i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s ( 0 ) 764–770 journal homepage: www.intl.elsevierhealth.com/journals/ijmi Electronic healthcare communications in Vietnam in 2004 ˆ` a , H Lee Seldon b,∗ , Hoang ´ Ch ` Vu˜ Anh Tran Ðuc a b a , Kiˆen Phan Nguyeˆ˜ n a Biomedical Electronics Center, Hanoi University Technology, Dai Co Viet Road, Hanoi, Vietnam Peninsula School of IT, Monash University, McMahons Road, Frankston, Vic 3199, Australia a r t i c l e i n f o a b s t r a c t Article history: Background: There is a lack of literature about health information systems (HIS) in “devel- Received 12 May 2005 oping” countries, including Vietnam However, computerization and network development Received in revised form are proceeding in these places, although not in a systematic, transparent way 13 December 2005 Objective: This is a preliminary overview of HIS’s and healthcare communications in Viet- Accepted January 2006 nam’s four-tiered public healthcare system It is to indicate the direction that nation might take in order to establish a modern, standards-compliant, national HIS Methods: We conducted site visits and interviews in Hanoi and nearby provinces Additional Keywords: information was derived from publications of the Vietnamese government and the United Vietnam Nations Healthcare communications Results: Many of the top-level “central” hospitals have HIS’s, although their quality and daily networks usage varies Fewer provincial hospitals have networks; district hospitals have a few stand- HL7 alone computers, and commune health centers have no computers Patients often go directly to higher-level providers, due to a widely held perception of better care at such sites Communications among healthcare units are largely on paper, consisting mostly of administrative matters and some hand-written patient referrals Telephones are used for discussions of specific matters Internet connections are almost all dial-up and often belong to individual staff members rather than the healthcare units Lower-level units derive much of their general medical information from television and newspapers However, there is considerable interest in computerization among healthcare workers at all levels Conclusion: Familiarization with computerized communications, i.e., training and hardware at all healthcare levels, must be the first step towards a modern healthcare communications network in Vietnam The skills to this already exist The aim of such a network must be to raise the level of information and quality of care at the lower levels Adherence to international standards, such as HL7, from the beginning would enable the country to bypass many years of haphazard development © 2006 Elsevier Ireland Ltd All rights reserved Introduction Little has been published in the international press about the healthcare system in Vietnam, and those articles which have appeared have been mostly concerned with the effects of the ∗ re-structuring of the system in the 1980s and 1990s [1–3] It is beyond the scope of this work to review the entire system, but several aspects are relevant to the aim of describing healthcare communications, the participants, and the information which is or should be transmitted Corresponding author Tel.: +61 99044336; fax: +61 99044124 E-mail address: Lee.Seldon@infotech.monash.edu.au (H.L Seldon) 1386-5056/$ – see front matter © 2006 Elsevier Ireland Ltd All rights reserved doi:10.1016/j.ijmedinf.2006.01.002 i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s ( 0 ) 764–770 The re-structuring replaced the universal public healthcare system with an arrangement involving reduced public care, introduction of fee-for-service, and the expansion of private providers The public system has retained its tiered structure of: • large, central, and specialist hospitals directly under the Ministry of Health (MoH) and located mostly in Hanoi or Ho Chi Minh City; • provincial hospitals (in each of 64 provinces); • district hospitals (∼50–100 beds, consultation and treatment rooms; staffed by doctors, nurses, administrators); • commune health centers (four to six beds, delivery room, medicine cabinet; staffed by doctors, pharmacists and nurses; not treat any serious cases, which are transported to the district hospitals, often by motorbike) The commune health centers also pay allowances to “Village Health Workers,” who are volunteers involved largely in immunization and family planning There are 26 “central” hospitals The distinction between provincial and district hospitals is not so clear as the hierarchy implies; it is based more on the number of beds and facilities than on geography They are all managed by the provincial departments of health, and there are 800 of these Finally, there are over 10,000 commune health centers, making an average of about 13 such for each provincial/district hospital Since the re-structuring, utilization of the public system has decreased significantly, at least at the lower levels [2] The top level may be over-utilized for a variety of reasons, including