Komentar dr. Brigite Skela Savič: Zdravje kot človekova pravica

Učinkovit zdravstveni sistem je ključni element za zdravo in pravično družbo, v kateri se zdravje razume kot človekova pravica, do katere dostop omogočimo s sodobnimi zdravstvenimi storitvami. Le te morajo biti zasnovane v racionalno mrežo, ki pokriva aktualne preventivne in kurativne potrebe državljanov danes in potrebe, ki jih lahko na osnovi spremljanja trendov in raziskovalnega dela napovemo v bližnji prihodnosti. Zlasti so pomembni preventivni mehanizmi krepitve in ohranjanja zdravja v družbi, razvijanje spodbud in odgovornosti za lastno zdravje vsakega državljana, presejalni testi, sodobna obravnava odkritih bolezni in zbiranje ustreznih podatkov o zdravju in boleznih državljanov ter njihova mednarodno primerjanje.

Prepričanje, da je zdravje človekova pravica, bi moralo biti temelj učinkovitega zdravstvenega sistema, katerega koristi imajo državljani in država. Pravica do zdravja in s tem povezana dostopna mreža zdravstvenih storitev ne sme biti samo fraza, temveč zaveza za politiko in vladajoče politične strukture, da delujejo konstruktivno s ciljem zagotavljanja najboljše zdravstvene obravnave za posameznika, skupnost in državljane.

Zato je za državljane pomembno, da dobro prisluhnejo, kaj o zdravju v družbi govorijo politične stranke in kaj dejansko naredijo, ko jim je zaupana možnost, da to področje vodijo. Kot državljane in davkoplačevalce nas mora zanimati učinkovit in integriran zdravstveni sistem, pri čemer učinkovit ne pomeni samo ekonomsko učinkovit, temveč se le ta v prvi vrsti kaže skozi mednarodne kazalnike zdravja in nacionalno postavljene kazalnike zdravja, ki so odzivni tudi na nacionalne in lokalne prioritete ter dostopnost do celostne skrbi za zdravje v družbi.

Še vedno je povezava med zdravjem populacije in ekonomsko rastjo premalo artikulirana. Investiranje v zdravje ohranja življenja, preprečuje bolezni, jih pravočasno odkriva in zdravi ter omogoča rehabilitacijo. Zdravje torej pogojuje uspešnost in učinkovitost družbe in nemogoče je pričakovati ekonomsko rast brez vložka v razvoj ljudi, tudi na področju njihovega zdravja. To bi bilo nedopustno in neetično. Skrbeti za zdravje ljudi je investicija v državno ekonomijo. Zdravstveni sistem je torej potrebno videti kot družbeno pomembni doprinos, ki ga izvajajo zdravstveni delavci in njihovi sodelavci in doprinaša k povečanju BDP.

Kako naj državljani prepoznamo v človeka usmerjene pristope v zdravstveni obravnavi?

Prva je investicija v zdravstveno pismenost v vseh življenjskih obdobjih, ker le ta omogoča, da državljan osvesti svojo vlogo in vlogo države pri krepitvi in ohranitvi lastnega zdravja. Sledi vključevanje strokovnjakov, znanstvenikov, neprofitnih organizacij, lokalne skupnosti in predstavnikov pacientov v analizo in razvoj zdravstvenega sistema.

V človeka usmerjena obravnava je danes prepoznani temeljni pristop, kako se zdravstvena obravnava izvaja. Pomeni obravnavati človeka, pacienta, njegove bližnje, oskrbovalce in druge sodelujoče z dostojanstvom, s spoštovanjem in sočutjem. Pomeni vključiti jih v odločanje o zdravju, zdravljenju, zdravstveni negi in oskrbi. Pomeni delati stvari z ljudmi in ne za njih. V človeka usmerjena obravnava ima z raziskavami dokazane koristi, saj znižuje ležalno dobo, manj je nujnih obravnav,  sprejemov v bolnišnico in napotitev do specialistov, manj laboratorijskih in invazivnih preiskav, prej so prepoznani pacientovi problemi, boljše so možnosti pravilnega zdravljenja in predpisovanja zdravil, poveča se možnosti pacienta za samooskrbo, idr. Daje koristi za udeležence obravnave, zdravstvene delavce kot izvajalce, zdravstveni sistem in celotni družbi.

Naslednje pomembno področje so oblike pomoči in skrbi za ljudi na domu, integracija zdravstvenih in socialnih potreb človeka, ki zahteva med sektorsko povezovanje za dobro človeka. Dolgoživa družba od nas zahteva povezovanje na ravni pacienta, družine, zdravstvenih delavcev in oskrbovalcev. Storitve, ki jih moramo razviti na področju dolgotrajne oskrbe zahtevajo od nas etično odgovornost, da končno uskladimo sektorje, financiranje storitev in ponudimo storitve v okviru zdravstveno – socialne skrbi za človeka. Če sta sektorja zdravstvo in sociala v naši  državi ločena, to še ne pomeni, da človek nima sočasno problemov na obeh področjih.

