gaxangrZlivebul SemTxvevebs avlens. yvelaze efeqturia globaluri biujetis principis danergva. damfinansebeli (sadazRvevo fondi) samedicino dawesebulebasTan SeTanxmebis safuZvelze adgens gasatarebel sawoldReTa raodenobas da Sesabamisad asanazRaurebel Tanxas, romlis farglebSi xorcieldeba orive mxaris SeTanxmeba, romelic misaRebia rogorc samedicino dawesebulebisaTvis, aseve damfinanseblisaTvis. amgvarad sawol-dRe gamoiyeneba rogorc globaluri biujetis gansazRvris erTeuli. evropis qveynebSi, sadac globaluri biujetis dadgenis gamoTvlis erTeulad gamoiyeneba sawol-dRe, mkveTrad Semcirda stacionarSi dayovnebis xangrZlivoba.

samedicino ekonomikuri standartebis mixedviT anazRaureba

samedicino ekonomikuri standartebiT anazRaurebis meTodi gulisxmobs nozologiuri standartebis mixedviT anazRaurebas. anazRaurebis erTeuls warmoadgens calkeuli nozologiebi an nozologiaTa jgufebi. nozologiaTa jgufSi gaerTianebulia daavadebebi, romelTa mkurnalobaze erTnairi xarjebia dawesebuli. yovel jgufze dgindeba erTiani tarifi. calkeul nozologias an nozologiaTa jgufs uwodeben samedicino ekonomikur standartebs, romlis Rirebuleba windawinaa gansazRvruli. samedicino ekonomikuri standartebiT anazRaurebis meTodi pirvelad SemuSavebul da danergil iqna a.S.S.-Si 1983 wlis oqtomberSi, sadac manamde moqmedebda faqtiur xarjebze (retrospeqtuli meTodi) dafuZnebuli anazRaureba, rac katastrofulad zrdida hospitalur xarjebs. a.S.S.-Si anazRaurebis aRniSnuli meTodi gamoyenebul iqna xandazmulTa dazRvevis saxelmwifo programis (Medicare) dasafinanseblad. diagnoziT erTnairi daavadeba gaerTianebul iqna erT jgufSi (dadginda aseTi saxis 473 jgufi), xolo TiToeuli SemTxvevis Rirebuleba TiToeuli jgufis farglebSi ganisazRvra. magaliTad, Stat niu jersSi nozologiaTa erT jgufSi mkurnalobis Rirebuleba meryeobda 1140 dolaridan 3900 dolaramde, xolo meore jgufSi 3000-dan 8700 dolaramde. nozologiaTa jgufebs ewoda diagnoziT gaerTianebuli jgufebi (Diagnosis-Related Groups - DRG). did britaneTSi igi cnobilia, rogorc samedicino daxmarebis saxiT erTmaneTTan dakavSirebuli jgufebi (Health care-Related Groups - HRG), xolo ruseTSi ki rogorc ­ klinikur-statistikuri jgufebi. am sistemaSi pacientTa gaerTianeba xdeba saavadmyofoTa resursebis moxmarebisa da gamoyenebis mixedviT. diagnoziT gaerTianebuli jgufebis (DRG) meTodis saSualebiT xorcieldeba msgavsi diagnozis mqone pacientTa hospitalizacia.

30

calkeuli daavadebebis erT jgufSi gasaerTianeblad gamoyenebul iqna iseTi kriteriumebi, rogoricaa: daavadebaTa da samkurnalo-diagnostikuri RonisZiebebis erTgvarovneba, samkurnalod gamoyenebuli saSualebebis msgavsi moculoba da Semadgenloba. daavadebaTa TiToeul jgufSi gaTvaliswinebulia pacientis asaki, sqesi, Tanmxlebi daavadebebis arseboba, hospitalizaciis saSualo xangrZlivoba. samedicino ekonomikuri standartebis detaluri Seswavla ganxorcielda ielis universitetSi, sadac gaanalizebul iqna niu-jersis, koneqtikutis, samxreT kaliforniis 170 saavadmyofos 700 000 daavadebis istoria. TiToeuli daavadebis faqtiuri xarjebis safuZvelze ganisazRvra TiToeuli nozologiuri erTeulis saSualo xarji. calkeuli nozologiuri erTeulebis garkveul jgufebSi gaerTianebis Semdeg dadginda TiToeuli klinikuri jgufis faqtiuri Rirebulebis saSualo maCveneblidan gadaxra. samedicino daxmarebisadmi standartuli midgomis Sesamsubuqeblad misi Rirebulebis gansazRvrisas gaTvaliswinebul iqna qveynis geografiuli mdebareoba. qveyana dayofil iqna 9 geografiul regionad, romlebic Tavis mxriv daiyo qalaqis, raionul da soflis doneebad. aRniSnulis gaTvaliswinebiT, standartis Rirebuleba gansazRvrul iqna saavadmyofos, regionisa da qveynis doneze. TiToeuli saavadmyofosaTvis ganisazRvra standartis Rirebulebis saSualo maCveneblidan gadaxris done, romelic warmoadgenda gansazRvruli samedicino dawesebulebis specifikurobis (samedicino daxmarebis done, xasiaTi) maxasiaTebels. nozologiuri standartebis Rirebulebis dadgenisas gaTvaliswinebul iqna iseTi faqtorebi, rogoricaa: personalis anazRaurebis done, samedicino dawesebulebis done (klinikuri da soflis saavadmyofoebi). am da sxva faqtorebis gaTvaliswinebiT standartis normativis diferencireba ganxorcielda 18 kategoriis mixedviT. damatebiTi dafinanseba ganisazRvra: · klinikuri saavadmyofoebisaTvis, sadac ZviradRirebuli samkurnalodiagnostikuri meTodebi gamoiyeneba; · zogierTi raionebis soflis saavadmyofoebisaTvis, romlebic saxelmwifos mxridan garkveul mxardaWeras saWiroeben; · iseTi saavadmyofoebisaTvis, sadac dauzRvevel pacientTa da xandazmuli asakis pirTa dazRvevis saxelmwifo programis (Medicare) monawileTa didi nawili mkurnaloben; · ZviradRirebul kategoriis pacientebisaTvis winaswari SeTanxmebis safuZvelze dadginda individualuri tarifebi (a. m. niu jersis StatSi tarifebis 50 % TiToeuli saavadmyofosaTvis calke ganisazRvreba) (Glaser, 1993). diagnoziT gaerTianebuli jgufebis (DRG) meTodiT Seiqmna sxvadasxva daavadebaTa saerTaSoriso klasifikaciis (ICDA-8) merve sruli gamocema. dayovnebis xangrZnivoba damoukidebel cvlad maCvenebels warmoadgens, romelic gansazRvravs resursebis moxmarebis dones. ielis universitetSi Seiqmna kompiuteruli programa (AUTODRG), ris saSualebiT gamoiyo kategoriebi, romlebic moicavdnen dayovnebis xangrZlivobaze dafuZnebul nozologiebis jgufebs. nozologiuri standartebis Rirebuleba yovelwliurad icvleba. misi yovelwliuri gadasinjva standartizaciisa da individualizaciis principebs Soris gonivruli dabalansebis saSualebas iZleva. koreqcia yovelwliurad xorcieldeba "ganaxlebis indeqsis" (up-to-date-index) mixedviT, romelic iTvaliswinebs momavali wlis mosalodnel da sasurvel cvlilebebTan dakavSirebul iseT xarjebs, rogoricaa axali teqnologiebis gamoyeneba, materialur-teqnikuri bazis ganaxleba, dasaqmebuli personalis xelfasis zrda. meore mxriv, "ganaxlebis indeqsSi" gaTvaliswinebulia agreTve, saavadmyofos xarjebis mosalodneli Semcireba, rac dakavSirebulia efeqturobis gazrdis mizniT ganxorcielebuli iseTi RonisZiebebiT, rogoricaa: ambulatoruli samedicino daxmarebis ufro intensiuri ganviTareba da Sesabamisad stacionaruli momsaxurebis moculobis Semcireba. indeqss adgens a.S.S.-is jandacvisa da socialuri daxmarebis saministros samedicino daxmarebis dafinansebis federaluri administraciis SemadgenlobaSi Semavali specialuri sakonsultacio komisia. "ganaxlebis indeqsis" gamoyenebiT saxsrebis gadanawileba xorcieldeba xandazmuli asakis pirTa dazRvevis saxelmwifo programis (Medicare) fiqsirebuli wliuri

