(6 Provinces), 2010 draft - Health System Assessment Resource

Transcription

ASSESSMENT OF
HEALTH SYSTEM
PERFORMANCE IN SIX
PROVINCES OF VIETNAM
DRAFT REPORT FOR COMMENTS
January 2010
This draft publication was produced for review by the United States Agency for International Development.
It was prepared by Tran Thi Mai Oanh, Tran Van Tien, Duong Huy Luong, Khuong Anh Tuan, Nguyen Khanh
Phuong, Le Quang Cuong, Amy Taye, Jim Setzer for the Health Systems 20/20 Project.
Mission
The Health Systems 20/20 cooperative agreement, funded by the U.S. Agency for International Development
(USAID) for the period 2006-2011, helps USAID-supported countries address health system barriers to the use of
life-saving priority health services. Health Systems 20/20 works to strengthen health systems through integrated
approaches to improving financing, governance, and operations, and building sustainable capacity of
local institutions.
January 2010
For additional copies of this report, please email [email protected] or visit our website at
www.healthsystems2020.org
Cooperative Agreement No.: GHS-A-00-06-00010-00
Submitted to: Robert Emrey, CTO
Health Systems Division
Office of Health, Infectious Disease and Nutrition
Bureau for Global Health
United States Agency for International Development
Recommended Citation: Tran Thi Mai Oanh, Tran Van Tien, Duong Huy Luong, Khuong Anh Tuan, Nguyen
Khanh Phuong, Le Quang Cuong, Amy Taye, Jim Setzer. January 2010. Assessment of Health System Performance in
Six Provinces Of Vietnam - Second Draft Report for Comments. Bethesda, MD: Health Systems 20/20 Project, Abt
Associates Inc.
Abt Associates Inc. I 4800 Montgomery Avenue, Suite 800 North
I Bethesda, Maryland 20814 I T: 301.347-5000 I F: 301.913.9061 I
www.healthsystems2020.org I www.abtassociates.com
In collaboration with:
I Aga Khan Foundation I Bitrán y Asociados I BRAC University I Broad Branch Associates
I Deloitte Consulting, LLP I Forum One Communications I RTI International
I Training Resources Group I Tulane University School of Public Health and Tropical Medicine
ASSESSMENT OF
HEALTH SYSTEM PERFORMANCE
IN SIX PROVINCES OF VIETNAM
DRAFT REPORT FOR COMMENTS
DISCLAIMER
The author’s views expressed in this publication do not necessarily reflect the views of the United States Agency for
International Development (USAID) or the United States Government
CONTENTS
Acronyms ....................................................................................... 7
Executive Summary ...................................................................... 9
1. Rationale .................................................................................. 13
2. Methodology ............................................................................ 14
2.1 General Information on the Six Provinces ................................... 14
2.1.1 Hanoi..................................................................................... 14
2.1.2 Hai Phong ............................................................................. 15
2.1.3 Quang Ninh.......................................................................... 15
2.1.4 Nghe An ............................................................................... 16
2.1.5 Ho Chi Minh City................................................................ 16
2.1.6 An Giang............................................................................... 16
2.2 Asessment Approach....................................................................... 17
3. Findings .................................................................................... 19
3.1
3.2
3.3
3.4
3.5
3.6
Governance....................................................................................... 19
Health Financing ............................................................................... 24
Health Service Delivery................................................................... 32
Human Resources ............................................................................ 41
Pharmaceutical Management .......................................................... 50
Health Information System ............................................................. 64
4. Discussion................................................................................. 72
4.1
4.2
4.3
4.4
4.5
Equity.................................................................................................. 72
Efficiency ............................................................................................ 74
Access ................................................................................................ 76
Quality................................................................................................ 77
Sustainability...................................................................................... 79
5. Recommendations .................................................................. 81
Annex A: Scoring Instruments .................................................. 83
Annex B: Changes to the Service Delivery Indicators............. 91
Annex C: The Availability of Statistical Indicators
at Provincial and District Level of Six Provinces ..................... 99
IV
LIST OF TABLES
Table 1. Demographic Statistics.................................................................. 14
Table 2: Governance Summary Scoring...................................................... 19
Table 3. Scores of Component on Revenue Collection in Provinces.... 25
Table 4. Number of Health Facilities and Beds in 6 Provinces................ 33
Table 5. Scores of Basic Components of Human Resources .................. 41
Table 6. Doctors Leaving the Public Sector – 2008
(Not Including the Retired Staff).................................................. 43
Table 7. Distribution of Health Workforce by Levels - 2008 (%) .......... 44
Table 8. Distribution of Health Workforce by Field of Works –
2008 (%) ........................................................................................... 44
Table 9. Propotion of Doctor/Nurse in Provincial General Hospitals
(one doctor/nurses) ....................................................................... 45
Table 10. Scoring on Components of Pharmaceutical Management
in 6 Provinces, 2008....................................................................... 51
Table 11. Scoring on Indicators of Budget Component in
6 Provinces ...................................................................................... 53
Table 12. Scores on Selected Indicators of Pharmaceutical Policies,
Laws, and Regulations Component in 6 Provinces ................... 55
Table 13. Scores on Indicators of Procurement Component in 6
Provinces.......................................................................................... 56
Table 14. Scores on Indicators of Storage and Distribution
Component in 6 Provinces ........................................................... 59
Table 15. Scores on Indicators of Appropriate Use Component
in the 6 Provinces........................................................................... 60
Table 16. Scores on Indicators of Access to Quality Products and
Services Component in 6 Provinces............................................ 62
Table 17. Average Number of Population per Prescriber and
Average Number of Population per Prescriber Pharmacist
in 6 Provinces, 2005-2008............................................................ 63
Table 18. Scores on Indicators of Financing Component in
6 Provinces ...................................................................................... 64
Table 19. Component Rating for Health Information System in
6 Provinces ...................................................................................... 66
Table B1. Result of Revising Health Service Delivery Module ................ 92
LIST OF FIGURES
Figure 1: Government Spending for Health as Percent of Total
Health Expenditure ........................................................................ 26
Figure 2: Number of Hosiptal by Level of Care in the 6 Provinces
in 2009.............................................................................................. 35
Figure 3: Number of Public Hospitals in 6 Provinces in 2009 ................. 36
Figure 4. Ratio of Health Professional Cadres in six Provinces
(per 10,000 populations) ............................................................... 42
Figure 5. Scores on Budget for Pharmaceuticals in 6 Provinces ............. 51
Figure 6. Percentage of Expenditures on Medicines in Total Hospital
Expenditures in Provincial Hospitals ........................................... 52
V
Figure 7. Scores on Pharmaceutical Policies, Laws, and Regulations
Figure 8: Scores on the Procurement Component in 6 Provinces......... 55
Figure 9. Scores on the Storage and Distribution Component in
6 Provinces ...................................................................................... 58
Figure 10. Scores on Appropriate Use Component in 6 Provinces...... 59
Figure 11. Scores on Access to Quality Products and Services
Figure 12: Average Number of Population per Drug Outlet in
5 Provinces ..................................................................................... 63
Figure 13. General Schema of MoH Health Information
System Flow .................................................................................... 65
VI
ACRONYMS
ADB
Asian Development Bank
ADR
Adverse Drug Reactions
AIDS
Acquired Immune Deficiency Syndrome
ARV
Anti Retroviral
CHC
Commune Health Center
CHS
Commune Health Station
CIF
Cost Insurance and Freight
DAV
Drug Administration of Vietnam
DHO
District Health Offices
DOH
Department of Health
DPC
District People’s Committee
EPI
Expanded Program on Immunization
GDP
Gross Domestic Product
GSO
General Statistic Office
HCFP
Health Care Fund for the Poor
HCMC
Ho Chi Minh City
HDI
Human Development Index
HI
Health Insurance
HIDS
Health Statistics Information Division
HIV
Human Immunodeficiency Virus
HIS
Health Information System
HMIS
Health Management Information System
HRH
Human Resources for Health
HSA
Health Systems Assessment
HSPI
Health Strategy and Policy Institute
ICT
Information and Communications Technology
IEC
Information, Education, Communication
IMR
Infant Mortality Rate
IT
Information Technology
JAHR
Joint Annual Health Sector Review
MMR
Maternal Mortality Ratio
7
8
MOF
Ministry of Finance
MOH
Ministry of Health
MPI
Ministry of Planning and Investment
NEML
National Essential Medicines List
NGO
Non-governmental Organization
NHA
National Health Accounts
NHP
National Health Programs
NMP
National Essential Medicines Policy
OOP
Out of Pocket
PHB
Provincial Health Bureau
PHD
Provincial Health Department
PPC
Provincial People’s Committee
SARS
Severe Acute Respiratory Syndrome
SOP
Standard Operating Procedures
TB
Tuberculosis
TOT
Training of Trainers
U5MR
Under 5 Mortality Rate
UNDP
United Nations Development Program
USD
US Dollars
VHW
Village Health Workers
VND
Vietnamese Dong
WB
World Bank
WHO
World Health Organization
WHR
World Health Report
EXECUTIVE SUMMARY
The Health Systems 20/20 project in collaboration with the Health Strategy and Policy Institute recently
conducted a sub-national health systems assessment in 6 provinces in Vietnam, complemented by a
review of multiple national assessments done recently. The methodology was based on USAID’s Health
Systems Assessment Approach1 adapted to the Vietnamese context. Data and information were
collected for all 6 health systems modules: governance, financing, service delivery, human resources,
pharmaceuticals, and HIS. Information in each module is divided into system components and then
subdivided by indicators within those components. The indicators are scored from 1-3, with one being
“not adequate” and three being “highly adequate”. Scoring is based on a defined set of criteria for each
indicator. The health systems assessment report provides scores for indicator and component data
collected in Hanoi, Ho Chi Minh City, Hai Phong, An Giang, Quang Ninh, and Nghe An Provinces.
Findings are presented by module. The assessment tool allows us to point to the components and
indicators which are areas for concern and make recommendations for improving health system
function.
Governance
The study results showed strong government involvement in monitoring health service providers.
Community institutions and civil society also play important roles in oversight of health service quality.
All public health care facilities in Hanoi and in the 5 provinces are implementing the hospital autonomy
policy. The policy encourages hospitals to provide new health care services, install new equipment, and
increase patients’ access to health services.
Although health systems in all 6 provinces generally received scores of “adequate”, the oversight
function, “licensing, certification of health service providers, and the oversight of health providers by
non-government organizations”, were evaluated as “not adequate”, due to the absence of licensing
procedures for public health professionals and absence of accreditation procedures for public health
providers.
Financing
Total health spending per capita is increasing annually in all 6 provinces and varies by province. In Hanoi,
total health spending per capita increased from 7 USD in 2005 to 30USD in 2008; in Hochiminh city, this
indicator increased from 23USD in 2005 to 39USD in 2008. In other provinces, these indicators are less
than 20USD per capita. However, these provincial level figures do not include OOP spending, which
continues to account for a major share of per capita spending on health services (about 70%).
Approximately 42% of the population of Viet Nam is covered by health insurance. The new Law on
Health Insurance enables people with health insurance cards utilize high-tech services. They will be paid
a maximum of about 1,500 USD per in-patient visit. Findings from focus group discussions showed that
the poor in studied provinces are able to access health care services in hospitals, except some
mountainous areas of Quang Ninh, where they sometimes struggle with costs which are not covered by
health insurance (such as transportation). There is a tendency for financial resources of the health
insurance fund not being used efficiently, partially due to user-fee-based payment method. Monitoring of
1
Islam, M. ed. 2007. Health Systems Approach: A How-To Manual. www.hs2020.org
9
service provision reimbursed by health insurance is inadequate due to a lack of managerial capacity and a
lack of standard treatment guidelines for hospitals.
Findings from the six study provinces showed that provincial allocations are not adjusted according to
different disease patterns or ability to collect revenue in each province. Local health budgets are
approved by the Provincial People’s Council. However, funds available in many localities are insufficient
to cover the total amount approved.
Service Delivery
Overloaded hospitals are a serious issue in Ha Noi, Hochiminh city and Hai Phong. The overload in Hai
Phong sampled hospitals is especially serious, indicated by two indicators: the high bed-population rate
(27.8 per 10,000) and occupancy rate is nearly 140%.
Every commune in the 6 provinces has a CHS. More than 70% of primary care facilities are adequately
equipped (varies by province). One area of concern is that CHSs infrastructure is worn and out-dated
in some communes and need to be repaired or updated. It is difficult for people to access good quality
health services in some commune CHSs and also at some district hospitals. The number of medical
doctors working at the commune level is decreasing in all 6 provinces.
Generally, the EPI program in all 6 provinces has been successful. Paradoxically, the EPI program in the
two biggest cities did not achieve as good of results as the other provinces. This is due to urban
migration. Hanoi and Ho Chi Minh City have high percentages of people who come from other
provinces and stay in the cities without registration. Therefore, Government authorities do not list
names of immigrant children for immunizations resulting in lower percentages of fully immunized
children in those cities.
Human Resources
Generally human resources management in the six study provinces is adequate in terms of number of
human resources for health available to achieve the MDGs. However, most of the 6 provinces are
coping with issues of health professional imbalances: mal-distribution of HRH between rural and urban
areas, unequal distribution between fields of medical practice (curative care and preventive care), and
improper health professional mix in term of assuring comprehensive care. They are also faced with
issues of losing health professionals from public sector to private, particularly in big cities. The
performance management system is not strong enough. Of the 3 provinces with job descriptions, the
descriptions were only available for certain positions. Mechanisms for in-service training facilities,
licensing for health practitioner is not strong enough to ensure the quality of HR in both public and
private.
The links and “feedback loops” between the health care system and pre-service training institutions are
not fully functional. Only HCM city, Hanoi and Hai Phong have established relationships with training
institutions such as Hanoi Medical College, HCM Medical and pharmaceutical College, Haiphong medical
College. Other provinces including Nghe An, Quang Ninh and An Giang have a passive link with the
training and education institutions.
Pharmaceutical Management
Emergency procurements are rarely required and only for a few categories of drugs. Data on adverse
reactions of drug is consistently reported in all health facilities including private ones, but there is no
system for the collection of data regarding the efficacy, quality, and/or safety of marketed pharmaceutical
products.
10
Different modes in purchasing medicines were applied in the six provinces. In public hospitals, all
medicines must be purchased through competitive bid. In Hai Phong, Quang Ninh and Nghe An, bidding
for drug procurement is held by Provincial Health Bureau. In An Giang, for provincial hospitals, bidding
for drug procurement is held by Health Bureau, but district hospitals use bidding results from the
provincial hospital (in An Giang). In Ha noi and HCM City, hospitals can conduct bidding separately.
Among the three indicators measuring the financing component in the six provinces, cost control
received "not adequate" score. This result reflects the fact that although cost control measures exist but
are not consistently enforced. The most common measure for price control of medicines is price
posting for retail drugs.
In all public hospitals, the common practice implemented to improve the use of medicines is to establish
a Therapeutic and Drug Committee. However, this committee does not always function well. The most
critical issue is the absence of national standard treatment guidelines (except for some priority diseases).
Some hospitals have developed their own treatment guidelines, but they are not standardized or
consistently applied.
Health Information Systems
In Vietnam, annual, bi-annual, quarterly and monthly reporting is strictly regulated. Every province and
district is responsible for timely report submissions. Currently, there is no defined mechanism for
reviewing and verifying the quality of data. Factors that may cause low data quality are: compulsory
useage of an impractical software (Medisoft); problems verifing the accuracy of private sector data;, and
a lack of historical data, even from the previous year.
At central levels, the officials do not provide feedback on reports that they receive from lower levels. At
provincial level, the Health Bureaus only received feedback if they feel there is something abnormal in
the report.
There is a lack of collaboration and information sharing within the health sector and with other sectors.
Overlaps in information collection, variations in data reported across ministries, and information that
fails to meet the needs of users, are all common concerns within the national health information
systems.
Recommendations
Although there were efforts to use evidence to formulate health policy and strategic plans at all levels of
health care in all six provinces, it is recommended to develop a more efficient health management
information system. The HMIS should include financial and human resources management data. This
software program should include all core indicators for monitoring and planning purpose and the data
need to be updated regularly and to make sure that reliable data on this area is always available.
To ensure equity and efficiency in the health system and in the poverty-reduction policy, it is necessary
to prioritize health-financing solutions with an orientation towards:
1. Increasing the share of total national health spending from public sources. The increased
government budget should focus on priority areas, including: (1) strengthening the grassroots
health care network and developing preventive medicine; (2) supporting health care for groups
in need of social protection, including people who have rendered meritorious service to the
nation, the poor, the near-poor and ethnic minority people and (3) providing support for
disadvantaged areas.
11
2. Expand health insurance coverage to protect the population from the risk of impoverishment
resulting from catastrophic health spending through effective implementation of risk pooling.
Provider payment methods should be adjusted so that they incentivize cost-effectiveness and quality
assurance in public and private hospitals.
In order to improve effectiveness of health service delivery and make health care accessible for
everyone in the community to achieve universal coverage, it is necessary consider following
recommendations:
1. Quality of health care services at grass-root level (including health services provided at
commune and district level) need to be improved in order to ensure that people can access
quality health care services in their communities.
2. Reorganizing health services and primary care at CHSs in order to meet people’s needs and
expectations in health care, including updating and refurbishing infrastructure.
3. Beyond improving HMIS within hospital for better management, it is also necessary to
strengthen health management information system at the community level to ensure that
everyone’s health in the community is monitored and managed.
Develop and implement appropriate policies for human resources development which include training,
recruitment and retention especially at grass-root level.
Findings from assessment on pharmaceutical management in six provinces suggested several measures to
strengthen this area:
1. National standard treatment guidelines urgently need to be developed, applied in hospitals and
used to supervise quality of care.
2. More specific guidelines on drug procurement should be issued.
3. Strategic cost control measures should be implemented to improve access to medicines
4. The Drug Administration should have annual reporting requirements.
In order to have better health management information systems, it is necessary to:
1. Provide practical, well designed software, to be used widely in the health care system, even at
grass-root level
2. Define a strategy for verifying quality of data collection throughout the system (applied for all
levels, all kinds of health facilities, public and private).
3. Provide training on health information data collection and processing as well analysis, especially,
in Provincial Health Bureaus.
12
1. RATIONALE
Strong health systems are critical to the achievement of better health outcomes. Health Systems 20/20
project addresses the financing, governance, operational, and capacity constraints in a health system that
impede the use of health care. Without adequate and well allocated public and private financing, people
must pay for care out-of-pocket or forgo care. Without properly trained and remunerated health
workers, there is no one to deliver quality care, especially in poor communities and remote areas.
Without competent governance, informed by input from a range of health care decision-makers, health
workers, and communities, health care financing will likely be inefficient, inequitable, and unresponsive to
users’ needs.
In fiscal year 2007, Health Systems 20/20 project used core funds to collaborate with Government of
Vietnam through the Health Strategy and Policy Institute (HSPI) to test the HSA instrument in 2
provinces, Ninh Binh and Can Tho. HSPI, with technical assistance from HEALTH SYSTEMS 20/20,
adapted and applied the health systems assessment tool to assess the six health systems building blocks
(governance, financing, human resources, service delivery, pharmaceutical management, and HIS) in the
Vietnamese context. The activity built HSPI’s capacity to carry-out health system assessments, including
data analysis, interpretation of findings, and report writing.
Building on the newly developed institutional capacity of HSPI, and using health systems assessment tool
already adapted for the Vietnamese context, Health Systems 20/20 received field funding to conduct the
Health Systems Assessment in 6 additional provinces: Hanoi, Ho Chi Minh City, Hai Phong, An Giang,
Quang Ninh, and Nghe An. Health Systems 20/20 took this opportunity to: (1) further institutionalize
health system assessment capacity within HSPI, (2) demonstrate the health systems assessment in 6
additional provinces, and (3) obtain Ministry of Health buy-in for future health systems assessments. Our
experience piloting the assessment approach in the first 2 study provinces showed that the instrument
could still be improved to make it more relevant to the Vietnamese context and the instruments
adapted to suit the various levels of health care system. In order to obtain MoH buy-in for future health
system assessments, HSPI included MoH experts in revising the instrument. Direct MoH involvement
produced an instrument that was easily accepted and approved by MoH leaders. MoH approval of the
health systems assessment tools and methodology was critical to institutionalizing the health system
assessment within the MOH. Assessments in the 6 additional provinces (Hanoi, Hai Phong, Quang Ninh,
Nghe An, Hochiminh, An Giang) used the MOH approved versions of the tools and have produced data
and a report endorsed by the MOH for use by provincial program managers and planners.
The results of the 6 additional assessments also provide health system strengthening data that can be
used by international donors for more effectively guide health system strengthening efforts across the 6
provinces.
13
2. METHODOLOGY
2.1
GENERAL INFORMATION ON THE SIX PROVINCES
Six provinces were suggested by USAID Vietnam for the assessment based on predetermined criteria.
Of the 6 provinces, Hanoi, Ho Chi Minh and Hai Phong are urban centers, while Nghe An, Quang Ninh
and An Giang represent rural areas. Table 1 provides a brief overview of the six provinces.
TABLE 1. DEMOGRAPHIC STATISTICS
Areas
2
Population
density
6,116,200
6,611,600
1,109,600
1,845,900
3, 348.5
2,095
6,099.0
1,522.1
(Person/km2)
1827
3155
182
1213
3,131,000
2,250,600
86,210,800
6,499
3536.8
331,150.4
Population
Hanoi
Ho Chi Minh City
Quang Ninh
Hai Phong
Nghe An
An Giang
Vietnam
(km )
Source: http://www.gso.gov.vn (Annual statistic year book 2008)
2.1.1
HANOI
The city is located on the right bank of the Red
River Delta. Hanoi is the capital and secondlargest city of Vietnam after merger of Ha Tay
province and some district of Hoa Binh and Vinj
Phuc provinces in May 2008. Hanoi's total area
increased to 1827 km2 divided into 29 districts
with the new population being 6,116,2002. The
Hanoi Capital Region, a metropolitan area
covering Hanoi and 6 surrounding provinces
under planning will have an area of 13,436
square kilometers with a population of 15
million by 2020. The population density (as of
2008) was 1827 people per sq. km with
3,545,300 people living in agriculture areas
(57.9%), The poverty household rate about
8,43%. The economy is moving toward the
industrial and service sectors with GDP grow
rate about 10%. Per capita income was US$
2,000 USD a year in 2008.
2
14
Annual statistic yearbook 2008. General Statistic Organization
190
636
260
Population
living in Rural
areas
GDP per capita
(USD)*2006
3,545,300
977,000
614,600
1,092,800
1050
1480
867
720
2,746,600
1,481,600
61,977,500
413
691
$2,600 (2007 est.)
2.1.2
HAI PHONG
Hai Phong is a sea-port city located in the
Northeast of Vietnam, far 102 km from Hanoi.
Hai Phong covers 1,522 sq.km with many
importance islands and big national seaport. It has
a population of 1,845,900 with 1,092,800
(59.21%) persons live in rural areas. The
population density was 1213 people per sq. km.
The economy is moving toward both the
industrial, agriculture and tourist services with
GDP grow rate about 13%. Per capita income
was US$ 960 a year in 2008 and the poverty rate
about 5.9%. 79% of population had access to safe
water3.
2.1.3
QUANG NINH
Quang Ninh is located in Bắc Bộ Gulf , the northeast area of Vietnam, far 195 km from Hanoi close to
Hai Phong, Lang Son and Bac Giang provinces. Quảng Ninh has a common international border with the
People’s Republic of China. The coastal line is 250 km with numerous estuaries and tidal flats and more
than 2,000 large and small islands.
The total area of Quảng Ninh is 6,099.0 sq. km, of which 2,833.2 sq. km is agricultural land.
The population of Quang Ninh is 1,109,600 people with 55.8% living in rural areas. The population
density of 182 person/km2. The poverty household rate about 7,4%. The economy is moving toward
both the mining, agriculture and tourist services with GDP grow rate about 7.5% and GDP per capita is
1000 USD in 2008. 83% percent of population had access to safe water 4.
3 http://www.haiphong.gov.vn/sokehoachdautu/vn/index.asp?menuid=633&parent_menuid=633&fuseaction=3&articleid=52
39
4 http://www.quangninh.gov.vn/Trangchu/tin_trong_nuoc/0024c6.aspx
15
2.1.4
NGHE AN
Nghe An is located in the North Central Coast of Vietnam,
300km from Hanoi. Nghe An close to Thanh Hoa province
in to the North, and Ha Tinh province to the South. In the
West, Nghe An have borderline with Lao Republic.
The total area of Nghe An is 6,499 sq. km. The population
of Nghe An is 3,131,000 people with 87.7% people living in
agriculture areas. The population density of 190
person/km2. The economy is moving toward industry and
agriculture with GDP grow rate about 10,6% and GDP
per capita is about 650 USD. The poverty household rate
about 14,5%.
2.1.5
HO CHI MINH CITY
Ho Chi Minh City is the biggest city in the South of Vietnam. Ho Chi Minh is also the central city for
economic, trade, science, and technology development. The total area of Ho Chi Minh city is 2,095 sq.
km with a population of 6,611,600 people, most of them living in urban areas (85%). The population
density is very high with 3155 person/km2. The economy is moving toward industry, trade and services
with GDP grow rate about 10% and GDP per capita is more than 2000 USD in 2008. The poverty
household rate about 8%. 91.5 percent of population has access to safe water.
2.1.6
16
AN GIANG
An Giang is located in the Eastern Mekong River Delta, 250km from Ho Chi Minh. An Giang close to
Can Tho and Kien Giang province and has long border with the Kingdom of Cambodia in the West. The
total area of An Giang is 3536.8 sq. km. The population is 2,250,600 people with 65.8% people living in
agriculture areas. The population density of 636 person/km2. The economy is moving toward agriculture
with GDP grow rate about 14,2% and GDP per capita is 590 USD5. The poverty household rate about
7,2 %6.
