Integrating services for maternal, newborn and child health and noncommunicable diseases at district-level facilities: Viet Nam

Viet Nam Photo source: Unsplash.com Integrating services for maternal, newborn and child health and noncommunicable diseases at district-level facilities 2 Integrating services for maternal, newborn and child health and noncommunicable diseases at district- level facilities: Viet Nam ii Integrating services for maternal, newborn and child health and noncommunicable diseases at district-level facilities: Viet Nam (Integrating services for maternal, newborn and child health and noncommunicable diseases at district-level facilities) ISBN 978-92-4-007903-8 (electronic version) ISBN 978-92-4-007904-5 (print version) © World Health Organization 2023 Some rights reserved. This work is available under the Creative Commons Attribution- NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). 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However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. iii Acknowledgements ................................................................................................................... iv Abbreviations ............................................................................................................................. v 1. Country profile ................................................................................................................... 1 1.1 Country context .......................................................................................................... 1 1.2 Socioeconomic conditions ......................................................................................... 1 2. Health systems ................................................................................................................... 3 2.1 Health governance ..................................................................................................... 3 2.2 Infrastructure, facilities and organization of care ...................................................... 4 2.3 Health workforce ....................................................................................................... 5 2.4 Health financing ......................................................................................................... 7 2.5 Health information system ......................................................................................... 9 2.6 Essential medicines and supplies ............................................................................... 9 3. Maternal, newborn and child health: situation analysis ..................................................... 9 4. Noncommunicable diseases: profile, trends and existing measures ................................ 12 5. Integrating NCDs into maternal, newborn and child health services at district-level facilities: challenges and opportunities .................................................................................... 13 5.1 Integrating NCDs into maternal, newborn and child health: Viet Nam context ...... 13 5.2 Quality of care assessment ....................................................................................... 15 6. Recommendations ............................................................................................................ 17 6.1 Policy recommendations .......................................................................................... 18 6.2 Project recommendations (PHC) ............................................................................. 18 References ................................................................................................................................ 19 Annex 1. Health insurance coverage for target groups in Viet Nam after adopting the revised Social Health Insurance Law ................................................................................................... 23 Annex 2. Mapping of existing projects related to the quality of care, maternal, newborn and child health, and NCDs implemented by various stakeholders ............................................... 24 Figures Figure 1.1 Viet Nam and South Asia: annual GDP growth 2012–2021 .................................... 1 Figure 1.2 Domestic general government health expenditure as % of GDP ............................. 2 Figure 1.3 Domestic general government health expenditure as % of general government expenditure ................................................................................................................................. 2 Figure 2.1 Viet Nam's health governance and health service delivery network ........................ 3 Figure 2.2 Health service delivery model in Viet Nam ............................................................. 4 Figure 2.3 Health workforce per 1000 population in Viet Nam, 2010–2019 ............................ 6 Figure 2.4 Reforms to attract and retain health workers in rural and remote areas ................... 7 Figure 2.5 Health expenditure trends in Viet Nam, 2008–2019 ................................................ 8 Figure 3.1 Maternal mortality ratio in Viet Nam, 2000–2017 ................................................. 10 Figure 3.2 Mortality rates of newborns, infants and children in Viet Nam, 2012–2020 ......... 11 Figure 4.1 Risk of premature death due to NCDs: males and females (%) ............................. 12 CONTENTS iv Acknowledgements This report was made possible thanks to the support and contribution of many individuals from the World Health Organization Secretariat at headquarters, the WHO Regional Offices for Europe and the Western Pacific, country offices in Tajikistan, Kyrgyzstan, and Viet Nam, and external experts. Due to the COVID-19-related restrictions travel was limited to Kyrgyzstan and Tajikistan, and not possible to Viet Nam. Thus, the analysis relies on data collected from secondary sources of available evidence and informal interviews with selected experts conducted in October- November 2021. Overall direction and coordination: Svetlana Akselrod, Téa Collins Research and analysis: Ketevan Chkhatarashvili, Flaminia Ortenzi Editorial support: John Dawson Contributors: Aliina Altymysheva, Daria Berlina, Annie Chu, Socorro Escalante, Pavel Esin, Jill Farrington, Aigul Kuttumuratova, Oleg Kuzmenko, Moise Muzigaba, Pham Thi Quynh Nga, Van Hien Pham, Mekhri Shoismatuloeva, Howard L. Sobel, Nurshaim Tilenbaeva, Igor Toskin, Özge Tuncalp, Martin Willi Weber, Wilson Milton Were, Nuhu Omeiza Yaqub JR, Shoira Yusupova. Special thank you to the WHO Project Steering Committee for their support: Shambhu Acharya, Svetlana Akselrod, Pascale Allotey, Nazira Artykova, Anshu Banerjee, Nino Berdzuli, Sergey Diorditsa, Rudolf Eggers, Zsuzsanna Jakab, Ana Carina Jorge Dos Santos Ferreira Borges Bigot, Bente Mikkelsen, Natasha Muscat, Victor Stefan Olsavszky, Kidong Park, Huong Tran, Melita Vujnovic. ACKNOWLEDGEMENTS v Abbreviations GDP gross domestic product NCD noncommunicable disease ODA official development assistance OECD Organisation for Economic Co-operation and Development PHC primary health care PPP purchasing power parity SDG Sustainable Development Goal STEPS STEPwise approach to chronic disease risk factor surveillance UNFPA United Nations Population Fund UNICEF United Nations Children’s Fund WHO World Health Organization 1 1. Country profile 1.1 Country context Viet Nam is a lower-middle-income country in South-East Asia with a population of 98 million, making it the world’s 15th most populated country. Viet Nam is divided into 58 provinces and five municipalities, which administratively are at the same level as provinces. Provinces are subdivided into provincial municipalities, townships, and counties, which in turn are organized into towns and communities (1). 