founding and evaluating efficiency of training model to transfer technology from polyclinic hospital of hoa binh province to district hospitals

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MINISTRY OF EDUCATION AND TRAINING - MINISTRY OF HEALTH
NATIONAL INSTITUTE OF HYGIENE AND EPIDEMIOLOGY




TRUONG QUY DUONG



CONSTRUCTION AND EFFECTIVENESS EVALUATION
MODEL TECHNICAL TRANSFER TRAINING OF HOA BINH
PROVINCE HOSPITAL FOR DISTRICT HOSPITALS

Specialization: Public Health
Code: 62 72 03 01



SUMMARY OF PUBLIC HEALTH DOCTORAL THESIS





HANOI - 2012
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This thesis was completed in:
NATIONAL INSTITUTE OF HYGIENE AND EPIDEMIOLOGY

Supervisor:
1) Prof. Dr. Dang Duc Phuc
2) Ass. Prof. Dr. Trinh Hong Son


Review 1: Prof. Dr. Pham Huy Dung

Review 2: Ass. Prof. Dr. Le Van Bao

Review 3: PhD. Do Hoa Binh


The thesis will be presented before Institute Thesis Expertise Board, held at
the National Institute of Hygiene and Epidemiology At on /
/ 2012.





The thesis could be found at:
- National Library
- Library of Institute of Hygiene and Epidemiology
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ABBREVIATIONS AND ACRONYMS


HI
:
Health Insurance
PT
:
Patient
DT
:
Doctor
HO
:
Hospital
GH
:
General Hospital
HS
:
Hospital Staff
DLI
:
Doctor Level I
DLI, DLII : Doctor Level I, Doctor Level II
HC
:
Health care
ED : Education
EIT : Efficiency Index of Intervention

HB : Hospital Bed
CL : Clinical
INT : Intubation
GC : General Clinic
HE :
Health
NE :
Neonatal
AV :
Average
TO : Total
HS : Health Station
TE : Test


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BACKGROUND


One of the pressing issues of Vietnam's health sector was that health care system
faced difficulties and shortcomings, such as distribution of the hospital system is not
balanced, especially the last treatment line all located in large cities; There were
disparities in healthcare quality between upline and downline; qualifications of medical
staff especially the facility line has not met people's needs
The above situation did not only affect the quality of patient care, also to
hospitals were suffering from overload in patients with increasing levels of stress.
General Hospital of Hoa Binh province was responsible for clinical activities for
people in the region, subject to clinic in HO are mainly people of ethnic minorities and

the poor. In recent years, HO is always in a state of overload, capacity utilization of
hospital beds high (125-150%). Status of district HOs to transfer PT to the provincial
clinic HO and PTs over-line occupied high percentage. One of the causes is health staff
qualification, ability of the district HO to meet the clinical needs is still restricted. From
the reasons above, we researched the subject to get two objectives:
1) Describe the situation demands and the ability to provide medical services for
inpatients of two hospitals in Tan Lac and Kim Boi district, Hoa Binh province
(2006-2008).
2) Develop and evaluate the initial effectiveness of technical transfer training
model of the provincial hospitals to improve medical care for district hospitals.
* The new contribution of the thesis:
Identified situation of in-patient clinical needs of the people in two district Tan
Lac and Kim Boi was high, while the ability to provide inpatient services of district
general clinic is limited about professional competence. In order to meet the increasing
clinical demand of the district HO for the people in the local. The highlight of the
thesis was that built and implemented the provincial hospital transfer techniques
training model to enhance the capacity for district GHO, focused on a number of fields
such as essential newborn care, external trauma ( the bone surgery), other products
(caesarean section, surgical diseases of the uterus, ovary), anesthesia resuscitation,
CPR. Effectiveness of post-intervention: the average duration of treatment (day) /1PT
decreased. Number of patients hospitalized, number of surgeries, tips markedly
increased, rate of patient transferred up-line and over-line significantly reduced;
neonatal care capacity, the bone surgery, caesarean section, uterus pathology surgery,
ovaries surgery were improved.
* Layout of the thesis:
The thesis consisted of 149 pages (35 results tables, 2 graphs, 1 figure). The thesis
structure into four chapters: Introduction 2 page; Chapter 1 - Overview 38 pages;
Chapter 2 - Subjects and Methods 24 pages; Chapter 3 - 39 page research results;
Chapter 4 - Discussion 45 pages; 2 pages Conclusions and Recommendations 1; Ref:
117 documents (84 Vietnamese, 33 English), which has 76 material (65%) published

since 2005.
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Chapter 1: OVERVIEW

1.1. Situation needs and ability to provide inpatient services KCB BV system of
Vietnam.
As defined by the World Health Organization (WHO): "Hospitals are an integral
parts of a social organization and health, its function is comprehensive health care for
people, both prevention and treatment; outpatient services of the hospital to reach out
to the family and living environment. HO is also a center for training health staff and
sociological research. "
1.1.1. Characteristics, roles, functions and duties of hospitals in Vietnam
Vietnam HO Systems has formed and developed over 100 years in the different
conditions of economic, social, political, and had an important contribution in the
protection and health care for people. However, our country HO system also showed
some survival should be overcome as the distribution of hospital beds was not balanced
between the regions; average number of hospital beds per 10,000 population was
low, leading to the overload at the hospital.
Most HOs had a bed capacity utilization was too high (103-120%), in which the
central hospitals line (>120%) and provincial and district HOs were> 110%, the
average of inpatient days was 7-14 days.
* Functions and duties of HO: Hospital was the basis clinical facility had clinical
function and health care for patients. Duties:
- Health Care was the main function, clinical services could be divided into
various categories: diagnosis and treatment, inpatient and outpatient, … in which
inpatient treatment was the most essential function.

- Staff training: HO was the basis for training practice health staff, more
specialized training such as general doctor and specialists, nurses, nursing care,
midwives, medical technicians,… upline hospital was responsible for training and
technology transfer for the downline HO through line direct system.
-Line direct - Support health system: HO System was organized according to
their technical. The service was responsible for the downline technical direction.
In addition, BV also have to perform many important tasks such as scientific
research; Prevention; International Cooperation; Economic Management,
1.1.2. Technical distribution in clinic
Vietnam Hospital System was divided into 3 levels: county / district HO,
provincial/ city HO; central HO.
Clinical and technical distribution of goal-oriented to infrastructure investment
and technical development and clinical decentralization to increase the treatment
efficiency of HO.
- Provincial/ City line: The facility provided services clinic with specialized
technical, professional, meet most people's health care needs in localities provinces.
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- At the district/ county line: The clinical facilities provided inpatient services
with the basic techniques, solving a number of emergencies and common illnesses
from community or from the health stations move up .
1.1.3. Current status of medical services provided to meet the clinical needs of the
people
* Organized providing health care services: The State Hospital played the leading
role in providing inpatient clinical services. Average: 24 patient-beds /10.000 people.
Since 2002, the number of patient beds /10.000 people has tended to increase. Number of
hospital beds in 2010 reached 20.5 beds/10.000 people, higher than the average in low-
income countries (12) and middle-income (16), higher than Indonesia (6), Philippines (13),
Malaysia (18), but lower than Thailand (22) and China (22). The hospital has increased the

