Evaluation of allocation and use of health financing in nam dinh province

Based on the calculated demand shorttầll, assess the current íinancial ĩsurces and trend analysis o f tìnancial resources can be offset in time to ían Dinh province, the author m akes a

11 NAM DINH PROVINCE

A u lh o r: Ninh Thi Hoai Thu

Supervisor: Dr H ans B lom kvist

l.o cu l Supervisor: I)r N g u y ên Phu Ha

The thesis has been carried out by thc author NinhThiHoai Thu in the ìmevvork o f the M aster’s degree program o f Public M anagem ent -U p p s a la Jẩversity It is certain that the thesis vvould not be fulfill well without the ỉnhusiastic help o f the Svvedish and Vietnamese instructors and a num ber o f eders and governm ental officials o f institutions related to the research field.

I am m uch obliged to Dr Hans Blomkvist - Uppsala University, Svveden

vb has offered very clearly oriented guides in the process o f my selecting oúcs and launching research, Dr Nguyen Phu Ha, leading me in the esarch process, giving me more knovvledge and helping me resolve liíìcultiesduring the whole process

I sincerely thank the lectures w ho were enthusiastic to impart useful navledge ot' the public m anagem ent o f the entire course Thanks for the

u p o rt o f the Universitv o f Econom ics and Business, o f coordinators and Ttgram m anagers who have created tầvorable conditions for the course

I am gratetul to the leaders and experts o f the Departm ent o f Planning

n F inance - Ministry o f Health, thc leaders o f Health Department o f Nam )ih province for their providing materials, answ ering in interviews and

ra tin g íầvorable conditions, which enables me to perlorm the subịect and

c e s s to data sources

It is also impossible íor me to tbrget the good feelings and thc support o f

11 c lassm ates, friends, colleagues who contributed their ideas, provided 'Ìtirmation to me during my fulfilling the thesis work

Y o u rs faithfully,

Tite Evaluation o f the al lo ca ti on and use o f health lìnancing in Nam Dinh province

l£^e: Pinal assignm ent tor M astcr Program in Public M anagem ent

Auh >r: NinhThiHoai Thu

Si|e.-visors:

- Dr Hans B lom kvist - Uppsala University, Sweden

- Dr Nguyen Phu Ha

Dae when the thesis is presented: 2014 - 12

Ain: The study aimed to evaluate the allocation and use o f íinancial

rs n r c e s o f Nam Dinh province, iđentiíy the strengths, weaknesses, 0)p)rlunities and threads o f Nam Dinh province’s health sector in allocation aid Lse addiíional ĩinancial resources, calculate the expected demand o f e;p:nses and income possibilities and then to propose solutions to increase rcvmues to meet spcnding needs and m anage hcalth financing in effective

lVehod: Analysis o f docum ents, in-dcpth interviews and SW OT

RĩSilt & C o n c lu s io n s : Health sector o i'N a m Dinh province in recent years hismade rem arkable achievem ents in various íìelds o f healthcare for the ptO'le, Nam Dinh has íìnished most important output indicators on or ahead oltie expected plan Plans to develop health sector closely linked with the 5 yta socio-econom ic developm ent plan from 2011 to 2015 and the p»rí)nnance indicators ot' the national health sector Hovvever, there is no liik between the plan and the annual budget vvith goals, outcom e and output

ncicators o f the sector, due to the current Capital expenditure and recurrent

ooenditure is expected to comply with the norms stipulated in Decision [ 51/2006 / Ọ D -T T g o f the Prime Minister, an annual increase o f about 15% til íầils to ensure adequate ílnancial resources required to minimum pcnding dem and o f Nam Dinh province’s health Ít inevitably leads to 'ulget deficits, required to cut down on some spending items, resulting in

01-guaranteed operating costs o f local health By necessity o f being vãlable with solutions to increase revenue sources, the author has applied

V O T analysis for strengths, vveaknesses, opportunities and challenges o f Jan Dinh province in the m anagem ent o f health íìnancing, assessment o f lbcation situation, from which calculates the actual spending needs o f the eilth sector and propose m easures to raise revenues tor the health sector eie

Based on the calculated demand shorttầll, assess the current íinancial ĩs)urces and trend analysis o f tìnancial resources can be offset in time to ían Dinh province, the author m akes a num ber o f recom m endations as )lows:

Ó' expenditures for investment and development

- For the local budget: The Province needs to increase investment Cipitals from the health hudget at least 20% over the previous year, and S)end 30% o f the total expenditures for invcstmcnt and development from tle local budget for health to implement The schem e o f upgrading the dstrict hospitals and the regional general hospital as deíìned in Decision N) 4 7 /2 0 0 8 /Ọ D -T T g o f the Prime Minister

