The proposed (ensuing) project will improve the health and nutrition status of the people of the Central Highlands region, in particular the poor, women and children, ethnic groups, and other vulnerable groups. The outcome will be improved use of health services, in particular also at commune and village levels.
The ensuing Project will comprise the following outputs: 1) Improved access to health services, 2) Improved quality of health services , 3) Increased affordability and financing of health services and 4) More effective management of health services. Some indicative components ave been identified. Under output 1, civil works and equipment for rehabilitation, upgrading or replacement of commune health stations in 4 provinces, completing/upgrading district hospitals, and contributing to one provincial hospital, and posting of specialists. Under output 2, development of provincial training systems for in-service training, and scholarships for ethnic minority students. For output 3, Improving arrangements for the poor and near poor to be able to better access fee or subsidized health care, and improving health care benefits for the poor. Four output 4, improving planning, budgeting, management skills, and health information system. ,
The proposed TA will have two major sets of outputs. The first set of outputs will facilitate the processing of the project through the Vietnamese government system, i.e. the preparation of the project detailed outline (PDO) and feasibility study (FS). The second set of outputs will prepare the required documentation to facilitate ADB processing of the project by (i) determining the feasibility of the proposed investments for priority infrastructure construction and improvement covering (a) preliminary engineering designs, (b) cost estimates and financing plan, (c) financial and economic viability and sustainability, (d) environmental and social soundness, and (e) detailed implementation arrangements; (ii) prepare an institutional capacity strengthening program for health human resources, covering (a) preliminary engineering designs, (b) needs and capacity assessments and (c) a human resource development plan; (iii) prepare the health financing requirements to provide subsidization for the disadvantaged groups covering (a) registration system development, (b) health service unit costs assessment and (c) a monitoring system; and (iv) proposed management capacity development investments covering (a) planning and management capacity assessments of the provincial and district health offices, (b) capacity strengthening program for health service managers and (c) a monitoring system development plan. Lastly the TA will undertake all the required background and safeguard studies and prepare the required (linked) documentation accordingly. This includes the project administration manual (PAM) with all the information and schedules describing project financing, implementation and procurement, a Central Highlands specific sector background, a development coordination matrix, a financial and economic analysis, a financial management and procurement capacity assessment of the EA, detailed project costing, a gender analysis and action plan, an indigenous peoples action plan, a social and poverty impact analysis, a summary poverty reduction and social strategy, an environmental assessment, and a risk assessment and management plan.
|Project Rationale and Linkage to Country/Regional Strategy
In 2010, Viet Nam's population was estimated to be 86.9 million, growing at 1.1% per annum, and rapidly aging with a life expectancy of 73 years. Viet Nam has reportedly reached most of its MDGs. Viet Nam's poverty rate reduced from 29% in 2002 to 15.5 % in 2006. Rural poverty is twice the urban rate. Poverty in ethnic groups is high at 52.3% in 2006. Although the maternal mortality ratio (MMR) has declined significantly, from 233 (per 100,000 live births) in 1990 to 91 in 2000, and an estimated 69 in 2009, it may be the only MDG indicator that will not be achieved. Targets for reducing child mortality and malnutrition have been achieved, and the rapid increase in HIV has halted. However, these data are partly based on hospital statistics, are masking regional disparities, do not capture the full burden of diseases and do not reflect the poor health status of vulnerable groups including the poor, ethnic and other disadvantaged groups (particularly women). Maternal mortality in rural areas is double that in urban areas and for ethnic minorities' mothers 4 times higher than for Kinh mothers. MOH has reported MMR above 300/100,000 live births among some ethnic minorities. The infant mortality rates (IMR) in rural areas was 20.4, twice the rate in urban areas (9.7), and much higher among ethnic Gia Rai and Ban Na. More than 60% of the Kinh have access to sanitation, while only 16% of those in minority ethnic groups. To improve and sustain its MDG indicators, Viet Nam will need to target poor ethnic groups particularly women and children, living in the northern mountains and in the Central Highlands.