2.2
ASESSMENT APPROACH
The Health Strategy and Policy Institute (HSPI) led the health systems assessment process with technical
assistance from USAID’s Health Systems 20/20 project. The health system assessment methodology was
based upon USAID’s Health Systems Assessment Approach7, adapted to suit the Vietnamese context,
the needs of a local team of experts, and the requirements of provincial rather than national data
collection. The Health Systems Assessment (HSA) tool was developed to enable policy makers and
program managers to undertake a comprehensive view of 6 major health systems functions (governance,
finance, human resources, service delivery, pharmaceutical management, and health information). The
tool allows users to assess each health system function using a set of performance indicators.
Data and information were collected on all 6 health systems modules: governance, financing, service
delivery, human resources, pharmaceuticals, and HIS. Information in each module is divided into system
components and then subdivided by indicators within those components. The indicators were scored
on a scale of 1-3, with 1 being “not adequate”, 2 being adequate and 3 being “highly adequate”. Scoring is
based on a defined set of criteria for each indicator. Definitions of what is not adequate, adequate, or
highly adequate varied by indicator.
The Health Strategy and Policy Institute completed the analysis in 4 stages.
http://www.mekongdelta.com.vn/mekongdelta/Solieu/GDP.htm#B%E1%BA%A3ng_2.3:
http://cema.gov.vn/modules.php?name=News&op=detailsnews&mid=2605
7 Islam, M. ed. 2007. Health Systems Approach: A How-To Manual. www.hs2020.org
5
6
17
1. Tabulation of data from interviews with key respondents and review of documents was
completed using excel based data entry sheets. The purpose of this step was to organize the
data in ways that would facilitate rapid access and analysis.
2. The performance of each health system indicator was scored using the 3 point scale of predefined criteria. System function scores were disaggregated by levels of care (central, provincial,
district, community). The purpose of this step was to provide an analysis of the strengths and
weakness of each system function. Scores for each health system function were summarized and
averaged to show trends.
3. The strengths and weaknesses of each systems function (governance, financing, HRH, etc) were
reviewed based on the combined scores for each component.
4. Next the analysis looked at the system as a whole based on WHO’s 5 health system
performance criteria: equity, access, efficiency, quality, and sustainability. The purpose of this
step was to show how the various health system functions operate in relation to one another
vis a vis the goals of the health sector as a whole. Select indicators from each functional area
(governance, human resources, financing, etc.) were combined to score each performance
criteria across the system as a whole.
There were several limitations to the assessment methodology. First, local circumstances were not
always clearly measured or represented by universal indicators. The analysis was conducted based on
the existing Health Systems Assessment indicators. Second, the analysis ends with an evaluation of the
system based on WHO’s 5 system performance criteria. The indicators used to represent each of the
performance criteria were selected based on the assessment team’s best judgment. The current tool
does not prescribe which indicators from the health systems functions should be used to represent each
of the 5 performance criteria. The analysis should be expanded further to include a health outcome
based evaluation. Other assessment limitations include: the limited number of districts sampled within
each province (2 districts per province); the potential for respondent bias; and limited data availability.
18
3. FINDINGS
The findings are organized and presented in six sections according the health system functions:
governance, health financing, health service delivery, human resources, pharmaceutical management, and
health information systems.
3.1
GOVERNANCE
SCORE OF GOVERNANCE COMPONENTS
All six provinces scored well on most components of governance. Rationale for each component’s score
are described in Table 2.
TABLE 2: GOVERNANCE SUMMARY SCORING
Component
Average score
Ha Noi
Responsiveness of government to public needs
Voice
Exercising local technical oversight of health service
quality
Production of services needed by the public
Information and reporting
Direction, oversight and resource allocation tasks
carried by government
2.5
2.0
2.0
2.25
2.0
2.0
Quang
Ninh
2.5
2.0
2.0
2.25
2.0
2.0
Nghe
An
2.5
2.0
2.0
Hai
Phong
2.5
2.0
2.0
An
Giang
2.5
2.0
2.0
HCM
City
2.5
2.0
2.0
2.25
2.0
2.0
2.25
2.0
2.0
2.25
2.0
2.0
2.25
2.0
2.0
COMPONENT 1: RESPONSIVENESS OF GOVERNMENT TO PUBLIC NEEDS
Government responsiveness to public needs was determined based on 2 indicators. First, whether
government and health provider organizations regularly organize forums to solicit input from the public
and concerned stakeholders (vulnerable groups, groups with particular health issue, etc.) about
priorities, services, and resources. Second, based on the capacity of the public and concerned
stakeholders to advocate and interact effectively with public officials in the establishment of policies,
plans and budgets for health services.
In the case of Vietnam, at the national level, the Ministry of Health (MoH) is in charge of development of
health care policy, particularly policy for disadvantaged groups. According to our findings, the MoH
frequently organizes forums to solicit public inputs on issues of priority selection, resources and service
delivery. A number of national workshops have been organized by the MoH in 2008 and 2009 to
determine priority health issues, solicit public inputs on the health insurance bill, the health care practice
bill and the food safety bill. Improving primary health care in terms of human resources and health
service delivery were among the priority policies. All draft health policies are published on the internet
for public inputs, before they are officially issued.
In all six provinces, researchers assessed the responsiveness of provincial health departments. Despite
the growth of private health care practices (especially in Hanoi and Ho Chi Minh City), most health care
19
services in the 6 provinces are provided by the public sector. The provincial health departments are
directly involved in public health service provision. This study found that, similar to the previous
assessment provinces, in all 6 provinces regular biannual meetings of the provincial, district and
commune people’s councils are the official forums in which the people – voters through the people’s
council representatives – present their opinions, views, reflections and questions on a variety of topics.
Health service provision, selection of health priorities, health resources, and health workforce are
among those issues discussed. Also similar to previous assessments, respondents in Hanoi and 5
provinces reported that before any people’s council meeting at any level, the people and social and civil
organizations can reflect their views and aspirations to the people’s council representatives; all the
people’s council representatives are responsible for actively contacting, meeting, and listening to their
voters. These meetings are the opportunities for the public to raise their voices concerning health
system shortcomings. The provincial and district people’s councils organize visits to health care facilities
to supervise how health care policy is implemented.
As with Can Tho and Ninh Binh (provinces from year 2008 study), the Provincial People’s Councils in
Hanoi, Quang Ninh, Nghe An, Hai Phong, An Giang and Ho Chi Minh City have a Cultural and Social
Committee (required by the law on organization of the people’s council); The cultural and social
committee is exclusively in charge of social affairs, including health. The cultural and social committee is
responsible for collecting voters’ opinions about social issues by meetings with voters and visiting health
facilities. The cultural and social committee makes routine reports during the people’s council sessions.
Leaders of provincial health departments, as well as directors of provincial and district general hospitals,
reported that they were invited to attend sessions of the provincial and district people’s councils
meetings to listen to people’s opinions regarding health system shortfalls and to give
explanation/answers to the committee’s questions. Local authorities respond to proposals from the
people and health service providers as much as possible.
The provincial government and provincial health department in Hanoi and all 5 provinces carefully
collects inputs from key stake holders during the preparation of annual health plan. The plan is drafted
based proposals submitted from all public health facilities. The draft plan is then sent to the key
stakeholders such as the provincial Department for Planning and Investment, Department of Finance,
health care facilities etc. Provincial people councils provide opinion on the most important issues
(investment, hospital waste processing, food safety etc.)
In Ho Chi Minh City and Hanoi, important health policy updates and projects are posted on the Medinet
website which is assessable to the public.
Apart from the above institutions, the people and local health service providers also have opportunities
to discuss and prioritize health issues through other social organizations (meetings of the Farmer’s
Association, Women’s Union, Youth Union) and other health events (the Vietnamese Physician Day).
There are many forums where local authorities and health care providers can discuss needed health
system improvements. In fact, the use of forums as a mode of obtaining stakeholder feedback is done
very well in all 6 provinces.
COMPONENT 2: VOICE
The voice component of governance was measured in two ways. First, the influence of technical
experts, civil society organizations and health service users on legislation concerning health; and second
the opportunities of the public, technical experts, and local communities to provide inputs into the
development of priorities, strategies, plans and budgets
20
Annual review meetings of the health plan and health budgets are held at different levels of care and act
as forums for the public, technical experts, specific groups and other key stake holders to express
their opinions. The annual planning of the health budget at national level and provincial levels involves
many stakeholders. The annual health budgeting is a bottom up process, starting at the lowest levels of
care. Each facility proposes a budget for next year, based on their priority needs. Final selection of
priorities and health strategy development is largely a central government responsibility, but local public
health service delivery facilities can express their voice.
In-depth interviews and group discussions indicate that community level opinions and expertise are
mainly solicited during policy implementation. Policy development is actually concentrated at the
provincial level people’s councils where they align budgets and policies.
One of the prominent health policies aimed at improving health care for the people in Vietnam is the
policy on free health care for the poor through a government subsidized health insurance scheme. The
provincial Health Care Fund for the Poor Management Board is responsible for monitoring and
supervising health care provision for the poor and eliminating any form of discrimination in health care
for the poor. Consultations and discussions in Hanoi, Quang Ninh, Nghe an, Hai Phong ,An Giang and
Ho Chi Minh City indicated that the process of selecting and reviewing the poor to be eligible for the
policy, has been implemented with active involvement of communities and the public.
It is important to note that the policy development process aligns with the decentralization in Vietnam.
Human resources management is decentralized to the provincial level, but the development of national
HRH policy is responsibility of central agencies. Health policies, strategies and guiding documents are
developed at central level, after obtaining opinions from central or regional forums and comments from
local people’s committees and leaders of provincial health departments. The procedure of development,
implementation and amendment of policies in a decentralized system such as Vietnam assures the
consistency of the policy development within a country. On the other hand, it also limits the pace of
policy adjustment and in consequence of delays, could affect the performance of the health system.
COMPONENT 3. EXERCISING LOCAL TECHNICAL OVERSIGHT OF HEALTH
SERVICE QUALITY
The capacity of clients/the public to oversee health service quality component of governance examined
whether there are government, voluntary, and private organizations that oversee the way provider
organizations follow protocols, standards, and codes of conduct in regard to medical malpractice, unfair
pricing patterns, discrimination against clients, etc.
The findings showed that there is a strong government system that monitors and supervises provider
organizations. Community institutions and civil society also play important role in oversight of health
service quality. All hospital directors interviewed during data collection mentioned a meeting of hospital
managers with representatives of the Council of Patients8. The meetings with heads of wards,
department and hospital managers, held regularly weekly (ward meetings) or monthly (all-hospital
meetings) in all provincial and district hospitals, create opportunities for patients to raise issues about
service efficiency and quality. Patient Council meetings, along with other activities (semi-annual meeting
of hospital directors with People Councils) contribute to improvement of performance and quality of
health care according need of the public.
Council of Patients: an organization, consisting patients, who are representatives for hospitalized patients, established in
all public hospitals.
8
21
Supervision of the performance of health care facilities in terms of clinical services or care pathways is
the responsibility of the Provincial Health Departments. Results from local interviews showed that in
each Provincial Health Department, there are functional divisions such as: Medical Professional Affairs
Division, Pharmaceutical Professional Affairs Division, Private Medical and Pharmaceutical Practice Division,
Finance and Accounting Division and Health Inspectorate whose tasks are to assure that all health care
facilities (public and private) follow the rules and procedures of medical ethics. These divisions take
regular and unplanned supervisory trips to health facilities. However, with the exception of Hanoi and
Ho Chi Minh City, they have limited staff and financing resources for supervisory activities. As discussed in
the service delivery section, the DOH has budgeted for supervisory visits and monitors the quality of
care 4 times per year. The DOH also receives monthly quality reports from the district hospitals.
COMPONENT 4: PROVISION OF SERVICES NEEDED BY THE PUBLIC
The health systems ability to produce services needed by the public was examined using two indicators.
First, whether health services are organized and financed in ways that offer incentives to public, NGO,
and private providers to improve performance in the delivery of health services; and second, whether
the public or concerned stakeholders have regular opportunities to meet with managers (directors) of
health service organizations (hospitals, health centers, clinics) to raise issues about service efficiency or
quality.
All public health care facilities in Hanoi and in 5 provinces are implementing the hospital autonomy
policy, that encourages hospitals to provide more services and to improve performance. New health
care services are provided, new equipment is in use and patients have better access to health services.
Researchers found again that all provincial and district level hospitals in Hanoi and 5 provinces hold
discussion forums between patients, patient’s families and leaders of clinical departments to solicit client
feedback. Meetings of the each department’s patient committee are scheduled once a week and of the
entire-hospital patient committee once a month. In some district hospitals meeting occurs only if there
were any problem that needed to be discussed. Patient committees decide whether or not to hold a
meeting. During the meetings, issues of quality of care, attitudes of patients, and proposals of patients
are discussed with leaders of the department and hospital. According to the hospital directors
interviewed, opinions from the patients help them understand the situation and issues to be addressed,
as well as services to be supplemented and developed.
Beside meetings of patient committees, there are other channels that health departments and facility
directors use to collect feedback, such as a telephone hot line and an internal mail box. It is compulsory
for directors of public health hospitals to meet with citizens and patients at their request.
COMPONENT 5: INFORMATION AND REPORTING
The information and reporting segment of the governance function looks at issues such as whether
policies and plans were evidence-based, the impact of using evidence to improve program results, and
the availability of information on allocation and utilization of resources. Results showed that this
component is functioning “adequately” in all 6 provinces. At national level, since 2009 regulatory impact
assessment is compulsory for policy formulation.
Vital statistics, disease patterns, and health care service provision data are collected from individual
health facilities and reported quarterly (for most health indicators) or monthly (for some indicators in
the national target programs). Important epidemiological statistics are collected and processed to
produce weekly report and even daily reports (such as SARS pandemics). Every year, the health
statistical yearbook is produced and distributed to relevant stakeholders and organizations, especially to
22
agencies responsible for planning, budgeting, management, and research. National health accounts and
data of the Vietnam National Health Survey are also available. All of these documents have become
important tools for the formulation of health care policies and plans.
In Hanoi, Quang Ninh, Nghe An, Hai phong, Anh Giang and Ho Chi Minh City, annual health planning
and budgeting relies on local epidemiological reports, population demographics, and socio-economic
conditions. Hospital leaders adjust their plans for hospital development and service provision according
to local trends.
Results from in-depth interviews with leaders of Provincial Health Department and People’s Council of
Hanoi, Quang Ninh, Nghe An, Hai phong, Anh Giang and Ho Chi Minh City indicated that the annual
financial report is prepared by health sector and sent to provincial people’s committee; the provincial
people’s council can access this report as needed. The provincial people’s committee and council of
these six provinces are mainly interested in hospital autonomy, level of hospital user fees charged, and
health care provision for the poor. There was no interest in analysis of other health financing issues.
Audits of health care expenditures in the public system are conducted annually in these six provinces
but audit reports are not available for public review.
COMPONENT 6: DIRECTION, OVERSIGHT AND RESOURCE ALLOCATION
TASKS CARRIED BY GOVERNMENT
Component 6 examined the governance relationship, including direction, oversight and resource
allocation tasks, between the government and health providers. Specifically, the assessment collected
information on standardised protocols for certification, issues of non-compliance with protocols,
procedures for investigating possible misuse of resources, procedures to address inequities and bias
within the system, and oversight of health providers by non-government organizations.
In general, the health system scored adequate, but licensing, certification of health service providers and
the oversight of health providers by non-government organizations, were evaluated as “not adequate”,
because while a licensing and accreditation system exist for private health professionals and private
health facilities, there are no licensing procedures for health professionals working in the health public
sectors and no accreditation procedures for public clinics and hospitals. The MoH is now drafting new
bill on health care practice to overcome those gaps.
According to current legislation, the provincial health departments in Hanoi and 5 provinces are
responsible for licensing new private health professionals, accreditation of private health facilities, and
renewing licenses. These tasks are assigned to the Division of private medical and private pharmaceutical
practice of the provincial health department. The division of health inspection, Medical Professional
Affairs Division and Pharmaceutical Professional Affairs Division of provincial health department9 are
responsible for monitoring and supervision of public health professionals in term of compliance with
regulations, protocols, standards and codes. Lack of adequate human and financial resources is common
in all 6 provinces and is one of constraints in monitoring and supervision activities.
There is a comprehensive mechanism to help providers and clients when regulations, standards and
codes of conduct are not complied with from national level to provincial level. The organizations are
mainly governmental, due to the political system of Viet Nam. In the 6 surveyed provinces, inspection
bodies (sector inspection bodies, such as health inspection, finance inspection and central, provincial
governmental inspection organizations) as well as the provincial procurator’s office investigate any
9
in Vietnamese: Thanh tra y tế, Phòng Nghiệp vụ y và Phòng nghiệp vụ Dược
23
misallocation or misuse of resources for health care. Those bodies follow procedures of reporting and
investigation. The public is aware of their rights to use these procedures.
The most important political organization that the public, social organizations, service providers and
relevant organizations can access to reflect the actual implementation of the policy and propose
measures for improvement is the Committee for Social Affairs of the National Assembly at central level
and Committee for Cultural and Social Affairs of provincial people council at provincial level. These
Committees actively supervise implementation of health policies, including pro-poor health policies and
policy on health care for vulnerable groups. In 2008, Committee for Social Affairs of the National
Assembly supervised implementation of Health insurance policy and conducted series of forums to
exchange information with social organizations and technical experts on the Health Insurance Bill. The
Bill went into effect on July 1, 2009.
Apart from the Committee for Social Affairs of the National Assembly, the Provincial People’s Council
in Hanoi and 5 provinces and the Provincial Health Department are the institutions that facilitate the
incorporation of public, mass organizations (such as Farmer’s Association, Veteran Association and
Women’s Union, etc…) suggested measures to assure equity in accessing health care. National mass
media as well as local television, radio and local printed press are the important channel of
communication for related agencies to raise their voice over the better implementation of equity in
health care.
The media in Viet Nam play an active role in the oversight of provider organizations. Enabled by the Law
of Media, national and local newspaper, television and radio have access to health facilities; provide the
public with information, comments and suggestions on issues related to quality of health services, drug
price control, health insurance management, overload in tertiary hospitals as well as allocation and
usage of financial resources.
There are a number of civil society organizations in Viet Nam health sector, such as the Viet Nam
Medical Association, Viet Nam Pharmaceutical Association, Viet Nam Association of Cardiologists etc,
but none of these organizations are actively involved in oversight of health care providers. The Red
Cross Associations is a similar situation. Other mass organizations such as Women association, Viet
Nam Farmers association, Youth Union etc are also not directly involved in the oversight of health
providers.
3.2
HEALTH FINANCING
This module consists of three components that reflect the structure of the three functions of the health
financing system: revenue collection, pooling and allocation of financial resources as well as purchasing.
There are 19 indicators in total, used to assess the performance of health financing system.
COMPONENT 1: REVENUE COLLECTION
Revenue collection for health is the most basic and important function of health financing system.
Revenue collection creates conditions in which the remaining functions of the health financing system
can be performed. The basic function of the health system is to care for and protect people’s health.
Revenue collection refers to the amount and sources of financial resources, as measured by 6 indicators:
total health expenditure as a percent of GDP; total health spending per capita; government expenditure
on health as a percent of total government expenditure; government spending on health as a percent of
total health expenditure; donor spending on health as a percent of total health spending; out-of-pocket
spending as percent of total health spending. Five indicators are used to assess the health financing
24
system at the provincial level (the indicator on total health expenditure as a percent of GDP is not
included because data on GDP by year is not available). Summary results are shown in Table 3.
The total health spending per capita is increasing annually in all 6 provinces. However, this indicator
varies between provinces. In Hanoi, total health spending per capita increased from 7 USD in 2005 to
30USD in 2008; in Hochiminh city, this indicator increased from 23USD in 2005 to 39USD in 2008. In
Nghe An, Quang Ninh and An Giang, total health spending per capita is less than 15USD and in Hai
Phong this indicator measured less than 20USD per capita. These results are not comparable with
national figure because data in provinces does not include OOP spending. If looking at the national
figure, it can be seen that health financing system of Viet Nam has grown rapidly, from a very low level
of health financing (28 US$/capita in 2003 [NHA 2003] to 46 US$/capita in 2006 [NHA 2006]. But it
should be emphasized that a major share of total resources continues to come from household out-ofpocket payments (accounts for about 70%).
Comparing this figure with that suggested in the health system assessment analysis (per capita
expenditures are above USD 30 and spending trends are closing the gap to meet the $34 target), it can
be interpreted that total health expenditure per capita in two big cities such as Ho Chi Minh and Hanoi
is highly adequate, but it is considered as not adequate in poorer provinces such as Nghe An, Quang
Ninh and An Giang. People living in those provinces have less access to health care due to geographical
barriers.
TABLE 3. SCORES OF COMPONENT ON REVENUE COLLECTION IN PROVINCES
Indicator
Average score
Hanoi
Total health spending per capita
3.0
HCM
City
3.0
Hai
Phong
1.5
Quang
Ninh
1.0
Nghe
An
1.0
An
Giang
1.0
Government expenditure on health as % of total
government expenditure
Government spending on health as % of total health
expenditure
Donor spending on health as % of total health
spending
Out-of-pocket spending as % of total health
spending
2.0
2.0
2.0
2.0
2.0
2.0
2.0
1.5
2.0
2.0
2.0
2.0
3.0
3.0
3.0
3.0
3.0
3.0
2.0
2.0
2.0
2.0
2.0
2.0
Government expenditure on health as a percent of total government expenditure indicates the
commitment of government to the health sector relative to other commitments reflected in the total
government budget. These indicators are not available in Hanoi and Ho Chi Minh city due to lack of data
on total government expenditure. In remaining provinces, this indicator accounts for about 7% in Quang
Ninh, 2-5% in Nghe An, 2-9% in An Giang and 5-6% in Hai Phong and it does not clearly increase by
year. According to WHO, if the share of Government expenditure on health as a percent of total
government expenditure the assessment analysis is less than 20% suggests a low commitment to the
health sector. However, the government of Vietnam has high commitment in making health care more
affordable to the poor and their vulnerable groups by providing health insurance cards for the poor,
near poor, ethnic minority people, children under six and other vulnerable groups as well. Therefore,
we give 2 score in each province and is considered as adequate in all of six provinces.
Despite improvements in the source structure of resources for the health sector in the past few years,
the goal of achieving an equitable and efficient health system has not yet been met. The share of
25
government spending for health as a proportion of total health expenditure accounts for more than 50%
in most of studied provinces, except Ho Chi Minh and Hai Phong (these percentages are 25-28% in
Hochiminh and 35-39% in Hai Phong). According to the assessment, the contribution of central,
provincial and district governments to the total health spending in provinces such as Hanoi, Quang Ninh,
An Giang and Nghe An are high and regarded as highly adequate (score of 3); Ho Chi Minh city is slightly
less than adequate (score of 1.5) and Hai Phong is adequate (score of 2) (Table 3).
Government spending for health as a proportion of total health expenditure is a measure of the relative
contribution of central and local government, relative to total health spending. According to Ministry of
Health estimates, the share of government spending for health as a proportion of total health
expenditure increased from 29.8% in 2003 to 31.0% in 2006. In 6 provinces, this indicator is relatively
high in almost all of studied provinces except Ho Chi Minh city (Figure 1). Information from qualitative
study showed that at the present, the government gives high priority to the health sector, therefore,
there is high commitment from the government to health sector in terms of budget allocation. In Ho
Chi Minh, the Provincial People Committee allows hospitals to receive interest-free loans from the
government for investing in equipment. This reflects the high commitment from the local authorities.
However, in order to score this indicator, it is also necessary to look at the OOP expenditure rate and
the coverage of health insurance. In all studied provinces, OOP expenditures are high and coverage of
health insurance is moderate. Therefore, we can give a score of adequate (2) for five provinces include
Hanoi, Quang Ninh, Nghe An, An Giang, Hai Phong and score of less than adequate (1.5) for Hochiminh
city (Table 3). If looking at this indicator in the hospital both at the provincial and the district level, a
very high share of hospital revenue comes from government budget allocations (account for more than
90% in district hospital). However, for hospitals in Hanoi and Hochiminh cities, due to the hospital
autonomy policy and their high ability to collect revenue, the majority of hospital revenue comes from
health insurance and OOP sources, but revenue from government budget still accounts for above 40%.
According to the HSA analysis framework, if this indicator is above 40% then it shows that the
government could act to address equity issues.
FIGURE 1: GOVERNMENT SPENDING FOR HEALTH AS PERCENT OF TOTAL HEALTH
EXPENDITURE
Govern spending for health/total health expenditure
05
06
07
08
05
06
07
08
05
06
07
08
05
06
07
08
05
06
07
08
05
06
07
08
100
80
60
40
20
0
Hanoi
26
Qninh
Nghe
An
HCM
An
Giang
Hai
Phong
The share of total health spending by donors measures the contribution of international agencies and
foreign governments to total health spending. Findings from survey in provinces showed that none of the
provinces are dependent on donor funds. Donor spending on health as total health spending accounts
for only a small share and was considered highly adequate (score of 3) for all six provinces.
Out-of-pocket spending as percent of total health spending represents the expenditure that households
make out of pocket at the time of using health care services and purchasing medicines, relative to total
health spending on health. In nation wide, the OOP spending accounts for about 70%. In the individual
provinces, disaggregated data on OOP spending is not available. However, examining the share of
revenue from user fees in the hospitals can reflect the OOP spending to some extent. The percentage
of revenue from user-fees varies between hospitals at different levels, but it is generally under 80%. In
addition, vulnerable groups such as the poor, ethnic minority people, children under six of age are
provided health insurance cards to alleviate the financial barrier to health care for this group of people.
Starting in 2010, the new law on health insurance will also provide financial support for the near-poor to
buy health insurance. Therefore, OOP across the 6 provinces received a score of adequate (2).
