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Researches Health System

Nguyễn Thị Xuyên*, Lê Quang Cường, Vũ Thị Minh Hạnh, Trần Thị Hồng Cẩm, Hoàng Thị Mỹ Hạnh, Vũ Thị Mai Anh, Trần Vũ Hiệp, Hoàng Ly Na

* Ministry of Health
Place of publication: Ministry of Health
Year of publication: 2010
The Health Strategy and Policy Institute, in cooperation with the Legislation Department, Ministry of Health, conducted this evaluation of 18-year of implementing of the law on examination and treatment (since the Law on People’s Health Protection and Care was in effect from 1989 to 2008) in Vietnam to collect evidence for legislative drafting and identify gaps in the existing regulatory system to recommend inputs for the Project: Law on Medical service delivery with a view to achieving fair treatment between the public and private sector and equity in health protection, care and promotion for the people.

(1) Review and examine existing normative documents directly or indirectly related to health care; (2) conduct case study of laws on medical care of specific countries in the region and the world; (3) review the present state of medical care legislation and enforcement; (4) identify gaps and challenges in terms of contents and implementing approach; and (5) recommend ways to update and improve the draft Law on Medical service delivery and enforcement once the law is in effect.
Methodology: This is a case study review. Qualitative and quantitative study approaches are jointly used. The study covers 8 provinces, including Ha Giang, Lam Dong, Bac Giang, Ha Tinh, Kien Giang, Hoa Binh, Binh Duong and Phu Yen.

