Essential Drugs Monitor No. 025-026 (1998)
(1998; 36 pages) [French] [Russian] [Spanish] View the PDF document
Table of Contents
Open this folder and view contentsEditorial. Managing Drug Supply
Open this folder and view contentsNational Drug Policy
Close this folderResearch
View the documentImproving quality of care in Hai Phong Province
View the documentSurvey highlights failings in public education in rational drug use
View the documentAdvantages of pre-packaged antimalarials
Open this folder and view contentsTraining
Open this folder and view contentsNewsdesk
Open this folder and view contentsDrug Information
View the documentMeetings & Courses
View the documentNetscan
View the documentLetters to the Editor
View the documentPublished Lately
Open this folder and view contentsRational Use
 

Improving quality of care in Hai Phong Province

JOHN CHALKER*

* Dr John Chalker was Project Manager for the Hai Phong Project, from December 1993 to March 1996, for Save the Children Fund UK.

BACKGROUND

IN 1993/94 the system of commune health stations (CHSs) in Hai Phong Province, Viet Nam, was in danger of collapse. This was a system that had provided a health station in every commune in Hai Phong with a staff of four to six para-medics, trained for three to four years at the secondary medical school (these schools exist in most provinces to train nurses, midwives and medical, pharmacy and laboratory assistants). The health stations were a focus for all preventive and curative activity. They were mainly financed by the commune, but carried out Health Ministry vertical control programmes as well as providing obstetric and curative care. Each commune has an average population of around 6,000 people, and few people are more than 10 or 15 minutes from their nearest station.

It was this extensive infrastructure that was a large contributory factor to Viet Nam’s excellent health statistics on infant mortality and life expectancy, which are comparable to countries with a much higher gross national product.

Since 1989, under the Government’s policy of “Doi Moi” or renewal, private practice in the health sector was legitimised. This new approach, coupled with inflation, meant that in practice investment in the stations virtually ceased. At the same time many private drug sellers (both licensed and unlicensed) appeared. Salaries for health workers reduced to non living wages in real terms (about US$6 a month). The stations fell into poor states of disrepair and equipment was not replaced.

In pre project research in early 1995, we found that the average value of drug stocks in a selection of Hai Phong CHSs was about US$20 per station. Drugs were bought locally by the health staff, and were sold and replaced frequently via user fees. The staff had very little retraining. District supervision of quality of treatment did not exist, and treatment standards were deteriorating.

At the same time attendance fell by more than half from 1989 to 1993. People had access to drugs from the proliferating number of drug sellers. In fact more than 70% went to these drug sellers as a first recourse when sick. At the drug sellers they would very often receive the wrong, frequently poor quality drug, in the wrong dose for the wrong length of time. Important and dangerous symptoms would be missed so that timely referral to hospital would be delayed.

The spiral of decline in the commune health workers’ morale: the decreasing respect of the public; the reduction of district supervision; and the lack of a living wage which led to increasing numbers of health workers starting a private practice or taking up other income generating activities; all illustrated a breakdown of the health services.

The consequence had serious implications for preventive care. With the reduced esteem of the CHSs due to declining curative activity, there was a concomitant reduction in motivation to finance the CHS by the communes. This threatened the very existence of the institutions that delivered the preventive care.

It was the project’s goal to break this cycle of decline.

THE PROJECT

The project was a co-operation between Save the Children Fund UK, and the Hai Phong Provincial Health Bureau, supported by the Ministry of Health and partly financed by the European Union.

Its objectives grew directly out of the previous analysis. They were all aimed at improving the quality of curative care at the CHSs and altering the public’s awareness of issues surrounding the rational use of drugs. It was assumed that this would increase the standing of the CHSs and therefore improve the chance of the commune investing in them, preserving the preventive care that they offered.


This poster, used in the project, gives two pieces of advice on antibiotic use: if you think you need antibiotics go to your doctor; and if you need antibiotics take the full course of treatment otherwise they will not be as effective next time.