Zdravstveni sistem ne more biti učinkovit, če si desetletja zatiskamo oči pred postavitvijo  kadrovskih normativov in standardov dela, če ne sledimo razvoju zaposlenih v zdravstvu, kot ga izvajajo v razvitih državah in za to posledično ne uvajamo novih storitev, ki bi jih lahko izvajali z ustrezno usposobljenimi zdravstvenim delavci. Že pred desetimi leti smo v državi uvedli Bolonjski sistem izobraževanja, sistematizacija delovnih mest in pogoji za zasedbo delovnih mest za zdravstvene poklice na ravni strokovnih magisterijev pa temu ne sledijo. S tem izgubljamo priložnosti, da se znanja in kompetence dosežene v izobraževanju prenesejo v zdravstveni sistem, kar bi mu dodalo znanja s področja spremljanja in razvoja lastnega dela, razvoj samostojnih in naprednejših oblik dela za prerazporeditev del in nalog v zdravstvenem timu, znanja o na dokazih podprtem delu, kakovosti, varnosti in še bi lahko naštevali.

Naše zavzemanje za kakovost in varnost je na ravni pridobivanja različnih standardov in dragih akreditacij, o tem da bi sistematično izmerili učinke slednjega na izide zdravstvene obravnave, pa nimamo povratnih informacij. Kje smo torej s kakovostjo in varnostjo? Ali imamo sistematično zbrane reprezentativne podatke iz vseh nivoje zdravstva? Seveda se ne rabimo vprašati ali se investicija v kakovost splača, to so potrdile že številne raziskave, pomembno je, kako se uvajanja kakovosti in varnosti v zdravstvu lotimo v državi.

Kako na torej deluje zdravstveni sistem, da bo zagotavljal pravico do zdravja?

Celovito skrb za zdravje ljudi bomo dosegli z jasno nacionalno vizijo in strategijo za doseganja ciljev na tem področju. Le ta se naj ne spreminja glede na vladajoče stranke, temveč naj izhaja iz dejstav, da je zdravje državljanov javno dobro in pomemben resurs za uspešno in zadovoljno družbo.

Zdravstvena služba naj bo dostopna, učinkovita, varna, v človeka usmerjena, minimizira naj neracionalne rabe resursov. Zdravstveni delavci naj bodo odzivni, pošteni, učinkoviti, dostopni, pravično razporejeni, zagotovljeni naj bodo ustrezni kadrovski normativi, ustrezna naj bo med poklicna  zastopanost, kompetentnost in produktivnost dela. Vodenje, menedžment in upravljanje naj temelji na transparentnih nacionalnih regulatorjih, spodbudah, odgovornostih, razvite naj bodo strateške in taktične usmeritve za zdravstveni sistem v državi, ki niso odvisne od aktualne politike. Zdravstvena informatika naj zagotavlja ustrezno zbiranje, spremljanje in analize podatkov, razširjanje in uporabo zanesljivih in pravočasnih informacij ter izboljševanje storitev.

Financiranje zdravja naj zagotavlja takšne vire za zdravstveni sistem, da se na osnovi analiz zdravstvenih potreb načrtujejo zdravstvene storitve, pri tem pa naj bodo državljani zaščiteni pred finančnim izčrpavanjem zaradi zagotavljanja zdravstvenih storitev. Medicinski produkti, vakcine in tehnologije naj bodo pravično dostopni, zagotovljena naj bo njihova kakovost, znanstveni pristop pri izdelavi in uporabi le teh ter stroškovno učinkovita raba. Za zdravje državljanov bomo morali nameniti več BDP, ob tem pa izvesti celovito reformo zdravstvenega sistema iz organizacijskega, stroškovnega in vsebinskega vidika.

Slovenija mora slediti smernicam in praksam razvitih držav na področju usposobljenosti managerjev v zdravstvu, saj je situacija trenutno taka, da lahko direktor zdravstvenega zavoda postane vsakdo z nekaj vodstvenih izkušenj. Prav tako je imenovanje direktorjev zdravstvenih zavodov preveč spolitizirano. Takšno delovanje močno odstopa od mednarodnih priporočil in praks, da je za vodenje zdravstvene organizacije potrebno imeti znanja, ki se najpogosteje pridobijo na podiplomskih programih izobraževanj in usposabljanj. Le z znanji o zdravstvenem sistemu in okolju v katerem sistem deluje, specifičnostmi vodenja, veščinami in principi poslovanja v zdravstvu ter razumevanjem profesionalizma različnih skupin zdravstvenih delavcev, bo direktor zdravstvenega zavoda pripravljen za delovanje v specifičnem okolju. Prav tako je potrebno za člane svetov zavodov zahtevati obvezno usposabljanje za prevzem funkcije.

