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

Implementation3) Experience of Vietnam from an evaluation of hospital

autonomy

Hospital network in Vietnam Public Private (137813 beds) (> 7000 beds)

Advance care

Essential care

Basic care

40 Hospit

als

235 Provincial Hospitals

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

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.

Objectives of evaluation

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)

Use of CT & MRI in central hospitals

CT 2005 2006 2007 2008

Tỷ lệ tăng 2008 so với 2005

Bạch Mai 0.024 0.031 0.042 0.045 1.8 K TW 0.057 0.082 0.105 0.148 2.6 BV Bình Định 0.013 0.014 0.021 0.056 4.4 Bv Chợ Rẫy 0.065 0.066 0.070 0.072 1.1 ĐK TW Huế 0.028 0.029 0.035 0.036 1.3 Mắt TW 0.006 0.007 0.007 0.006 1.0

Hình 1. Số lần chụp MRI/lượt BN qua các năm 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.

Service abuse to make profit by:- Tendency of increasing utilization of high tech laboratory

tests and equipment to increase the revenues

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

Bệnh viện Chênh lệch chi phí BQ 1 lượt khám bệnh (2008 và 2005)

Chênh lệch chi phí BQ 1 đợt điều trị nội trú (2008 và 2005)

Nhóm BV TCTP 1.82 1.58

Nhóm BVTW 1.29 2.10 Nhóm BV tỉnh 2.97 1.83 Nhóm BV huyện 2.25 2.24

Hospital Out patient treatment In patient treatment

Full autonomy

Central hosp.Provincial hosp.

District hosp.

The expenditure for medicines occupied 56% to 65% total expenditure for technical services

Treatment cost increase (in 2008 compare to 2005)

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

Private/M arket

Opeing Public

Basi c Publ i c

B A C PB- Budgetary unitsA- Autonomous unitsC- Corporatized unitsP- Privatized units

2008

Private/Public Mix

Join venture/sharing benefit

Self operation budget

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 for-profit

2002

Policy warning: High risk of “selective services” with investment is mainly for high-

tech 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 government need to consider?

- Impact of hospital autonomy to service quality, patient safety, equity - Health technology assessment for more effective investment and rational

use of technology

What further evidences are needed?

Thank you for your attention