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Thesis Summary COMMUNITY-BASED EVIDENCE ABOUT THE HEALTH CARE SYSTEM IN RURAL VIETNAM This thesis contributes further evidence for policy-making on health care system reform in Vietnam. The author aims to provide insights into the provincial rural health system ten years after health sector reform was launched, through assessing availability of health care services, patterns of access of health care services when people are ill, and the costs of care and the performance of public and private providers. The following questions are addressed: 1. Which health care providers, i.e., public or private, are dominant in providing curative services to rural people when they are ill? 2. How much inequality exists between the poor and the non-poor in access to health care services in general, and public health care services in particular, when they are ill? Which factors explain the gap in use of services between the poor and the non-poor? 3. What policy and strategies should Vietnam consider implementing in order to reach the goals of better equity and quality of care for rural populations? These research questions were addressed using community-based survey data collected in 2001 from Hung Yen province, in which three components of the system -- user, provider, and community context -- are described and linked together in analysis. In addition, a supplementary health care provider survey collected in 1999 in three other provinces (Thai Binh, Binh Thuan, An Giang) is used to provide evidence about the availability of healthcare services in general and of private health care providers. The thesis is divided into two parts with a total of 9 chapters. Part A (chapters 1-4) provides background for the research questions raised about the commune health care system in rural Vietnam, the framework used in evaluating this health care system, and the data sources used in this thesis. Part B consists of five chapters (chapters 5-9) that presents research results on various dimensions of the rural health care system. It also provides conclusions on the health care system in rural Vietnam, and proposes policies and strategies for strengthening this system toward equity and efficiency. Chapter 1 presents the research rationale and objectives. It examine the international context of health sytem research, the Vietnamese context of health sector reform since the ?Doi Moi?, and the current trend of health sector reform, and the previous research done so far related to health system reform in Vietnam. The research questions addressed by the thesis are presented at the end of this chapter. Chapter 2 describes the historical development of rural health care system in Vietnam. It startes with an overview of social changes in the rural Vietnam including revolution and wars and both the positive and negative impacts on the health of rural populations. The evolution of the rural health care system is then outlined, from the single national provider system (public) to the reforms of 1989 where a public-private model for rural health care was introduced. Chapter 3 provides frameworks for analysis of availability, health accessibility, quality and efficiency of the rural health care system, and inequality of healthcare service utilization. It starts with a statement about the concept of health care system used in this thesis. Then five theoretical models for assessing the health care systems (health service utilization model, triangular model, model for improve quality of care, health care services as an open system, and the World Bank?s framework for assessing the performance of the health sector in serving the poor) are presented. The strategy of using these frameworks to assess the rural health system in Vietnam is explained. The link between the research questions and methodology used was described. Chapter 4 provides detailed descriptions of the two data sources and analysis strategies used to address the thesis research questions. The design and data collection methods of the health care provider surveys and household surveys in the four provinces are presented, followed by the specific strategy of using information from each database for the thesis objectives. The chapter ends with a presentation of the overall strategy of data analysis. Chapter 5 assesses availability of the commune health care system in rural areas of Vietnam with empirical data from all the four provinces. The findings show that both public and private health care providers are available in rural Vietnam, with a slight dominance of private services. There were commune health centers (CHCs) in all communes with at least one private physician in the majority of the communes. The average number of private providers ranged from 2.7 to 7.7 per 10,000 population in the four provinces. Many of them practiced without formal registration and under limited government supervision. Chapter 6 estimates perceived need of care by measuring the burden of non-fatal health problems with data from 3,498 people of 900 households randomly selected in Hung Yen province. Compared to the better off, the poor suffered significantly more long-term health ailments (an excess of 78 cases per thousand population) and more short-term morbidity (an excess of 112 cases per thousand population). The study found that the gap in household wealth index contributed approximately 55% of the explained gap in prevalence of long-term health conditions, equivalent to the gap of 60 cases per thousand