chs COMMUNITY HEALTH STRATEGY

Research – Training - Consultancy

Review of the Pilot Application

Integrated Supervision for Quality of Care (IS/QoC) in Private Health Establishments Providing STI Services

in An Giang Province

Prepared by the Center for Community Health Strategy Ha Noi, August 2006

“This study is made possible by the generous support of the American people

through the United States Agency for International Development (USAID).

The contents are the responsibility of the Center for Community Health

Strategy and do not necessarily reflect the views of USAID or the United

States Government.”

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List of contents

1INTRODUCTION ........................................................................................................ 5

1.1 Background information of the STI/HIV/AIDS project and assessment purposes .. 5

1.2 Rational for using IS/QoC as means to enhance public-private partnership (PPP) . 8

1.3 Policy context for supervision of private sector for quality of care.......................... 9

1.4 Structure of the report ............................................................................................. 11

2. METHODOLOGY OF THE ASSESSMENT.......................................................... 12

2.1Conceptual framework............................................................................................. 12

2.2 Assessment criteria ................................................................................................. 13

2.3 Assessment process................................................................................................. 13

2.4 Limitation of the assessment 14

3 FINDINGS................................................................................................................. 14

3.1 Appropriateness ...................................................................................................... 14

3.2 Acceptability ........................................................................................................... 19

3.3 Applicability ........................................................................................................... 20

3.4 Feasibility................................................................................................................ 22

3.5 IS/QoC approach and the PPP 24

3.6 Comparison of the IS/QoC tools used in the public sector and the private sector 26

4. CONCLUSIONS FROM THE FINDINGS 28 5. RECOMMENDATIONS.......................................................................................... 30

5.1 Improving the methodolog...................................................................................... 30

5.2 Policy and strategy.................................................................................................. 32

5.3 Exploring the possibility to selectively apply IS/QoC............................................ 32

5.4 Improving public- private partnership .................................................................... 34

6. CONCLUSIONS 34 Annex 1 IS/QoC methodology ..................................................................................... 36

Annex 2 Inspection system of Vietnam........................................................................ 38

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Acknowledgements

We would like to thank Mr. Le Ngoc Bao and Dr. Dang Van Tuyen from Pathfinder International for their orientation of the project and help with the development of the study questionnaires. We also highly appreciate the support from Dr. Phan Hoang Dao of the An Giang Preventive Medicine Center during the field trip. His patience and enthusiasm has enabled us to finish the field trip successfully. We would like extent our appreciation to Dr. Mai Hoang Anh, Director of the An Giang Centre for HIV/AIDS and Tuberculosis Control for his collaboration and support. We are grateful to all persons interviewed at public and private clinics in four districts in An Giang province. This report can not be finished without their good collaboration.

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List of Abbreviations CHC Community Health Center DHB District Health Bureau DHC District Health Center IS/QoC Integrated Supervision for Quality of Care MOH Ministry of Health PPP Public – Private Partnership RH Reproductive Health STIs Sexual Transmitted Infections PHS Provincial Health Services PMC Preventive Medicine Center

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1. INTRODUCTION

This independent assessment is conducted by the Center for Community Health Strategy

(CHS) at the request of Pathfinder International in order to review the pilot initiative to

introduce Integrated Supervision for Quality of Care (IS/QoC) for quality improvement

of STI Services and HIV/AIDS prevention education and counselling imparted to public

and private health providers in the context of public-private partnership. The consultant

team consists of a medical doctor and public health expert – Dr. Dao Thanh Huyen, and

an economist – Dr. Le Vu Quan with the research assistance of an economic analyst –

Ms. Dao Thanh Hong. The study started on the 3rd of August and ended on the 30th of

August with field work taken place in An Giang from the 7th to 11th of August 2006.

1.1 Background information on the STI/HIV/AIDS service project in An Giang

Since 2004, with a financial support from Pfizer Foundation, Pathfinder International

(PI), in partnership with An Giang Provincial Health Service (PHS), has implemented a

2-year project on “Improving STI/HIV/AIDS Services in Viet Nam: a Model Program of

Public – Private Sector”. The project aims at improving the quality of STI/HIV/AIDS

services of public and private health sectors through fostering the public-private

partnership (PPP) in order to effectively address HIV/AIDS prevention, care and

treatment. Selected private and public healthcare providers were invited to attend courses

on STI diagnosis, care and treatment, HIV/AIDS counselling, and standard precautions

skills. Along with the capacity building for both public and private health providers, the

project has also helped define a mechanism of public private partnership with the

establishment of an advisory group for PPP and involvement of private sector in issues

that concern them.

In August 2005, Pathfinder received a funding from the President’s Emergency Plan for

AIDS Relief (PEPFAR) to continue the pursuit of the objectives of Pfizer Foundation

funded project in An Giang. One of the project activities is the pilot application of a

supportive supervision approach that the public sector can use to supervise the private

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sector. Although the public sector has a mandate to supervise the private sector for

quality assurance, there is a lack of supervision methodology and approaches for the

public sector to supervise the private sector. This pilot supervision model has been the

result of the adaptation of the Integrated Supervision for Quality of Care (hereafter,

IS/QoC), which has been developed and implemented by the Reproductive Health

Projects (RHPs) for the last 5 years. This IS/QoC has been approved by the Ministry of

Health (MOH) for supervision of RH sector. While this approach was proven to be

effective for applying in the public sector for the improvement of the quality of care1, the

pilot application at private sector would provide evidences to the extend the public sector

could use it to supervise the private sector for quality improvement. This is the first time

that this method was applied at the private settings.

To introduce this approach, Pathfinder in partnership with the Preventive Medicine

Centre (PMC) has organized training sessions on IS/QoC for provincial and district

supervisors in March, 2006. The objective of the training is to equip public supervisors

with necessary knowledge and skills to effectively apply the adapted supervision

methodology to supervise both public sector and private sector health services for the

improvement of the STI services and HIV/AIDS prevention.

After the training sessions, a pilot period of the introduction of IS/QoC has been

conducted at the public and private health settings in the area of STIs care and treatment

and HIV/AIDS counselling services. Twenty-five public and private clinics (seven

public and eighteen private clinics) were chosen in four selected districts in An Giang

(Long Xuyen, Cho Moi, Chau Phu and Phu Tan) for the pilot period. The participants

from these clinics were volunteering to participate in this pilot project. After the

selection process, an orientation workshop on IS/QoC methodology, its role and

significance in the context of fostering the PPP was conducted in May 2006 for health

managers, supervisors, and for public and private healthcare providers. After that,

IS/QoC visits were taken to selected public and private health facilities.