availability of clinical services. In 2009, the whole health sector has made more than 2
million surgeries (level 3 or higher), up 8% from 2008. Total number of new clinical
techniques was done in the hospital reached 3062 times (up 27.3%), total number of new
clinical techniques were deployed to reach 2,481 times (up 52.2%).
* Ability to access and clinical service use level of the people: Regarding the
hospitalization, the period 2002-2006, on average, every 100 people with about 9 times to
enter the public HO for inpatient clinic/ year. In two years (2008, 2009), this ratio had
increased to 12 times/100 people. This rate was quite high compared to other countries like
the U.S. (11.7), Canada (7.8), Singapore (9.39) were the countries with older population,
with the incidence of chronic diseases was higher. The rate of hospitalization in the State
HOs of minority ethnics (53.5%) was lower than the Kinh (85.9%).
1.1.4. The challenge for HO in clinical service providing
- Number of HS for clinic is lacking compared to payroll norms and actual
needs. Norms HS in clinical sector were in accordance with Joint Circular No.
08/2007/TTLT-BYT-BNV.
Distribution of HS unevenly between regions and between rural and urban areas,
especially mountainous and remote areas lacked HS drastically, clinical service quality gap
between regions has the distinct difference Health human resources which were not in
sufficient quantity to have unreasonable shift by three trends from disadvantaged areas to
areas with economic conditions - social development. So lack of HS was common
condition in the downline health facilities, especially in rural, regional and remote areas.
- The pattern of disease has been much changed: The model of disease in our
country today alternating between infectious disease and infection.
- Overload exacerbated HO: Currently, the country's number of beds to 17
patient beds /10.000 people, much lower than some countries in the region. The 2-3
patients/1bed situation was common in many provincial hospitals, especially the
central hospital which bed capacity was up to 120-160%
1.2. BV model to participate in training and technology transfer services for
medical facilities KCB lower
1.2.1. On the world

In most developed capitalist countries, HO provided inpatient clinical services
which were private. HOs competed with each other to attract patients to recover capital
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and high profitability. Therefore, the large private HOs prestigious training technology
transfer for the lower HO (small HO) only took place in nature orders the contract "to
buy, sell," but not the mandatory provisions such as in Vietnam. However, private
hospitals had professional training programs and technical support for medical facilities
in the community and directly participate in the activities of community health care.
1.2.2. Model upline hospitals support downline hospitals to improve the quality of
clinic in Vietnam
To overcome the overload situation for upline HO, the Ministry of Health issued
Decision 1816/2008/QD-BYT approving the project " Appoint professional staff
rotation from upline HO to support downline HO to raise the quality of health care
activities "(referred to as project 1816), with 3 objectives: (1) Improving the clinical
quality of the downline HO, especially in mountainous, remote areas lacked health staff
(2) Reducing overcrowding on routes to hospitals, particularly central hospital, (3)
technology transfer and on-site training to improve skills for health staff downline.
The appointment of professional staff rotate from upline hospital to support the
HO downline in order to improve the quality of clinic had an important implications in
the protection, care, improve people's health, proceed to the fairness in health care in
different regions throughout the country and simultaneously training on-site staff
resources in place with professional qualifications meet the needs of local people.
The result in the internal rotation of the provinces/cities: 31/41 provinces had
alternate plans of district support staff, 26/41 had planned to send officials to support the
communal health stations. There were 464 officers turns were sent to support the 186 HO/
General district clinics, 543 officers were sent to support the 452 commune health stations.
1.2.3. Some studies about the rotating support staff for lower to improve clinical
quality

Grobler and colleagues studied "solution to increase the percentage of health
staff working in rural and less health services", in 1996 - 2007 showed the result of the
appointment of medical staff to work in the rural areas.
Henderson and Tulloch (1998-2007), studied "Policies to encourage and retain
health staff in Asian and the Pacific countries". Lehmann and colleagues "Policies to
attract health staff working in rural and remote areas in the low and middle income" in
1997 - 2007, showed rotating staff in developing countries was necessary.
Le Quang Cuong, Vu Thi Minh Hanh and colleagues (2009) made "Research 9
months to implement the proposed solutions to improve the Scheme in 1816", showed
the implementation of Scheme 1816, it needed to have the solution to ensure the
sustainability and effectiveness of the Scheme.

Chapter 2: SUBJECTS AND METHOD

2.1. Subjects, materials, location, study period
2.1.1. Study subjects
- Study subjects: All patients on the inpatient full medical records at two General
Clinics Tan Lac and Kim Boi in 2006 - 2010 (total of 86 381 patient turns). Health staff
group directly involved and provided training services (TR)for improving clinical
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capacity GH of Hoa Binh province. Hospital leaders group, departments, and office
staff, medical personnel were sent for training, technical transfer of the district GH.
2.1.2. Materials Research
- Medical records of all patient were referral, overline from Tan Lac and Kim Boi
GH to Hoa Binh province GH from 2006 - 2010.
- The general reports analyzing data related to clinical activities, training, direct
line of General planning department, Direct line bureau and some offices relevant to
Hoa Binh province GH in the years 2006-2010.

- Reports of inpatient clinic and professional activities of the two GH annually
in 5 years (2006-2010).
2.1.3. Location, time studies
- Location of study: In Hoa Binh province GH and two district GHs Tan Lac and
Kim Boi, Hoa Binh province.
- Research Time: 5-year study. In which: Description study (01/2006-12/2008);
Intervention study (01/2009-12/2010).
2.2. Research Methods
2.2.1. Study Design
Design cross-sectional descriptive study, combining quantitative research with
qualitative analysis of secondary data and intervention studies had compared before
and after intervention (no control group).
2.2.2. The study described the actual need and ability to provide clinical services at
district GH
- Select two GHs districts ( Tan Lac and Kim Boi GH district) with the criterion is
the number of patients and referral rate, overline and referral rates of patients with
different diagnosis with Hoa Binh GH high.
- Key indicators described the status and needs the ability to provide inpatient
services of District GH: Number of clinic in average/1000 people / year; Some
personal characteristics (ethnicity, age, condition economic, health insurance card, ),
PT referral, overline rate, the disease had a high referral rate, the percentage of patients
with differential diagnosis upline and downline; bed use rate; treatment day average;
the rate of implementation techniques in accordance with regulation
2.2.3. Develop a model training of technical transfer in Hoa Binh province GH to
enhance medical capacity for district GH.
* Pursuant to build the model:
- The legal documents related such as: HO Regulation; Decision No. 1816/QD-
MH the Ministry of Health, Decision of the Ministry of Health issued the regulations
of technical distribution and list of medical technique for HOs; Circular of the Ministry
of Health Regulated Health staff to annually attend the training course constantly