COMPONENT 2: POOLING AND ALLOCATION OF FINANCIAL RESOURCES
Risk pooling is the collection and management of financial resources so that large unpredictable
individual financial risks become predictable and are distributed among all members of the pool. Risk
pooling in Viet Nam is implemented primarily through pooling of tax revenues to provide government
subsidies for healthcare and social health insurance, which together account for 90% of public health
spending [NHA, 2004-2006]. For the purpose of the rapid assessment, the indicators on pooling and
allocation of financial resources focus on the government health budget allocation and health insurance.
This component is measured by 9 indicators: provincial government of health budget trends; process of
budget formulation; budget allocation structure; central and local government budget allocations for
health in decentralized systems; percent of government health budget spent on curative and preventive
care; percent of government health budget allocation for province, district and commune levels; percent
of government health budget allocation for the poor, children under six year of age and other
vulnerable groups (added indicator for Vietnam); percent of government health budget spent on health
workers salaries, training, medicines and supplies and other recurrent costs; local level spending
authority.
The “Provincial government health budget trends” indicator looks at whether the province’s
expenditures keep pace with inflation and with population growth, whether the province has a mandated
level of government spending on health as percentage of total government spending, and any differences
between the authorized budget and actual expenditure. These indicate whether the provincial budget is
sustainable source of funding to the health sector.
In all of 6 provinces, findings from in-depth interviews point out that budget allocations for health over
the past five years are mostly reliable and equitable in the comparison with local available financial
sources. However, financing sources for health are becoming inadequate due to price increases,
increased spending on medicines and other health expenses, and salary raises. The budget allocation is
not increasing as the same rate as the price level. In most of the 6 provinces inflation is not taken into
the consideration (except Ho Chi Minh city, inflation rate is allowed at 10%). The authorized budget is
not much different from the actual expenditures in institutions which do not collect revenue, such as the
provincial health office. But it is different in hospitals because the authorized budget from the
government is supplemented by user fees and health insurance reimbursement revenue.
27
Budgetary Process in Province
The process of drafting health budget occurs according to national guidelines and is therefore the same
between the 6 provinces. Budgets are created from the bottom-up, beginning at the district level. In June
every year, health facilities draft expense estimates based on budget norms and submit them to their
finance unit. After being synthesized, these budget estimates are sent to the People’s Council for
approval and then are sent on to a higher level finance unit. At the central level, the MoF receives
estimates from specific ministries and provinces then synthesizes them. Synthesized expense estimates
will be compared with revenue collection estimates in order to make it balance with the available
financial sources.
Although the budgets are created from the bottom-up but they cannot be paid in full by the MoF
because of their limited budget. Input-based budgeting is used rather than performance-based. The
budgets are not developed based on estimates of resources requirements for the population’s health
needs. Budgeting norms for the health sector are based on the number of health workers and the local
population size. However, each institution varies in their approach to budgeting. For example, hospital
budget allocations are based on number of planned beds while preventive care budgets are based on the
number of health workers and population size. Vietnam is applies per capita-based budget allocations
with prioritized coefficients for mountainous and island areas as stated in the Decision 151/2006/QDTTg of the Prime Minister on expenditure norm for health (1.35-1.72 and 2.4 respectively). This
indicator is given a score of adequate (2) for all six provinces.
The budget allocation structure indicator showed that program budgets allocate funding either by
preventive program or by service delivery areas. However, within each program, line-item budgets are
used. For the approval process of Ministry of Finance, criteria used for approval are annual availability of
funding sources and actual expenditures in the previous year. All of the study provinces were found
highly adequate (score 3) in this area.
Regarding “the central and local government budget allocations for health in decentralized systems”
indicator, the central and local health funding allocations are not proportional to local needs or varying
abilities to collect additional revenue across provinces. For provinces/cities such as Hanoi, Hochiminh
and Quang Ninh which have a high capacity to collect addition revenue, the local governments have
means to add resources. In Quang Ninh, provincial authorities decided to use tax revenues to provide
additional funding for the health and education sectors. Poorer provinces such as Nghe An and An
Giang, have no way to add financial resources for health sector. Hanoi, Hochiminh, Quang Ninh were
found adequate (2) while Nghe An, An Giang, were not adequate (1) and Hai Phong was slightly less
than adequate (1.5) because central/provincial health fund allocations are not proportional to local needs
and local governments have no means to add resources.
In all studied provinces the percent of government health budget spent on preventive care is increasing
over time. Preventive care is receiving increasing amounts of attention. In addition, according to the
Resolution No.18/2008/NQ-QH12 issued in 2008 by National Assembly, it is indicated that the
government commit to ensure to allocate budget at a proportion of 30% for preventive care each year.
Government funding is the main source of resources for health facilities at district and commune levels.
However, budget allocations to grass-roots level health facilities are still not adequate to cover actual
expenditure. Improve health care service quality at the grass-root level has a direct impact on improving
health care service availability and access for people at the community level. Recently, the Prime
Minister issued Decree No.47/2008/QD-TTg in 2008 on investment for all district hospitals in the whole
country. For commune health stations, the Prime Minister also issued Decree No. 950/QD-TTg
requesting investment in commune health stations in disadvantaged areas. This reflects high commitment
28
from the government in providing financial resource to improve quality of health care at the grass-root
level.
In order to make health care more affordable and accessible for the poor, children under six and other
vulnerable groups, the government implemented a policy on health care for the poor and provides free
health insurance cards for these vulnerable groups. The percent of government health budget allocated
for the poor, children under six year of age and other vulnerable groups is an additional indicator that
can be looked at in Vietnam. On average the percent of the government health budget allocated to poor
and vulnerable groups is about 14% (8-22%) in the six provinces. All of the poor, children, and
vulnerable groups are provided health insurance cards.
About 34-70% of government budget is used to pay for health worker salaries. The remaining budget is
insufficient to cover medicines and some recurrent costs. The cost of medicines is partly covered by
government funding, but mainly funded from health insurance and user fees. A score of “better than
adequate” (2.5) was given to Hanoi, Hochiminh, An Giang, Nghe An, Quang Ninh and an “adequate”
score (2) was given to Hai Phong.
The hospital autonomy policy is applied in all hospitals so the health facilities have autonomy in making
procurement of medicines or hiring of supplemental personnel. However, procurement of medicines
must follow the bidding regulations (see pharmaceutical section). The hospitals themselves do not have
the right to set prices for services, they must be approved by the provincial people’s committee based
on the existing fee schedule of the MoH. Tracking and auditing budget expenditures is required for all
hospitals.
Pooling of Tax Revenues to Subsidize Health Care
Tax revenues are used to subsidize public provision of preventive health programs, primary health care
and hospital care. They are also used to purchase health insurance or reimburse providers for health
services for certain target groups of the population, such as the poor, ethnic minority people, orphans
and widows of war, and children under the age of six.
Government funds are allocated to both the central and local budgets. The local health budget includes
funds from the People’s Committee of each locality allocated towards health activities and local health
facilities. In 2006, the total local health budget was VND 6388 billion, accounting for 49.8% of the total
recurrent budget for health [Vietnam Health Report, 2006].
Pooling Through Social Health Insurance
Social health insurance is the other main mechanism for risk pooling. Approximately 42% of the
population of Viet Nam is covered by health insurance. Through this risk-pooling mechanism, their
curative care costs are paid by the health insurance agency thus reducing the risk of impoverishment for
the covered population when they face high medical costs. With the new Law on health insurance,
people with health insurance cards will be able to use high-tech services. They can be reimbursed a
maximum amount of about 1,500 USD per one in-patient visit. Findings from group discussions showed
that the poor in studied provinces are able to access health care services in hospitals, except some
mountainous areas of Quang Ninh. The poor sometime still have difficulty in accessing hospitals due to
indirect costs which are not covered by health insurance.
Previously there has been a strong concern about susceptibility to impoverishment among the near-poor
not covered by health insurance or other schemes should they face catastrophic health expenditures.
However, starting in January 2010, according to the new law on health insurance, the near-poor will
29
receive some financial support from government to buy health insurance. Thus increasing access of the
near-poor to health care services.
Resource Allocation
The central government budget for health is allocated to provinces and municipalities based on their
population sizes and regional adjustment coefficients. At the local level, the local government (People’s
Council, People’s Committee) has some discretion in the allocation of funds for preventive and curative
care and to each facility, although normally funds are allocated based on the number of beds or number
of staff members, using line-item budgets and annual plans.
Findings from the six studied provinces show that allocations to provinces are not adjusted for differing
disease patterns or abilities to collect revenue within each province. Local health budgets are approved
by the National Assembly. However, funds available in many localities are insufficient to cover the total
amount approved. The allocation of funds for health at the local level focuses on the curative-care
sector and the proportion allocated to preventive medicine is typically low. In studied provinces, the
amount allocated to preventive medicine is only about 16.9% of the total government health budget
(range from 5% to 33% of the total government health budget). Hanoi and Hochiminh have the lowest
proportions allocated to preventive medicine (accounting for less than 20%). An Giang and Hai Phong
have the highest proportions allocated to preventive medicine (about 30%-32%). However, the budget
allocated for preventive care is increasing annually. This is due to the government issues Resolution
No.18/2008/NQ-QH12 dated 3/6/2008 on improving the implementation of policy on social mobilization
in order to improve quality of health care for people. With this Resolution, the government will commit
to allocate 30% of their budget for preventive care each year. In reality, the amount actually paid to a
hospital is based on the number of planned beds and for preventive medicine, based on number of staff
and population.
In six studied provinces, the percentage of government health budget spent on health worker salaries
accounts for 60-80% of the budget and the remaining funds are not sufficient to cover recurrent costs
including essential medicines. Thus, the percent of the government health budget spent on health
worker salaries, training, medicines and supplies, other recurrent costs is not adequate. Funds to cover
services mainly come from user fees and health insurance resources.
COMPONENT 3: PURCHASING AND PROVIDER PAYMENT
Purchasing refers to the many arrangements for buyers of health care services to pay health care
providers and suppliers. Three indicators are used to assess this component: policies for user fee
payments in the public sector; allocations of user fee revenue; informal user fees in the public sector.
User fee policies were introduced in 1994 by the Decree No.95-CP. Patients pay user fees for both out
patient and in patient services. User fee policies generally have a negative effect on the utilization of
health services. In order to make health care more accessible and affordable for the poor and other
vulnerable groups, a fee exemption policy was introduced. In 2002, the health care fund for the poor
policy, provided all poor and vulnerable people with health insurance cards. The “poor” were identified
based on MOLISA’s criteria. Fee exemption or health insurance cards for the poor promote financial
equity, access for the poor, and use of services by priority population groups. The user fee policies are
set up centrally and according to the HAS framework, appear “adequate” (2) in all 6 study provinces.
All user fee revenue is retained at the facility level. Following the regulation indicated on the Decree
No.43/2006/ND-CP on hospital autonomy policy and Cirlucar No.71/2006/TT-BYT, hospitals must
allocate user fee revenue to the following funds: professional development fund (25-30%), award fund
30
(10/15%), fund to keep income stable (5-10%), and the fund to cover additional salary from revenue and
expenditure difference. There is no figure on average percentage that user fee revenue constitutes of
non-salary operating costs for hospitals and for Commune Health Stations because in reality, revenue
from user fees and health insurance are mingled together.
Informal user fees in the public sector indicator are not a common problem in any hospital and do not
constitute a major barrier to accessing services at any level. All 6 hospitals scored “better than
adequate” (2.5) on this indicator.
Purchasing Using Funds from the Government Budget
The Government uses its funds to purchase health services for the population in two ways. First, it
provides direct budget subsidies to public health facilities to cover some inputs needed to provide
preventive and curative services, mainly salaries, with a small portion for services and other
administrative fees. Second, the government budget is used to purchase compulsory health insurance for
certain vulnerable target groups (including about 17 million poor people) and the health insurance fund
reimburses health facilities for services provided to the insured. Under social insurance, reimbursement
for health services is based on a fee-for-service mechanism that has numerous short-comings as
mentioned above.
Health Insurance
The health insurance fund covers curative care expenditures for the population enrolled in social health
insurance schemes (compulsory and voluntary). Health insurance agencies sign contracts with health
facilities and reimburse service costs based on user fees set by local governments according to the
government guidelines on allowable ranges of fees. Patients are subject to some co-payments for
services using high-level technology. However, with the new Law on health insurance, in-patients visits
will be covered by the health insurance agency up to a maximum of 1,500 USD per in-patient visit.
The health insurance agency applies a ceiling to total reimbursements at district hospitals. In addition,
payment for referral care at higher-level facilities is taken from the health insurance fund at lower level
facilities. In provincial and central hospitals, no ceilings are imposed on reimbursements.
Findings from the field studies showed that the financial resources of the health insurance fund
(reimbursements) are not being used efficiently by service providers and are creating a moral hazard. In
addition, the current insurance schemes are facing a funding deficit. Monitoring of health insurance
reimbursements for service delivery is inadequate due to a lack of managerial capacity and a lack of
standard treatment guidelines for hospitals.
Payment Method for Patients Paying Out-of-pocket User Fees
Patients subject to user fees pay public and private hospitals on a fee-for-service basis. In the public
health sector, the user-fee schedule was not established based on a systematic costing exercise covering
all costs; fees for most services have not been updated since 1995. In the private health sector, the user
fees are determined by providers. With about 70% of the population paying for health services out of
pocket10, and more than 60% of outpatient services being provided by the private health sector, the lack
of a regulatory environment for quality assurance and the fragmentation of purchasing power by
individual patients are negatively influencing the efficiency of household out-of-pocket spending.
Around 42% of the population are covered by health insurance and 10% are benefiting from free health services for
children under the age of six. The remaining 50% still have to pay for health services out of pocket.
10
31
3.3
HEALTH SERVICE DELIVERY
This section presents findings from the health service delivery module. In the original module, several
components of the service delivery function were considered, including: access, coverage, and utilization;
service outcomes; organization of service delivery; quality assurance of care; and community
participation in service delivery. There are total 31 indicators of 7 components in the original
assessment. Each component was scored according to detailed indicators and definitions.
After revising, there are 5 components with 36 indicators, including 26 original indicators and 10
supplemental indicators. 5 indicators were removed from Health service delivery module. A full
description of revised components and indicators are presented in table B1 of Annex B.
COMPONENT 1: AVAILABILITY
Service availability was examined in the six provinces based on 3 indicators: Number of Hospital beds
(per 10 000 populations); Number of primary care facilities in health system per 10,000 populations; and
Percentage of primary care facilities that are adequately equipped.
Data from the assessment indicated that availability of health services in six assessment provinces was
“adequate”. With the exception of Quang Ninh, the public health network in all 5 provinces has a wide
coverage, see figure 2. At the provincial level, there are provincial general hospitals and provincial
specialized hospitals such as for tuberculosis, lung disease, and traditional medicine. At the district level,
district hospitals administer inpatient services using basic techniques, resolve emergencies, and treat
common diseases. At the commune level, the commune health station (CHS) focuses on preventive care
and provision of outpatient services. However, most CHS have some beds for inpatients in cases of
delivery, emergency, or for monitoring patients. Table 4 shows the distribution and occupancy of health
facilities by province.
32
TABLE 4. NUMBER OF HEALTH FACILITIES AND BEDS IN 6 PROVINCES
Ha Noi
Population
Number of districts
Number of commune
Provincial level
Number of provincial
general hospitals/ regional
hospitals
District level
Number of district hospitals
Commune level
Number of commune health
stations (CHS)
CHS/10,000 pop
Public bed
Number of planned beds
Number of actual beds
Bed occupancy rates (%)
Non-state Provider
Number of non-state
hospitals
Total number of non-state
hospitals beds
State & non-state sector
Total number of bed
Bed/10,000 population
TP.HCM
Hai Phong
Quang
Ninh
Nghe An
An Giang
6,200,000
29
577
6,424,519
24
322
1,858,201
15
224
3,128,532
20
478
2,253,865
11
154
27
30
9
8
4
16
17
11
12
577
322
224
478
154
0.9
0.5
1.2
1.5
0.7
7,241
7,546
110
19116
109.6
4,380
5,116
137
4,225
4,225
125
4,390
4,390
114
13
29
2
4
3
435
1947
57
273
190
7,981
12.9
21,063
32.8
5,173
27.8
4,498
14.4
4,580
20.3
Based on our findings, the overall number of treatment beds in Hai Phong and An Giang is adequate to
achieve their local needs and objectives. The ratio of hospital beds to population in 2007 was about 27.8
and 20.3 beds per 10,000 population in Hai Phong and An Giang provinces, respectively. Hochiminh city
has a highest ratio bed/10,000 population is 32.8.
However, data on number of hospital beds in table 4 does not fully reflect the local situations. Ratio of
hospital beds to population of Hanoi is only 12.9, lower than any other province. However, these figures
do not include the central level hospital facilities. Given that Ha Noi and Ho Chi Minh city are the two
biggest cities in Vietnam and have many central level hospitals we anticipate that the ratio of hospital
beds to population in Hanoi and Hochiminh city must be adequate.
At present, private hospitals are well developed in 5 of the provinces, but not in Quang Ninh. Ho Chi
Minh city, Ha Noi and Nghe An are 3 provinces with the highest number of private hospitals and clinics.
There are 13 private hospitals in Ha Noi with a total of 435 beds; 4 private hospitals with 273 beds in
Nghe An. Distribution of private hospitals in the 6 provinces are shown in figure 3.
When the number of beds is disaggregated by facility, the number of usable hospital beds available
closely matches the true need at hospitals in Quang Ninh, Nghe An and An Giang. Quang Ninh and
Nghe An provinces have many mountainous districts and ethnic minorities. Therefore occupancy rate in
district hospitals is only 70% to 90%, because some people have difficulty accessing health care services
due to barriers such as geography, customs, awareness etc. Other hospitals in Ha Noi, Ho Chi Minh
city, and Hai Phong, however, are overloaded with bed occupancy rates higher than 100%. Overloaded
hospitals are a serious issue in both Hanoi and Hochiminh city. There are 2, 3, sometime 4 patients per
33
bed at the in many central hospitals as well as city’s hospital. The overload in Hai Phong sampled
hospitals is quite serious, indicated by two indicators: the high bed-population rate (27.8 per 10,000) and
occupancy rate is nearly 140%.
Commune health station (CHS) in Vietnam is considered primary care facilities. According to the
assessment results, 100% of communes in all 6 provinces have CHS. However, the number of CHS per
10,000 people varies by province. The national ratio is 1.3 CHS/10,000. This ratio is quite adequate in
Hai Phong and Nghe An with 1.2 and 1.5 CHS/10,000, respectively. Ha Noi and An Giang have less than
1 CHS/10,000 with 0.9 and 0.7 CHS/10,000, respectively. The ratio in Ho Chi Minh city even lower with
only 0.5 CHS/10,000. The explanation for this situation is that Ha Noi and Ho Chi Minh city have high
density of population; meanwhile An Giang province has a large population in commune as do other
provinces in the Mekong river delta. Each commune often has more than 10,000 up to 15,000 people.
Therefore, the ratio of CHS/10,000 is less than 1.
The percentage of primary care facilities that are adequately equipped in 6 provinces is more than 70%
and varies by province and commune. Most CHS in Hai Phong, Ha Noi, Ho Chi Minh and An Giang have
enough health workers, basic equipment, essential drugs, telephone service and access to an ambulance.
Some CHS in Quang Ninh and Nghe An lack medical equipment and access to an ambulance due to
difficult road conditions. There are also CHS there with run-down infrastructure in need of repair or
rebuilding.
34
FIGURE 2: NUMBER OF HOSIPTAL BY LEVEL OF CARE IN THE 6 PROVINCES IN 2009
35
FIGURE 3: NUMBER OF PUBLIC HOSPITALS IN 6 PROVINCES IN 2009
36
COMPONENT 2: SERVICE DELIVERY ACCESS, COVERAGE
The assessment of Service delivery, access, and coverage, in this study is based on 6 indicators:
Percentage of people living within standard distance from a health facility; Private sector service delivery;
Existence of user fee exemptions and waivers; Existence of work place programs that offer health
services to employees and Percentage of employees has Health insurance card and work contract, and a
supplemental indicator “Percentage of the poor and other vulnerable group have providing Health
insurance card”.
Access to health services and coverage in Vietnam is quite “adequate”. In Vietnam, there is no regulation
of standard distance from a health facility. However, coverage of health facility could be measured by
population density and distribution of health facilities. Normally, each commune has a commune health
station (CHS) and each district has at least one hospital. CHS and district hospitals are often located at
the city center or most convenient place of commune or district. Based on the assessment results, the
length of a commune is about 10 km and a district is about 40-50 km. Most of people can access CHS
within an hour and district hospital within two hours. Therefore, coverage of health facility in 6
provinces is quite adequate. However, in mountainous areas, communes and districts can be large and
people have greater difficulty accessing health care services. Difficulties include no roadways, long route,
poor road quality, even muddy roads in the rainy season.
Private sector is growing rapidly in all 6 provinces in recent years, especially in Ho Chi Minh, Ha Noi and
Nghe An. Hai Phong and An Giang have 2 and 3 private hospitals, respectively and the 2 provinces also
have many private practitioners. However, private hospitals and clinics are concentrated in wealthy
areas and populous urban areas. In rural areas, the private practitioner network is thinly scattered with a
few private practitioners, traditional healers, pharmacies etc.
It is not easy to measure the indicators “Existence of work place programs that offer health services to
employees” and “Percentage of employees has Health insurance card and work contract”. According to
labour laws, workers are protected by a health insurance scheme. Work place programs are included in
the regulations of many companies: persons employed for more than 3 months are required to have a
contract and to buy health insurance. However, to increase profits, many companies, both foreign and
domestic, do not buy health insurance for their workers. It is very difficult to evaluate the percent of
workers holding health insurance cards in all 6 provinces.
One of the priorities of the Vietnamese Government is to ensure equity in health care. In order to
support the poor in an active, comprehensive and effective manner, in 2002 the Government issued
Decision No. 139/2002/QĐ-TTg on health care for the poor. The Decision clearly identified eligible
target population, which included: poor people; people living in communes under especially difficult
socio-economic conditions and people of ethnic minorities. As of 2009, the percentage of poor has
received Health Insurance card for the poor is higher than 99% in all 6 provinces. Furthermore, children
under 6 and the elderly above 85 years olds also were provided Health Insurance cards.
COMPONENT 3: SERVICE DELIVERY UTILIZATION
Assessment of the Service delivery utilization component in this study based on 7 indicators: (i)the
percentage of births attended to by skilled health personnel per year; (ii) Percentage of births delivery at
health facilities per year; (iii) DPT3 immunization coverage; (iv) Immunization coverage: one-year-olds
immunized with 6 main diseases & vaccine Hepatitis B (%); (v) Contraceptive Prevalence (% of women
aged 15-49); (vi) percentage of pregnant women who received one or more antenatal care visits and;
(vii) Increased number of primary care or outpatient visits per person to health facilities per year.
37
Similar to Ninh Binh and Can Tho provinces, the utilization of services in the six assessment provinces in
general were good, and received scores of “adequate” and “highly adequate” depending on the situation
of each province.
In recent years, reproductive health care (RHC) has significantly improved. Most of deliveries in six
provinces occur at health facilities and are attended by skilled health personnel. In Ha Noi, Hai Phong,
Ho Chi Minh and An Giang, these provinces have only around 0.01% - 0.03% of pregnant women do not
receive professional birth attendance. However, different from these provinces as well as Ninh Binh and
Can Tho from the last assessment, the rate of pregnant women not receiving professional birth
attendance in Nghe An and Quang Ninh province was quite high. In province such as Nghe An, there
were 530 unattended deliveries outside health facilities in 2008. This situation occurred not only in
mountainous areas, but also in lowland areas. An indepth interview with the head of Occupational health
Dept. of DOH in Nghe An found that some Christians in a few villages near the sea did not want to
deliver in the health facilities due to messages taught by their parish priest. Quang Ninh and even Ho
Chi Minh have few cases of delivery outside health facilities. In Ho Chi Minh, there are some villages
located on an island in the river. In 2008, there were two pregnant women in this village who delivered
their babies outside of a health facility. These results indicate that reproductive health needs be
improvement in certain areas. Nghe An, Quang Ninh and Ho Chi Minh provinces scored lower than the
other 3 provinces.
It is important to note that most pregnant women in the survey provinces use prenatal services. Each
pregnant woman on average had more than 3 contacts with health facilities for prenatal care. However,
there are differences in terms of the quantity and quality of reproductive health services received by
urban/rural and by economic status.
Gynaecological care is also quite good in the two assessment provinces overall. It is poor in some
remote areas in Nghe An and Quang Ninh provinces due to limited funds, equipment, human resources,
living condition, and education of local people. Most of health facilities at the district and commune
levels provide consultation, testing, and diagnostic services for common gynaecological diseases. The
percentage of people using a modern contraceptive method is increasing, but the exact number of
women using them is difficult to determine. The rate of couples from 15-49 years old using
contraceptive methods is estimated around 60-80 %.
The national expanded programme on immunization (EPI) provides free vaccinations against seven
diseases: tuberculosis, diphtheria, whooping cough, tetanus, polio, measles and hepatitis B. Similar to
Ninh Binh and Can Tho provinces, the rate of children fully vaccinated against all seven diseases is about
95%. The rate of one-year-old children immunized with three doses of diphtheria, tetanus toxoid, and
pertussis is about 97%. In addition to vaccinations against the seven childhood diseases, children in
certain areas are also vaccinated for free against other diseases, such as Japanese encephalitis. Most
pregnant women are immunized against tetanus (around 97%). Generally, the EPI programme in all 6
provinces is quite successful, with decreases in disease outcomes. However, there was a paradox
regarding the EPI program in the two biggest cities. Hanoi and Hochiminh Provinces’ EPI coverage was
not as good as other provinces due to urban migration. These two cities have high percentages of
people who come from other provinces and stay there without registration. The government authorities
do not have lists of migrant children’s names resulting in a shortfall of immunization coverage among
children living in these cities.
COMPONENT 4: SERVICE DELIVERY OUTCOMES
The performance of service delivery within the health system can also be examined using indicators to
measure whether service delivery is achieving desired outcomes. Assessment of Service delivery
38
outcomes in this study is based on 8 indicators included 4 original indicators and 4 additional indicators.