patients’ perception that these hospitals provide better care [3] In contrast, the private sector appears to comprise a large number of individual providers of various sizes, with no apparent regulation or system Although patients often prefer private providers, due to a perception of greater accessibility and better care [3], at least in the case of tuberculosis (TB) this may not be justified Private practitioners have a poorer record in the diagnosis and treatment of TB, due in part, by their own admission, to poor record-keeping, lack of standardized protocols for diagnosis and treatment, lack of expert supervision, etc [4] Several of these deficits could be linked to a lack of health information systems and communications The MoH has a schedule of fees which depend on care level and economic levels of the regions However, individual provinces, hospitals and even commune health services are allowed to add their own fees to support themselves [2], so there is no unified fee structure The services and drugs which incur fees vary widely from province to province or commune to commune (This is, however, not unlike the situation at the primary care level in Australia, where individual practitioners are allowed to determine their fees beyond the fixed Medicare rebate.) Continuing education, whether medical or technical, is problematic [2] The Ministry of Health lacks the educational and communications infrastructure to provide unified training or to monitor knowledge levels, even via a professional registration system The Ministry provides training programs, but with little standardization External donor programs provide some training, but this tends to be focussed around spe- 765 cific projects or illnesses, e.g., TB or HIV, and to be designed by the donors, again with little coordination with other programs Training in information systems by MoH apparently does not exist On the other hand, in 2002 an agreement was signed between the MoH and the Ministry of Education and Training (MoET) for the latter to provide technical training in the healthcare system The MoET has contracted some universities, e.g., the Hanoi University of Technology (HUT), to manage the training HUT has in turn appointed its Biomedical Electronics Center (BME) to technical training for some hospitals To date (2004) almost all the training provided by BME has been linked to purchases of new medical devices and has been in Hanoi Prevention programs are welcome, but suffer from a shortage of funds, as they not collect fees Fees charged in the public and private sectors go only to support cures of health problems, rather than prevention [2,3] (This again is similar to the situation in Western countries.) Preventative healthcare, more than perhaps any other discipline, relies on the dissemination of information to the public and the collection of information from the public Anecdotal evidence indicates considerable reliance on selftreatment or treatment by untrained friends, relatives or shamans [3] This may be due partly to financial considerations, i.e., the impression that doctors are more interested in maximizing their profits than in providing quality service Also, visitors to a clinic not always receive an examination by a fully qualified doctor, but often by an “assistant doctor” or other paramedic, which reduces their trust in the service being provided Doctors often dispense medication themselves as an integral part of consultations, and as a supplement to the doctors’ incomes Many medications, including antibiotics, are purchased over the counter [3] This unregulated over-use of medications can, of course, lead to numerous new problems Any attempt to regulate the dispensing of medication would require information and communications systems Background Although Ladinsky et al [2] write about “Health Information Systems,” they mention statistics and data (or lack thereof), evaluation, planning, etc The lack of systematic or standardized data collection implies that any statistics may be unreliable Numbers may be reported to fulfill expectations or to enhance the status of the reporting body, rather than to reflect reality [3] No mention is made of any communications infrastructure, electronic records or such In the absence of this, planning becomes very difficult The recent SARS and “bird flu” epidemics have emphasized the urgent need for reliable record-keeping and reporting mechanisms within the healthcare system This study was undertaken to understand the current (2004) status of communications in Vietnam’s public healthcare system Due to the unregulated and sometimes nontransparent nature of the private healthcare sector, that has been omitted at this time Following the determination of the status quo, technical, and social factors influencing the establishment of a realistic, reliable reporting system are discussed 766 i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s ( 0 ) 764–770 Permission for this project was obtained from the Faculty of Electronics and Telecommunications, the