31

biujetis farglebSi, rac gulisxmobs erTi saavadmyofosaTvis indeqsis gazrdis SemTxvevaSi, meore saavadmyofosaTvis mis Semcirebas. diagnoziT gaerTianebuli jgufebis (DRG) meTodi farTod dainerga evropis sxvadasxva qveynebSi. qveynis specifikidan gamomdinare, misi gansxvavebuli variantebi danergil iqna SveciaSi (1985), fineTSi (1987), portugaliaSi (1989), kanadaSi (1990), did britaneTSi (1992), irlandiaSi (1993), avstraliaSi (1993), italiaSi (1995), belgia (1995), germaniaSi (SemTxvevebis da procedurebis mixedviT 1995 wels; G-DRG 2003 wels), safrangeTSi (1997), avstria (1997), Sveicaria (1997), espaneTis kataloniis regioni (1998), daniaSi (1999), norvegiaSi (1999), niderlandebSi (2003), iaponiaSi (diagnozis procedurebis kombinacia - 2003), koream sakuTari DRG-is sistema ganaviTara, magram jer kide ar danergila (Fischer 2003). zogierT qveynebSi (ruseTi, ungreTi) samedicino ekonomikuri standartebi gamoyenebul iqna retrospeqtuli (SemTxvevebis faqtiuri raodenobis anazRaureba) anazRaurebis erTeulad. komunisturi reJimis ngrevis Semdeg, aRmosavleT evropisa da yofili sabWoTa kavSiris qveynebSi, SeiniSneboda sabazro ekonomikis principebiT gataceba da samedicino daxmarebis moculobis dagegmarebaze uaryofiTi damokidebuleba. am qveynebSi ar iqna gaTvaliswinebuli dagegmarebisaTvis saWiro ekonomikuri informaciis aucilebloba da Sesabamisad ar iqna danergili samedicino daxmarebis xarisxze kontrolis sistema. aRniSnul qveynebSi dadginda mxolod nozologiuri standartis Rirebuleba da ara SemTxvevebis raodenoba (retrospeqtuli anazRaureba), ramac erTi mxriv, hospitalizaciis vadebis Semcireba, xolo meore mxriv, dausabuTebeli hospitalizaciis zrda gamoiwvia. kontrolis sistemis ararsebobisas saavadmyofo cdilobs standartis SemosazRvruli Rirebulebis kompensirebas hospitalizaciis SemTxvevaTa raodenobis zrdiT. 1992 wels ungreTSi retrospeqtuli anazRaurebis erTeulad danergil iqna samedicino ekonomikuri standartebi. SemuSavda 500 nozologiuri jgufi, romelTa tarifebi dadginda amerikuli klasifikaciuri niSnebis mixedviT. tarifebi diferencirebulia saavadmyofoTa specifikisa da doneebis mixedviT. anazRaureba xorcieldeba SemTxvevebis faqtiuri raodenobis mixedviT (retrospeqtuli anazRaureba), romelsac mTlianad sadazRvevo fondi axdens. 1996 wels Catarebuli kvlevebiT dadginda, rom ungreTSi samedicino ekonomikuri standartebis danergviT mkveTrad gaizarda saavadmyofoebis muSaobis intensifikacia, kerZod: · gaizarda hospitalizaciis SemTxvevaTa raodenoba; · gaizarda dausabuTebeli hospitalizaciis SemTxvevaTa raodenoba; · SeiniSneba stacionaruli samedicino daxmarebis mZime formebis zrda; · Semcirda hospitalizaciis saSualo xangrZlivoba; · gaizarda qirurgiuli operaciebis, garTulebuli SemTxvevebis da Tanmxlebi daavadebebis raodenoba; · mkveTrad gaizarda sawolTa fondi (115-dan 90 sawolamde yovel 10 000 mosaxleze). samedicino ekonomikuri standartebis mixedviT anazRaurebis meTodis gamoyenebiT mniSvnelovnad Semcirda stacionarSi dayovnebis xangrZlivoba. pacients hospitalizaciamde utardeba diagnostikuri gamokvlevebi, ris Semdegac dgindeba ambulatorul Tu stacionarul doneze mkurnalobis saWiroeba. mkurnalobis bolo etapi da reabilitacia xorcieldeba an ambulatorulad an binaze. aqve aRsaniSnavia, rom a.S.S.-Si saavadmyofoebs gaaCniaT ambulatoruli miRebis ganyofilebebi. garda amisa, farTod gamoiyeneba kerZo praqtikis eqimebTan saxelSekrulebo urTierTobebi. stacionaris ekonomia agreTve miiRweva samedicino daxmarebis sxva rgolebTan mWidro TanamSromlobis saSualebiT. yovelive zemoaRniSnulis Sedegad, mniSvnelovnad gaizarda qirurgiuli daavadebebis ambulatorulad mkurnalobis SemTxvevebis raodenoba. magaliTad, aRniSnuli meTodis danergvis meore welsve Tvalis kataraqtis yvela operacia ambulatorul pirobebSi Catarda (Glaser, 1987). miuxedavad aRniSnulisa, eqspertTa TvalsazrisiT, samedicino ekonomikuri standartebis retrospeqtuli anazRaurebis erTeulad gamoyeneba ar uzrunvelyofs jandacvis resursebis efeqturad ganawilebas, radgan zrdis im SemTxvevaTa

32

raodenobas, romelTa mkurnaloba SesaZlebelia ambulatorul pirobebSi (Docteur and Huxley 2003). maTi azriT, aseT SemTxvevaSi mizanSewonilia samedicino daxmarebis xarisxisa da Sesabamisi kontrolis meqanizmebis SemuSaveba, rac sakmaod ZviradRirebuls warmoadgens da naklebad misaRebia reformirebis gzaze mdgari ganviTarebadi qveynebisaTvis, sadac jandacvaze mwiri Tanxebia gamoyofili (Bojan F. et., 1995). dasavleT evropis zogierT qveynebSi, amerikuli midgomisagan gansxvavebiT samedicino ekonomikuri standartebi gamoiyeneba rogorc anazRaurebis erTeuli (globaluri biujetiT anazRaurebis dadgenisaTvis) da ara meTodi. misi saSualebiT damfinansebels saSualeba eZleva gansazRvros stacionaruli daxmarebis moculoba da saavadmyofosTan SeTanxmebiT daadginos globaluri biujeti. am TvalsazrisiT, samedicino ekonomikuri standartebi saavadmyofos struqturuli efeqturobis zrdas ganapirobebs. kerZod, igi xels uwyobs hospitalizaciis rigebis Semcirebas, raionebsa da saavadmyofoebs Soris finansebis ufro samarTlianad ganawilebis uzrunvelyofas. struqturuli efeqturobis gazrdis mizniT xorcieldeba stacionaruli daxmarebis moculobisa da dafinansebis zemo zRvaris gansazRvra. saavadmyofoebi, romlebic meti moculobis samedicino daxmarebis Catarebas gegmaven, Rebuloben damatebiT dafinansebas da piriqiT: saavadmyofoebs, romelTa datvirTvis maCvenebeli dabalia, SedarebiT mcire dafinanseba dgindeba. dadebiTi mxareebi: xarjebis Semcireba radgan anazRaureba xorcieldeba ara faqtiurad gaweuli xarjebis, aramed nozologiuri standartebis winaswar dadgenili Rirebulebis mixedviT, xarjebi prognozirebadia. aRniSnuli garemoeba xarjebis mniSvnelovan Semcirebas ganapirobebs. angariSsworebis simartive radgan nozologiuri standartebis tarifebi windawinaa dadgenili, mcirdeba dasamuSavebuli angariSebis moculoba. stacionarSi dayovnebis xangrZlivobis Semcireba anazRaurebis aRniSnuli meTodis gamoyenebisas samedicino dawesebuleba da personali ar aris dainteresebuli pacientis stacionarSi dayovnebis gaxangrZlivebiT, radgan igi anazRaurebas Rebulobs mxolod dadgenili standartis Sesabamisad. ase magaliTad, Tu mwvave pnevmoniis mkurnalobisaTvis standartiT gansazRvrulia 7 dRe, saavadmyofo ar aris dainteresebuli pacientis stacionarSi dadgenilze meti xniT dayovnebiT, radgan dayovnebis gaxangrZliveba misTvis ekonomikurad wamgebiania. izrdeba mkurnalobis intensifikacia ganvixiloT aseTi SemTxveva. mwvave pnevmoniis mkurnalobisaTvis standartiT gansazRvrulia 7 dRe, xolo pacients mkurnalobisaTvis dasWirda 5 dRe. im SemTxvevaSi, rodesac samedicino dawesebulebas anazRaureba eZleva standartiT dadgenili 7 dRis da ara faqtiurad gatarebuli 5 dRis mixedviT, igi 2 dRis ekonomiis xarjze Rebulobs mogebas. aRniSnulis gamo, samedicino dawesebuleba ar aris dainteresebuli pacienti standartiT gansazRvruli vadis dasrulebamde daayovnos stacionarSi, rac mkurnalobis intensifikaciis gazrdas da Sesabamisad hospitalizaciis vadebis Semcirebas ganapirobebs. uaryofiTi mxareebi ganmeorebiTi hospitalizaciis saSiSroeba SeiZleba warmoiqmnas pacientze gasawevis momsaxurebis moculobis dausabuTebeli Semcirebis mcdeloba. samedicino personali dainteresebulia stacionaridan droze adre gaweros pacientebi, ramac SesaZlebelia pacientTa ganmeorebiTi hospitalizacia ganapirobos. cxadia, aseT SemTxvevaSi pacients Tavidan utardeba samkurnalodiagnostikuri RonisZiebebi, rac zrdis jandacvis xarjebs. stacionaruli samedicino daxmarebis mZime formis nozologiebis zrda Semosavlebis gazrdis mizniT, eqimebi cdiloben pacientebi gaataron SedarebiT mZime, Tanmxlebi daavadebiT da garTulebebiT, riosTvisac irCeven ZviradRirebul nozologiur standartebs. aRniSnuli garemoeba stacionaruli samedicino daxmarebis