Despite the country's rapid economic development, the Central Highlands (CH) continues to be one of the poorest regions in Viet Nam with relatively poor health (service) indicators; e.g. poverty among the EM is 52.6% (national 16%), infant mortality rate is 27 (national 16), child malnutrition rate is 28.5 (national 18.9), and the maternal mortality rate is 300, (national 69)3. The main factors contributing to this situation are 1) inadequate health services, 2) lack of health personnel, 3) insufficient skills among available staff, 4) financial barriers for the population to access health services and 5) insufficient managerial oversight. In addition, the region hosts a considerable number of ethnic migrants from other areas in Viet Nam, whose social-cultural practices may inhibit access to health services as well. While earlier ADB support concentrated on the provision of district hospital services, there is a persisting lack of first-line adequately equipped commune health stations that would address the populations immediate health needs. Personnel from outside the region are hard to get or find it difficult to stay in the CH, not least due to communication barriers with ethnic populations or the lack of work incentives. There are not sufficient schools to train local health staff, and ensure an adequate and sustainable supply3.
The Health Care Fund for the Poor (HCFP) has been replaced with a new health care financing scheme where everyone has to pay 5%; this proves difficult for a large part of the population in the CH, nor does it provide for substantial treatment, and thus people have started staying away from seeking public health services, increasing morbidity and mortality. With the changing poverty line criteria the government is faced with more (near) poor people that are unable to afford health services. Development partners (DPs) are exploring ways of programmatic social sector subventions to be provided from the central government to provinces that are unable to provide them from their local resources; the PPTA will explore how this could be further supported as well as how anticipated economic development may replace these subventions in the future.
In the Social-Economic Development Plan (SEDP) 2011 2015, the Government of Viet Nam (GoVN) gives high priority to the health sector as a core pillar of sustainable socio-economic development. Through its new Five Year Health Sector Plan and Strategy (2011 2015) it wants to achieve the best possible health for all citizens by ensuring access to quality health care. Having reached most MDGs nationally, the government is acutely aware that regional disparities continue to exist, with poor physical access, insufficient and/or unqualified health workers and high out-of-pocket expenses in rural areas affecting the sustenance of the health MDGs, in particular for the poor, women and children. In addition, increasingly faced with a non-communicable diseases burden, there is an urgent need for improved diagnostic and treatment services as well as more qualified staff. Lastly, the new Health Sector Strategy identified that capacities in management, health policy and strategy development need to be build to better respond to changing requirements of the health care system towards equity, efficiency and development. Provincial authorities have limited capacity in health system development and improving services; e.g. plans are not evidence based, ignore recurrent costs, do not reflect disease prevention nor control, fall short of targeting underserved rural communities and are under-resourced to enable subsidization of services for the poor.
The draft ADB's Country Program Strategy (CPS) for Viet Nam 2011 2015 is fully aligned with the government's SEDP. Among others it aims for a broad based inclusive growth to improve the socialist orientation of the economy, and develop the appropriate human resources and infrastructure system required for it. The project was confirmed during the Country Program Confirmation Mission in May 2011 and its justification has been documented in the sector ASR supporting a) improved access to PHC for the disadvantaged, b) improved quality of human resources, and c) improving sector governance. The Project Completion Report (PCR) on the first phase of the project concluded that the project had been successful, with a substantial impact in terms of health facility utilization due to improved service delivery, through an expanded district hospital and preventive services network, increasing health staff in quantity and quality and covering poor and EM people through the HCFP. Key lessons of the earlier as well as ongoing health projects: i) clustering provinces, ii) focusing on PHC, iii) emphasis on sector and human resource planning, iv) appropriate selection of staff, equipment and civil works sites, and v) alignment of implementation procedures, are captured in the new project design. The project addresses remaining lacunas in the PHC network in remote areas using the experiences of earlier ADB projects in strengthening HR, improving infrastructure and subsidizing health services for the poor.