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Researches Health System
STUDY ON CURRENT SITUATION OF OVERCROWDING, UNDERCROWDING IN HOSPITALS AT LEVELS AND RECOMMENDED SOLUTIONS FOR IMPROVEMENT


1. Introduction
Study to evaluate the current situation on overcrowding and undercrowding in hospitals at levels is a ministerial level project implemented in 2008-2009 in 6 cities and provinces representing 3 regions. Survey is conducted in 5 central hospitals, 10 provincial hospitals (including 3 OBGYN and 1 pediatrics) and 12 district hospitals with the objective:
1) Identify the overcrowding and undercrowding in hospital at levels
2) Identify causes of over- and undercrowding in hospital at levels
3) Study and analyze lesson learnt from models and measures to limit overcrowding in some hospital at present
4) Recommend short- and long-term solutions to gradually limit overcrowding and improve performance of hospitals at levels.

2. Results
2.1 Overcrowding
Overcrowding is common in most hospitals at levels, especially serious overcrowding at central and provincial levels. Undercrowding happens at some specialized provincial hospitals in areas of functional rehabilitation, mental health, social diseases prevention (TB, leprosy) and district general hospitals in mountainous and remote areas. However there have been no governance measures to control and monitor the implementation of bed occupancy indicator <90% (according to WHO recommendations for developing countries). It has led to a fact that many hospitals report high bed occupancy rate, at more than 100% (district hospitals) but in reality there are not many inpatients (related to budget allocated for hospitals based on number of patient bed).
2.2 Reasons of hospital overcrowding 
Hospital overcrowding has a systematic reason and reflect that the health system and medical care organizational network with decentralization, patient management, screening and receiving has yet to meet the medical care needs in addition to non-synchronized policies rather than purely hospital mistakes. Particularly: 
The health care needs and economic capacities of the people keep increasing while service delivery capacities of health care at grassroots level remain limited, especially at district level (many hospitals have yet to provide all services according to referral level, particularly some specialties like pediatrics, obstetrics, tumors, etc.)
Examination and treatment at primary care level has not meet the requirements of preventing and managing preventable diseases and reduce bypassing by one third of patients visiting provincial and district levels, who can be managed, examined and treated at primary care level of commune health center.
Regulations and mechanism on referral levels are not appropriate with lack of regulations. Adverse referral mechanism together with unwanted impact by hospital autonomy policy, health socialization (hospital trying to increase revenue, attract more patients, retaining patient, etc.), health insurance and user fees (not consistent among levels, localities together with inappropriate payment methods) have contributed to raise overcrowding in hospitals at upper levels (more than 50 – 90% patients visiting central hospitals may seek for health care services at provincial, district levels or even commune health center. However upper level hospitals still receive and retain patients without referring or willing to refer back to lower levels).
2.3 Negative impacts of overcrowding 
Quality of services and patient safety 
Overcrowding, overload will lead to the risks of unable to ensure the service quality and patient safety. Many studies have prevent the close relationship been bed occupancy rate at more than 85%, number of patient/room with increase in nosocomial infections and hospital mortality.
Time for patient examination and treatment is less, especially those visiting the outpatient department. Physicians do not have enough time for examination and counseling for patients. Various researches have proven a close association between short examination time and increase of errors in examination, irrational prescription and lack of counseling for patients.
Adding beds, receiving too many patients while surface areas do not increase, inappropriate investment in physical infrastructure and lack of human resources will make hospitals not able to ensure technical standards according to existing regulations (area/bed, ratio of areas for departments, wards and public areas, hospital environment, etc.)
Impact on healthcare professionals 
Lack of human resources, extra working hours and increased workload affect health of healthcare professionals. Many hospitals must organize for extra working hours at outpatient clinic/department to avoid long awaiting patients. The fact that healthcare professionals cannot take compensate leave is very popular, affecting their health and service quality. Studies have proven a close relationship between overcrowding with increased number of staff with stress and those taking anti-stress medicines. 

3. Conclusion
Hospital crowding takes place at all levels, more severe with upper levels
Hospital overcrowding has a systematic reason and reflect that the health system and medical care organizational network with has yet to meet the medical care needs rather than purely hospital mistakes. Key reasons include:
The health care needs and economic capacities of the people keep increasing while service delivery capacities of health care at grassroots level remain limited. This is one of the reasons of hospital crowding at upper levels.
Examination and treatment at primary care level has not meet the requirements of preventing and managing preventable diseases and reduce bypassing.
Regulations and mechanism on referral levels are not appropriate together with unwanted impacts of hospital autonomy policies, health socialization, health insurance and user fees. These have contributed to increase overcrowding at upper levels.
Scientific evidences show that high bed occupancy rates and crowded patients reduce the quality of health care services and cannot ensure patient safety (increase infection rate, mortality, irrational prescription, lack of counseling, etc.)

4. Recommendations and Solutions
In the immediate future, focus on re-examination, supplement and development of policy instruments as well as mechanism to control task distribution and treatment according to referral level 
Limit upper level hospitals to receive simple cases that can be dealt with at lower levels (for each level, limit to certain percentages of services that can be delivered at lower level)
Make hospitals to fully deliver services appropriate with referral level before allowing to develop new technical services (or permit the development of new technical services that can supplement or replace existing services regulated for each referral level)
Develop referral mechanism adverse to technical assistance and monitoring by upper level hospitals
Re-examine legal documents on health insurance payment method and services prices among referral levels, localities together with developing relevant prices to create conditions and encourage lower level hospitals to develop techniques and attract patients to the right levels.
In parallel with on-going investment projects on physical infrastructure, equipment for grassroots level, it is needed to give priority to develop health human resources for primary health care that are capable of delivering examination, treatment and management of preventable or chronic diseases. Emphasis should be placed on salaries, allowances, training and incentives for staff to work at grassroots level. 
Study to develop management models for some disease groups in the community via mobilizing health human resources within community: private health, social welfare workers.
In urban areas, especially large cities study to permit the establishment of day care department or hospital models. These are effective models to help reduce overcrowding of inpatient beds in some countries, encouraged for implementation. However these models require a significant personnel and it is needed to have a separate operational mechanism to ensure patient safety (extra hour counseling, home-based services or transport to hospital in case of abnormal signs). On the other hand, these models can only service patients in the hospital catchment areas (treatment during daytime and being at home in the evening). In Vietnam, there should be systematic regulations in place to allow such models function. 
Adding bed solution: Adding beds can only partially resolve the situation of two or three patients sharing one bed. It is not a long-term solution because at present, bed adding does not go together with increasing budget for hospitals to ensure technical criteria (ratio of man/bed, area/bed, etc.). 
 
 

07/08/2012
HEALTH STRATEGY AND POLICY INSTITUTE  
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