- Based on survey results about demand situation on the ability to provide
medical services of two studied district GHs. Training needs of clinical capacity
improvement of two Tan Lac and Kim Boi district GHs. Qualifications and skills to
practice the technical services of the medical staff in two Tan Lac and Kim Boi district
GH; capability of technology transfer training of Hoa Binh province GH
* Model building content: Completing direct line network to manage, operate and
carry out the training activities. Construction training management cycle and the
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specific steps of the training cycle; The contents and training activities of technical
transfer; indicators to assess the effects of model
* The training technology transfer; Focusing on a number of fields such as essential
newborn care, the bone surgery, caesarean section, operating on the surgical pathology of
the uterus, ovaries to improve the quality of emergency and treatment for patients in
district GH. The primary active intervention of the model was the province GH organized
training courses of technical transfer mainly in province GH and a part of the district.
- The Effectiveness access indicators of intervention: measured index that had
investigated the situation (before intervention), before-after comparison, some indexes
was calculated efficiency index. Judged by the results of monitoring, evaluation during
and after training, combining interviews, focus group discussions with the objects
2.2.4. Evaluation of research
* Review of HO professional personnel: As compared with the payroll norms first
line: polyclinic facilities Class III standards prescribed in the Circular No.
08/2007/TTLT-BYT-BNV dated 05/6/2007 of the joint MOH-Ministry of the Interior
Ministry guiding to the payroll in the State health facilities.
* Evaluated the professional activities of the district GH: Evaluation indicators
such as: The bed occupancy rate, average duration of treatment (days), patient referral
rate, overline rate, the percentage of patients with other diagnoses with provincial GH
According to the "Hospital Management" of the Ministry of Health published in

2001. Assess the ability to perform a number of techniques in treatment of district GHs
under the "Decision No. 23/2005/QD-BYT of the Ministry of Health regulating the
distribution of technical and engineering list. Evaluation of treatment results overall,
the results of surgical treatment of bones, caesarean section, operating on the surgical
pathology of the uterus, ovaries and result emergency care for treatment of neonatal
diseases.
Chapter 3: RESEARCH RESULTS

3.1. Situation needs and ability to provide inpatient services of two Tan Lac and
Kim Boi district GHs, Hoa Binh province (2006-2008)
3.1.1. Situation needs of inpatient medical care in two district GHs
Table 3.1. Demand for inpatient medical care of patients at two
Tan Lac and Kim Boi GHs, Hoa Binh province in three years (2006-2008)
Year Index
District
Kim Boi Tan Lac
2006
Population 109958 74549
Total times of inpatient clinic in district GH 7124 6359
Times of inpatient clinic average/100/yea
r
6.5 8.2
2007
Population 111295 75455
Total times of inpatient clinic in district GH 9673 6357
Times of inpatient clinic average/100/yea
r
8.7 8.4
2008
Population 112647 76372

Total times of inpatient clinic in district GH 10777 8859
Times of inpatient clinic average/100/yea
r
9.6 11.6
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Count the times of inpatient clinic average/100/year for 3 years (2006-2008) has
ranged from 6.5 to 9.6 (Kim Boi) and from 8.2 to 11.6 (Tan Lac ).
* Some features of inpatients at two hospitals: Muong ethnic majority (86.42% in
Kim Boi and 78.40% in Tan Lac). Mostly in the working age group, from 16-59 years
(61.0 to 66.90%). Over 50% of patients with health insurance card. Over 70% of poor
patients.

Table 3.6. Referral patients from two hospitals to Hoa Binh provincial GH
in 3 years (2006-2008)
Index
Kim Boi GH Tan Lac GH
2006 2007 2008 TB 2006 2007 2008 TB
Total times of
inpatient clinic
7124 9673 10777 9191 6359 6357 8859 7192
Total times of
referral patients
816 946 1369 1044 232 371 572 392
Percentage (%) of
times patients
with transit
10.28 8.91 11.27 10.20 3.50 5.50 6.07 5.17
Compare rates

(%) referral
patients times (in
comparison with
the previous year)
Reduced
1.37%
(p>0.05)
Increa
sed
0.33%
/ year
Increased
2.0% (p<0,001
Increase
d 1.29%
/ year
Increased
2.36%
(p<0.001)
Increased
0.57%
(p<0.05)
For Kim Boi GH: Rate of referral patient times up to Hoa Binh province GH in 2007
(10.28%) compared with 2006 (8.91) 1.37% decreased (p> 0.05) and 2008 (11 , 27%)
compared with 2007 (8.91%) increased 2.36% (p <0.001). In average increased 2.42%/
year. For Tan Lac GH: The rate of referral patient times up to Hoa Binh province GH in
2007 (5.50%) compared with 2006 (3.50) increased 2.0% (p <0.001) and 2008 (6.07 %)
compared with 2007 (5.50%) increased 0.57% (p <0.05). Increased average 1.29% / year.
Table 3.7. Overline patients of the two hospitals
Index

Kim Boi GH Tan Lac GH
2006 2007 2008 TB 2006 2007 2008 TB
Total inpatient
times had clinic
7124 9673 1077
7
9191 6359 6357 8859 7192
Total times of
p
atient overline
331 510 633 491 276 326 506 369
Percentage (%) of
patient times
overline
4.65 5.27 5.55 5,07 4.16 4.88 5,40 4.88
Comparison of
percentage of
patient times
overline (to the
Increased
0.62%
(p<0.05)

Increased
0.45%
/year
Increased
0.72%
(p<0.05)

Increased
0.62%
/year
Increased Increased
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next- previous
year)
0.28%
(p>0.05)
0.52%
(p>0.05)
* In 12 kinds of disease transited from two district GHs up to province GH, in 3
years (2006-2008): Surgery was the highest percentage (21.02 to 25.79%),
resuscitation (7.51 - 11.40%), neonatal morbidity (7.03 to 11.40%), obstetric pathology
(9.71 to 10.81%), pediatric pathology (9.33 to 9.79% ), general internal diseases (11.27
to 7.91%), ophthalmology disease (6.10 to 6.64%); other diseases below 4%.
* Referral patient were diagnosed in two HO different from Hoa Binh GH: Kim
Boi GH had 298/3131 patient times (9.52%) were diagnosed with a difference. Tan Lac
GH had 103/1175 patient times (8.77%) differential diagnosis. In 2006 both HO had
different diagnostic rate was the highest 19.53% and 12.07%.
3.1.2. Ability to provide medical services of the two districts GH
3.1.2.1. Current status of professional personnel
Table 3.13. The payroll norms under the working hours of
Tan Lac and Kim Boi GH (2007)
District GH Unit
Under working
hours
Circular No. 08/2007/TTLT-

MOH-MI

Kim Bôi
Person/ bed
0,54 1,10-1,20
Tân Lạc 0,59 1,10-1,20
As compared with the payroll norms first line: Polyclinic facilities got Class III
standards prescribed in Circular No. 08/2007/TTLT-MOH-MI of joint MOH-Ministry
of the Interior. The two hospitals only got 50% of the prescribed norms.
Table 3.14. Division rate departments, the professional parts of two HO (2007)
Department
Kim Boi
GH
Tan Lac
GH
Circular No.
08/2007/TTLT-MOH-
MI
Department Structure
Clinic 64.80 75.00 60 - 65%
Subclinical & Pharmaceutical 22.22 11.36 22 - 15%
Management, administrative 12.98 13.64 18 - 20%
Professional Structure
Doctors/Nurses, midwives,
nurses, technicians
1/2.25 1/3 1/3 - 1/3.5
University pharmacists/Docto
r
0/13 1/3 1/8 - 1/15
University pharmacists/

College Pharmacis
t

0/2 1/0.5 1/2 - 1/2.5
- Kim Boi GH structure reached the regulations of Circular 08; Tan Lac GH
structure for clinical high and low for subclinical, pharmaceutical; Management,
administrative structure in two hospitals were lower than the regulations. The ratio of
doctors / nurses, midwives, nurses, technicians of Tan Lac GH structure reached one
third as prescribed. This ratio in Kim Boi GH is 1/2,25. Other indicators did not meet
regulations.
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3.1.2.2. Professional activities of the hospital
Table 3.15. Professional activities of two hospitals in 3 years (2006-2008)
Index
Kim Boi GH Tan Lac GH
2006 2007 2008
X
± SD
2006 2007 2008
X
± SD