1.2 Socioeconomic conditions Since launching a series of economic reforms in 1986, Viet Nam has rapidly progressed from being one of the poorest countries in the world to becoming a lower-middle-income country. It was one of the very few countries globally that maintained gross domestic product (GDP) growth in 2020 when the COVID-19 pandemic negatively affected much of the world’s economy. GDP growth slowed down to 2.6% in 2021 but is expected to rebound to 5.5% in 2022 (Figure 1.1) (2). As a result of Viet Nam’s economic growth, during the period 2010– 2020 poverty declined significantly in the country, with the World Bank’s low- and middle- income country poverty rate1 dropping from 16.8% to 5%, and over 10 million people being lifted out of poverty (3). Figure 1.1 Viet Nam and South Asia: annual GDP growth 2012–2021 Source: World Bank Development Indicators (online database). Washington (DC); World Bank Group (https://databank.worldbank.org/source/world-development-indicators). In 2020, the country’s economy was faced with three major challenges: the COVID-19 pandemic, the severe drought in the Mekong delta, and floods in Central Viet Nam. As a result, GDP growth fell to 2.9%, which was the lowest in a decade, despite Viet Nam demonstrating 1 2011 purchasing power parity (PPP) US$ 3.20 per day poverty line. 2 strong leadership and capacity in the fight against COVID-19 and enacting quick and effective responses (4). Viet Nam’s government’s expenditure on health as a percentage of GDP is higher than the regional average for South Asia (Figure 1.2). Health expenditure as a share of total government expenditure is 10%, which is also higher than the regional average (Figure 1.3).2 Figure 1.2 Domestic general government health expenditure as % of GDP Source: World Bank Development Indicators (online database). Washington (DC); World Bank Group (https://databank.worldbank.org/source/world-development-indicators). Figure 1.3 Domestic general government health expenditure as % of general government expenditure Source: World Bank Development Indicators (online database). Washington (DC); World Bank Group (https://databank.worldbank.org/source/world-development-indicators). Health outcomes have significantly improved along with rising living standards. For instance, the infant and under-5 mortality rates fell from 32.6 to 16.7 per 1000 live births and from 43.9 to 20.9 per 1000 live births, respectively, during the period 1993–2020. Life expectancy 2 World Bank Development Indicators (online database). Washington (DC); World Bank Group (https://databank.worldbank.org/source/world-development-indicators). 2,10 2,39 1,94 1,91 2,14 2,17 2,10 2,30 0,90 0,86 0,85 0,90 0,91 0,94 0,90 0,98 2012 2013 2014 2015 2016 2017 2018 2019 Vietnam Domestic general government health expenditure % of GDP South Asia Domestic general government health expenditure % of GDP 8,93 9,78 8,51 7,90 9,64 10,09 10,22 10,07 3,57 3,45 3,45 3,58 3,55 3,51 3,33 2012 2013 2014 2015 2016 2017 2018 2019 Vietnam Domestic general government health expenditure % of general government expenditure South Asia Domestic general government health expenditure % of general government expenditure 3 increased from 70.5 to 75.4 years between 1990 and 2019, which is the highest in the South Asia region for countries with comparable income levels (1). 2. Health systems 2.1 Health governance The governance of the health system is decentralized to enhance accountability and cross- sectoral collaboration. The Ministry of Health is responsible for developing health policies and technical guidelines, as well as for monitoring the implementation process, while local authorities administer health-related activities in their provinces (Figure 2.1) (5, 6). Figure 2.1 Viet Nam's health governance and health service delivery network Abbreviations used: CHC = community health clinic; DOH = Department of Health; FP = family planning; IEC = information, education, and communication; MOH = Ministry of Health; VHW = village health worker. Source: Teo and Huong (5). Although the final decision on health-related policies and guidelines rests with the Ministry of Health, the policy development process involves contributions from lower administrative levels. The final decision is implemented across the whole health service delivery network (6). The continuity and stability of policies are guaranteed regardless of the political cycle. Indeed, overall national socioeconomic development strategies and plans are renewed every five to 10 years and inform each sector’s long-term policy direction. Any new policies must be informed by the evaluation of policies already in place, to identify successes, challenges and lessons learned (6). - Departments - Research institutes, medical universities - National general and specialist hospitals - Provincial general and specialist hospitals - Provincial preventive health centers - Population and FP Dept. - HIV/AIDS prevention and control centers - Food safety Dept. - Reproductive health centers - IEC health centers District Population and Family Planning Centers Population collaborators Government Provincial People’s Committee District People’s Committee Commune People’s Committee District Health Office Private Health Facilities MOH 63 Provincial DOH District Health Centers (District hospitals and Preventive health) VHWs CHCs Poly-clinics 4 2.2 Infrastructure, facilities and organization of care Health care services in Viet Nam are provided by both the public and private sectors, with the public sector accounting for the majority of both inpatient and outpatient care (83.4% and 72.1%, respectively). However, the private sector in health care is growing rapidly, particularly in urban settings where people are willing to pay more to receive faster and better-quality care in modern facilities. Public–private partnerships are also encouraged by the government, especially at the hospital level (6). Public health facilities are linked to government administrative institutions at all levels (central, provincial, district and commune) (Figure 2.2) (6). Figure 2.2 Health service delivery model in Viet Nam Abbreviations used: MoH = Ministry of Health. Source: Oanh, Phuong and Tuan (6). The current health service delivery model consists primarily of treatment provided in hospitals. National and central hospitals, located in major urban centres, provide specialized tertiary-level services for patients referred from provincial hospitals. Provincial and district hospitals provide secondary-level care, and more specialized treatment for patients referred from commune health stations, which deliver basic primary care and prevention services (6). Viet Nam’s health care system is highly hospital oriented and the bed occupancy rate in the country is very high (almost 100%), especially at central and provincial hospitals, causing overload and related difficulties. Currently, the government allows patient self-referral to any health facility (patients can decide which facility or specialist to visit). Therefore, given the limited capacity of primary health care (PHC) facilities to provide a broad range of services and make essential medicines available, many patients prefer to bypass the PHC level and go directly to hospitals (6).3 3 Viet Nam health care system. Purpose built case study. Available at: https://massdesigngroup.org/work/research/purposebuilt-downloads. 