33

struqturis garTulebas ganapirobebs. Sedegad, ekonomikuri informacia sakmarisi ar aris stacionaruli momsaxurebis struqturis Rrma analizisaTvis. amgvarad, aRniSnuli meTodi saSualebas iZleva saavadmyofoebis efeqturi saqmianobisa da mkurnalobis vadebis Semcirebis Sedegad Semcirdes araefeqturad moqmedi stacionarebis Senaxvis xarjebi, riTac SesaZlebelia ukeT anazRaurdes kvalificiuri personalis muSaoba da perspeqtivaSi amaRldes stacionaruli momsaxurebis done. am meTodis gamoyenebisas erTidaigive saxis stacionarebis jgufebisaTvis tarifebi centralizebulad dgindeba. aqve aRsaniSnavia, rom am meTodis danergva moiTxovs did mosamzadebel samuSaoebs. aucilebelia Sesabamisi standartebis safuZvelze samedicino momsaxurebis xarisxze kontrolis gaZliereba, rom aRmoifxvras pacientze gasawevi samedicino momsaxurebis dausabuTebeli Semcireba.

anazRaureba SemTxvevis saSualo Rirebulebis mixedviT

SemTxvevis saSualo Rirebulebis mixedviT anazRaureba gulisxmobs samedicino dawesebulebis dafinansebas TiToeul pacientze an calkeul SemTxvevaze gansazRvruli saSualo fasis mixedviT. SemTxvevis saSualo Rirebuleba SesaZloa gansxvavebuli iyos samedicino dawesebulebis ganyofilebebis profilis mixedviT. erTidaigive saxis stacionarebisaTvis momsaxurebis tarifebi SesaZloa dadgindes centralizebulad. mkvlevarTa azriT, aRniSnuli meTodi SesaZloa gamoyenebul iqnes sadazRvevo sistemaze gadasvlis sawyis etapebze, rom Semdgom igi Seicvalos ufro efeqturi meTodebiT. dadebiTi mxareebi: · mcirdeba administraciuli xarjebi, radganac mcirdeba dasamuSavebeli angariSebis moculoba; · samedicino personali dainteresebulia Seamciros mkurnalobis vadebi; · xarjebis moculoba mniSvnelovnad prognozirebadia. uaryofiTi mxareebi: · SeiZleba warmoiqmnas pacientze gasawevis momsaxurebis moculobis dausabuTebeli Semcirebis mcdeloba; · stacionarebisaTvis ekonomikurad momgebiania mxolod msubuqi simZimis avadmyofebis mkurnaloba, romelTa mkurnalobis Rirebuleba saSualoze dabalia (sawyis etapze, radgan Semdgom periodSi erTi pacientis mkurnalobis TviTRirebulebis Semcirebis gamo mcirdeba tarifebi); · ekonomikuri informacia sakmarisi ar aris stacionaruli momsaxurebis struqturis Rrma analizisaTvis.

globaluri biujeti

globaluri biujetiT dafinansebis meTodi warmoadgens prospeqtuli xasiaTis dafinansebas, romelic gulisxmobs damfinansebelsa da samedicino dawesebulebas Soris samedicino daxmarebis moculobaze da Rirebulebaze winaswar SeTanxmebas. globaluri biujetis samedicino dawesebulebisaTvis SemuSavebis ori midgoma arsebobs: · infrastruqturis mixedviT; · istoriuli monacemebis mixedviT. infrastruqturis mixedviT dadgenili globaluri biujeti infrastruqturis mixedviT dadgenili globaluri biujeti farTod gamoiyeneboda sabWoTa kavSirSi. am SemTxvevaSi biujetis formireba xorcieldeba muxlobrivi xarjebis mixedviT (biujetur-muxlobrivi dafinanseba). igi damokidebulia dawesebulebis simZlavreze, personalis raodenobasa an sawolTa fondze. biujeturmuxlobrivi dafinanseba prospeqtuli anazRaurebis meTods warmoadgens. aseTi dafinansebis dros ar xdeba momsaxurebis saxeebs Soris resursebis gadanawileba, igi

34

mkacradaa gansazRvruli TiToeuli muxlis mixedviT. misi saSualebiT damfinanseblebi akontroleben samedicino momsaxurebis mTlian xarjebs, xolo mimwodeblebi dainteresebuli arian xarjis SekavebiT. aqve aRsaniSnavia, rom dabalia samedicino momsaxurebis xarisxi. infrastruqturis mixedviT dadgenili fiqsirebuli biujetis uaryofiTi mxareebia: · biujetur-muxlobrivi dafinanseba resursebis marTvisa da dagegmarebis mouqnelobas ganapirobebs; · erTmaneTisagan ara gamoyofili samedicino daxmarebis mimwodebeli (samedicino dawesebuleba) da damfinansebeli, isini erTmaneTTan arian integrirebuli; · dafinansebis gazrdis mizniT samedicino dawesebuleba dainteresebulia gazardos personalis raodenoba da Sesabamisad sawolTa datvirTvis maCvenebeli; · radgan hospitalizebuli pacientebis raodenobis zrda damatebiT xarjebs moiTxovs, amitom saavadmyofo dainteresebulia stacionarSi dayovnebis xangrZlivobis gazrdiT; · dabalia samedicino daxmarebis xarisxi. istoriuli monacemebis mixedviT dadgenili globaluri biujeti biujetur-muxlobrivi dafinansebisagan gansxvavebiT istoriuli monacemebis mixedviT dadgenili globaluri biujeti damokidebulia samedicino dawesebulebis mier Sesrulebuli samuSaos moculobaze. igi farTod gamoiyeneba ganviTarebul qveynebSi. idealur SemTxvevaSi, globaluri biujeti ganisazRvreba saSualo suladobrivi anazRaurebis formuliT (mag., did britanaTSi gamoiyeneba formula RAWP), romelSic gaTvaliswinebulia samedicino daxmarebis moculobis meryeoba geografiuli adgilmdebareobis mixedviT. am formulis gamoyenebiT SesaZlebelia samedicino daxmarebis moculobis SedarebiT ufro swori prognozireba. globaluri biujetis ZiriTadi damaxasiaTebeli niSnebia: 1. dafinanseba limitirebulia (fiqsirebulia) drois gansazRvruli periodisaTvis, romelic dgindeba finansuri wlis dasawyisSi; 2. prospeqtuli dafinanseba (ZiriTadad yovelTviurad); 3. samedicino daxmarebis Rirebuleba winaswar gansazRvrulia.

globaluri biujetis meTodis dadebiTi mxareebia: 1. saavadmyofosTan angariSsworebis simartive. advilia saqmis warmoeba, mxolod finansuri wlis dasawyisi warmoadgens sirTules, radgan swored am periodSi mimdinareobs globaluri biujetis dadgena.; 2. mniSvnelovnad mcirdeba dawesebulebis mier Sesrulebul samuSaosa da damfinanseblis anazRaurebas Soris dayovnebis xangrZlivoba; 3. biujetur-muxlobriv dafinansebasTan garkveuli msgavsebis gamo, yofili sabWoTa kavSiris qveynebSi globaluri biujetis meTodis danergva advilad ganxorcielebadia. aseve. advilad ganxorcielebadobas xels uwyobs erTaderT damfinansebelTan urTierToba. ramdenime damfinanseblis SemTxvevaSi aucilebelia maTi moqmedebis SeTanxmebis garkveuli sqemis SemuSaveba. damfinanseblebi unda SeTanxmdnen stacionaris dafinansebis sakuTar wilze, romelic maTTan dazRveuli pacientebis proporciulad ganisazRvreba. kalendaruli periodis dasrulebis Semdgom warmoebs TiToeuli damfinanseblis mier gadaxdili Tanxis gadaangariSeba, romlis dros gaTvaliswinebulia faqtiurad Sesrulebuli samuSaos moculoba da hospitalizaciis xasiaTi; 4. mniSvnelovnad mcirdeba jandacvis xarjebi, izrdeba resursebis dazogvis stimuli; 5. stacionaruli samedicino daxmarebis xarjebi prognozirebadia; 6. damfinansebels danaxarjebze kontrolis Zlieri berketebi gaaCnia; 7. SezRuduli dafinansebis gamo saavadmyofo hospitalizaciis raodenobis gazrdiT ar aris dainteresebuli; 8. izrdeba rogorc damzRvevis aseve samedicino dawesebulebis ekonomikuri saqmianobis done. orive mxare, samedicino daxmarebis moculobisa da tarifebis SeTanxmebis procesSi, hospitalizaciis safuZvlianobis

35

analizis Catarebisas, Sesasrulebeli samuSaos struqturas iseTi saxiT gegmaven, rom uzrunvelyon ZvradRirebuli resursebis efeqturi gamoyeneba; 9. globaluri biujetis formirebis procesSi CarTulia samedicino personali. isini monawileoben Sesasrulebeli samuSaos struqturisa da moculobis dagegmarebaSi. aRniSnuli zrdis samedicino personalis pasuxismgeblobis dones dagegmili samuSaoebis Catarebisas. maT mier klinikuri xasiaTis gadawyvetilebebis miRebisas umravles SemTxvevaSi gaTvaliswinebuli iqneba samedicino daxmarebis xarjebi; 10. globaluri biujeti xels uwyobs samedicino dawesebulebis struqturul cvlilebebs; 11. samedicino dawesebulebis mmarTvelobiTi damoukidebloba da ekonomikuri motivacia xels uwyobs mkurnalobis dabalxarjviani meTodebis danergvas, pacientTa nakadis regulirebas. 12. iqmneba samedicino daxmarebis moculobisa da misi Rirebulebis balansirebis SesaZlebloba. Tu gamiznulia moculobis gazrda, maSin Sesabamisad Semcirdeba TiToeuli daxmarebis Rirebuleba da piriqiT, moculobis Semcireba SesaZleblobas iZleva gaizardos hospitalizaciis TiToeuli semTxvevis Rirebuleba; 13. mniSvnelovnad xels uwyobs pacientis kmayofilebis donis amaRlebas, rac ganpirobebulia im garemoebiT, rom globaluri biujetiT dafinansebis pirobebSi samedicino dawesebuleba finansdeba avansis saxiT (winaswar), rac Tavis mxriv xels uwyobs medikamentebiT da sxva aucilebeli samedicino moxmarebis sagnebiT samedicino dawesebulebis droul uzrunvelyofas.