4 original indicators included Life expectancy at birth, total (years); Mortality rate, infant (per 1,000 live
births); Maternal mortality rate (per 100, 000 live births); Prevalence of HIV, total (% of population aged
15–49). 4 additional indicators included Disability adjusted life year (DALY); Incident rate of HIV in year;
Tendency of Tuberculosis & malaria and; Percentage of Child malnutrition.
According to data provided by the 6 study provinces, the score of this component indicates that nearly
all basic health outcome objectives in all 6 provinces have reached or even exceeded national health
targets. Successfully achieved outcomes include those for: the infant mortality rate, maternal mortality
rate, the under-five mortality rate, and child malnutrition.
The life expectancy at birth in all 6 provinces has not yet been estimated. According official MOH
reports, life expectancy in Vietnam was 72 years in 2008, similar to high income countries. However,
regarding quality of life, DALYs in Vietnam is only 61 years on average. Thus, many people suffer from
disabilities later in life. Therefore, DALY indicator provides a more realist ic picture than life expectancy
for evaluating health service delivery outcomes.
The rate of maternal mortality was estimated to be highest in Quang Ninh and Nghe An provinces with
16.3 and 14 maternal deaths per 100,000 live births, respectively. This indicator is 6.6 in Ha Noi and
lowest in An Giang with only 2.3 maternal deaths per 100,000 live births. It is surprise that all 6
provinces have low infant mortality rate, around 5 and 6 cases per 1,000 live births. The indicator in Ha
Noi has only 1.7. However, this figure is identified by analyzing available data from existing reporting
system. Many studies provided an evidence of under reporting regarding mortality data. On average,
service delivery outcomes in the assessment of 6 provinces were found to be slightly better than
“adequate”. HIV/AIDS is still a big health problem of all 6 provinces. Infection rates continue to increase
in the 6 provinces and across the whole country. HIV/AIDS is reported to be the major cause of
mortality and morbidity in all 6 provinces.
COMPONENT 5: ORGANIZATION AND INTEGRATION OF PUBLIC SERVICE
DELIVERY SYSTEM
Assessment of component Organization and Integration of public Service Delivery System in this study
based on 4 indicators: Availability of integrated primary health care services (immunizations, TB, prenatal
care, family planning, malaria, nutritional services); Availability of primary health care services through
vertical programs; Existence of information systems that can store and retrieve information over time
about patients; Existence of referral mechanisms between different levels of health care.
The organization of public service delivery is important to allow for a functional health system. For the
purposes of provincial health system assessment the availability of integrated primary health care
services (immunizations, TB, prenatal care, family planning, malaria, nutritional services) and the
existence of referral mechanisms between different levels of health care were used as indicators of the
organization of service delivery. The assessment of the 6 provinces indicated that all 6 provinces
received scores of less than adequate for the organization and integration of the health system
component, due to concerns over the distribution of patient loads as well as the ineffectiveness of the
referral system. Integration of health service delivery in all 6 provinces is also less than adequate.
In all 6 provinces, based on MOH regulations on treatment capacity, each facility develops a list of
specialized treatments that they would like to offer and submits to DOH. Then DOH will examine
capacity as well as equipment, human resources available etc. and approve the list of specialized
treatments that a particular facility can provide. If a facility encounters difficult cases beyond their
capacity, they will refer the cases to a higher level. Each health facility has a record of patients referred.
39
If a hospital wants to refer a patient, a certificate of technical meeting with the director and his signature
are required. At least one health professional accompanies the patient to the referral facility. Most of the
district hospitals in the 6 provinces have ambulances.
COMPONENT 6: QUALITY ASSURANCE OF CARE
To improve and ensure quality of health care service is a priority of the health care system as well as
health facilities. Assessment of the Quality Assurance of Care component in this study is based on 8
indicators. Five original indicators were used to examine this component of service delivery function in
Vietnam: the existence of national policies for promoting quality of care; the existence of quality
standards adapted to local level situations; the existence of clinical supervision by provincial/district level
supervisor; the percentage of supervision visits to health centers planned that were actually conducted;
and the existence of other methods assuring quality of care besides supervision (accreditation and
certification renewals, quality improvement methodologies, health audits, client satisfaction surveys,
community quality assurance teams). An original indicator was moved from Service Delivery Outcomes
component is Availability of updated clinical standards for MOH priority areas, high burden diseases
areas, and/or areas responsible for high morbidity and mortality; Two indicators were added: availability
of technical guidelines & regulations at health facilities and availability and application of International
Organization for Standardization (ISO) standards in health facilities operations to improve quality of
care.
Quality of care is a major concern in many health facilities. In general, it is not easy to measure quality of
care directly. In many health facilities, quality of care was influenced by low economic development,
poor investment in infrastructure and a shortage of human resources in terms of both quantity and
quality, especially a shortage of doctors in district hospitals and in mountainous provinces. According to
our findings, inspite of the challenges, quality of care in the assessment of 6 provinces appeared
“adequate”.
At the provincial level, some policies were launched for promoting quality of care. DOH of the 6
provinces conducts monitoring and supervising annually. Budgets for these supportive supervision
activities are allocated within the state budget of DOH. Furthermore, DOH collaborates with other
sectors to monitor quality of care. Twice a year, DOH, province, and district people’s councils organize
a team to visit health facilities to examine quality of care, in terms of infrastructure, hygiene condition,
and professional activities. To monitor quality of care, all health facilities, included private sector report
on treatment activities at least 4 times per year. Some facilities, such as district hospitals send monthly
reports to the provincial DOH.
Availability of Updated Clinical Standards
The Ministry of Health’s therapeutic department drafted and distributed clinical standards for some
priority areas, such as high burden diseases, high morbidity and mortality or emerging issues. In theory,
these clinical standards were provided to both public and private health facilities, but in practice they are
mainly applied in the public sector. It is interesting to note that 70 % of physicians working in the private
sector also work in public facilities. In Ho Chi Minh, DOH estimated that more than 90% of public
sector physicians also working for the private sector. Therefore, a majority of private sector employees
are also aware of clinical standards.
In these provinces, the Department of Medical Professionals, DOH has held training of trainers (TOT)
workshops for both public and private providers. The workshop trains participants in clinical standards
for diseases such as HIV/AIDS, bird flu, dengue fever, and cholera. After the workshop, participants
return to their work and train the health care staff at their facilities. Through these trainings most health
40
personnel are trained in the latest clinical standards, included private sector, district and commune
levels. Furthermore, some hospitals have developed additional treatment guidelines and professional
regulations, based on MOH guidelines or others official documents. These trainings and standards
improve the quality of care of health facilities.
Quality Standards Adapted to Local Level Situations
Based on the standards provided by the MOH, health facilities adapt themselves to deal with local
situations. All health facilities have a treatment board and a pharmaceutical board. The main task of
these boards is researching (internet, books, official document) the latest clinical procedures; receiving
treatment guidelines (from MOH and others) and developing treatment guidelines as well as lists of
pharmaceuticals needed for hospitals. Treatment guidelines are updated annually to meet with the latest
health care procedures and standards. Clinical standards also regularly reviewed and updated at both the
provincial and district levels. A quick assessment of the 6 provinces found that some district hospitals
have developed treatment guidelines for the most common diseases in the hospital as well as emergency
cases.
It is interesting that An Giang is a pioneer province in Vietnam developing and applying ISO for hospital
management. Some hospitals in An Giang province has achieved certificate of ISO for hospital
management. It is a very good measure and scale to ensure quality of care.
3.4
HUMAN RESOURCES
This section presents five components: human resources data, human resources planning, human
resources policies, performance management, training and education. Each component is measured by a
number of indicators. Total, the human resources module has 20 indicators. To obtain the information
that best reflects the indicator, several questions and a data sheet have been designed to fit in to
Vietnamese context based on the pilot test of the HSA tool in 2008. The summary results of
component scores for human resources are presented in table 5.
TABLE 5. SCORES OF BASIC COMPONENTS OF HUMAN RESOURCES
Component
Average score
Hanoi
Human resources supply
2.0
HCM
City
3.0
Hai
Phong
2.5
Quang
Ninh
2.0
Nghe
An
1.5
An
Giang
1.5
Human resource planning
1.8
2.3
1.8
1.6
1.6
1.6
Human resources policies
2.1
2.2
2.1
2.1
2.1
2.1
Performance Management
2.0
2.2
1.9
1.9
1.9
2.0
Training and Education
1.8
2.2
1.8
1.5
1.5
1.5
COMPONENT 1: HUMAN RESOURCES SUPPLY
There are four provinces (Quang Ninh, Hai Phong, Nghe An and Ho Chi Minh City) that have the right
coverage of total health professionals for the health system to meet MDG as WHO recommendations
(at least ratio of 23/10,000 populations) (Figure 4). Among those provinces, Hai Phong and Ho Chi Minh
City have ratios of doctors per 10,000 populations which are equal or greater than the Master plan
41
targets for the health system by the year 2020 11 (at least 7 doctors/10,000 populations by the year
2010; 8/10,000 by 2015 and 9/10,000 by the year 2020).
According to number of health professionals under the administration of the Provincial Health Bureau,
Ha Noi and An Giang lack health professionals both in ratio of health professionals and doctor per
populations (Hanoi: 15.3/10,000 with only 2.9 doctors/10,000; Nghe An: 22.3/10,000 with 4.3
doctors/10,000 compare to National data with 32.1/10,000 and 6.4 doctors/10,000 population). Nghe
An is also far from reaching the target of 7 doctors/10,000 populations with recent ratio of 4.3/10,000.
Ha Noi appears to have a very low number of health professionals because Ha Tay province was added
into Hanoi City in 2008. However, Ha Noi does not seem to be lacking health professionals. There are
a large number of highly skill health professionals in many health facilities that belong to MOH12 and
other Ministries are not taken into account (Ministry of Defended, Ministry of Police, MOLISA etc.).
FIGURE 4. RATIO OF HEALTH PROFESSIONAL CADRES IN SIX PROVINCES (PER 10,000
POPULATIONS)
(Sources: Health statistic year Book 2007, Provincial reports 2008)
40
35
32.5
35.4
33.6
32.1
30
23.4
25
22.7
19.7
20
15
10
6.4
4.3
5
6.4
7.3
7.2
4.3
3.7
Health staff/10,000
An
hG
ian
g
TP
.HC
M
Ng
he
An
Ha
iP
ho
ng
Qu
an
gN
inh
Ha
No
i
Na
tio
nw
ide
0
Doctor/10,000
WHO recommend (23-health professionals/10,000 pop.)
Target to the year 2010 (07 doctors/10,000 pop.)
According to the guideline in Circular 08/2007/TTLB-BYT-BNV about the number and staff skills-mix in
public health facilities, none of the health care facilities in the six provinces have met the criteria
designated in the Circular for either quantity or staff skills-mix. That situation is more serious in lower
level facilities and in the preventive care facilities (district hospital, district health center and some
specialized hospital such as Psychology hospital, Hospital for Tuberculosis and pulmonary diseases).
Decision 153/2006/QĐ-TTg of Minister approves the Master plan for health system by the year 2010 and vision 2020.
About 6731 health professional work in 17 Central hospitals in Ha Noi (Source: General department of examination and
treatment – MOH, 2008)
11
12
42
Regarding the health workforce retention, all six provinces have been facing with difficulty of maintaining
human resources for health, particularly, in keeping highly-skilled health practitioners. All provinces are
experiencing migration of human resources moving from rural to urban areas, lower to higher-level
health facilities (commune, district hospitals to provincial hospitals or city level hospitals), from public to
private health facilities, and from the preventive field to curative field. Particularly, An Giang, Nghe An,
Quang Ninh, an Hai Phong are losing health professionals moving to work in bigger cities such as Ha
Noi and Ho Chi Minh city while the provinces have difficulty in recruiting new doctors or skilled health
staff (Table 6). On the other hand, Ha Noi and Ho Chi Minh City have highly skilled doctors and nurses
from other provinces coming to get a job. However, these two Cities also have the serious problem of
losing health staff from public sector (to work in private sector). Within the public sector, all provinces
are coping with problems caused by health staff moving from lower level to upper level health facilities
(at commune and district level, particularity in the suburb areas such as Nha Be, Hoc Mon districts in
HCM City, Soc Son, Thach That in Ha Noi etc.). Currently, the HRH situation is under control, but in
coming years, without a policy or measure to control HRH issues, the provincial health systems will
have trouble with health workforce development and management in order to implement health care
activities.
TABLE 6. DOCTORS LEAVING THE PUBLIC SECTOR – 2008
(NOT INCLUDING THE RETIRED STAFF)
Doctors leaving a public facility
Specialist
Ha Noi
Ho Chi Minh
Hai Phong
Quang Ninh
Nghe An
An Giang
9
34
9
2
3
13
General
doctor
15
86
0
1
0
1
Total
23
120
9
3
3
14
(Sources: Report of Provincial health Bureau and Dept. of human resource Management – MOH -2008)
COMPONENT 2: HUMAN RESOURCES PLANNING
Human resources planning is an important component of the HRH function within the health system.
For the purposes of assessing the HRH planning system, four indicators were used: the distribution of
health care professionals by level of care in urban and rural areas; presence of a human resources data
system; existence of a functioning HR planning system; percentage of the health budget dedicated to HR.
The total score shown that human resources planning in five provinces is not quite adequate enough
with “inadequate” score (1.6-1.8), except Ho Chi Minh City with score of 2.2 (Table 5). With the
exception of Ho Chi Minh City which had a total score of 2.3, the remaining fives provinces have
inadequate human resource planning and there have many constrains and limitation that need to
improve.
43
TABLE 7. DISTRIBUTION OF HEALTH WORKFORCE BY LEVELS - 2008 (%)
Hanoi
HCM
Commune level
22
City
7
% CHS with a doctor
84
District level
Provincial level
30
48
Hai
Phong
Quang
Ninh
Nghe
An
An
Giang
Nation
wide
35
25
18
21
24.7
83.5
84.4
100
73.15
72.1
67.3
22
71
34
31
28
47
33
49
40
39
33.2
42.1
Source: Dept. of Human Resources Management – MOH, 2008
In terms of health workforce distribution, all provinces are facing an unbalanced workforce distribution,
particularly between grassroots level and upper levels, curative care and preventive care fields. The
distribution of health professionals is skewed toward higher levels of care, thus the distribution of HRH
at the commune level is the lowest with 7% - 35% total of health workforce (Table 7). Hai Phong has a
more balanced distribution of HRH workforce for primary health care at commune level and essential
services at district level (35% and 34% total number of health professionals). The other provinces have
a low rate of health workforce at commune level with only 1/3 of the total number of health
professionals. Of those, Ho Chi Minh City has lowest number of health workforce at commune level
with 7%. This data is similar to the data in nationwide, in which only 24.7% total health professionals
work at commune level and about one third work at district level. The coverage rate of doctor to
health commune stations in all six provinces are higher than that in nationwide (72.1 - 100% compare to
67.38% in nationwide). About one third of CHS in An Giang and Nghe An have no doctor (27.9% and
26.7%).
TABLE 8. DISTRIBUTION OF HEALTH WORKFORCE BY FIELD OF WORKS – 2008 (%)
Hanoi
Curative care
Preventive care
CHS(primary care)
Other
60.0
17.7
20.6
1.6
Hai
Phong
54.6
8.4
28.8
8.2
Nghe An
61.3
12
16.5
6.2
An Giang
67.1
11.4
19.9
1.6
Nationwide*
81.8
12.9
NA
4.2
* National Health Report 2006 (include data at central level).
According to the 2006 Health Report from the MOH, there is an imbalance of health workforce
between rural and urban areas with 59% of doctors, 82% university pharmacists and 55% of qualified
nurses work in urban areas while the urban areas have only 7.4% total population13.
There is also an imbalance of human resources for health between curative and preventive care. Health
staff working in the field of preventive care constitutes only 8.4% to 17.7% (HCM City). National data in
2006 shows the same situation of low number of health professionals for preventive care just around
13% (Table 8). Another report issued in 2007 shows that a large number of health professional who
work in preventive care are not specialized in preventive or public medicine (only 20% have university
degree). According to the report, the health workforce for preventive care now just adapts 68.6%
demand of heath workforce for district health centers14.
13
14
44
Health Report 2006 - MOH
Join Annual Health Review 2007, MOH - Vietnam
TABLE 9. PROPOTION OF DOCTOR/NURSE IN PROVINCIAL GENERAL HOSPITALS (ONE
DOCTOR/NURSES)
Doctor
Ha Noi
HCM
Hai Phong
Quang Ninh
Nghe An
An Giang
568
1,458
222
117
164
212
Nurse
1,612
5,165
584
336
477
904
Doctor/Nurses
2.8
3.5
2.6
2.9
2.9
4.3
Circular No
08/TTLBBYT-BNV
3 - 3.5
3 - 3.5
3.0
3.0
3.0
3.0
The proportion of doctor per nurses indicates the hospital’s ability to ensuring comprehensive care.
Among all general hospitals at the provincial level in 4 provinces (Ha Noi, Hai Phong, Quang Ninh and
Nghe An), this indicator was not as high as the proportion that recommended in the Circular 08/TTLBBYT-BNV by MOH and Ministry of Interior (1 doctor/3 - 3.5 nurses). In An Giang, the proportion is
higher than the recommendation but in fact, they are still lacking doctors (Table 9).
Human resources data systems are functioning in all six provinces, based on the national system
regulated by the Ministry of Interior and Ministry of Health15. Reporting on human resources within the
Health system and to the MOH is conducted regularly (3 months, 6 months and annual). However, data
collection activities and HRH management functions are mostly conducted manually without any
consistent electronic options. All health organizations at any level only use computers with very simple
software to enter and save HRH information, (Microsoft excel, word). Health facilities collect HRH
information, fill in the required forms as assigned by MOH, Ministry of Interior and local government,
and then report to higher levels. Human resources data is available at all levels but with limited accuracy
and consistency. In addition, the staff responsible for human resources management is not trained in
HRH management. All those responsible for human resource management recognize the value of
accurate HRH data for management and planning. However, HRH information is not always used
effectively in managing and planning HRH at the provincial level to achieve the goals of the provincial
master plan.
In this respect, only Ho Chi Minh City has a good plan for human resources, with consistent guidelines
for human resource planning at all levels of care. Ho Chi Minh City has been applying ISO 9001-2000
since 2005, which includes human resource management system. They have developed a standardized
reporting form with guidelines based on ISO 9001-2000 for use in all facilities.
None of the six provincial health bureaus have annual budgets for human resource development,
including training, education, and management. Every year, the Provincial Health Bureau and Provincial
Bureau of Interior make a financial plan for HRH, but it very difficult to distinguish the HRH activities
budget within the total budget for the health sector. Officers from PHB responsible for HRH
management could not show the budget for HRH in-service training. They list the amount of budget that
is paid for salaries, fees, and for long-term training of staff as an aggregate figure. Generally, the
estimated budget for training health staff is insufficient. Country-wide, according to Health Statistics Year
Book 2007, the national budget for training health staff is only 1.2% of total national budget for health
Guideline from MOH for manage and report human resource; All sectors in Nationwide have to implement the
Ministry of Interior regulation and guideline in human resource management in general
15
45
sector16. Since the implementation of hospitals autonomy mechanisms according to Decree
43/2006/NĐ-CP, hospitals have the ability to budget for health staff training and education according to
demand at their hospital. However, the budget given is usually just enough for short-term, in-service
training or technical transferred activities (usually, provincial hospitals allocate around 50,000,000 VND,
district hospitals around 12,000,000 to 15,000,000 VND each year for staff training). For preventive care
facilities, they are not able to allocate budget to support their own staff to join training and skill upgrade
courses. They have to seek support from national health programs or other resources. The main reason
is the shortage of revenue for providing preventive health services. Ho Chi Minh City has their own
health system structure at the district level. All health facilities and organizations are administered by the
district people’s committee17 (according to Circular No 03/2008/TTLB-BYT-BNV, district health center,
district hospital and CHS are under administration of Provincial health bureau). Therefore, the district
people’s committee have more responsibility in allocating funds for human resources for health at the
local level. Moreover, HCM City is a rich city and Local People Committee are able to allocate the
budget to support human resource training for health facilities within districts.
COMPONENT 3: HUMAN RESOURCES POLICIES
To assess the human resources policies, seven indicators considering both national and local policies are
scored. The indicators are: availability of a functioning job classification system; availability of functioning
compensation and benefits system; availability of a formal process for recruitment, hiring, transfer, and
promotion; availability of employee conditions of service documentation; presence of a formal
relationship with union; registration, certification, or licensing is required for categories of staff; and the
availability of a salary scale. The total score is better than adequate (above 2.0) for all six provinces.
Indicating that the recent human resources policy is influencing health system development at the local
level. However, there have a number of limitation or constrains should be corrected to improve human
resource development contribute to the effectiveness of the health care system. Given the political
characteristics of Vietnam, six provinces generally have consistent policies for human resources both in
terms of national and local regulations.
Regarding the availability of a functioning job classification system, all the provinces follow the national
government regulations such as labor laws. The job classification system for the MOH and other
government staff is similar to the WHO classification system. Therefore, the score for this indicator
consistent across all the provinces.
A functioning compensation and benefits system does exist; the government has issued a national
regulation for compensation and benefits since 2002. The minimum salary scale is updated regularly by
government according to economic growth. The national standards are used to determine salary
upgrades and merit awards for staff who work in public sector. Solution 46/NQ-TW/2006 of Central
communist Party determined that human resource for health is a special objective and needs unique
policies for human resource development. The government has launched specific policies for improving
salary and providing special allowances for health professionals working in hospitals, preventive care and
in rural areas18.
Since 2006, the implementation of autonomy for public organizations (Decree 43/2006/ NĐ-CP) allows
health care facilities more independence in financial, performance and human resource management
Health Statistics Year Book 2006. M.O.H-Vietnam
This structure is differ from the direction of Decree 13/2008/NĐ-CP and Circular 03/2008/TTLB-BYT-BNV that
indicate there only administrative health unit is under direct administration of people committee and CHS, district health
center and district hospital are belong to the administration of provincial health bureau.
18 Resolution 46/NQ-TW; Decision 46/2009/QĐ-TTg; Decision 75/2009/QĐ- TTg; Decision 1816/QĐ-BYT; and Decision 1544/2007/QĐ-TTg .
16
17
46
(Autonomous management). Health care facilities can develop their own system of determining salary
upgrades and merit awards for their staff. This applies mostly to facilities providing curative care, since
they receive higher revenue from providing health services19. However, in practice, the total income and
benefits of health professionals vary greatly by type of facility (level of hospitals general and specialized
hospital); field of medicine (curative and preventive care facilities) and by the rural and urban area. The
basic salary and specific allowance for health personals is not much difference between provinces and
levels of care. But the extra salary or other benefits that high revenue hospitals can provide is significant,
particularly, at the highest levels of care, hospitals in Ha Noi and Ho Chi Minh City or in provincial
hospitals at big city like Hai Phong. The uniform standards for salary and compensation benefits assures
equity between health professional groups within each facility. The reason is that every health facility has
to develop their own regulation for additional salary and benefit mechanism according to direction of
Decree 43/2006/NĐ-CP, and that document were discussed and agreed by all staff in the facilities.
Similarly, the formal process for recruitment, hiring, transfer, promotion, and employee conditions of
service documentation are also available in all levels of the local health system across the six provinces.
This process is based on National Labor Laws, Ordinance on Law Officer, Civil Servants and recently
the Law on Officer, Civil Servants20. To facilitate the implementation of national regulations in each
province, the provincial people’s committee develops their own directive documents. based on national
regulations, to guide local organizations including the health sector on implementation in the local
context.
Vietnam has very few social association or organization representing employees. The most common is
National Trade-Union; each sector has their own Trade Union so that the National Trade-Union
represents to all labor unions throughout the nation. The health sector also has a trade union that
represents all laborers working in health sector. The relationship between the health sector and the
trade union is very close and membership is not restricted. All health care staff can join the union and
participate freely in union activities. Health staff also benefit from the protection of the Union. In both
provinces, there are strong relationships between the trade union and the health sector. This segment
of civil society participation is highly adequate.
The weakest indicator of this component is the registration, certification, and licensing system. The
system for registration, certification and licensing is mainly applied for the private health sector. Personal
licensing is only required for the head of a private health facility rather than for every health
professional. In the private sector, all health care professionals (traditional practitioner, physicians,
pharmacists, technicians, etc.) have to follow the Ordinance for Private Health Practice and Decree
103/2003/NĐ-CP21. The regulation describes procedures for registration, certification, and licensing for
private health practitioners and facilities. The MOH is responsible for registration, certification, and
licensing for all private hospitals in nationwide. While the Provincial Health Bureau is responsible for
health practitioners, polyclinics, and drug stores in their local area. In reality, the department of private
health management at the local level faces significant challenges managing the private sector activities.
They lack the requisite personnel and management skills. In the public sector, only certain departments
require certification of technical skills (X ray room, Nuclear treatment room etc.).
Join Annual Health Report – 2008, MOH
Law Officer, Civil Servants 22/2008/QH12 on November 13, 2008
21 Ordinance 07/2003/PL-UBTVQH11; Decree 103/2003/NĐ-CP: Specify the Ordinance 07/2003/PL-UBTVQH11
19
20
47
COMPONENT 4: PERFORMANCE MANAGEMENT
The performance management component is measured using indicators such as: the availability of job
descriptions; the existence of supervision plans (clinical and administrative supervision); the percentage
of supervision visits to health centers planned that were actually conducted; the availability of a formal
mechanism for individual performance planning and review; and the availability of a functioning incentive
program where needed. The total score for this component in six provinces is in the “slightly less than
adequate” range (1.8 – 2.0). According to the score, Ha Noi, Ho Chi Minh City and An Giang have
relevant performance management systems for human resources (score of above 2.0). Three other
provinces did not have adequate performance management for human resources (scored less than 2.0).