5 With the ageing population and the growing burden of NCDs in the country, the government recognizes the urgent need to strengthen PHC and reduce the burden on hospitals. Reforms have been implemented to shift the hospital-oriented health care system towards a more PHC- oriented model, including investments in district health centres and commune health stations, capacity-building for human resources, and the introduction of the family medicine model at commune health stations.4 As an example, since 2016 PHC facilities are being upgraded with modern equipment to enable them to diagnose and treat NCDs locally (6). Although some progress has been achieved, Viet Nam Social Security reported a decline in patient load at commune health stations, mainly because of the existing self-referral policy (6). 2.3 Health workforce The health care sector of Viet Nam faces significant human resource shortages. According to the Ministry of Health, a significant part of the health workforce has left the sector because of low remuneration and a poor working environment, with long working hours in overcrowded facilities (6, 7). To address such shortages, the country adopted the Master Plan for Health Workforce Development 2012–2020, which had a long-term vision towards 2030 and set targets focusing on (6): ¨ increasing human resources for health numerically, and improving their geographical distribution, skills and competencies; ¨ improving training and education programmes; ¨ conducting capacity-building in human resource management; ¨ improving staff retention in rural and remote areas. 4 Decision No. 2348/QĐ-TTg dated December 2016. Photo © WHO/Quinn Mattingly 6 According to the latest available data from 2019, the overall number of health workers has slightly increased over the past 10 years, but specific targets of the Master Plan, such as reaching one doctor and two nurses per 1000 population, have not been achieved (Figure 2.3) (8). The basic salaries of health workers are comparable to other professional sectors: 3 873 000 Vietnamese dongs (around US$ 163) per month (9), but this seems to be insufficient given the highly demanding nature of the health care sector. The total income of health workers might be 20–50% higher than the basic salary, thanks to additional allowances. Most practising health workers are employed in the public sector (77%), but the private sector is growing and attracting more qualified staff because of the better salaries and benefits offered, as well as the government’s encouragement of public–private partnerships (10). Figure 2.3 Health workforce per 1000 population in Viet Nam, 2010–2019 Source: Oanh, Phuong and Tuan (6). In addition to numerical shortages, inadequate health workforce skills and competencies and uneven geographical distribution represent major challenges. As hospitals located in urban settings receive greater investment, they can afford better equipment, offer better work environments, and provide more opportunities for professional development, thus attracting more qualified staff, contributing to shortages in rural and remote facilities (6). The Vietnamese Government recognizes the importance of health workforce development at the grass-roots level (including PHC and health care facilities in rural and remote areas) and has implemented several reforms in this regard, as shown in Figure 2.4. 7 Figure 2.4 Reforms to attract and retain health workers in rural and remote areas Source: Nguyen and Hoai (11). As a result of these efforts, in 2020, 99.7% of communes had health stations, 95% of which had an obstetrician or gynaecologist, or midwife, and 90% of which had a physician (12). 2.4 Health financing Health care in Viet Nam is mainly funded through domestic resources. Major reforms in the 1980s introduced liberalization and privatization of health care facilities and the pharmaceutical market and official user fees at public health facilities (13). By the early 1990s, out-of-pocket payments represented more than 70% of total health expenditures. To address financial barriers to access to care, the government developed several policies targeting vulnerable population groups. The most significant policy change was introduced in 2002 when the Health Care Fund for the poor was established and low-income individuals were offered health insurance coverage. Alternatively, health care providers had the option to provide free care to the poor and then get reimbursed for the services delivered. However, the second option caused administrative problems and incentivized providers to only register the most severe cases to receive higher reimbursements. In response to these issues, in 2005 the government issued Decree No. 63, which mandated full subsidies of premiums for the poor, making enrolment mandatory for this group (13). In 2009, a national social health insurance programme was created under the Social Health Insurance Law, which introduced compulsory enrolment for children aged under 6 years, elderly persons, and poor and near-poor persons. The government fully subsidizes health insurance premiums for children aged under 6 years, elderly and poor persons, and ethnic minorities, and provides partial subsidies for the near-poor and students (14). The Vietnamese social health insurance benefit package is quite comprehensive as compared to other countries in the region, especially as it relates to subsidized medicines. Viet Nam’s medicines list currently includes 1201 non-traditional medications and 408 medicines from the World Health Organization (WHO) Model List of Essential Medicines, including vaccines, as well as expensive medicines that are not mentioned in the WHO list. The country has no 2006 Decree No. 43 grants autonomy to public health facilities 2007 Decision No. 1544 on training under nominated regime 2009 Decree No. 64 on preferential and attraction allowance in disadvantaged areas Decision No. 75 on allowance for village health workers 2010 Decree No. 116 on allowance for cadres and civil servants in disadvantaged areas 2011 Decision No. 73 on peculiar allowance for health workers 2013 Circular No. 22/MOH on continuous medical education for health workers 2014 Decree No. 117/Govt. officially recognizes commune health staff as indicated by Law on Civil Servants 8 specific criteria for selecting benefits to include in the social health insurance benefit package (such as analysis of cost–effectiveness). This is rather determined based on the historical provision of services and general guidance under the Social Health Insurance Law. In addition, each province has its sublist of