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Health financing and delivery in Vietnam : looking forward
Vietnam's successes in the health sector are remarkable. Between 2000 and 2005, Vietnam achieved reductions in mortality rates for all ages, while some of its neighbors saw little change or even increases. To date, its infant and under-five mortality rates are comparable to those of countries with substantially higher per capita incomes. According to the data assembled in 'Health Financing and Delivery in Vietnam', the country continues to perform strongly in the sector, but its health care system is facing new challenges, as do those of other countries. By international standards, for example, a large percentage of Vietnamese households make out-of-pocket health care payments that exceed a reasonable fraction of their income. The country has been expanding the breadth of health insurance coverage, but questions remain on how to further expand coverage, how to decrease health care costs, and how to increase the overall quality of care. 'Health Financing and Delivery in Vietnam' reviews the country's successes and the challenges it faces, and suggests some options for further reforming the country's health system. These include the issue of stewardship—what different parts of government (for example, the Health Ministry and the health insurer) should be doing at each level of government, and what different levels of government (for example, the central government and the provincial government) ought to be doing. 'Health Financing and Delivery in Vietnam' will be of interest to readers working in the areas of public health and social analysis and policy.
eBook
Health financing and delivery in Vietnam
Vietnam's successes in the health sector are legendary. Its rates of infant and under-five mortality are comparable to those of countries with substantially higher per capita incomes. Vietnam continues to be an over-achiever in the health sector according to data assembled in this book. Like other countries, though, Vietnam faces challenges in its health system. By international standards, for example, Vietnam has a high incidence of catastrophic household health spending-a large fraction of households make out-of-pocket payments for health care that exceeds a reasonable fraction of their inco
Publication
Continuity of primary care for type 2 diabetes and hypertension and its association with health outcomes and disease control: insights from Central Vietnam
Background
Vietnam is undergoing a rapid epidemiological transition with a considerable burden of non-communicable diseases (NCDs), especially hypertension and diabetes (T2DM). Continuity of care (COC) is widely acknowledged as a benchmark for an efficient health system. This study aimed to determine the COC level for hypertension and T2DM within and across care levels and to investigate its associations with health outcomes and disease control.
Methods
A cross-sectional study was conducted on 602 people with T2DM and/or hypertension managed in primary care settings. We utilized both the Nijmegen continuity of care questionnaire (NCQ) and the Bice - Boxerman continuity of care index (COCI) to comprehensively measure three domains of COC: interpersonal, informational, and management continuity. ANOVA, paired-sample t-test, and bivariate and multivariable logistic regression analysis were performed to examine the predictors of COC.
Results
Mean values of COC indices were: NCQ: 3.59 and COCI: 0.77. The proportion of people with low NCQ levels was 68.8%, and that with low COCI levels was 47.3%. Primary care offered higher informational continuity than specialists (
p
< 0.01); management continuity was higher within the primary care team than between primary and specialist care (
p
< 0.001). Gender, living areas, hospital admission and emergency department encounters, frequency of health visits, disease duration, blood pressure and blood glucose levels, and disease control were demonstrated to be statistically associated with higher levels of COC.
Conclusions
Continuity of primary care is not sufficiently achieved for hypertension and diabetes mellitus in Vietnam. Strengthening robust primary care services, improving the collaboration between healthcare providers through multidisciplinary team-based care and integrated care approach, and promoting patient education programs and shared decision-making interventions are priorities to improve COC for chronic care.
Journal Article
Patient-Centered Care: Transforming the Health Care System in Vietnam With Support of Digital Health Technology
Background: Over the recent decades, Vietnam has attained remarkable achievements in all areas of health care. However, shortcomings including health disparities persist particularly with a rapidly aging population. This has resulted in a shift in the disease burden from communicable to noncommunicable diseases such as dementia, cancer, and diabetes. These medical conditions require long-term care, which causes an accelerating crisis for the health sector and society. The current health care system in Vietnam is unlikely to cope with these challenges. Objective: The aim of this paper was to explore the opportunities, challenges, and necessary conditions for Vietnam in transforming toward a patient-centered care model to produce better health for people and reduce health care costs. Methods: We examine the applicability of a personalized and integrated Bespoke Health Care System (BHS) for Vietnam using a strength, weakness, opportunity, and threat analysis and examining the successes or failures of digital health care innovations in Vietnam. We then make suggestions for successful adoption of the BHS model in Vietnam. Results: The BHS model of patient-centered care empowers patients to become active participants in their own health care. Vietnam’s current policy, social, technological, and economic environment favors the transition of its health care system toward the BHS model. Nevertheless, the country is in an early stage of health care digitalization. The legal and regulatory system to protect patient privacy and information security is still lacking. The readiness to implement electronic medical records, a core element of the BHS, varies across health providers and clinical practices. The scarcity of empirical evidence and evaluation regarding the effectiveness and sustainability of digital health initiatives is an obstacle to the Vietnamese government in policymaking, development, and implementation of health care digitalization. Conclusions: Implementing a personalized and integrated health care system may help Vietnam to address health care needs, reduce pressure on the health care system and society, improve health care delivery, and promote health equity. However, in order to adopt the patient-centered care system and digitalized health care, a whole-system approach in transformation and operation with a co-design in the whole span of a digital health initiative developing process are necessary.