globaluri biujetis meTodis uaryofiTi mxareebi: 1. radgan saavadmyofo dainteresebulia SezRudos gasawevi samedicino daxmarebis moculoba, SesaZlebelia warmoiqmnas momsaxurebis calkeuli saxeebis (gamokvlevebi, diagnostikuri RonisZiebebi) dausabuTebeli ekonomiis mcdeloba. 2. samedicino personali ar aris dainteresebuli Seamciros mkurnalobis vadebi; 3. ar axdens stacionarebis saqmianobis intensifikaciis stimulirebas; 4. ar axdens ar SeiniSneba stacionarebs Soris konkurenciis stimulirebas.

sxvadasxva qveynebis gamocdileba globaluri biujetiT dafinansebis meTodi 80-iani wlebidan farTod dainerga evropis bevr qveynebSi (germania, safrangeTi, belgia, niderlandebi, didi britaneTi, irlandia, espaneTi). niderlandebSi zogadi profilis saavadmyofoebis dafinansebisaTvis gansazRvrulia globaluri biujeti. globaluri biujetiT dafinanseba SemoRebul iqna 1983 wlis ianvarSi. 1984 wels igi gavrcelda stacionaruli tipis fsiqiatriul dawesebulebebisaTvis da meddis saxlebisaTvis. saavadmyofoebi da sadazRvevo fondebi SeTanxmdebian momavali wlisaTvis mosalodnel danaxarjebze da gansazRvraven dawesebulebis mTlian biujets. saavadmyofosaTvis globaluri biujetis dadgenaSi monawileobs jandacvis samxareo sabWo (County Council), romelic ZiriTadad jandacvis saministros rekomendaciebs eyrdnoba. safrangeTSi 1983 walmde saxelmwifo saavadmyofoebis dafinansebisaTvis gamoiyeneboda retrospeqtuli meTodi sawol/dReebis mixedviT. 1983 wels SemoRebul iqna globaluri biujetis meTodi. saavadmyofoebis dafinanseba germaniaSi germaniis saavadmyofoebSi Zireuli reformebi 1993 wlidan, Semdgom ufro mwvaved 2004 wlidan daiwyo. SemoRebul iqna biujeturi dafinansebis SedarebiT ufro mkacri meTodebi, mkveTrad gaizarda saavadmyofoebSi ambulatoruli momsaxurebis gawevis SesaZlebloba. 2004 wlis ianvridan saavadmyofoebis mimdinare xarjebis dafinansebis erTaderT sistemad ganisazRvra samedicino ekonomikuri standartebiT anazRaurebis

36

meTodi. man Secvala 1993-2003 wlebSi arsebuli anazRaurebis Sereuli sistema (sawol/dReebis, hospitalizaciis SemTxvevebis, ZviradRirebuli procedurebis mixedviT) germaniaSi saavadmyofoebis dafinansebis ori wyaro arsebobs: kapitalur xarjebs ixdian federaluri mxareebi, xolo mimdinare xarjebs ­ saavadmyofoebis salaroebi (nawilobriv kerZo sadazRvevo kompaniebi). kapitaluri xarjebis dafinansebisaTvis saavadmyofoebi unda iTvlebodnen federaluri mxaris mier SemuSavebul e. w. saavadmyofoTa registrSi. aRniSnul registrSi miTiTebulia agreTve aucilebeli specialobebi, samedicino daxmarebis TiToeuli profilisaTvis saWiro sawolTa raodenoba da a. S. saavadmyofoebisa da sawol raodenobas adgens sammxrivi komisia, sadac Sedian federaluri mxaris mTavrobis, saavadmyofoebis da saavadmyofo salaroebis warmomadgenlebi. saavadmyofo salaroebi valdebuli arian xelSekruleba gaaformon saavadmyofoTa registrSi myof saavadmyofoebTan. xangrZlivi wesiT kapitaluri dabandebebisaTvis saWiroa individualuri subsidireba (ase finansdeba saavadmyofos mSenebloba, mowyobiloba danadgarebis Secvla). saavadmyofo romelic ar Sedis saavadmyofoTa registrSi SeiZleba dafinansdes saavadmyofo salaros mier, magram amisaTvis saWiroa sxa saavadmyofo salaroebis da federaluri mxaris mTavrobis Tanxmoba. amasTan aseTi saavadmyofo ar finansdeba federaluri mxaris mier. saavadmyofo salaro kapitalur xarjebze dafinansebas axdens mxolod ukiduresad gamonaklis SemTxvevaSi. federalur mxareebs gansxvavebuli midgoma aqvT saavadmyofoTa registris SemuSavebaSi, sawolTa fondis dagegmvasa da investiciebis ganxorcielebaSi. ase magaliTad, berlinis mxarem 1991-2001 wlebSi sawolTa fondi 40 %-iT Seamcira. saavadmyofo salaroebi anazRaureben mimdinare xarjebs, maT Soris samedicino daniSnulebis sagnebis, personalis xelfasebis, agreTve axali mowyobilobadanadgarebis SeZenis (mowyobiloba-danadgarebis eqspluataciis saSualo xangrZlivoba sami welia) da saeqspluatacio xarjebs. saavadmyofos mimdinare xarjebis dasafarad saWiroa federaluri mxaris saavadmyofos salaroebis asociaciebis an maTi warmomadgenlebis Tanxmoba. saavadmyofoebs SeuZliaT kerZo avadmyofebs standartzeda gadasaxadi gadaaxdevinon. aseTi avadmyofebi ixdian 10 evros dReSi (maqsimum 28 dRis ganmavlobaSi) da igi ZiriTadad kvebaze da palataSi ganTavsebaze ixarjeba. 1992 wlamde qveyanaSi moqmedebda "xarjebis sruli gadaxdis principi": saavadmyofo ramdensac daxarjavda, saavadmyofos salaro valdebuli iyo srulad aenazRaurebina xarjebi. faqtiuri xarjebis anazRaureba xorcieldeboda sawol/dRis Rirebulebis mixedviT, romelsac federaluri mxare TiToeuli saavadmyofosaTvis adgenda. saavadmyofos SigniT sawol/dRis Rirebuleba Tanabari iyo yvela ganyofilebisaTvis. 1993 wels miRebuli kanonis Tanaxmad "jandacvis struqturis Sesaxeb", saavadmyofo salaroebis xarjvis zrda SesabamisobaSi unda yofiliyo Semosavlebis (sadazRvevo Senatanebi) zrdasTan. yoveli saavadmyofosaTvis dadginda biujeti. 1993 wlidan saavadmyofoebi finansdeboda dRiuri tarifis oretapiani sistemiT: pirveli komponenti ­ TiToeuli saavadmyofosaTvis dadgenili iyo ZiriTadi dRiuri ganakveTi arasamedicino xasiaTis xarjebis dasafaravad, xolo TiToeuli ganyofilebisaTvis sakuTari dRiuri ganakveTi samedicino xasiaTis xarjebis (medikamentebi, procedurebi, mkurnaloba) dasafaravad. meore komponenti savaldebulo gaxda 1996 wlidan: hospitalizaciis xarji (pacientis saavadmyofoSi mTeli droiT yofnis xarjebs faravs) da procedurebis xarjebi. globaluri biujetis gamoTvla globaluri biujetis SemTxvevaSi samedicino daxmarebis mimwodebelsa da damfinansebels Soris xdeba ekonomikuri interesebis urTierTSeTanxmeba. orive mxaris urTierTSeTanxmebiT dgindeba Sesasrulebeli samuSaos moculoba, samedicino daxmarebis erTeulis Rirebuleba. xelSekrulebis dadebis Semdeg tardeba monitoringi da fasdeba aRebuli valdebulebebis Sesruleba. globaluri biujeti ZiriTadad, dawesebulebis mier wina wels Sesrulebuli samuSaos moculobis gaTvaliswinebiT dgindeba. samedicino dawesebuleba wlis bolos warmoadgens srul statistikur da finansur angariSs, momavali wlis