- The province should spend at least 40% o f lottery revenues (expected líttery source for investment, upgrade o f infrastructure, social welfare, sich as education, health, culture and sport is about 50 -70 billion

\N D /y e a r) for health, especially for investment and upgrade o f the povincial general hospital, district hospitals and inter-district regional g-neral hospitals, preventive health centers and etc

- For Central budget: Although the province regulates the adjustment rate

o f the Central budget, because o f the total provincial budget for investment and de v el op m e n t in av erage level (estimated 80 0-1000 billion VND/year),

it ca n n ot sp e n d m ore for health It req uires the Central b u d g et to c o n tin u e to

support the province to upgrade provincial general hospital into regional medical center; upgrade the district health system, especially the district hospitals and district preventive health centers

For recurrent e x p e n d itu re

- Ensure that the level o f recurrent expenditure on health per capita prescribed by the Prime Minister, including expenditure increase by 2 0 % because the province has ad ịustment rate o f t h e budget Annual increase in recurrent expenditure over the previous year is 20% to reduce shortage in recurrent expenditure

- Recurrent exp enditu re íor provincial hospital beds is around 35-45 million VN D/ yea r, district hospital beds 30-35 million/year, provincial preventive health centers: 31-35 million VND/staff/year, district preventive Health centers: 28-32 million VND/staff'/year to ensure regular operation o f the unit, so that these units can purchase, repair and maintain assets,

e qu ipm ent and have íìnancial resources for the etTective implementation o f autonomy, selt-responsibility under Decree No 43 /2 0 0 6/ N D -C P

For the íin an cial m a n a g e m en t

* Enhance the role o f the Dep art m ent o f Health in Consulting the People's

Co m mi tte e to allocation o f local health budget, both regular and investments; the Dep artme nt o f Health is allowed to m an a g e the general budget; the Department o f ỉỉe al th is responsible for:

- Gui di n g the business units un de r D ep art m en t o f Construction to estimate budget to report to the Dep art m ent o f Finance, De partm ent o f Planning and Investment and the People's Com mi tte e, People's Council for consideration and decision

- Preparing a plan for allocation o f the budget for health services in local units, including provincial, district and c om m une health íầcilities Consult the Department o f Finance, Department o f Planning and Investment to the People's Committee for approval.

- Delivering estimates, adịusted estimates íor the health units in the province, the preventive medicine centers and district hospitals

- With regard to the communal level, based on the annual budget allocation for each district health department, the Department o f Finance implements supplementation to the district budget to assign estimates o f recurrent expenditure, expenditures for medical staffs in communes, allovvances for medical staffs in villages in the CHS The allocation for each c om m une is decided by the district People's Committee

* Promote the implementation o f socialization o f iocal health activities such as: Encourage the đeveloprnent o f non-public health facilities; the province needs to take land and allocate land without collection o f land use fees for private hospitals; when planning residential areas and new urban areas and industrial zones, thc province nccds to regulate land arcas for hospital construction Encourage the public medical tầcility to borrovv capitals, implement joint ventures and associate to install machinery and equipment to serve medical examination

* Recommend the Provincial People's Committee to base on the actual situation in the locality, the People's Council to issue fee levels o f some basic health services at commu ne to raise revenues for the operation o f commune

health centers such as hcalth Insurance, health care fund for the poor in order

to improve the quality and performance o f CHS

Suggestions for íuture research: The limitations o f the thesis wi 11 be

discussed and what can be suggested to study turther in future research proịects

C o n trib u tio n o f the thesis: This study providcs directions for changes in the

m a n a g e m e n t and use o f íinancial resources o f Nam Dinh province Ít also provides useful r e c om m e nd at io n s in attracting sources o f revenue to assure tasks for medical ex pen se s o f Na m Dinh province

This is a reíerence to the offìcers involved in the reasonable and eíìlcient planning and allocation o f íỉnancial resources

Table of Contents

ACCR ONYMS 9

LIST OF T A B L E S 10

1 lntroduction 1 1 1.1 General introduction 11

1.2 Obịectives of the study 14

1.3 Study questions 15

1.4 Study methods 15

2 Reference framework 16

2.1 Strengths 17

2.2 Weaknesses 17

2.3 Opportunities 18

2.4 Threats 19

3 Study method 19

4 Data source 20

4.1 Secondary data source 20

4.1.1 Data from reports settlements of revenue and expenditure 20

4.1.2 Data from nevvspapers and internet 21

4.2 Primary data source 21

5 Researching results 22

5.1 Assessment of implementation oí the State Budget Law and its implementing g u id e lin e s 22

5.1.1 Mechanisms and tbrms of budget management 22

5.1.2 Implementation of expenditure norms/ hudget allocation norms 25

5.1.3 Evaluation ofthe implementation of the Govemment's Decree No 43 32 5.2 Construction of cost estimates and expenditure needs of the health sector in Nam D i n h 34