Job descriptions are available only for certain positions. All provinces applied the national system in
which persons with certain positions have a detailed mission and objectives described by the authorities
in their promotion letter. However, that is not a very clear job description or mechanism for
supervising the performance of the health workforce. Health professionals who are not in the position
of administration or management system do not have the document of listing their mission or work in
detail. Ho Chi Minh City and An Giang have been applying ISO 9001-2000 for administration in the local
health system, in which all the health care facilities start to develop and apply job description or TOR
for health professionals in every position, particularly, in the hospitals at all levels. HCM City and An
Giang scored adequately for this indicator (2.0). It is very difficult to have a job description for all health
staff, particularly in preventive care facility and at the CHS; The reason being shortages of HRH at the
district health center, CHS, and preventive health facilities at provincial level. Health staff are juggling
multiple activities simultaneously.
All six provinces lack of formal mechanisms for individual performance planning and review; At all levels
of care, performance reviews are implemented periodically, but only with key health staff responsible for
important health programs or activities. The health staff in charge of certain health programs have to
write reports describing their activities and their progress to the director. They neglect to review the
individual’s performance planning and goals for the future.
For the supervision activities, with the shortage of HR in some levels or (district and CHS) facilities
(preventive facilities), each staff member has multiple objectives and expansive TORs. (e.g. one staff at
district Center for preventive medicine or CHS usually has to manage 3-4 national health programs). A
staff member may report to several different supervisors, one for each program in which they are
involved. This is challenging for performance improvement. Individual performance reports are not
frequently documented but usually brought to monthly, quarterly or annually meeting to share
information and progression of activities with the others health staff within the organization.
The performance management system includes supervision of both clinical and administrative
performance. Each health facility has technical and administrative supervisors. They are usually heads of
departments, team leaders, or directors of health facilities. Performance management and surveillance is
mostly based on paper report or weekly progress meetings. The performance managers’ roles are not
only inspection and surveillance but also supportive and problem solving focused. The supervision plan is
available but not enforced or regularly implemented in all six provinces.
In all six provinces, planned supervisory visits to health centers were regularly conducted but the
frequency varied by the levels of care. The district supervision visits from district health center to CHS
were more frequent than those at provincial level since the district health center is directly responsible
for managing and providing technical direction for their CHS. Every year, the Provincial Health Bureau
(PHB) and Provincial Center for Preventive Medicine (PCPM) and other provincial health centers (the
Centers for Social Diseases Prevention, HIV/AIDS prevention center etc. ) make plans to visit health
48
facilities to supervise the implementation of CHS on specific activities that belong to the direction of
each organization (curative care, preventive care, and national health programs). The District Health
Center and District Health Administrative Unit also make a certain number of visits to the CHS to
supervise health care activities. All provinces reported that 100 percent of planned visits were carried
out.
Another weakness of HR performance management is the lack of meaningful incentive payments.
Incentive packages are available in all levels of care and types of health facilities according to the national
regulation system. The basic incentive package is not significant enough to attract or encourage health
staff. The government has launched policies for commending and rewarding government staff and
employers who work in public sector. These reward schemes only include commendation with a
present or a small amount of money. Currently, due to the economic transition as well as hospital
reform and higher revenue from hospital autonomy, some progressive health facilities (mostly hospitals)
may choose to use their own resources to offer incentive packages to their staff. Such incentives are
being used moderately in big city such as Ha Noi, Ho Chi Minh and Hai Phong, and in the hospital at
urban areas of the provinces.
COMPONENT 5: TRAINING AND EDUCATION
The training and education component was assessed by using three key indicators: the availability of a
formal in-service training component for all levels of staff; the availability of a functioning management
and leadership development program; and the availability of links and “feedback loops” between the
organization and pre-service training institutions. Overall scores are range from 1.5 to 2.2, of those, Ho
Chi Minh City had relevant training and education system for human resource with high score of 2.2,
then Ha Noi, Hai Phong range in second with score of 1.8, the remaining 3 provinces each scored of 1.5.
In-service training is available in all provinces but not formally or systematically, inspite of the Circular
for in-service training and knowledge upgrade reinforcement issued by the MOH in 200822. To date, no
province has developed their own regulation or formal system for in-service training of their health staff.
The in–service training has been implemented spontaneously depending on the local health organization
or national health program. Departments of MOH or National health programs usually plan training
programs on various topics for a period of 2 weeks to more than 3 months. All provinces send their
staff to attend the training courses when they are announced by the MOH or local authority. Training
courses are held at either the central or provincial level depending on time period required, the type of
training, and the course curriculum. In-service training can also be included through Training of Trainers
(TOT). In that case, provincial staffs are trained at the central level and then return to their province to
train other staff.
One weakness of this component is that there is no policy indicating the mandatory amount of inservice training that public or private health practitioners need to complete. Among the 6 provinces, Ha
Noi, Hai Phong and HCM City have more advantage in training and education because they have
National training institutions located in their cities. Moreover, these three provinces each have their
own high quality training institutions so that they can develop their own training plans in harmony with
the local demands on human resources. Ho Chi Minh City has very good mechanism for human
resource development planning. The City People’s Committee has authorized Local health Bureaus to
co-ordinate with hospitals to provide in-service training for health staff.
All provinces have leadership and management development programs but they do not have enough of
them nor are they focused on strengthening capacity of health system management. Except HCM City,
22
Circular 07/2008/TT-BYT dated 28 May 2008 about in-service training for health staff - MOH
49
five provinces have leadership programs that only focus on very general management skills and are not
systematically available for every level of care. There are no formal management and leadership training
programs available for all levels and types of staff. Since 2005, HCM City developed a formal program
for strengthening leadership and management capacity for all sectors include health sector. The local
people’s committees also allocate significant funding for the program. There are several health care
management and hospital management training courses that have been held in Ho Chi Minh in
cooperation with Singapore or other international organizations. They have also organized many
oversea study tours to learn and exchange experience in health management.
As for the links and “feedback loops” between the health care system and pre-service training
institutions, only HCM city, Hanoi and Haiphong have established relationships with training institutions
such as Hanoi Medical College, HCM Medical and pharmaceutical College, Haiphong medical College
among other training institutions. Other provinces including Nghe An, Quang Ninh and An Giang have a
passive links with the training and education institutions. The relationship is generally only a one-way
interaction in which the provincial health bureau or health care facilities try to organize and send staff to
attend training courses at the institutions based on the local needs. The provinces do not actively
follow-up by asking for feedback from the training institutions.
Ho Chi Minh City has very good system and mechanism in linking and coordinating with training
institutions. The people committee of HCM City had authorized to the City health Bureau to coordinate with Pham Ngoc Thach medical University to train new doctors, high skill nurses base on the
demand of the local health system according to a yearly plan. Moreover, all medical institutions under
the administration of HCM City are forced to recruits only students that are the resident of the city
rather than elsewhere.
3.5
PHARMACEUTICAL MANAGEMENT
Medicines are important resources for the health system and make up a major share of total health
expenditures. Pharmaceutical management is among the key areas of health system performance.
Pharmaceutical management represents the whole set of activities aimed at ensuring the timely
availability and appropriate use of safe, effective, quality, medicines and related products and services in
any health care setting.
In general, pharmaceutical management across the 6 provinces is fairly good, with most components
scoring “adequate” or slightly higher. Table 10 presents the summary scoring results for each
component in the 6 provinces at the provincial and district levels. In the 6 provinces, the pharmaceutical
management system was examined within the following components: budget; pharmaceutical policies,
laws, and regulations; procurement; storage and distribution; appropriate use; access to quality products
and services; and financing. The assessment was conducted at provincial and district levels, separately.
Among the seven components of pharmaceutical management, budget and access to quality products
received the highest scores in all provinces with average scores of more than “adequate” (2.6 and 2.5).
The component of appropriate use appears to be the weakest area of pharmaceutical management,
receiving the lowest average scores of less than “adequate” (1.6 and 1.5) for province and district level,
separately. Procurement is also relatively low profile with average score at province level is less than
"appropriate" (1.9).
50
TABLE 10. SCORING ON COMPONENTS OF PHARMACEUTICAL MANAGEMENT IN 6
PROVINCES, 2008
Province
Ha Noi
Hai Phong
Quang
Ninh
Nghe An
HCMC
Component
Budget
Pharmaceutical
policies, laws, and
regulations
Pro
Dist.
Pro.
Dist.
Pro.
Dist.
Pro.
Dist.
Pro.
Dist.
2.8
2.0
2.6
2.0
2.3
2.0
2.7
2.0
2.5
2.0
2.5
2.0
2.0
2.0
2.7
2.0
2.8
1.9
Procurement
Storage and
distribution
Appropriate use
Access to quality
products and
services
1.8
2.0
1.7
1.7
2.0
2.0
1.8
1.8
2.0
2.0
2.0
1.8
2.0
2.0
2.1
1.7
1.7
2.5
1.3
2.3
1.7
2.5
1.8
2.5
1.7
2.3
1.7
2.3
1.3
2.5
Financing
2.0
2.0
2.0
2.0
2.0
2.0
2.0
An Giang
Pro.
Dist.
2.5
1.9
2.0
2.0
2.6
2.0
1.7
2.2
1.7
2.0
1.7
1.8
1.5
1.6
1.3
2.3
1.7
2.5
1.3
2.5
1.7
2.5
1.3
2.3
2.0
2.0
2.0
2.0
2.0
COMPONENT 1: BUDGET
The budget component reflects the amount of financial resources devoted to pharmaceuticals.
Indicators used to examine the financing component of pharmaceutical management include: the total
expenditure on pharmaceuticals (% of total expenditure on health); the total expenditure on
pharmaceutical, and the government and private expenditure on pharmaceuticals.
Figure 5 shows the wide variation of scores on budget for pharmaceuticals among provinces, especially
at provincial levels. Less difference is observed at district level. However, in all 6 provinces this
component received adequate or higher scores.
FIGURE 5. SCORES ON BUDGET FOR PHARMACEUTICALS IN 6 PROVINCES
3.0
2.5
2.0
Province level
1.5
District level
1.0
0.5
Ha Noi
Hai
Phong
Quang
Ninh
Nghe
An
HCMC
An
Giang
51
This component received the highest score among seven components of pharmaceutical management.
Although total expenditures on medicines increased in most provinces, the percentage of spending for
pharmaceuticals compared with total expenditures did not increase annually in all hospitals, particularly
at the provincial level. Figure 6 shows that in most provincial hospitals the share of expenditures on
medicines in total hospital expenditures decrease during 2005-2008. Therefore, except Hanoi other
provinces have low score for indicator on total expenditure on pharmaceuticals as percentage of total
expenditure on health (Table 11). There is a discrepancy in share of pharmaceutical spending in total
expenditures among provincial hospitals. It varied largely from 24% to 53% in 2008.
FIGURE 6. PERCENTAGE OF EXPENDITURES ON MEDICINES IN TOTAL HOSPITAL
EXPENDITURES IN PROVINCIAL HOSPITALS
70
Municipal Viet
Tiep hos. (Hai
Phong)
Municipal Ha
Dong hos.
60
50
40
Quang Ninh hos.
30
Municipal
Nguyen Trai
hos. (HCMC)
An Giang hos.
20
10
0
2005
2006
2007
2008
Nghe An hos
In most of hospitals, health insurance and user fees paid for pharmaceuticals, not government budgets. In
several hospitals the study showed that government expenditure on drugs dropped significantly while
user fees and health insurance spent on drugs increased. It should be noted that at the provincial and
particularly district levels, historical data on expenditures of drugs is usually not available or not
accurately reported.
52
TABLE 11. SCORING ON INDICATORS OF BUDGET COMPONENT IN 6 PROVINCES
Province
Indicator
Total expenditure on
pharmaceuticals (%
of total expenditure
on health)
Total expenditure on
pharmaceuticals
Government
expenditure on
pharmaceuticals
Private expenditure
on pharmaceuticals
Total component
Ha Noi
Hai Phong
Quang Ninh
Nghe An
Pro.
Dist.
Pro.
Dist.
Pro.
Dist.
Pro.
3.0
3.0
2.0
2.3
1.0
2.5
1
3.0
2.7
3.0
3.0
3.0
3.0
2.0
1.7
1.0
2.3
3.0
3.0
3.0
3.0
3.0
2.8
2.6
2.3
2.7
Dist.
HCMC
An Giang
Pro.
Dist.
Pro.
Dist.
NA
2.0
3.0
1.0
2.5
3.0
3.0
3.0
3.0
3.0
3.0
1.5
1.0
NA
3.0
1.0
1.0
2.0
3.0
3.0
3.0
3.0
3.0
3.0
3.0
3.0
2.5
2.5
2.0
2.7
2.8
2.5
2.0
2.6
There is a large difference between provincial and district level scores for the indicator on "Government
expenditure on pharmaceuticals ". This indicator varied by hospital depending on its financing status. In
Ho Chi Minh City, while in the municipal hospital government expenditure on medicines increased from
12 billion in 2005 to 26.7 billion in 2008 in Nha Be district hospital it dropped from 368 million in 2005
to 58 million in 2008. In many hospitals, 100% of the money spent on drugs is from user fees and health
insurance revenues, not government funds. This was the case in Cam Pha district hospital in Quang Ninh
province and studied hospitals in Hai Phong and An Giang provinces.
There is no data on private expenditures for pharmaceuticals in the studied provinces, but results from
Vietnam Living Standard Survey described household expenditures on medicines as increasing annually
nationwide.
COMPONENT 2: PHARMACEUTICAL POLICIES, LAWS, AND REGULATIONS
This component refers to the legal framework for pharmaceutical management. It is comprised of 10
indicators. Most of these indicators only apply to the national level. At the province and district levels,
indicators related to implementation of pharmaceutical policies, laws and regulation are examined: (1)
Existence of a system for the collection of data regarding the efficacy, quality, and/or safety of
marketed pharmaceutical products (post-marketing surveillance); (2) Mechanisms exist for the licensing,
inspection, and control of pharmaceutical personnel, manufacturers, distributors/importers, and
pharmacies/drug retail stores; and (3) the Existence, management, and organization of a national
essential medicines list (NEML).
In general, at the provincial and district levels this component focuses on the implementation of
pharmaceutical policies, laws and regulations. This component received "adequate" average scores in
almost all provinces (Figure 7). Among the 6 study provinces, Ho Chi Minh City received the lowest
scores for this component. As shown in Figure 7, there is almost no difference in the selected indicators
between province and district level within a province.
53
FIGURE 7. SCORES ON PHARMACEUTICAL POLICIES, LAWS, AND REGULATIONS
COMPONENT IN 6 PROVINCES
2.2
2.0
1.8
1.6
1.4
1.2
1.0
0.8
0.6
0.4
0.2
-
Province level
District level
Ha Noi
Hai
Phong
Quang
Ninh
Nghe
An
HCMC
An
Giang
Table 12 presents scores on critical indicators related to the three indicators measured at local level.
Table 12 shows that most provinces received quite low scores for the indicator on the existence of a
system for the collection of data regarding the efficacy, quality, and/or safety of marketed pharmaceutical
products (post-marketing surveillance). The study found that there is no system for the collection of
data regarding the efficacy, quality, and/or safety of marketed pharmaceutical products, but data on
adverse drug reactions (ADR) is consistently reported in all health facilities including private ones.
However, the ADR tracking system is focused only on adverse reactions to drugs rather than on the
quality and effectiveness of drugs. Thus all provinces were scored as "not adequate" for this indicator.
The mechanisms for licensing, inspection and compliance to pharmaceutical regulation, exist and work
regularly but reports and statistics are not available. All provinces received "adequate" or higher scores
for this indicator. Essential medicines are a key issue in national drug policies, but national essential
medicines list (NEML) was not always available in investigated health facilities, especially in HCM City
and An Giang province. Currently not much attention is paid to NEML but rather to the list of
medicines used in hospitals.
54
TABLE 12. SCORES ON SELECTED INDICATORS OF PHARMACEUTICAL POLICIES, LAWS,
AND REGULATIONS COMPONENT IN 6 PROVINCES
Province
Indicators
10 Existence of a system
for the collection of data
regarding the efficacy,
quality, and/or safety of
marketed pharmaceutical
products (post-marketing
surveillance)
11 Mechanisms exist for the
licensing, inspection, and
control of pharmaceutical
personnel, manufacturers,
distributors/importers, and
pharmacies/drug retail
stores
12, 13, 14, 15. Existence,
management, and
organization of a national
essential medicines list
(NEML)
Ha Noi
Hai Phong
Quang Ninh
Nghe An
HCMC
An Giang
Pro.
Dist.
Pro.
Dist.
Pro.
Dist.
Pro.
Dist.
Pro.
Dist.
Pro.
Dist.
1.0
1.0
1.0
1.0
1.0
1.0
1.0
1.0
1.0
1.0
1.0
1.0
2.0
2.0
2.0
2.0
2.0
2.0
2.0
2.0
2.0
2.0
3.0
3.0
2.0
2.0
2.0
2.3
2.0
2.0
2.0
2.0
1.0
1.0
1.0
1.0
COMPONENT 3: PROCUREMENT
This component received quite low scores in comparison with other components. The indicators
included in this aspect of pharmaceutical management focus on the procedures, operations, and
processes required to procure pharmaceuticals in Vietnam. Figure 8 shows that Ho Chi Minh City and
An Giang received the worst results on the procurement assessment while Nghe An and Quang Ninh
have better scores relative to the other provinces.
FIGURE 8: SCORES ON THE PROCUREMENT COMPONENT IN 6 PROVINCES
2.5
2.0
1.5
Province level
District level
1.0
0.5
Ha Noi
Hai
Phong
Quang
Ninh
Nghe
An
HCMC
An
Giang
55
Scoring of each of the procurement component indicators is presented in Table 13. Formal standard
operational procedures (SOPs) for conducting procurement in the public sector do not exist. There are
guidelines on public procurement but no specific guidelines for drug procurement are included. A key
informant in HCMC reported that "every hospital has its own way to conduct procurement". Different
modes in purchasing medicines were applied in all six provinces. In public hospitals, all medicines used
for health insurance patients must be purchased through competitive bidding. However, different modes
for purchasing medicines were applied in six provinces. In Hai Phong, Quang Ninh and Nghe An, bidding
for drug procurement is conducted by the Health Bureau. While in Hanoi and HCM City, hospitals can
conduct bidding separately or directly purchase of drugs using bidding results from other hospitals. In
Ho Chi Minh City specific guidelines for conducting procurement of drugs have recently been released
by the Health Bureau. Each hospital conducts bidding separately or directly purchases drugs using the
bidding results from other hospitals. If a hospital purchases drugs directly there is no commitment from
the company on fixed price over one as is the case when bidding is held. Hai Phong and Quang Ninh
applied similar mode in conducting pharmaceutical procurement. Drug procurement bidding there is
conducted by the Health Bureau. After bidding results are published, all hospitals are required to sign a
contract with the Provincial Pharmaceutical Company on drug supplies. The company acts as a
coordinator in supplying drugs to all hospitals. In An Giang, different modes of procurement are applied
for provincial and district levels. At the provincial level, bidding was conducted for all drugs in An Giang
provincial hospital. The remaining provincial hospitals used available bidding results from An Giang
hospital to purchase drugs in their hospitals. These hospitals organize additional bidding for specialized
drugs and drugs not included in the bidding by An Giang. At the district level, bidding for the purchase of
drugs was held at one selected district hospital then the bidding results were used for the remaining
district hospitals. All six provinces received "adequate" scores for this indicator.
TABLE 13. SCORES ON INDICATORS OF PROCUREMENT COMPONENT IN 6 PROVINCES
Province
Ha Noi
Pro. Dist.
Hai Phong
Pro. Dist.
Quang Ninh
Nghe An
Pro. Dist. Pro. Dist.
HCMC
Pro. Dist.
An Giang
Pro. Dist.
Indicators
16 Existence of formal
standard operational
procuedures (SOPs) for
conducting procurement in
the public sector
17. Use of generic of
nonpropriety names (INN)
for MoH procurements
18. Procurement Operations
(number of procurement
operations per year)
19. Percentage of MoH
pharmaceuticals procured
through competitive bid
20. Existence of a pre-or
post-qualification process
related to product safety,
efficacy, and quality
21. Samples requested and
tested
Total component
56
2.0
2.0
2.0
2.0
2.0
2.0
2.0
2.0
2.0
2.0
2.0
2.0
1.0
1.0
2.0
2.0
2.0
2.0
2.0
2.5
1.0
1.0
1.0
1.0
3.0
2.3
3.0
2.7
3.0
3.0
3.0
3.0
2.0
2.0
2.0
1.0
3
3
3
2.33
3
3
3
3
3
3
3
3
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2.0
2.1
1.7
1.7
1.8
1.7
2.0
1.8
2.0
2.0
1.7
1.5
For the use of generic of non-proprietary names (INN) in MoH procurements, only Quang Ninh and
Nghe An received "adequate" scores while other provinces received scores of less than adequate (below
2). The use of generic of non-proprietary names (INN) for drug procurement is not consistently
reported in hospitals. It is common that both non-proprietary names and propriety names are used in
drug bidding. Generic names are used in the list of drugs for inviting bidders but in the final list of drugs
brand names appear, especially for specialized medicines. In Hanoi, both non-proprietary names and
proprietary names are used in bidding. In Dong Anh district hospital, only 10-15% drugs for bidding are
listed by their proprietary names, but those listed make-up much more than 15% of the value. In Quang
Ninh, generic names are regularly used in purchasing drugs but specialized drugs are bought using brand
names. In Hai Phong most drug procurement used generic names but there were also some brand name
drugs. In An Giang, there are 2 different packages for generic drugs and brand-name drugs in each
bidding. Brand-name drugs accounted for one third of the total drugs for bidding in An Giang provincial
hospital. In Nghe An, specialized drugs procured with brand names accounted for 10% of the total drugs
procured. Hanoi, HCMC and An Giang received "inadequate" scores while the remaining provinces
received "adequate" scores or higher.
Although number of drugs procured varies by hospital, every hospitals has a plan for drug procurement.
The frequency of drug procurement is not the same among hospitals. It can be once a month as in Dong
Anh district hospital in Hanoi. Some hospitals conduct procurement of pharmaceuticals twice a month
like Municipal Nguyen Trai hospital in HCMC, An Giang general hospital and Cho Moi district hospital in
An Giang province. It is also quite common to have drug procurements every 6 months as they do in
Quang Ninh, Nghe An and Ha Dong hospitals. In most hospitals, emergency procurements are rarely
required and only for certain categories of drugs. However, in An Giang Province emergency drug
procurements occured more often. There were 3-4 emergency drug procurements last year in An
Giang hospital. In Cho Moi hospital, there were also some emergency procurements. Therefore, An
Giang province received a lower score for this indicator.
The percentage of MoH pharmaceuticals procured through competitive bid is regulated. All
pharmaceuticals purchased with government funds or health insurance funds must be through
competitive bidding. Therefore all provinces scored "highly adequate" for this indicator except the
district level in Hai Phong. The district hospital studied in Hai phong reported that only 70-80% of drugs
are purchased through competitive bid.
In all 6 provinces, there are no specific regulations on the pre or post qualification process related to
product safety, efficacy, and quality. Qualification of pharmaceutical products are mainly guaranteed by
registration with the proper authority. Drugs purchased were checked for expiry date, quantity,
packaging, labeling and subjective assessment. Sampling and testing are not included in procurement
process. This is randomly done by an authorized agency and not consistently applied for all drugs. Thus
this aspect of procurement received low scores, with all provinces receiving "inadequate" for these
indicators.
COMPONENT 4: STORAGE AND DISTRIBUTION
There is significant gap between province and district level with regards to storage and distribution
(Figure 9). While in most province, the component received "appropriate" score at province level, at
district level it got 1.6 to 1.8 only. An Giang has lowest score on this component comparing with other
provinces.
57
FIGURE 9. SCORES ON THE STORAGE AND DISTRIBUTION COMPONENT IN 6 PROVINCES
2.5
2.0
1.5
Province level
District level
1.0
0.5
Ha Noi
Hai
Phong
Quang
Ninh
Nghe
An
HCMC
An
Giang
Table 14 provides scores for specific indicators of the storage and distribution component. In most
hospitals, estimates for drug procurement were made based on quantity consumed in the previous year
and quantity in-stock. There is no standardized method for estimating the quantity of drugs to be
purchased. In HCMC, recently Health Bureau provided guidelines on drug procurement.
Standard operating procedures for drug distribution were launched through promoting “Good
Distribution Practice” in most of the provinces. There are standard operating procedures for drug
distribution, especially in hospital and for trading companies. However these procedures are applied
only at certain levels for ordering, distribution, storage, and withdrawal of drugs. In Hanoi and HCMC,
implementation of “Good Distribution Practice” has been fostered recently. In Quang Ninh and Nghe
an, they are starting to implement “Good Distribution Practice”.
Vertical programs procure drugs using their own SOPs or guidelines and have separate drug
procurement planning and budgeting. This fact results in poor coordination between pharmaceuticals
from vertical programs and other sources within the facilities. In Quang Ninh hospital it is reported that
"There is a large waste concerning with medicines provided by national health program. Expired drugs
commonly occurred due to excess supply".
All hospitals reported the value of inventory lost was less than 5%. With regard to the existence of
refrigeration units with functional temperature control, pharmacies did not appear to meet this criteria,
except Good Practice Pharmacies which accounted for low share in total of pharmacies and drug
retailers in the provinces. In Ha Noi, there are about 300 Good Practice Pharmacies among total of
1200 pharmacies. In Quang Ninh province, the number of Good Practice Pharmacies accounted for 13
% of total licensed pharmacies.
58
TABLE 14. SCORES ON INDICATORS OF STORAGE AND DISTRIBUTION COMPONENT IN 6
PROVINCES
Province
Ha Noi
Hai Phong
Quang Ninh
Nghe An
HCMC
An Giang
Pro.
Dist.
Pro.
Dist.
Pro.
Dist.
Pro.
Dist.
Pro.
Dist.
Indicators
Pro.
Dist.
