Pham Le Tuan, PhD Toronto, July

Outline  Introduction  Methods  Results  Discussions and policy implications

Introduction  Private providers have become an important part of many health systems  The Doi Moi process launched in Vietnam in 1986 paved the ways for many substantive health reforms.  The private sector was legalized in same time with the introduction of health insurance two decades ago  Currently, the State owned Social Health Insurance covers some 60% of total Vietnamese population.  A relatively broad benefit package is entitled to the insured but only available in public facilities and a few accredited private hospitals.  The study aims to explore the possibility for collaborating with private providers for the provision of ambulatory care at the primary level in the Mekong region, Vietnam

Methods  Study site: In Mekong Region.  Focus group discussion with government officials: exploring knowledge, views, assessment and attitude towards private providers.  Facility survey: assessing the professional competency of private providers, their qualification, availability of equipment…  Private provider in-depth interview: focusing on potential for and challenges regarding public-private partnerships.  Exist survey of private providers clients: aiming to understand health seeking behaviors, fees, and perceived quality of care.  Data analysis: data entry using SPSS 10, and data analysis using STATA 10. Qualitative data were coded for key themes.

Results  Results of FGDs with health officials Private providers were recognized for its role in assisting the public sector to reduce crowding within the public hospitals Overuse of antibiotics and induced-demand interest Good quality as evidenced by the courtesy of personnel and short waiting time Strong consensus in favor of public-private collaboration to improve competition between service providers The collaboration should be piloted in qualified policlinics Challenges: wide variation of fees for services, “low quality medicines”, low awareness of the population; and lack of human resources for regulating, M&E and quality assurance.

FGDs with health officials  A strong consensus in favor of collaborating with private providers to provide ambulatory health services for insured individuals.  Public-private partnership could improve competition between service providers and be an impetus for both public and private health providers to improve their quality of care.  Such collaboration should be first piloted in qualified policlinics and specialized clinics. The pilot should be rigorously monitored and evaluated before being scaled up.  Challenges to such collaboration: the wide variation between fees for services actually charged by private providers and those regulated by the SIA; limited list of medicines; additional administrative burdens for SIA; low awareness of the health insurance benefit package and co-payment rules; and lack of personnel and relatively weak capacity for regulation, monitoring, and quality assurance.

Results of health facility survey Province Specialized clinic Policlinic General hospital Total Ben Tre5308 Can Tho5218 Kien Giang7119 Tien Giang3317 Tra Vinh6208 Total

Characteristics of participants FrequencyPercent Age > Gender Male Female Education level Did not go to school105.0 Primary school Secondary school High school College/university2110.5

Characteristics of participants Occupation Unemployed21.0 Farmers Students31.5 House workers Retired63.0 Civil servants136.5 Employees Venders Fishermen, gardeners31.5 Others84.0 Average income (VND)* <500, ,000-1,000, ,000,000-1,500, ,500,000-2,000, > 2,000, Defined as poor according to local criteria Yes63.0 No Possession of a 139 card Yes466.7 No233.3 Possession of a health insurance card** Yes No8341.5

Health seeking behavior Characteristic DecisionFrequencyPercentN First provider sought Yes No Closest provider Yes No The nearest provider to home Public owned Another private facility Traditional health facility21.2 Reason for choosing facility Proximity Familiarity of provider Good attitude of provider Reasonable price115.5 Convenient opening- hours Good quality service Recommended by someone3216.0

Healthcare expenditures

Clients’ satisfaction Private providers Neither satisfied nor dissatified SatisfiedVery satisfied Cleanliness of the facility5(2.5%)113(56.5%)82(41%) Wait time for services7(3.5%)107(53.5%)86(43%) Explaination given by the provider 0(0%)106(53%)94(47%) Cost of services5(2.5%)145(72.5%)50(25%) Overall perceived quality of care 1(0.5%)104(52%)95(47.5%) Public providersVery dissatisfiedDissatisfied Neither satisfied nor dissatified Satisfied Cleanliness of the facility - 2(6.1%)20(60.6%)11(33%) Wait time for services 1(3%)18(54.5%)8(24.%))6(18.2%) Explaination given by the provider 1(3%)13(39.4%)9(27.3%)10(30.3%) Cost of services-1(3%)18(54.6%)14(42.4%) Overal perceived quality of care -8(24.2%)19(57.6%6(18.2%)

Discussion  Key findings Government officials have relatively positive attitudes towards private providers. Almost all surveyed private providers serve insured patients, although they are not paid by the insurance agency. The vast majority of providers expressed their willingness to collaborate with the public sector to provide health services for insured people. Clients who sought care at both public and private sector were much more satisfied with the private providers. Collaborating with private providers to offer ambulatory care at the primary level to health insurance beneficiaries seems feasible and promising from both health officials’ and private providers’ viewpoints. The collaboration should be piloted and evaluated before being scaled up.

Policy implications Provides practical evidence on the possibility collaboration between public and private for ambulatory care at primary level. Both public and private sectors have gradually been driven towards each other. The Mekong regions seems ready for a major next step in public-private partnership, with a controlled experiment extending insured primary care benefits through accredited private providers. The partnership is operationally and administratively feasible as ambulatory services are technically simple and could be monitored at a low cost.

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