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Researches Human resources for health
IDENTIFYING PRECONDITIONS TO MATERIALIZE THE STATED POLICY OF SENDING DOCTORS TO THE COMMUNE AND IMPROVING THE PERFORMANCE OF COMMUNE LEVEL DOCTORS

 Nguyễn Bạch Ngọc, Vũ Văn Hoàn et al.

 
Place of publication: Ministry of Health
Year of publication: 2008
Objectives
1. Evaluate the implementation of the state policy of sending doctors to work at commune health centers;
2. Identify preconditions to effectively materialize the state policy of sending doctors to the commune;
3. Make policy recommendations to meet the requirements for effectively materializing the state policy of sending doctors to the commune.
 
Participants: Leaders of various levels involved in the implementation of the state policy to send doctors to the commune; doctors who are working at commune/ward health centers in the selected provinces; senior students of medical colleges; and community members at survey sites.
Survey sites: The review took place at Thai Nguyen Medical College, Can Tho Medical College and three provinces representing the North, Central and South of the country: Tuyen Quang, Quang Nam and Hau Giang. Two districts from each of the provinces and three communes from each district were selected.
 
Methodology 
Cross-sectional descriptive study, combining quantitative and qualitative analyses; Quantitative study: data collection through statistical forms, analysis of secondary data, collection of respondents’ comments using self-administered questionnaires: Doctors working in commune health centers (18 qualified commune health centers), senior students (155 questionnaires), and community members (1,800 questionnaires).

Findings
1. Present status of actions taken to send doctors to the commune under Directive 06, dated Jan. 22, 2002, of the Central Party Executive Committee, and Decree 46, Feb. 23, 2005, of the Politburo, and outcomes of this movement
Findings indicate that various measures adopted to send doctors to the commune appear to be less feasible. For example, while the training to upgrade physician assistants to doctors is a good approach, it is facing the problem of physician assistant scarcity (old age, staff shortage). While selected training of physician for the commune level was emphasized, only 6 out of 31 selected training doctor graduates in 6 surveyed districts returned to the commune to work, implying the limited success of this approach, given the lack of a strict regulatory framework. Many provinces have resorted to financial incentives, but they are not enough to attract doctors to the commune. The most important factor to retain and encourage doctors to come and work at the commune, working conditions, has not been paid attention to or improved, resulting in 15 active doctors resigning/leaving their jobs. Some district doctors have been seconded to the commune to increase doctor coverage for the commune. But as the districts themselves are in serious shortage of doctors, support to the commune is very limited. Evidence shows that communes having a doctor in the three selected provinces are very low in percentage (58.6% in Tuyen Quang, 32.2% in Quang Nam, and 30.2% in Hau Giang). The country level was only 65.1% in 2006 (and could be even much lower in the years after), and the target of having 80% of the communes having a doctor by 2010 may be difficult to come true.
2. Medical students’ understanding about the stated policy of sending doctors to the commune and their concurrence with mandatory commune-based working term
38.7% of graduated medical students know about the stated policy of sending doctors to the commune after college, and only 39.4% of the students have had the opportunity to discuss about this policy, implying that they are not seen as a target group of the policy. This is different from many other countries where regular medical students are viewed as the most important and reliable manpower supply to the country. The rate of 47.7% of the graduated students would go to the commune if they have to indicates that they are not quite ready to take on the countryside mission. Nevertheless, 69% of the respondents agree with the mandatory countryside service scheme as it helps improve equity in access to health services. Alongside with the mandatory system, the terms of service should be made specific, as should the benefits for compliance and punishment for non-compliance or under-performance. This is a promising sign, as people have turned their thinking to responsibility and equity, and such demand is justified and needs to be taken into account by policy makers.
3. Identifying preconditions for implementing the stated policy of sending doctors to work at commune health centers 
As the findings are compiled, 5 preconditions to successfully implement the stated policy of sending doctors to commune/ward health centers have been identified. They are: 
(1) Sufficient provision of working conditions at commune health centers (infrastructure, equipment, recurrent funding);
(2) Consistent and relevant policies and schemes (career allowance, regional incentives etc.);
(3) Regulatory framework (mainstreaming the stated policy with mandatory commune-based termed service, coupled with benefits for compliance and punishment for non-compliance);
(4) Career development opportunities (continuum of training, advanced training, expansion of eligible service list where applicable);
(5) Creation of opportunities for career and status promotion, respect from the community. 
 
Recommendations 
To be able to send doctors to commune health stations (CHSs), a countryside termed service scheme should apply to all graduated medical students (except those with excellent schooling performance). The term of service may be 3 years for doctors working in remote CHSs and 4 years for lowland areas. The term may be shorter for women. Doctors will have 6 months to one year of practicum at the district hospital before taking their posts at the communes. 
Rights and benefits for complying people: being immediately eligible for the starting pay grade; Upon completion of the service term: being selected/taking recruitment exams to work in the public health system; being transferred to upper public health institutions; further training (Master’s, doctorate training, specialization of 1st and 2nd degree); being granted practice certificates upon completion of the service term; some other political/social privileges, and so on;
Punishment for non-compliance: Refund of training costs (whole or part, depending on the tuition fee level); non-issuance of practice certificates and licenses for durations equal to the commune-based service term;
(2) The following preconditions need to be consistently employed to improve the living and working conditions at commune health centers, drawing and retaining doctors and their commitment to commune health.
a) Improvement of work environment at CHSs: making sure CHSs have the full equipment range as required by the Ministry of Health; Increasing the recurrent budget for CHSs; local governments to be responsible for developing the CHC like with local schools; 
b) Financial arrangements: apart from normal salary, career allowances (on-call duty, hazardous environments etc.) should be increased. Region-based incentives should be introduced and increase over time for those willing to work permanently at the commune after the service term.
c) Creating professional development opportunities: Duration and contents of obligatory and regular continuum of training should be clearly specified for commune doctors studying at upper health institutions. Mixed training should be provided tailored to local needs. The list of eligible services should be expanded where applicable (having the right equipment or certificates for advanced skills). 
d) Creation of opportunities for career and status promotion, respect from the community: Providing more opportunities for commune doctors to achieve promotion in terms of social status, respect of the community through various means, equal treatment in nomination and selection of such titles as people’s physician, outstanding physician, emulative fighter, worker’s hero in the reform era, and so on.
 
 

03/12/2013
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