International Relations Office and the Rector of Hanoi University of Technology, and from the Faculty of Information Technology of Monash University Methods The current state of electronic communications in the public healthcare system was assessed by interviews with people and organizations who could provide information about their own or other healthcare units Some of them are included in Acknowledgements Formal visits to hospitals were not conducted due to organizational hurdles (In a reversal of the agreement between the MoH and MoET mentioned above, each official visit to talk to hospital staff required written permission from the MoH The authors were required to ask permission first from university offices, then from the MoET, and then from the MoH.) The interviews were in Hanoi and the provinces of the northern part of Vietnam Although the interviews were not formally structured, the questions derived from the following list: (Q 1) Does this healthcare unit have (A) computers? If the answer was “yes,” then the location, users and usage, software, network structure, etc were discussed If not, then they were asked if plans to purchase computers existed (B) a fixed-line telephone? (C) a fax? (D) a mobile phone? (E) a typewriter? (Q 2) How are patient records kept and filed (paper, computer, not kept, etc.)? (Q 3) With whom you communicate often regarding patients (other hospitals, doctors, friends, etc.)? (Q 4) How you communicate with another doctor, or order a test, or refer a patient (letter, telephone, fax, mobile phone, email, )? (Q 5) If a patient came to you and said that he had earlier visited another doctor or hospital, would you contact the other doctor or hospital? If so, how (letter, etc.)? (Q 6) How you find information about diseases or treatment (books, journals, television, www, etc.)? (Q 7) Do you receive information about diseases and treatments? If so, from whom and how (from hospitals, MoH, UNDP, UNICEF, WHO, etc by newspaper, mailed report, email, etc.)? How you prefer to receive information? (Q 8) If the level of computerization or electronic communications was low, the interviewees were asked if the staff of the unit were interested in these technologies or had undertaken any steps to acquire them It was conceived to not only establish existing structures, but also to determine existing and preferred communication methods and partners, whether they are currently used or not In several cases the questions about computerization did not need to be asked, as the situation was clear The number of interviews was limited, due in large part to the restrictions mentioned above In depth interviews were conducted at one Ministry of Health Department, one general, two provincial/district hospitals, and three commune clinics Visits to two additional general and one additional provincial/district hospitals did not include official interviews Private citizens, including a few doctors, were informally interviewed Several interviewees provided information not only about their own service unit, but also about others The limited number of interviews could introduce a “sampling error” in view of the total numbers mentioned above, and that must be kept in mind On the other hand, the answers to our questions were consistent and reflected what we saw and experienced Some interviewees volunteered information about other service units; for example, commune health center workers were familiar with all of the centers in their district and said that there was no significant difference among them This is not intended to be a statistical analysis, as the state of the system is clear without any tests of statistical significance Results The results of our survey are summarized in Table There has been some development of HIS’s in Vietnam ˜ˆ in Ho Chi Minh Some of the central hospitals, e.g., Cho Ray City, the National Cancer Hospital, and the Dental Hospital in Hanoi, have HIS’s developed by the MoH in collaboration with the United Nations Development Program (UNDP [5]) Some provincial hospitals also have HIS’s, e.g., Thai Nguyen, Vung Tau, and Tien Giang These systems all have similar basic structures, with linked databases for a patient master index (“BN”), consultations and emergency (“PIC”), finance (“TC”), radiology and pathology (“XN”), and pharmacy (“Duoz”) Some HIS’s have “external links” to the MoH, district hospitals, and the Internet (although the nature of these links was not specified by the MoH) The implication from the list of hospitals is that some central and some provincial hospitals not have HIS’s Descriptions of “typical” institutions are useful for understanding healthcare information systems and communications One central hospital has about 500 beds and covers most categories of care for a catchment area covering more than one province It employs 100 doctors and 300 nurses Many of the doctors have postgraduate degrees It includes radiology and laboratory pathology, each with modern machines which, however, are not connected to the hospital LAN