Lê Quang Cường, Lý Ngọc Kính ^*, Khương Anh Tuấn, Trần Thị Mai Oanh, Dương Huy Lương, Nguyễn Thị Minh Hiếu, Trịnh Ngọc Thành, Hoàng Thu Thủy, Nguyễn Thị Thắng et al.

* Administrative of Medical Services,  MoH

Place of publication: Ministry of Health

Year of publication: 2011

Introduction

Before the year of 1980, there were no phenomenon of patient overcrowded in public hospital. This phenomenon has been started since health system changed to adopt with the revolution of social economic development of Vietnam toward market economic. Particularly, in recent 10 years, the situation of hospital overcrowding have been being more serious and common occurred in all level and becoming an emerging issue of health sector that need to be solved. Health Strategy and  Policy Institute have been assigned by MOH to conduct this study to evaluate the situation of hospital overcrowded comprehensively and to identify the main causes in order to provide evidence for MOH and related policy makers to develop relevance policy solution.

Objectives      

·         To assess the situation of hospital overcrowding and under-crowding at different levels.

• To identify the causes of hospital over- and under-crowding.
• To investigate the lesson learnt from models and initiative solutions to limit overcrowding in some hospitals at present.

·         To propose short-term and long-term recommendation and solutions to gradually limit overcrowding and improve performance of hospitals at level

Methods

This is a cross-sectional descriptive study using a combination of quantitative and qualitative methods. Implementation period from 2008 - 2009. Fieldwork study in three regions across the country with 27 hospitals, including 5 central hospitals, 10 provincial hospitals include both general and specialist hospitals, 12 district hospitals in six provinces/cities. The study used available national data on hospital beds utilization in health facilities and people’s health services utilization from the hospital inspection reports and annual population living standard surveys. Evaluation criteria for overcrowding based on the rate of hospital bed use and the number of patients that one doctor examination per day, in which the rate of hospital bed use > 85% is considered to be overcrowded and <65% is under-crowded.

Totally, 9,283 visited patients at reception departments of hospitals were interviewed and 4,562 medical records were randomly selected in order to investigate the reasons of hospital utilization, reason of bypassing, the appropriate of hospital admission etc. The in-depth interview and focus group discussion with  manager of health facilities, local health organizations (DOH and hospital  directors, head of departments), health staffs and in-patient in the hospitals were also conducted.  

The collected data after cleaned were analyzed by using Stata 10. The main indicators for presenting results are bed occupancy rate, patient examined by doctor per day, rate of bypassing patient at upper level hospital, rate of inappropriate hospital admission in term of technical level etc. the related qualitative information related to unexpected impact of current policy were analyzed for identify the causes and supplementing the quantitative analysis.

Results

Overcrowding

Overcrowding is common in most hospitals at levels, especially serious overcrowding at central and provincial levels. BOR often more than 100% and range from 120 – 150%, event reached to 200% at big central hospital such as Bach Mai hospital, K hospital in Ha Noi, and Tumor & K  hospital in HCM city. The patient overcrowding occurred both in inpatient wards and in reception departments in which 2-3 patient per bed and one doctor have to take examination for 60 – 100 patients/day respectively. 

Under crowding 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.

Main causes of hospital over-crowding

·         The needs of people for health care services increased while the quota for increasing the number of hospital bed is very limited causing the imbalance of the need and the provision.

• The quality of services at health care facilities at lower levels is not good enough in combination with weak compliance of referral system that made the patient did not believe in the service at lower level health facilities and high rate patient  bypassing  to upper level hospital: 80% patient in central hospitals just believe on the services in that hospitals; 75% hospital of patient in central hospitals is bypassing patient, 90% at children hospital; 56% of in-patient at Central gynecology hospital are normal delivery or infection; 58% and 20.7% of patient at provincial  and  district hospitals that should be treated at lower health care facilities.
• The unexpected impact of some current policies

      + Hospital autonomy and social-mobilization applied in state hospital that lead to increased join investment between hospital with different type of investors in investment of providing more services but focus on high tech and high cost medical equipment to attract more patient. In the other hand, hospital have to marketing to attract and try to keep any patient that should be treated at lower level according to the technical level in order to increase hospital revenue.

+ Current regulation related to price and payment mechanism for service provision are not appropriate  that both not encourage patient using service at lower level health facilities and not encourage hospital provide services (with the same services but HI payment for hospital as well as benefit of patient using that services in upper level hospital is higher than that at lower hospital).That lead to patient tend to go to upper level hospitals.

Negative impacts of over-crowding

·         Overcrowding has impact on the quality of services and patient safety: Patient overcrowding will lead to the risks of unable to ensure the service quality and patient safety. 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.

·         Impact on health 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.

Conclusion

·         Hospital crowding takes place at all levels, more severe with upper levels.

·         The causes of hospital overcrowding are systematic and hospital overcrowding is a phenomenon that reflect the in appropriate of health system/health care network not adopt the need of health care. It is not simply an error of hospitals. The key causes 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.

+ Primary health care has not met 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, and 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.).

Recommendations and solutions

·         Need to review and adopt the list of technical level in the way of creating the flexibility for lower health facilities to be able to optimize themselves in providing as much as possible the services according to their capacities.

·         Re-examine legal documents on health insurance payment method and services prices among referral levels, localities together with developing relevant prices and payment to create conditions and encourage lower level hospitals to develop techniques and attract patients to the right levels. Focus on regulation and mechanism in controlling the bypassing and inappropriate hospital admission.

·         Continue priority in investment in primary care and district hospital both infrastructure, medical equipment, and human resources. The investment plan for hospital should be developed in comprehensive way with different stages of investment based on the need of local people instead of based on available resources.

·         To re-examine the current regulation of hospital quota that need to base on actual need of the local in the parallel with apply mechanism to monitor the compliance of health service quality assurance (technical standard for infrastructure, medical equipment, human resources)

·         To develop the models in management of some disease groups at the commune level by mobilization of health professional in the communes, encouraging the participation of  private health care providers and social worker.

·         To improve hospital management and administration by applying informative technology at different levels from grassroots level to central level in order to follow up and  manage patient  better through health care network.