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Hospital overload in Hanoi and Ho Chi Minh City – An assessment and recommendations Le Quang Cuong, Tran Thi Mai Oanh, Khuong Anh Tuan, Duong Huy Luong and colleagues 1. Introduction Hospital overload has become a significant challenge for the health sector in Vietnam in the recent years. Hospital overload is particularly serious at central hospitals and in big cities. Overload adversely affects the quality and outcome of treatment, inflicts difficulties for the healthcare services, and thus reducing the efficiency and and equity of the healthcare system. Little is known about the magnitude and causes of hospital overload. It is critically urgent to identify and analyze the problem of overload to formulate feasible and comprehensive policies. The Health Strategy and Policy Institute in collaboration with the World Health Organization carried out this study to assess and analyze causes of the hospital overload. Findings from this study provide important inputs for developing appropriate solutions to minimize the problem and increase the efficient utilization of hospitals. 2. Objectives 1)To assess the magnitude of overload in some central hospitals in Hanoi and Ho Chi Minh CityHo Chi Minh City 2)To identify causes of hospital overload including those related to service providers and users 3)To propose solutions to minimize the problem and increase efficiency of hospital utilization 3. Study method This is a retrospective and cross-sectional study, conducted in Hanoi and Ho Chi Minh City. Sample hospitals were selectedbased on the following criteria: Hospitals with highest bed occupancy rate and hospitals representative to general and specialist hospitals. The five chosen hospitals were Bạch Mai Hospital and Cho Ray Hospital - representing the general hospitals, and Phu San Trung Uong (Central Obstetric Hospital), Nhi Trung Uong (Central Children’s Hospital), and Phu San Tu Du (Tu Du Obstetric Hospital) - representing the specialist hospitals. Both qualitative (in-depth interviews, focus group discussion) and quantitative methods (tabulation, descriptive statistics, case analysis, patient interview cards) were used. 4. Main results All studied hospitals faced serious overload with bed occupancy rates ranging from 165-200%; the actual bed usage was 200% higher than the planned occupancy. The annual number of occupancy days per bed varied from 390 to 774 (the normal level is 280 days/bed/year). Overload was experienced in both outpatient and inpatient services. Within general hospitals, overload mostly occurred in inpatient services at departments treating chronic diseases. Overload was more serious in the first weekdays and during morning times. Professional staff endured long working hours. The assigned staff size/bed was lower than the standard specified in Regulation No. 08/2007/TTLB-BYT-BNV: 0,57-1,09 staff/bed compared to the regulated standard of 1.45-1.55 staff/ bed. Other indicators such as number of doctors per nurse and health staff per patient are also much lower than the minimum standard. Understaffing, to a large extent adversely affected the quality of healthcare services (time length for a physical examination and consultation was only 3-5 minutes/patient). Major causes of hospital overload oPatient bypassing was a leading cause: about 60% patients admitted to Bach Mai và Cho Ray Hospitals were not referred. In the Central Obstetric Hospital and Central Children’s Hospital, the corresponding rate was 90-95%. Insured patients were more likely to seek health services at the right facilities (46% compared to 15% of the uninsured, and the difference is statistically significant), oTechnical system that channelled patients to healthcare facilities was efficient, especially for obstetric and pediatric care. In general, over 50% patients could be treated at district level and one third of patients could be treated at provincial level. At the Central Obstetric Hospital, the rate of natural delivery cases was as high as 33% and at Tu Du Obstetric Hospital, this rate was even higher (46%). Ninety four percent of patients at the Central Pediatric Hospital could have been treated at lower level. Most of patients admitted to central hospitals suffered from a single disease (5% patients at Central Obstetric and 10% patients at Tu Du had only one disease). oPatients including those in the lower economic ladder were inclined to go directly to central hospitals: 73.7% patientsadmitted in Bach Mai Hospital had not sought care at any other health care facilities. This rate was also very high in Central Obstetric and Tu Du (89% and 97%, respectively). The main reason for this care-seeking behavior was that people had more confidence in the quality of care in centralhospitals (better resources in terms of professional staff, medical equipment, and infrastructure). oManagement and medical examination procedures were complicated and very time-consuming restraining both patients and health staff. oHospitals were actively attracting more patients despite of their overload status:Hospitals were under pressure to raise revenue from their services because of the Degree 43//2006/NĐ-CP that required hospitals to be financially autonomous. 5. Recommendations Short-term solutions:Improve organization and management; Rearrangeand rationalize administrative offices to yield more space for patient areas; Improve treatment and monitor length of stay; Strengthen daytime openning departments or wards within hospitals to reduce patient load for examination and treatment; Computerize and apply management information system. Long-term strategies: Strengthen technical capacity, transfer technology, and improve physical infrastruture for lower level healthcare facilities; Build district hospitals, develop a network of satellite hospitals, and increase investment in communal health stations; Develop appropriate hospital fee schedule with differential payment schemes across levels of care; Develop universal health insurance; Diversify hospital services such as home-based care, family doctors, daytime-operating hospitals model; Innovate hospital management mechanism; Develop and issue criteria and standard for hospital management and operation; Give priorities to health workforce development including advanced training and continuous training; Give priorities to specialty training with spearhead specialties and hospital management.
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