1 Cf. Integrated Supervision for Reproductive Health Care, Issue 1, October 2004, The Reproductive Health Projects, Pathfinder International.

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This independent assessment is conducted when the pilot project has been implemented

for almost three months. Each of the selected private and public health providers has

received one or two supervision visits from the public health supervisors from the district

and the provincial level with the support from Pathfinder technical staff.

The purposes of the assessment are:

• To evaluate the applicability, appropriateness, acceptability and feasibility of the

IS/QoC as a model of supportive supervision that the public sector can use to

supervise the private sector in order to improve the quality of STI and HIV/AIDS

services.

• To recommend improvements to the methodology for the use of and to its

acceptance among private sector in the context of PPP for scale up and expansion.

Specifically, the assessment will evaluate the appropriateness of the IS/QoC methodology

(supervisory techniques, tools and strategies, etc.) adapted and applied at the private

health settings and recommend improvements where necessary. The assessment will

investigate the willingness, acceptance, motivation and commitments from stakeholders

to the IS/QoC implementation. It will also explore the possibility and related conditions

for IS/QoC sustainability, e.g., whether it is a potential method that public sector can help

private sector in improving the quality of the STI and HIV/AIDS services, or other any

services, in the context of PPP. To add more value to the assessment, a comparison of

the application of the method for public and private sectors is also conducted in order to

highlight the difference and challenges in the use of the IS/QoC tools in the two sectors.

This would suggest the changes in strategies, tools and processes to make the approach

viable. The recommendations focus on methodological improvements, and on what need

to be done and how to develop the mechanisms and required policies for the

establishment of an enabling environment for adoption of the IS/QoC.

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1.2 Rational for using IS/QoC as means to enhance PPP for improvement of the

quality of STI and HIV/AIDS services

Originally, IS/QoC was developed in response to the identified shortcomings in the

supervision practices within the Maternal and Child Health network of the Ministry of

Health aiming at improving the quality of reproductive healthcare services. In 2004 the

MOH approved the IS/QoC approach for supervision of the Reproductive Health sector.

One of the most important parts is a strong supervision system through which problems

can be found early (or even prevented) and solved rapidly. Good supervision also helps to

ensure that the changes that have been introduced can be sustained.

IS/QoC is based on teamwork, empowerment, accountability and monitoring progress

through measuring change in quality of care from the clients’ and providers’

perspectives. It is a management tool in which clients, providers and managers can

identify quality of care issues through its five sources of data: Self-assessment, Facility

review, Service statistics, Observation of Services and Coaching, and Client Exit

Interview. From these findings, service providers and supervisors work together to

identify solutions and implement improvements. IS/QoC encourages supportive

coaching and modeling by supervisors, as well as the routine use of performance and

client satisfaction indicators to monitor service quality (see Annex 1, IS/QoC

methodology for further details). For supervision of private healthcare providers, all five

components of IS/QoC were applied with the same principles for improvement of the

quality of care as the ultimate outcome. The results which were obtained from a

supervision visit conducted at private health clinics were expected to be the same as those

from public sector: improved quality of care, including improved quality of services and

increased client’s satisfaction to the care they received.

In addition, one of the expectations of the introduction of IS/QoC in the private sector is

the improvement of the PPP. The public sector has a clear mandate to regulate and

support the private sector to improve the quality of its services. This is a delicate task

and must be undertaken in a supportive and constructive way especially in the

hierarchical relationship formed through the examination/inspection roles where the

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public sector regulates and manages the private sector.

1.3 Policy context for supervision of private sector for quality of care

1.3.1 Policy environment

While private healthcare sector in Vietnam has a long history of existence, its roles were

officially recognized under the Ordinance No 07/2003/PL-UBTVQH of the National

Assembly on the 25th of February, 2003 on Private Medical and Pharmaceutical Practice.

The Ordinance provides an overall framework for the private practice and the inspection

and supervision activities to the sector. In the ordinance, the roles of the People

Committees at all levels were mentioned as the “inspection agency” for private practices

with the support from the PHS. Following the Ordinance, the MOH issued Circular No.

01/2004/TT-BYT on January 6 2004, in which Chapter 6 has detailed information on

“Examination, Inspection and Handling of Violations”. Among other objectives, the

circular focuses on the roles of public health and government agencies in the examination

and inspection, and punishment in cases of violation.

Article 76 of the Circular states:

1. At national level: “The Therapy Department, the Traditional Medicine

Department, the Medical equipment and construction Department, Vietnam

Pharmaceutical Management Department and the Preventive Medicine and HIV/AIDS

Control Department coordinate with the concerned departments and the MOH’s

Inspectorate in inspecting the private medical and pharmaceutical practices throughout

the country”.

2. At province level: “The provincial/municipal Health Service is responsible for

organizing the examination and inspection of the private medical and pharmaceutical

practices”.

Article 77 of the Circular states:

“Violators of the provisions of this Circular shall, depending on the seriousness

and nature of their violations be disciplined, administratively handled or examined for

penal liability; if causing damage, they must pay compensation according to law

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provisions”.

The details of the examination and inspection contents of the public to private sector are

documented in two publications:

• Procedures and inspection provisions of private medical practice (MOH, 2003)

• Procedures and inspection provisions of private pharmaceutical practice (MOH,

2001)

These documents define the superior role of the public sector over the private sector. All

the provisions and procedures that the public sector uses to inspect the private sectors are

regulated by the MOH. Among these provisions, quality of care was not a prioritized

issue over other administrative issues.

Apparently, there is a lack of a legal policy framework for the supervision of the private

sector within the healthcare system in Vietnam. The existing legal framework supports

the inspection of private sector by the public sector. It should be noted that inspection

and supervision are not totally the same. While both inspection and supervision have

some similar contents for quality assurance, inspection serves the functions of state

management which heavily focuses on administrative procedures such as license

checking. Inspection looks for violating of the laws and regulations with administrative

measures. Supervision focuses specially on improving quality of care by promoting

behaviour changes under the framework of teamwork and empowerment. Currently,

supervision visits have only been applied in donors’ projects with the endorsement from

the local authorities but without legal supportive system.