22. Pharmaceuticals
procured based on reliable
estimates
1.0
1.0
1.0
1.0
1.0
1.0
1.0
1.0
2.0
2.0
1.0
1.0
2.0
1.7
2.0
2.0
2.0
2.0
2.0
1.5
2.0
2.0
1.0
1.0
1.0
1.0
1.0
1.0
1.0
1.0
1.0
1.0
1.0
1.0
1.0
1.0
3
3
3
3
3
3
3
3
3
3
3
3
3
2
3
2
3
2
3
2
3
2
3
2
23.Existence of procedures
to manage distribution of
pharmaceuticals
24. Existence of independent
supply systems for vertical
programs
25. Value of inventory loss
26. Existence of refrigeration
units with functional
termperature control at
each level of the distribution
system
COMPONENT 5: APPROPRIATE USE OF DRUGS
The appropriate use of drugs was measured using 3 indicators: the existence of functioning
mechanisms/tools to improve the use of medicines in hospitals and health facilities; the existence of
national therapeutic guides with standardized treatments for common health problems; and the
existence of treatment guidelines used for basic and in-service training of health personnel.
This component received lowest score among the seven components of pharmaceutical management.
Figure 10 shows that all provinces scored less than "adequate" for this component. Among the 6
provinces, Nghe An had the lowest scores for this component. Significant disparities exist between the
provincial and district levels in Hanoi, HCMC and An Giang provinces.
FIGURE 10. SCORES ON APPROPRIATE USE COMPONENT IN 6 PROVINCES
2.0
1.8
1.6
1.4
1.2
1.0
0.8
0.6
0.4
0.2
-
Province level
District level
Ha Noi
Hai
Phong
Quang
Ninh
Nghe
An
HCMC
An
Giang
59
There are critical issues related to all three indicators used to measure function of the appropriate use
component (table 15). In all public hospitals, the common solution for improving the use of medicines is
to establish a Therapeutic and Drug Committee. However, the functionality and effectiveness of this
varies among hospitals. In HCMC, there is Therapeutic and Drug Committee in all hospitals to monitor
and promote rational use of drugs, however it does not function consistently well. In Hanoi, there is
Therapeutic and Drug Committee in all hospitals but the committee performs differently between
provincial and district hospitals. In Dong Anh, the Therapeutics and Drugs committee, with occasional
other expert assistance, conducts district hospital medical reviews once a month. In Thach That district
hospital there is Therapeutic and Drug Committee, but they do not conduct medical reviews due to a
lack of capacity. In Quang Ninh and Hai phong provinces, the Therapeutic and Drug Committees
conduct medical reviews once a month. In An Giang province, the committee does not function well in
all hospitals. One interviewee explained that "In many hospitals, the Committee for Drug and
Therapeutics worked not very well in providing consultation on rational use of drug, supervising drug
prescribing". In Nghe An province, the performance of the committee is better at province level.
However, medical reviews are seldom conducted. Even at the provincial hospital, the committee was
not fully functional nor did it conduct medical reviews.
The most critical issue impeding appropriate use of drugs is the absence of national treatment guidelines.
Some hospitals or clinical departments develop their own treatment guidelines, however they are not
standardized, nor are they consistently applied, as in the Nguyen Trai hospital in HCMC. Treatment
guidelines exist but are not current or not regularly available in all health facilities. In Thach That
hospital, there were standard treatment guidelines from the 1990s. In Quang Ninh hospital, there are no
national treatment guidelines available yet. In An Giang provincial hospital, standard treatment guidelines
are developed by the hospital for the most common diseases. Treatment guidelines are not consistently
used as training or supervision tools in any province.
TABLE 15. SCORES ON INDICATORS OF APPROPRIATE USE COMPONENT IN THE 6
PROVINCES
Ha Noi
Pro. Dist.
27. Existence of functioning
mechanisms/tools to improve the
use of medicines in hospitals and
health facilities
28. Existence of national
therapeutic guides with
standardized treatments for
common health problems
29. Existence of treatment
guidelines used for basic and
inservice training of health
personnel
Hai Phong
Pro. Dist.
Quang Ninh
Pro. Dist.
Nghe An
Pro. Dist.
HCMC
Pro. Dist.
An Giang
Pro. Dist.
3.0
2.0
3.0
3.0
3.0
3.0
2.0
2.0
2.0
2.0
2.0
2.0
1.0
1.0
1.0
1.3
1.0
1.0
1.0
1.0
2.0
1.0
2.0
1.0
1.0
1.0
1.0
1.0
1.0
1.0
1.0
1.0
1.0
1.0
1.0
1.0
COMPONENT 6: ACCESS TO QUALITY PRODUCTS AND SERVICES
Access to quality products and services as a component of the pharmaceuticals management system
examines whether the population has access to pharmaceuticals and whether there are mechanisms in
place to ensure that the quantity and quality of prescription drugs issued are acceptable. Several
indicators were used to examine this component including: the percentage of a set of unexpired tracer
60
items available; the percentage of the population having access to a public or private health
facility/pharmacy that dispenses pharmaceuticals; the existence of licensing provisions or incentives that
increase geographic access by consumers/patients to quality products and services through private
wholesalers and retailers; the population per licensed pharmacist or pharmacy technician; the population
per authorized prescriber.
This component has a fairly good profile with an average score of better than “adequate” (2.5) for all
provinces (table 16). Indicators scores are quite similar across the 6 provinces (Figure 11). Most of
indicators were given "adequate" or "highly adequate" scores in the investigated provinces except the
indicator related to licensing provisions for pharmacies in remote areas which can sell non prescription
drugs without a licensed pharmacist.
FIGURE 11. SCORES ON ACCESS TO QUALITY PRODUCTS AND SERVICES COMPONENT IN
6 PROVINCES
3.0
2.5
2.0
Province level
1.5
District level
1.0
0.5
Ha Noi
Hai
Phong
Quang
Ninh
Nghe
An
HCMC
An
Giang
61
TABLE 16. SCORES ON INDICATORS OF ACCESS TO QUALITY PRODUCTS AND SERVICES
COMPONENT IN 6 PROVINCES
Ha Noi
Pro. Dist.
30. Percentage of a set of
unexpired tracer items
available
31. Percentage of the
population having access to
a public or private health
facility/pharmacy that
dispenses pharmaceuticals
32. Existence of licensing
provisions or incentives
that increase geographic
access by
consumers/patients to
quality products and
services through private
wholesalers and retailers
33. Population per licensed
pharmacist or pharmacy
technician
34. Population per
authorized prescriber
35. Population per drug
retail outlet in private
sector
Hai Phong
Pro. Dist.
Quang Ninh
Pro. Dist.
Nghe An
Pro. Dist.
HCMC
Pro. Dist.
An Giang
Pro. Dist.
3.0
3.0
3.0
3.0
3.0
3.0
3.0
3.0
3.0
3.0
3.0
2.0
3.0
3.0
3.0
3.0
3.0
3.0
3.0
2.0
3.0
3.0
3.0
3.0
1.0
1.0
1.0
1.0
2.0
2.0
2.0
2.0
1.0
1.0
1.0
1.0
3
2
3
3
2
2
2
2
2
2
3
3
2
2
2
2
1
1
2
2
3
3
2
2
3
3
3
3
3
3
3
3
3
3
3
3
For drugs in NEML, or other specific programs, stock-outs rarely occur. Certain brand-name drugs with
single suppliers did cause stock-out in district hospitals. In Vinh Bao hospital stock-outs rarely occur for
antibiotics and specialized drugs. In Cho Moi hospital stock-outs are rare and when they occur are due
to delivery delays by the pharmaceutical company.
In Vietnam, licensing provisions exist for private pharmacies or drug sellers and only licensed
pharmacists can sell drugs. Thanks to the growth of drug retail networks nationwide, there are licensed
pharmacies in all communities. Most of them are private ones. There is total of 4018 drug retailers in
HCMC including pharmacies, company agents, and corporate pharmacies. In Hanoi, there is total of
3325 drug retailers of which 1483 are pharmacies. In Quang Ninh, there is total of 497 drug outlet of
which 82 are private pharmacies, 230 are drug agents and 184 are drug stalls at the commune health
station. In Hai Phong, there is total of 609 drug retailers of which 165 are privately owned. In Nghe An,
there is a total of 1313 drug outlets of which the majority are privately owned. However, the
distribution of pharmacies is uneven, mainly concentrated in urban areas. Figure 12 shows that there is
disparity in number of population per drug outlet among provinces. HCMC has the highest density of
drug outlets by population then followed by Hanoi. Hai Phong has lowest number of drug outlets
compared with population density. There are several difficulties associated with private practice in the
pharmaceutical area: lack updated information on policies and professional issues; there are fewer
opportunities to improve one’s professional capacity; and frequent inspections.
62
FIGURE 12: AVERAGE NUMBER OF POPULATION PER DRUG OUTLET IN 5 PROVINCES
3,500
3,031
3,000
2,500
2,000
2,385
2,233
1,839
1,645
1,500
1,000
500
Hanoi
Hai Phong
Quang Ninh
Nghe An
HCMC
The issue concerning with the shortage of pharmaceutical manpower, especially pharmacists has been
addressed in a recent training policy. Licensed pharmacists are available in most public health facilities.
However, there is still an uneven distribution of pharmacists between the public and private sectors.
Many provinces face shortages of pharmacists in public facilities. Decreases in population per pharmacist
were observed in Quang Ninh and An Giang only while there is no consistent trend in other provinces.
In HCMC, licensed pharmacists are available in most public health facilities but few private pharmacies
exist. The population per pharmacist is increasing (from 3200 in 2006 to 4800 in 2008). In Hanoi,
population per pharmacist is also increasing. In Qunag Ninh, population per pharmacist is decreasing and
but the ratios remain quite high relative to the national average. In Hai Phong and Nghe An, population
per pharmacist is not consistently decreasing and is relatively low compared with the national average. In
An Giang, the population per pharmacist is decreasing.
Table 17 shows that there is no clear trend towards decreasing the population per prescriber in all six
provinces. This means that although the number of medical doctors increased over the last several
years, it is still out paced by population growth. Similar conclusions can be drawn for the population per
pharmacist.
TABLE 17. AVERAGE NUMBER OF POPULATION PER PRESCRIBER AND AVERAGE NUMBER
OF POPULATION PER PRESCRIBER PHARMACIST IN 6 PROVINCES,
2005-2008
Hanoi
Hai
Phong
Quang
Ninh
Nghe An
HCMC
An Giang
2005
1,382
900
Population per prescriber
2006
2007
2008
1,390
1,417
1,293
843
854
896
Population per pharmacist
2005
2006
2007
2008
13,557
14,170
16,045
22,737
8,261
8,928
9,325
7,239
871
876
885
895
34,803
40,419
35,413
26,419
1,187
990
1,083
1,204
1,049
1,099
1,231
988
1,082
1,193
993
1,097
18,663
11,307
24,932
21,733
16,683
26,314
19,518
16,791
20,468
19,209
20,726
19,236
63
COMPONENT 7: FINANCING
The financing component of pharmaceutical management was measured using the following indicators:
the population per drug retail outlet in private sector; the proportion of the annual national expenditure
on medicines by the government budget, donors, charities, and private patients; the existence of
mechanisms to recover the cost of pharmaceuticals; and the existence of price control mechanisms for
pharmaceuticals in the private sector.
All six provinces received the score of “adequate” for the financing component. Among the three
indicators measuring financing component in six provinces, only price control was "not adequate" (Table
18). Price control measures exist, but they are not consistently enforced. Price posting for retailing
drugs is a common price control measure. Strong and strategic price control efforts have not been
applied yet. Data from the Vietnam Household Living Standard Survey show that out of pocket expenses
for healthcare in general and for medicines in particular vary considerably among income groups.
However, this could not happen with drugs used in special programs. A policy exists for cost recovery
of pharmaceuticals in public health facilities and the amount recovered represents a significant
percentage of actual costs of procurement. Thus, this indicator was found "adequate" overall in the six
provinces.
TABLE 18. SCORES ON INDICATORS OF FINANCING COMPONENT IN 6 PROVINCES
Ha Noi
Pro. Dist.
37. Proportion of the annual
national expenditure on medicines
by the government budget, donors,
charities, and private patients
38. Existence of mechanisms to
recover the cost of
pharmaceuticals dispensed in MoH
facilities
39. Existence of price control
mechanism for pharmaceuticals in
the private sector
3.6
Hai Phong
Pro. Dist.
Quang Ninh
Pro. Dist.
Nghe An
Pro. Dist.
HCMC
Pro. Dist.
An Giang
Pro. Dist.
2.0
2.0
2.0
2.0
2.0
2.0
2.0
2.0
2.0
2.0
2.0
2.0
3.0
3.0
3.0
3.0
3.0
3.0
3.0
3.0
3.0
3.0
3.0
3.0
1.0
1.0
1.0
1.0
1.0
1.0
1.0
1.0
1.0
1.0
1.0
1.0
HEALTH INFORMATION SYSTEM
General Schema of MoH Health Information System Flow
For primary health care: Routine health information data flows though a paper-based system from
commune health stations through the district health centers and then to Provincial Health Bureaus. The
Provincial Health Bureau use a software called “Grassroots Health Program Software” to manage and
compile the data. After that, the Provincial Health Bureaus send it on to the Health Statistics Division
belonging to the Department of Planning and Finance, Ministry of Health.
For national health programs: Routine health information data flows though a paper-based system from
commune health stations through the district health centers and then to the corresponding program
subdivisions under the Provincial Preventive Health Center (EPI, malaria control, hemorrhage dengue
fever control, Iodine supplement, vitamin A supplement programs) or HIV/AIDS Control Provincial
Center (HIV/AIDS control programs) or Reproductive Health Provincial Center (maternal and child
64
health and Malnutrition control programs). The responsible persons for these Provincial Centers
compile and then send their data to the corresponding program office at central level.
For public hospitals: District, Provincial, and Central Hospitals use a software program called “Medisoft”
for health information management and reporting. District and Provincial Hospitals send reports to the
Provincial Health Bureau as well as to Department of Curative Management, Ministry of Health. The
Provincial Health Bureau uses the Medisoft Software Program to manage and compile data and then
send it to the Health Statistics Division in the Department of Planning and Finance, Ministry of Health.
Central Hospitals only send statistical data to the Department of Curative Management, Ministry of
Health as required.
For private facilities: Routine health information data flows though a paper-based system from private
hospitals to the Department of Curative Management, Ministry of Health. For private polyclinics paperbased health information data is sent to the Provincial Health Bureaus for management and compiling
and then reported to the Department of Curative Management, Ministry of Health regularly (See figure
13).
FIGURE 13. GENERAL SCHEMA OF MOH HEALTH INFORMATION SYSTEM FLOW
General Statistic
Office
Ministry of Health
Dept. of Preventive Care
Dept. of HIV/AIDS control
Dept. of MCH
Ministry of Health
Dept.of Planning and Finance
Health statistic Division
Ministry of Health
Dept. of Curative Care
Central
Hospital
Provincial Health Bureaus
Provincial Preventive Center
Provincial Reproductive Health
Center
District Health Center
Provincial Hospital
District Hospital
65
The Health Information Systems function of the health system was broken down by seven components:
(1) Health Status Indicators-Mortality; (2) Health Status Indicators-Morbidity; (3) Health System
Indicators; (4) Resources, Policies and Regulation; (5) Data Collection and Quality; (6) Data Analysis;
and (7) Use of Information for Management.
The first three components are (1) Health Status Indicators-Mortality; (2) Health Status IndicatorsMorbidity; and (3) Health System Indicators including vital statistics. The availablity of these statistical
figures provides a crude measure of the health information system functionality. The seven original
indicators included in this component were (1) Maternal mortality ratio; (2) Mortality Rate, under age 5;
(3)HIV prevalence among pregnant women aged 15-24; (4) Proportion of children under 5 years who
are underweight for age; (5) Number of hospital beds (per 10,000 population); (6) Contraceptive
Prevalence (% of women aged 15-49); and (7) Percentage of disease surveillane reports received at the
national level from districts compared to the number of reports expected. While adjusting the
instruments to match the Vietnamese context, we decided to add the following indicators: (1) Infant
mortality rate; (2) Pregnant women prevalence among women aged 15-24 & 25-49; (3) HIV prevalence
among population aged <15, 15-24, 25-49, >49; (4) Proportion of newborn who are low birth weight
(<2500g); (5) Contraceptive Prevalence (% of couple with women aged 15-49); (6) Abortion proportion;
(7) Proportion of birth deliveries assisted by health staff; (8) Proportion of women who received post
natal care; and (9) Proportion of children under aged 5, who received fully vaccination. The total of
statistical indicators were collected in six provinces were 16. These figures were collected in the period
four year from 2005 to 2008.
The availability of these statistical indicators is shown in table C1. Most of the requested indicators are
available in 6 studied provinces at both provincial and district levels, all except data regarding HIV
infection among women and people by age groups.
The other four components used to examine the health information system function were: (4)
Resources, Policies and Regulations; (5) Data Collection and Quality; (6) Data Analysis; and (7) Use of
Information for Management. Each of these four components is further disaggregated into a number of
indicators. All together, they include 19 indicators.
The summary scoring information for these components is presented in the table 19 below.
TABLE 19. COMPONENT RATING FOR HEALTH INFORMATION SYSTEM IN 6 PROVINCES
Component
Average Score for Component
Quang
Ninh
Resources, Policies &
Regulation
Data Collection and
Quality
Data Analysis
Use of Information for
Management, Policy
Making, Governance &
Accountability
66
Ha Noi
Nghe An
Hai Phong
Hochiminh
An Giang
2.2
2.2
1.7
2.0
1.8
1.7
1.9
1.8
2.0
1.75
2.1
1.8
1.8
1.7
1.6
1.6
1.75
1.75
1.8
1.8
1.8
1.75
2.0
1.75
COMPONENT 4: RESOURCES, POLICIES, AND REGULATION
Resources, policies, and regulations govern the status and availability of health information. Five
indicators were used to measure the impact of resources, regulations, and policies on the health
information system functioning in Vietnam’s Quang Ninh, Ha Noi and Nghe An provinces. The
indicators include: (1) the availability of financial and/or physical resources to support HIS-related items
within MoH/central budget, regional, and/or district budgets; (2) the presence of international donors
providing specific assistance to support strengthening the entire HIS or its individual and/or vertical
components in more than one region; (3) the existence of policies, laws, and regulations mandating
public and private health facilities/providers to report indicators determined by the national HIS; (4) the
presence of clear procedures for allocating resources and planning in the health system based on the
information products of HIS; and (5) all relevant stakeholders collaborate in the selection of the core
indicators and the indicators have been selected according to explicit criteria.
The national government is responsible for providing the equipment, forms, training and ICT, and
operational costs to run HIS, but there is no specific line item in the budget for HIS operations. In
QuangNinh, Hanoi, NgheAn, and Ho Chi Minh city, all expenses for activities related to HIS are covered
by the operating costs of the facilities. In Hanoi and Hai Phong Health Service, there is a specific line
item in the budget for HIS management.
For public hospitals: The Ministry of Health developed a software program called Medisoft for hospital
management and introduced it in public hospitals nationwide. However, the software application is not
well implemented because hospitals at lower levels lack computers and also skills to deal with the
software application. Limited investment in the health information system and lack of equipment
characterise electronic HIS in Vietnam. All public hospitals at the provincial and district level of the six
provinces are using the Medisoft program for HIS management and reporting. In some provinces such as
Hai Phong and Quang Ninh, a project was implemented for “injury prevention”. And “injury accident
software” was applied in data collection of accident cases in hospitals.
For other health facilities such as preventive health centers, commune health stations and private
clinics/hospitals: All health facilities have paper record books, forms, and instruments for data collection
and regular reporting. However, these forms only allow data to be collected manually. Documents are
stored as hard-copies only. All facilities of studied provinces are utilizing distributed record books and
forms according to the MoH’s regulations. A few facilities applied the Ministry of Health named
grassroots health software.
Equipment and software (e.g. computer, printers, telephones) for data analysis and reporting is highly
available in higher level facilities (national, provincial level) and curative facilities (provincial, district
hospitals). But, it is only available in a limited number of CHS. Especially, in Nghe An province, very few
commune health stations are equipped with computers.
At the provincial and district levels, the amount of full time health information officers is suitable for the
HIS workload. But in commune health station, a single staff member is responsible for many kinds of
work including HIS. In the six provinces, Health information staff had received short courses on health
information only. Very few health information staff had had in-depth statistical training (Yen Hung
hospital (Quang Ninh)
In Ha Noi, Quang Ninh, Nghe An, Hai Phong, and An Giang, donors are providing coordinated support
only to development of health information systems for specific vertical programs. This support has very
little positive impact on the development of the entire health information system. Donor support
focuses only on certain aspect of interest. In Quang Ninh, Hai Phong provinces, the program “Injury
67
prevention” provides (1) statistic forms and record books; (2) allowances for data collectors; and (3)a
short training course for almost all health statistics staff of the whole province. In Nghe An province,
JICA supports software programs and computers (2 computers for each facility of 10 districts). In An
Giang province, SIDA project supports software programs for collecting data on its project activities. In
Ho Chi Minh city, there are no international donors supporting the development of the health
information system.
The MOH requires that all public and private health facilities/providers report to a State administrative
agency. The MOH Health statistics and Information Division (HIDS), within the Planning and Finance
Dept. determines which health indicators are required. The main responsibility of HIDS Division is
updating the indicators list and supplying the list to the MOH. In the six study provinces, the Planning
Division of the Provincial Health Bureaus(PHB), is responsible for collecting the required data from
public facilities and the Division of Private Practice Management is responsible for data from private
facilities.
The development of HIS as well as the creation of reporting forms is decided by MoH and the
Government Statistics office (GSO). MoH will send these forms to the Provincial Health Bureau (PHB)
and then the PHBs provide them to all health facilities in the province. Data reports from public facilities
are submited regularly and on time, but the data quality is difficult to verify. Private sector data mainly
comes from big private facilities. Small and far flung health facilities often submit reports late.
In Vietnam, the MOH has procedures for planning resource allocation based on health outcome data.
Despite provincial and local planners priorities, however, they must not exceed their budget allocations.
Due to limited resources, many funding requests are cut during budget allocation procedures. All
studied provinces reported insufficient funds for HIS and other health priorities. Thus, clear procedures
exist for using HIS data in planning, but budgets often too tight to adjust according to need.
All provinces use core indicators stipulated by the MoH. All relevant stakeholders collaborate in the
selection of the core indicators and the indicators have been selected according to explicit criteria
including usefulness, scientific soundness, reliability representativeness, feasibility, and accessibility. Only
in Quang Ninh, besides using MoH core indicators, some core indicators were added based on local
conditions. For instance, core indicators related to health and environment were developed with the
collaboration between stakeholders such as the Provincial People’s Committee, the Provincial
Department of Natural resources and Environment, and the Provincial Preventive Health Department.
One issue currently facing HIS the lack of a systematic approach to data collection. According to a
recent HMN assessment, certain indicators are repeatedly collected, creating overlaps among
institutions and extra workload. Other indicators are completed overlooked, and not collected by
anyone (200623). In addition, a standard mechanism to review and update HIS data for planning and
management is lacking at both the national and provincial levels. HIS indicators are used for planning and
management, but data are not frequently updated. Furthermore, data on private sector activities is
lacking. Laws and regulations governing data collection in the public sector are not easily applied in the
private sector. Large private facilities submit regular reports to State administrative agency, while smaller
private facilities go unsupervised.
For example, mortality indicators such as IMR, U5MR, and MMR were used to allocate budgets for
maternal and childcare program. Despite provincial and local planner’s priorities, however, they must
not exceed their budget allocations. Due to limited resources, many funding requests were cut during
23
68
Vietnam HMN Assessment 2006.
allocation procedures. Six provinces reported insufficient funds for HIS and other health priorities. Thus,
clear procedures exist for using HIS data in planning, but in practice budgets often prove too tight to adjust
according to need.
COMPONENT 5: DATA COLLECTION AND QUALITY
Data collection and quality is critical to health planning and information systems. It can be difficult to
verify. Six indicators were used to examine data quality: (1) the percentage of districts represented in
reported information; (2) Percentage of private health facility data included in reported data; (3)
Availability of clear standards and guidelines for data collection and reporting procedures; (4) The
number and type of reports does overburden the staff and supervisors regularly provide feedback; (5)
Presence of procedures to verify the quality of data reported, such as data accuracy checklists prior to
report acceptance, international data quality audit visits; and (6) The availability of national summary,
which contains HIS information, analysis, and interpretation (most recent year).
In Vietnam, the MOH has clear reporting procedures reporting which are applied at the provincial,
district and commune levels. However, quality checks only examine the data in comparison with the last
report. It is difficult to verify the accuracy of district and provincial reports. Currently, there is no
defined mechanism in Vietnam for reviewing and verifying the quality of data.
Other factors that may contribute to low quality data are the lack of consistency among data collection
forms and data collection forms that do not agree with/fit with the MOH official software (Medisoft).
All the staff, responsible for data management at different levels of care, reported difficulties in entering
data from the data forms into the software and/or exporting the data to reporting forms.
Collecting and reviewing private sector data poses significant challenges in Vietnam. In Quang Ninh, Ha
Noi and Nghe An, most private facilities obey monthly and annual reporting requirements. In Hai
Phong, Ho Chi Minh City and An Giang, only big and urban facilities submit quarterly reports as
requiremed by the Provincial Health Bureaus. Data collected from private sector is included in national
reports. However, as with public sector data, it is difficult to verify the accuracy of information provided
by the private sector. There is a lack of information sharing between the private sector and State
management agencies.
The MOH has created national guidelines for data collection and reporting procedures. The guidelines
include things like formulas for calculating percentages, etc. The MOH sends the guidelines to the
provincial department of health. The occupational medicine division then organizes training workshops
for the health facilities of six provinces on the proper way to collect, calculate, and report data. These
reporting standards are provided to both public and private health facilities. In almost studied provinces,
guidelines are available at the provincial level, but they are often stored on bookshelf and not readily
available at the district level. In Hai Phong province, the guidelines are not available at both provincial
and district levels. Therefore, the issue of available reporting guidelines can be considered a weakness of
HIS in Vietnam.