37

savaraudo xarjTaRricxvas ZiriTadi punqtebis saxiT (xelfasebi, medikamentebi, kveba, momsaxureba, avadmyofis movla, Ramis morigeoba, laboratoriuli gamokvleva da a. S.). damfinansebeli mxare analizs ukeTebs samedicino dawesebulebaSi gatarebuli pacientebis statistikur informacias, romliTac ganisazRvreba momdevno wels Sesasrulebeli samuSaos moculoba. dawesebuleba aanalizebs damfinanseblis mier warmodgenil proeqts da molaparakebis periodSi gansazRvravs xelSekrulebis saboloo pirobebs. aRsaniSnavia, rom globaluri biujetiT SesaZlebelia gaTvaliswinebuli ar iyos samedicino dawesebulebis iseTi xarjebi, rogoricaa personalis swavleba da momzadeba, kapitaluri xarjebi (remonti) da a. S. 1. samedicino dawesebulebis statistikuri monacemebis analizi globaluri biujetis gamoTvlisaTvis pirvel etapze xorcieldeba samedicino dawesebulebis statistikuri monacemebis analizi. amisaTvis ZiriTadad samedicino dawesebulebis mier wina wels Sesrulebuli samusaos statistikuri monacemebis analizi keTdeba. aqve aRsaniSnavia, rom, samedicino dawesebulebaSi mimdinare reformebze naTeli warmodgenisaTvis ufro mizanSewonilia ukanaskneli ori-sami wlis monacemebis Sefaseba. momavali wlis biujetis dasadgenad, mizanSewonilia sruli statistikuri monacemebis wlis bolos warmodgena. monacemebis Seswavla xorcieldeba samedicino dawesebulebis TiToeuli ganyofilebis doneze. ZiriTadad Semdegi saxis statistikuri monacemebis analizi keTdeba: · arsebul sawolTa raodenoba; · gatarebul sawol-dReTa raodenoba; · namkurnalev avadmyofTa raodenoba; · mkurnalobis xangrZlivoba · sawolTa datvirTvis maCvenebeli. statistikuri informaciis Segrovebis Semdeg tardeba misi analizi. kerZod gansakuTrebuli yuradReba eqceva Semdeg garemoebebs: · daavadebaTa struqturis Seswavla simZimis xarisxis mixedviT; · yvelaze xSirad gamoyenebuli nozologiebi; · dausabuTebeli hospitalizaciis raodenoba; · stacionaruli mkurnalobis gaxangrZlivebuli SemTxvevebi; · ganmeorebiTi hospitalizaciis SemTxvevebi, romlebic samedicino daxmarebis dabali xarisxiT gaweviTaa ganpirobebuli. 2. samedicino dawesebulebis finansuri maCveneblebis analizi globaluri biujetis gamoTvlisaTvis meore etapze xorcieldeba samedicino dawesebulebis finansuri maCveneblebis analizi. igi tardeba samedicino dawesebulebis TiToeuli ganyofilebis doneze. ZiriTadad Semdegi saxis finansuri monacemebis analizi keTdeba: · samedicino dawesebulebis Semosavali; · samedicino dawesebulebis mier gaweuli danaxarji; · Semosavlebsa da faqtiur danaxarjebs (pirdapiri da arapirdapiri xarjebis) Soris sxvaobis dadgena. xarjebi ori saxisaa: cvladi da mudmivi. cvladi xarjebi samedicino dawesebulebis mier Sesrulebuli samuSaos moculobazea damokidebuli. Sesrulebuli samuSaos moculobis mixedviT igi SeiZleba gaizardos, an Semcirdes. cvlad xarjebs ganekuTvneba medikamentebi, kveba... mudmivi, fiqsirebuli xarjebi danaxarjebis ZiriTad nawils warmoadgens. masSi SesaZlebelia Sediodes dawesebulebaSi dasaqmebul specialistTa fiqsirebuli xelfasebi. globaluri biujetiT dafinanseba xels uwyobs samedicino dawesebulebis optimizaciis process. misi danergva samedicino dawesebulebis arsebuli struqturis mniSvnelovan cvlilebebs moiTxovs. mkveTrad icvleba samedicino dawesebulebis simZlavre.

38

zogierT qveynebSi (germania, safrangeTi, holandia) saxsrebis ekonomikuri gamoyenebis mizniT damfinansebeli samedicino dawesebulebisagan Warbi personalis Semcirebas moiTxovs. Warbi personalis arsebobisas, mizanSewonilia, damfinansebelsa da samedicino dawesebulebas Soris, urTierTSeTanxmebiT ganisazRvros im personalTa aucilebeli raodenoba, romelic ganaxorcielebs samedicino momsaxurebas. samedicino dawesebuleba mxolod raodenobis dadgenis Semdeg gansazRvravs Tu visTan gaaformebs xelSekrulebas. samedicino dawesebulebis finansuri maCveneblebis analizisas xorcieldeba Semosavlebsa da faqtiur danaxarjebs, agreTve samedicino dawesebulebisaTvis dadgenil globalur biujetsa da faqiurad gaweul danaxarjebs Soris sxvaobis dadgena. amisaTvis tardeba Semdegi samuSaoebi: · erT namkurnalev pacientze daxarjuli Tanxis gansazRvra da misi Sedareba sxva, msgavsi samedicino dawesebulebis mier gaweul xarjis saSualo maCvenebelTan; · erT namkurnalev pacientze gaweuli xarjebis struqturis Seswavla punqtebis mixedviT da misi Sedareba sxva ganyofilebis an sxva samedicino dawesebulebis analogiuri ganyofilebis monacemebTan. · globaluri biujetiT dadgenil xarjebze meti xarjebis gawevis, an piriqiT, cvladi xarjis (medikamentebi, kveba...) sruli saxiT gamouyeneblobis mizezebis dadgena. zemoTaRniSnuli samuSaoebis Catarebis Semdeg xorcieldeba yvela gamoTvlili maCveneblebis dajgufeba samedicino dawesebulebis ganyofilebebis mixedviT da specialuri analitikuri cxrilis Sevseba (ix. cxrili). 3. samuSaos moculobis gansazRvra samedicino dawesebulebis mier Sesasrulebeli samuSaos optimaluri moculobis dasadgenad mniSvneloba eniWeba Semdeg sakiTxebs: · hospitalizaciis Semcirebis mizniT im nozologiebis dadgena, romelTa mkurnaloba SesaZlebelia Catardes ambulatorul pirobebSi. · samedicino daxmarebis xarisxis gaTvaliswineba. · samedicino daxmarebis moculoba unda Seesabamebodes saavadmyofos profils da funqciebs. globaluri biujetis meTodis erT-erT dadebiT mxares resursebis dazogva warmoadgens. mkvlevarebis mier Catarebuli analizis Sedegad dadginda, rom globaluri biujetis danergvam jandacvaze danaxarjebis 13 %-iT Semcireba gamoiwvia. stacionaruli daxmarebis moculobis efeqturi dagegmvis mizniT mizanSewonilia poliklinikis TiToeuli ubnis mier stacionarSi gagzavnili pacientebis SemTxvevebis Seswavla. am dros yuradReba eqceva iseTi SemTxvevebisa da nozologiebis gamovlenas, romelTa mkurnaloba SesaZlebelia Catarebuliyo ambulatorul-poliklinikur pirobebSi. mniSvnelovania agreTve stacionarSi ubnis eqimis umomarTvod, an saswrafo samedicino daxmarebiT moxvedril pacientTa Seswavla. aRniSnuli monacemebis SeswavliT gamovlindeba ambulatorul/poliklinikur doneze arsebuli susti mxareebi, Cndeba dausabuTebeli hospitalizaciis Semcirebis SesaZlebloba, agreTve iseTi saorganizacio-ekonomikuri cvlilebebis gatareba, romelic stimuls miscems stacionaruli mkurnalobis sanacvlod, ambulatorul-poliklinikur doneze gaizardos Sesasrulebeli samuSaos moculoba. aseT saorganizacio-ekonomikur cvlilebas ganekuTvneba dawesebulebis daintereseba gadavides samedicino daxmarebis mravaldonian (mravaletapian) sistemaze, dRis stacionarebisa da ambulatoruli ganyofilebebis Seqmnis gziT. mxolod aseT SemTxvevaSia SesaZlebeli stacionaruli samedicino daxmarebis moculobis Semcireba. resursebis ekonomiurad gamoyenebis mizniT, aseTi stimulis arsebobisas, saavadmyofo cdilobs daavadebaTa SedarebiT msubuqi formebis mkurnaloba ambulatorul an dRis stacionarebSi (sadac xarjebi mcirea) Caaataros. amisaTvis tardeba mkurnalobis intensiuri da Semdgomi etapebis (mkurnalobis dasruleba, reabilitacia) erTmaneTisagan gancalkeveba. aRniSnuli procesis efeqturad ganxorcielebisaTvis samedicino daxmarebis TiToeul dones (stacionari, ambulatoria, dRis stacionari)