No. of beds in
plan
70 100
140 103±35
70 75 85
77±8
Productivity of
using beds (%)
144.2 134.3 106.9
124.6±19.3
151.4 143.6 159.2 151.4±7.8
Total No. of
times inpatient
clinic
7124 9673 10777
9191±1874
6359 6357 8859
7192±1443
Total No. of days
inpatient clinic
36332 48365 53883
46193±8974
31795 38777 48724
39765±8508
Average of
duration
treatment (day)
5.1 5.0 5.0
5.03±0.06
6.0 6.1 5.5 5.9±0.3

Total No. of tests
33572 36721 45243
38512±6038
45362 48974 52187
48841±3414
Total No. of
surgeries
436 512 587 512±76 597 624 679
633±42
Total No. of tips
243 291 285
273±26
219 265 287
257±35
Total No. of
imaging tests
2871 3248 3583
3234±356
3056 3219 3427
3234±186

* Results of treatment in two hospitals in three years (2006-2008): The rate of
recover treatment in two hospitals over 80%; mortality rate is 0.07%.
* Ability to perform technical services in clinical and subclinical basically
classified for district HOs. Kim Boi GH had made 212/289 (73.4%) services; Tan lac
GH had made 221/289 (76.5%) services. Both GHs had full subclinical technique
services in technical distribution.
* Ability to meet the clinical equipment, subclinical equipment served by two
district HOs in distribution of technical: The basic equipment for first aid, internal
treatment, surgery and subclinical in both HOs were sufficient in technical distribution.

Except for the equips supported for essential newborn care at two hospitals were not
available.
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3.2. Develop and evaluate the effectiveness of initial training model of technology
transfer from province HO in order to improve the clinical capacity for district
hospital
3.2.1. Building a model of technology transfer and training of provincial HO to
promote the clinical capacity of district hospitals
* To complete the direct line network to manage, administer and organize the
training activities: Direct line network was set from the Health Department to the
communal health stations. Provincial GH had Direct line Office and its branches;
district GH had a direct line subcommittee.
* Construction training management cycle: Construction Training cycle with 14
specific steps, each step had tools to collect specific information and close to reality.
* Technical training transfer activities: Hoa Binh Province GH had opened the
training courses/ class for doctor, nursing, medical technicians of the two hospitals to
focus on a number of fields such as essential newborn care , the bone surgery,
caesarean section, operating on the surgical pathology of the uterus, ovaries,
resuscitation, anesthesia recovery.
3.2.2. Initially evaluate the effectiveness of the model
Table 3.20. Professional activities of two HOs (before - after intervention)
Index
Average 3
years
(2006-2008)
Average 2
years
(2009-2010)

Comparison the
number of times
(Increased,reduced)
Kim
Boi
Tan
Lac
Kim
Boi
Tan
Lac
Kim
Boi
Tan
Lac
No. of beds in plan
103 77 135 93
Increased Increased
Productivity of using beds
(%)
124.6 143.5 100.0 130.9
Reduced Reduced
Total No. of times
inpatient clinic
9191 7192 10072 8544
Increased 1.1 Increased
1.19
Total No. of days inpatient
clinic
46193 39765 48832 44429

Increased 1.06 Increased
1.12
Average of duration
treatment (day)
5.03 5.5 4.8 5.2 Reduced 0.23
Reduced
0.3
Total No. of tests
38512 48841 39523 50472
Increased 1.03 Increased
1.03
Total No. of surgeries
512 633 654 777
Increased 1.3 Increased
1.23
Total No. of tips
273 257 326 292
Increased 1.2 Increased
1.14
Total No. of imaging tests
3234 3234 6313 9246
Increased 2.0 Increased
2.86
Table 3.21. Referral patients from two hospitals to Hoa Binh province HO
Index
Average 3
years
(2006-2008)
Average 2 years
(2009-2010)

Comparison of
times
(Increased,Reduced)
Kim
Boi
Tan
Lac
Kim
Boi
Tan
Lac
Kim
Boi
Tan
Lac
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(1) (2) (3) (4)
Total No. of times
inpatient
9191 7192 10072 8544 Increased
1.10
Increased
1.19
Total No. of times
referral patient
1044 392 528 376
Reduced
2.0

Reduced
1.04
Percentage (%) of times
referral patient
10.2 5.17 5.24 4.40 Reduced
1.95
Reduced
1.18
Comparison of rate (%)
referral patient times
Reduced
4.96%
Reduced
0.77%

Total patients on referral from 2 BV BVDK Hoa Binh reduced 2.0 times and 1.04
times. Patient referral rate of 2 BV decreased 4.96% (p1-3 <0.001; EIT = 48.63%) and
0.77% (p (2-4) <0.01; EIT = 14.89% ).
Table 3.22. Rate of some diseases referred from Kim Boi GH to Hoa Binh province GH
(before - after intervention)
Clinical disease
Average 3 years
(2006-2008)
Average 2 years
(2009-2010)
P
(EI %)
Reduction
level
PT Inferral PT Inferral

Emergency&intensive
care (%)
255
(100.0)
78
(30.59)
279
(100.0)
58
(20.79)
<0.001
(32.05)
1.3 times
Obstetrics
(%)
918
(100.0)
101
(11.0)
1007
(100.0)
78q
(7.75)
<0.01
(29.54)
1.3 times
Paediatrics (%) 3098
(100.0
97
(3.13)

3395
(100.0)
72
(2.12)
<0.001
(32.26)
1.3 times
Neonatal diseases
(%)
73
(100.0)
73
(100.0)
80
(100.0)
14
(17.50)
<0.001
(82.50)
5.2 times
Emergency & Intensive care reduced 1.3 times (p <0.001; EIT = 32.05%);
Obstetrics decreased 1.3 time (p <0.01; EI = 29.54%). Paediatrics decreased 1,3 time (p
<0.001; EIT = 32.26%); Neonatal decreased 5.2 times (p <0.001; EIT = 82.50%).
Table 3.23. Rate of some diseases referral from Tan Lac GH to Hoa Binh province GH
(before - after intervention)
Clinical disease
Average 3 years
(2006-2008)
Average 2 years
(2009-2010)

P
(EI %)
Reductio
n level
PT Refered PT Refered
Emergency&Intensiv
e care (%)
200
(100.0)
45
(22.5)
236
(100.0)
29
(12.29)
<0.001
(45.38)
1.6 times
Obstetrics
(%)
216
(100.0)
42
(19.4)
257
(100.0)
29
(11.28)
<0.001
(41.86)

1.4 times
Paediatrics
(%)
2163
(100.0
38
(1.76)
2569
(100.0)
32
(1.25)
<0.01
(28.98)
1.2 times
Neonatal
(%)
45
(100.0)
45
(100.0)
53
(100.0)
7
(13.20)
<0.001
(86.80)
6.4 times
The rate of referral average 2 years (2009-2010) compared with average 3 years
(2006-2008):-Emergency & Intensive Care reduced 1.6 times (p<0.001; EIT =
45.38%); Obstetrics reduced 1.4 times (p <0.001; EIT = 41.86%); Paediatrics

12


decreased 1.2 times (p<0.01; EIT = 28.98%); Neonatal decreased 6.4 times (p <0.001;
EIT = 86.80%).
* Referral patients from two Hoa Binh province GHs:
After intervention: Total No. of times that referral patient from Tan Lac and Kim
Boi GH to Hoa Binh province GH in average of 2 years (2009-2010) decreased1.6
times and 1.3 times compared to an average of 3 years (2006-2008). The rate of PT
oveline in Tan Lac and Kim Boi GH decreased 2,1 % (p1-3 <0.001; EIT = 39.64%)
and 1.58% (p (2-4) <0.001; EIT = 32, 38%).