Journal Article
Health-financing reforms in southeast Asia: challenges in achieving universal coverage
In this sixth paper of the Series, we review health-financing reforms in seven countries in southeast Asia that have sought to reduce dependence on out-of-pocket payments, increase pooled health finance, and expand service use as steps towards universal coverage. Laos and Cambodia, both resource-poor countries, have mostly relied on donor-supported health equity funds to reach the poor, and reliable funding and appropriate identification of the eligible poor are two major challenges for nationwide expansion. For Thailand, the Philippines, Indonesia, and Vietnam, social health insurance financed by payroll tax is commonly used for formal sector employees (excluding Malaysia), with varying outcomes in terms of financial protection. Alternative payment methods have different implications for provider behaviour and financial protection. Two alternative approaches for financial protection of the non-poor outside the formal sector have emerged—contributory arrangements and tax-financed schemes—with different abilities to achieve high population coverage rapidly. Fiscal space and mobilisation of payroll contributions are both important in accelerating financial protection. Expanding coverage of good-quality services and ensuring adequate human resources are also important to achieve universal coverage. As health-financing reform is complex, institutional capacity to generate evidence and inform policy is essential and should be strengthened.
Journal Article
Mental health stigma and health-seeking behaviors amongst pregnant women in Vietnam: a mixed-method realist study
Background
Approximately 15% of women in low-and middle-income countries experience common perinatal mental disorders. Yet, many women, even if diagnosed with mental health conditions, are untreated due to poor quality care, limited accessibility, limited knowledge, and stigma. This paper describes how mental health-related stigma influences pregnant women’s decisions not to disclose their conditions and to seek treatment in Vietnam, all of which exacerbate inequitable access to maternal mental healthcare.
Methods
A mixed-method realist study was conducted, comprising 22 in-depth interviews, four focus group discussions (total participants
n
= 44), and a self-administered questionnaire completed by 639 pregnant women. A parallel convergent model for mixed methods analysis was employed. Data were analyzed using the realist logic of analysis, an iterative process aimed at refining identified theories. Survey data underwent analysis using SPSS 22 and descriptive analysis. Qualitative data were analyzed using configurations of context, mechanisms, and outcomes to elucidate causal links and provide explanations for complexity.
Results
Nearly half of pregnant women (43.5%) would try to hide their mental health issues and 38.3% avoid having help from a mental health professional, highlighting the substantial extent of stigma affecting health-seeking and accessing care. Four key areas highlight the role of stigma in maternal mental health: fear and stigmatizing language contribute to the concealment of mental illness, rendering it unnoticed; unconsciousness, normalization, and low literacy of maternal mental health; shame, household structure and gender roles during pregnancy; and the interplay of regulations, referral pathways, and access to mental health support services further compounds the challenges.
Conclusion
Addressing mental health-related stigma could influence the decision of disclosure and health-seeking behaviors, which could in turn improve responsiveness of the local health system to the needs of pregnant women with mental health needs, by offering prompt attention, a wide range of choices, and improved communication. Potential interventions to decrease stigma and improve access to mental healthcare for pregnant women in Vietnam should target structural and organizational levels and may include improvements in screening and referrals for perinatal mental care screening, thus preventing complications.
Journal Article
Views by health professionals on the responsiveness of commune health stations regarding non-communicable diseases in urban Hanoi, Vietnam: a qualitative study
Background
Primary health care plays an important role in addressing the burden of non-communicable diseases (NCDs) in low- and middle-income countries. In light of the rapid urbanization of Vietnam, this study aims to explore health professionals’ views about the responsiveness of primary health care services at commune health stations, particularly regarding the increase of NCDs in urban settings.
Methods
This qualitative study was conducted in Hanoi from July to August 2015. We implemented 19 in-depth interviews with health staff at four purposely selected commune health stations and conducted a brief inventory of existing NCD activities at these commune health stations. We also interviewed NCD managers at national, provincial, and district levels. The interview guides reflected six components of the WHO health system framework, including service delivery, health workforce, health information systems, access to essential medicines, financing, and leadership/governance. A thematic analysis approach was applied to analyze the interview data in this study.