1.3.2 Supervision mechanism

As mentioned earlier, there is no legal framework for the supervision of private sector. In

practice, the supervision mechanism is not in place for the public sector to supervise the

private sector. At present, some CHCs conduct supervision of private sector every

quarter, but the majority of them do not perform supervision. In general, the roles of

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CHC in supervision are not clear. There is a routine meeting of private clinics at CHC

for updating information according to individual projects and national target programs.

In contrary with the supervision, there is a clear examination and inspection mechanism

and legal framework for the public sector to examine the private sector (See Annex 2 for

more details of the inspection system). The existing mechanism so far reinforces

examination and inspection which, indeed, sets the notions of the PPP. The “supportive

supervision” or “quality of care” or “client rights” themes are lacking in the existing

system, guidelines, and mechanism.

While supervision and inspection are not interchangeable, the supervision and the

inspection are two systems that may complement each other in assuring quality of care

due to the same nature of facility and skill review under one common framework of

national standards and guidelines.

1.4 Structure of the report

This report is organized as follows. Following the Introduction in Sections 1, Section 2

provides the methodology of the assessment. The findings from the field work are

presented in Section 3. In this section we include the main achievements and challenges

found after the pilot period, stratified into the appropriateness, acceptability, applicability

and feasibility of IS/QoC in the context of PPP including technical components and

financial and human resources. Section 4 summarizes the assessment criteria. Section 5

offers recommendations based on the findings from the field work. Our recommendations

focus on improving the IS/QoC methodology including revision of IS/QoC content,

related policy and strategy and possibility for scaling up and expansion of IS/QoC in the

context of PPP. Section 6 concludes the report.

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2 METHODOLOGY OF ASSESSMENT

2.1 The conceptual framework

In order to understand the concept of IS/QoC and how it is practiced in the context of

PPP, the CHS team applied qualitative method. The team worked closely with PI staff in

Ha Noi and the project personnel at the site in An Giang to design detailed questionnaires

for the assessment. In-depth interviews (IDIs) and clinic visits were conducted to collect

information. There are four targeted groups were called for interview: (1) Policymakers;

(2) Supervisors; (3) Supervisees (private and public clinics); and (4) Clients. These

targeted groups were analysed in the interaction within an enabling environment for the

operation of the IS/QoC. Enabling environment includes policy, system and mechanism,

as well as norms which define the applicability, the acceptance and the feasibility of the

supervision tools. The enabling environment also involves the public-private partnership

context and its defined authorization. The framework for the assessment is summarized

in Figure 1.

Figure 1: The conceptual framework for the assessment

Policymakers Health

Supervisors Supervisees

Find common grounds on appropriateness, acceptability, and feasibility of IS/QoC in all three groups.

ClientsIS/QoC

Improving the quality of

STI/HIV/AIDS Services

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2.2 Assessment criteria

There are four issues to be addressed in the assessment: (1) Appropriateness; (2)

Acceptability; (3) Applicability and (4) Feasibility. The four issues will be assessed to

answer the following questions:

Appropriateness: Does the supervision meet the expectation for a supervision visit? Does

the IS/QoC approach help to improve the relationship between public and private sectors?

Does it help to improve the quality of care in the private sector?

Acceptability: Should IS/QoC tool be used for supervision of private sector? What are the

possible benefits that the partnership built from integrated supervision could bring to the

private sector/supervisors/clients? Who are the possible losers in IS/QoC application?

Applicability: Did IS/QoC tool help the private clinic/supervisees solve their critical

problems? What is the level of impact? Could each of the five IS/QoC components be

applied in the private clinic settings?

Feasibility: Could IS/QoC visits feasible financially and technically (in terms of finance

and human resources)? What is the motivation and commitment for the continuation of

the supervision visits to private sector? Is there an enabling environment for the operation

and continuation of the tools?

2.3 Assessment process

CHS team worked in three districts of An Giang (Long Xuyen, Cho Moi, and Phu Tan).

We visited and conducted a total of 14 interviews. They are as follows.

- 1 official from the District Health Bureau

- 1 officials supervisor from the Provincial Health Service

- 1 inspector from the Provincial Health Service

- 2 officials from the Preventive Medicine Centre

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- 2 supervisors/lecturers from the province

- 2 supervisors from the districts

- 2 supervisees from public clinics

- 3 supervisees private clinics

We planned to observe one supervision visit to a private clinic to assess the applicability

of the IS/QoC methodology. However, due to the change in the schedule from the

project personnel, the observation could not be taken.

2.4 Limitation of the assessment

The clients (patients) are the direct beneficiaries of the IS/QoC. However, since this pilot

has only been implemented for three months and it was difficult to encounter a returned

client who could tell the changes in the service provision during a short field work, our

team was not able to assess the clients’ benefits. We could only review the filled client

exit interview forms provided by the supervisees and explored the personal view of the

supervisors and supervisees regarding client benefits resulted from IS/QoC.

In addition, due to limited time of the pilot application, the assessment at this point of

time might not reflect exactly the view of supervisors and supervisees as if the

supervision activities would have been in place for a longer period of time when

supervision activities are more stable and repeated routinely.

3. FINDINGS 3.1 The appropriateness of the IS/QoC application at the private healthcare clinics Expectation for a supervision visit:

The common notion that both supervisors and supervisees expressed was that supervision

visit should provide an opportunity for an exchange of information and professional

knowledge and skills aiming at improving the quality of care. According to the

supervisors we interviewed, a supervision visit should assist private clinics to improve

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the “clinical standards” which in turn will benefit the clients. A supervisor should

support private clinics to improve the quality of care, such as improving the facilities for

infection control. One supervisor noted, “The condition of the private clinics is not as

good as that of public facilities, there is no privacy and no infection control. Our

objective is to assist them to create an environment equipped with these facilities (a roller

blind and a hand-washing sink), given their limited space and financial resources.” The

supervisees want to receive from a supervision visit updated information and new

knowledge. This wish was repeated among different supervisees:

Supervision should provide us with updated information.

