Komentar dr. Brigita Skela Savič: Zdravje mora imeti v politični perspektivi razvoja države ključno razvojno mesto

Življenjska doba človeka se v zadnjih desetletjih podaljšuje. Večina ljudi živi bolj zdravo in dlje, vedno bolj postajajo pomembne socialne in družbene determinante zdravja ter vlaganje v stroškovno učinkovite intervencije za krepitev zdravja, zmanjševanje neenakosti v zdravju in družbi. Analiza OECD »Health at a Glance« (2017) pokaže, da je dvig pričakovane življenjske dobe povezan z bolj zdravim življenjskim slogom, večjimi prihodki in boljšo izobrazbo posameznika.

Ni pomembno samo, koliko denarja za zdravstvo se porabi na prebivalca, temveč tudi, kako učinkovito so ti viri porabljeni.

DOLGOŽIVA DRUŽBA JE DEJSTVO

Ženske živijo v povprečju 5 let dlje kot moški, ljudje z visokošolsko izobrazbo živijo okrog 6 let dlje kot tisti z nižjo stopnjo izobrazbe. Povprečna pričakovana življenjska doba pri rojstvu je bila leta 2015 v državah OECD 80,6 let, leta 1970 pa 70 let.

Kratka analiza stanja v Sloveniji pokaže, da je današnja pričakovana življenjska doba 80,9 let. Zmanjšuje se smrtnost za srčno žilnimi boleznimi in rakom, povečuje se breme duševnih in kroničnih bolezni.

Kajenje in debelost ostajata aktualna javno zdravstvena problema, onesnaženost zraka je še vedno prepogosto spregledan javnozdravstveni problem, uživanje alkohola je naraslo v trinajstih državah OECD. Slednje predstavlja velik problem tudi v Sloveniji. Slovenci močno presegamo porabo alkohola na prebivalca in smo med 35 državami OECD na 5. mestu s porabo 11,5 litra, povprečje OECD je 9 litrov. V Sloveniji dosegamo dobre rezultate na področju racionalne rabe antibiotikov, zmanjševanja ležalne dobe, števila bolniških postelj na prebivalca, imamo pa priložnosti za izboljšave pri preživetju pacientov 30 dni po miokardnem infarktu, petletnem preživetju pri raku dojke, povečanju deleža cepljenja proti gripi, idr.

PORABLJEN DENAR ZA ZDRAVSTVO NARAŠČA 

V povprečju stroški za zdravstvo v državah OECD naraščajo. Ni pomembna samo poraba denarja na posameznika, temveč tudi, kako se viri povezani z daljšanjem življenjske dobe uporabljajo. OECD poudarja, da je potrebno nadaljevati z izboljšavami v dostopu do zdravstvene obravnave, zlasti na področju obravnave kroničnih bolezni na primarni ravni.

V Sloveniji za zdravstvo namenimo 2835 USD, povprečje OECD je 4003 USD, manj od nas v Evropi dajo države, ki so nastale z razpadom socialističnih držav ter Portugalska in Grčija, več pa vse druge evropske države, največ Švica (7919 USD), sledijo Luksemburg (7463 USD), Norveška (6647 USD), Nemčija (5551 USD), Irska (5528 USD), idr. (Graf 1).

GRAF 1: Health expenditure per capita, 2016 (or nearest year). Vir: Health at a Glance 2017 (stran 135).

Vendar vložek sredstev v zdravstvu ni v vedno v korelaciji s pričakovano življenjsko dobo ob rojstvu (Graf 2), pomembni mehanizmi so še učinkovitost zdravstvene obravnave, življenjski stil in v nadaljevanju razložene socialne determinante zdravja.

GRAF 2: Life expectancy at birth, 1970 and 2015 (or nearest year). Vir: Health at a Glance 2017 (stran 51).

Zagotavljanje ustreznih finančnih in materialnih virov je ključnega pomena za delovanje zdravstvenega sistema. Viri se morajo uporabljati premišljeno, da ne pride do nepotrebnega trošenja.

Delež BDP za zdravstvo v skupini OECD 35 je v razponu med 4,3% v Turčiji in 17,2% v ZDA, povprečje OECD 35 je 9%, Slovenija zdravstvu nameni 8,6% BDP (Graf 3).

GRAF 3: Health expenditure as a share of GDP, 2016 (or nearest year). Vir: Health at a Glance 2017 (stran 137).

Na ravni posameznika slovenska analiza Neenakosti v zdravju v času ekonomske krize (NIJZ, 2018) opozori na strukturo neposrednih izdatkov za zdravstvo iz žepa posameznika, ki se glede na dohodek zelo razlikuje, saj manj premožni trošijo predvsem za zdravila, bolj premožni pa bistveno več za ambulantne in zobozdravstvene storitve. Opazne so velike razlike v obsegu in strukturi neposrednih izdatkov za zdravstvo iz žepa v zadnjih desetih, kar bi lahko vplivalo tudi na povečevanje neenakosti v zdravju v Sloveniji.