Forty percent of the patients present directly to the hospital, rather than being referred, because the higher standard of care and comfort is visible, and the fees are not significantly higher than at “lower category” institutions Each patient is assigned a numerical ID (and is given a card with the number), and hardcopy patient files are stored by ID The hospital has extensive links with other countries and exchanges students and staff with them, but these links have been developed by the hospital itself with various international organizations It is partly through these links that the staff have become acquainted with HIS’s; in addition, the hospital has an infor- Table – Summary of computerization and communication in Vietnam’s public healthcare system Level Type of institution Has HIS? Internet connection Computer hardware “General” or National Specialty Hospital Yes, many Dial-up PCs around the hospital Province Province hospital Yes, some Dial-up or Internet cafe, no internal email system PCs, network in some cases District District hospital No Dial-up, but often only by individual staff members PCs located in administration area Vietnamese HIS, Oracle, Microsoft Windows, Word, Excel Microsoft Windows, Word, Excel Microsoft Windows, Word, Excel Communication partners Communication modes Vertical to MoH, province and district hospitals Paper letter, floppy disk Statistical reports (monthly, quarterly, annual), referrals Vertical to MoH, general or district hospitals Paper letter Statistical reports, referrals Vertical to province and communes, horizontal to other districts Paper letter, floppy disk Regulations, notices of training and workshops, referrals (from templates), statistical reports Receive information from MoH Receive general information Fax· · · Telephone· · · Commune/ Village No Health center Village Health Worker Microsoft Windows, Word, Excel N/A You can buy medicine with or without prescription Fax· · · No, but one may be located at People’s Committee NA Vertical to district, horizontal to other communes Paper letter (often handwritten)· · · Telephone (one at People’s Committee, one at Health Station, one at Post Office, few private)· · · Reports and notices as above; referrals, receive general and some specific information, announce emergency case No No Commune Verbal (at weekly meetings), paper Reports, letters, notebooks with records Dial-up, but often only by individual staff members PC No No NA No Telephone· · · Updated price of medicine Receive information from MOH on medicine trade 767 NA, not applicable Pharmacy (mostly private, some self-supporting hospital ones) Communication content i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s ( 0 ) 764–770 National Ministry of Health Computer software 768 i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s ( 0 ) 764–770 mation systems department with several qualified staff The hospital data network is about 80% complete; PCs are located around the site The main software package is an extensive HIS called MedisoftTM , from a Vietnamese company, Links Co Ltd (http://www.toancausoft.com.vn/) (This is in contrast to the MoH/UNDP package mentioned above.) It is a client/server system built on an OracleTM DBMS; this version runs on Microsoft WindowsTM According to the company’s web site, the product is installed in about 20 hospitals around Vietnam It was selected by the hospital, rather than by the MoH The databases include patient demographics, financial accounts, test results (which are entered manually), paper record index, etc Diagnoses are even coded in ICD-10 Data are entered mostly by nurses and administrative staff Numerous views are possible, including individual patient records, discharge summaries, and statistical summaries However, in contrast to this sophisticated HIS, links to the Internet are dial-up (to a government Internet Service Provider, ISP), and communications with all other healthcare units are on paper or by telephone or occasionally via floppy disk A province hospital may comprise several buildings containing a few hundred beds It also has pathology and radiology departments, although the latter is basically restricted to plain film Although a few such hospitals have a HIS, generally computerization is still minimal, with a few PCs located in the accounting and perhaps administration areas Clearly there is no dedicated Internet connection Staff are, of course, well trained medically, yet examinations, test orders and results, etc., are all on paper forms filled out by hand Patient accounts are also paper forms with amounts hand-written (and payments are in cash) Communications with other units are as in the big general hospitals A district hospital has about 100 beds; the largest category of care is obstetrics, followed by geriatrics (often mental problems) and then pediatrics One sample district has 243 paid healthcare workers, of whom 105 are based at the hospital, and of these 27 are doctors All records and documents are on paper, and most are hand-written Patient