A supervisee

They also compared supervision and inspection due to the confusion of the terminologies,

and somehow same contents of the two tasks (e,g, facility review, client records, clinical

observation, etc). They agreed that although both supervision and inspection aim at

improving quality of care and can complement each other, the operations should be

different with the separate systems. While the latter plays the role of “state management”

focusing on administrative procedures, the former is more supportive and informative.

However, they are not interchangeable, supervision cannot replace inspection.

While an inspection visit focuses on assigned standards and administrative management

procedures, a supervision visit focuses on technical aspects, such as diagnosis and

treatment, infection prevention techniques, and availability of medical instruments.

A supervisee

Inspection follows the principles from the Ministry of Health and the Health Service;

supervision is just focusing on examination and treatment. The two are totally different

and both necessary.

A supervisee

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How does the IS/QoC meets the above expectations?

The good thing about IS/QoC is it is highly supportive.

A supervisor

IS/QoC has met the expectations of the supervisors and supervisees in the following

aspects:

• A friendly and supportive atmosphere has been built up between the supervisors

and the supervisees in IS/QoC, which was not found in other inspection missions.

The supervisees feel confident to raise questions and to ask for help. The

supervisors have chances to provide feedback and coaching if needed.

• During the supervision visits supervisees received guidance and technical support

from supervisors.

Both supervisors and supervisees were satisfied after the supervision visits. Supervisees

expressed their wish to receive more supervision visits with the IS/QoC approach like

what they have received in the past three months. However, many visits during a short

period of time, e.g., more than one time per quarter, can cause inconvenient to the visited

clinics, because these visits can be confused with inspection visits that often occurred

when the clinic had a fault or a problem.. A supervisee argued, “Although IS/QoC has

helped me to gain more knowledge to treat STDs patients (one successful case in

particular), my clients do not like to see the clinic being visited regularly (4-5 times so

far)2 because they do not understand the difference between supervision and inspection.”

In terms of the supervision frequency, most people said that 2-4 times per year is

appropriate.

The appropriateness of individual components

Self assessment was praised as useful tool to involve supervisees and to put them at ease 2 It is required to do one visit per quarter, but in some places, more than one visit had been made from March to August, in which, one visit was conducted during practicum training and two other visits were made during the pilot period.

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to express themselves. This makes the IS/QoC different from traditional supervision

methods from top down level.

Self assessment is good and I have applied it to other fields.

A supervisee

In terms of client exit interview, there are conflicting reports about its appropriateness.

Some interviewees thought that client interviews are not appropriate at the private

healthcare settings due to a number of reasons. Most of the clients at private clinics are

those who have a close contact with the health providers such as their neighbors or those

living within the nearby areas (especially in the rural areas); giving evaluation in paper

sounds unfamiliar to their clients because they can provide direct verbal feedback. In

addition, the interaction between private health providers and clients is favorable and

clients can express themselves easily. Another reason is that clients of a private clinic

often highly value the clinic and they come with a prejudice in favor of the health

provider and a satisfactory attitude, which can lead to a bias in their evaluation. One of

the examples of the satisfaction was that almost all answers in client exit interview forms

collected were given highest scores without any comments. Thus the client exit interview

data is not statistically reliable to evaluate the satisfaction of the clients.

When I told the clients to fill out the client exit interview form they said that it doesn’t

matter; the most important is that you (the service provider) cure my disease. If the

disease is gone I will come back again when I’m sick, if not I will not come back.

A supervisee

The private health providers also consider their clients as “the king” – a good client-

centered approach. In addition, one estimated that about 7% of the clients are illiterate

female, and therefore they can not fill out the exit interview form. These phenomena

suggests alternative ways to get clients’ evaluation of the services, such as frequent ask

for informal feedback from clients by providers, more open ended questions rather than

questions for scoring, or spreading out the intervals for getting client feedback.

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Other supervisors and supervisees showed their strong support the client exit interview,

and saw that this activity helps them improve their services. One interviewee commented

that “Client exit interview is a necessary component of IS/QoC. It provides a channel of

anonymous communication between the private clinics and the clients. Nevertheless,

client exit interview can only improve the quality of care if the private clinics take action

to address the concerns of the clients. Not all concerns were addressed by private clinics

because of the financial and technical constraints”. This supports client interview form

in addition to other approaches to get feedback from clients (e.g, direct feedback). And

as the interview pointed out, it is essential that private providers need to realize the

importance of taking client perspectives in order to take actions.

With regard to facility review, it is very useful in helping private clinics to improve the

organization of services, privacy for clients, and safer working environment. However,

the impact of this activity is questionable after several visits, when small changes have

been made. In reality, private clinics often have a simple setting (some clinics just have a

bed and a table), organization of services is therefore very simple. Most of the private

clinics we visited are located together with the residence of the service providers. They

have narrow, limited space and inadequate conditions. Private health providers can make

necessary changes following the recommendations of supervisors right away if the

change is feasible to implement. In other cases, interviewees noted that “Facility cannot

be improved due to limited resources…” This may imply necessary conditions to make

sure that facility meets the required standards and ensures the quality of care, such as: 1)

Facility standards should be made sure right from the licensing process. This is most

feasible or 2) Financial support is provided for quality improvement if needed (this is not

feasible, though). It should also be noted that facility improvement for ensuring quality

of care is an on-going process as the services develop. This needs great internal

initiatives and should be reinforced in the IS/QoC training.

There is one component of the IS/QoC that most of the interviewees thought it is not

appropriate in private clinics, that is the client statistics. In fact, client statistics from

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private sector are not reliable and not accurate (due to the issue of taxation). In addition,

in the case of STI/HIV/AIDS, the number of the clients coming to a private clinic was

very small (1-2 clients per year). Thus there was no impact from this activity.

3.2 The acceptability of the IS/QoC within the private clinic context

According to health policymakers, and from both supervisors and supervisees

interviewed, IS/QoC is acceptable for use within the private sector and can strengthen the

PPP. It even further stressed that IS/QoC should be used to support private health

providers in building PPP.

Routine supervision should be applied to the private sector in order to improve the quality of care.

A supervisor

Supervisees see the benefits of the supervision visits as noted: New information was given during each supervision visit. A supervisee Even though supervisors are ready to supervise private clinics, but they see themselves as

“the possible losers” in terms of time and finance. They expressed that they would do if

their leaders assign the task to them. This further endorses the fact that there has not been

a policy and mechanism for supervision of private sector. It this activity is taken

routinely, it is necessary to develop a policy and a working mechanism for IS/QoC for the

private sector.

