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Researches Health System

                Dương Huy Lương, Nguyễn Thị Thắng, Nguyễn Hoàng Giang, 

           Hoàng Thu Thủy, Trần Thị Mai Oanh

Place of publication: Ministry of Health
Year of publication: 2011
Primary level of care (including district and commune health) plays a vital role in the health system, being the first line provider of essential health services to the community. With this role, the commune health station (CHS) has the main function and mandate of providing primary medical care, disease and epidemic control, maternal-child health care and implementation of various targeted health programs.
Over the years, as various policies of the Party and government on strengthening and optimizing the population level health system are introduced, commune health has made recognizable progress. The public now has better access to primary health care (PHC) services at the commune, especially when health insurance related medical care is offered at the commune. Nevertheless, commune health centers are also facing challenges in fulfilling their missions, given the quantity and quality deficiency of the health workforce at the commune level, as a considerable proportion of CHSs are still without a doctor, while some centers have not been able to fill the designated staff list by the Ministry of Health’s standards, and infrastructure and equipment remain barely adequate, particularly in mountainous areas, given the sizable workload CHSs carry. This study  is conducted  aiming at assessing the performance of select mountainous commune health centers in fulfilling their functions and tasks; assessing commune health centers’ ability to meet PHC needs in the new context, thereby recommend ways to improve the effectiveness  of mountainous commune health stations.
Target groups, survey sites and methodologies
Target group and survey sites
The target groups include health workers being managers at the province and district levels, all health workers at commune health centers and community members.  
The study was conducted in 4 mountainous provinces, including Dien Bien, Cao Bang, Kon Tum and Binh Dinh, with 2 districts selected from each province, and all the communes in the 2 districts.
A cross-sectional descriptive design is used, coupled with retrospective data collection (for 5 years prior to the time of survey). Samples are chosen through non probability sampling. The four selected provinces present the mountainous areas in the Northeast, Northwest, Central Highland and Northern central regions of the country. Two districts are selected from each province, with one easily accessible district and the other being hard-to-reach. All the communes in the districts are included (112 communes in total, from 8 districts in 4 provinces) for review of infrastructure, operation and staffing arrangements. Data collection techniques employed include focus group, in-depth interview and questionnaires.
Fulfillment of fundamental roles and mandates of mountainous CHSs
Medical service delivery: Findings indicate that on average, a number of visits at CHSs in 4 study provinces per  person per year  is  1.2 times, with the highest figure recorded in Cao Bang (1.4 times) and lowest in Binh Dinh (0.9 times a year). Among study communes, one commune maintains a low average number of visits  of 0.1 times a person a year (in Dien Bien), while another reports as high as 5.1 times in Cao Bang. Health insured clients seeking medical care at CHSs have a high proportion in Cao Bang, Dien Bien and Kon Tum (over 80% of the total number of patient visits at CHSs). The average number of referrals in communes with a doctor (5.4%) is lower than in communes without a doctor (7.8%). 
Maternal-child health care: Childbirths at the CHSs remain relatively low (24.4%), especially at CHSs in Binh Dinh, with only 10.7% of the total annual childbirths. 45 out of 112 CHSs report no childbirth at the CHSs  in 2009, including Cao Bang: 16/28 CHSs; Binh Dinh: 19/24 CHSs; Dien Bien: 5/28 CHSs; Kon Tum: 5/22 CHSs. Giving delivery at home  accounts for 28.4%. Findings of the qualitative study reveals in part that the reason for not having a birth  at the CHSs  are from  both demand side and supply side. From the demand  side, it is due to backward custome and low level of accessibility. From the  supply side, it is concern about poor infrastructure  of CHSs or people’s preference of a hospital near their home.
Epidemic control and implementation of health programs: Evidence shows that most CHSs have had an annual epidemic control action plan in place. On average, 15.9 health programs are on-going at the surveyed CHSs, with the lowest number being 13 and the highest being 19 programs. Health programs with the least presence include school-based programs, diabetes control, antihypertensive control, cancer, among others. Bookkeeping for the programs is another area of concern. There is an average of 42.5 books register in the communes, with a high of 76 and low of 27. Such large amount of paperwork consumes  staff’s working time while reliability remains questionable.
Commune health centers’ ability to meet PHC needs
Infrastructure: Of the total 112 surveyed CHSs in the 8 selected districts, 6% of them are still based in makeshift facilities. By estimates of center managers, the current infrastructure settings of the CHSs below the acceptable level remain at 38%. CHSs with adequate number of rooms in line with the national benchmark for commune health only account for 16.5%.
Equipment: Most of the CHSs rate their office equipment availability as insufficient or acceptable. By estimates of CHS managers in Binh Dinh and Kon Tum, CHSs in shortage of office equipment take up about 54% of the total (mostly furniture, file lockers, computers, printers etc.). In terms of medical equipment, Dien Bien has 50% of the CHSs reporting to have what they need, while the ratio in Kon Tum is 27.3%, Cao Bang: 18.4%, and surprisingly only 8.3% in Binh Dinh. 
Drug supply: CHSs in shortage of medicine supply based on the designated list in all the four provinces accumulate to 44.9%, with the highest rate of listed drug shortage recorded in Cao Bang, at 72%. Similarly, in terms of drug and chemicals supply for outbreak control, only Binh Dinh has a sufficient rate of over 90%. 
Health workforce: Findings indicate that adequately staffed CHSs in line with the national benchmark for commune health account for 23%. In comparison with Circular 08, sufficiently staffed centers are only 43.2% in percentage, with 2 provinces having considerably low ratios being Kon Tum (18.2%) and Cao Bang (5.3%). CHSs with a doctor account for 42.3%, with most of the doctors being upgraded physician assistants, at 90%. 
Health workers’ professional competence: The proportion of CHSs able to deliver all the listed medical procedures and services as required of the respective level of care under Decision 23/2005/QĐ-BYT is very low (2.7%). Commune health workers’ professional qualifications are also an area of concern. Findings on the knowledge of commune health workers who are doctors and physician assistants on management of common diseases, first aid and outbreak control indicate a high percentage of correct diagnosis of tuberculosis (93.4%), while the correct answers to other questions remain at below 50%. Notably, emergency care for respiratory tract foreign matter intrusion and criteria for malaria diagnosing return very low percentages of correct answers, at 9.8% and 6.6% respectively. Dividing the knowledge measurement by topics on a 5-point scale, the average score for first aid is only 1.7 points, with common disease diagnosing scoring 2.4 points and outbreak control getting 1 point. 
Basically, the CHSs have fulfilled their roles and mandates as required and helped improve access to health services at the population level. The quality of care at CHSs, however, remain to be improved, due to deteriorated infrastructure (38% of the physical facilities in under par state), equipment shortage (in 30% of the surveyed communes), insufficient supply of listed drugs (45%), understaffing (43% under Circular 08), and lack of professional quality of commune health workers (only less than 3% of the centers are able to provide the full range of prescribed procedures). Too much paperwork (42.5 registers per CHS on average) adds burden to the commune health workers. 
To attract and retain health workers in disadvantaged areas, the government needs to introduce suitable remuneration and incentives schemes, coupled with upgrade of infrastructure and equipment to improve working conditions for frontline health workers.
Review and restructuring of CHSs’ roles and mission adapted to the current socioeconomic context and medical care needs are needed. Potentials to integrate health programs to relieve overload for population level health workers is also advisable. 

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