population, and also 55% of the explained gap in short-term morbidity, equivalent to the gap of 38 cases per thousand population between the two groups based on the Oaxaca decomposition (D=0). Gaps in education, gender, health insurance, and occupation played a minor role in explaining the wealth-related inequalities in non-fatal health burden. Chapter 7 describes patterns of use of health care services when people are ill by type of providers, by type of illnesses, and by poverty ranking level. Findings in this chapter reveal a high level of self-medication, greater access to private than public services, and less use of public services or any health care services by the poor in comparison to the better off. Self-funded purchases of drugs for self-medication and use of private curative services were even common in those with health insurance. A single private provider contact for treatment of illness costs on average 2.6% of the total annual expenditure per capita, and self-medication with drugs purchased at private health care facilities costs 1.0% of total annual expenditure per capita, similarly these at district hospitals and commune heath centers were similar. Finally, the percentage of ill people with no access to any health care providers during their illness episode was high, regardless of their wealth or health insurance status. Chapter 8 compares the quality of private and public health services using a framework proposed by the World Bank for evaluating the quality of health care in developing countries. Results from this chapter show that technical quality of care was poorer in the private sector than among public providers while costs for patients were similar in private and public facilities, and client satisfaction was similar in public and private facilities. Chapter 9 summarizes the results from Chapters 5-8 to identify the main characteristics of the rural health system with a view to system sustainability and proposes policies and strategies for strengthening the quality of the public health care sector and improving its equity and efficiency. The main features of the current rural health care system in Vietnam identified from the community-based evidence found in this research are: (1) primary health care services are available and there is equality in physical access; (2) financial resources for the CHC system are diversified with Government resources the key contributors; (3) private health care providers for outpatient services, public providers for inpatient services; (4) quality of treatment services is below the national standard; (5) public services are available but under utilized; (6) the rural health care system is not a pro-poor system; (7) direct payment is the main component of total health care expenditure; and (8) the economic relationship of the rural health care system is a user-provider model rather than a health care triangular model. Nine recommendations to strengthen the rural health care system were then developed based on a critical view of the objectives of the Vietnam health sector reform for the period 2001-2010 supported by evidence found in this research. This chapter ends with a section to remind readers about the limitations of this study and then proposes future research with specific questions covering three main dimensions of health care system reform in Vietnam (accessibility, quality of care, and overall management). A study with a sentinel site approach to follow-up the impact of the social and health sector reform policies is also proposed to help the government make timely adjustments to their policies to protect the poor. / PhD Doctorate

In South Africa professional nurses undergo training which gives them different levels of skills. It is difficult for professional nurses to render comprehensive primary health care services without specific knowledge and skills. Some lack skills in preventative and promotive health care delivery; others are not trained to take care of a pregnant woman or a baby after delivery, or of a mental health patient; while yet others are only curatively oriented. It is possible that they do not recognise their own limitations and are not aware of the skills needed to render comprehensive primary health care services. Their perceptions could influence their practice and severely affect the quality of health services. The aim of this research was to explore and describe the perceptions that professional nurses working in primary health care clinics have of the skills required to render quality comprehensive primary health care services, and the perceptions they have of their own level of skills to render quality comprehensive primary health care services, as well as to formulate guidelines for the facilitation of trained professional nurses to truly render quality comprehensive primary health care services. A qualitative design was followed. Permission was obtained from the Potchefstroom District Health Manager to conduct this research. Purposive voluntary sampling was used to identify the three samples who complied with the set selection criteria. Data collection was done by means of semi-structured interviews. Experts in qualitative research evaluated the semi-structured interview schedule. A trial run was done and the interview schedule was then finalised to conduct the interviews. The interviews were recorded on audiotape and then transcribed. The interviewer made field notes to serve as an analytical basis for the collected data. Data was collected until data saturation was