5.2.1 Priorities, strategies and activities of local sectors: 34

5.2.2 Pinancial demand ot Mcdical Service in Nam Dinh province 40

5.3 Financial resources of the medical Service in Nam Dinh 48

6 Conclusion, recommendation and contribution o f the thesis 50

6.1 Conclusion and recomendation 50

6.2 Contribution of the thesis 52

Reíerence 53

Appendix 55

LIST O F T A B L E S

Table 1: S W O T m o d e l 15

Table 2: Comparisons betvveen the norms o f Decision 151 and Decision 139 .25

l able 3: Budget allocation norms o f Nam Dinh Province 27

Table 4: Synthesis o f tìnancial sources in 2011-2013 27

Table 5: Group structures oí'bud get expenditure on disease prevention 30

Table 6: Structures o f expenditure on health care in 2 0 1 2 31

Table 7: Structures o f expenditures on health care in 2 0 1 3 31

Table 8: Factors atTecting the needs and priorities o f the Health Sector D e v e l o p m e n t 34

Table 9: Synthesis o f priorities, objectives and st ra te g ie s 37

Table 10: The inain criteria to prepare a tìnaneial p l a n 40

Table 11: Expected íìnancial de ma nd o f t h e medical Service in Nam Dinh 46 Table 12: Expected tìnancial capacity and shortage o f revenues o f the health sector in Nam D i n h 47

Table 13: Current status and tendency tor financial c h a n g e s 49

1.1 General introduction

Nam Dinh province located in the Red River Delta with an area o f 1673.6 km2 The west borders on NinhBinh, 1 la Nam bordered on the north, the east is adịacent to Thai Binh province vvhile the South borderson the East Sea with a coastline o f 72 km2 The province's population is over 1,982,250 people; the province has 9 districts, 1 city, 203 communes and 26 wards

Currently, the Health Department comprehensively manages province and district level health units, including 7 provincial hospitals, 7 provincial health centers, 11 district-level hospitals, 10 district-level health centers and

10 district-level preventives, 4 regional polyclinics, medical schools, branches o f Population and Family planning, totaling up to 41 units Districts’ Health Departments are assigned to manage the 232 health centers

o f communes, wards and townships

Medical network oi' Nam Dinh province is covered with medical tầcilities from province to district and commune Including 19 general hospitals and 8 specialty centers, 10 preventive medicine centers and 1

Healthdepartment’s office, Branch o f Population and Pamily Planning, and 4 regional polyclinics and 232 co m m u n e health centers; o f which:

- Province level: + 8 General hospitals and clinics

+ 1 Sanatorium+ 7 Provincial SpecialtyCenter + 1 Office o f Department, under State management + 1 Branch o f Population and Pamily Planning + 1 Nam Dinh medical school

- District-level: + 10 preventive medicine centers

+ lO g e n e r a l h osp ita ls

+ 4 regional polyclinics

- Commune-level: + 232 health centers o f communes, wards and

towns

Nam Dinh province is the center o f the Southern region o f the Red River Delta, which makes it responsible for not only mission o f healthcare for people within locally but also for healthcare íor those who reside through surrounding provinces such as Thai Binh, Ninh Binh, Ha Nam I heretbre, in Decision No 153/2006/ỌD-TTg dated 30/6/2006 by the Prime Minister approving the overall development plan o f Vietnam health system for period

to 2010 and Vision to the year 2020 identiíìed investment in upgrading general hospitals o f Nam Dinh into the general hospiíal o f Southern region o f the Red River Delta

Although Nam Dinh province is a Central province oi' the region with relatively early developed industry, in recent times its such development has not been prioritized any more, as a result its agriculturai and rural development is still mainlv covered Per capita income as well as payments

to State budget is relatively low, expenditure needs are great so r ece i\ in g proportion o f assistance compared with balance o f local budget is over 63%, vvhich is the highest figure in the Red River Delta provinces Proportion o f people living in rural areas account for more than 80%, and with more than134,000 poor people according to the poverty line, approximately 160,000 children under six years o f age Therefore, one o f the Central tasks o f the province is to upgrade the health facilities, especially provincial general hospitals to meet the needs o f healthcare íor people in the region, district- level hospitals, commu ne health centers to meet the needs o f healthcare tbr rural people, the poor, children under six years right on the place o f residence