39

sakuTari ekonomikuri dainteresebis stimuli unda gaaCndes. damfinansebelma mxarem xeli unda Seuwyos samedicino dawesebulebis mcdelobas resursebis ekonomiurad gamoyenebis TvalsazrisiT. kerZod, damfinansebelma mizanSewonilia aanazRauros stacionaruli samedicino daxmarebis mTliani Rirebuleba (da ara Semcirebuli tarifebi), samedicino daxmarebis gawevis donis (dRis stacionari iqneba Tu stacionari) miuxedavad. samedicino dawesebulebas unda mieniWos ufleba, hospitalizaciis SemTxvevebis SemcirebiT miRebuli ekonomia gamoiyenos rogorc dRis stacionarebis, an ambulatoruli daxmarebisaTvis, aseve daavadebaTa ufro rTuli SemTxvevebis dasafinanseblad (amiT izrdeba medikamentebis ufro srulyofilad gamoyenebis SesaZlebloba, Sesabamisad, matulobs agreTve im samedicino personalis anazRaureba, romelic mZime avadmyofebis mkurnalobiTaa dakavebuli). mizanSewonilia agreTve, damfinansebelma dRis stacionaris tarifebi Seamciros mxolod garkveuli wlebis Semdgom, rodesac globaluri biujetis danergva samedicino dawesebulebis simZlavris mniSvnelovan cvlilebebs gamoiwvevs. hospitalizaciis Semcirebam SesaZlebelia rTuli SemTxvevebis raodenobis gazrda ganapirobos, rac mniSvnelovnad zrdis samedicino daxmarebis TiToeuli erTeulis xarjebs. aRniSnuli mdgomareoba seriozuli ekonomiuri analizis Catarebas moiTxovs, radgan saavadmyofo ar unda dazaraldes hospitalizaciis rTuli SemTxvevaTa wilis gazrdiT. mizanSewonilia, rom samedicino daxmarebis rTuli SemTxvevebis dadgenili Rirebuleba didad ar gansxvavdebodes faqtiuri xarjebisagan. aranakleb mniSvnelovania, hospitalizaciis raodenobis SemcirebiT miRebuli ekonomiis saavadmyofosaTvis Tavisi nebiT gamoyenebis uflebis miniWeba. globaluri biujetis gamosaTvlelad gasawevi samedicino daxmarebis moculoba mravldeba TiTo daxmarebaze gansazRvrul Rirebulebaze. mniSvnelovania, rom globaluri biujetis dros iqmneba samedicino daxmarebis moculobisa da misi Rirebulebis balansirebis SesaZlebloba. Tu gamiznulia moculobis gazrda, maSin Sesabamisad Semcirdeba TiToeuli daxmarebis Rirebuleba da piriqiT, moculobis Semcireba SesaZleblobas iZleva gaizardos hospitalizaciis TiToeuli semTxvevis Rirebuleba. mTavaria, gaweuli samedicino daxmarebis moculoba dafinansebas Seesabamebodes. amisaTvis aucilebelia gatarebul avadmyofTa raodenobisa da maTze gaweuli xarjebis analizi. dadgenil unda iqnes, Tu ramdenad gansxvavdeba TiToeul SemTxvevaze gansazRvruli tarifebi faqtiuri danaxarjebisagan. mniSvnelovani gansxvaveba migviTiTebs dausabuTebeli hospitalizaciis SemTxvevaTa siWarbes, an am SemTxvevaTa dabal Rirebulebas. zemoaRniSnulis gaTvaliswinebiT, cxadia, rom globaluri biujetis formireba ufro xelsayrelia stacionarisa da ambulatoriis gaerTianebis SemTxvevaSi. aseT dros advili mosaxerxebelia finansuri saSualebebis samedicino daxmarebis erTi donidan meore doneze gadaadgileba. rogorc zemoT avRniSneT, globalurma biujetma SesaZlebelia samedicino daxmarebis SedarebiT dabali xarisxi ganapirobos (Lewis et al., 1996). aranakleb mniSvnelovania samedicino personalis eTikuri mxare. mkvlevarTa mier Catarebuli analiziT dadginda, rom zogierT qveyanaSi, globaluri biujetiT dafinansebisas samedicino personali maTTvis gankuTvnili samuSao drois mxolod 15 %-ze naklebs muSaoben, xolo pacientis momsaxurebasTan dakavSirebuli xarjebi 12 %-s ar aRemateba. zemoaRniSnulis aRmosafxvrelad, globaluri biujetis dadgenisas, garkveuli SeTanxmeba unda iqnes miRweuli samedicino daxmarebis xarisxTan dakavSirebiT. bevr qveyanaSi mxareebs Soris xelSekrulebis dadebisas iTvaliswineben samedicino daxmarebis xarisxis maCveneblebs (sawolTa saSualo datvirTva, sawolTa brunvis koeficienti, stacionarSi saSualo dayovnebis xangrZlivoba. rodesac efeqturobis kriteriumad gamoyenebulia stacionarSi dayovnebis xangrZlivoba, daavadebis simZime). radgan globaluri biujeti fiqsirebulia da igi Sesrulebul samuSaoze ar aris damokidebuli, samedicino dawesebulebas SeiZleba gauCndes uaryofiTi stimuli, Seamciros daavadebis samkurnalod saWiro samedicino procedurebis raodenoba, umkurnalos mxolod saSualo simZimis pacientebs da Tavidan moiSoros daavadebaTa mZime SemTxvevebi, an xarjebis Sekavebis da Sesabamisad mogebis maqsimizaciis mizniT, minimaluri xarjebiT Caataros samedicino momsaxureba. zemoaRniSnulis Sedegad mniSvnelovnad Semcirdeba samedicino daxmarebis xarisxi.

40

globaluri biujetiT anazRaurebis warmatebiT ganxorcielebisaTvis mizanSewonilia, mTavari aqcentis gakeTeba ara xarjebis Semcirebaze, aramed samedicino daxmarebis moculobisa da Rirebulebis dadgenaze. winaaRmdeg SemTxvevaSi, arasworad dadgenili, Semcirebuli limitirebis SemTxvevaSi samedicino dawesebulebas ar eqneba ekonomikuri stimuli, rac uaryofiTad imoqmedebs samedicino daxmarebis xarisxze. globaluri biujetis efeqturad ganxorcielebisaTvis da resursebis samarTlianad gadanawilebisaTvis mniSvnelovania samedicino dawesebulebebisaTvis damoukidebeli marTvis uflebis miniWeba. isini TviTon unda wyvetdnen iseT sakiTxebs, rogoricaa: gamoyofili Tanxebis TavianTi Sexedulebisamebr gadanawileba, sawolTa fondis Semcireba, damfinansebelTan samedicino daxmarebis SeTanxmebuli moculobis zeviT fasiani momsaxureobis SemoReba, finansirebis damatebiTi wyaroebis mopoveba (gamouyenebeli saSualebebis arendiT gacema an gayidva da a. S.). amasTan ufro efeqturia samedicino daxmarebis ara danawevrebuli (fragmentuli), aramed mTeli paketis (ambulatoruli da stacionaruli samedicino daxmareba) dafinanseba. rodesac stacionaris momsaxurebiT sargeblobs ramdenime sadazRvevo organizacia, globaluri biujetiT stacionaris momsaxurebis asanazRaureblad isini xelSekrulebas aformeben dazRveulTa raodenobis proporciulad stacionaris saqmianobis avansirebaze, risTvisac axorcieleben stacionarSi namkurnalev dazRveulTa raodenobis da Semadgenlobis urTierTSoris proporciulad gadanawilebas. 4. stacionaruli samedicino daxmarebis TiToeuli SemTxvevis Rirebulebis dadgena samedicino daxmarebis TiToeuli SemTxvevis Rirebulebis dasadgenad gamoiyeneba ori midgoma: · winaswar dadgenili tarifebi; · Sesrulebuli samuSaos faqtiuri danaxarjebi. erTi SemTxvevis saSualo faqtiuri danaxarji gamoiTvleba mTliani danaxarjebis SefardebiT SemTxvevebis faqtiur raodenobasTan. aRsaniSnavia, rom erTi SemTxvevis saSualo faqtiuri danaxarji SeiZleba mniSvnelovnad iyos gazrdili da ar iTvaliswinebdes stacionaris resursebis optimalur da efeqtur gamoyenebas (mag. mowyobiloba danadgarebis mocda, dawesebulebis gamouyenebel farTobze maRali sameurneo danaxarjebi da sxva.) orive midgomisaTvis damaxasiaTebeli uaryofiTi mxareebis aRmosafxvrelad (Semcirebuli tarifi, dabali ekonomikuri efeturoba), TiToeuli SemTxvevis Rirebulebis gansasazRvravad gamoiyeneba normativi. am dros iyeneben ara namkurnalev pacientTa faqtiur raodenobas, aramed dadgenil normativs, romelic iTvaliswinebs saavadmyofos sawolTa fondis mTlian datvirTvas. saavadmyofos yvela arsebuli simZlavre unda iZleodes realur Semosavals. maTi Senaxvis xarjebi avtomaturad ar unda gadaeces damfinansebels. finansuri normativebis gaTvlisas gansakuTrebuli yuradReba eqceva xelfasze da medikamentebze danaxarjebs. Tu samedicino dawesebulebas dagegmili aqvs rTuli daavadebebis mkurnalobis raodenobis gazrda, maSin aucilebelia, gaTvaliswinebul iqnas samuSaos sirTulis Sesabamisi, xelfasze danamati da medikamentebis ufro meti moxmareba. dawesebulebis mier Sesasrulebeli samedicino daxmarebis gegmiuri moculobis da finansuri normativebis Sefasebis Semdgom dgindeba mTliani biujeti. winaswar gansazRvruli mTliani biujeti da samedicino dawesebulebisgan mosalodneli dafinanseba dabalansebulia. igi daaxloebiT wina wlis moculobis Sesabamisia. dadgenilTan SedarebiT mniSvnelovani gadaxris SemTxvevaSi SesaZlebelia deficitis Sesavsebad saWiro damatebiTi zomebis miReba. globaluri biujeti finansur gegmas warmoadgens, romelic gansazRvravs resursebis ekonomiur, SezRudul gamoyenebas. dawesebuleba valdebulia Seasrulos dadgenili finansuri gegma.