achieved. Data analysis was done by means of open coding. A co-coder was appointed and two consensus meetings took place. The findings indicated that professional nurses perceive the skills required to render quality comprehensive primary health care services as the ability to assess, diagnose and manage patients, as well as specific skills acquired during the various nurse training programmes. The more comprehensively trained, the more competent they feel. The less comprehensively trained, the more negative they experience their work. They view their own level of skills as ranging from adequate to lacking and inadequate, depending on their training. They feel that it is impo~ant to develop skills ranging from computer skills to the full range of skills. The conclusions drawn are that the professional nurses with different training and levels of skills are well aware of the skills required to re.nder comprehensive primary health care services. They maintain that trained professional nurses need qualifications in General Nursing, Midwifery, Community Nursing, Psychiatric Nursing and Clinical Nursing Science, and Health Assessment, Treatment and Care. The professional nurses with all five qualifications feel confident and enjoy their work, whereas those who are not fully trained lack certain skills and experience negative feelings working in the primary health care clinics. Recommendations are made for nursing education, nursing research and nursing practice with specific reference to the formulation of guidelines for the facilitation of trained professional nurses to truly render comprehensive primary health care services, with a focus on quality control, orientation, mentoring, planning of training, support systems, and consultancy. / Thesis (M.Cur.)--Potchefstroom University for Christian Higher Education, 2003

In South Africa professional nurses undergo training which gives them different levels of skills. It is difficult for professional nurses to render comprehensive primary health care services without specific knowledge and skills. Some lack skills in preventative and promotive health care delivery; others are not trained to take care of a pregnant woman or a baby after delivery, or of a mental health patient; while yet others are only curatively oriented. It is possible that they do not recognise their own limitations and are not aware of the skills needed to render comprehensive primary health care services. Their perceptions could influence their practice and severely affect the quality of health services. The aim of this research was to explore and describe the perceptions that professional nurses working in primary health care clinics have of the skills required to render quality comprehensive primary health care services, and the perceptions they have of their own level of skills to render quality comprehensive primary health care services, as well as to formulate guidelines for the facilitation of trained professional nurses to truly render quality comprehensive primary health care services. A qualitative design was followed. Permission was obtained from the Potchefstroom District Health Manager to conduct this research. Purposive voluntary sampling was used to identify the three samples who complied with the set selection criteria. Data collection was done by means of semi-structured interviews. Experts in qualitative research evaluated the semi-structured interview schedule. A trial run was done and the interview schedule was then finalised to conduct the interviews. The interviews were recorded on audiotape and then transcribed. The interviewer made field notes to serve as an analytical basis for the collected data. Data was collected until data saturation was achieved. Data analysis was done by means of open coding. A co-coder was appointed and two consensus meetings took place. The findings indicated that professional nurses perceive the skills required to render quality comprehensive primary health care services as the ability to assess, diagnose and manage patients, as well as specific skills acquired during the various nurse training programmes. The more comprehensively trained, the more competent they feel. The less comprehensively trained, the more negative they experience their work. They view their own level of skills as ranging from adequate to lacking and inadequate, depending on their training. They feel that it is impo~ant to develop skills ranging from computer skills to the full range of skills. The conclusions drawn are that the professional nurses with different training and levels of skills are well aware of the skills required to re.nder comprehensive primary health care services. They maintain that trained professional nurses need qualifications in General Nursing, Midwifery, Community Nursing, Psychiatric Nursing and Clinical Nursing Science, and Health Assessment, Treatment and Care. The professional nurses with all five qualifications feel confident and enjoy their work, whereas those who are not fully trained lack certain skills and experience negative feelings working in the primary health care clinics. Recommendations are made for nursing education, nursing research and nursing practice with specific reference to the formulation of guidelines for the facilitation of trained professional nurses to truly render comprehensive primary health care services, with a focus on quality control, orientation, mentoring, planning of training, support systems, and consultancy. / Thesis (M.Cur.)--Potchefstroom University for Christian Higher Education, 2003