Table 3.25. Differential diagnosis of two GHs compared to Hoa Binh province GH
(Before - after intervention)
Index
Average 3
years
(2006-2008)
Average 2
years
(2009-2010)
Reduction
level
Kim
Boi
(1)
Tan

Lac
(2)
Kim
Boi
(3)
Tan
Lac
(4)
Kim
Boi
Tan
Lac
Total No. of times
referral patient
1.044 392 528 376

Total No. of times that
patient had different
diagnosis
298 103 84 39
3.55
times
2.15
times
Percentage (%) of
times That PT had
different diagnosis
28.54 26.28 16.03 10.37 1.78
lần
2.53

times
Comparison of the rate
No. of times patients
had different diagnosis
Decrease
d
12.51%
Decreased
15.91%

After intervention: Percentage of patients with differential diagnosis of Tan
Lac and Kim Boi GH in comparison with province GH reduced 12.51% (EIT =
43.83%) and 15.91% (EIT = 60.54%).
Table 3.26. Results of treatment and mortality in two hospitals
(before - after intervention)
Treatment result
Kim Boi GH Tan Lac GH
BI
(2006-
2008)
AI
(2009-
2010)
P
BI
(2006-
2008)
AI
(2009-
2010)

p
Total No. of inpatients
(%)
27574
(100)
20145
(100)
21575
(100)
17087
(100)

Recove
r
22263 17602 17702 15171
13


(%) (82.0) (87.38) <0,05 (82.0) (88.78) <0.05
Better
(%)
1922
(6.98)
1352
(6.71)
2520
(11.7)
1067
(6.25)

<0.01
Refer province GH
(%)
3131
(11.35)
1057
(5.25)

<0,01
1.175
(5.40)
752
(4.40)

<0.05
Worse
(%)
238
(0.86)
123
(0.61)

<0,05
162
(0.75)
91
(053)

<0.05
Mortality

(%)
20
(0.07)
11
(0.05)

<0,05
16
(0.07)
6
(004)

<0.05
The rate of patients treated: Kim Boi GH, from 82.0% BI has increased 87.38%
AI increased (p <0.05). Tan Lac GH, from 82.0% (BI) has increased to 88.78% (AI),
the difference was statistically significant (p <0.05).


* Results of treatment of certain specific diseases in both two HO (before - after
intervention):
Table 3.28. The results of trauma operations of the two hospital
Surgical Results
Kim Bôi GH Tân Lạc GH
BI
(2006-
2008)
AI
(2009-
2010)
P

BI
(2006-
2008)
AI
(2009-
2010)
p
Trauma patients with upper limb
fractures and lower limb indicated
the bone surgery (%)
185
(100)
137
(100)

257
(100)
168
(100)

-Open the bones (nail, screw bands)
(%)
0

123
(89.78)

-
0 157
(93.45)

-
+ Recovery
(%)
123
(100.0)

-

157
(100.0)

-
+ Implication 0

0

+ Mortality 0

0

- Refer to province GH
(%)
185
(100)
14
(10.22)

<0.05
257

(100)
11
(6.55)

<0.05
Before the intervention, both hospitals were not able to open the bone. After
intervention training delivery techniques, two hospitals had surgery the bone was from
89.78 to 93.45% of the patients limb fractures or lower limb, with no complications
and death.
Table 3.29. Result of some obstetric surgeries in two hospitals
(before - after intervention)
Surgical Result
Kim Bôi GH Tân Lạc GH
(2006-
2008)
(2009-
2010)
EI
(%), p
(2006-
2008)
(2009-
2010)
EI
(%), p
1. Women had caesarean
section indicated (%)
754
(100)
492

(100)
825
(100)
548
(100)

- Caesarean section (for foetus)
(%)
572
(75.86)
492
(100.0)
31.82
<0.05
608
(73.70)
548
(100)
35.68
<0.05
+ Recover 565 492

604 548

14


(%) (98.78) (100.0) >0.05 (99.34) (100) >0.05
+ Implication
(%)

7
(1.22)
0

-
4
(0.66)
0

-
+ Mortality 0 0

0 0

- Refer to province GH
(%)
182
(24.14)
0


-
217
(26.30)
0
-
2. Patients with surgical diseases
of the uterus, ovaries (%)
568
(100)

387
(100)
861
(100)
568
(100)

- Surgery for lumpectomy
(%)
154
(27.11)
387
(100,0)
268.87
<0.05
273
(31.71)
568
(100.0)
215.36
<0.05
+ Recover
(%)
153
(99.35)
387
(100.0)

>0.05
271

(99.27)
568
(100.0)

>0.05
+Implication
(%)
1
(0.65)
0
-
2
(0.73)
0
-
+ Mortality 0 0

0 0

- Refer to province GH
(%)
414
(72.89)
0


-
588
(68.29)
0

-
- The caesarean section: Before intervention, surgery in two hospitals only had
caesarean section of 73.70 - 75.86% of the cases were indicated, the recovery rate
reached from 98.78 - 99.34%, complication rate from 0.66 - 1.22%. After intervention,
in both HOs caesarean section of 100% of the cases were indicated and the percentage
recovery was 100%, no complications, EIT reached from 31.82 - 35.68%, p <0.05.
- The surgical ovarian cysts, uterine fibroids : Before the intervention, surgery
in two HOs only reached from 27.11 - 31.71% of the cases were indicated, the rate
reached from 99.27- 99, 35% complication rate from 0.65 - 0.73%. After intervention,
both two HOs had caesarean section of 100% of the cases were indicated and the
percentage recovery was 100%, no complications, EIT was from 215.36 - 268.87%,
p<0.05.
Table 3.32. Practical skills and some technical services of the neonatal intensive care
of doctors, nurses (before - after training)
Practical Skills
Ability to implement level
Adjust
ment
level
Befor training
(n=23)
After training
(n=23)
A B C A B C
Technical neonatal suction
phlegm (%)
0 9
(39.1)

14
(60.9)
23
(100)
0

0

Better

Techniques of endotracheal
suctioning (%)
0 7
(30.4)
16
(69.6)
21
(91.3)
2
(8.7)
0

Better

Technique for CPAP patients
ventilated (%)
0

0

23
(100)
22
(95.7)
1
(4,3)
0

New,
better
Technical phototherapy in the
treatment of neonatal jaundice (%)
0

6
(26.1)
17
(73.9)
23
(100)
0

0

New,
better
Capillary blood sampling
technique infants (%)
0 0

23
(100)
20
(87.0)
3
(13.0)
0

New,
better
Intravenous injection techniques
infants (%)
0 2
(8.7)
21
(91,3)
20
(87.0)
3
(13.0)
0

New,
better
15


Intramuscular injection technique
for infants (%)
0 11

(47.8)
12
(52.2)
23
(100)
0

0

New,
b
ette
r
Process put in the umbilical vein
(%)
0
3
(13.0)
20
(87.0)
20
(87.0)
3
(13.0)
0

New,
b
ette
r

Techniques for infants fed by tube
(%)
0
2
(8.7)
21
(91.3)
21
(91.3)
2
(8.7)
0

New,
b
ette
r
Process eye, skin, umbilical cord
care for infants (%)
0
12
(52.2)
11
(47.8)
23
(100)
0

0

New,
better
Techniques used infant incubators
(%)
0
5
(21.7)
18
(78.3)
23
(100)
0

0

New,
b
ette
r
- Before training, ability to perform reach level A was 0/23 (0%), reaching level
B from 0-52.2%, the level C from 47.8- 100%.
- After training, reaching level A from 87.0 -100%, the level B from 0- 13.0%,
and level C was 0%. Thus, the level A increased from 0% to 87-100%, level B
decreased from 13.0 - 0% and levels C decreased to 0%.