V OECD 35, razen v ZDA, so viri financiranja zdravstva različne državne sheme in obvezno zdravstveno zavarovanje. Za stroške bolnišnične obravnave se v povprečju porabi 40% sredstev za zdravstvo. Število zdravnikov in medicinskih sester narašča od leta 2000 naprej. Povečuje se raba generičnih zdravil.

Staranje populacije zelo povečuje potrebe po dolgotrajni oskrbi. 13% starejših od 50 let tedensko neguje odvisne sorodnike ali prijatelje, 60% teh neformalnih oskrbovalcev so ženske.

Zato je ena od ključnih prioritet razvoja zdravstva in sociale zagotavljanje sistemskih pristopov na področju dolgotrajne oskrbe, saj bodo potrebe po dolgotrajni oskrbi z leti močno naraščale. Več o dolgotrajni oskrbi in potrebah neformalnih oskrbovalcev v zapisu »Zdravje in potrebe neformalnih oskrbovalcev v družini – izzivi dolgotrajne oskrbe v Sloveniji« (Skela Savič, 2018).

SOCIALNO-EKONOMSKI DEJAVNIKI IN ZDRAVJE

Socialno ekonomski dejavniki in življenjske razmere posameznika se vedno bolj izkazujejo kot pomembni mehanizmi, ki vplivajo na zdravje posameznika in na njegove življenjske navade.

Nizki osebni prihodki imajo učinke na slabo zdravje, vendar ta povezava ni linearna, medtem ko ima dolgotrajno pomanjkanje prihodkov dokazano negativne učinke na zdravje. Brezposelnost poslabša duševno in fizično zdravje posameznika, prav tako so pomembni pogoji za delo. Delo preko delovnega časa se izkazuje kot škodljivo za zdravje, povečuje stopnjo stresa in tveganja za srčno žilne bolezni. Nevarnost za poslabšanje zdravja predstavljajo še delo s škodljivimi substancami, nevarnost za izgubo dela in nezadovoljstvo na delovnem mestu (povz. Health at a Glance, 2017).

Slovenska analiza »Neenakosti v zdravju v času ekonomske krize« (NIJZ, 2018) ugotavlja slabše izide pri osebah z nizkim socialno-ekonomskim položajem, prikazanim s stopnjo dosežene izobrazbe. Analiza povzame, da sta zdravje in uporaba zdravstvenih storitev pri brezposelnih pričakovano slabša kakor pri zaposlenih, zato so brezposelni nedvomno ranljiva skupina, ki potrebuje usmerjene ukrepe.

IZOBRAZBA ZAGOTAVLJA BOLJ ZDRAV ŽIVLJENJSKI SLOG

Bolje izobraženi posamezniki in njihovi otroci živijo bolj zdravo, so manj odvisni od sprotnih prihodkov in redkeje izgubijo delo. Zato razvijejo bolj zdrav življenjski slog, so bolje informirani o zdravih in nezdravih vedenjih in praksah in več prakticirajo dobre prakse za ohranitev zdravja. So bolj poučeni o zdravstvenem sistemu, pravicah, uporabljajo preventivne in specialistične programe zdravstvene obravnave, kar ima svoje učinke zlasti na pojav in obravnavo kroničnih bolezni (povz. Health at a Glance, 2017).

Visoko izobraženi prebivalci Slovenije živijo dlje in so boljšega zdravja kot nižje izobraženi, zato nižje izobraženi prebivalci potrebujejo dodatno pozornost, da bi lahko izkoristili svoje potenciale, aktivno prispevali družbi in dočakali zdravo starost (NIJZ, 2018).

KADRI V ZDRAVSTVU

V Sloveniji smo na področju števila zaposlenih zdravstvenih delavcev in delavcev v sociali pod povprečjem držav OECD s 6,3 zaposlenega na 1000 prebivalcev (Graf 4).

GRAF 4: Employment in health and social work as a share of total employment, 2000 and 2015 (or nearest year). Vir: Health at a Glance 2017 (stran 151).

Naši kadrovski normativi so zelo nizki in z zaposlovanjem kadrov ne sledimo razvitim državam in posledično se tako soočamo z večjimi težavami z obvladovanjem zdravstvenih in socialnih problemov dolgožive družbe. Podobna situacija je s številom zdravnikov (Graf 5).

GRAF 5: Practising doctors per 1000 population, 2000 and 2015 (or nearest year). Vir: Health at a Glance 2017 (stran 153).

