Viet Nam: Local Health Care for Disadvantaged Areas Sector Development Program

Health / Health insurance and subsidized health programs - Health sector development and reform

The development problem. Inequitable access to responsive and affordable LHC services is a key cause of health status disparities in Viet Nam. Viet Nam's regions show widely differing performance on key health indicators, which vary by a factor of 2.9 for the infant mortality rate, 3.0 for under-5 child mortality, and 2.7 for child malnutrition (Supplementary Document 1). Remote and mountainous areas have inadequate primary health care (PHC) services, and poorer health outcomes. A deficient LHC system increases vulnerability to an epidemic of emerging noncommunicable diseases (NCDs). Weak LHC in border areas can fail to detect and contain emerging, epidemic-prone transboundary diseases and thus decrease regional health security (RHS). The government is aware that LHC reforms are essential for achieving universal health coverage (UHC), meeting the health-related targets of the Sustainable Development Goals (SDGs), ensuring RHS, and supporting inclusive growth.

Binding constraints. Key obstacles to realizing the LHC system reform agenda contained in the master plan are (i) weak public investment management capacity to ensure

adequate local health care infrastructure that meets quality standards, (ii) unresponsive service delivery models, and (iii) weak health workforce development and management.

The Ministry of Health (MOH) and provincial governments lack an investment framework and robust mechanisms to direct investments under the master plan. Reforms to strengthen public financial management capacity are required to ensure sound government and development partner financing for master plan implementation, particularly in upgrading the commune health station (CHS) infrastructure.

The LHC system is unresponsive to Viet Nam's epidemiological profile. Up to 70% of patients referred to provincial hospitals, including for NCD management and illnesses related to

ageing, could be treated at the PHC level. Utilization of the LHC system, particularly for maternaland child health, remains low. To reverse this trend, service delivery systems need to be reoriented. In border and remote areas, an accessible CHS network is essential for timely detection of and response to emerging and epidemic-prone threats to RHS. Health financing mechanisms for LHC services are needed, including health insurance benefit packages for NCD management, long-term care, and sexual and reproductive health (SRH) services.

Ensuring adequate health staff in CHSs with the requisite skills to provide PHC services is a core reform area under the master plan. The regulatory frameworks that govern health workforce development and staffing require strengthening, including policies for the delivery of continuing medical education and balanced deployment of female, male, and ethnic minority health professionals. Systems for health professional licensing need to be upgraded.

Government strategy. The government is prioritizing strengthening of LHC as it seeks to achieve UHC and meet the health-related SDGs. The master plan sets out the framework to (i) consolidate the LHC organizational structure; (ii) reorient operational, service delivery, and financing mechanisms; (iii) strengthen LHC human resources; and (iv) guide investments in LHC system infrastructure (Supplementary Appendix 2). The government is committed to meeting its legal obligations under the International Health Regulations, which require that minimum core public health capacities for responding to health security threats (HSTs) be established.

Asian Development Bank engagement. The Asian Development Bank (ADB) has supported strengthening PHC since 1995 in combination with regional cooperation to control communicable disease (Supplementary Appendix 3). The program will consolidate work undertaken by ADB to improve primary health service delivery through better quality management systems and workers, with an intensified focus on the communes. The program is consistent with the ADB strategy for health cooperation, and continues ADB support for health system strengthening and enhanced health security. The program will strengthen PHC services in border areas by improving disease surveillance and control, enhancing outbreak response capacity, and addressing the needs of mobile populations. The program aligns with the medium- to long-term ADB strategy to assist the government achieve UHC through strengthened health service delivery, health human resources (HHR), and health financing. It complements ADB assistance to policy and institutional reforms on HHR and health financing (Supplementary Appendix 4).

Development partner coordination. Master plan implementation will be supported by ADB through the program, and by a proposed World Bank project, and will benefit from strong synergies between the proposed interventions (Supplementary Appendix 5). The program will establish the required regulatory frameworks and systems for managing government and development partner investments under the master plan. The World Bank will support investments in infrastructure, equipment, and training. Parallel investments for equipment and training under the program's project grant will complement World Bank investments through delineation in geographic areas of focus. The program will complement the European Union's Health Sector Policy Support Program to enhance health sector policy and planning systems.

Proposed modality. A sector development program lending is proposed. The program will support key policy reform actions to strengthen the LHC system, including RHS, by establishing a regulatory and institutional framework to direct investments under the master plan to be financed by the government and development partners. The framework will also be critically important as program loan funds will be used for investment in CHSs, which demonstrates the government's commitment to the implementation of the master plan and RHS. The policy reforms will provide an enabling environment for effective delivery of project grant support, which encompasses investments in capacity building, equipment, quality assurance, and analytical work for enhancing LHC and responsiveness to RHS threats.

Public investment management for local health care

Service delivery models for local health care network

Local health care workforce development and management

The program is expected to bring positive impacts to ethnic minorities such as improving the capacity of ethnic minority health care staffers, improving access to and quality of health services for ethnic minorities, especially in disadvantaged and remote areas. As positive impacts

on ethnic groups are expected, the program is classified category B for indigenous peoples. An EMDP was prepared to ensure project grant activities benefit ethnic minorities during implementation.

The CPMU and DOH in each province will ensure full implementation of the EMDP. The project will assist with training and capacity building of MOH/CPMU and DOH, including for implementation of the EMDP, through training and field visits. The EA will hire a gender and ethnic minority specialist (18 person-months) and a communications specialist (15 person-months) to assist the project in implementing and monitoring the measures described in the EMDP.