Observation of services, even though useful for coaching and feedback, it is difficult and

not always acceptable at private clinics. Clients did not always accept to be observed

when coming to a private clinic and health providers felt inconvenient when being

observed. However, observation of services is to monitor the level of providers’ skills in

providing services and to provide coaching if needed. An alternative way than direct

observations can be used to identify gaps in providers’ clinical skills is to have

observation of services during training sections at hospitals and training sites where

patients are well informed and volunteer for this. Other way is to do clinical practices on

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models in order to find gaps in the skills.

3.3 Applicability of the IS/QoC at the private clinics

The questions of applicability here is whether the tools can be used within the private

settings and for what purposes. IS/QoC is applicable to the supervision of a private clinic

for the purposes of technical support, technology update and information sharing.

IS/QoC is beneficial in providing updated information, new knowledge, and new

treatment protocols, resulting in more effective care and treatment.

A supervisee

Facility review can be implemented to a private clinic, but the effectiveness is dependent

on supervisors:

The supervisors visit many clinics, they have a broader view than me and they can

provide advice, e.g., recently a supervisor advised me to install a hand-washing basin.

But this (the capacity to provide advice) is dependent on the supervisors.

A supervisee

Client exit interview can be done at the private settings, but the effectiveness is not high

as mentioned in the above section on appropriateness. In addition, most of the clients of

the private health clinics are repeated clients; they would not fill out after every visit.

This can be taken into consideration for guiding the use of the tool.

Client exist interview is a new idea with unknown effectiveness, but should be applied.

A supervisee

They just filled in once, the next time they would not do it again.

A supervisee

Observation of services can not always be carried out. In the STI/HIV project, it is rarely

to meet a STI client during a supervision visit. Instead, the supervisors discussed with

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the supervisees about the treatment protocols and “check if the supervisees still

remember”.

Client statistics are not always applicable because the data collected from private sector is

not reliable. The barriers for data collection of private sector include: 1) The level of

awareness on the use of client statistics is still low; 2) The impact of reporting client

volume on the taxation payment prevents the providers from reporting the true number of

clients; 3) In case of STI and HIV/AIDs, the client volume is small (1-2 clients per years)

the data collection seemed not meaningful.

Client statistics from the private sector are not real.

A supervisor

Doing business in a private sector, we want to keep our work secret.

A supervisee

Self assessment was considered a communication tool for supervisors interact with

supervisees and it is applicable at private setting. Overall, IS/QoC indeed helps health

providers at the private clinics to improve the quality of care. However, it was stressed

that the changes should not be costly and should not require dramatic infrastructure

renovation, given the limited space and resources from the private sector, as noted in the

section on appropriateness above.

Most of the supervisors feels confident in using the IS/QoC tools, with the support of the

checklists provided by the IS/QoC handbook. They praised the checklists as useful tools

for supervision, and they need more checklists for supervision. Some supervisors would

like to separate the checklists to the IS/QoC handbook, because they would use the

checklist regularly during each visit. Some expressed the concern about the

inconsistency between the checklists in the IS/QoC handbook and the inspection

provisions of private medical and pharmaceutical practices set by the MOH (e.g., facility

review checklist). There is a need for making the checklists more consistent with the

criteria set by the MOH.

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3.4 Feasibility of the IS/QoC at the private clinics

Policymaker and both supervisors and supervisees thought that supervision should be

conducted to support private health providers. However, there are several constraints that

prevent the IS/QoC from applying to the private healthcare settings.

Policy environment: there is existing policy for the inspection and examination and a

clear mechanism/system for inspection. However, at present there is no supervision

mechanism/system, particularly supervision policy for the private sector. It is stressed

during the interviews that supervision is different from inspection. While inspection is

mandatory and necessary, the supervision should have its own system to support the

inspection process, in the way that supervision provides advice of standard practices for

the preparation of inspection. A health service manager made a point during the interview

that, “Inspection from PHS is not sufficient enough to ensure the quality of care in the

private sector. IS/QoC provides more necessary tools. However, the current policy for

supporting IS/QoC has not been in place”.

Human resources: IS/QoC requires a fair amount of person-time from supervisors, e.g., if

each supervision visit involves one to two supervisors, thousands of supervisor-time are

needed each year to supervise thousands of private clinics in the whole province.

However, there are limited human resources at the district and provincial levels to

provide supervision of private sector. At the commune level, human resources are more

feasible; however, there is not a clear mandate for a CHC to supervise the private sector

independently. In addition, the capacity of a CHC to supervise a private clinic is also

questionable, especially in the context that there are different levels of medical

professionals practicing in private health services. For example, in terms of professional

status, it is difficult for a nurse from the CHC to perform supervision to a private clinic

operated by a doctor. Or in another scenario, a retired experienced doctor can be

supervised by a young inexperienced doctor. One policymaker cautioned, “the seniority

complex is a sensitive norm that must be overcome in order for the supervision to be

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successful”. This issue can make the supervision at the commune level not effective. This

is also true at district level. One suggested that there should be a medical professional at

provincial level (e.g., provincial hospitals) among supervision team to provide technical

support if needed.

It is also clear that there has not been in place human resource established for supervision

of private sector. In the pilot period, some HS staff who were involved in inspection

visits were also chosen to be supervisors. The double roles of these staff made the

supervision visits difficult. One noted “It would be more convenient if a supervisor

should be a different person than an inspector, otherwise they (supervisees) are afraid”.

Financial resources: financing is also a problem for sustainability. Currently, there is no

budget allocation for the public sector to supervise the private sector. In addition,

transportation and allowance are costly if district and provincial staff supervise the

private health providers. There is only a limited budget allocated to the province and

district to inspect a certain number of private clinics annually.

The most constraint for the supervision of private sector is the financial issue.

A supervisor

Timing issue: at present, most private health providers are “semi-private”; they work for

the public sector and open their private practices before and after official hours.

Therefore, reaching them to provide supervision is difficult and not feasible in the long

term. However, for those who are “real private”, the opening hours is the whole day, the

supervision can take place during official hours.

If there is an involvement of the private sector for training, timing is also a problem.