41

samedicino dawesebulebis mier faqtiurad Sesrulebuli samedicino daxmarebis moculoba SesaZlebelia dadgenili moculobisagan gansxvavdebodes. amasTan, globaluri biujetis dadgenis Semdeg masSi cvlilebebis Setana garkveul sirTules warmoadgens, radgan damatebiTi saxsrebis moZieba problemebTanaa dakavSirebuli. aseT SemTxvevaSi, anu, globaluri biujetis gadaWarbebis, an piriqiT, misi limits qveviT Sesrulebis SemTxvevaSi, xelSekrulebaSi mkafiod unda iqnes dadgenili, Tu vin dafaravs deficits, rogor moiqces samedicino dawesebuleba da vin iRebs pasuxismgeblobas biujeturi Tanxebis gadaWarbebis, an arasruli xarjvis SemTxvevaSi. garda amisa, aucilebelia ganisazRvros e. w. "riskis derefani", anu faqtiuri moculobis gegmiuridan SesaZlo gadaxra. dadgenil sazRvrebSi anazRaurdeba samedicino daxmarebis SeTanxmebuli moculoba ­ rogorc gegmiuri moculobis gadaWarbebis, aseve misi Seusruleblobis SemTxvevaSi. magaliTad, rodesac dagegmilia 100 SemTxvevis anazRaureba da "riskis derefani" 5 %-s Seadgens, 105 da 95 SemTxveva dafinansdeba rogorc 100 SemTxveva. 106 SemTxveva anazRaurdeba SedarebiT dabali fasiT, xolo 94 SemTxvevis dros saavadmyofo ar miiRebs erTi SemTxvevis dafinansebas. aqve aRsaniSnavia, rom biujetis simciris pirobebSi samedicino dawesebulebas ufleba aqvs uari Tqvas mTeli mosaxleobis momsaxurebaze, an cdilobs moZebnos dafinansebis alternatiuli wyaro. zogierT qveynebSi dadgenili globaluri biujetis gadaWarbebiT Sesrulebisas samedicino dawesebulebas damatebiTi anazRaureba eZleva. aseT SemTxvevaSi, saavadmyofos SeiZleba gauCndes gansazRvrul moculobaze metis Catarebis stimuli. aRninulis sawinaaRmdegod, damfinansebeli cdilobs TiToeul damatebiT hospitalizaciaze kontrolis gaZlierebas. agreve urTierTmolaparakebis safuZvelze dgindeba biujets zeviT dafinansebis zRvari. magaliTad, germaniaSi sawol/dReebis gegmaze naklebiT Sesrulebis SemTxvevaSi saavadmyofo mainc Rebulobs dafinansebas, mxolod tarifis 25 %-iT naklebs. misi gadaWarbebisas ki misi Rirebulebis mxolod 75 % anazRaurdeba. 5. samedicino daxmarebis erTeulis Rirebulebis dadgena globaluri biujetis dasadgenad ganisazRvreba TiToeuli samedicino daxmarebis erTeulis Rirebuleba, romelic samedicino dawesebulebisaTvis SeiZleba iyos: · erTiani (unificirebuli); · sxvadasxva (individualuri). pirvel SemTxvevaSi sxvadasxva tipisa da donis samedicino dawesebulebisaTvis SemuSavebulia erTnairi, unificirebuli tarifi. meore SemTxvevaSi ki adgili aqvs sxvadasxva saxis samedicino dawesebulebebisaTvis tarifebis dadgenis individualur midgomas. TiToeul dawesebulebas samedicino daxmarebis Rirebuleba individualurad ganesazRvreba. individualuri tarifebis SemTxvevaSi damfinansebels aqvs samedicino dawesebulebis SerCevis ufro meti SesaZlebloba. cxadia damfinansebeli xelSekrulebas gaaformebs im samedicino dawesebulebasTan, romelic samedicino daxmarebis xarisxis gaTvaliswinebiT dabali fasebiT bevri moculobis samuSaos Seasrulebs. individualuri da erTiani tarifebis dadgenisas mniSvnelovania samedicino dawesebulebebs Soris konkurenciis gaTvaliswineba. sakonkurso SerCevis parametrebs warmoadgens samedicino daxmarebis moculoba da xarisxi. magaliTad, 1999 wels yazaxeTSi Catarebuli konkursis safuzvelze SeirCa is dawesebulebebi, romlebsac momsaxurebis SedarebiT dabali fasebi hqondaT dawesebuli. garkveuli xnis Semdeg dadginda, rom aRniSnulma saavadmyofoebma ver SeZles samedicino daxmarebis saWiro xarisxiTa da pirobebiT uzrunvelyofa. aucilebeli gaxda sakonkurso SerCevis prioritetebis gadasinjva. upiratesoba mieniWa im saavadmyofoebs, romelnic mosaxleobis mxridan farTo moTxovniT sargeblobdnen. amgvarad, saavadmyofos muSaobis prioritetul moTxovnas samedicino daxmarebis xarisxi unda warmoadgendes (i. Seimani, 2000). konkurenciis pirobebSi individualuri tarifebi ekonomikuri araefeqturobiT xasiaTdeba, radgan damfinansebeli iZulebulia samedicino daxmareba daafinansos samedicino dawesebulebis mier individualurad dadgenili tarifebis mixedviT.

42

amasTan mxedvelobaSia misaRebi, rom samedicino daxmarebis maRali TviTRirebuleba SeiZleba ganpirobebuli iyos samedicino personalis siWarbiT, Senoba-nagebobebis da samkurnalo-diagnostikuri mowyobilobebis araefeqturi gamoyenebiT. zemoaRniSnulidan gamomdinare, individualuri tarifebi ufro mizanSewonilia samedicino dawesebulebebs Soris konkurenciis arsebobis SemTxvevaSi ganisazRvros. konkurenciis ararsebobis dros ki erTiani, unificirebuli tarifebi unda iqnes SemoRebuli. cxrili: tarifis sxvadasxva saxeebis danergvis mizanSewoniloba tarifis saxe individualuri tarifi erTiani tarifi danergvis konkurenciis konkurenciis mizanSewoniloba arsebobisas arsebobisas damfinansebeli konkursis safuZvelze samedicino dawesebulebebs Soris axdens im samedicino dawesebulebebis SerCevas, romlebic Sesabamisi profilis mixedviT saWiro simZlavres da dadgenili biujetis farglebSi xarisxis standartebiT gaTvaliswinebul samedicino daxmarebas uzrunvelyofen saangariSo periodSi. mniSvnelovania sxvadasxva tipisa da donis samedicino dawesebulebebisaTvis erTiani da individualuri tarifebis erTmaneTTan swori Sexameba. amisaTvis SemuSavebulia tarifebis dadgenis etapobrivi sistema. pirvel etapze xorcieldeba damfinansebelsa da yvela samedicino dawesebulebebs Soris SeTanxmeba. tarifebis dasadgenad SeimuSaveben faswarmoqmnis erTian, zogad pirobebs da sxvadasxva tipisa da donis samedicino dawesebulebebisaTvis tarifebis saSualo Rirebulebas. meore etapze xorcieldeba SeTanxmeba damfinansebelsa da konkretul samedicino dawesebulebas Soris, romelic exeba samedicino daxmarebis moculobas da Rirebulebas. radganac SemuSavebulia sxvadasxva tipisa da donis samedicino dawesebulebisaTvis tarifebis saSualo Rirebuleba, damfinansebeli awarmoebs individualur tarifze SeTanxmebas. individualuri tarifi Tavis mxriv dgindeba samedicino daxmarebis dagegmili moculobis gaTvaliswinebiT. globaluri biujetis gamoTvlisas iTvaliswineben rogorc mudmiv, aseve cvalebad danaxarjebs. erTi sawol-dRis RirebulebaSi Sedis cvalebadi danaxarjebis wilic. globaluri biujeti = 1 sawol/dRis Rirebuleba X sawol/dReebis saerTo raodenoba. globaluri biujetis gamoTvlisas gasaTvaliswinebelia ori midgoma: · Sesasrulebeli samuSaos moculoba da sawol/dRis winaswar dagegmili Rirebuleba ucvlelia; · Sesasrulebeli samuSaos moculoba da sawol/dRis winaswar dagegmili Rirebuleba icvleba. pirveli variantis SemTxvevaSi mosalodnelia mniSvnelovani sxvaoba dafinansebasa da Sesasrulebeli samusaos dagegmil moculobas Soris. am dros, samedicino dawesebuleba cdilobs Seamciros Sesasrulebeli samuSaos moculoba. samedicino dawesebulebis finansuri Sefaseba naturaluri maCveneblebi finansuri maCveneblebi xvedriTi finansuri maCveneblebi

Semosavl ganyofileb 1 ebsa da is sawol namkurnal mkurnal 1 pacientis pacientis ganyofil sawolTa faqtiur ganyofile dReTa ev obis Semosavali sxvaobi fasi fasi ebis raodenob danaxarj ba s% raodenob pacientTa xangrZli dadgenili mTliani tarifis faqtiuri a ebs a raodenoba voba mixedviT xarjis tarifebis danaxarji Soris mixedviT mixedviT sxvaoba erTeul erTeul pacienti dReebi lari lari lari % lari lari i i 1 2 3 4 5 6 7 8 9 10 11 bavSvTa

43

Terapia qirurgia nevrologi a infeqciuri travmatol ogia ginekolog ia samSobiaro reanomacia sul stacionaris globaluri biujetis gamoTvla 1 pacientis 1 sawol dagegmili Rirebuleba dRis mkurnalobis dagegmili sawolTa sawol dReTa pacientTa cvladi ganyofileba xangrZlivob Rirebuleba sul raodenoba raodenoba raodenoba xarjebi a erTeuli erTeuli pacienti dReebi lari lari lari 1 2 3 4 5 6 7 8 bavSvTa Terapia qirurgia nevrologia infeqciuri travmatolo gia ginekologia samSobiaro reanomacia sul naturaluri maCveneblebi

globalur i biujeti

lari 9

globaluri biujetis gamoTvla rodesac ar icvleba stacionaris mier Sesrulebuli samuSaos struqtura 1 pacientis dagegmili naturaluri maCveneblebi 1 sawol Rirebuleba globaluri mkurnalobi dRis dagegmili biujeti sawolTa sawol dReTa pacientTa s cvladi ganyofileba sul Rirebuleba raodenoba raodenoba raodenoba xangrZlivo xarjebi ba erTeuli erTeuli pacienti dReebi lari lari lari lari 1 2 3 4 5 6 7 8 9 bavSvTa Terapia qirurgia nevrologia infeqciuri travmatolo gia ginekologia samSobiaro reanomacia sul