records are filed by date (At the initial visit to a hospital, patients are asked to buy a booklet, like a school exercise booklet, in which the staff then write notes The patients are told to bring the booklet with them on each subsequent visit This, interestingly, represents a form of portable, patient-centered health record towards which many “technologically advanced” nations are striving.) There are three stand-alone PCs, one (very old, with MB of RAM) for general typing and documents, one for accounting, and one for data collection and statistics (using Microsoft ExcelTM ) The last one had a boot-up problem for months before the interview, and no support was available Three staff members are slightly familiar with PCs There is no Internet connection Data and statistical reports may be delivered on floppy disks via the post office There is essentially no transfer of individual patient records to (or from) other healthcare units, although answers to questions about specific cases can be gathered by fixed-line telephone General medical information or education is often gathered from the radio or television The hospital staff members are definitely interested in computerization and would like training A typical commune health center is surrounded by about a dozen villages within a 3–7 km radius It has six staff mem- bers, of whom one might be a doctor, a couple are pharmacists, and a couple are nurses Each village has a (volunteer) health worker During winter the patients are mostly geriatric or pediatric Patient records are on paper and are filed by date; any letters are written by hand Some records are kept by the Village Health Workers General healthcare information is gathered during monthly meetings of all the directors of commune health centers in a district It is also received from visiting speakers (often from donor organizations, especially for preventative care), from television or other medical personnel For assistance with specific cases, a staff member telephones the district hospital or other commune health centers Statistical reports are delivered quarterly to the district during one of the monthly meetings Orders for drugs are made by a monthly “proposal” (estimate) on paper and delivered to the district Information from the MoH passes through the province and district levels before reaching the commune health centers Information exchange with the village health workers, besides at monthly meetings, is by face-to-face conversation after travel to or from the village The commune health center has one fixed-line telephone, no PC, no fax, and no mobile phone The staff is interested in computers and would like one for patient records They have submitted a proposal for training to higher levels, but have not as yet received any Overall, computer hardware and software are present at most levels of Vietnam’s public healthcare system, but only sporadically at lower levels District hospitals and commune health clinics are too small to warrant investment in networks Throughout the system, PCs use the Microsoft WindowsTM operating system and some Microsoft OfficeTM products The situation for Internet connections is not entirely clear If any permanent, high bandwidth connections exist, they would be at some central hospitals, but we have not encountered any such Connections below this level are dial-up, and may often be private connections of individual staff members, rather than institutional connections The commune health centers apparently not have connections (or computers on the premises) However, the Internet is growing rapidly in Vietnam, and several large, private Internet Service Providers exist Internet cafes advertising ADSL connections seem to be in every town with paved roads, and they appear to be very popular, although mostly with teenaged children In any case, this aspect of health information systems may change very quickly, at least around cities and larger towns Much of the communication among units in the healthcare system comprises reports, notices, and other administrative material Most communications are on paper and are sent via the Vietnamese postal service Many reports and referrals are hand-written; at higher levels some are typed by administrative staff Reports tend to follow a hierarchical path, with districts reporting to provinces, which collate the data and then report to the MoH There are relatively few patient-specific messages such as referrals Commune health centers send written referrals with patients who must be transferred to higher level facilities for treatment Such centers within travelling distance of Hanoi tend to transfer patients directly to the large, central city hospitals rather than to the next district or provincial hospital i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s ( 0 ) 764–770 Discussion As described in Section 4, communications among providers in Vietnam’s public healthcare system are largely on paper and largely administrative in nature As can be inferred from Section 1, the system would benefit