With the health characteristics mentioned above, Nam Dinh has identiíỉed key tasks required budget priorities as follows:

- To strengthen o f develop m en t o f hcalth system s to increase the accessibility o f health services o f the people

To enhance accessibility to Health services for the people, to leave people to be examined and treated right at the íầcilities, it is necessary to upgrade ỉầcilities, retroíìt equipment, machines to deploy services distributed

to the provinces, districts, com m une s and disease prevention activities within local range Accordingly, in the Corning period the province should concentrate on: investment in upgrading provincial general hospitals and some speciality hospitals, including the construction o f new Pediatrics hospital, investment in upgrading district-level hospitals, preventive health- care tầcilities

- To im prove the quality o f health services

Ọuality o f health services depends on manyíầctorssuch as proíessional qualiíications o f medỉcal staíT in the deployment o f medicaltechnology, liealth services; on equipmentserved for diagnosis and treatment; on financialabiiity and attitude and sense o f medical staff in serving patients, on cognitive abilities o f the patients

Currently, the province has 308 staíì’ with post graduate qualilìcation (Ph.D, Master, Specialist I, and II), 520 doctors, 48 pharmacists o f tertiary level It is a province with high-quality mcdical staff, howcver, the conditions for paticnt services (on inírastructure, equipment) have not met yet so it could not maximize the dynamism and creativity o f them in supplying and improving the quality ol'health services

Some issues to be set up in the Corning period is to: Strengthen medical sta ff to ensure the quantity and structure o f health work force in each level as well as each unit EtTectively organize, manage and use the work ĩbrce in supply and improvement o f quality in medical examination and treatment to the people ỉmprove qualification o f medical staff along \vith education, propaganda o f medicalethics, attitude when serving patient for health workers

- To ensure the íìnancial resou rces to care for and protect the health

o f the social policy objects

The social policy obịects such as those vvho have contributed to the revolution are enịoying preferential allowance monthly and objects o f social protection and other obịects to be bought social Insurance card by the State has been fully implemented under Decree No 63/2005 / ND -C P and Joint Circular No 21/2005 / TTLT.

- To strengthen the prevention o f diseases, reduce the morbidity and death by dangerous iníectious diseases

It is necessary to íocus and take care o f mother and child health, food hygiene and safety, communication and heaỉth education because there are many diseases getting and passing away related to respiratory, diarrhea .

From the index and epidemic disease situation mentioned above, during 2009-2011, Nam Dinh province continues to attach much importance to disease prevention sector and increase spending to sastify disease prevention,

o f which, priority over the care and protection o f mother and children healths, ensure o f quality o f food hvgiene and saíety, HIV / AIDS prevention, prevention o f new diseases, infectious diseases

- To increase efficiency o f health íinancing

In the case the budget is limited, thc eíTicicnt use o f resources is a very important content, theretbrc, it is required to focus on the tasks as strengthening o f monitoring the use o f tìnancial resources, improvement o f capacity o f staíT working in tìnance issue, transỉcr o f autonomy o f íinance í'or the units

1.2 O bjectives o f the study

The study aimed to evaluate the allocation and use o f ílnancialresource

o f Nam Dinh province, identify the strengths, vveaknesses, opportunities and threats o f the healthsector o f Nam Dinh in allocation and use o f oíììnancialresources, calculatespendingneeds and expectcapacity o f source o f

meetspendingneeds and manage effectivelyhealthfinancing

1.3 Study questions

Some essay quesions to be tbcused to ansvver including:

- Assessment o f the real status o f healthtìnancing m a n a g em en t in local, period o f 2011-2013

- What íầctors related to the allocation and use o f financial resources o f

N am Dinh province create strengths, weaknesses, opportunities and threats for health care system o f Nam Dinh province?

- Pormation o f estimate and minimum expenditure needs for Nam Dinh province and identification o f short fall funding compared to the revenue

- What should Nam Dinh province do to mobilize workforce and allocate budget for health reasonablly and effectively?

1.4 Study mcthods

S W O T model was íormed as o f 60th -70th year ago at Stantbrd Research Institute and was a tool comm on ly used in the analysis and evaluation o f the strengths, vveaknesses, opportunities and threats o f a guideline, policy or an industry to propose necessary measures which should be supplemented or amcnded Analysis under S W O T model is the evaluation o f the data arranged in the íbnn o f a S W O T under a logical order to help readers understand as well as present and discuss to make decision easier

S W O T model is applied not only to enterprises but also to State agencies and non-governmenta! organizations This method proposed by Albert

1 ỉumphrey when studying the Portune 500 companies

T able 1: SVVOT model

Four elements o f SW OT model includes:

Strengths: Kactors, advantages inside can be mobilized and promoted

Weakness: Weaknesses inside (subịective) can he overcame.