Pri številu medicinskih sester na 1000 prebivalcev smo na spodnji meji razvitih držav (Graf 6), vendar je podatek zavajajoč glede na realno stanje. Pomemben podatek za razumevanje Grafa 6 je, da je skladno z Direktivo 2013/55/EU za regulirane poklice izobraževanje za poklic medicinske sestre regulirano na visokošolski ravni. Direktiva vključuje minimalne pogoje za izobraževanje naslednjih zdravstvenih poklicev: zdravniki, zobozdravniki, medicinske sestre, babice in farmacevti.

V Sloveniji omenjeno Direktivo upoštevamo za vse navedene poklice, razen za medicinske sestre. Dejansko je v sistemu le 2,5 diplomirane medicinske sestre na 1000 prebivalcev, preostali 6,3 na 1000 prebivalcev so kadri s končano srednješolsko izobrazbo programa zdravstvena nega, ki po končanem strokovnem izpitu pridobijo strokovni naslov tehnik zdravstvene nege in se jih umešča v prvo od štirih ravni kompetenc v zdravstveni negi. Ravni kompetenc so: 1. tehnik zdravstvene nege, 2. diplomirana medicinska sestra splošne smeri, 3. diplomirana medicinska sestra specialistka, 4. magistrica/doktorica zdravstvene nege/zdravstvenih ved s kompetencami za napredne oblike dela v zdravstveni obravnavi. Več o ravneh kompetenc lahko preberete v Skela Savič (2017).

GRAF 6: Practising nurses per 1 000 population, 2000 and 2015 (or nearest year). Vir: Health at a Glance 2017 (stran 161).

Slovenija tako prikazuje napačne podatke o kadrih, ki jih lahko z Evropsko direktivo umeščamo v kategorijo »medicinske sestre« oz. ne doda opombe, ki bi pojasnila skupno število kadra v zdravstveni negi. Tehnik zdravstvene nege ni nosilec zdravstvene nege, nima licence za poklic, zato je preštevanje pomembno razumeti kot v primerih zobozdravnikov, ko višje dentiste (danes jih ne izobražujemo več) ne štejejo v kategorijo zobozdravnikov, ali primer Nemčije, ko zdravnikove asistente ne štejejo v kategorijo zdravniki.

Realno v Sloveniji zelo primanjkuje diplomiranih medicinskih sester in te množično zapuščajo slabo plačana in neurejena delovna mesta.

V njihove kompetence nenehno vstopajo tehniki zdravstvene nege, kar za obe skupini predstavlja velik stres in nevarnost za kakovostno zdravstveno obravnavo pacientov. Številne mednarodne raziskave so pokazale pomen stopnje izobrazbe medicinskih sester za zniževanje smrtnosti pacientov in incidentov, vendar slovenski zdravstveni management in Ministrstvo za zdravje žal tem usmeritvam ne sledita in še vedno se večinsko zaposluje srednješolsko izobražen kader v zdravstveni negi.

DOLGOŽIVOST JE DEJSTVO, NA KATEREGA SE JE TREBA PRIPRAVITI

Zbrani podatki publikacije »Health at a Glance« (2017) nas ponovno opozorijo, da je dolgoživost dejstvo, na katerega se moramo ustrezno pripraviti tako znotraj zdravstvenega in socialnega sektorja in obema nameniti več denarja in več kadrov. Zdravje državljanov oblikujejo tudi drugi dejavniki, kot so delovno in bivalno okolje, stopnja izobrazbe, brezposelnost, delovni pogoji, idr. Na to področje opozori tudi slovenska analiza Neenakosti v zdravju v času ekonomske krize (NIJZ, 2018).

Zaključimo lahko, da zdravje družbe dejansko sega v vse družbene sektorje in mora imeti v politični perspektivi razvoja države ključno razvojno mesto. Brez zdrave družbe ne bo mogoče graditi države, ki bi se umeščala med najbolj razvite države sveta.

Zato se na zdravje in zdravstveni sistem ne sme gledati kot ekonomsko kategorijo, temveč kot kategorijo, ki prinaša družbeno blaginjo, seveda ob upoštevanju učinkovite rabe vseh potrebnih resursov.

Prihodnost učinkovite zdravstvene politike je v upoštevanju socialnih in družbenih determinant zdravja, vlaganju v stroškovno učinkovite intervencije za krepitev zdravja, zmanjševanje neenakosti v zdravju in družbi ter v preprečevanju in obvladovanju kroničnih obolenj in postavitvi sistemov dolgotrajne in palitivne oskrbe. Za vse navedeno je nujen dialog o strategiji razvoja zdravstva, kadrovski in finančni politiki v zdravstvu tako na nivoju strokovnjakov, kot zdravstvenih managerjev, ki bo odgovorila na izzive, ki so pred nami.

Zdravje ljudi mora postati apolitična tema, o kateri se dogovarjamo brez elitizma, v interesu zdravja državljanov, vezivno tkivo naj bo med poklicno sodelovanje in spoštovanje.

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

Njen prispevek je bil objavljen na spletnem portalu Metina lista

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