The burden of reporting rests mainly in communal level because: (1) many kinds of reporting forms need
to be fulfilled for curative care activities, national health programs, health insurance, and (2) the lack of
health staff in commune health station, with no full time health information staff.
Feedback loops in the HIS system are incomplete. Data producers at lower levels only receive feedback
from the Provincial level when the information they submitted is abnormal. No feedback at all comes
from the central level after receiving the report.
69
There is no regulation of procedures to verify the quality of data reported in Quang Ninh and Nghe An,
Hai Phong, Ha No, An Giang. Data quality was verify by (1) cross check between health facilities; (2)
regular or sudden audit visits of Provincial Health Department. Only Ho Chi Minh city applied ISO 90012000 from 2005 about procedure on report data quality verification and it was done regularly.
Annual national statistic book is available. Nevertheless, the information there is raw descriptive data
(with only basic analysis and interpretation). There is no summary report on health statistic information.
COMPONENT 6: DATA ANALYSIS
The data analysis component was examined in terms of availability of qualified personnel and
infrastructure to conduct analyses.
At the central level, the different formats in which different data sources provide information is
challenging. In recent years, the MOH has published the health statistics year book annually. Data from
this book is available and could be used for analysis however, the central level lacks the personnel
required to conduct data analysis. The current situation is similar in the 6 studied provinces. There are
no health information staff who can conduct data processing and analysis in the Provincial Health
Bureaus. Most data collected at the local level, which is stored in books or printed reports, are raw
data. The provinces lack the physical infrastructure and human resources needed to publish the data in
more usable formats. In fact, in health facilities at provincial and district level, there is enough health
information staff for collecting data and filling the forms, but no specific training for them on how to
process and analyze data.
The dissemination of the reports of national health programs are different depending on the
requirement of each. For example, report on vitamin A utilization frequently twice a year, report on
reproductive health frequently quartly. Reports are sent to relevant organizations and presented in
annual meeting of provincial health sector or website (Ho Chi Minh city).
Appropriate and accurate denominators such as population by age groups, by facility catchment area, by
sex, number of pregnant women, etc. are available for analysis. But the age group range clasificaion
according to GSO is not suitable for health planning and management.
COMPONENT 7: THE USE OF INFORMATION FOR MANAGEMENT, POLICY
MAKING, GOVERNANCE AND ACCOUNTABILITY
The indicators used to measure this component included whether the data was used for planning,
budgeting, or fundraising activities in the past year and whether feedback was given to data providers to
inform them of program performance.
The health information system lacks quality data, especially on private sector performance.
Dissemination of existing data is limited, mostly kept among internal users. Some existing data sources
are used for planning budget allocations. In each public health facility, planning for a new year depends
on the statistical data of the last year, budgets and targets coming from the higher level.
At central levels, the officials do not provide feedback on reports that they receive from lower levels. At
provincial levels, they only provide feedback to lower levels if they feel something is abnormal in the
reports.
70
There is a lack of collaboration and information sharing within the health sector and with other sectors.
Overlaps in information collection, variations in data reported across ministries, and information that
fails to meet the needs of users, are all common concerns within the national information systems.
71
4. DISCUSSION
The report uses WHO health systems performance criteria to examine the provincial health system
performance: equity, efficiency, access, quality, and sustainability. A few indicators from each functional
area were chosen to provide insight into these criteria across the provincial health systems.
4.1
EQUITY
Equity in health care is one of the targets the Vietnam health care system constantly focused on
achieving. As a developing country, Vietnam has been implementing a national health policy protecting its
most vulnerable population groups: the poor and ethnic minority groups. In all studied 6 provinces,
including Hanoi Metropolis, free health care policy for under six year children and the poor has been
implemented. Party organizations, provincial people councils, and the provincial governments have
frequently organized forums to solicit public inputs to improve health care services for their people,
with special attention to the vulnerable populations.
Equity refers to the absence of systematic disparities in health between social groups who have different
levels of underlying social advantage or disadvantage – that is different positions in a social hierarchy.24
Based on a literature review, equity in health implies that ideally, everyone should have a fair
opportunity to attain their full health potential and more pragmatically that none should be
disadvantaged from achieving this potential, if it can be avoided.25 Equity simultaneously requires that
relatively similar cases be treated in similar ways, and relatively different cases be treated in different
ways. Therefore, there are two types of equity: (1) horizontal equity: the allocation of equal or
equivalent resources for equal needs; (2) vertical equity: the allocation of different resources for
different levels of needs.
There are a number of financing indicators used to measure equity. For example, government spending
on health as percent of total health expenditure. the WHO suggests that a low value for this indicator
(below 40%) means that the government has limited ability to act to address equity issues. According to
results of this study, the share of government spending for health as a proportion of total health
expenditure accounts for more than 50% in most of studied provinces, except Ho Chi Minh and Hai
Phong (these percentages are 25-28% in Ho Chi Minh City and 35-39% in Hai Phong). According to the
assessement, the contribution of central, provincial and district governments to the total health spending
in provinces such as Hanoi, Quang Ninh, An Giang and Nghe An are highly adequate meaning that the
government has the ability to act to address equity issues; It is assessed “adequate” for Hai Phong and
close to adequate in Ho Chi Minh city.
Equity in the health service delivery should refer to equal access to available care for equal need. This
implies equal entitlement to the available services for everyone, a fair distribution throughout the
country based on the health care needs of access in each geographical areas and the removal of barriers
to access.
Equity of access to health care services is measured by the HSA indicators such as the “existence of user
fee exemptions and waivers”. However, equity also implies equal quality of care. Providers must strive
to deliver quality services for all sections of the community, so that everyone can expect the same
24
25
72
WHO’s definition.
Margaret Whitehead, 1993. Conceptualizing equity in health and health care.
standard of professional care. As mentioned in the service delivery findings, the local team suggested
adding an indicator evaluate availability of the health care service: “Percentage of primary care facilities
with medical doctor and adequately equipped”.
Results of assessment in health service delivery shows that most of poor people (99.9%) and children
under 6 have health insurance card. The result reflects the government of Vietnam’s great commitment
to providing equity for health care.
According the assessment results, 100% of all communes in all 6 provinces have CHS. However, quality
of care varies by CHS, by geographic area, from province to province etc. More than 70% of primary
care facilities are adequately equipped. Some CHS infrastructure is old or worn-out, and needs repair or
an upgrade. The number of medical doctors at CHSs is decreasing in all 6 provinces. Therefore, the
result shows only moderate success in providing equity in term of quality of health care service at
commune level.
To assess the equity of health system in term of human resources, the distribution of health care
professionals by level of care in urban and rural areas, curative care and preventive care were chosen to
discus. In general, the distribution of human resources in the 6 provinces is skewed and does not
ensure the equity of health system. The 6 provinces have an unbalanced allocation of health
professionals by level of care, between rural and urban areas, and by field of medical practice (curative
and preventive).
The distribution of health professionals at the grassroots level is low in number and quality. Nearly one
third of health professionals work at the commune level. But some CHS do not have doctors (16 -28%
of CHS, except Quang Ninh province). Moreover, doctors who works at the grassroots level are usually
junior doctors or assistant doctors without special training for primary health care.. The result of this
study also indirectly show the inequality of health care professional distribution between rural and urban
areas, in which the rural areas have fewer health care professionals both in quantity and in quality.
Except Hai Phong and HCM City, the four remaining provinces have majority of communes located in
rural areas (including Hanoi, since it merged with Ha Tay province), where the number of health
professionals is not high enough. Hai Phong has a better balance of health professionals by level of care,
apart from the distribution by field of medicine (curative and preventive care).
There are only 8.4 – 17.7% of health professional working in preventive care facilities in provincial and
district level, while more than 60% work in curative care (except HaiPhong with 54.6%). Grassroots
level facilities provide mainly primary health care services, most of which are preventive medical
services, administered directly to the commune. Therefore, increasing the number and quality of health
workers for preventive care would improve preventive care as well as primary care.
The indicator suggested to measure equity in pharmaceutical management is the existence of licensing
provisions or incentives that increase geographic access by consumers/patients to quality products and
services through private wholesalers and retailers. As described in our findings, only licensed
pharmacists can sell drugs. There are no provisional exceptions to increase geographic access to
medicines. A strong drug retail network exists nationwide and licensed pharmacies or drug sellers are
available in all communities. However, distribution of pharmacies is uneven between city and rural,
lowland and mountainous areas. Consumption of drugs varies among income groups. Results from the
household surveys provided that there is a disparity in drug consumption across income groups in
Vietnam. Figure 10 showed that the rich people spend 5 times higher for medicines for self-treatment
comparing with the poor. Vietnam Health Survey in 2002 provided that average cost of medicines for
each out-patient visit also varied largely by quintile groups.
73
Denominators such as population by specific age group, by facility catchment area, by sex, number of
pregnant women are available. But the appropriateness and accuracy of these denominators creates
some issues.
Population by age groups often divided in the following groups: < 1; 1-4; 5-9; 10-14; 15-19; 20-24; 2529;…54-59; 60-64; >65. According to the regulations of the Policy “Free Health Care for the child
under 6”, all children under six years old will be covered health care free of charge. Each child under six
has a card for free health care or health insurance card
.At both the national and provincial level, there is no exact figure for the number of children under 6. so
in each province, the local authority only allocate budget for permanent resident children under 6. Free
Health Care Card or Health Insurance card has been sent to children under six, who are permanent
residents of their province. People who are legal residents, but have moved illegally, are not registered
and do not have a health insurance card yet. Non legal resident children under six do not benefit from
the policy for free health care to children under six.
4.2
EFFICIENCY
Efficiency of health care system in six provinces is supported by diverse forums and
procedures/protocols that give the public, technical experts, and local community’s opportunities to
provide inputs into the development of priorities, strategies, plans and budgets. In addition, frequent
direct dialogue between health service providers and patient councils in all hospitals contribute to the
efficiency and quality of health care services.
Budget allocation according to program budgets provides a way to track whether spending is achieving
the intended results. In the 6 study provinces budgeting includes program and historical budgets.
Program budgets (separate budgets are created for curative and preventive care) provide a way to
evaluate whether funding is being used efficiently for priority services and health policy initiatives.
Historical budgeting does not reflect changing needs and it becomes out of step with funding
requirements. Therefore, it tends to lead to inefficiency with more funding allocated to some functions
than needed and less to others.
Level of investment is another indicator to measure efficiency in health financing. In Vietnam as well as in
six provinces, high priority in terms of budget allocation is given to grass-root level and preventive care.
There are a number of investment projects from government provided to district hospitals and
commune health station in order to upgrade health facilities at grass-root level. The government is also
committed to allocating 30% of government budget to preventive care.
Existing systems to track and audit expenditure against budget authorizations is another indicator that
reflect efficiency in health financing and that are essential to good financial management and
accountability and can be key to efficient management.
Efficiency of health service delivery could be evaluated by several indicators. In this report, the local
team suggests evaluating the efficiency of health service delivery in two categories: preventive care and
curative care.
The availability of integrated primary health care services was used to assess the efficiency of preventive
service delivery. Achievement of good preventive care results should indicate a high level of efficiency.
Service provision indicators showed that the availability of integrated primary health care services
(immunizations, TB, prenatal care, family planning, malaria, nutritional services were “adequate” for all
six provinces. In all six provinces, although many grass-roots programs are vertical national programs,
74
most of them are fairly integrated at the commune level. The reporting systems of each are problematic.
Each CHS has approximately 25 monitoring books for 31 health programs. Employees estimated that
they are spending 20-30% of their time at work on surveillance and report writing.
The local team suggests the efficiency of the curative care system be evaluated by the existence of
referral mechanisms between levels of health care. Referral mechanisms are less than adequate in all six
provinces. This situation is best illustrated by the hospital overloads in 3 cities. In many hospitals, there
are 2, even 3, 4 patients per bed. Many patients seek health care at the central or provincial level, rather
than the commune or district level. Therefore, efficiency of the curative care system in six provinces
should be improved.
The efficiency of health system performance in term of human resources is measured base on linkages of
links and “feedback loops” between the organization and pre-service training institutions. Good
mechanisms for exchanging information and coordinating between health facilities and training
institutions improve health system functioning. Pre-service training based on skills needed in health care
facilities is critical so that the right numbers and cadres of personnel enter the workforce to meet the
demand for health care. Training institutions can also provide in-service training to health facilities and
organizations. In turn, the health care organization can offer practicum sites to the training institution.
A significant weakness within the health system of most provinces is the lack of mechanism for
determining the existing needs for staff cadres, specialties, and in-service training. Institutions lack the
necessary information for coordinating HRH training with the local HRH needs. The major reason for
this is that medical colleges are under management of MOH or MOT and local secondary medical
schools are under provincial people committee, moreover, the training institutions themselves are not
considered the a health priority.
Among the 6 provinces, only the 3 large cities have adequate scores (Ha Noi: 2, HCM city: 2.5, and Hai
Phong: 2) for HRH management. These three cities have a greater ability to ensure the efficiency of
human resource performance than those in the other three provinces (Nghe An, Quang Ninh and An
Giang). In order to improve human resources’ performance, a comprehensive measure or policy to
ensure the coverage of human resource both in number and in the appropriate distribution is required.
As mentioned in the findings on pharmaceutical managment, there are three efficiency indicators: (1) the
use of generic or nonpropriety name for MoH procurement; (2) the percentage of MoH
pharmaceuticals procured through competitive bid; and (3) the value of loss inventory. Figure 12
indicates that all six provinces have a high percentage of MoH pharmaceuticals procured through
competitive bid and minimal inventory loss. All pharmaceuticals purchased by government budget or
health insurance funds must be through competitive bidding. Hai Phong, Quang Ninh and Nghe An
received "adequate" score for the use of generic of nonproprietary names (INN) for MoH
procurements. The other provinces received scores of less than adequate. The use of generic of
nonproprietary names (INN) for drug procurement is not consistently reported in hospitals. Both
nonproprietary names and proprietary names are commonly used in drug bidding. Drug selection is a
complicated dance between the goal of medicines for all at affordable prices and the from giant
pharmaceutical companies goal of making a profit.
Pharmaceutical policy is lagging behind recent trends. Although there are regulations for drug
procurement they are not being appropriately adjusted to handle the issues emerging during their
implementation.
For example, mortality indicators such as IMR, U5MR, MMR and morbidity especially emerging diseases
75
were used to allocate budget for health planning. Despite the MOH’s need for accurate data to support
planning, HIS funding requests were often ignored. A lack of resources prevents HIS from functioning
well and from contributing to the efficiency of the health system.
4.3
ACCESS
Access is a measure of the extent to which a population can reach the health services it needs.
Assessment results indicated that there are procedures and institutions that clients, providers, and
concerned stakeholders can use to fight bias and inequity in accessing health services. The simplest
evidence is that personal telephone number of all hospital directors in six provinces are available to the
public and their phones have to be switched on all time to receive and answer to comments/complains
and suggestions from public. All public health facilities have to arrange reception room and time to meet
people to solve health care access problems. Department of health office, local government office and
local people council offices are place people can access and ask for intervention in case of inequity in
accessing health care services.
If per capita total spending on health care is below 30 USD people are likely to have poor access and/or
low quality of care. Results from 6 study provinces showed that highly adequate total health expenditure
per capita in two big cities such as Ho Chi Minh and Hanoi meant people have good access to health
care in these two provinces. In contrast, low per capita total health expenditure in provinces such as
Nghe An, Quang Ninh and An Giang indicated that people living in these provinces have poorer access
to health care services. Evidence showed that even though the poor and other vulnerable groups have
health insurance cards, many of them still can not come to health facilities due to: (1) geographical
difficulty; (2) indirect costs; (3) their health seeking behaviour; (4) backward customs
When OOP spending represents a large share (above 80%) of private health spending it can be a barrier
to accessing care and can threaten the financial status of the households (push some into medical
poverty trap). In the 6 study provinces, OOP spending is high, but compensated for with the health
insurance for poor and vulnerable groups. In addition, beginning in 2010, according to the new law on
health insurance, the near poor will also be provided financial assistance to buy health insurance.
The “number of primary care facilities in health system per 10,000 populations” was used to evaluate
accessibility of health services. However, access to health services could be measured by a list of
dimensions, such as the availability of health services, availability of health care staff, infrastructure,
equipment, geographical location etc/
In all six provinces, the availability of health services is fairly good in term of quantity of health facilities.
Every commune in all 6 provinces has a CHS. However, the ratio of CHS per 10,000 population varies
by provinces, range from 0.5 of Ho Chi Minh city; 0,9 of Ha Noi to 1.5 of Nghe An. Yet these results do
not mean that people in Ho Chi Minh city and Ha Noi are more disadvantaged than people in Nghe An
or An Giang provinces in term of access to health care. Ha Noi and Ho Chi Minh city have high
population density and the coverage are of each commune/ward is quite small. People in Nghe An,
Quang Ninh and An Giang must travel longer distances (up to 30 KM) and over more difficult roads to
CHS than people in the 3 largest cities.
The availability of medical doctors is also different. Nghe An province has 20% CHS without medical
doctor and many CHS can not access to ambulance due to difficult road. Percentage of CHS without
medical doctor in Quang Ninh province is even higher. Therefore, even though the ratio of primary care
facilities in health system per 10,000 population is higher in Nghe An, Quang Ninh and An Giang the
76
people in the urban areas (Hanoi, Hai Phong, and HCMC) have better access to health care. In general,
accessibility to primary health care for most people in all six provinces is quite good.
People in mountainous and remote areas in Nghe An and Quang Ninh face geographic barriers to
access. Quang Ninh has many islands and Nghe An has a lot of ethnic minorities living in mountainous
areas.
Adequate numbers of health care professionals and the appropriate distribution of those human
resources are needed to ensure health service coverage. This indicator is useful for cross-country
comparisons, for monitoring targets, and for comparing against international standards. Among the 6
provinces, only two cities have adequate numbers of both general health professionals and doctors (Ho
Chi Minh City and Hai Phong). The rest (except Ha Noi) also have adequate numbers of health staff
(according to WHO recommendations), but the amount of highly skilled professionals, such as doctors,
is still very low. Hanoi province has the lowest ratio of health professionals per population but in fact
there are plenty of doctor and other type of health professionals (more than 11,000 health professionals
from health organization at central level and a large number of health professionals from health facilities
of military and other sector that are located in Hanoi26). However, having the right number of health
professionals is not enough to ensure the access to health services, an appropriate distribution of human
resources should also be considered.
All 6 provinces lack health professionals in the rural areas or lower levels of care. However, Ha Noi and
Ho Chi Minh City have a lower risk of losing doctors or highly skilled health staff moving to other
provinces but they have a high risk of losing health professionals from lower level facilities to higher
level, from preventive to curative services, and particularly, from public to private health facilities. Other
provinces have more risk of health professionals moving to big cities and face difficulty recruiting health
professionals to work in their provinces. If the present workforce imbalances continue, the shortage of
health workers will become more serious, particularity in disadvantaged areas and at lower level of care.
The population per licensed pharmacist or pharmacy technician is used to evaluate accessibility in
pharmaceutical management area. All 6 provinces have "adequate" or higher scores for this indicator.
Public health facilities always have licensed pharmacists. Due to market liberalization, private pharmacies
exist in most places. However, the number of people served by a licensed pharmacist decreased annually
in only 3 of the provinces. In order to assure accessibility to quality pharmaceuticals the issue of human
resources development for pharmaceuticals needs more attention.
The health information system lacks quality data, especially on private sector performance.
Dissemination of existing data is limited, mostly kept among internal users. Some existing data sources
are used for planning and budgeting. In each public health facility, planning for a new year depends on
both statistical data of the last year and budget allocations.
4.4
QUALITY
The formulation of policies, plans, regulations, procedures, and standards based on research and
evaluation (indicator 8) to is one of indicators for assessment of health care quality. All 6 provinces
scored adequate (2.0) for this indicator, which means that provincial government officials have access to
recent data or research and evaluation studies in formulating policies and annual health service plan but
do not systematically use the information in formulating policies and plans. One of reasons is the
weakness in health management information system, especially in poorer provinces. HMIS needs to be
improved so that can provide more reliable evidence for policy and plans formulation.
26
Source: Department of human resources management – MOH, 2008.
77
Health financing’s impact on quality is measured by the percent of government health budget spent on
salaries of health workers, medicines. If the percent of government health budget spent on salaries
accounts for the majority of health spending (70-80%) and the remaining budget is not sufficient to cover
the costs of medicines then the financial shortfall affects the quality of care as well as equity. In the 6
provinces, government budget spending on health worker salaries accounted for 60-80%. The budget to
cover services comes primarily from user fees and health insurance reimbursements. Funding from the
government budget is not adequate to cover professional activities. Therefore, policies on user fees and
health insurance are necessary to increase revenue for hospitals.
It is difficult to assess the quality of health care services in all 6 provinces. Quality is reflected through
the availability of updated clinical standards for MOH priority areas, high burden diseases areas, and/or
areas responsible for high morbidity and mortality. In Vietnam, the MOH Therapeutic department
designs and provides clinical standards for some priority areas, including common diseases, high
morbidity and mortality diseases or emerging issues, etc. In theory, these clinical standards provided for
both public and private health facilities, but mainly for the public sector. The shortfall of clinical
standards is that they are not adapted to local conditions. Health systems assessment results
demonstrated that some hospitals in the 6 provinces have adapted national treatment guidelines to take
into account local situations. The practice was not commonly implemented in all health facilities,
especially at low levels such as district hospitals and CHS.
Finding from An Giang shows that they are pioneering the application of ISO for hospital management.
Some hospitals of An Giang province have received a certificate of ISO for hospital management. It is an
excellent measure to ensure quality of care. The lessons learned from ISO application in An Giang
should be used to improve quality of care in other hospitals.
The quality of care impact by human resources can be measured by the availability of registration,
certification, or licensing systems as recommended by the HSA tools. In Vietnam situation, we suggest
the availability of a formal in-service training component for all levels of staff as a supplemental indicator
as well.
Neither of these two indicators scored well, both were less than adequate. The system of registration,
certification, or licensing system is available but applied only for non-state health care provider, not for
public health facilities (State Ordinance for private health care practice and its supporting regulations).27
Moreover, the licensing for professional practices apply only to the head of non-state health care
facilities, not for all health professional work in state health care facilities. In Vietnam, Ministry of Health
established curriculum certification and procedure of licensing, relicensing for private health care
professional work in private sector but the curriculum of certification and criteria of licensing,
relicensing for health professional are simple and only based on available reference documents, not
based on licensing tests for medical knowledge and practice28.
All six provinces lack regulations to manage the knowledge enhancement of health care professionals,
particularly for those working at non-state providers (in-service training and education, technical
exchange and transfer etc.). In 2008, the MOH launched the Circular No 07/2008/TT-BYT regarding
compulsory in-service training for both in public and private health sector staff. Staff are required to
have at least 20 hours in-service training per year for updating the knowledge and skills. However, there
is currently no mechanism nor budget in place to implement that regulation (setting up in-service
State Ordinance 07/2003/PL-UBTVQH11 about health care practice in private; Decree 103/2003/NĐ-CP; Circular No
07/2007/TT-BYT.
28 Health professional need to show the document that certify their practice time of 5 years working in any health care
facility but not specify the type or quality of health facility. That means any kind of health care facilities for both private
and public able to provide that certification. It is not assure the quality of service and safety.
27
78
training curriculum, criteria for accreditation of in-service training institution, regular budget etc.). As it
stands today all health care facilities in the 6 provinces/cities have to allocate heir budgets to support the
staff attendance of required training courses. The health care facilities also have not included annual inservice training for all health professionals in their plans for the year.
Thus, the impact of human resources shortcomings on quality is quite serious requires implantation of
very specific policy measures29.
According to HSA guidelines, pharmaceutical impact on quality includes the following indicators: (1) the
existence of functional mechanism/tools to improve the use of medicines in hospitals and health facilities;
and (2) the existence of a system for the collection of data regarding the efficacy, quality and safety
marketed pharmaceutical products. Regarding the first indicator, almost all hospitals in Vietnam have a
Committee for drug regulation and for medical record reviews to assure treatment quality. However,
the performance of this committee is not enforced. There are also significant differences between the
provincial and district hospitals with regard to the efficacy of this committee. In addition, the lack of
national treatment guidelines is critical hindrance to monitoring and evaluating the quality of care in
general and appropriate use of medicine specifically.
Vietnam does not have a routine system for data collection regarding the efficacy, quality and safety
marketed pharmaceutical products. Rather a system to collect information on adverse reactions of drugs
exists in all health facilities including private ones.
The MOH has clear reporting procedures which are applied in every province at the provincial, district
and commune levels. There is no regulation of procedures to verify the quality of data reported in
Quang Ninh and Nghe An, Hai Phong, Ha No, An Giang. Data quality was verified by (1) cross check
between health facilities; (2) regular or sudden audit visits of Provincial Health Department. Only Ho
Chi Minh city applied ISO 9001-2000 from 2005 about procedure on report data quality verification and
it was done regularly. Collecting and reviewing private sector data also poses significant challenges in
Vietnam. As with public sector data, it is difficult to verify the accuracy of information provided by the
private sector.
The other factor contributing to the low quality of data is the lack of consistency on data collection
forms throughout the system, including mis-matching between the MOH official software (Medisoft) and
paper forms.
4.5
SUSTAINABILITY
In the 6 provinces, annual financial audits and public expenditure reviews are available and stakeholders
can question officials about health expenditures and thus contribute inputs to improve the sustainability
of the health system. At national level and provincial level, allocation and utilization of resources is
regularly tracked (via the NHAs, annual financial report, living standard surveys etc).
In the 6 study provinces, donor funding accounts for only a small share of total health expenditure.
Health financing in those provinces is therefore considered sustainable.