approved services, which can lead to inequalities across provinces (14). The benefits package also includes a range of expensive high-technology medical services, once again without clear inclusion criteria. Overall, the package covers all ambulatory services, as well as basic and advanced hospital services and curative care (15). Annex I presents information on health insurance coverage for target groups in Viet Nam after the adoption of the revised Social Health Insurance Law. Viet Nam has made significant progress towards achieving universal health coverage. According to WHO, by 2018, almost 87% of the population was covered by social health insurance, but enrolment rates were still quite low among the near-poor and other groups whose premiums were substantial, if not fully subsidized. Enrolment compliance was also weak among vulnerable groups for whom enrolment was mandatory (16). Furthermore, enrolment in social health insurance does not always translate into effective coverage. Indeed, utilization rates among the poor and other vulnerable groups are still low due to a lack of health literacy and confidence in district hospital services, and other non-financial access barriers. High out- of-pocket payments expose households to financial catastrophe due to health expenses and pose financial barriers to access, resulting in large inequalities in utilization between the poor and the rich. Figure 2.5 presents health expenditure trends in Viet Nam. Figure 2.5 Health expenditure trends in Viet Nam, 2008–2019 Source: WHO Global Health Expenditure Database (https://apps.who.int/nha/database/ViewData/Indicators/en). 38 36 40 39 42 47 42 42 47 46 42 44 7 37 37 37 41 41 43 45 45 45 43 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 Domestic General Government Health Expenditure as % Current Health Expenditure Out-of-pocket as % of Current Health Expenditure 9 2.5 Health information system The health information system of the Ministry of Health and the large-scale surveys of the General Statistics Office are the two main sources of official health data in Viet Nam. Through the health information system, data are regularly collected (monthly or quarterly) from public health facilities under the Ministry of Health using dedicated forms (electronic or paper). Annual reports are sent to the Health Statistics Unit of the Ministry of Health (17). General Statistics Office data are collected through surveys with national representative samples using internationally recognized methodologies. Examples include census surveys (every 10 years), population change and family planning surveys (annually), and Multiple Indicator Cluster Surveys (every three to five years). There are also some other large-scale surveys conducted in collaboration with WHO and other international partners (17). The Ministry of Health annually publishes the Health statistics yearbook based on data collected from both the health information system and the General Statistics Office. However, these publications are often issued with delays, and their format is not user friendly (for example, too long, vague, or diluted messages), which makes them difficult to use for decision- making processes (17). Although Viet Nam’s health information system is quite comprehensive in terms of indicators and domains covered, it has important limitations, including (17): ¨ poor data quality, as there is no mechanism for verification, supervision, and monitoring of data collection and reporting processes; ¨ lack of quality indicators in some programmatic areas, including NCDs and maternal, newborn and child health; ¨ the limited reach of data collection, as data are only obtained from public facilities under the Ministry of Health; ¨ lack of the foundational infrastructure for a systematic and harmonized application of information technologies, to ensure connectivity and information sharing across the health system. 2.6 Essential medicines and supplies It was not possible to obtain the most updated and accurate information related to the pharmaceutical market in Viet Nam. Limited information on subsidized drugs under the social health insurance programme is available in section 2.4 on health financing. 3. Maternal, newborn and child health: situation analysis Improvement of maternal, newborn and child health is a priority for the Government of Viet Nam, which developed and implemented the National Action Plan on Maternal, Newborn and Child Health, 2016–2020. The plan included comprehensive interventions to improve the availability, affordability and quality of health services (18). 10 Over the past two decades, Viet Nam has made significant progress in maternal, newborn and child health. According to the United Nations Children’s Fund (UNICEF), the maternal mortality ratio in the country decreased from 68 deaths per 100 000 live births in 2000 to 43 in 2017 (Figure 3.1) (19). Figure 3.1 Maternal mortality ratio in Viet Nam, 2000–2017 Source: UNICEF (19). This achievement can be attributed to the government’s efforts to improve access to and quality of maternal and child services at commune health stations; the quality of primary care facilities; the efficiency of procurement of medical equipment; and access to and quality of training for health workers. Viet Nam’s national strategy on reproductive health care services highlights the need for at least three antenatal care consultations for uncomplicated pregnancies at the PHC level (that is, commune health stations). Commune health stations are responsible for performing uncomplicated delivery and for assisting with home delivery. In cases of early recognition of labour complications such as obstetric haemorrhage or newborn problems such as asphyxia, commune health stations are to refer patients to upper-level facilities. For instance, district hospitals perform caesarian sections, manage high-risk pregnancies, and care for low-birth- weight and premature babies. In terms of postnatal care, commune health stations assist with immunizations as scheduled by national guidelines and the promotion of breastfeeding (18). With regard to the utilization of antenatal care services in Viet Nam, according to the 2021 Multiple Indicator Cluster Survey (20), 97% of women aged 15–49 years with a live birth in the previous two years received antenatal care from a skilled provider, and almost 88.2% had more than four consultations. Most of them (92.4%) had their first antenatal care consultation during the first three months of pregnancy. Almost 75% of maternal deaths in Viet Nam are related to severe bleeding (mostly after childbirth), infections (usually after childbirth), high blood pressure during pregnancy (pre- eclampsia and eclampsia), complications from delivery and unsafe abortion (21). 