O presente estudo enquadra-se no campo cuidados em saúde e sua temática refere-se à avaliação do serviço de saúde da criança na rede básica do município de Colombo Paraná. Constitui-se seu objeto o desempenho das Unidades Básicas de Saúde (UBS) e das Unidades de Estratégia Saúde da Família (USF) do município. Os objetivos foram: avaliar a presença e a extensão dos atributos essenciais e derivados relativos à Atenção Primária à Saúde (APS) no cuidado prestado na atenção primária às crianças, sob a ótica das suas famílias, e comparar o desempenho das UBS e USF quanto a esses atributos. Os sujeitos da pesquisa foram responsáveis por crianças de 17 a 22 meses cadastradas e assíduas às atividades das unidades de saúde do município, numa amostra aleatória total de 482 pessoas, sendo 247 das Unidades Básicas e 235 das Unidades de ESF. A coleta de dados foi feita em domicílio e o instrumento utilizado foi o Primary Care Assessment Tool (PCATool) versão criança, já validado em 2008 e utilizado como referência pelo Ministério da Saúde do Brasil. As entrevistas aconteceram entre junho e julho de 2012. As análises, com auxílio do software Statistica 10.1, incluíram o teste t de student para comparação de variáveis quantitativas e o teste qui-quadrado para variáveis qualitativas; para verificação da consistência interna dos itens do instrumento foi obtido o Alfa de Crombach para cada um dos atributos e para o instrumento total. Um estudo piloto foi realizado para garantir a eficácia do instrumento e da entrevista. O estudo seguiu a Resolução 196/96 do Conselho Nacional de Ética em Pesquisa. A pesquisa revelou que as Unidades de ESF obtiveram escores superiores ao mínimo exigido em Afiliação, Coordenação, Integralidade, Orientação Familiar e Acessibilidade, metade dos 10 atributos estudados, indicando que os responsáveis das crianças atendidas nessas unidades referem ter mais frequentemente acesso à utilização dos serviços de saúde, utilizam com mais frequência a unidade de saúde como porta de entrada para o sistema de saúde, estabelecem com maior constância um atendimento integrado entre os serviços e referem reconhecer a valorização dos profissionais quanto ao vínculo com a família. No que tange às UBS, todos os escores ficaram abaixo do ideal para a APS, apontando que essas unidades apresentam maior dificuldade em vincular seus usuários e reconhecê-los como parte de uma comunidade. Observou-se que os trabalhos de avaliação desempenham um papel fundamental no aprimoramento dos eixos de intervenção com o propósito de aderir ao foco do Ministério da Saúde em transformar os serviços de saúde em Atenção Primária. No município em questão, concluiu-se que as unidades de ESF estão mais próximas das diretrizes da APS do que as UBS, entretanto há a necessidade de rever as ações vinculadas à assistência à criança a fim de alcançar consonância com os atributos da APS em ambas as unidades. / This study is placed in the health caring field and its thematic refers to the evaluation of childs health care in the city of Colombo Paraná. Its object of study is the performance of Basic Health Units (UBS) and the Strategy Units of Family Health (USF). The study aims: to evaluate both the presence and extention of the essential attributes and derivates relative to the APS regarding the care given at the primary care of the children at their family perspective, and to compare the UBS and USF attributes performance. This research subjects were responsible for 17-22 month-old children, registered and assiduous to the city health units activities, in a random sample of 482 people: 247 from the Basic Units and 235 from the ESF units. Data was collected at their houses and the Primary Care Assessment Tool (PCATool), childrens version, was used. PCATool was validated in 2008 and used by the Brazilian Health Ministry as reference. Interviews were held between June and July 2012. The samples, using the software Statistica 10.1, included the t student test to compare the quantitative variants and the qui-square test, for qualitative variants; Crombachs Alfa was obtained in order to verify the intern consistency of instrument items for each one of the attributes and total instrument. A pilot study has been performed as to guarantee both the instrument and interview efficacy. This study followed Resolution 196-96 from Research Ethics National Council. The research revealed that the ESF units obtained scores higher than the minimum required in Affiliation, Coordination, Integrality, Familiar Orientation and Accessibility, half the studied attributes, indicating that the ones responsible for the children who attend those units refer to having more frequent access to health services, use more often the health unit as an entrance door to the health system, establish more constantly an integrated service and recognize the professional valorization regarding the bond with the family. Regarding the UBS, all the scores were below ideal for the APS, indicating that those units seem to struggle to bond with its users and recognizing them as part of a community. It has been observed that assessment works play a fundamental role in perfecting the intervention axis aiming at joining the Health Ministry focus, which is to transform health services into Primary Care. In that city it has been concluded that the ESF units are closer to APS directress than UBS, however it is necessary to revise the child assistance related actions in order to reach consonance with the APS attributes at both units.

