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Researches Health System

Lê Quang Cường, Trần Thị Mai  Oanh, Trần Văn Tiến*, Dương Huy Lương,
Khương Anh Tuấn, Nguyễn Khánh Phương, Phan Hồng Vân,
Amy Taye**, Jim Setzer**
*Department of Health Insurance, MoH;  
**Abt Associates, United States
Place of publication: Ministry of Health
United States Agency for International Development
Abt Associates, United Sates
Year of publication: 2010

Objec tives
The Health Systems 20/20 project in collaboration with the Health Strategy and Policy Institute recently conducted a sub-national health systems assessment in 6 provinces in Vietnam, complemented by a review of multiple national assessments done recently.
The methodology was based on USAID’s Health Systems Assessment Approach1 adapted to the Vietnamese context. Data and information were collected for all 6 health systems modules: governance, financing, service delivery, human resources, pharmaceuticals, and HIS.  Information in each module is divided into system components and then subdivided by indicators within those components.  The indicators are scored from 1-3, with one being “not adequate” and three being “highly adequate”. Scoring is based on a defined set of criteria for each indicator. The health systems assessment report provides scores for indicator and component data collected in Hanoi, Ho Chi Minh City, Hai Phong, An Giang, Quang Ninh, and Nghe An Provinces. 
Main Findings
Findings are presented by module. The assessment tool allows us to point to the components and indicators which are areas for concern and make recommendations for improving health system function.
The study results showed strong government involvement in monitoring health service providers. Community institutions and civil society also play important roles  in oversight of health service quality. All public health care facilities in Hanoi and in the 5 provinces are implementing the hospital autonomy policy. The policy encourages hospitals to provide new health care services, install new equipment, and increase patients’ access to health services.
Although health systems in all 6 provinces generally received scores of “adequate”, the oversight function, “licensing, certification of health service providers, and the oversight of health providers by non-government organizations”, were evaluated as “not adequate”, due to the absence of licensing procedures for public health professionals and absence of accreditation procedures for public health providers.
Total health spending per capita is increasing annually in all 6 provinces and varies by province. In Hanoi, total health spending per capita increased from 7 USD in 2005 to 30USD in 2008; in Hochiminh city, this indicator increased from 23USD in 2005 to 39USD in 2008. In other provinces, these indicators are less than 20USD per capita. However, these provincial level figures do not include OOP spending, which continues to account for a major share of per capita spending on health services (about 70%).
Approximately 42% of the population of Viet Nam is covered by health insurance. The new Law on Health Insurance enables people with health insurance cards utilize high-tech services. They will be paid a maximum of about 1,500 USD per in-patient visit. Findings from focus group discussions showed that the poor in studied provinces are able to access health care services in hospitals, except some mountainous areas of Quang Ninh, where they sometimes struggle with costs which are not covered by health insurance (such as transportation). There is a tendency for financial resources of the health insurance fund not being used efficiently, partially due to user-fee-based payment method. Monitoring of service provision reimbursed by health insurance is inadequate due to a lack of managerial capacity and a lack of standard treatment guidelines for hospitals.
Findings from the six study provinces showed that provincial allocations are not adjusted according to different disease patterns or ability to collect revenue in each province. Local health budgets are approved by the Provincial People’s Council. However, funds available in many localities are insufficient to cover the total amount approved.
Service Delivery
Overloaded hospitals are a serious issue in Ha Noi, Ho Chi Minh city and Hai Phong. The overload in Hai Phong sampled hospitals is especially serious, indicated by two indicators: the high bed-population rate per 10,000) and occupancy rate is nearly 140%. Every commune in the 6 provinces has a CHS. More than 70% of primary care facilities are adequately equipped (varies by province).  One area of concern is that CHSs infrastructure is worn and out-dated in some communes and need to be repaired or updated. It is difficult for people to access good quality health services in some commune CHSs and also at some district hospitals. The number of medical doctors working at the commune level is decreasing in all 6 provinces. Generally, the EPI program in all 6 provinces has been successful. Paradoxically, the EPI program in the two biggest cities did not achieve as good of results as the other provinces. This is due to urban migration. Hanoi and Ho Chi Minh city have high percentages of people who come from other provinces and stay in the cities without registration. Therefore, Government authorities do not list names of immigrant children for immunizations resulting in lower percentages of fully immunized children in those cities.
Human Resources
Generally human resources management in the six study provinces is adequate in terms of number of human resources for health available to achieve the MDGs. However, most of the 6 provinces are coping with issues of health professional imbalances: mal-distribution of HRH between rural and urban areas, unequal distribution between fields of medical practice (curative care and preventive care), and improper health professional mix in term of assuring comprehensive care. They are also faced with issues of losing health professionals from public sector to private, particularly in big cities. The performance management system is not strong enough. Of the 3 provinces with job descriptions, the descriptions were only available for certain positions. Mechanisms for in-service training facilities, licensing for health practitioner is not strong enough to ensure the quality of HR in both public and private. 