Opportunities: Opporlunities caused hy external environment can not eliminate entirely, but can minimize the impact

EíTects o f S W O T analysis:

- To help organization knovv how to use their precious resou rces in the best way to:

+ Promote strengths to take advantage / opporlunities

+ Promote strengths to minimize diíTiculties / challenges

+ Take advantage / opportunities to overcome vveaknesses

+ Overcome weakness to limit challenges

- Make suggestions about strategies that organization should consider to apply based on the determination o f the mutual iníluences between íầctors such as:

+ What programs are thriving?

+ What programs need to stop?

+ What programs need to change, and

+ What programs need to move to indcpendcnt status?

For Health tìnancing issue o f Nam Dinh province, S W O T model is applied to analyze the various tầctors aíTecting the publie expenditure in Health sector o f Nam Dinh province, irom that to make difference alternatives for public expenditure in Health sector o f Nam Dinh province become more eíTective and reasonable Besides, other tools can be used for analysis and evaluation (such as synthetic methods o f data analysis) to obtain thorough and comprehensive analysis to the above issue

2 R eíerence fram ew ork

Strengths, weaknesses, opportunities, threats (S W OT ) for the allocation and use o f health tìnancing o f Nam Dinh province

2.1 S tren gth s

- Health issues related to universal health should be closely cared and guided by the Party and State leadcrship; clearly reílected in Decree No 46-

NQ 1 w dated Pebruary 23, 2005 by the Politburo on protection and care o f

p e o p k 's health in the new situation affirming that the important position o f the Health sector is the basic íbundation o f health career development

- H um a n resources serving for Health sector: Medical staíT is o f high quality (o vc r 400 st a ff with postgraduate qualifications (PhD, masters, specialist I, II), 550 doctors, and 55 pharmacists o f university level

- Inv estment in Capital co n stru ction ten d s to increase during the period

2009 -2 01 2, for facilities, Health sector has inany improvements in the provincial and district levels because in recent years, the province

i m pl em en ted Decision No 47/2008 / Q D - T T g and Decision 930 / Q D - T T g

o f the G o ve r nm e nt for construction, renovation and upgrading o f health inírastructure for General hospital, levels o f province, district and region; Tuberculosis, Pediatrics/ obstetrics and gynecology hospitals, Intectious o f provincial levels via G o v e r n m e n t bond funds

2.2 W c a k n esses

- Although Nam Dinh province located in center o f area and had industry

d ev el op m e n t early, Ít does not has strong promotion in recent time so the main stil! is agriculture and rural Proportion o f people in rural areas makes

up more than 80%, more than ! 34,000 poor people under the poverty standards, approximately 160,000 children under age 6 Meanvvhile, infrastructure equ ipmen t as well as the medical station scale o f c o m m un e are poor and do not meet standards (although they werc classiíìed National standards but still lacks o f sotne criteria) and not satisfy health care needs for people in rural area

- N u m b e r o f sick-beds, num ber o f health workers is lower than the average o f the vvhole coưntry Use capacity o f sick-beds, number o f inpatient treatments days at the provincial and district levcl o f Nam Dinh higher than average o f the whole country

ĐAI H Ọ C Q U Ố C GIA HÀ NÒI

- Team o f doctors and nursing s t a í ĩ (including physicians, nurses, midvvives) o f the Preventive Medical Center o f provinces and districts, specialized centers are insufficient.

- Funding tbr training and capacity improvement for health workers at all levels in the province are small, thus acquisition o f knowledge, treatment methods or new specialized skills wi 11 be limited These matters also affect the quality o f medical services

- Health insurance also has some limitations such as payment process is passive, and slow leading to diữìculties for the hospital, the number o f patients exceeds the higher level leading to deíìcit o f fund

- Kinancial m a n a g em en t skills oí' s o m e health íầcilities d o not m eet the

requirements Some units, advising department is weak, confuse in building

o f íìnancial autonomy plan, and build internal spcnding rcgulations, especially in building o f additional wage payment plan for each individual building o f block norms for each division, building o f economic and technical norms tor proíessional expenses

- There are no ful 1 documents regulating on economic and technical norms o f sector so many units still meet diHlculty to build the cost norm o f the test, radiographs to save expenditure vvhile ensuring quality o f Service

2.3 O pportunities

- At Decision No 1 53/2006 / Ọ D -T T g dated June 30, 2006 by the Prime Minister approving the development plan o f overall health system in Vietnam for the period until 2010 and Vision to 2020, identiíìed investmcnt

in upgrading General Hospital o f Nam Dinh province into General hospital

o f South area o f the Red River Delta

- In the National strategy on protection, care and improvement o f people's health for the period o f 201 1-2020, Vision to 2030, has stated that

"To ensure adequate funding for reguỉar operations o f commune and ward heaỉth center and allowance for medical sta ff o f villages, hamlets".