68 65 62 59 57 54 51 49 49 48 47 47 46 46 45 45 44 43 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 11 Evidence shows low awareness levels among women in Viet Nam about symptoms of complications during pregnancy, childbirth or in the postpartum period, and where to seek care in case of need. This leads to delays in seeking care, especially for women living in remote areas (22). User fees, both official and unofficial, are also a well known barrier to health care seeking, together with low education levels and other cultural issues. In addition to these challenges, other factors preventing women from seeking care in Viet Nam include discrimination and negative attitudes from health staff towards women in general and ethnic minorities in particular (23). For maternal and child health, Viet Nam set higher targets than the Sustainable Development Goals (SDGs): less than 45 maternal deaths per 1000 live births (Viet Nam’s target) versus less than 70 (SDG target); and less than 17.5 under-5 deaths per 1000 live births (Viet Nam’s target) versus less than 25 (SDG target). However, Viet Nam has not adopted the indicator for decreasing mortality in children less than 28 days old, for several reasons, including: (a) national statistics do not capture these data and the only source for this information is the Multiple Indicator Cluster Survey, which is conducted every five years; and (b) lack of awareness regarding the importance of these data – to reduce mortality in children aged under 1 year, the country should reduce mortality in children less than 28 days old (Figure 3.2) (24). Figure 3.2 Mortality rates of newborns, infants and children in Viet Nam, 2012–2020 Source: World Bank Development Indicators (online database). Washington (DC); World Bank Group (https://databank.worldbank.org/source/world-development-indicators). Under-5 mortality rates have dropped from almost 24.9% in 2005 to 21.4% in 2017.5 This reduction, however, did not take place equally in all regions, and disparity in mortality rates 5 World Bank Development Indicators Database. 17,9 17,8 17,6 17,4 17,3 17,1 17 16,9 16,7 22,4 22,2 22 21,8 21,6 21,4 21,3 21,1 20,9 11,5 11,3 11,2 11,1 10,9 10,7 10,5 10,2 10 2012 2013 2014 2015 2016 2017 2018 2019 2020 Mortality rate, infant (per 1,000 live births) Mortality rate, under-5 (per 1,000 live births) Mortality rate, neonatal (per 1,000 live births) 12 remained unchanged among regions during the 2005-2017 period. In 2017, the wealthiest region in the country had a mortality rate as low as 12.6%, while the most disadvantaged region had a three times higher mortality rate (36%) (25). When data are disaggregated by sex, in 2017 mortality for boys was almost double that of girls, and mortality among rural children was more than double that of urban children (24, 25). Looking at current trends and the rate of reduction of under-5 mortality during the 2005–2017 period, Viet Nam is unlikely to meet its target of 17.5 under-5 deaths per 1000 live births by 2030 (24). 4. Noncommunicable diseases: profile, trends and existing measures In parallel to the rapid economic growth, Viet Nam has experienced a fast and wide process of urbanization over the past 20 years, reaching an urbanization rate of 40% by early 2020. Rapid urbanization has been accompanied by environmental deterioration, increased air pollution, worsening of lifestyle habits (including physical inactivity and unhealthy diets), and a consequently increased burden on health care services (1). In Viet Nam, 77% of all deaths are related to noncommunicable diseases (NCDs). However, the risk of premature death due to NCDs has been slowly declining in recent years. This trend is more evident among the male compared to the female population; however, the risk of premature death due to NCDs for females is about half that for males (Figure 4.1) (26). Figure 4.1 Risk of premature death due to NCDs: males and females (%) Source: World Health Organization (26). The leading causes of mortality in the country among NCDs are cardiovascular diseases (31%), followed by cancers (19%), chronic respiratory diseases (6%) and diabetes (4%) (26). The 2015 STEPS survey on risk factors for NCDs (27) found that the prevalence of hypertension in the study population was almost 19%, of which only 43% of cases had been diagnosed before the study, and only 14% were being treated at a health facility and were 13 keeping their blood pressure under control. Of the study population, 4% had impaired fasting glycaemia, and 4% had raised blood sugar or were currently on medication for diabetes. Nearly 30% of participants had never had their blood pressure measured by a qualified health worker, and almost 67% had never tested their blood glucose. These data reveal low awareness among individuals and communities about NCD risk factors, as well as gaps in health service delivery concerning prevention, early diagnosis and treatment of NCDs. Regarding alcohol consumption and diet quality, about 44% of participants had consumed alcohol in the previous 30 days; more than half (57%) did not meet the WHO recommendation regarding fruit and vegetable consumption, and the average consumption of salt was two times higher than the WHO recommendation. The survey revealed that the prevalence of NCD risk factors is high in Viet Nam. While more specific information about the prevalence of NCDs among pregnant women was not available, it can be assumed that it is a significant issue, given the trends for the general population. To improve maternal and child health outcomes, it is crucial for countries to have reliable data about the prevalence of NCDs and their risk factors among pregnant women. Annex 2 presents a summary of existing projects on the quality of care, maternal, newborn and child health, and NCDs implemented by various stakeholders in Viet Nam. 5. Integrating NCDs into maternal, newborn and child health services at district-level facilities: challenges and opportunities 5.1 Integrating NCDs into maternal, newborn and child health: Viet Nam context As mentioned above, Viet Nam is undergoing rapid economic, demographic and epidemiological transitions. Population ageing and the growing burden of NCDs are associated Photo © WHO/Quinn Mattingly 14 with an increased prevalence of multimorbidities and functional decline. There is also a growing need for health services and long-term care for the elderly. Viet Nam’s current health service delivery model, which is hospital oriented and focused on episodic curative care, is both inefficient and ill-suited to providing long-term, continuous care, with a person-centred approach. To better serve the changing health needs of its population, Viet Nam will need to improve health system efficiency – specifically, by shifting low- complexity services out of the hospital setting and by improving the quality of care at the PHC level, particularly for NCDs and chronic conditions. A stronger PHC system, with effective referral and management practices, would contribute to ensuring continuous, high-quality care for patients as they move through the health service delivery system, which is an essential prerequisite for implementing an integrated care model in Viet Nam (5). At the macro level, key areas for improvement and challenges to the adoption of integrated care models include the following (5): ¨ From the policy and legal perspectives, the concept of care integration is mentioned across a range of government documents; however, there is no cohesive policy on integrated care. There are also gaps in the legal framework, such as on patient choice and data sharing processes, that must necessarily be addressed to operationalize care integration. ¨ Governance and management of health services continue to follow the hierarchical