The links and “feedback loops” between the health care system and pre-service training institutions are not fully functional. Only Ho Chi Minh city, Ha Noi and Hai Phong have established relationships with training institutions such as Hanoi Medical College, HCM Medical and pharmaceutical College, Haiphong medical College. Other provinces including Nghe An, Quang Ninh and An Giang have a passive link with the training and education institutions.
Pharmaceutical Management
Emergency procurements are rarely required and only for a few categories of drugs. Data on adverse reactions of drug is consistently reported in all health facilities including private ones, but there is no system for the collection of data regarding the efficacy, quality, and/or safety of marketed pharmaceutical products. 
Different modes in purchasing medicines were applied in the six provinces. In public hospitals, all medicines must be purchased through competitive bid. In Hai Phong, Quang Ninh and Nghe An, bidding for drug procurement is held by Provincial Health Bureau. In An Giang, for provincial hospitals, bidding for drug procurement is held by Health Bureau, but district hospitals use bidding results from the provincial hospital (in An Giang). In Ha noi and HCM City, hospitals can conduct bidding separately. Among the three indicators measuring the financing component in the six provinces, cost control received "not adequate" score. This result reflects the fact that although cost control measures exist but are not consistently enforced. The most common measure for price control of medicines is price  posting for retail drugs.
In all public hospitals, the common practice implemented to improve the use of medicines is to establish a Therapeutic and Drug Committee. However, this committee does not always function well. The most critical issue is the absence of national standard treatment guidelines (except for some priority diseases). Some hospitals have developed their own treatment guidelines, but they are not standardized or consistently applied.
Health Information Systems
In Vietnam, annual, bi-annual, quarterly and monthly reporting is strictly regulated. Every province and district is responsible for timely report submissions. Currently, there is no defined mechanism for reviewing and verifying the quality of data. Factors that may cause low data quality are: compulsory usage of an impractical software (Medisoft); problems verifying the accuracy of private sector data;, and a lack of historical data, even from the previous year.
At central levels, the officials do not provide feedback on reports that they receive from lower levels. At provincial level, the Health Bureaus only received feedback if they feel there is something abnormal in the report.
There is a lack of collaboration and information sharing within the health sector and with other sectors. Overlaps in information collection, variations in data reported across ministries, and information that fails to meet the needs of users, are all common concerns within the national health information systems.
Although there were efforts to use evidence to formulate health policy and strategic plans at all levels of health care in all six provinces, it is recommended to develop a more efficient health management information system. The HMIS should include financial and human resources management data. This software program should include all core indicators for monitoring and planning purpose and the data need to be updated regularly and to make sure that reliable data on this area is always available.
To ensure equity and efficiency in the health system and in the poverty-reduction policy, it is necessary to prioritize health-financing solutions with an orientation towards:
1. Increasing the share of total national health spending from public sources. The increased government budget should focus on priority areas, including: (1) strengthening the grassroots health care network and developing preventive medicine; (2) supporting health care for groups in need of social protection, including people who have rendered meritorious service to the nation, the poor, the near-poor and ethnic minority people and (3) providing support for disadvantaged areas.
2. Expand health insurance coverage to protect the population from the risk of impoverishment resulting from catastrophic health spending through effective implementation of risk pooling.
Provider payment methods should be adjusted so that they incentivize cost-effectiveness and quality assurance in public and private hospitals.
In order to improve effectiveness of health service delivery and make health care accessible for everyone in the community to achieve universal coverage, it is necessary consider following recommendations:
1. Quality of health care services at grass-root level (including health services provided at commune and district level) need to be improved in order to ensure that people can access quality health care services in their communities.
2. Reorganizing health services and primary care at CHSs in order to meet people’s needs and expectations in health care, including updating and refurbishing infrastructure.
3. Beyond improving HMIS within hospital for better management, it is also necessary to strengthen health management information system at the community level to ensure that everyone’s health in the community is monitored and managed.
Develop and implement appropriate policies for human resources development which include training, recruitment and retention especially at grass-root level.
Findings from assessment on pharmaceutical management in six provinces suggested several measures to strengthen this area:
1. National standard treatment guidelines urgently need to be developed, applied in hospitals and used to supervise quality of care.
2. More specific guidelines on drug procurement should be issued.
3. Strategic cost control measures should be implemented to improve access to medicines
4. The Drug Administration should have annual reporting requirements.
In order to have better health management information systems, it is necessary to:
1. Provide practical, well designed software, to be used widely in the health care system, even at grass-root level.
2. Define a strategy for verifying quality of data collection throughout the system (applied for all levels, all kinds of health facilities, public and private).
3. Provide training on health information data collection and processing as well analysis, especially, in Provincial Health Bureaus.

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