from the creation of a faster, more standardized communications network Given the tendency toward overloading at the upper levels of healthcare and under-utilization at the lower (cheaper) levels [6], a main aim of any healthcare information network must be to raise the quality of care at the lower levels by providing more and better medical information and links to higher levels for discussions of specific cases In addition, a network for reporting could be useful in: • assessing the status of communicable diseases, e.g., SARS or “bird flu”, and/or serious diseases (in both the public and private sectors); • assessing the use or over-use of certain drugs, e.g., antibiotics; • assessing and standardizing the training level of medical and allied health practitioners When thinking about a future digital healthcare communications network in Vietnam, there are two general categories of problems to solve The first is obviously the existence of the network infrastructure The second is the use of computerized communications by the healthcare personnel The current infrastructure imposes several constraints on any system to be implemented Given the general shortage of stable network connections and computers, especially at the lower levels of the system and in rural areas, a realistic, reliable electronic communications system may not rely on fixed or permanent computer networks Indeed, any such system will first require placement of PCs in district hospitals and commune health centers There is a possibility that this might be approached; there are some commercial initiatives (e.g., PC ´ ´ Thanh Giong http://www.elead.com.vn) to place a million lowcost PCs with young people in rural areas by 2009 However, the PCs must be purchased by the rural population, so they may not be able to afford the hardware without financial assistance, e.g., from donor organizations or the national government It remains to be seen if some of these will find their way into healthcare centers; we have not found evidence of any such plan The use of telephones (PSTN) as interfaces would require either computers and modems or voice recognition systems The latter can be excluded at present as too complex, but the computer-and-modem approach is very feasible at present Many of the units which already have dial-up connections to the Internet not use them for patient-specific healthcare messages or general medical information—an example of the second problem mentioned above Although mobile phones are very prevalent in the cities, they are still rare in rural areas A network which accepted them as “user interfaces” would be more accessible than a fixed-line network, but only in metropolitan areas However, the supporting infrastructure is being extended into rural areas, although the final coverage may be affected by the 769 inability of the rural population to afford mobile phones (Average annual income for farm workers is much less than the national average of US$ 350.) So the physical infrastructure is being established, albeit slowly The choice of software will likely be strongly influenced by financial considerations, and thus possibly by donor organizations Robust, open-source software would warrant serious consideration, and nowadays much such appropriate software exists Proprietary systems, even those created in Vietnam, are financially unaffordable by any of the lower-level healthcare units However, the second problem – that of usage of digital communications by the players – must also be solved For many centuries nations like China and Vietnam have had a cash economy, and even today the penetration of “invisible” transactions like credit cards is significantly less than in Western countries It is impossible to quantify philosophy of trust in transactions involving visible, tangible goods and currency This mitigates against the use of electronic data communications on the part of both the health care provider and the patient On the other hand, the uptake of mobile phones in the cities proves that the people are quite capable of establishing and using complex communications technology So any use of such modes of communication in healthcare must be preceded or accompanied by a process of familiarization, at least in more traditional regions So to approach the problem of usage, we note that the most frequently encountered applications are Microsoft Word and ExcelTM (the latter for tables of statistics) As hardware is installed in more healthcare units, usage of these applications will certainly expand A simple additional measure for communications could be the provision of email software and dial-up Internet accounts to as many healthcare units as possible This would follow the current, sporadic use of email, largely by individual staff members Usage can certainly be accelerated by training staff at all levels to use computers and electronic systems for communication The lack of such training was seen by many as a major obstacle to computerization As mentioned in Introduction, a framework for training