2.4 Threats

- During the past time, the province only have a í'ew O D A proịect, investment Capital from local budget is very limited Moreover, this Capital also must íocus on investment in maternity hospital, gencral hospital o f province to do tasks in the area

- Disease structure changes, non-communicable diseases such as hypertension, diabetes tend to rise, this results in medical costs for these diseases will increase

- Medical staff are o f high quality, but the conditions to serve the patients (on inírastructure, equipment) have not met up yet so they cannot maximize the dynamism and creativity in supplying and improving quality

- Health sector expenditure complies with the rules, norms and guidelines o í 't h e Ministry o f Pinance, Ministry o f Planning and Investment and the Ministry o f Health, however, Social Insurance o f the province still has a number o f limitation in issuing some documents guiding implementation

3 Study method

Essay using synthetic - analysis methods, comparison method o f data

c ombined vvith the interview to analyze S W O T model in the allocation and use o f health tìnancing in Nam Dinh province

After identifying the study objectives and study questions, thc researcher conducted to collect a secondary data through a numbcr o f sources as follows: reports and settlements quarterly - yearly o f health units in the province, ỉìnal report o f year o f Department o f Health, Department o f Finance o f Nam Dinh province, tbrmer studies and articles o f individuals as well as organizations implemented previously

Aíter synthesis, analysis and comparison o f these data sources, the researcher gives judgments and assessment o f allocation and use o f health financing in Nam Dinh province in recent years, then, propose some solutions to improve the efficiency o f use o f health financing

Interview wi 11 help researcher reintbrce the identification, assessment o f the allocation and use situation o f health tìnancing in Nam Dinh province and the reasonableness o f the proposed solutions

The researcher conducted to intervievv some officials, leaders at the General hospital and clinic; preventive medical center o f district, city and State m anagement unit as Nam Dinh Department o f Health

Results trom the analysis, synthesis, and comparison o f data will be used

to analyze S W O T model hy the researcher to detennine strengths, weaknesses, opportunities and threats o f Nam Dinh province in allocation and use o f health financing Simultaneously, thereby to give assessments o f status o f the allocation and use o f íìnancial Health in recent years, identiíy

s o n e difíìculties,challenges, and make recommendations accordingly

4 Data source

4.1 Secondary data source

4 ỉ Ị Data fro m reports, settỉements o f revenue and expenditure

Secondary data was collected from reports, settlements o f revenue and exoenditure quarterly, yearly o f Health care íầcilities from province level to district and comm une levels; from data o f the Department ot' Health, Department o f Finance; final reports from the projects and programs as vvell

a s t h e published results o f the Conterence, Workshops, surveys and scientitìc research implemented by organizations and individuals

4.1.2 Data fr o m newspapers and internet

B es id es the data collected from reports and settlement quarterly and annual, resea rch er also conducted a revievv o f articles related to health

pr ogr am s in the recent period T hes e articles generally reíer to the

c o m m u n i ty health pr og r am s being impleme nted in hospitals, schools,

c o m m u n e s and districts Hovvever, synthetic sources o f iníbrmation from the media, internet we re only given iníbrmation on the implementation o f the primary health care program and had no detailed iníbrmation about the income and ex p en di tu re during program execution Many articles also highlighted the ditTiculties and solutions íor local health programs, but they were only an objective assessment for a speciíìc health programs, rather than indicating the situation o f the whol e health sector in Nam Dinh province Hovvever, these are the data sources contributing to give the actual situation o f the implementation o f health programs

4.2 Prim ary data source

To increase the accuracy o f the data, as well as clarify the íactors affecting the allocation and use o f Health iìnancing o f Nam Dinh province, the researcher conducted interview withrelatcd obịects Since Nam Dinh province m an a ge s the enlirc sector íìnancial, so staff working on tìnancial

m a n a ge m en t is relatively large and experienced management The Hnancial

m an a ge m en t has implemented at the 3 levels: provincial-level (general hospitals and clinics, branch o f population, medical schools ), district-level (general hospitals, preventive healthcare centers ), commune-level (health centers) Therelbre, the author has chosen interviews with a number o f offícers, em p lo y ee s and working leaders in all levels: General hospitals and clinics o f provincial; Preventive health center o f districts; cities, health centers o f co m m u n e, wards, towns, and State management unit as Nam Dinh D e p ar tm en t o f Health to ensure diversity and rcpresentation throughout the province

Intervien> contents: The author has direct interviews with íherespondents (see the attached list in appendix)

Intervievv questions focus on some questions as follows:

(r eve nu e - expenditure sources)?