We hypothesised that if the commune health stations offered a good service, where common diseases were well managed; where necessary drugs at affordable prices were supplied in the right doses at the right times; where people with more serious problems were referred in a timely way to hospitals; where they had the basic drugs as a well managed revolving fund; and where the necessary basic equipment was present, then several consequences would follow.

The first would be that more people would use the CHS. If this were the case, then the small profit made on drug sales would increase. These together would improve the health workers’ morale and financial situation. The second consequence would be that the commune, district and provincial people’s committees would realise what an excellent resource they had in the CHSs and would mobilise more funds to maintain them. In this way the institutions of preventive care would be preserved and the spiral of decline would be broken.

Strategy

We aimed to affect several aspects of quality of care. We would improve the basic medical equipment, drug availability and the level of staff training. In addition we would help them construct a sustainable accounting system for ongoing drug supply, develop standard treatment guidelines, create district supervision of the quality of prescribing and accounting, and improve the rational use of drugs.

Changing people’s prescribing habits has been shown worldwide to be extraordinarily difficult. These habits are not just formed from a rational knowledge base, but are affected by many financial, social and cultural factors. Prescribing (both bad and good) is a habit. To break the bad habits and establish good habits a combination of “carrot” and “stick” need to be employed over a considerable period. We hypothesised that if good prescribing habits could be established for more than half a year then there was every hope that they would continue. We therefore used other aspects of improving quality of care as both carrots and stick towards changing prescribing habits.


Participants at one of the district workshops which drew up standard treatment guidelines

Photo: Save the Children Fund

We reasoned as follows:

1. Carrot

Research: if all work was based on locally found research results, the “top down” image would be broken and we would be seen to be basing our work on the real situation.

Treatment guidelines: if simple guidelines were developed, then it would be easy to judge the quality of treatment. If these guidelines concentrated on the most frequently seen conditions in all districts covering more than 80% of patients, then only some 10 conditions would need to be covered.

Limited drug list: by looking at the guidelines and adding a few more for emergency situations, an agreed list of drugs could be determined.

Participation: if the health workers participated in forming these treatment guidelines and drug list, they would be more likely to have a sense of ownership of the results.

Retraining: by concentrating on the management of these 10 basic conditions and the limited list of drugs, retraining could be feasible and effective.

Supervision: regular supervision of quality of prescribing from the district health centre would be a vital aspect of in-service training, morale building and developing a unified system.

Drug fund: if the CHS had a sufficient drug fund to stock the needed drugs from the limited list, it could purchase these drugs locally and sell them at a competitive price to the private market. This would please health worker and public alike.

Accounting system: developing an accessible, transparent book keeping system kept by the CHS would help to ensure the existence of an ongoing revolving fund.

Equipment: the possibility for the CHS to choose basic equipment from an agreed list every three months for nine months would act as a real incentive to change prescribing habits.

Patient load: with an increasing patient load, income would increase.

2. Stick

Withholding of equipment: if the agreed treatment guidelines and book keeping system were not followed, then the equipment would not be forthcoming.

Peer pressure: the withholding of equipment would be public knowledge.

Supervision: the regular supervision would also be a form of inspection.

Public expectation: if, through a series of television and radio programmes, leaflets and posters, the public were informed about key aspects of drug use and CHS service, then their demand for irrational treatment would decrease.

PHASED IMPLEMENTATION

The project was implemented, district by district, in all 12 districts in 217 communes in Hai Phong covering a population of 1.6 million people. In each district the whole process took up to one year. We started with the rural areas and ended with the urban and island districts. Work started in the first district in June 1994 and the last in January 1996. It covered a series of activities aimed at improving aspects of quality of care.

Pre implementation in each district

Baseline research on key drug use indicators and which diagnoses were being made at CHSs was carried out in all CHSs of the district. This was either done by retrospective examination of out patient books or if these were absent, by prospectively giving prescription pads and examining them after one month.

As a pre-condition for joining the project, each district health office had to agree to set up and run a team of supervisors to monitor the quality of treatment and of book keeping in each commune each month. This information was to be fed back to the provincial health office and project office every month, establishing a record of key indicators for each CHS and aggregated for each district. It was mainly on the basis of these records that the decision was made whether to donate or not, money for equipment to each CHS each three months. The key indicators used were those that had been shown to be most problematical during baseline research (see Table1).