44

stacionaris muSaobis naturaluri da finansuri maCveneblebis mosalodneli cvlilebebi

mkurnalobi mkurnalobi glob. pacientis ekonomii ekonomiis s biujet Rirebuleba s s Sedegad sawol pacientT pacientTa sawol pacientT xangrZlivo xangrZlivo dayovnebis i Sedegad miRebuli raodenobi dReTa a dReTa a ba xangrZlivob miRebul rezervi ba ganyofileba raodenob raodeno s raodeno raodeno is gazrda i glob. Semcireba ba a ba ba rezervi biujetTan SedarebiT Secv Secvl lis dRe % pacienti % amde Semde g 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 bavSvTa Terapia qirurgia nevrologia infeqciuri travmatolog ia ginekologia samSobiaro reanomacia sul

samedicino momsaxurebis dafinansebis meTodebis Sefaseba

samedicino momsaxurebis dafinansebis sistemis mimarT wayenebul saerTo moTxovnebs warmoadgens: · dafinansebis sistema unda atarebdes xarjebis zrdis sawinaaRmdego xasiaTs; · samedicino momsaxurebis dafinansebis xarjebi sadazRvevo organizaciisaTvis prognozirebadi unda iyos. · ar unda moiTxovdes monitoringisaTvis saWiro did xarjebs; · samedicino momsaxurebis TiToeuli saxis anazRaurebam samedicino momsaxurebis mimwodeblebs unda miscen finansuri resursebis efeqturi gamoyenebis stimuli. anazRaurebis arcerTi meTodi ar warmoadgens idealurs, yovel maTgans gaaCnia rogorc dadebiTi, aseve uaryofiTi mxareebi. Sesrulebuli samuSaos mixedviT anazRaurebis uaryofiTi mxareebis aRmosafxvrelad evropis qveynebSi miRebul iqna garkveuli zomebi, romelic iTvaliswinebs fasebis regulirebas, samedicino daxmarebis xarisxze kontrols, xarjebis Sekavebas. jandacvis xarjebis zrdis Sesamcireblad resursebis gamoyenebaze mkacri kontroli dawesda, samedicino daxmarebis moculoba da xarjebi limitirebuli gaxda, dadginda samedicino daxmarebis TiToeul saxeze gansazRvruli tarifebi, SemoRebul iqna sajarimo sanqciebi procedurebis Warbad da dausabuTeblad daniSvnis SemTxvevaSi. mikrodoneze samedicino momsaxurebis efeqturobis gazrdis mizniT bevr qveynebSi iyeneben finansuri waxalisebis formebs, risTvisac SemoRebulia anazRaurebis Sereuli, kombinirebuli meTodebi. ase magaliTad, did britaneTSi gamoiyeneben anazRaurebis Sereul sistemas, romelic mniSvnelovan gavlenas axdens samedicino daxmarebaze eqimis damokidebulebaze. did britaneTSi arsebuli suladobrivi dafinansebis rTuli, diferencirebuli forma iTvaliswinebs mosaxleobis socialurekonomikur mdgomareobas, asaks, sqess da a. S. garda suladobrivi dafinansebis meTodisa arsebobs miznobrivi dafinansebis meTodic. miznobrivi dafinansebis meTodis saSualebiT eqims damatebiT eZleva anazRaureba profilaqtikuri RonisZiebebis gansazRvruli donis misaRwevad. skandinaviis qveynebSi SemoRebul iqna dafinansebis Sereuli sistemebi. fineTSi eqimebis Semosavlis 60 % fiqsirebuli xelfasiT finansdeba, 20 % suladobrivi meTodiT, 15 % Sesrulebuli samuSaos mixedviT, xolo 5 % damatebiT dafinansebas Seadgens (15, gv. 243). norvegiaSi ojaxis eqimebi Rebuloben 50 % suladobriv

45

dafinansebas, 30 % Sesrulebuli samuSaos mixedviT, xolo 20 %-s pacientis Tanagadaxdis saSualebiT (15, gv. 243). daniaSi zogadi praqtikis eqimebis anazRaurebis 1/3-s suladobrivi anazRaurebis meTodi warmoadgens, xolo danarCen 2/3-s Sesrulebuli samuSaos mixedviT anazRaureba (Davis 2002). eqspertTa azriT, iseTi sistemebisaTvis, romlis safuZvels warmoadgens suladobrivi da fiqsirebuli xelfasiT anazRaurebis meTodebi, yvelaze ufro mizanSewonilia dafinansebis Sereuli meTodis arseboba (15, gv. 243). Tumca, Zalian Znelia dafinansebis meTodebs Soris garkveuli balansis miRweva da maTi SedarebiT idealuri TanSewyobisaTvis konsensusis miRweva. jandacvis xarjebis Sesamcireblad bevr qveynebSi SemoRebulia pacientis mier Tanagadaxda. Tanagadaxdis principi sagrZnoblad amcirebs eqimis dainteresebas, gazardos vizitebisa da samkurnalo RonisZiebebis raodenoba. magaliTad, SveciaSi eqimTan vizitisas pacienti ixdis 6 a.S.S. dolars, saberZneTSi dolarze naklebs. pirveladi samedicino daxmarebis sistemaSi pacientis mier Tanagadaxda saerTod ar gamoiyeneba iseT qveynebSi, rogoricaa: italia, germania, portugalia da espaneTi. miuxedavad imisa, rom limitebis daweseba da sakontrolo RonisZiebebi mniSvnelovnad amcireben jandacvis xarjebs, jandacvis msoflio organizaciis eqspertebis TvalsazrisiT, Sesrulebuli samuSaos mixedviT anazRaureba warmoadgens yvelaze ufro ZviradRirebul meTods da misi danergva yofili sabWoTa kavSiris qveynebSi, gansakuTrebiT jandacvis sistemis reformirebis sawyis etapebze araa rekomendirebuli. misi mTavari mizezebia: · am qveynebSi jandacvaze gamoyofili saxsrebi mniSvnelovnad mcirea; · Sesrulebuli samuSaos mixedviT anazRaurebis meTodisTvis damaxasiaTebelia gaTvlebis procedurebis da kontrolis meqanizmis sirTule, eqimTa dabali profesiuli eTika; · Sesrulebuli samuSaos mixedviT anazRaureba ar iZleva profilaqtikuri RonisZiebebis Catarebis stimuls. yofili sabWoTa kavSiris qveynebSi, sadac jandacvaze mcire dafinansebaa da amasTan erTad, avadobis maRali done aRiniSneba, rac Tavis mxriv cxovrebis arsebul wesTanaa dakavSirebuli, ufro prioritetulia prevenciuli medicinis ganviTareba. cxadia, profilaqtikuri RonisZiebebi mniSvnelovnad amcirebs xarjebs, rac esoden sagulisxmoa mwiri dafinansebis SemTxvevaSi. samedicino momsaxurebis meTodebis arCevisas gansakuTrebuli mniSvneloba eniWeba meTodebis erTmaneTTan Sesabamisobas. ase magaliTad, poliklinikis suladobrivi meTodiT dafinanseba kargad ver exameba stacionarebis samedicino ekonomikuri standartebiT dafinansebis meTods. aseT SemTxvevaSi poliklinikas ar aqvs hospitalizaciis Semcirebis interesi, maSin roca stacionari dainteresebulia gazardos moculoba. praqtika gviCvenebs, rom aseT pirobebSi xdeba finansuri saSualebebis TandaTanobiTi gadanawileba stacionaruli momsaxurebis mxares (rac ekonomikurad araracionaluria). saWiroa poliklinikis ekonomikuri interesis stimulirebis uzrunvelyofa, stacionaruli momsaxurebis calkeuli saxe Tavis doneze gadmoitanos. ase magaliTad, momsaxurebis aseTi saxeebisaTvis poliklinikis dafinanseba mkurnalobis dasrulebuli SemTxvevis mixedviT (zog SemTxevvaSi Sesrulebuli samuSaos mixedviT anazRaurebis meTodiT). mniSvnelovania "fonddamWeris" (Fundholding) elementebis farTod gamoyeneba, anu stacionaluri samedicino momsaxurebaze gankuTvnili finansuri saSualebebis garkveuli nawilis poliklinikaze gadacema. samedicino momsaxurebis integrirebuli miwodebis sistemisaTvis, romelic axorcielebs rogorc poliklinikur, aseve stacionarul momsaxurebas, SesaZloa gamoviyenoT globaluri biujetiT anazRaureba. globaluri biujetiT anazRaurebisas suladobrivi normativi struqturul ganyofilebebs Soris momsaxurebis moculobisa da Rirebulebis Sesabamisadaa gayofili. aseTi meTodis erT-erT variants warmoadgens suladobrivi normativiT ganyofilebis nawilobrivi dafinanseba da sarezervo pulis formireba, romlidanac sadazRvevo organizacia afinansebs iseT SemTxvevebs, romlis mkurnaloba SesaZlebelia rogorc poliklinikurad, aseve stacionarulad, anu maT Soris konkurencia xorcieldeba damatebiTi finansuri saSualebebis mosapoveblad.

46

Information

Tengiz verulava

46 pages

Report File (DMCA)

Our content is added by our users. We aim to remove reported files within 1 working day. Please use this link to notify us:

Report this file as copyright or inappropriate

207270


You might also be interested in

BETA
Tengiz verulava