Hovv is the implementation situation o f health programs at the tầcility?

- Are there any difficulties in the implementation o f health programs

in locality?

D e pe nd in g on each subject, the researcher will give some additional questions as follows:

- With annual health financing source, whether is it sufficient to

pe río rm the duties o f local health or not?

- What are some íầctors affecting to the health budget?

- W h a t are some solutions for the allocation and use o f health care íìna nci ng in the province?

5 R esea rch in g results

5.1 A s se ssm e n t o f im plem entation o f the State Budget Law and its

im p lem e n tin g gu id elines

5 / / M echanism s a n d fo r m s o fb u d g e t managem ent

a) Recurrent expenditure

- Every year in mid-July, Provincial People's Committee holds a

c o n ĩe r e n c e to m a k e e s t im a t c s o f State bu dget reven u es and expenditure on

the request o f the G o v e r n m e n t to hand in to Ministries and submit to the Government

- Sectors base on the missions assigned to estimate annual State budget revenues and ex penditures o f their owns in orđer to submit to the Department o f Planning and ỉnvestment and Departinent o f Finance tor revievv and synthesis, to submit to Provincial Peoplc's Committee for approval and to submit to all Ministries and the Government

Thus, the D ep art m en t o f Health makes estimates o f budget revenues and expenditures íor the whol e sectors to report to the Department o f Pinance,

Department o f Planning and Investment, to submit Provincial People's Com mittee for decision.

Bases for making estimates are: Proposal o f t h e Department o f Health on expenditure norms to health lầcilities to meet the minimum needs o f sector expenditure; obịective íầctors affecting estimates next year such as inílation; new regimes prescribed by the State; increased workload such as beds, staíììng, increasing number o f health tầcilities, etc

b) Expenditure on Investm ent

(i) Expenditure on Investment from local budget balance: Every year, the Department o f Health makes and synthesizes expenditure estimates o f investment in health projects, reports to the Department o f Planning and Investment for synthesis and submits to People's Committee in the Province tbr approval; hcnvever, despite great demand o f estimate establishment o f Health sector, numbers o f estimate submission are very lovv, only ha lf o f the estimates o f health sector Upon submitting estimates, Provincial People's Committee has assigned the names for each prọịect

(ii) Targe ted ex penditure on investment from Central budgct for the local area

Targeted provincial budget is a d d e d hy the Centre from Capital

investment o f National Target Programs to prevent social diseases, dangerous epidemics and HIV/AIDS and upgrade health system o f provinces and districts

The Province has not increased annual Capital investments in health from local budgets o f at least 20% over previous year and spent 30% o f total investment in health under the implementation o f Decision No.225; thereíore, investment in district hospitals is very limited

By assessm ent o f budget m anagem ent in Nam Dinh Province, based

on interviews with leaders ()f the D epartm ent o f Health, essays identiíying strengths and w eaknesses o f Nam Dinh Province in

m anagem en t o f health financing are listed as follows:

a) StrenỊỊths:

Nam Dinh Department o f Health manages comprehensively health tìnancing o f provincial and district units, thus making estimates and allocation estimates, cost estimates and revievv o f final accounts on non- business expenditure to medical units under its management are very convenient uniíìed under íiuidance o f protessional work and manatiement o f health economics, and all managed in a sector Punding for recurrent expenditure o f units is guaranteed by district health sector based on the íĩrst- year estimates

b) YVeaknesses:

Although Nam Dinh Department o f Health is assigned to manage the vvhole sector budget, estimates made by Department o f Health achieve relerence purposes only, reílecting demand on expenditure on health o f the province because expenditure deinand is huge, but ability to meet budget estimates is limited Discussion on budget is olten based on expenditure estimates in previous year, expenditure norms are approved hy the People's Council; increased amount undcr the regimes o f planned year and increased amount due to increased vvorkload such as staffing, sock-beds, etc are calculated on the basis o f local budgets, not calculated on the basis o f expenditure needs o f units