Preparation

In each of the 12 districts, a series of workshops was carried out - normally two in each district but this varied with the number of staff needing to attend. The workshops were with:

Key commune and CHS leaders, to agree the plan of activity of the project. This was basically to enlist their support and explain the approach. It included them approving regular supervision by district staff, the formalising of the selling of drugs, instigating an accounting system and agreeing that the CHS drug seller could purchase drugs from the agreed list from any registered drug seller. They would also understand that equipment donation was dependent on good prescribing.

CHS curative staff, to create a standard treatment guideline based on the most frequent diagnoses and to agree a drug list. A senior staff member from the Ministry of Health’s Education and Science Department facilitated these workshops. The standard treatment guidelines were based on commune prescribing patterns over previous months and on the diagnoses made. This information was found either by looking at records or if these did not exist, by supplying duplicate prescription pads to all staff, collecting them after one month and analysing the data. Treatment guidelines were made for the 10 most common conditions that covered more than 80% of patients seen in each particular district. While the process was participatory, the final say rested with the facilitator, who was familiar with national and WHO policies for treating the most prevalent diseases.

Compilation of the drug list was then relatively easy, as usually eight or nine drugs had been used in the treatment guidelines and then, extra drugs were discussed and agreed, using the same facilitator. Each district’s drugs list was slightly different, containing between 29 and 31 drugs. When the programme ended they were combined into one list of some 32 drugs.

CHS book keepers, to develop an appropriate book keeping system.

District supervisors, to develop and learn methods to monitor the agreed key drug use indicators that were seen to be a problem on the basis of the research findings.

At the conclusion of the workshops a ceremony was held, where each actor (from the Provincial Health Bureau, District Health Office, Commune Peoples Committee and CHS) signed a contract to agree their role in the plan of activities. A week of retraining for all curative staff was organized through the secondary medical school, to reinforce basic diagnosis and treatment for common conditions.

With this done, Save the Children Fund UK transferred an average of US$300 to each CHS for them to set up a revolving drug fund. It also supplied books and calculators for book keeping. This took around two months in each district.

In addition an information campaign on key drug use issues was launched using television, radio, newspapers, posters and leaflets. The messages were based on survey results (see Boxes 1 and 2).

Box 1

The Information, Education and Communication (IEC) campaign in Hai Phong to promote the rational use of drugs

IEC campaign principles

Messages were agreed and prioritised on the basis of research. These messages addressed the same problems found with CHS prescribing. They were repeated as often as possible, using a variety of media channels.

Main problems identified

• Antibiotics are used too often.
• When antibiotics are used they are used in too small a dose.
• Injections are often preferred to tablets.
• The majority of sick people are not using CHSs.

Agreed messages

• Never use injections if tablets will do. Injections can be dangerous and are usually not necessary.

• If you need antibiotics, you must use a full dose. Not finishing the dose means that next time you need them they may be less effective.

• When you are ill do not self prescribe, ask your local expert. Use your Commune Health Station.

• Save the Children Fund from the UK is here to help upgrade your local Commune Health Stations. Using your local CHS when you are ill is beneficial for your health and the station.

Media used

These were variously applied from June 1994 to November 1995.

Two posters were designed in Hai Phong for the first two messages and every CHS was given four or five of each.

Four radio programmes (short plays of five minutes starting and finishing with the message) were written and recorded first by a district radio and secondly by provincial radio. They were transcribed onto cassette and distributed to every CHS to broadcast on the commune public address system.

Four radio spots each 30 seconds long were treated the same way.

TV programmes. Provincial TV recorded four programmes, each approximately five minutes long, with a respected person talking about one of the messages. These were shown several times over several months.

TV spots of one minute were treated in the same way.

Newspaper advertisements were taken out for each of the messages on the provincial newspaper’s back page.

Leaflets. A simple leaflet was designed and given to each houshold in five communes.