public service administrative structure, with weak accountability mechanisms for achieving objectives. New governance and management arrangements will need to be developed to improve provider responsiveness and accountability. ¨ On financing, current provider payment mechanisms do not promote a cooperative and complementary relationship among various levels of care. Significant reforms would be needed to align incentives towards care integration. Financing could also be used as a lever to improve performance and accountability. ¨ Human resources policies will have to focus on improving the quality of services and health worker competencies and skills at the PHC level. Training programmes will need to be redesigned and adapted, as they currently do not include elements of care integration. At the micro level of front-line service delivery, the following gaps remain (5): ¨ Providers at different levels of care remain separate in administrative and managerial arrangements. There are no established multidisciplinary teams and there is no concept of joint management of patients. ¨ Many patients bypass PHC, especially at the commune level, due to poor quality of care, which undermines the critical role of PHC as the first point of contact for patients. 15 ¨ Tools to facilitate interaction among providers have not been put in place yet. Most interaction among providers relates to technology transfer and professional support provided by higher to lower levels of care. Clinical guidelines are applied unevenly, and they lack a clear definition of who should deliver each intervention or service, and where. In addition, there are significant gaps in health information systems. Health data are often duplicated and fragmented, and health workers are neither allowed nor required to share patient information for purposes of coordinating patient care across providers and levels. Finally, strengthening the existing monitoring and evaluation framework will be essential to understand health system performance, helping build the case on the importance of integrated care for Viet Nam, and evaluating the impact of integrated care reforms (5). Adopting person-centred, integrated health service delivery models has the potential to help Viet Nam address the evolving health needs of the population, reduce pressure on the health care system, improve the quality of services delivered, and promote health equity. However, this will require a whole-system approach, including the adoption of digital health technologies and the participation of all relevant stakeholders in all stages of health system transformation (28). 5.2 Quality of care assessment In 2016, the Ministry of Health developed the Vietnamese hospital quality assessment criteria to encourage hospitals to establish quality improvement mechanisms and activities, increase satisfaction and safety among patients, staff, and management, and improve health outcomes (29). The 83 criteria apply to all hospitals (both public and private) at all administrative levels, Photo © WHO/Quinn Mattingly 16 and set standards for patient care; health workforce development; professional performance; quality improvement; and professional knowledge, competencies, and skills (30). However, the current criteria need to be updated, and additional indicators related to the quality of services should be included. Despite the existing hospital quality criteria, poor quality of care is still a major obstacle to the improvement of population health in Viet Nam and all developing countries, especially for maternal, newborn and child health services. For instance, the evidence shows that poor quality of care is among the main reasons for unsatisfactory results of large-scale programmes aimed at improving the coverage of maternal, newborn and child health services (31, 32). This may also apply to the low utilization of PHC services for NCDs and hospital overcrowding, because of patient assumptions about a better quality of care at higher-level facilities. One of the greatest obstacles in assessing the quality of care in Viet Nam and worldwide is the lack of reliable and accurate data, especially in low- and middle-income countries (33). A study conducted by the United Nations Population Fund (UNFPA) (34) in 2017 identified more than 30 different determinants of inequity in access to maternal, newborn and child health care in Viet Nam, including the impact of informal fees, and the many testimonies of discrimination and negative attitudes from health staff towards women in general and ethnic minorities in particular (23). Evidence suggests that women prefer to deliver either in private clinics or at home, which is partly attributable to the attitude of health care staff towards them. However, services provided at private clinics require out-of-pocket payments and are not accessible to everyone. Other identified causes for inequity are income and education level, ethnicity, and urban or rural location (23). These findings were also confirmed by the 2015 Viet Nam district and commune health facility survey, which raised important concerns regarding the quality and equity of basic health services provided by the grass-roots health care system in Viet Nam (35). Although the country has made significant progress on some health outcomes measured at the national level, important gaps remain, such as the relatively high rate of infant mortality among ethnic minority groups – 44 per 1000 live births compared to 10 per 1000 live births among the prevalent ethnic groups (Kinh and Hoa). These numbers suggest the presence of inequities in quality of care. Assessing the quality of care is challenging, and a systematic evaluation of the quality of care – as opposed to health outcomes – has not previously been conducted in Viet Nam (36). Major identified gaps in the quality of basic health services provided by the grass-roots health care system in Viet Nam include: ¨ poor quality of services provided at the district and commune levels (including for common diseases, such as diarrhoea, pneumonia, hypertension and diabetes); ¨ inadequate knowledge and skills of health workers, with some doctors still prescribing unnecessary and potentially harmful treatments; ¨ much lower availability of medicines and equipment as compared to higher levels of care, especially with regard to managing the growing burden of NCDs. 17 Quality of care for maternal, newborn and child health and NCDs requires further exploration, as it will otherwise be difficult to continue improving health outcomes related to these programmatic areas. 