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Researches Health System

 Vũ Thị Minh Hạnh, Nguyễn Thị Hồng Yến*, Trần Thị Hồng Cẩm, Trần Vũ Hiệp, Hoàng Thị Mỹ Hạnh, Vũ Thị Mai Anh, Trịnh Thị Sang, Nguyễn Việt Hà,Nguyễn Trọng Quỳnh, Hoàng Ly Na

* Administrative of Medical Services, MoH
Place of publication: Ministry of  Health
Year of publication:  2012
1. To review the implementation and outcomes of Project 1816, 2008-2011, 3 years after commencement;
2. To recommend solutions for effective implementation of Project 1816 and sustainability of the transferred techniques.
The survey site encompasses national level hospitals that have rotational outreach secondment and select provinces.
Methodology: Cross-sectional description, combined with retrospective study by mixed use of quantitative and qualitative data collection.  
Results and discussions
Background of survey sites: All the surveyed higher level hospitals have hospital bed use at or beyond 100%, including specialized hospitals. Some of the hospitals are in a serious overcrowding, such as Bach Mai hospital (165%), Cho Ray hospital (139%) and National Children’s hospital (119%). Most of the remaining hospitals are short-staffed compared to the existing norms. All destinations of rotated expatriate share a same status of health service delivery limitation. Most hospitals in these locations have not yet been able to provide the full list of services required for their respective levels of care. Local clients seeking medical care often have to rely on referrals or bypass the designated level of care. 
Project organizing and implementing processes: 100% of the surveyed sites have held project orientation internally, through regular briefings or major meetings with full attendance of departmental management and mass organizations. Project Steering committees have been in place at all levels of care and service sites. Needs assessment:  Survey mode employed: through statistical questionnaires, telephone; empirical vertical technical assistance; inviting senior officials and professionals from lower levels to higher entities for in-person interviews; or sending senior officials to service sites for observation and firsthand data collection; and reference to referral data from lower levels. 95% of province and district level hospitals have requested support from above, in which areas of expertise in need of assistance and the number of outreach staff needed are clearly listed. 100% of national level hospitals and 2 academy-affiliated hospitals have had project action plans in place. 
Progress after 3 years of implementation
Outreach staff rotation: 72 hospitals have had staff members sent on outreach missions. 3,954 national level personnel went on outreach mission over the three years. 269 province level hospitals sent 2,915 outreach staff members to support 360 district level hospitals. 305 district level general hospitals sent 4,434 health workers to support 2,116 commune health centers. Most of the rotated expatriates were men (61%). The middle-aged group takes up the majority (88.4%). More than 90% of the rotated expatriates are married. 70.4% of them have post-graduate qualifications. Over 60% of them have more than 3 years of working experience. Most of them have taken 1-2 tours (47.4% & 24.8% respectively). Notably, 3.6% of them have had more than 3 tours. The shortest tour lasts 5 days, whereas the longest is 90 days and the average tour duration is 63.6 days, which is longer than that found in the 9-month review (61 days). Most of the rotated expatriates are aware of the importance of the project (64%). 
Rotated expatriate’ contributions to lower health levels: On a national scale, after three years of project implementation, 2,493 training courses were delivered to lower level health workers by outreach personnel, with 66,403 participants. Three years into project implementation, 5,101 medical techniques across 26 specialties were transferred to the lower levels. The respective number of techniques transferred by province level professionals is 1,702. 
Recognition of lower health care levels for rotated expatriates: The great efforts of the majority of rotated expatriates have been well recognized and valued by the management and colleagues in lower level hospitals.
Initial influence of the project: The reputation and status of the source hospitals in terms of technical capacity have been enhanced. The lower levels’ health service delivery capacity has been significantly improved. Patients benefit from immediate access to hi-tech services, thus save costs in seeking medical care, while social security is improved. The paperwork hassle in health care has been relieved in part, as well as the health expenditure burden. Flexible forms of expertise sharing are created, including telephone and emails, in case specific clinical cases require. The relationship and technical partnership between various levels and specialist units are strengthened, creating a synergy for the entire health system. Albeit a stopgap solution, this approach has been particularly effective in upgrading the technical capacity for lower levels of care. It has contributed to translating Resolution 46 and Directive 06 in real life. 
Lessons learnt and challenges 
Lessons learnt
Upper level facilities: Segregation of duties should be down to the details for every member of the project Steering committee, tying the members to their responsible sites. Need assessment for lower levels should be truly fact-based and unbiased. A clear distinction of supporting methods between “take-over” sites and “transfer” sites should be drawn. Having staff members who are capable to receive the transferred skills is vital to the success of the whole exercise. Preliminary training is needed for lower levels before actually sending rotated expatriates to the field. A close link between technical assistance duties and project implementation needs to be established. Binding agreements should be signed with the receiving lower levels. Advocacy, orientation and persuasion for the employees should be strengthened, taking into account personal family background, when sending the staff out on outreach missions. Material and mental support should be extended to rotated expatriates.
Lower level facilities: Political commitment from local Party committees, governments and civil society should be leveraged. Partnership and networking with higher level hospitals are needed to explore potentials and enlist interest and support from them. Strategies for development of various techniques and services in the hospital need to be worked out. More advertisement of Project 1816 to the general public and community is needed.
Challenges and drawbacks
A number of upper hospitals seem inactive in surveying and planning. Some tend to send rotated expatriates out just for compliance purposes, resulting in the seconded personnel’s qualifications not meeting the lower level hospital’s expectations and needs. 
Many lower level hospitals seem inert and dependent on upper hospitals’ support, while they themselves are not quite ready to accept the new skills.  Majority of lower level hospitals lack strategic plans to develop specific techniques for their own benefit, resulting in poor sustainability and efficiency of the techniques and skills transferred from the upper level.
Specific general requirements in the project implementing guidelines seem irrelevant. Some of the existing policies are impractical.
Organization and implementation indicated actions: Elevating the pro-activeness and flexibility of participating entities; Adjustment of existing regulations that need improvement; Allocation of project funding needs adjustment by adopting lump sum approach for individual techniques to be transferred. Attaching project implementation with technical assistance; Integrating project outcomes as part of the criteria for annual all-round rating of hospitals; Tying project implementing outcomes with the movement for learning and following the ethical example of Ho Chi Minh, and implementation of other stated policies in the health sector; Regular update on the service delivery capacity of upper and lower hospitals, as well as related normative documents.
Supporting indicated actions: Advising the government to introduce a Decree on health workers’ social responsibility to enhance the regulatory effectiveness of the project; Adjusting specific non-optimal regulations on drug lists and equipment lists by levels of care, and HI reimbursing norms, to help ensure the sustainability of the techniques transferred to lower levels; The Ministry of Health needs to counsel the government on setting aside reliable public resources for this activity. Incremental formation and maintenance of a network of subsidiary hospitals and inter-commune clinics (by geographical areas); Taking initiative in developing a high quality workforce for lower levels of care by diversifying training modes and target groups; Updating and optimizing the remuneration system to attract and retain talents for lower levels of care, especially in remote areas and grassroots level.
Levels of care, especially in remote areas and frontline points of service.

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