Meetings. A key physician from each district was trained on the messages, but this has not yet been taken any further.

Cost. All these inputs came to a total of US$2,200.

Ongoing work

With satisfactory results from the regular supervision of the district teams, at three monthly intervals, each CHS was allowed to choose around US$250 worth of basic medical equipment from an agreed list. This equipment was conditional on following the treatment guidelines and book keeping system.

Initially some CHS staff found it difficult to understand and adhere to the new accounting and prescribing procedures. However, the district health team’s supervisory visits and at least one early visit from a Save the Children team member helped to resolve problems. After this visit, when processing the monthly information for the district, the project wrote to the district health officer highlighting any unsatisfactory practices within particular CHSs, (such as overuse of antibiotics or injections). If, after warnings, bad practices went unchanged, the requested equipment was refused until improvements had been made.

The supervisors’ motivation and abilities were another concern. If highly qualified the supervisors were reluctant to travel around to the CHSs. If they were less highly qualified they were more willing to travel but did not have the authority to advise the medical assistants on their practice. This problem was tackled differently in each district, but on the whole the supervisors managed to collect the necessary information. The head of the district health office reviewed the supervisors’ progress each month when they came in to collect their salaries. The review was based on the information that had been collected. When information had not been collected for the month because the supervisors had not done their work, equipment distribution was stopped in the whole district. We also stopped delivery if the information seemed unreliable, for example if everything was scored at 100%. The reliability of the supervisors’ information was checked through evaluation exercises and was found to be very good. Supervision results showed a large improvement in prescribing habits and book keeping over the first five months of activity for each district (see Table 1).

Box 2

The Information Education and Communication campaign evaluation

Evaluation

Two hundred households from five communes were randomly selected and interviewed.

The results showed that the IEC campaign had been memorable:

• 89% of households could report some IEC messages.

• Only 25% claimed no change in knowledge. The other 75% claimed a change in knowledge, practice or both.

The most effective means of communication was the commune public address system. 67% of respondents remembered at least one message from these.

52% of all households remembered something from TV (51% of the households owned a TV).

53% remembered something that their CHS staff had told them.

Newspapers and posters were less effective with only 7.5% and 15% remembering something from these.

The leaflet was not remembered very often (37%), but in the communes where the leaflet was not distributed to each house, respondents were twice as likely not to remember any message.

Conclusions

IEC campaigns based on locally made programmes and research-based messages can be very effective and inexpensive in Viet Nam. Commune public address systems are still effective in rural areas. This is based on the decentralised media system of province, district and commune. This has profound implications for future campaigns on, for example, nutrition, weaning practices or HIV.

(A full report of the IEC evaluation is available from the address at the end of the article).

Evaluation

Supervisors’ data were checked by quantitative evaluations in December 1995, before the project had finished and then again in September 1996, six months after the end of the external inputs.

These were retrospective studies, in the eight rural districts which the original project covered, and where the baseline research was carried out. The studies involved randomly choosing 40 CHSs and looking at the out patient book, the accounting books, the drug cabinet and performing some interviews. From the out patient book, the last 30 treatments were looked at in each CHS for the prescribing indicators.

A major impact

As the project was started district by district over an 18-month period, the baseline research in new districts acted as a rolling control to the results shown. Each new district showed broadly the same pattern of results as the original baseline, thus showing that most of the impact could be attributed to the project activities.

The most significant finding was the large improvement in the prescribing parameters as can be seen in Table 1. In each district these improvements took place in the first month after the workshops, and then went on improving over the next few months to reach a plateau which was maintained to six months beyond the end of the project (see Table 1). This shows that good prescribing becomes a habit when maintained due to incentives over a considerable period.

The treatment guidelines and agreed limited list of drugs were successfully developed in each district. The week of retraining concentrated on these. Each district guidelines covered around 10 conditions that covered more than 80% of patients. The 12 district guidelines were eventually combined into one book for the Province. As shown in Table 1, the guidelines were followed in a large percentage of cases. The CHSs stocked an average of 27 of the 29 or 30 recommended drugs, but continued to stock an average of 23 other drugs, and 55% of CHSs stocked specifically non regulation drugs such as steroids, gentamycin and lincomycin. When asked they said that they sold these profitably over the counter, from their drug store, and therefore liked to stock them. Anecdotally this is an improvement on the pre-existing situation when all CHSs stocked such drugs.