In principle, the Department o f Health and Department o f Finance uniíy data and protect estimates o f recurrent expenditure beíore People's Committee o f the Province (including expenditure on c om m une level) The Department o f Planning and Investment unify and protect planned targets, estimates o f expenditure on investment development, expenditure on National Target Program beíore People's Committee o f the Province for the Pcople's Council for adoption But in íầct, proportion o f health budget increasing over previous year is mainly based on ability o f local budgets for recurrent expenditure and expenditure on investment and development, submitted to the People’s Council for adoption and the CommissioiVs People

o f the Province for decision

5 ì 2 Impỉementation ()f expenditure norm s/ budget allocation norms

Budget allocation norms are made in accordance with Decision No

1 5 1/2006/ỌD-TTg dated June 29th 2006 o f the Prime Minister, in which total expenditure on local health is allocated according to population and economic - social areas as follows:

T ab le 2: C om parisons betvveen the norm s o f Decision 151 and Decisiơn

139

Unit: dong/person/vear

Region

Allocation norms in

2007 in accordance with Decision

No 151

Coeíĩicient compared

to urban areas

Allocation norms in

2003 in accordance with Decision

No 139

Coeíììcient compared

to urban areas

%between Norms

No 151 and Norms

Source: The author synthesis and comparison

- Expenditure norm to health care for the poor: is apart from expenditure

n orm s o f per Capital a b o v e and subịects prescribed by the Government, expenditure under provisions o f the Prime Minister for each period

- For administrative expenses o f local health care, more funds are also allocated to local hospitals in regions/areas: For provinces and cities directly

under Central g o v ern m en t, h osp itals under local m a n a g em en t w h ich are

guaranteed by local budgets, but operate in areas under provisions o f the

Ministry o f Health, are allocated with additional local budgct expenditure o f 30% expenditure estimates last year from Central budget, assigned by competent authorities.

- In addition, local budget ex penditures on regimes, policies and new

tasks are balanced and added a n n u a lly trom Central budget, such as

additional íunding to implement wage reíorms, adịustment o f the premium for subjects o f social policies, poor people, ethnic minorities, near poor people and children under six, from 200 8 additional expenditure was

allocated to help buy health Insurance tor th e near poor people, etc.

Implem entation o f provinciaỉ norms:

In 2011, i f calculated according to norms stipulated in Decision

No 15 1/2006/ỌD-TTg, total expenditure on health services o f the Province vvas about 152,750 million V N D ( e x c lu di n g tunds íor hcalth insurance íor the poor people), plus amounts o f exp end itu re undcr grovving regime during the year, including increased salary, increased expenditure on the poor and children

Meanwhile, recurrent expenditure allocated in 201 1 was 131,323 million VND Thus, it can be said that the Province has not allocated expenditure on health carc in accordance with n or m s stipulated in Decision

No 151/2006/ỌD-TTg o f the Prime Minister, leading to low level o f recurrent expenditure allocated for specitlc health íầcilities in comparison vvith demands o f expenditure

Implem entation t)f budget aỉỉocation norms fo r units, areas o f expenditure:

As stipulated in Decision No 1 5 1/2006/ỌD-TTg, the Province issued budget allocation norms to health services tbr the use o f budget units, including:

- Budget allocation for provincial and district hospitals: according to planned sick-beds and characteristics o f each type o f hospitals; Rehabilitation iỉospitals and Sanatorium a n d Hye 1 lospitals have the lowest allocation level, followed by traditional medicine hospitals and psychiatric

hospitals, vvhile general hospitals in the Province have the highest level oi' spending; budget allocation to district hospital is 34 million VND/sick-beds

As 1'or regional polyclinics, budget is allocated according to staííìng

- For allocation to preventive medicine centers at provincial and district levels, specialized centers under staffìng, the lowest level is in HIV/A1DS Prevention Centers which are allocated for 37 million VND/staíT, the highest

is in provincial preventive medicine centers which are allocated for 63 million VN D/ staff

Table 3: Budget allocatỉon norms o f Nam Dinh Province

I Provincial level

2 Specialist Hospital 30-45 million VND/sick-bed

II.District level

3 Preventive Medicine Center in District 45-52 million VND /staf f

III C om m u n e lcvel

1 Expenditures on salaries 30 million VN D/ co m m u ne

(e x c lu d in g salaries and

allowances)

Source: Nam Dinh Department o f Health

On the basis o f expenditure allocation nornts to units and areas, ttìtaỉ health ýìnancing in Nant Dinh province are as foỉỉow s:

Table 4: Synthesis o f Financial sources in 2011-2013

Unit: million VND

I E xpenditure on Investm ent

d evelop m en t

22,274 29,525 134,357 186,156

1 Central assistance 16,000 24,000 114,000 154,000

- National Target Program s 4,000 2,000 5,000 11,000