Their (private sector) knowledge is outdated but when we invited them to a training

session they did not participate due to the fear of time loss

A supervisor

If the training is only one day we can attend.

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A supervisee

There is also an opinion that IS/QoC is more feasible if being used for training follow up,

when all of the tools, e.g., observation of services with coaching and feedback, and

helping with organization of services, are highly applicable for supporting the

participants to apply the knowledge gained from a training course. As the time for

training follow up is limited,3 there would not be a big problem for human resources and

financial issues.

It would be better if private health providers are invited every three month for receiving

updated information. Supervision visits cannot cover many private clinics.

A supervisee

There is a common theme from the interviews that IS/QoC’s benefit is the provision of

updated information. For this issue, alternative methods to supervision for providing the

private sector with information can be considered. However, it is noted that only

providing update information does not guarantee quality improvement.

In fact, there is regular monthly meetings hosted by the CHC or the District Health

Bureau, which provides information and instruction from different national targeted

programs so that the private sector can collaborate for a common purpose. The

information given seems limits to the national targeted programs and the current

outbreaks, while there is no other updated information for professional development.

3.5 IS/QoC and the PPP

There are a number of evidences showing that IS/QoC improves the partnership between

public and private sector. First, IS/QoC did improve the supervision environment.

Supervisors were praised for their friendly and supportive roles. They performed

coaching and provided updated information as well as instruction for improvement of

client flow and organization of services. IS/QoC could be even more helpful if

supervisors were doctors at provincial and district levels, those who are more competent

on professional knowledge and respectable in the medical community. 3 Normally, a training follow-up takes up 2-3 visits.

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I want to be supervised by supervisors at district or provincial levels, who are more

competent.

A supervisee

Second, private health providers take a more active role during the supervision visits

instead of a passive role during the inspection visits because it is easier to communicate

with the supervisors than with the inspectors. The supervisees also know that the

supervisors are there to help them rather than pointing out violations for fining as in the

case of an inspection visit. Third, IS/QoC can make the work of inspection more

effective, if the content in the IS/QoC training material is consistent with the inspection

content. From a point of view of an inspector, one noted, “if the supervision is being

carried out thoroughly and consistent with the inspection procedures and guidelines, the

job of inspecting the private clinics would be a lot easier for the inspection team and less

stressful for the private health providers.” This could definitely strengthen the

partnership between the public and private sector in health services according to one

inspector interviewed. IS/QoC has changed the dynamic interactions between two

sectors and it connects two sectors.

When we come they (private sector) like it very much because they know that we come to

support them. Especially some private health providers who are no longer working in

the public sector want to network with public sector to have updated information.

A supervisor

It should also be noted that the IS/QoC could make some initial change for the

partnership related to information giving to the private sector and the new interaction it

can establish. However it did not touch the foundation of the partnership – the inferiority

that the public sector sees the private sector and the absolute role of public sector over the

private sector – which are not within the supervision scope. The private sector is still

standing outside of the health system.

Private sector feels inferior to the public sector, they are not self assertive. Their

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knowledge is always outdated.

A supervisor

Private clinics are not allowed to sell and to administer medicines but they do that

illegally; they do not comply with the regulations of the government. That’s why they do

not want the public sector/the government officials to visit their clinics.

A supervisor

It is also noted during the field visits that most of the “real private” health providers are

assistant doctors or assistant nurses while most of the “semi-private” health providers are

doctors. “Real private” health providers are those who left the public sector and work full

time at their private clinics. “Semi-private” ones are those who work for the public sector

during official hours and work for private sector (e.g., at their clinics) after official hours,

who have better access to information and have connection with the public sector. While

a majority of private health providers in reality are “semi-private” (some estimated that

70% of private health providers are those “semi private), there is a small number of

health providers who lack a connection with public sector and lack access to information.

This might have implication for PI in the future when considering the target groups for

intervention, i.g, to choose “real private” health service providers to provide information,

training and coaching and to strengthen their partnership with public sector.

3.6 Comparison of the IS/QoC tool used in the public sector and the private sector

While there is only inspection mechanism for private sector, the inspection and

supervision system is clearer with the public sector. The supervision system called “chi

dao tuyen” has been functioning within different networks: the maternal and child

healthcare network, the preventive network (based on different national targeted

programs) and the curative network. Private clinics have regular monthly meetings

where they can receive updated information from the public sector.

Even though most of the interviewees thought that IS/QoC should be used for both public

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and private sectors, when discussing individual components/tools of the IS/QoC, the

application of the tools for the two sectors is somewhat different.

The facility review and the observation of services were identified by the interviewees as

more useful tools if being applied at the public sector. Public sector often has complex

structures involving different departments and authoritative structures; the facility review

could help improve the client flow and the organization of services. Private sector often

has simple structure, and the client flow is often not an issue. Client volume in the public

sector is often higher than in the private sector, especially in the case of STIs. It is more

likely to observe a STI client in a public dermatology clinic rather than in any private

clinic. Client statistics is also an issue for the private sector, while it is a strong tool for

the public sector where the client load is high and the data is reliable. Report of the total

client load is often not reliable for the private sector with the reason mentioned above,

especially if the client volume is high. This suggests that client statistics report for the

private sector should target specific issues with clear purposes rather asking them to

report their total number of clients coming to the clinic.

Most of the private health providers thought that client exit interviews are even more

necessary for public sector where the ownership, the responsibility and accountability of

individuals are not as high as private sector. Client exit interview will be a good tool to

receive a reflection from the clients and to keep track of the quality of care. This stresses

the necessity of client exist interview for the public sector, which does not mean

undermine its importance for the private sector in getting feedback from clients.

I think it would be best if client exit interview is used for the public sector where the

responsibility is not high because of the low ownership from public health providers – the

responsibility belongs to the collective, not the individual.

A supervisee

In a public clinic, it does not matter if the attitude of the health providers is not positive.

But if it happens at private sector they will lose clients.

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A supervisor

The motivation for the application of IS/QoC is also different for public and private

sector. Private sector wants to improve the quality of care to attract more clients in order

to generate more profits. They actively found ways to improve their services and

considered clients as “their kings”. For public health providers, the motivation for

applying IS/QoC is different. They are pushed by their supervisors and their leaders to

improve their services. They have clear annual targets to follow and to monitor. IS/QoC

could be a conductor where the supervisors/managers can use to monitor the

improvement of the quality of care and the implementation of plans. This could be

applied for the private sector. Indicators on quality of care can be set and monitored by

the public sector or a managing organization.

