1. IMPLEMENTATION OF HOSPITAL AUTONOMY: VIETNAM EXPERIENCES Health Strategy and Policy Institute - Vietnam

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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.

8. 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.

9. 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)

10. Use of CT & MRI in central hospitals - 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

11. 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)

12. Average expenditure per one treatment HospitalOut patient treatmentIn 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)

13. 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

14. B- Budgetary units A- Autonomous units C- Corporatized units P- 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 f or- profit 2002

15. 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?

16. -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?

17. Thank you for your attention