Table 3:33. Results of treatment of some neonatal diseases of Kim Boi GH
(Before - after intervention)
Disease
Year

(2006 – 2008)
Year
(2009 – 2010)
P
2-5
Total
diseases
(1)
Refer to
Province
GH (2)
Total
diseases
(3)
Recover

(4)
Refer to
Province
GH (5)
Preterm neonates
(%)
139
(100.0)
139
(100.0)
58
(100.0)
41
(70.70

17
(29.3)

<0.01
Jaundice due to
increased
Bilirubin
(%)
35
(100.0)
35
(100.0)
16
(100.0)
11
(68.8)
5
(31.2)

<0.01
After birth
asphyxia (%)
28
(100.0)
28
(100.0)
12
(100.0)
10
(83.3)

2
(16.7)

<0.01
Pneumonia
(%)
18
(100.0)
18
(100.0)
8
(100.0)
4
(50.0)
4
(50.0)

<0.05
Total:
(%)
220
(100.0)
220
(100.0)
94
(100.0)
66
(70.2)
28
(29.8)

<0.01
Table 3:34. Results of treatment of some neonatal diseases inTan Lac GH
(Before - after intervention)
Disease
Year
(2006 – 2008)
Year
(2009 – 2010)
P
2-5
Total
diseases
(1)
Refer to
Province
GH (2)
Total
diseases
(3)
Recover

(4)
Refer to
Province
GH (5)
Preterm neonates
(%)
82
(100.0)

82
(100.0)
39
(100.0)
32
(82.0)
7
(18.0)

<0.01
16


Jaundice due to
increased Bilirubin
(%)
23
(100.0)
23
(100.0)
14
(100.0)
10
(71.4)
4
(28.6)

<0.01
After birth asphyxia
(%)

18
(100.0)
18
(100.0)
9
(100.0)
8
(88.9)
1
(11.1)

<0.01
Pneumonia
(%)
11
(100.0)
11
(100.0)
5
(100.0)
3
(60.0)
2
(40.0)

<0.01
Total:
(%)
134
(100.0)

134
(100.0)
67
(100.0)
53
(79.0)
14
(21.0)

<0.01
Table 3:33 and 3:34 showed:
- For Kim Boi GH: Before intervention (2006-2008), collected 220 infants
suffering from diseases such as weakness of prematurity, jaundice due to
hyperbilirubinemia, asphyxia after birth only preliminary emergency then transferred
all (100%) to province GH. After intervention (2009-2010), earning 94 newborns with
diseases as above, had treated 66 children (70.2%), number of children referring up to
province GH was 28 (29.8%). The difference between the two transit rate was
statistically significant (p <0.01).
- For Tan Lac GH: Before intervention (2006-2008), collected 134 infants
suffering from diseases such as in Kim Boi GH and only preliminary emergency and
then move the entire (100%) to province GH. After intervention (2009-2010), earned
67 newborns with diseases as above, had treated 53 children (79%), number of children
turning up province GH was 14 (21%). The difference between the two transit rate was
statistically significant (p <0.01).
Table 3:35. Assessment regulations and skills essential newborn care
Criteria
Kim Boi GH Tan Lac GH
Before
training
After training

Before
training
After training
Regulations on
referral
Not Good Good Not Good Good
The number of
infants in
A few/ no one
Average 10 - 12
infants/month
A few/no one
Average 8 - 10
infants/month
Treating disease
Dermatitis,
umbilical
infection
Respiratory
failure,
pneumonia,
jaundice,
prematurity
Dermatitis,
umbilical
infection
Respiratory
failure,
pneumonia,
jaundice,

prematurity
Quality of
treatment (using
the standard
regimen)
Not Good Rather good Not Good Rather good
No. of referral Many (all) A few Many (all) A few
Regulation
pregnant room
Not Good Good Not Good Good
Tools, drugs Not Enough Enough, good Not enough Enough, good
Supply tools Not Good Good Not Good Good
Neonatal Yes (not good) Rather good Yes (not Rather good
17


resuscitation skills
in the room to
suffocation
good)
Respiratory
emergency
neonatal CPAP
No Rather good No Rather good
Using incubators No Good No Good
Care and treatment
of jaundice
hyperbilirubinemia
free
No Good No Good

Neonatal medical
record
Not Good Good Not Good Good
Documents
essential newborn
care
No Yes No Yes
To the compliance of the regulations and skills essential newborn care: In both
HOs before intervention almost was not good, did not perform well or not well, so
there is no neonatal patients in district GH. After intervention, the compliance of
regulations and skills essential newborn care was done rather good and sufficient, so
that every month more than 10 newborns hospitalized the district GH for emergency
care and treatment.
Box 4
: Results Discussion of Group doctors and nurses that were Heads of Clinical
Department of Kim Boi district GH:
«In the past, when meeting with neonatal emergencies such as neonatal respiratory
failure, cerebral hemorrhage, septicemia, skin infections, cord infection, eye infections,
pneumonia, jaundice, loud milk, both physicians and nurses were confused fear,
even if they only escorted the emergency cases sent to provincial GH they were still
fear and lack of confidence in transit The tracking and prediction of disease
condition, especially the case infant patients and severe neonatal diseases of the doctors
and nurses would be extremely difficult and stressful, or who needed to make a number
of techniques such as emergency birth: intravenous injection procedure peripheral
vessels (umbilical vein set cathette, blood arterial, blood heels and put intubation tube,
set sonde of stomatch ). After the expert team (physicians, technicians, nurses) were
trained technical transfer from Hoa Binh Province GH, most pathological cases were
in-aid treatment, good treatment at our hospital.
Box 5: Results Discussion of group leaders of Tan Lac GH:
«In the past, without provinces GH training to improve professional capability,

techniques such as intensive care anesthetist could not set intubation tube and did not
know spinal anesthesia After the training, intensive care anesthesiologist put intubation
tube technical, spinal anesthesia as expertise». «Previously, HO had to transfer all infants
on emergency to Hoa Binh province GH (about 50 children / year) and also moved with
wrong position. After the physician and nurse team had training course about neonatal
care in Hoa Binh province GH, they were almost entirely successful with neonatal
emergency, only transferred the babies weight from 1.3 kg or less, babies from 1.5 kg or
more were kept for treatment with very good results and no mortality ».
18