However, it is quicker for the private sector to implement the action plan compared to the

public sector where the bureaucracy and the hierarchical approval process are long.

Public sector implements (action plans) slower: anything which relates to financial

issues need to wait for the leader’s approval.

A supervisor

IS/QoC is more feasible for the public sector in terms of time, human resources and

financial issues. While the public sector is limited in number, there are thousands private

clinics in the entire province. The human resource available at province and district

levels is far from adequate to assume this task. In addition, most of the private clinics

work before and after official hours which makes the supervision visits more difficult.

Besides, there is a mechanism in place for supervision of public sector, but there is not a

clear mechanism for supervision of private sector.

4. CONCLUSIONS FROM THE FINDINGS

In general, IS/QoC help improve the quality of care at private health settings and

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facilitate the good interaction between supervisors and supervisees. There are different

levels of appropriateness, acceptability, applicability and the feasibility among different

components when they are applied at private sector:

• The appropriateness: High

IS/QoC is highly appropriate to apply in the private sector as well as the public sector

aiming at improving the quality of care. IS/QoC can facilitate changes and create a

supportive environment for learning and sharing information. In the case of

STI/HIV/AIDS, the result was also positive. Private sector had a chance to learn new

skills (especially STI/HIV counseling) and applied what they learnt in their practices.

• The acceptability: Medium

IS/QoC is acceptable within the private sector. However, numerous visits might have

negative impact to the reputation of the private clinics. Observation of services is not

always acceptable by both clients and health providers.

• The applicability: Medium

Overall, IS/QoC is applicable to the private settings. Components including self

assessment and facility review are highly applicable and effective in the way they

promote participation, active learning and using client perspectives. However, client

statistics is not always applicable due to the unreliability of the data. Observation of

services is not always applicable, especially for a specific case such as a STI client due to

a small number of clients. Client exit interview filled by clients is not applicable in

certain situation, especially when the clients are the clinic’s regular patients or those who

cannot read and write.

• The feasibility: Low

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There is a lack of policy and mechanism for supervision of private sector. Human

resources constraint is a problem if the district and provincial level conduct the

supervision of private sector. Financial constraint is also a barrier with high cost of

transportation and allowance for supervisors. Currently, the only connection between

public and private sectors so far has been established through inspection mechanism, and

monthly meeting organized by the CHC.

• The impact of IS/QoC: Medium to High (on the work of private health providers)

IS/QoC has brought new knowledge, information and standards to the private sector.

They wish to receive more similar support in the future. Positive changes were

mentioned through the IS/QoC visits such as arranging new lavatory for hand washing

after each client, or a blind curtain to set a private place for examination of clients.

Supervisees saw that the impact of these visits to their work as “medium”, some

evaluated “high”. Supervisors thought that small changes could be made very quickly at

a private clinic, but if the changes require high cost or need a radical change in

infrastructure (e.g, separate place for waiting and examining clients) it would not be

feasible. IS/QoC also bring new momentum for improving the partnership between

public and private sector in terms of supportive attitude and networking.

5. RECOMMENDATIONS

5.1 Improving the methodology for application of IS/QoC to the private sector:

Revision of IS/QoC module and content for supervision of private sector

• It was found from the assessment that not all of the IS/QoC tools which has been

used for the public sector are applicable at the private health settings. The tools

which are most appropriate were self assessment, facility review and client

interview, even though these tools/components should be further revised. The

new way of interaction with clients, the counseling skills that the IS/QoC has

transferred to the private health providers, and the friendly styles from the

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supervisors are the new skills and behaviors that proved to be effective in

contributing to the improvement of the quality of care. The revision of the

IS/QoC can focus on these components which work (self assessment, coaching,

intercommunication skills, feedback skills and behavior styles with client

perspectives). These are also “cross-cutting components” that can be used in any

context and setting in health service provision, not only in case of STI care and

treatment. Some revisions of the IS/QoC content can be:

Facility review: It is noted that private sector has limited resource

to build their clinics; however, the facility should meet basic

standards for quality of care. In facility review content, basic

concepts for quality of care should be introduced, such as privacy,

infection control and necessary information and instruction

provided to clients. Hands-on experiences can be enhanced, such

as introduction of facility models for private sector. The required

standards from the MOH should also be included (e.g, the

requirement of the area for establishing a private clicic).

Client interview: Client interview can be optional with different

approaches, e.g., frequent asking for direct feedback, more open

ended question rather than questions for scoring in the interview

form, and the frequency for asking feedback from regular clients.

Private providers can decide on which approach fits best in their

context.

Client statistics: there should be clear on the benefits of client

statistics and how it is applied in private setting, especially in case

the client volume is small.

Observation of services: it might be difficult to observe a client

with specific diseases like HIV/AIDS in order to provide coaching.

While observation of services is necessary, other methods to

support private providers can be introduced, such as practice on the

models for coaching.

The IS/QoC handbook should have standardized checklists which

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include the requirements from the MOH and consistent with the

inspection provisions to support the inspection provisions, e.g.,

checklists for facility review and availability of essential and

emergency drugs. (Please note that IS/QoC is to improve quality

of care while inspection is to ensure that standards are followed,

they are separate and complementary).

5.2 Policy and strategy

Despite the fact that the public sector regulates private sector under inspection

framework, supervision of private sector requires great additional effort, which

is not feasible for the existing resources; e.g., finance constraint and the lack of

human resource. However IS/QoC can be applied in certain context (such as,

improving the care and treatment of specific disease like the case of STIs at

selected private clinics). This can be done through a specific project targeting

specific disease in the form of training follow up or even routine supervision

when resources are available. If this is done, a policy and mechanism should be

provided by the Health Services for supervision of private sector.

It can also be thought of different mechanism for improving quality of care of

private sector, e.g., periodic update training of professional skills and strict

provisions on ensuring quality of care regulated by the public sector (which can

be related to licensing process).

