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Management of free healthcare services for children under six years of age in Ninh Binh, Da Nang and Tien Giang provinces Dam Viet Cuong, Phan Hong Van, Khuong Anh Tuan, Hoang Thi Phuong and colleagues Background Decree No. 36/2005/ND-CP issued on 17th, March 2005 provided details on the implementation of the Law on Child Protection, Care and Education. Specific stipulations of this law guarantee theprovision of free healthcare card for children under six years of age. There was a need to evaluate the management and implementation of this policy. Objectives 1.Evaluate the management of free health services for children in three provinces of Ninh Binh, Da Nang and Tien Giang. 2.Identify issues to be adjusted and/or supplemented and recommend feasible solutions to improve the management of this policy, taking into account context-specific conditions of these provinces. Methods This is a cross – sectional study, conducted in 3 provinces of Ninh Binh, Tien Giang and Da nang. In each province, investigation was carried out at the Provincial Heath Bureau, Commission for Population, Family and Children, Provincial General Hospital, one private health facility, District Health Centers, District Hospitals, District Public Heath Bureaus, Commune/Ward Health Stations, District People’s Committees, Commune People’s Committees. Interview was conducted with mothers with children under 6 years of age. Main findings 1. Management of medical check-up and treatment for children under 6 - In the provinces, there was no preparation in terms of planning, procedures,and tools necessary for this policy implementation. Monitoring and supervision were mostly based on periodical reports submitted from the lower-level units. - Inspection focused mostly on private healthcare facilities on a periodical basis and when a lawsuit was filed. As to the public healthcare facilities, there was only annual cross-check due to a lack of professional staff. 2. The implementation of free examination and treatment for children under 6 at the central level and in the 3 provinces - At the central level, there were detailed documents such as Circular 14 from Ministry of Health and Circular 26 from the Ministry of Finance, providing guidance on the implementation of Decree 36. - In the 3 studied provinces, concerned agencies had specific documents facilitating the policy implementationsince July 1, 2005. Almost all children (>80%) under 6 years old residing in these provinces received health card (HC). Apart from the strengths, there existed some limitations: the burdensome requirements to follow referral system; lack of equipment and personnel at the grassroots facilities; and long waiting time at higher level facilities due to overload. People had high regard for this policy but did not have proper understanding of the HC and its usage due to limited information and instructions. 3. Examination and treatment for children under 6 after the implementation of Decree 36 - Overcrowding atmedical centers because patient (1) bypassed referral system and went directly to higher health facilities; (2) Took advantage of HC and made unnecessary visits - While this policy was implemented, the number of consultations in private clinics remained unchanged probably due to following reasons: (1) Overcrowding in public hospitals and free examination and treatment services available during working hours in most hospitals; (2) local people’s care-seeking habits - Free-of-charge services were applied to common diseases only. There were no clear policies on expensive medical procedures such as surgeries and healthcare providers adopted different care and payment practice. - There were no clear regulations in preventive care. - Some physicians did not know coverage limits and approved drug list, and thus hesitated to give expensive yet effective prescription. That had certain effects ontreatment quality. - Registration and administrative forms were not appropriate and cumbersome, increasing workload forphysicians. Recommendedsolutions 1. Enhancing monitoring and supervision - Design and introduce specific supervision mechanisms, tools, contents, schedules for both public and private health facilities - Allocate fund and provide training for relevant personnel in monitoring and supervision 2. Strengthening inspection and checking - Increase number of inspectors at provincial and district level - Allocate fund for periodical and random inspection trips - Develop plans for periodical inspection at both public and private healthcare facilities - Develop a mechanism for inter-sectoral coordination 3. Improving the policy - Provide clear instruction and guidance on approved drug list and payment. There should be separate forms for in-patients and out-patients. - The referral system should be restructured. It is necessary to: (1) allocate sufficient state budget for child healthcare services; and (2) improve the quality of grassroots health clinics to avoid overcrowding at medical centers. - Suggested procedures: + Option 1: Continue to grant free medical check-up and treatment for children under six years of age but remove permanent residence card requirement. The granting procedure should be simplified and more accurate. + Option 2: Replace the current free healthcare card by health insurance card for eligible children + Option 3: Use birth certificate as proof for admission to a healthcare facility 4. Reducing over-crowding and improving quality of healthcare - Improve capacity of commune health stations and provide pediatric training to their staff and sufficient medical supplies - Contract private health facilities for their services and provide training/ update pediatrics knowledge for private physicians. - Improve management to prevent abuse of free child healthcare services. 5. Improving communication - Diversify information, education, and communication activities. Special attention should be given to direct communication when the health card is granted . - Better explanation of application procedures, eligibility, and payment through training conducted at healthcare facilities.
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