Chapter 4: DISCUSSION

4.1. On the status of demand and the ability to provide inpatient clinical services
of two Tan Lac and Kim Boi district GHs (2006 - 2008)
4.1.1. Situation of medical inpatients need at two GH in Tan Lac and Kim Boi.
The results of our study showed that: in Kim Boi GH, total hospitalized patients
in 2007 compared with 2006 increased by 35.8%; in 2008 compared to 2007 increased
by 11.4%. In Tan Lac GH, total inpatient patients in 2008 compared with 2006 and
2007 increased by 39.3%. Report of the Ministry of Health showed that total number of
inpatient patients of 614 district HOs in 2008 compared to 2006 increased by 36.8%.
* Regarding the number of patients hospitalized at the district HO compared to
the population:
Our result showed that the average number of inpatient patients/100people/year
for 3 years (2006-2008) has tended to increase gradually, from 6.5%; 8.7%; 9.6 % in
Kim Boi GH and from 8.2%; 8.4%; 11.6% at Tan Lac GH.
Report of the Ministry of Health showed that situation-patient hospitalization of
people (2002-2006), average 9 times in public HO/100 people (9%) to hospitalize/year.
In two years (2008, 2009), this ratio increased to 12%. This rate is quite high compared
to other countries in the world, including developed countries like the US (11.7%),

Canada (7.8%), Singapore (9.39% ).
Studies of the Thai Nguyen Medical University showed that the average number
of patients with hospitalization/100 people / year (at the district HO in 2005) of Bac
Kan province was 6.7%, Lai Chau province was 7.8 %, Son La province was 5.7%.
* On some characteristics of patients at two district HOs study found: Most of the
Muong ethnic people (78.4 - 86.42%), the working age (61.0 to 66.90 %), age group of
children (aged 15 and under) accounted for 30.7 - 34.5%; Health insurance card (54.14
- 57.02%; of poor people section (73.2-75%). At time of the study, in Kim Boi district
nearly 100% and Tan Lac district nearly 25% of the population were benefiting from
Decision 139 of Prime Minister of health care for the poor, made the poor people had
more favorable conditions for access to inpatient services in district GH.
Studies of the Thai Nguyen Medical University '' Assessing on the
implementation policy health care for the poor in northern mountainous'' in 2007
showed that patients turn rate at district HO of Son La province, Lai Chau, Lao Cai, Ha
Giang, Bac Kan, Yen Bai average was 43.7% (2003) to 53.7% (2005), of which only
about 20% of these patients were poor.
- Percentage of times patients referred from Kim Boi GH and Tan Lac GH to
Hoa Binh province GH had tended to increase over time, in 2007 compared to 2006
had increased 1.58% and 2.0% (p <0.01 ), 2008 compared to 2007 increased by 3.25%
and 0.57% respectively(p <0.05).
- Percentage of times overline patients from Tan Lac and Kim Boi GH to Hoa
Binh province GH in 3 years (2006-2008) was 5.07% and 4.88% and tended higher
year after year.
19


A study by Dao Van Dung showed that the percentage of leave line and over line
were high, averaging 10-20%, only about 80% of patients seeked medical strictly right
line, This was one of the causes of overload the upline HO (provincial and central
line HO).

Thus, referral line rate, overline rate from Tan Lac and Kim Boi district GH up to
Hoa Binh province GH similar to the general situation of the country. Some reasons for
the referral status of patients and exceeded the high line and tends to increase as the
demand for health care of people increasingly high; accessibility of people to hospitals
on improved routes, the hospital charges between the various lines are not much,
quality of health services in downline had not been believed by the people.
- In 3 years (2006-2008), Tan Lac and Kim Boi district GH had 298/3131 (9.52%) and
103/1175 (8.77%) respectively referral patients with different diagnosis of Hoa Binh
province GH. By that time, the proportion of patients in both transit district GHs
diagnosis different from province GHs tended to reduce but still high proportion.
Differential diagnosis on the same patient presented professional level of
diagnosis and treatment by a physician upline and downline, and also reveal the
difference of the concept, schools of disease between clinical physicians together.
However, in Vietnam the diagnostic process, treatment of each clinical pathology had
been regulated consistency and clarity by the Ministry of Health. Therefore, if the rate
differential diagnosis with other line was high, first to consider the qualifications,
competence diagnosis and treatment of lower levels and between the two lines.
4.1.2. Regarding the ability to provide medical services for inpatients of two Tan Lac
and Kim Boi district GHs
* Current status of the number and qualifications of medical human resources :
- Kim Boi district HO in 2007 with 54 employees, of which doctors the most
(1DLI internal medicine, 12 GD and 15 physicians), 9 technical officers, 4 college
nurses, 2 college midwives, 2 college pharmacists, 1 druggist, 1 traditional physician
and 7 other components . Tan Lac district GH in 2007 had 44 employees, including:
doctor, physician, most college nurse (1DLI internal medicine, 5 general doctor, 16
physicians and 12 college nurses), 2 pharmacists, 2 college midwives, 2 technical
officers, 1 traditional physician and 8 other components.
The above results showed that the quantity and qualifications of both hospitals,
compared with the payroll norms of Polyclinic class III standards stipulated in the
Circular dated 05 08/2007/TTLT-MOH-IM/ 6/2007 of the joint MOH-Ministry of the

Interior guiding to the payroll in the state health facilities [30] showed that the two
hospitals only 50% of the prescribed level.
* Current status of professional activities of the two Tan Lac and Kim Boi GHs
- Capacity of beds used on average for 3 years (2006-2008) was 124.6% (Kim
Boi GH) and 143.5% (Tan Lac GH). The average duration of treatment for a patient is
5.03 days (Kim Boi GH) and 5.5 days (Tan Lac GH). Total number of tests, surgeries,
tips and diagnostic imaging tests increased year over year.
- A basic indicator to assess the availability of clinical services was the average
inpatient hospital beds per 10,000 people (excluding the bed kept at communal health
stations/ ward). Since 2002, the number of hospital beds per 10,000 people has tended
20


to increase, from 16beds/10.000 people in 2002 to 20 beds/10.000 people/ in 2008. By
2010, the number of hospital beds reached 20,5 beds/10.000 people , higher than the
average of low-income (12) and middle-income countries(16), higher than Indonesia
(6), Philippines (13), Malaysia (18), but lower than Thailand (22) and China (22).
- The index tests, surgery, tips and diagnostic imaging tests at the hospital: At two
Tan Lac and Kim Boi GH in 3 years (2006-2008), all of these indicators were shown in
the increase than the previous year expressed in the medical demand for the people
tended to rise very clearly, this was also consistent with the general data of the
hospitals in the whole country.
- The treatment results and mortality in Tan Lac and Kim Boi GH in 3 years
(2006-2008): Percentage of treated group of children <6 years and children aged 6-15
age group with highest proportion (85%) from the 16-59 age group (80% &82%) from
60 and older group (58.04% & 55.04%). Mortality, only in 2 groups, >60 years group
and children <6 years group (0.4% and 0.58%). Treatment outcome and mortality
reflects the quality of hospital clinic services in aspect ratio recovery treatment, better,
worsen, hospital transfer and mortality during treatment. However, there are many
other criteria as comprehensive patient care, diet control,

