Hospital autonomy: Vietnam experiences

Report
IMPLEMENTATION OF HOSPITAL
AUTONOMY: VIETNAM EXPERIENCES
Health Strategy and Policy Institute - Vietnam
Content of presentation
1) Introduction of public hospital network
2) Introduction of policy on hospital autonomy VN and
Implementation
3) Experience of Vietnam from an evaluation of hospital
autonomy
Hospital network in Vietnam
Public
Private
(137813 beds)
(> 7000 beds)
Advance care
40
Hospit
als
Essential care
235 Provincial
Hospitals
Basic care
705 District Hospitals
(including 48 Hosp. of other sectors) +
607 regional policlinics)
10,979 Commune Health Stations
>95 private hosp., (04
foreign-funded hosp.)
Private
practitioners
Hospital autonomy policy (Cont.)
Objectives of Decree 43/2006
1) Better health services delivery, improve quality and
increase hospital revenues
2) Social mobilization of resources for health sectors in
order to reduce subsidy from government to health
facilities
Experience of Vietnam from an
evaluation of hospital autonomy

The evaluation conducted by HSPI and number of departments
of MOH

Time: Oct to Nov 2009 (after 3 years of policy implementation)

Side of study: 18 hospitals included:
7 central hospital (2 fully autonomy)
5 provincial hospitals (1 fully autonomy)
6 district hospital
Objectives of evaluation
1) To analyze the implementation process of Decree No. 43 in
hospitals and to review the organization of implementation based
on the legal documents concerned.
2) To assess the results from implementing Decree No. 43 in public
hospitals in terms of task accomplishment, organizational
structure, staffing and financing.
3) To make recommendations as related to the current autonomy
policy to assure efficient, equity and development oriented supply
of health services.
MAIN FINDINGS
Positive impacts of hospital autonomy (compare 2008 to 2005)

Organization: Hospitals are more active in rearranging their
departments and wards and human resource as well

Technical activities:

More active in expanding types of healthcare services that help
increase the number of patient contacts to hospitals (outpatient:1.3
– 1.5 times, in patient: 1.2-1.4 times)

BOR increased 13 - 25%

Average number of lab tests/patient contact has increased by 1.3
- 2.1 times.

The average number of CT-scanner tests/patient contacts
increased by 2-3 times at provincial and central hospitals. The
average number of ultrasound tests/patient contact increased by
1.4 - 1.5 times.
MAIN FINDINGS
Positive impacts of hospital autonomy:

In terms of finance:

Hospital revenues increased by 1.8 times - 3 times (the main
increase found from the technical services )

Expenditure for health services increased 2-2.8 times

Change in hospital expenditure: spending for HRH increased
1.8 -2.7 times;


Hospital staff’s income increases increased 0.5 – 2.3 times
Investment in medical equipment are increased.
MAIN FINDINGS
Hospital autonomy may lead to the following threats

Service abuse to make profit by:
- Increasing unnecessary hospital admission for inpatient care
to increase hospital revenues.
- Lengthening hospitalization stay (central hospitals: 9.4 days up to
10.1 days; provincial hospitals: 6.8 days up to 7.4 days; district
hospitals: 5.8 days up to 6 days)

Service abuse to make profit by:
- Tendency of increasing utilization of high tech laboratory
tests and equipment to increase the revenues
Use of CT & MRI in central hospitals
CT
Bạch Mai
K TW
BV Bình Định
Bv Chợ Rẫy
ĐK TW Huế
Mắt TW
Hình 1. Số lần chụp MRI/lượt BN qua các năm
2005
0.024
0.057
0.013
0.065
0.028
0.006
2006
0.031
0.082
0.014
0.066
0.029
0.007
2007
0.042
0.105
0.021
0.070
0.035
0.007
2008
0.045
0.148
0.056
0.072
0.036
0.006
Tỷ lệ tăng
2008 so
với 2005
1.8
2.6
4.4
1.1
1.3
1.0
Bảng 20. Tỷ lệ sử dụng CT/lượt BN qua các năm
- Binh Dinh hospital: CT use/patient increased by 4.4 times
- 20% of doctors in the staff survey responded there would be lab-test
overuse.
MAIN FINDINGS
Hospital autonomy may lead to the following threats
 Affected service quality
- hospital of overcrowd (BOR 103% - 172%),
- heavy workload in almost all hospitals while lack of staff
(nurses/doctor low with 1.9 nurses/doctor compare to requirement as
3 – 3.5)
Average expenditure per one treatment

Treatment cost increase (in 2008 compare to 2005)
Bệnh viện
Hospital
Chênh lệch chi phí BQ 1 lượt
Out
patient
khám
bệnh
(2008treatment
và 2005)
Chênh lệch chi phí BQ 1 đợt điều
patient
treatment
trịInnội
trú (2008
và 2005)
Nhóm
BV TCTP
Full autonomy
1.82
1.58
Central
hosp.
Nhóm
BVTW
Provincial
hosp.
Nhóm
BV tỉnh
District
Nhóm
BVhosp.
huyện
1.29
2.97
2.25
2.10
1.83
2.24
The expenditure for medicines occupied 56% to 65% total
expenditure for technical services
MAIN FINDINGS
Hospital autonomy may lead to the following threats
 The gap in terms of benefits among hospitals at different levels in
autonomy implementation: hospital autonomy brings more benefits for
central hospitals, due to
+ higher revenue
+ higher income for health staff
+ easier for investment
 Create a bigger gap in attracting and retaining health workforce to
work in rural areas
What government need to consider
The diversification of private investment in public hospital without strong
regulation create the tendency of privatizing the public hosp toward forprofit
Join venture/sharing
benefit
Priv a te /M ark et
Self operation
budget
Op ein g Pu b li c
Private/Public
Mix
Basi c Publ i c
B- Budgetary units
A- Autonomous units
C- Corporatized units
P- Privatized units
B
A
C
2002
2008
P
What government need to consider?
Policy warning:
 High risk of “selective services” with investment is mainly for hightech equipments and easy to collect the revenues.
 Risk of service overuse or abuse lead to increase the expenditure
for health and OOP as well as patient safety.
 Weak hospital performance regulation and management
• Financial transparence
• High-tech services investment
• Quality control
• HMIS
What further evidences are needed?
- Impact of hospital autonomy to service quality, patient safety, equity
- Health technology assessment for more effective investment and rational
use of technology
Thank you for your attention

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