A review of Vietnam’s healthcare reform through the Direction of Healthcare Activities (DOHA)

DOHA (or Chỉ đạo tuyến in Vietnamese) literally means guidance line or level in English. The term DOHA has been used as the English translation for some time, and documents translated by the Ministry of Health commonly use phrases such as “Technical Direction” or “Giving guidance to hospitals at lower levels,” with further explanations including “regional medical guidance activities” and “guidance and support from higher to lower level hospitals”.

The DOHA has two major missions [18]:

DOHA has recently focused on technology transfer training from central to provincial hospitals to help alleviate the excessive numbers of patients in provincial or district hospitals. So, DOHA covers collaboration activities among hospitals at different levels [18].

The concept behind DOHA first appeared in Vietnam as one of the five tasks for hospitals in 1961 and since then, DOHA has been clarified in hospital regulations in 1969, 1971, and 1978 as an important hospital activity [19]. In 1997, regulations set out that DOHA was one of the seven tasks of hospitals and its organizational structure was also clarified [18]. In 1998, the Minister of Health identified Bach Mai Hospital, the central hospital in northern Vietnam, located in Hanoi, as a pilot hospital for a trial implementation of DOHA [20]. Bach Mai Hospital set up a DOHA department, staffed by two medical doctors, and strengthened its training provision to lower level hospitals [6] [20]. Since then, more practical and detailed regulations for DOHA have been developed. Table 1 shows the six current areas of DOHA based on Decision 4026/QD-BYT in 2010 [18].

Central hospitals (Level I) have a DOHA center and training center. These draw on the functional capacity of these healthcare facilities and play a key role in coordination and management of DOHA across specialties at both the central hospitals and in hospitals in the provincial DOHA network. The concept of DOHA has developed to promote the sharing of roles and improved collaboration among healthcare facilities, to improve the quality of medical services.

Table 2 shows the laws and regulations related to DOHA, which have changed over time [18]. DOHA was defined as one of the seven responsibilities of hospitals in the hospital regulation of 1997, the others being medical service, staff training, scientific research, prevention activities, international cooperation, and hospital management. In 2004, according to the “Instructions for strengthening DOHA activities in medical services,” the purpose of DOHA was to demonstrate the fulfillment of medical services for local people and guarantee equitable healthcare. The instructions included the importance of establishment of DOHA networks, covering central, provincial, district, and commune levels, and concrete implementation procedures such as planning and approval processes for DOHA and its budget. In 2009, the Law on Examination and Treatment stated that provision of guidance and support for use of medical technology to lower levels was part of the responsibilities of higher level hospitals [6].

The Vietnamese Minister of Health also signed Decision No. 1816/QD-BYT, in 2008, on the project “Dispatching healthcare workers from higher-level hospitals to support lower-level hospitals with the aim of improving quality of examination and treatment” [18]. By the end of 2009, one and a half years after its initial implementation, an average reduction of 30% in overcrowding at higher level facilities had been observed [18]. However, bypassing lower level facilities is still relatively common and many people still seek care at provincial and central hospitals to treat diseases that could easily be handled at the district or even commune level [18]. This bypassing leads to an increased burden on high-level facilities and under-utilization of services at lower levels, causing unnecessary waste across the whole system. This project was further supported, and staff rotation strengthened, by Decision No. 5068/QD-BYT (Table 2) in 2012, which regulates the content of some training and technical skills transfer as well as supporting the Satellite Hospital Project [21].

In 2013, the Vietnamese Prime Minister set out targets to be achieved by the year 2020. The target for the bed occupancy rate of central hospitals in Hanoi and Ho Chi Minh City (which exceeded 120%) was set at 100% or less; and district and provincial hospitals were expected to achieve occupancy rates of 80% [22]. There was also a limit set for the number of patients per day seen by each doctor, to reduce patient waiting times. This decision indicates a commitment to address patient numbers comprehensively. There have been a number of projects to support this, including improvements in hospital facilities to increase the number of beds, introduction of family doctors, strengthening of primary healthcare and preventive medicine, and improved health education and promotion activities for local people. DOHA-related policy documents published in 2013 based on this prime ministerial decision were designed to further improve the feasibility of technical transfer activities under DOHA. Technical skills transfer training under DOHA is based on a standard list of medical technologies that can be implemented at each level in the Ministry of Health circular on “Professional technical lists for each level of health facilities (43/TT-BYT)” [23]. The list consists of 28 clinical fields with 17,216 medical technologies and specifies medical technologies required at each level [23]. Lower level hospitals that have received technology transfer training from higher level hospitals must submit documents such as training completion reports to the provincial Department of Health to obtain official approval and a license to introduce the new technologies or procedures. These activities call for strong commitment and proactive ownership of the process of training management from both higher and lower level hospitals.

The Satellite Hospital Project (2013–2020) evolved from the Vietnamese Prime Minister’s target to reduce the number of patients in higher level hospitals [21]. This project aims to upgrade the technical capacity for examination and treatment in provincial hospitals designated as satellite hospitals through technical skills transfer by central or core hospitals. This project is expected to reduce the number of patients referred from provincial to central hospitals and alleviate the subsequent overload at central hospitals. Satellite and core hospitals are required to set out a development plan covering facilities, medical equipment, and human resources. The first phase of the project covered 2013 to 2015, and the second phase from 2016 to 2020. Five specialties with very high bed occupancy rates were prioritized in the first phase: oncology, traumatology, cardiology, obstetrics, and pediatrics. During 2016–2020, more specialties will be added, including endocrinology, neurology, intensive care, hematology, and infection control [24].

The main elements of the project are:

In Vietnam, the term “referral” means patient referred from lower to higher level healthcare facilities [22]. Referral activity is part of DOHA, and therefore the referral process is managed by hospitals’ DOHA departments. Patient referral is a process to manage the issue that healthcare staff at lower levels often have insufficient resources (facilities, equipment, and diagnosis and treatment capacity) to manage patients’ clinical conditions. The Ministry of Health defines referral activities as any activities including “patient referral activity and management of patient referral information among health facilities.” This is also covered by the Ministry of Health Circular 14/TT-BYT in 2014 on regulation on referral among health facilities [18]. Patient referral among healthcare facilities takes into account the technical capacity of each healthcare facility, based on the standard lists of medical technologies.

One of the expected outcomes is reducing the number of patients referred to higher level hospitals, together with improved outcomes of treatment at all levels. Some provincial hospitals have collected the number of patients referred from district hospitals and to central hospitals. Table 3 shows the trends in Yen Bai provincial hospital, about 150 km to the northwest of Hanoi, the capital city of Vietnam, serving a population of 771,000 [18]. The number of patients referred from Yen Bai provincial hospital to higher level hospitals in Hanoi steadily increased from 2010 to 2012. After the implementation of the strengthened DOHA activities from 2013, the level of referrals remained stable. Slightly fewer patients were examined in the provincial hospital during 2013.