* The ability to provide medical technical services of Tan Lac and Kim Boi district GH
According to Decision No. 23/2005/D-MOH by the Ministry of Health dated
30/08/2005 regulating the distribution of engineering and technical categories for every
lines treatment. The results of our study showed ability to provide some clinic technical
services was limited such as resuscitation techniques and anti-toxic: 61.29 -64.50% of
technical provisions was done; Anesthesiology (67.44%); Surgery (77.6 - 84.50%);
Obstetrics (84.3%), Paediatrics (60.4 to 62.5%).
4.2. Develop and evaluate the effectiveness of initial training model of technology
transfer of the province GH to improve clinical capacity for district hospital
In Vietnam, the issue of patient overload in province/ city hospitals especially the
central hospital was a hot issue for many years, became the focus of the entire society
and also caused many troubles burning for patients and family members when patients
used the hospital clinic services. To overcome the overload of patients to hospitals at
provincial/ municipal and central level, on 05.26.2008 the Minister of Health issued the
Decision No. 1816/2008/D-MOH approving the project "Professional staff rotate from
upline hospitals to support downline hospitals to improve quality healthcare "(referred
to as Project 1816), with 3 objectives: (1) - Improved clinical quality in lower line HO,
especially in mountainous and remote areas lacking medical staff, (2) - Reduce
overcrowding for upline hospitals, especially the central level HO and (3) - Technology
transfer and training in-site to improve skills of downline health staff.
The appointment of professional staff rotate from upline hospital to support downline
HO in order to improve the clinic quality had an important meaning in the protection,
care, improve people's health, then proceed to the public fairly in the work of health
care by people in different regions throughout the country; simultaneously to train local
staff have professional clinical qualifications to meet the needs of local people. This
was a very sound policy and timeliness of the Ministry of Health in the current
situation. We found that the professional staff rotate appointed from the Central
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Hospital to support provincial HO/ city was well-suited, however, if applied this
method to appoint professional staff rotation from provincial GH to support district GH
would be very difficult to deploy on the wide range, as in a province with many district
hospitals in the state of similar lack of manpower, lack of expertise and limited
resources institutional quality
From the actual situation of Hoa Binh province GH, the payroll professional staff
limitations, qualifications and professional competence has been uneven, if in the same
election time professional staff rotating down all 11 district HOs to support
professional (job training in-site kind of practice only) there was not enough staff and
more specialized activities of the provincial hospital would be delayed and there was
not even staff remain to receive technology transfer from academic staff rotation of the
central hospital. Therefore, we propose model province GHs should organize classes,
training courses of technology transfer for the professional staff at district GH right in
Hoa Binh province GH.
4.2.1. On the building of a training model of technology from province GH transfer
to improve the medical capacity of district hospitals
4.2.1.1. Complete network of Direct lines
One of the main tasks of the Directing line (DL) was the training activity for
lower line. Before implementing the research activities, General Plan Office of Hoa
Binh province GH was in charge of referrals and training. With the consent of the
Health Department of Hoa Binh province, a network of direct line of Hoa Binh
province has been established. Direct Line Network included all levels, from the Health
Department to the communal health stations. Network system of the Direct Line
included: (1) Department of DL and (2) Branch DL in Hoa Binh province (3) Sub-
Committee DL in the district GH. Department of DL of Hoa Binh province GH
managed all the training courses of HO that carried out follow the steps in the order
management cycle training.
4.2.1.2. On construction the training management cycle
Training management cycle in our model was built based on the principles of
general management "Survey - Planning - Implementation - Evaluation." Training

management cycle was to build 14 concrete steps
4.2.2. On the results of training activities improving medical capacity for Tan Lac
and Kim Boi district GH
Primarily intervention of the model was the province GH organized training
courses about technology transfer for the two health staff of Tan Lac and Kim Boi
district GH as required to improve clinical capacity of each district GH.
The result of intervention activities on technology transfer and training of the
model showed that there were two forms of organization model: The first mode was an
training organization to technical transfer for district GH in Hoa Binh Province GH had
many beneficial conditions: although the diseases in province GH were variety,
equipment conditions were available, technical service for training courses were quite
adequate, modern, uniform, stable; students practiced techniques daily in the clinical
departments, besides class time and during working hours, students could practice in
clinical departments, non-working hours, students to do their duty directly in the
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clinical departments and had opportunities to exchange with all officers and employees
of the department. The second mode was that the professional staff appointed by the
provincial GH rotating support for the district GH to improve the clinical quality.
4.2.3. On initial evaluation of the model
After intervention, initially some indicators of the professional activities of
district GH have improved in the direction of better and more positive, in particular:
- Average duration of treatment (day)/ 1PT fell from 0.23 to 0.3 day, other
indicators such as total number of inpatient days, total number of tests, total surgeries,
tips, total imaging tests increased from 1.03 times (lowest) to 2.86 times (highest).
- The patient referral: Average 2 years (2009-2010), total patient referrals from 2
distric GHs to Hoa Binh GH reduced from 2.0 to 1.04 times. Patient referral rate of Tan
Lac and Kim Boi GH decreased 4.96%. Our results equivalent to the statement of Ha
Nam Province GH, in two years (2008 and 2009) HO appointed 19 doctor times

support and technology transfer for 6 district hospital with the method " learning by
doing "and direct examination, treatment, surgery patients, resulting in a referral rate of
patients of six district hospitals decreased by 4%.
- For patients over line: Total times overline patient from Tan Lac and Kim Boi
GH to Hoa Binh province GH in average of 2 years (2009-2010) decreased 1, 6 times
and 1.3 times compared to an average of 3 years (2006-2008). In general, patients
overline for many reasons as objective and subjective: Epidemic diseases, mental
attitude of service, qualifications and ability to provide hospital services to meet
people's needs , health insurance ceiling, the propagation direction, etc. but, we
believed that the professional qualifications of health staff and service providers ‘s
ability of HO were fundamental factor and very important.
- The differential diagnosis between the two distric GH and Hoa Binh GH: results
of our study showed that patients with total differential diagnosis in Tan Lac and Kim
Boi GH, Hoa Binh province GH in average 2 years (2009-2010) decreased 3.55 times
and 2.15 times compared to an average of 3 years (2006-2008). The rate of patients with
differential diagnosis in Tan Lac and Kim Boi GH with provincial GH reduced 12.51%
(p1-3 <0.001; EIT = 43.83%) and 15.91% (p (2-4) < 0.001; EIT = 60.54%). In the report
on the health status of Vietnam Ministry of Health in 2007 showed that the quality of
professional activities of the HO, in 2001, only 64% of patient referrals from provincial
hospital or district hospital to central HO and only 51% of patients referrals from district
hospitals to provincial hospitals were diagnosed correctly from the lower line.
- Neonatal care filed was markedly improved the most:
+ For Kim Boi GH: Before intervention (2006-2008), collected 220 infants
suffering from diseases such as weakness of prematurity, jaundice due to
hyperbilirubinemia, asphyxia after birth only preliminary emergency then transferred
all (100%) to province GH. After intervention (2009-2010), earning 94 newborns with
diseases as above, has treated 66 children (70.2%), number of children turning up
province HO was 28 (29.8%). The difference between the two transit rate was
statistically significant (p <0.01).
+ For Tan Lac GH: Before intervention (2006-2008), collected 134 infants

suffering from diseases like in Kim Boi GH and only preliminary emergency and then