6. Recommendations One of the components of WHO’s project on Improving the Quality of Hospital Care to Reduce Maternal, Newborn and Child Deaths and Accelerate the Achievement of the SDG Health Targets focuses on integrating NCDs and postpartum depression care into district-level maternity wards in three project countries: Kyrgyzstan, Tajikistan and Viet Nam. Work on this project began during the COVID-19 pandemic, which limited the ability of the team to travel to the project countries. One team member was able to travel to Kyrgyzstan and one to Tajikistan, but the team was unable to travel to Viet Nam. Therefore, the data for Viet Nam were collected by the team and by WHO country staff through secondary analyses of existing reports and interviews with Ministry of Health staff. Unfortunately, the data available were insufficient to develop concrete recommendations for the implementation of the project in Viet Nam. Overall, it is evident that health insurance in Viet Nam has a positive impact on access to and utilization of services; however, antenatal care coverage is still insufficient and several access barriers remain, especially for ethnic minorities. Among the major challenges to achieving better maternal, newborn and child health outcomes is inequity in access to and poor quality of care. However, these issues will require further exploration, including reviewing lessons learned from the experiences of other countries that have a similar context to that of Viet Nam. The next section provides a set of general recommendations related to health system building blocks. Photo © WHO/Quinn Mattingly 18 6.1 Policy recommendations While health financing in Viet Nam has already undergone significant reforms and there has been some progress, changes in epidemiology and demographics and the increasing demand for health care will continue to put upward pressure on health spending. The role of public financing for health is ever more important to ensure sufficient coverage of essential services and maintain adequate financial protection. Policy recommendations include the following: 1. allocate a greater proportion of GDP to health care services, resulting in greater access to high-quality care; 2. increase the coverage of existing health insurance schemes, especially for those who are not involved in the formal sector; 3. develop clear criteria for the inclusion of drugs and services in the benefits package, based on analyses of cost–effectiveness; 4. establish and follow evidence-based guidelines and protocols for when to admit and refer patients to hospitals, and put in place measures for their enforcement at both the PHC and hospital levels; 5. develop a policy to retain and expand human resources for health; 6. develop training programmes for primary care physicians on the management of pregnant women with NCDs; 7. develop and strengthen a health information system that will provide accurate disaggregated data and enable the process of evidence-based policy-making; 8. establish mechanisms to enable the systematic monitoring of the quality of care provided at both the PHC and hospital levels; 9. implement specific studies to obtain qualitative data regarding the quality of care. 6.2 Project recommendations (PHC) Specific project recommendations include the following: 1. provide advanced training to family doctors and nurses in the timely detection of high-risk pregnancies, including those complicated by hypertension, cardiovascular diseases, diabetes or pre-eclampsia; 2. develop clinical protocols for the management, timely referral, and, if necessary, transportation of high-risk pregnant women. Additional inputs and more concrete recommendations regarding the integration of NCD care into maternal, newborn and child health care will be provided by the local health system, NCD, and maternal, newborn and child health experts at a later stage in the project. 19 References 1. The World Bank in Vietnam: Vietnam at a glance. Washington (DC): World Bank (https://www.worldbank.org/en/country/vietnam, accessed 21 October 2022). 2. Baccini L, Impullitti G, Malesky EJ. Globalization and state capitalism: assessing Vietnam’s accession to the WTO. CESifo Working Paper Series SSRN 3036319. SSRN; 2017 (https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3036319, accessed 21 October 2022). 3. From the last mile to the next mile: 2022 Vietnam poverty and equity assessment. Washington (DC): World Bank; 2022 (https://documents1.worldbank.org/curated/en/099115004242216918/pdf/P17626 1055e180087097d60965ce02eb562.pdf, accessed 21 October 2022). 4. 2020 UN country annual results report: Viet Nam. 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Viet Nam General Statistics Office; 2019 (https://www.gso.gov.vn/en/dataand-statistics/2020/09/statistical-yearbook-2019/, accessed 22 October 2022). 9. Result of the Viet Nam household living standards survey 2018. Viet Nam General Statistics Office; 2018 (https://www.gso.gov.vn/en/data-and- statistics/2020/05/result-of-the-vietnam-household-living-standards-survey-2018/, accessed 22 October 2022). 10. Griffiths P, Ball J, Drennan J, James L, Jones J, Recio A et al. The association between patient safety outcomes and nurse/healthcare assistant skill mix and staffing levels and factors that may influence staffing requirements. Southampton, REFERENCES 20 United Kingdom: University of Southampton; 2014 (https://eprints.soton.ac.uk/367526/, accessed 22 October 2022). 11. Nguyen T, Hoai THT. Human resources for health in Viet Nam. 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Ha NT, Anh NQ, Toan PV, Huong NT. Health insurance reimbursement to hospitals in Vietnam: policy implementation results and challenges. Health Services Insights. 2021;14. doi:10.1177/11786329211010126. 16. Health financing in Viet Nam. Geneva: World Health Organization; 2022 (https://www.who.int/vietnam/health-topics/health- financing#:~:text=Social%20health%20insurance%20in%20Viet,and%20the%20e lderly%20above%2080, accessed 22 October 2022). 17. Vietnam national and provincial primary health care scorecards. World Bank, Australian Aid, and Primary Health Care Performance Initiative; 2019 (https://openknowledge.worldbank.org/bitstream/handle/10986/33964/Vietnam- National-and-Provincial-Primary-Health-Care- Scorecards.pdf?sequence=1&isAllowed=y, accessed 22 October 2022). 18. Heo J, Kim SY, Yi J, Yu SY, Jung DE, Lee S et al. Maternal, neonatal, and child health systems under rapid urbanization: a qualitative study in a suburban district in Vietnam. BMC Health Services Research. 2020;20:90 (https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-019-4874- 7, accessed 22 October 2022). 19. Maternal, child and newborn health. UNICEF Data Warehouse (https://data.unicef.org/resources/data_explorer/unicef_f/?ag=UNICEF&df=MNC H&ver=1.0&dq=VNM.MNCH_MMR.......&startPeriod=1970&endPeriod=2022, accessed 23 October 2022). 21 20. General Statistics Office and UNICEF. Findings of the Viet Nam survey measuring Sustainable Development Goal indicators on children and women 2020–2021. Hanoi, Viet Nam: General Statistics Office; 2021 (https://mics.unicef.org/news_entries/208/FINDINGS-OF-THE-VIET-NAM- SURVEY-MEASURING-SUSTAINABLE-DEVELOPMENT-GOAL- INDICATORS-ON-CHILDREN-AND-WOMEN-2020-2021, accessed 23 October 2022). 21. Maternal health in Viet Nam. Geneva: World Health Organization (https://www.who.int/vietnam/health-topics/maternal-health, accessed 23 October 2022). 22. Viet Nam midwifery report 2016. Hanoi, Viet Nam: UNFPA and Ministry of Health of Vietnam; 2017 (https://vietnam.unfpa.org/sites/default/files/pub- pdf/Web_Midwifery_Eng.pdf, accessed 23 October 2022). 23. Målqvist M, Hoa DTP, Thomsen S. Causes and determinants of inequity in maternal and child health in Vietnam. BMC Public Health. 2012;12:641. doi:10.1186/1471-2458-12-641. 