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Researches Health System

Lê Quang Cường, Lý Ngọc Kính*, Cao Hưng Thái*, Phạm Văn Tác**, Vũ Thị Minh Hạnh, Trần Thị Mai Oanh, Trần Thị Hồng Cẩm, Hoàng Thị Mỹ Hạnh, Trần Vũ Hiệp, Vũ Thị Mai Anh 

* Administrative of Medical Services, MoH; ** The Personnel Department, MoH
Place of publication: Ministry of Health
Year of publication: 2009
On 26/5/2008, the Minister of Health signed Decision 1816/QD-BYT, which approves the Project “Fielding rotated professionals from upper level hospitals to lower levels to improve the quality of medical care”. The project objectives include: To improve the quality of medical care at lower levels, especially in the mountainous, remote areas with staff shortage; To reduce overcrowding for upper level hospitals, especially central level hospitals; and To transfer technologies and conduct on-site training to improve skills and qualifications for lower level health care professionals. The project has worked and to ensure the sustainability it is needed to carry out an assessment of the implementation in the last period to identify emerging issues as well as barriers to remove, thereby making recommendations on more appropriate and feasible solutions. 
To evaluate the organization for project implementation at levels.
To identify initial results of 1816 project implementation.
To analyze advantages and disadvantages during project implementation.
To recommend solutions to improve the effectiveness, ensure sustainability of 1816 project implementation in the next future.
This is a cross-sectional survey in combination with retrospective analysis, using both quantitative and qualitative data collection methods. In all, there are 29 group discussions with Project Steering Committees at levels, 60 in-depth interviews with health leaders from central to grassroots level and leaders of province’s People’s committees, questionnaires delivered to 389 staff on rotation at lower levels.
Research locations 
Institutions sending rotation staff: Central level hospital: Bach Mai Hospital, Hue Central General Hospital, Cho Ray Hospital; Central specialized hospitals: National Hospital of TB and Lung Diseases, National Pediatrics Hospital, Vietnam-Germany Friendship Hospital; 1st Degree Hospitals of 3 large cities: Saint Paul (Hanoi), Viet-Tiep Hospital (Hai Phong) and Gia Dinh People’s Hospital (Hochiminh city). 
Localities: 5 provinces receiving rotation staff from upper levels include Tra Vinh, Dien Bien, Ha Nam, Quang Nam and Dak Nong.
Key findings
Organization for implementation: 
All surveyed institutions have organized for disseminating this MOH policy to crowded staffs. 
All institutions at central level, more than 95% of institutions at provincial and district level have established Steering Committees to carry out the project.
All central level hospitals, 97% of provincial level and 98% of district level have developed plans to implement the project. 86.1% staff prepare plans before rotation.
93% central level hospitals, 76% provincial hospitals have conducted supportive monitoring for rotation staff.
Results after 9 months of project implementation: 
There are 1,794 high technical qualification staffs in surveyed institutions rotated from upper level hospitals to lower ones.
More than 90% of staff understand the importance of project implementation; more than 85% of them are ready to carry out the job; 78% have seriously complied with rotation decision; 85% have successfully accomplished given tasks …
Central level hospitals have transferred to lower levels 80 clinical and bi-clinical techniques. Relevant data for provincial and district hospitals are 110 and 90.
Upper level hospitals have provided many new equipment for lower levels, old medical devices have been restored and put back into operation.
There are 139,661 patient visits directly attended by rotation staff from upper level hospitals; 97,415 patient visits with direct treatment and 6,529 cases of operation.
Technique implementation processes at many lower level hospitals have been guided by rotation staff for adjustment or established in a systematic and scientific way.
97% of provincial hospitals, 77.3% of district hospitals are content with contributions by rotation staff from upper levels.
Initial impact of project implementation: 
Upper level institutions: Reputation, professional position of managing hospitals keep raising. Technical capacities of staff have been trained, challenged and developed during on duty time at lower level, contributing to reduce overcrowding status for upper levels.
Lower level institutions: Health care service delivery capacities have been significantly improved, especially in specialties with support from upper level hospitals. Hospital reputation keeps growing. Patients can access locally to high tech services, minimizing health care expenditures and contributing to ensure social welfare.
Difficulties, obstacles: 
Upper level institutions: Some units remain passive in receiving and implementing the project, coordinating rotation staff not relevant to the support needs by lower levels. Some institutions do not have sufficient flexibility in applying regulations …
Lower level institutions: Some units remain passive in receiving and implementing the project. Most lower level hospitals lack technical development orientations. Capacities of needs assessment and planning for support proposal remain limited. Some lower level hospitals rely on upper levels and yet to prepare human resources, physical infrastructures and medical devices to receive technology transfer. With some high tech services and few patients at lower levels, there were a waste when fielding staff from upper levels for technical transfer.
There are some obstacles in the general provision in the project implementing guidelines such as: regulations on criteria of rotation staff by patient bed number; regulations on rotation time of 3 months/person/time; regulations on reporting to Steering Committee on project implementation on weekly and monthly basis; role of coordination, monitoring and timely adjustment by leading hospitals in regions as well as standing sections of the Central Project Steering Committee, which sometimes carried out not in a closely and timely manner.
Current policies: The list of drugs by levels and health insurance reimbursement lists according to current regulations have limited the treatment outcome of upper levels health professionals once working at lower level. There has not been satisfactory incentives to attract rotation staffs as well as to keep them work at lower levels. 
Unexpected impact: There is a possibility to increase overcrowding at upper levels. The autonomy mechanism under Decree 43 has brought about adverse effects when some upper level hospitals wish to raise incomes from increasing patients from lower levels.

Immediate solutions:
Timely consolidate obstacles in organizing for project implementation.
Supplement some cost items in the budget allocation structure for project implementation for grassroots levels. 
The Central Project Steering Committee advice MOH to cooperate with other line Ministries and Sectors to develop budget allocation mechanism for 1816 project implementation for provinces nationwide and submit to competent level for approval.
Adjust, revise the regulations on rotation staff criteria based on patient bed number at 3 months/person/time by contracted form for techniques to transfer. 
Issue criteria to identify capacities to receive technological transfer of lower levels and target, type of recognition for technological transferring results.
Strengthen the monitoring and supporting role of assigned hospitals, ensuring the technical assistance to lower levels.
Supplement members being leaders of general/specialized hospitals who are in charge of technical assistance in different regions in to the Project Central Steering Committee.
Develop a web-portal on 1816 project, which is included in the MOH homepage to timely update needs for support from lower level health facilities as well as responsive capacities by upper levels, and related legal documents.
Longer - term solutions:
Adjust some inappropriate regulations on drug list, medical devices lists by levels as well as health insurance reimbursement lists …
Create mechanism and necessary conditions to promote the role on technical assistance for lower levels by regional hospitals in technical transfer support. 
Enact legal documents to supplement and improve the legal corridor to project activities.
Actively create qualified human resources for lower referral levels via diversifying training forms and target groups.
Supplement and improve incentive policies to attract and maintain staffs rotating to lower levels.

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