The supervision system eventually functioned well in all districts. The information produced in this way was shown as reliable when compared to the evaluation research (see Table 1). In two districts, after three months, when the equipment was due, we refused to release the equipment to any of the CHSs, as we felt the supervision results were unreliable or they had not been produced. After this things improved. The conditionality of equipment donation on reliable and regular supervision proved an effective incentive.

CONCLUSIONS

A drug fund was supplied to each CHS, tracked by an accounting system. Interestingly only an average of US$150 (out of the US$300 supplied) was used to buy drugs, presumably because there was a consensus that this purchased enough of the products on the drug list to have a sufficient store. This has important implications for funding of projects in the future. The excess money was kept safely in reserve, and may help the drug fund’s sustainability. The accounting system was only fully operated in around 65% of the CHSs. Profit was not one of the things we asked to be recorded, as this is a sensitive issue with potential tax consequences. However the average monthly purchasing of drugs was around US$150, so assuming a 10% mark up, an extra US$15 a month served to supplement salaries which were only $6 a month. This was not a fortune, but was a significant addition.


At the end of a series of training workshops John Chalker presents a participant with a set of posters, a cash box plus padlock and a calculator. Inside the box are all the accounts and record keeping books necessary for one year. All commune health stations received these

Photo: Save the Children Fund

All 217 CHSs eventually received the equipment they requested, although some was delayed because the station did not fulfil the criteria of good prescribing. Using the equipment donation in this way provided a much-needed leverage to give an incentive towards rational drug use.

Patient attendance increased during the project and maintained that level for six months after the project’s end (see Table 1). This may have been in part due to the IEC campaign (see Boxes 1 and 2). This means that although each patient may be treated more rationally, and therefore be given fewer drugs, the overall profit from selling drugs should have increased due to the number of patients being seen.

Table 1

Hai Phong baseline, Hai Phong research and Hai Phong latest supervisors’ reports


Hai Phong Baseline

Research RESULTS

Latest Supervision Reports

Research RESULTS

Latest Supervision Reports


n = 690

n = 1,200

n = 4,050

n = 1,200

n = 6,510

MONTH

August 1994

December 1995

September 1996

Patient numbers per CHS per month

76

115

120

114

137

ITEM/PT

2.3

1.4

1.5

1.5

1.4

% patients given VITAMINS

75%

8%

8%

6%

6%

% patients given INJECTIONS

33%

7%

7%

6%

6%

% patients given ANTIBIOTICS

69%

46%

45%

48%

43%

% antibiotic DOSES OK

29%

91%

98%

93%

98%

% treatments following the STG


92%

93%

86%

95%

The quality of care given to patients improved in the form of better drug and equipment supplies, better staff knowledge in diagnosis and treatment, and above all better prescribing.

It should be emphasised that this was first and foremost a practical project to improve the deteriorating health care situation, and only secondly a research project. The Hai Phong authorities had no interest in research as such, but wanted benefit for their people as soon as possible. The whole project was run on operational research lines. The justification was that all information used should be locally derived to increase the relevance, and that supervision data were a useful management tool and a necessary way of assessing whether equipment should be donated or not.

The project itself was multi-faceted, using innovative together with well-tried techniques that had been shown to work in other situations. This means that we cannot say which part of the project was responsible for its success. However this was never the intention. It is the very multiplicity of approaches that has now been shown to be effective. The innovation is the combination of the factors involved, with particular focus on the conditional donation of chosen equipment depending on good prescribing and the effective setting up of district wide supervision.

For further information on the Programme contact: The Field Director, Save the Children Fund UK, 218 Doi Can Street, Ba Dinh District, Hanoi, Viet Nam. Reports on the Programme evaluations, including the public information campaign, are available from this address. Other publications are pending.

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