24. National review: Viet Nam’s Sustainable Development Goals with a child focus. Hanoi, Viet Nam: Ministry of Planning and Investment, Department of Science, Education, Natural Resources and Environment, and UNICEF; 2018 (https://www.unicef.org/vietnam/reports/national-review, accessed 23 October 2022). 25. Nguyen CM, Nguyen MP. The roles of social economic status and undernutrition in regional disparities of the under-five mortality rate in Vietnam. Tropical Medicine and International Health. 2020;25(11):1362–72. 26. Noncommunicable diseases country profiles 2018. Geneva: World Health Organization; 2018 (https://apps.who.int/iris/handle/10665/274512, accessed 21 October 2022). 27. National survey on the risk factors of non-communicable diseases (STEPS): Vietnam 2015. Hanoi: Ministry of Health, General Department of Preventive Medicine; 2016 (https://extranet.who.int/ncdsmicrodata/index.php/catalog/590/download/4309, accessed 23 October 2022). 28. Dang T, Nguyen T, Hoang Van M, Santin O, Tran O, Schofield P. Patient- centered care: transforming the health care system in Vietnam with support of digital health technology. J Med Internet Res. 2021;23(6):e24601 doi:10.2196/24601. 29. Luong DH, Ngoc KL, Hong PD, Le MD, Daly AN, Thu TD et al. The status of baby friendly hospital initiative under hospital quality assessment criteria implementation: a report in Vietnam. Diversity and Equality in Health and Care. 2018;15(4):129–36. 22 30. Decision number 4858/QD-BYT: promulgation for hospital quality assessment criteria. Government of Viet Nam, Ministry of Health; 2013 (https://thuvienphapluat.vn/van-ban/The-thao-Y-te/Quyet-dinh-6858-QD-BYT- Bo-tieu-chi-chat-luong-benh-vien-Viet-Nam-2016-331011.aspx, accessed 23 October 2022). 31. Filippi V, Ronsmans C, Campbell OM, Graham WJ, Mills A, Borghi J et al. Maternal health in poor countries: the broader context and a call for action. Lancet. 2006;368(9546):1535–41. 32. Graham WJ, Varghese B. Quality, quality, quality: gaps in the continuum of care. Lancet. 2012;379(9811):e5–e6. 33. Dettrick Z, Gouda HN, Hodge A, Jimenez-Soto E. Measuring quality of maternal and newborn care in developing countries using demographic and health surveys. PLoS One. 2016;11(6):e0157110. doi:10.1371/journal.pone.0157110. 34. Exploring barriers to accessing maternal health and family planning services in ethnic minority communities in Vietnam. Hanoi: UNFPA and Government of Viet Nam, Ministry of Health; 2017. 35. Quality and equity in basic health care services in Vietnam: findings from the 2015 Vietnam district and commune health facility survey. Washington (DC): World Bank; 2016 (https://microdata.worldbank.org/index.php/catalog/2728, accessed 23 October 2022). 36. Public expenditure review. World Bank and Ministry of Finance (Vietnam); 2015. 23 Annex 1. Health insurance coverage for target groups in Viet Nam after adopting the revised Social Health Insurance Law Source: Thuong NTT. Impact of health insurance on healthcare utilization patterns in Vietnam: a survey-based analysis with the propensity score matching method. BMJ Open. 2020;10:e040062. doi:10.1136/bmjopen-2020- 040062. 24 Annex 2. Mapping of existing projects related to the quality of care, maternal, newborn and child health, and NCDs implemented by various stakeholders Donor engagement in Viet Nam started in the late 1980s when diplomatic relations were re-established following the Doi Moi reforms. According to The Organisation for Economic Co-operation and Development (OECD), the Development Assistance Committee estimates that 35% of health aid is dedicated to investment projects, 25% to technical cooperation, and only 0.8% to programmatic support. 6 The Development Assistance Committee also underlines the fragmentation of donor support in the country. Major development partners for health-related development targets Source: Asian Development Bank; 2018 (https://www.adb.org/projects/documents/vie-50285-002-rrp). 6 OECD aid at a glance charts: https://www.oecd.org/countries/vietnam/aid-at-a-glance.htm. 25 The official development assistance (ODA) report of the Ministry of Health for the third quarter of 2017 showed that the ministry was managing over 30 ODA projects, for a total commitment of approximately US$ 1.6 billion. The World Bank and the Global Fund to Fight AIDS, Tuberculosis and Malaria each accounted for 25% of the total health sector assistance, followed by the Japan International Cooperation Agency (about 16%), the Asian Development Bank (about 13%), and the European Union (about 8%). Communicable disease control represents the top priority for donor assistance, with a particular focus on HIV/AIDS.7 The most recent available information about major donor projects is presented in the table above. A qualitative study of the changing donor landscape in Viet Nam found that donors proliferated in the health sector because (a) Viet Nam had clear health needs; (b) improving population health was already a priority for the Vietnamese Government; and (c) health was perceived as a less politically sensitive sector compared to others.8 Both the Government of Viet Nam and donor organizations made some efforts towards aid coordination in this early phase of donor proliferation. For example, the Ministry of Health established a directory of health sector donor activities, and the Netherlands and Sweden sponsored feasibility studies on donor coordination mechanisms and began consultative meetings with the Ministry of Health, the World Bank and WHO. During the late 1990s and early 2000s, donors and the Ministry of Health were also considering adoption of a sectorwide approach that would pool donor funds into a common account to support a variety of programmes. However, the Ministry of Health decided not to pursue a sectorwide approach in the end because of human resources and information systems constraints, and anticipated difficulties in securing cooperation from other government units.9 Findings from the same qualitative case study indicated that donor agencies and government units in Viet Nam were pursuing a range of political, economic and institutional objectives in addition to maximizing population health benefits from health sector aid. Harmonization, alignment and shared ownership were perceived by donors and government officials as useful tools to increase the efficiency and sustainability of aid-funded health programmes. On the other hand, these principles constrained the achievement of other important objectives and were therefore applied selectively by all parties involved. In addition, the interests of donors and government officials responsible for developing health aid effectiveness policies differed in some cases from the interests of those charged with the implementation of aid-funded projects.10 7 Local health care for disadvantaged areas sector development program: report and recommendation of the President. Asian Development Bank; 2018 (https://www.adb.org/projects/documents/vie-50285-002-rrp, accessed 23 October 2022). 8 Wood Pallas S, Khuat THO, Le QD, Ruger JP. The changing donor landscape of health sector aid to Vietnam: a qualitative case study. Social Science and Medicine. 2015;132:165–72. doi:10.1016/j.socscimed.2015.03.027. 9 Ibid. 10 Ibid. 26 For further information, please contact: Global Noncommunicable Disease Platform World Health Organization Avenue Appia 20 1211 Geneva 27, Switzerland gnp@who.int