Results
Six themes, related to the six building blocks of the WHO health systems framework, were identified. These themes explored the responsiveness of commune health stations to NCDs in urban Hanoi. Health staff at commune health stations were not aware of the national strategy for NCDs. Health workers noted the lack of NCD informational materials for management and planning. The limited workforce at health commune stations would benefit from more health workers in general and those with NCD-specific training and skills. In addition, the budget for NCDs at commune health stations remains very limited, with large differences in the implementation of national targeted NCD programs. Some commune health stations had no NCD services available, while others had some programming. A lack of NCD treatment drugs was also noted, with a negative impact on the provision of NCD-related services at commune health stations. These themes were also reflected in the inventory of existing NCD related activities.
Conclusions
Health professionals view the responsiveness of commune health stations to NCDs in urban Hanoi, Vietnam as weak. Appropriate policies should be implemented to improve the primary health care services on NCDs at commune health stations in urban Hanoi, Vietnam.
Journal Article
Analysis of strategies to attract and retain rural health workers in Cambodia, China, and Vietnam and context influencing their outcomes
Background
Many Asia-Pacific countries are experiencing rapid changes in socio-economic and health system development. This study aims to describe the strategies supporting rural health worker attraction and retention in Cambodia, China, and Vietnam and explore the context influencing their outcomes.
Methods
This paper is a policy analysis based on key informant interviews with stakeholders about a rural province of Cambodia, China, and Vietnam, coupled with a broad review of the literature.
Results
Cambodia, China, and Vietnam have implemented medical education, provided financial incentives, and provided personal and professional support to attract and retain rural health workers. More socio-economic development was related to a wider range of interventions and their scope. The health system context influenced the outcomes. Increased autonomy of public hospitals attracted more health workers from rural primary health facilities in China and Vietnam. Health financing policies for universal health coverage in China and Vietnam have increased the utilization of health services. Subsidies for poor people to access health services in Cambodia have provided financial incentives to retain rural health workers. However, the dismantling of the referral system in China and Vietnam has resulted in a high rate of health workers moving from primary health facilities to higher-level hospitals while clear definition of primary healthcare package in Cambodia guided its planning of primary health workforce. The prosperous private health sector in Cambodia and Vietnam attracted more health workers from rural primary health facilities, impeded implementation and determined effectiveness of financial incentives.
Conclusions
Socio-economic and health system reforms including health financing, public hospital autonomy, abolition of referral system and prosperous private sector have both positive and negative impacts on the design, implementation, and effectiveness of interventions to attract and retain rural health workers. Interventions to attract and retain health workers in rural and remote areas need to be considered within overall health system reform.
Journal Article
Advancing universal health coverage in China and Vietnam: lessons for other countries
Background
China and Vietnam have made impressive progress towards universal health coverage (UHC) through government-led health insurance reforms. We compared the different pathways used to achieve UHC, to identify the lessons other countries can learn from China and Vietnam.
Methods
This was a mixed method study which included a literature review, in-depth interviews and secondary data analysis. We conducted a literature search in English and Chinese databases, and reviewed policy documents from internal contacts. We conducted semi-structured interviews with 16 policy makers, government bureaucrats, health insurance scholars in China and Vietnam. Secondary data was collected from National Health Statistics Reports, Health Insurance Statistical Reports and National Health Household Surveys carried out in both countries. We used population insurance coverage, insurance policies, reimbursement rates, number of households experiencing catastrophic heath expenditure (CHE) and incidence of impoverishment due to health expenditure (IHE) to measure the World Health Organization’s three dimensions of UHC: population coverage, service coverage, and financial coverage.
Results
China has increased population coverage through strong political commitment and extensive government financial subsidies to expand coverage. Vietnam expanded population coverage gradually, by prioritizing the poor and the near-poor in an incremental way. In China, insurance service packages varied across regions and schemes and were greatly determined by financial contributions, resulting in limited service coverage in less developed areas. Vietnam focused on providing a comprehensive and universal service packages for all enrollees thereby approaching UHC in a more equitable manner. CHE rate decreased in Vietnam but increased in China between 2003 and 2008. While Vietnam has decreased the CHE gap between urban and rural populations, China suffers from persistent disparities among population income levels and geographic location. CHE and CHE rates were still high in lower income groups.
Conclusion
Political commitment, sustainable financial sources and administrative capacity are strong driving factors in achieving UHC through health insurance reform. Health insurance schemes need to consider covering essential health services for all beneficiaries and providing government subsidies for vulnerable populations’ in order to help achieve health for all.
Journal Article