O presente estudo enquadra-se no campo cuidados em saúde e sua temática refere-se à avaliação do serviço de saúde da criança na rede básica do município de Colombo Paraná. Constitui-se seu objeto o desempenho das Unidades Básicas de Saúde (UBS) e das Unidades de Estratégia Saúde da Família (USF) do município. Os objetivos foram: avaliar a presença e a extensão dos atributos essenciais e derivados relativos à Atenção Primária à Saúde (APS) no cuidado prestado na atenção primária às crianças, sob a ótica das suas famílias, e comparar o desempenho das UBS e USF quanto a esses atributos. Os sujeitos da pesquisa foram responsáveis por crianças de 17 a 22 meses cadastradas e assíduas às atividades das unidades de saúde do município, numa amostra aleatória total de 482 pessoas, sendo 247 das Unidades Básicas e 235 das Unidades de ESF. A coleta de dados foi feita em domicílio e o instrumento utilizado foi o Primary Care Assessment Tool (PCATool) versão criança, já validado em 2008 e utilizado como referência pelo Ministério da Saúde do Brasil. As entrevistas aconteceram entre junho e julho de 2012. As análises, com auxílio do software Statistica 10.1, incluíram o teste t de student para comparação de variáveis quantitativas e o teste qui-quadrado para variáveis qualitativas; para verificação da consistência interna dos itens do instrumento foi obtido o Alfa de Crombach para cada um dos atributos e para o instrumento total. Um estudo piloto foi realizado para garantir a eficácia do instrumento e da entrevista. O estudo seguiu a Resolução 196/96 do Conselho Nacional de Ética em Pesquisa. A pesquisa revelou que as Unidades de ESF obtiveram escores superiores ao mínimo exigido em Afiliação, Coordenação, Integralidade, Orientação Familiar e Acessibilidade, metade dos 10 atributos estudados, indicando que os responsáveis das crianças atendidas nessas unidades referem ter mais frequentemente acesso à utilização dos serviços de saúde, utilizam com mais frequência a unidade de saúde como porta de entrada para o sistema de saúde, estabelecem com maior constância um atendimento integrado entre os serviços e referem reconhecer a valorização dos profissionais quanto ao vínculo com a família. No que tange às UBS, todos os escores ficaram abaixo do ideal para a APS, apontando que essas unidades apresentam maior dificuldade em vincular seus usuários e reconhecê-los como parte de uma comunidade. Observou-se que os trabalhos de avaliação desempenham um papel fundamental no aprimoramento dos eixos de intervenção com o propósito de aderir ao foco do Ministério da Saúde em transformar os serviços de saúde em Atenção Primária. No município em questão, concluiu-se que as unidades de ESF estão mais próximas das diretrizes da APS do que as UBS, entretanto há a necessidade de rever as ações vinculadas à assistência à criança a fim de alcançar consonância com os atributos da APS em ambas as unidades. / This study is placed in the health caring field and its thematic refers to the evaluation of childs health care in the city of Colombo Paraná. Its object of study is the performance of Basic Health Units (UBS) and the Strategy Units of Family Health (USF). The study aims: to evaluate both the presence and extention of the essential attributes and derivates relative to the APS regarding the care given at the primary care of the children at their family perspective, and to compare the UBS and USF attributes performance. This research subjects were responsible for 17-22 month-old children, registered and assiduous to the city health units activities, in a random sample of 482 people: 247 from the Basic Units and 235 from the ESF units. Data was collected at their houses and the Primary Care Assessment Tool (PCATool), childrens version, was used. PCATool was validated in 2008 and used by the Brazilian Health Ministry as reference. Interviews were held between June and July 2012. The samples, using the software Statistica 10.1, included the t student test to compare the quantitative variants and the qui-square test, for qualitative variants; Crombachs Alfa was obtained in order to verify the intern consistency of instrument items for each one of the attributes and total instrument. A pilot study has been performed as to guarantee both the instrument and interview efficacy. This study followed Resolution 196-96 from Research Ethics National Council. The research revealed that the ESF units obtained scores higher than the minimum required in Affiliation, Coordination, Integrality, Familiar Orientation and Accessibility, half the studied attributes, indicating that the ones responsible for the children who attend those units refer to having more frequent access to health services, use more often the health unit as an entrance door to the health system, establish more constantly an integrated service and recognize the professional valorization regarding the bond with the family. Regarding the UBS, all the scores were below ideal for the APS, indicating that those units seem to struggle to bond with its users and recognizing them as part of a community. It has been observed that assessment works play a fundamental role in perfecting the intervention axis aiming at joining the Health Ministry focus, which is to transform health services into Primary Care. In that city it has been concluded that the ESF units are closer to APS directress than UBS, however it is necessary to revise the child assistance related actions in order to reach consonance with the APS attributes at both units.