5.3 Exploring the possibility to selectively apply IS/QoC within the existing

inspection/supervision system

• The current inspection system is in place at the provincial and district level, in

which the provincial and district levels have inspection authority (with the highest

authority is given to the provincial level). Commune level provides update

information and supervises private sector under the authorization of the district

level. Private sector expects that provincial and district supervisors/inspectors to

change their inspection style to be more supportive. This is an area that IS/QoC

methodology can be replicated, with the application of cross-cutting themes such

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as the supportive supervision style, the interpersonal communication skills, and

the quality of care with client perspectives.

Involvement of the Inspection Department of the Provincial Health Service in

IS/QoC training: The Inspection Department of the PHS has the highest

authority of inspection in the province and is providing training to the staff of

the DHB in inspection. They have high influence on inspection/supervision

behaviors at provincial and district level. With their involvement in the

training, the interpersonal interaction between the inspectors, the supervisors,

and the supervisees could be strengthened.

Providing commune and district level updated information so that they can

transfer the knowledge to the private sector: One of the biggest challenges for

the private sector, especially for those who are considered as “real private” in

the rural areas, is the lack of updated information and knowledge of national

standards. During the interviews there is an expression of the need from

private health providers to receive updated information and support from the

public sector, and networking opportunity. This has also been praised as the

most useful feature of the IS/QoC when the supervisors provided the

supervisees with updated information and standards through coaching and

feedback. At present, the commune level is responsible for providing updated

information to the private sector and supervision of national target programs

at least one per month. This system has been effective in remote areas where

most of private health providers are not doctors. It could be considered using

this existing channel for providing private sector with updated information,

with support from the district health and province health staff. It is cost

effective (larger number of supervisees involved in a meetings and

workshops) compared to IS/QoC for the purpose of providing updated

information.

IS/QoC can be used in follow-up training for a specific disease update such as

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STIs management: With coaching and feedback techniques

supervisors/trainers can support trainees to apply the knowledge/skills gained

from the training. Other techniques including analysis of client statistics and

facility review can also help trainees to apply updated

information/knowledge/standards. In addition, IS/QoC used in follow-up

training is more feasible in terms of human and financial resources if used

within a certain period of time.

5.4 Improving public – private partnership

In terms of the partnership between public and private sector, one of the

findings is that the private sector is working relatively outside of the health

system. IS/QoC has promoted the partnership and enhanced the connection

between two sectors. However, public sector can also change the way it works

with private sector and make private sector a part of the health system by

involving private sector in a network for exchange of information, knowledge

update and establishment of referal network which includes private sector.

6. CONCLUSIONS

The public sector regulates private sector through licensing process and inspection

mechanism especially when faults are reported. However, this mechanism has not

promoted quality of care as an important part of health service provision. This should

be considered further in inspection strategy to improve quality of care. In addition,

improving the quality of care of the private sector can be done through different

mechanisms, such as through IS/QoC, through training to provide updated

information, and strict provisions on quality of care that could be related to licensing

process (e.g., certification of certain techniques or periodic training in order to

maintain practice license).

Even though a good method for improving quality of care at the private sector,

especially in providing update knowledge and skills, IS/QoC applied for supervision

of private sector by public sector is not feasible in terms of human resources and

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finance. In addition, there has not been in place a policy and mechanism for

supervision of private sector. However, IS/QoC can be applied in certain context,

e.g., within a project to target specific disease with targeted private clinics when

resources are available. In addition, the good features of IS/QoC can be explored

further in other areas, e.g., training of IS/QoC for inspectors in order to build up

supportive supervision style. IS/QoC is good method in training follow up to help

trainees apply what they learnt. IS/QoC approach also helps facilitate the dynamic

change in PPP; however, the PPP should be institionalized by recognising private

sector to be a part of the health system through networking, information sharing and

referral system.

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Annex 1: IS/QoC Methodology

IS/QoC involves five components: client interview, facility review, observation of

services, service statistics review and self assessment:

1. Client Interview: This is a tool to measure QoC from the client’s perspective.

Clients are asked to fill out a number of questions on the quality of care they have

received after each visit. Client exit interviews are done regularly along the

supervision intervals. The results are analyzed to identify progress or problems of

the quality of care.

2. Facility Review: This is an evaluation of the site by the supervisor and the site

manager using client perspectives. A checklist can be used as a guide for facility

review.

3. Observation of Services: The observation is conducted by the supervisor during

IS/QoC visits with the support of clinical checklists. The supervisor then provides

feedback and coaching as needed in order to help supervisees improve their skills

and knowledge.

4. Service Statistics Review: The supervisor and the staff member responsible for

data collection review and analysed the service data, which are collected during the

supervision intervals and before supervision visits, to identify problems as well as

to monitor the progress of quality improvement.

5. Self Assessment: This is a participatory process for supervisees to identify and to

solve their own problems. Supervisees are asked what worked and what need to be

improved, The problems will be solved, altogether with the problems found from

other sources, by the supervisee with support from the supervisor.

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Figure A1. IS/QoC as a tool for supervision practices

Service Statistics

ACTION PLAN

IS/QoC Visit

Self Assessment

Observation of Services

IDENTIFICATION OF PROBLEMS

Improvement in Quality of Care

Follow Up

Facility Review

Client Interview

Feedback And

Coaching

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Annex 2: Organization of the Inspection System in Vietnam

In each province, the examination and inspection system is established at the provincial,

district, and commune levels.

At the provincial level, the Inspection Department of the PHS has the highest inspection

authority, while the Professional Department supports all technical aspects of the

inspection team. The Inspection Department primary function is to conduct annual

inspection to the private sector or in the cases of reported violations. According to an

inspector, there is about 20-30% of private clinics are inspected randomly annually. The

Inspection Department also provides training to the newly formed District Health Bureau

(DHB).

At the district level, the DHB under the District People’s Committee is responsible for

inspecting private sector for every six months. Because of the high number of private

clinics, the Department only conducts spot-check to private sector clinics.

At the commune level, the Commune Health Center (CHC) has no responsibility in

inspection, but it can accommodate the DHB during inspection mission.

During the examination/inspection visits, there are facility review (medical equipments

and drugs), statistic checking and administrative checking (mainly on licensing issues).

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Figure A2: Organization of the Inspection System in Vietnam

Government Inspection

Government

Ministry of Health

Health Inspection Board

Provincial People’s Committee

Provincial Health Service Provincial Inspection

Inspection Department

District People’s Committee

District Inspection District Health Center

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