Naslednja pomembni korak je prenova zdravstva kot sistema z opredelitvijo funkcij in odgovornosti,  s čemer mislimo na vsaj tri funkcije. Prva je izvajanje zdravstvenih storitev iz vidika opredelitev vsebine, količine, kakovosti in učinkovitosti izvedbe in merjenja izzidov na nacionalni ravni in sodi v kategorijo primarne funkcije. Druga je spajanje zdravstvenega zavoda z okoljem na strokovni, medresorski, državni in mednarodni ravni in sodi v skupino sodelovalne in razvojne funkcije. Tretja je odgovornost za dostopen, učinkovit in v razvoj usmerjen zdravstveni sistem na ravni zdravstvenega zavoda, zdravstvenega sistema in družbe, ki sodi na polje funkcije družbene odgovornosti za zdravje v družbi.

Nacionalna mreža javnih zdravstvenih zavodov in zdravstvenih storitev glede na demografijo in potrebe po zdravstvenij storitvah ima za cilj povezovanje vseh ravni zdravstva kot organizacijskih sistemov, določitev mreže zdravstvenih zavodov in mreže storitev na primarni, sekundarni in terciarni ravni s ciljem racionalizacije, stroškovne učinkovitosti, varnosti, večje dostopnosti in strokovnega in raziskovalnega povezovanja. Hkrati z oblikovanjem nacionalne mreže javnih zdravstvenih storitev je potrebno oblikovanje »novih«, mednarodno primerljivih storitev na področju krepitve zdravja, stanj povezanih z dolgoživostjo populacije, preprečevanja, zgodnjega odkrivanja in celovite obravnave kroničnih obolenj, s čemer se bo povečala dostopnost do zdravstva, kakovost in učinkovitost zdravstvene obravnave ter zdravje družbe.

To se kaže v uvedbi mednarodo primerljivih in uveljavljenih naprednih oblik dela ali napredne prakse (»Advance practice«) različnih zdravstvenih strokovnjakov z zaključenim strokovnim magisterijem, ki imajo kompetence za poglobljeno samostojno strokovno delo s pacienti in za vodenje, spremljanje in izboljševanje področja dela. Ta področja delovanja so kronične bolezni, tveganja za nezdrav življenski slog, zdravje otrok in mladostnikov v šolah, duševno zdravje v skupnosti, zdravstveni problemi starostnikov in ranljivih družbenih skupin, zdravje v ruralnih področjih, idr.

Postavi se tudi vprašanje, ali imamo v državi dovolj strokovnih in znanstvenih informacij za odločanje o stanju v zdravstvenem sistemu v državi iz vidika organizacije in procesov dela, kadrov, obsega storitev, menedžmenta, zdravstvene ekonomike, kakovosti in varnosti, učinkovitosti, idr. Uvajanje izboljšav je v razvitem svetu prepoznano kot znanost (health care impovement science), ki proučuje  zmogljivosti zdravstvenega sistema, načrtovanje storitev, izboljšav in novosti v sistemu organizacije, financiranja in razvoja zdravstvenega sistema, pričakovanih in razvijajočih kompetenc zdravstvenih delavcev, idr. Če želimo reformiratii zdravstveni sistem in doseči trajne spremembe, moramo delovati na pospeševanju uvajanja mednarodno uveljavljenih dobrih praks, uvajati na dokazih podprto delovanje zdravstvenega sistema na vseh področjih (stroka, upravljanje, pacient) in lastno delo sistematično spremljati, analizirati in izboljševati.

Sistematične pristope na področju kakovosti in varnosti lahko dosežemo le z nacionalno akreditacijo zdravstvenih zavodov (javnih, koncesioniranih, zasebnih), ki temeljijo na postavljenih standardih, normativih in merjenju učinkovitosti dela. V ta namen je potrebno izdelati nacionalna merila za akreditacijo zdravstvenih zavodov v skladu z mednarodnimi smernicami, standardih in priporočilih v EU, ki naj bo razvijajoči se dokument v smeri večanja zahtev ob vsaki naslednji akreditaciji. Akreditacije zdravstvenih zavodov naj bodo kot obveznost za delovanje in morajo biti brezplačne, izvaja jih naj nacionalna agencija za kakovost v zdravstvu v sodelovanju z mednarodnimi strokovnjaki. Mednarodna akreditacija naj bo sekundarni pristop in odločitev zdravstvenega zavoda in ne more nadomestiti nacionalne.

Državljani Slovenije morajo imeti enak dostop do vseh oblik zdravstvene obravnave, čakalne vrste naj bodo usklajene s smernicami za dopustne časa čakanj, enoten sistem naročanja naj bo odgovor na nedopustne razlike v doseženih cenah za zdravila in zdravstvene materiale. Pri oblikovanju enotnega sistema naročanja se naj Slovenija poveže v Evropske mreže za javna naročil. Prav mreženje med državnimi zdravstvenimi sistemi bi lahko pripomoglo k odpravi čakalnih vrst, primerna je tudi izmenjava kadrov na področju redkih bolezni, saj v 2 milijonski državi sami ne moremo poskrbeti varno za vse redke bolezni.

dr. Brigita Skela Savič je znanstvena svetnica in izredna profesorica na Fakulteti za zdravstvo Angele Boškin

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