Context of the regulatory system on health service delivery in Vietnam: Since 1989, as many as 250 normative legislative documents pertaining to medical care have been released and are still in effect, and 84 other documents are no longer in use. The patient’s as well as physician’s rights and obligations, despite having been addressed in the existing legal system, remain perfunctory and not detailed enough. The current legal framework only defines the responsibilities of medical services in case of emergency care, while other common types of medical care are not included. Forms of medical practice and requirements for newly formed health institutions are defined in details for the private sector. The existing regulatory system only addresses practitioner certification of heads of private medical services who are Vietnamese nationals. Regulations on clinical and technical aspects in medical care are mostly present in ministerial level legislation. 
International laws on medical care and applicability in Vietnam
The patient’s rights: the rights to decide on personal health care issues, to select a representative, to be provided with necessary information, medical papers and records during treatment, and so on. The practitioner’s obligations: more responsibilities to the patients, co-workers, profession and society; additional regulations specifying that an individual practitioner is allowed to own one private clinic, practitioners are not allowed to delegate control of their private clinics to a colleague, among others.
Context of orientation, dissemination and implementation of laws and regulations on medical are in specific municipalities
           (1) Education and dissemination of legislation on medical care: Timing for legal education and dissemination remains spontaneous and inconsistent. Education and dissemination work often takes place in an undisciplined manner both in terms of timing and resources preparation. There is no consistent mechanism in the country’s health sector which clearly defines who is responsible for being the focal point for introduction, orientation and implementation of normative documents. Education and dissemination are mostly directly done by health agencies. Television, medical staff and village health workers are the channels through which health-related laws and regulations are communicated to the public with the highest ratios (87.5%, 77.3% and 71.4% respectively). Depending on the topic and scope of the specific policy, orientation and dissemination may be conducted on one or more audience groups. The ways legislation is communicated and introduced are wide-ranging and pluralistic, with distinct variance by levels of care: the province, district and commune. People doing orientation work are mostly part-time staff and lack the kind of expertise needed for legal communication to different levels of health care both in and outside the health sector. Funding limitations are common. Communication and dissemination of regulatory instruments in the local context over the years have made impressive progress, improving the level of understanding of all parts of the society, especially the common people, about laws on medical care. But for different reasons, the knowledge on laws on medical care of related groups seems to remain below expectation. 
 (2) Implementation of laws on medical care: Implementing documents of laws on medical care often center on itemization of the provisions, how the rights in health care of special groups are observed and user fee. The main audit and monitoring method is self-supervision, where the umbrella organization or mass organization of various levels does the monitoring. Funding for this area of activity has not been included in the regular budgetary plan. Audit plans are made every year, while staffing inadequacy remains common, with the mostly used audit mode being professional auditing. Again, funding for this category of operation is barely sufficient. Sanctions against law infringement in the area of medical care: underway despite various challenges and setbacks due to the absence of an implementing mechanism, lack of details and clarity of the implementing documents, and so on. 
(3) Compliance, enforcement and application of laws on medical care by medical practices and patients On the side of medical practices: compliance with general rules on health service delivery; compliance with clinical and technical protocols; introduction of the right preferential policies in health service delivery for special beneficiaries; improved enforcement of hospital rules. On the side of the patients: Compliance with regulations on division of levels in health care; eligible rights and benefits in health care catered to.
The impact of the Law on People’s health protection and care on health service delivery in Vietnam over the years: The health network has been improved over time, while the quality of care becomes better. Access to health services is increased, especially among beneficiaries of social welfare policies. Available resources for health are expanding, while health indicators are incrementally improving.
Challenges and drawbacks
(1) Education, dissemination and implementation of normative documents: Focal implementing agencies in the health sector are not really reliable and aligned in terms of organization. The main workforce for this area of activities on the ground is in shortage, both in terms of number and quality. The annual action plan in the health sector of all the 8 provinces are not yet in existence. No funding allocations are available in the annual budgetary plan of the local Health Departments. How the normative documents are disseminated and implemented has not been consistently communicated to the municipalities. Low levels of public awareness and language discrepancy among the communities emerge as major barriers to the translation of the normative documents in real life. The awareness of the significance of educating and disseminating the policies and enforcement of a portion of local authorities, managers and population remains to be improved.
(2) Irrationalities of legislative implementing documents: The enactment process of implementing documents for health-related laws in general and laws on medical care contains considerable inconsistency and isolation from actual needs. While normative instruments on health service delivery are in general well-written, some implementing documents remain inconsistent and divorced from reality. Implementing documents do not hinge on necessary conditions for the provisions of the law to rapidly take effect in the real world. Some of the implementing documents are not revised despite being clearly outdated. Some new documents are contradictory to existing and in-effect ones.
(3) Lack of consistency and inclusiveness in terms of contents and scopes of the existing normative documents on health service delivery
Remuneration for medical workers: the existing compensation system for health workers offers not much distinction along different positions and qualification, where health workers’ pay grades are defined by number of years in service, rather than education, competence, responsibility or workload. Allowances for public health workers are not proportionate to their work efforts. Leave compensation for health workers can hardly be materialized in many medical practices due to their already understaffing situation. Career incentives are not reasonable, as preferential treatment by length of service for staff members of Health Departments is absent and no occupational insurance for health workers is available, and so on.
Existing gaps in regulations on user fee and health insurance (HI): The existing below-par user fee schedule is causing all sorts of problems to health providers. Regulations on HI-related medical care at commune health centers, especially on the HI-related drug list at the commune level fall short of meeting the clients’ medical needs.
Drawbacks in regulations on medical care for special groups: regulations on free medical care for under-6 children under Circular 14/2005/TT-BYT; regulations on medical care for dwellers of ethnic and disadvantaged areas under Decision 139/2002/QĐ-TTg on health service delivery to the poor, and so on.
Gaps in regulations on the organization of the health system: the position and title chart for health workers in commune health centers remains irrelevant, while staffing rules for medical practices, particularly at the province and district levels are very restricted, hindering expansion and upgrade of service quality.
Gaps in regulations on private medical practice: Circular 07/2007/TT-BYT, May 25, 2007, providing guidelines on private medical practice, traditional medicine and medical equipment provision, and application forms for private medical practice are introduced without national consistency, making it difficult for local Health Departments in adopting ISO standards in government administrative procedures. 
In implementing the provisions of the Law on People’s health protection and care, the normative system for health service delivery in Vietnam has been updated, perfected and proven effective in real life over the years. International laws related to health service delivery often address specific aspects of medical care, coupled with detailed and complete implementing guidelines for each item. Education and dissemination of normative documents have been done on a regular basis in diverse forms, involving many line agencies, mass organizations and civil society. Implementation of laws on health service delivery has been high on the agenda of the municipalities to date. 
1. In respect of what needs to be present in new normative instruments to be released soon and amendment of existing legislation: issues related to the rights and obligations of patients; rights and obligations of medical practitioners, rights and obligations of medical practices, institutional health providers and individual health providers, including regulations on professional protocols in medical care, medical malpractice, curative care and addressing patients’ grievance on medical malpractice, use of new techniques and new cures.
2. Ways to increase effectiveness in education and communication of laws on medical care and implementation of the regulatory system in practice: Increased review and assessment of the existing regulatory system; renewal of the production of implementing documents for normative instruments; development and introduction of guidelines on the protocols for communication, dissemination and implementation of normative documents; provision of guidelines on organizational structure and staffing; supporting local health authorities in annual action plan preparation; increased fund allocation for legal education; further promotion of the role of the Legal education committee; Increased information, education and communication. 

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