already exists in the agreement between the MoH and the MoET However, even a small scale, systematic program across a healthcare region has yet to be implemented (Of course, this cannot happen until a plan for hardware installation is also implemented.) If such training could be coupled with the “million PCs” initiative mentioned above, then that might actually create the necessary basis of computerized, “literate” healthcare units From that to a healthcare information network would then not be such a great step Finally, another factor in digital healthcare communications warrants a mention HL7 version 2.x is becoming accepted worldwide as the “standard” for healthcare communications, and there is a chance that version 3.x will gain acceptance in the coming years Therefore, any system in Vietnam should comply with these standards as much as possible (This represents a challenge, but also an opportunity If the Vietnamese can create a standards-compliant system from the start, then they can bypass the decades of haphazard and incompatible systems created and later discarded in Western countries.) On the other hand, the standards have 770 i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s ( 0 ) 764–770 been developed for the USA and other Western nations, and parts of them are not applicable to Vietnam, as well as to other Third World countries (For example, in Vietnam pharmacy orders are rare.) The standards are understood at the technical level; for example, staff at the BME of HUT are currently studying the HL7 standard with respect to its appropriateness for Vietnam, and one commercial HIS (MedisoftTM ) claims to be HL7-compliant (but we were unable to verify this) Given the constraints mentioned above, it is still too early to propose or design specific health care networks for Vietnam, at least beyond those already existing in the large central hospitals It is now up to the MoH to implement plans to provide PCs and training to the staff at all levels in the public healthcare system Summary points What was known before the study: i Vietnam has had a four-tier public healthcare system for over 20 years ii Health records, such as they are, have been almost exclusively on paper iii Patient-related communications have been largely between adjacent tiers of the system, and have used paper and telephones iv Some general healthcare information has been distributed hierarchically on paper from the MoH Lower healthcare levels have derived much general information from the media What the study has added to our knowledge: i Computerization is often left to the individual healthcare units, especially at the lower levels There are few systems and no integrated systems at these levels ii Network communications between healthcare units are based on dial-up connections, often belonging to individual care providers rather than to the units iii Healthcare workers at all levels show great interest in computerization and networking of the public healthcare system They are aware of the relevant applications for health care iv The skills to create a national, standards-compliant healthcare information system already exist within Vietnam Acknowledgements We are greatly indebted to numerous people for information and assistance Among them are Nguye˜ˆ n Thanh Thuy and ˆ´ Khoa Nguye˜ˆ n Thu Ha` of Plan Vietnam, Eng Nguye˜ˆ n Tuan (Director, Central Institute for Medical Science Information, ´ Thuaˆ n (Head, Department of ElecMoH), Prof Nguye˜ˆ n Ðuc ˜ tronics and Biomedical Engineering, HUT), Nguye˜ˆ n Vieˆ t Dung ˆ` Huy I´ch (Director, Biomedical Electronics Center, HUT), Tran ˆ Thanh and Tien ˆ (Director, Lang Giang District Hospital), Tan ˆ (Deputy Director, Uong Bi Lu.c Commune Health Centers, Tan ˘ Ða.i (Uong Bi General HospiGeneral Hospital), Eng Cao Van tal), Marie Ryan and many more references [1] S Flessa, T.D Nghiem, Costing of services of Vietnamese hospitals: identifying costs in one central, two provincial and two district hospitals using a standard methodology, Int J Health Plann Manage 19 (2004) 63–77 [2] J.L Ladinsky, H.T Nguyen, N.D Volk, Changes in the healthcare system of Vietnam in response to the emerging market economy, J Public Health Policy 21 (2000) 82–98 [3] A Sepehri, R Chernomas, A.H Akram-Lodhi, If they get sick, they are in trouble: healthcare restructuring, user charges, and equity in Vietnam, Int J Health Serv 33 (2003) 137–161 [4] V.K Diwan, K Lonnroth, H.L Nguyen, Public–private mix and general practitioners: a view from a disease control program, in: M.H Pham, et al (Eds.), Efficient, Equity-Oriented Strategies for Health: International Perspectives—Focus on Vietnam, Center for International Mental Health, University of Melbourne, Melbourne, 2000, pp 121–137 [5] United Nations Development Programme, Vietnam Development Cooperation (CD), Ha Noi, 2004 [6] General Statistical Office, Result of the Survey on Households Living Standards 2002 Statistical Publishing House, Hanoi, Vietnam, 2004, p 71  ... 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