The process of budget formation is another indicator that reflects the sustainability of the finance
system. Bottom-up budgets based on local health situations are more likely to reflect actual health
funding needs. If these budgets are done well and eventually approved and executed, funds are more
In 2009, MOH has submitted the Law of Examination and Treatment to National assembly. This Law about the
registration, certification, and licensing system for health professional and condition to practice.
29
79
likely to be allocated effectively and specific local services more likely to be sustainable. In the six
provinces, bottom-up budgets based on local resources requirements have been made but are not
commonly approved due to shortage of budget.
In health service delivery there is a tendency of expanding and using the private sector. Private hospitals
are well developed in all 6 provinces, except Quang Ninh. Ho Chi Minh city, Ha Noi and Nghe An are
the top 3 highest private sector provinces and have a wide assortment of private hospitals and clinics.
Over time the expansion of private sector health care options may improve the sustainability of the
health care system. Vertical health program is another indicator that is used to measure sustainability in
terms of health services delivery. These programs are funded from government budget and are not
dependent on the donors. In addition, the current emphasis is on strengthening the health system as
whole. The capacity of the district and provincial health authority to conduct supervision is a key to
sustaining quality of care.
In general, human resources impact on sustainability varies. Within the MOH, there is no National
program or specific courses for developing and strengthening management capacity in health. Most
available courses are usually for short periods of time and only focus on certain aspects of the health
management. In the three largest cities in this assessment, local health bureaus have already organized
many short courses with technical support from foreign partner as well as sent their staff to attend the
training courses in other countries. Current managers of health facilities and organizations are medical
doctors or pharmacists by training. Thus, they face significant challenges in managing the health facilities
in the recently decentralized system.
In the future, a consistent program for management and leadership development of health sector should
be developed and applied through out the health system, at all levels.
Promoting the use of essential drug through existence of a National Essential Medicines Policy indicated
the impact of pharmaceutical management on the sustainability of the health system. The list of ED in
Vietnam is updated regularly. However, the implementation of this policy is facing challenges due to
impacts of market forces, especially from trading and production companies. The study found that
although essential medicines are key issue in national drug policies, the national essential medicines list
(NEML) is not always available, especially in HCM City and An Giang province. Currently not much
attention paid to NEML but rather to the list of medicines used in hospitals.
Failure of the HIS system to provide consistent, accurate data has a direct impact on the sustainability of
the health system. Data flows between levels of care may not be portraying an accurate picture of the
situation at each level. Thus governance and management cannot be sure that they are planning and
allocating resources to the appropriate health systems issues. The lack of feedback from upper levels of
reporting provides no incentive to lower levels of care to improve their health outcomes, nor to assure
that the data provided is accurate.
80
5. RECOMMENDATIONS
Although there were efforts to use evidence to formulate health policy and strategic plans at all levels of
health care in all six provinces, it is recommended to develop a more efficient health management
information system. The HMIS should include financial and human resources management data. This
software program should include all core indicators for monitoring and planning purpose and the data
need to be updated regularly and to make sure that reliable data on this area is always available.
To ensure equity and efficiency in the health system and in the poverty-reduction policy, it is necessary
to prioritize health-financing solutions with an orientation towards:
1. Increasing the share of total national health spending from public sources. The increased
government budget should focus on priority areas, including: (1) strengthening the grassroots
health care network and developing preventive medicine; (2) supporting health care for groups
in need of social protection, including people who have rendered meritorious service to the
nation, the poor, the near-poor and ethnic minority people and (3) providing support for
disadvantaged areas.
2. Expand health insurance coverage to protect the population from the risk of impoverishment
resulting from catastrophic health spending through effective implementation of risk pooling.
Provider payment methods should be adjusted so that they incentivize cost-effectiveness and quality
assurance in public and private hospitals.
In order to improve effectiveness of health service delivery and make health care accessible for
everyone in the community to achieve universal coverage, it is necessary consider following
recommendations:
1. Quality of health care services at grass-root level (including health services provided at
commune and district level) need to be improved in order to ensure that people can access
quality health care services in their communities.
2. Reorganizing health services and primary care at CHSs in order to meet people’s needs and
expectations in health care, including updating and refurbishing infrastructure.
3. Beyond improving HMIS within hospital for better management, it is also necessary to
strengthen health management information system at the community level to ensure that
everyone’s health in the community is monitored and managed.
Develop and implement appropriate policies for human resources development which include training,
recruitment and retention especially at grass-root level.
Findings from assessment on pharmaceutical management in six provinces suggested several measures to
strengthen this area:
1. National standard treatment guidelines urgently need to be developed, applied in hospitals and
used to supervise quality of care.
81
2. More specific guidelines on drug procurement should be issued.
3. Strategic cost control measures should be implemented to improve access to medicines
4. The Drug Administration should have annual reporting requirements.
In order to have better health management information systems, it is necessary to:
1. Provide practical, well designed software, to be used widely in the health care system, even at
grass-root level
2. Define a strategy for verifying quality of data collection throughout the system (applied for all
levels, all kinds of health facilities, public and private).
3. Provide training on health information data collection and processing as well analysis, especially,
in Provincial Health Bureaus.
82
ANNEX A: SCORING INSTRUMENTS
83
SUMMARY SCORE OF GOVERNANCE COMPONENTS OF HA NOI, QUANG NINH, NGHE AN, HAI PHONG, AN GIANG AND
HOCHIMINH CITY
Average Score for Indicator
Component
(1)
Responsiveness of
government
to public
needs
(2)
Voice
84
Indicator
1. Government and health
provider organizations
regularly organize forums to
solicit input from the public
and concerned stakeholders
(vulnerable groups, groups
with particular health issue,
etc.) about priorities,
services, and resources.
2. The public and concerned
stakeholders have the
capacity to advocate and
participate effectively with
public officials in the
establishment of policies,
plans and budgets for health
services
3. Technical experts, civil
society organizations, and
health service users have
influence on legislation
concerning health.
4. There are forums and
procedures that give the
public, technical experts, and
local communities
opportunities to provide
inputs into the development
of priorities, strategies, plans
and budgets.
Ha
Noi
Quan
g
Ninh
Nghe
An
Hai
Phon
g
An
Gian
g
HCM
City
2.0
2.0
2.0
2.0
2.0
2.0
3.0
3.0
3.0
3.0
3.0
3.0
2.0
2.0
2.0
2.0
2.0
2.0
Ha
Noi
Quan
g
Ninh
Nghe
An
Hai
Phon
g
An
Gian
g
HCM
City
2.5
2.5
2.5
2.5
2.5
2.5
2.0
2.0
2.0
2.0
2.0
2.0
2.0
2.0
2.0
2.0
2.0
2.0
Ha
Noi
Quan
g
Ninh
Nghe
An
Hai
Phon
g
An
Gian
g
HCM
City
5. There are government,
voluntary, and private
organizations that oversee
the way provider
organizations follow
protocols, standards, and
codes of conduct in regard to
medical malpractice, unfair
pricing patterns,
discrimination against clients,
etc.
2.0
2.0
2.0
2.0
2.0
2.0
6. Health services are
organized and financed in
ways that offer incentives to
public, NGO, and private
providers to improve
performance in the delivery
of health services.
2.0
2.0
2.0
2.0
2.0
2.0
Component
Indicator
(3)
Exercising
local technical
oversight of
health service
quality
(4)
Production of
services
needed by the
public
7. The public or concerned
stakeholders have regular
opportunities to meet with
managers (directors) of
health service organizations
(hospitals, health centers,
clinics) to raise issues about
service efficiency or quality.
(5)
Information
and reporting
8. Government officials rely
on research and evaluation
studies when they formulate
policies, plans, regulations,
procedures, and standards
2.5
2.5
2.5
2.5
2.5
2.5
2.0
2.0
2.0
2.0
2.0
2.0
Ha
Noi
Quan
g
Ninh
Nghe
An
Hai
Phon
g
An
Gian
g
HCM
City
2.0
2.0
2.0
2.0
2.0
2.0
2.25
2.25
2.25
2.25
2.25
2.25
2.0
2.0
2.0
2.0
2.0
2.0
85
Component
(6)
Direction,
oversight and
resource
allocation
tasks carried
by
86
Ha
Noi
Quan
g
Ninh
Nghe
An
Hai
Phon
g
An
Gian
g
HCM
City
9. Service providers use
evidence on program results,
patient satisfaction, and other
health related information to
improve the services they
deliver.
2.0
2.0
2.0
2.0
2.0
2.0
10. The allocation and
utilization of resources is
regularly tracked and
information on results is
available for review by the
public and concerned
stakeholders.
2.5
2.5
2.5
2.5
2.5
2.5
11. Information about the
quality and cost of health
services is publicly available to
help clients select their health
providers or health facilities.
1.0
1.0
1.0
1.0
1.0
1.0
2.5
2.5
2.5
2.5
2.5
2.5
1.0
1.0
1.0
1.0
1.0
1.0
Indicator
12. Service providers use
evidence on program results,
patient satisfaction, and other
health related information to
lobby government officials for
policy, program, and/or
procedural changes.
13. Protocols, standards, and
codes of conduct, including
certification procedures, have
been developed for and
disseminated to training
institutions, health service
facilities, and health providers.
Ha
Noi
Quan
g
Ninh
Nghe
An
Hai
Phon
g
An
Gian
g
HCM
City
2.0
2.0
2.0
2.0
2.0
2.0
Component
government
Indicator
14. There are government
and private organizations to
help providers, clients, and
other concerned
stakeholders when
regulations, protocols,
standards, and/or codes of
conduct are not complied
with.
15. Procedures exist for
reporting, investigating, and
adjudicating misallocation or
misuse of resources.
16. There are procedures and
institutions that clients,
providers, and concerned
stakeholders can use to fight
bias and inequity in accessing
health services.
17. Civil society organizations
(including professional
organizations, specialized
health related NGOs, the
media) provide oversight of
public, NGO, and private
provider organizations in the
way they deliver and finance
health services
Ha
Noi
Quan
g
Ninh
Nghe
An
Hai
Phon
g
An
Gian
g
HCM
City
2.0
2.0
2.0
2.0
2.0
2.0
3.0
3.0
3.0
3.0
3.0
3.0
3.0
3.0
3.0
3.0
3.0
3.0
1.0
1.0
1.0
1.0
1.0
1.0
Ha
Noi
Quan
g
Ninh
Nghe
An
Hai
Phon
g
An
Gian
g
HCM
City
87
INDICATOR AND COMPONENT RATING FOR HUMAN RESOURCES
Component
Indicators
Average Score for Indicators
Hanoi
Human
resources data
Basic indicators for
distribution of health
professionals per
population (10.000)
Human
Resources
Planning
The distribution of
health care professionals
by level of care, field of
medicine (curative,
preventive)
Presence of human
resources data system
Existence of a
functioning HR planning
system
Percentage of budget
dedicated to HR
Availability of a
functioning job
classification system
Availability of functioning
compensation and
benefits system that is
used in a consistent
manner to determine
salary upgrades and
merit awards
Availability of formal
process for recruitment,
hiring, transfer, and
promotion
Human
Resources
Policies
88
HCM
Hai
Phong
Quang
Ninh
Average Score for Components
Nghe
An
An
Giang
2
3
2.5
2
1.5
1.5
1.5
2
1.5
1.5
1.5
1.5
2
2.5
2
2
2
2
2
2.5
2
2
2
2
1.5
2
1.5
1
1
1
2
2
2
2
2
2
2.5
2.5
2.5
2.5
2.5
2.5
2
2
2
2
2
2
Hanoi
HCM
Hai
Phong
Quang
Ninh
Nghe
An
An
Giang
2
3
2.5
2
1.5
1.5
1.8
2.3
1.8
1.6
1.6
1.6
2.1
2.2
2.1
2.1
2.1
2.1
Component
Indicators
Hanoi
Availability of employee
conditions of service
documentation
Presence of a formal
relationship with unions
Registration,
certification, or licensing
is required for
categories of staff in
order to practice
Availability of salary scale
Performance
Management
Training and
Education
Availability of Job
descriptions
Existence of supervision
plan (clinical and
administrative
supervision)
Percentage of
supervision visits to
health centers planned
that were actually
conducted
Availability of a formal
mechanism for individual
performance planning
and review
Availability of a
functioning incentive
package including
monetary and nonmonetary
Availability of a formal
in-service training
component for all levels
of staff
HCM
Hai
Phong
Quang
Ninh
Nghe
An
An
Giang
2
2.5
2
2
2
2
3
3
3
3
3
3
1.5
1.5
1.5
1.5
1.5
1.5
2
2
2
2
2
2
1.5
2
1.5
1.5
1.5
2
2.5
2.5
2.5
2.5
2.5
2.5
2.5
2.5
2.5
2.5
2.5
2.5
1.5
2
1.5
1.5
1.5
1.5
2
2
1.5
1.5
1.5
1.5
1.5
1.5
1.5
1.5
1.5
1.5
Hanoi
HCM
Hai
Phong
Quang
Ninh
Nghe
An
An
Giang
2.0
2.2
1.9
1.9
1.9
2.0
1.8
2.2
1.8
1.5
1.5
1.5
89
Component
Indicators
Hanoi
Availability of a
functioning management
and leadership
development program
Availability of links and
“feedback loops”
between the
organization and preservice training
institutions
90
HCM
Hai
Phong
Quang
Ninh
Nghe
An
An
Giang
2
2.5
2
1,5
1.5
1.5
2
2.5
2
1.5
1.5
1.5
Hanoi
HCM
Hai
Phong
Quang
Ninh
Nghe
An
An
Giang
ANNEX B: CHANGES TO THE
SERVICE DELIVERY INDICATORS
Study site of health system assessment: 2 provinces in 2008 and 6 provinces in 2009
This section presents findings from the health service delivery module. In the original module, several
components of the service delivery function were considered, including: access, coverage, and utilization;
service outcomes; organization of service delivery; quality assurance of care; and community
participation in service delivery. There are total 31 indicators of 7 components in the original
assessment. Each component was scored according to detailed indicators and definitions.
After revising, there are 5 components with 36 indicators, including 26 original indicators and 10
supplemental indicators. 5 indicators were removed from Health service delivery module.
Component 2 Service Delivery Access, Coverage was examined in six provinces of this report based on
4 indicators. In the original instrument, there are 4 indicators in Service delivery access, coverage, and
utilization component and 6 indicators in Service delivery access and utilization component. To avoid
overlap between two components, after revising, there are 13 indicators in the one component Service
Delivery Access, Coverage and utilization included 9 original indicators; supplement 4 indicators and 1
indicator were moved to other component. However, it is clearly that 13 indicators in one component
could be too much. Our suggestion is that the component Service delivery access and coverage and
utilization should be divided by two smaller components: The first is Service delivery access and
coverage and the second is Service delivery utilization. Therefore, assessment of component Service
delivery access and coverage in this study based on 6 indicators: Percentage of people living within
standard distance from a health facility; Private sector service delivery; Existence of user fee exemptions
and waivers; Existence of work place programs that offer health services to employees and Percentage
of employees has Health insurance card and work contract and a supplement indicator “Percentage of
the poor and other vulnerable group have providing Health insurance card”.
91
TABLE B1. RESULT OF REVISING HEALTH SERVICE DELIVERY MODULE
Component
Original Indicator
Revised Indicator
1. Availability of
services
1
Note & Suggestion
Icluding 3 indicators
Explanation
Original instrument has 1indicator,
but 2 indicators were supplemented
from other component
1. Number of Hospital beds (per 10
000 population)
2
10. Number of primary care
facilities in health system per
10,000 population
Moved from Service Delivery
Outcomes component
The indicator 10 measures availability
of service, not indicate outcome of
service delivery
3
11. Percentage of primary
care facilities that are
adequately equipped
Moved from Service Delivery
Outcomes component
The indicator 11 measures availability
of service, not indicate outcome of
service delivery
Including 11 indicators
In the original instrument, there are 4
indicators in Service delivery access,
coverage, and utilization component
and 6 indicators in Service delivery
access and utilization component.
After revising, there are 11 indicators
included:
- 8 original indicators
- Supplement 3 indicators
- (Move 2 indicators to other
component)
2. Service
delivery access,
coverage, and
utilization
4
2. Percentage of births attended to
by skilled health personnel per year
5
Percentage of births delivery
at health facilities per year
92
This indicator measure accessibility
of pregnant to health care facility
Component
6
Original Indicator
3. DPT3 immunization coverage: oneyear-olds immunized with three
doses of diphtheria, tetanus toxoid,
and pertussis (DPT3) (%)
7
8
4. Contraceptive Prevalence (% of
women aged 15-49)
9
5. Percentage of pregnant Women
who received 1+ antenatal care visits
(%)
Note & Suggestion
Immunization coverage: oneyear-olds immunized with 6
main diseases & vaccine
Hepatitis B (%)
It is important to measure coverage
of immunization program for
children with 6 main diseases and a
disease with high prevalance
This component is overlap with
component 2 Service delivery
access, coverage, and utilization
2’. Service
delivery access
and utilization
10
Revised Indicator
14. Percentage of people living
within standard distance from a
health facility
15. Household expenditures on
health care and financial access
16. Existence of user fee exemptions
and waivers
Should be merged to component 2 Service delivery access, coverage, and
utilization to avoid overlap between
two components.
Should not devide to national level
and sub level, because all national
indicator could be and should be
collected at province level.
Should be moved to Health financing
Module
Should supplement indicator “Rates
of the poor and other vulnerable
group have providing Health
insurance card”
11
Explanation
This indicator is outcome indicator,
could be evaluate equity of finacial
access to health care
17. Increased number of primary care
or outpatient visits per person to
health facilities per year
93
Component
12
13
Original Indicator
18. Private sector service delivery
Proportion of hospitalizations (or
number of hospital days) that take
place in the private vs. the public
sector
Utilization of private providers for
health services in rural vs. urban
areas per type of provider
Percentage of women seeking
prenatal services from public vs.
private providers
Revised Indicator
Note & Suggestion
Availability of private sector
in rural area and remote area
Should supplement sub-indicator to
the indicator Private sector service
delivery.
Explanation
This sub-indicator could be evaluate
availability, coverage and accessiblity
of private sector in rural area and
remote area.
19. Existence of work place programs
that offer health services to
employees
14
Percentage of employees has
Health insurance card and
work contract
This indicator could be measure to
evaluate percentage of employees
have protected by health program.
There are 11 indicators in this
component, may be too big and
many indicator in one component.
Our suggestion is we should divide
them to two smaller components:
The first is Service delivery access
and coverage and the second is
Service delivery utilization. If so,
indicators of component Service
delivery access and coverage are
number 10, 12, 13, 14 and indicators
of component Service delivery
utilization are number 4, 5, 6, 7, 8, 9
and 11.
94
Component
Original Indicator
Revised Indicator
3. Service
Delivery
Outcomes
15
Note & Suggestion
Including 7 indicators:
4 original + 3 new indicators
Explanation
In the original instrument, there are 8
indicators in this component. After
revising, there are 6 indicators
included:
- Supplement 3 indicator
- (Move 4 indicators to other
component)
This is important indicator to
evaluate service delivery outcome.
Although DALY is not easy to collect
this data, but it is necessary to know
how is healthy year and disability year
of people in national level as well as
provice level. Life expectancy at birth
is good indicator to evaluate outcome
of health delivery. However, DALY is
more comprehensive indicator.
6. Life expectancy at birth, total
(years)
16
Disability adjusted life year
(DALY)
17
7. Mortality rate, infant (per 1,000
live births)
18
8. Maternal mortality rate (per 100,
000 live births)
19
9. Prevalence of HIV, total (% of
population aged 15–49)
Mortality rate, children under
5 (per 1,000 live births)
20
Incident rate of HIV in year
21
Tendency of Tuberculosis &
malaria
22
Percentage of Child
malnutrition
10. Number of primary care facilities
in health system per 10,000
population
It is important to evaluate tendency
of HIV and effort of prevention
programs
HIV is emerging issue today, but we
should not ignore TB and malaria.
Has been moved to 1. Availability of
services component
This indicator is not evaluate outcome
of service delivery.
95
Component
Original Indicator
11. Percentage of primary care
facilities that are adequately equipped
12. Availability of updated clinical
standards for MOH priority areas,
high burden diseases areas, and/or
areas responsible for high morbidity
and mortality
13. Ratio of health care professionals
to the population
Should be renamed to
“Organization and
Intergration in Service
Delivery System”
4.Organization of
service delivery
23
20. Availability of integrated primary
health care services (immunizations,
TB, prenatal care, family planning,
malaria, nutritional services)
21. Availability of primary health care
services through vertical programs
22. Existence of information systems
that can store and retrieve
information over time about patients
23. Existence of referral mechanisms
between different levels of health
care
24
25
26
96
Revised Indicator
Note & Suggestion
Has been moved moved to 1.
Availability of services component
Should be moved to Quality
Assurance of Care component
Explanation
This indicator is not evaluate outcome
of service delivery.
This indicator is not measure
outcome of health service, but
contribute to improve quality of care.
This is process indicator.
Should be moved to Human
Resources Module
Although this indicator evaluate
availability of health care professional,
but this indicator could be overlap
with Human resource Module.
Futhermore, this indicator is not
evaluate outcome of service delivery.
Most of indicators in this component
refer to level of intergration in service
delivery system; between National
target program (vertical program) and
other primary health care programs;
intergration of storing, accessing and
sharing health information of patient;
intergration and collaboration in
activities of health service delivery
among different level of care.
There are 4 original indicators in
this component & no change.
Component
Original Indicator
Revised Indicator
5. Quality
Assurance of
Care
27
28
29
30
31
32
Note & Suggestion
Including 8 indicators:
- 1 original indicator has moved
from other component and;
- supplement 2 new indicators
Explanation
24. Existence of national policies for
promoting quality of care
25. Existence of quality standards
adapted to local level situations
26. Existence of clinical supervision
by provincial/district level supervisor
27. Percentage of supervision visits to
health centers planned that were
actually conducted
28. Existence of other methods
assuring quality of care besides
supervision (accreditation and
certification renewals, quality
improvement methodologies, health
audits, client satisfaction surveys,
community quality assurance teams)
12. Availability of updated clinical
standards for MOH priority areas,
high burden diseases areas, and/or
areas responsible for high morbidity
and mortality
This indicator has been moved to
this component from the
component 3 Service Delivery
Outcomes
33
Availability of technical
guidline & regulation at health
facility
34
Availability and applying ISO
in health facilities operation
to improve quality of care
This indicator is not measure
outcome of health service, but
contribute to improve quality of care.
This is process indicator.
Clinical standards may not available in
many developing countries, Our
suggesstion is new indicator
“Availability of technical guidline &
regulation at health facility”
It is not easy to evaluate quality of
care as well as Quality Assurance of
Care. ISO is a good indicator to
evaluate Quality Assurance of Care.
97
Component
Original Indicator
Community
participation in
service delivery
29. Presence of official mechanisms
to ensure the active engagement of
civil society and the community in
management of the health system
(community health committees,
community representation in
provincial/district level decision
making bodies)
30. Presence of official mechanisms
to ensure the active engagement of
civil society and the community in
service delivery
31. Existence of official mechanisms
for obtaining community views on
priorities, quality, and barriers
related to health services
98
Revised Indicator
Note & Suggestion
This component should be moved
to Governance module.
Should be moved to Governance
Module
Module
Module
Explanation
All 3 indicators in this component
refer to participatation of community
in service delivery, or participation of
user side. So all 3 indicators not
evaluate direct performance of health
service delivery as well as outcome of
service. Therefore, all this component
should be excluded from Service
delivery module, but should be moved
to Governance Module. The
Governance Module should consider
accept community participation
component and avoid to overlap with
original indicator in Governance
Module.
ANNEX C: THE AVAILABILITY OF
STATISTICAL INDICATORS AT
PROVINCIAL AND DISTRICT LEVEL
OF 6 PROVINCES
99
Component
Indicators
The availability
Quang Ninh
Prov.
level
Health Status
IndicatorsMortality
Health Status
IndicatorsMorbidity
Health System
Indicators
100
1. Maternal mortality
ratio
2. Mortality Rate,
under age 5
2A. Infant mortality
rate
3. HIV prevalence
among pregnant
women aged
15-24
25-49
3A. Pregnant women
prevalence among
women aged
15-24
25-49
3B. HIV prevalence
among population
aged
<15
15-24
25-49
>49
4. Proportion of
children under 5 years
who are underweight
for age
4A. Proportion of
newborn who are low
birth weight (<2500g)
5. Number of hospital
beds (per 10,000
population)
Ha Noi
Dist.
Prov.
level
Nghe An
Dist.
Prov.
level
Hai Phong
Dist.
Prov.
level
Hochiminh City
Dist.
Prov.
level
An Giang
Dist.
Prov.
level
Dist.
+
level
+
+
level
+
+
level
+
+
level
+
+
level
+
+
-
level
+
+
+
+
+
+
+
+
+
+
+
-
+
+
+
+
+
+
+
+
+
+
+
-
-
-
-
-
-
-
-
-
-
+
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
?
+
?
Component
Indicators
The availability
Quang Ninh
Prov.
level
6. Contraceptive
Prevalence (% of
women aged 15-49)
6A. Contraceptive
Prevalence (% of
couple with women
aged 15-49)
6B. Abortion
proportion
6C. Proportion of
birth deliveries
assisted by health staff
6D. Proportion of
women who received
post natal care
6E. Proportion of
children under aged 5,
who received fully
vaccination
7.Percentage of
disease surveillane
reports received at
the national level from
districts compared to
thenumber of reports
expected
Dist.
Ha Noi
Prov.
level
Dist.
Nghe An
Prov.
level
Hai Phong
Dist.
Prov.
level
Hochiminh City
Dist.
Prov.
level
An Giang
Dist.
Prov.
level
-
level
+/-
+
level
+
+
level
+
-
level
+
-
-
-
-
+
+/-
+
+
+
+
+
+
+
+
-
-
+
+
+
+
+
+
+
+
+
?
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
-
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
level
Dist.
level
+
101

(6 Provinces), 2010 draft - Health System Assessment Resource

Transcription

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