Determinants of medical equipment performance to improve management capacity within health system in Viet Nam

1 Background
Medical equipment is one of the major contributors to the rapid progress of healthcare and the improvement of public health services. The constant increase in the variety and complexity of available health technologies require good management capacity to allocate the resources efficiently. The review of the World Bank's global $1.5 billion investment in medical devices showed that there are cases where 30% of the more sophisticated equipment stock was unused and the rest had 25-35% downtime. A root cause turned out to be ineffective management including planning, acquisition and subsequent operations .
In the context of limited public health care funding, ensuring resources for medical equipment and infrastructure is challenging for Vietnam. There is no official data by Vietnam Ministry of Health (MOH) on total budget for medical equipment investment, maintenance and effectiveness throughout the health system. There are international guidelines and recommendations by WHO, especially for developing countries, on how to organize the management according to the equipment life-cycle . How well Vietnam equipment management practice follow the recommended guidelines and how WHO guidelines and recommendations can apply in Vietnam are basic questions to be investigated.
The research will thus address one important, but often neglected, building block of the Vietnamese health system; Technologies, with particular focus on finding determinants of medical equipment performance to improve management effectiveness via education and training intervention.
2 Rationale
In Viet Nam, as in many other countries of a similar income level, health technology management is not well-developed. There is no sound evidence on the effectiveness of the health technologies. According to a recent report, the percentage of medical equipment in good use condition ranges from 20% to 50% of total medical equipment in use in hospitals at all levels. In addition, the percentage of equipment being maintained drops to 30% in central and provincial level hospitals, and even to 10% in district level hospitals .
The education of e.g. public health experts and/or clinical engineers in Health Technology Management is not systematically taking place in Vietnam. However, Department of Medical Equipment Management at the Hanoi School of Public Health (HSPH), the only of its kind among all health related universities in Vietnam, is responding to the importance of this area and is eager to identify priority areas to be addressed in the curriculum of master of hospital management and continuous training for health professional training program.
Access to functioning and safe medical equipment at the point-of-care is key for providing health care services to the population. Typically technology "intensive" services profit more from an improved technology infrastructure. In this sense, everybody using health care services will eventually benefit from the system change.
3. Importance
There is no current data or studies of similar systematics or scope. In the area of health systems and policies, there is thus a great interest in obtaining such reference data. The research is proposed specifically in Vietnam because of its development level - the health care expenditure on health technology in relation to the presence of appropriate management practices and education is particularly poor, i.e. there is great potential for improvement.
4. Research Impact
At all stages of the research, relevant stakeholders and policy-makers will be involved closely. The results of the research will on one hand inform the MOH in the development of policies and actions on the other hand allow the HSPH in curriculum development and on design further research.

The proposed research will be investigating 30 public hospitals in Viet Nam. That allows coverage of all hospital classes, according to Circular 43/2013/TT-BYT dated 11/12/2013 by Vietnam MOH , in different geographical regions within Vietnam.
The input variables will be chosen along the management cycle. For parameters in which specific equipment types are concerned, the study will focus on 4-5 key technologies (e.g. Incubator, autoclave, anaesthesia machine, x-ray machine, etc.) in order to obtain complete and comparable results. Variables are:
a) Human resources presence, education and skills
b) Degree of adoption of Health Technology Assessment
c) Equipment procurement costs as share of total expenditures
d) Equipment repair practices (mix of in-house and outsourced services)
e) Following of preventive maintenance practices
f) User training and documentation

The dependent variable will be the performance of the equipment. This is a combined indicator comprising of different qualitative and quantitative dimensions:
i. Presence of functional devices necessary to provide clinical services
ii. Average down-time of devices
iii. Number of incidences
iv. Safety status of devices
v. Satisfaction of staff, i.e. equipment users
vi. Total costs of unitized equipment
The data will be collected by visiting the study hospitals and making in-depth interviews, focus group discussions, self-administered questionnaires, analysis of the electronic inventory and accounting data, technical inspections and checks. The data will be analysed by multivariate regression in order to find determinants for good performance.
In addition, a desk study will be done to synthesize available reference materials. Interviews with key informants such as policy makers from MOH, provincial health department, educators, relevant professional associations, medical equipment manufacturers will be organized.

Impact
1 Short term impact (during the grant)
- The research objectives are in line with the priorities of the Ministry of Health (MoH) and the development plans of the Hanoi School of Public Health (HSPH). The project is aiming at having practical involvement of the partners from an early stage. This will be assured by regular board meetings and joint activities. As a result, the research grant as has, and will further put health technology management on the agenda of both the HSPH and the MoH, raise the importance and create the necessary awareness for a system change.
- There is little or information and evidence on the determinants of medical equipment performance in the Vietnamese health care system. The data collection in both the qualitative and the quantitative study will inform decision-makers and key stakeholders throughout the process of the research. Reports on sub-topics and preliminary data analysis will be shared and discussed as early as possible in order to generate targeted data and evidence needed to improve the health system.
2 Mid-term impact (by the end of the grant)
- The Department of Medical Equipment Management at the HSPH is committed during and after the research to use the newly generated evidence to identify priority areas for the curriculum of the master of hospital management and continuous training for health professional training program. Health workers are expected to benefit from the advancements in academic and non-academic education.
- The health technology industry is complex and growing at a fast pace. In many countries, actual structures in place are dating back from times when devices and instruments were rather simple and basic. International experience together with the survey in the country will generate improved capacities and alongside suggest and promote structures (positions, job-profiles, responsibilities) to meet the needs of today's health technology infrastructure in Vietnam.
- The research outcomes will also identify and compare successful and less successful ways of managing medical devices in hospitals through number of indicators. A clear, concise and targeted dissemination of the research findings and an active dialogue of the HSPH with the hospital management are envisaged to assure effective management practices will be adopted.
- Medical devices are part of the public health policy. The HSPH with her advisory role and specific experts will during and after the research promote and advocate a policy change together with the MoH that is reflecting the importance of medical devices for health care services provision and make use of the evidence generated in this work.
3 Indirect and long-term impact (beyond the grant)
- The research outcome will allow the health care providers and decision-makers to measure the impact of medical devices on the Quality of Care (e.g. if the equipment used is effective, efficient, accessible, patient centred, equitable and safe). The work eventually proposes an approach for decision-making at country level, to make informed strategic interventions for predictable improvement in quality of care.
- Financial resources for medical devices and subsequent operations are limited in the Vietnamese heat care system. Even more important the scare resources are used in an economic way. Currently, cost-effectiveness is often compromised by new or donated equipment which is idle, used incorrectly or non-functional. The study will deliver answers to the question of cost-effectiveness of specific medical device groups and concrete recommendations for improvements.
- The research project is also creating further heath systems research capacity at the HSPH. In a future full-scale project, the researchers would aim for building a regional team, and apply a similar methodology in neighboring countries. The work will contribute to the advancement of scientific knowledge nationally and internationally and constitute a basis for further research.