A 23-year old female farmer from the K’Ho ethnic minority was at the new Pediatric Department at Lam Ha District Hospital in Lam Dong with her 12-month old son. She had brought him there for treatment about 5 to 6 times. At first she took him to Commune Medical Station for treatment, but he did not get better, so she came to the hospital. The travel allowance provided to her under the project's Health Care for the Poor Fund helped her to get to the hospital. She had health insurance and was aware of her entitlement to free health care. She was very happy that she had also received food at the hospital.

Ethnic minority women in the Central Highlands of Viet Nam have the worst health indicators, maternal mortality continues to be stubbornly high and their utilization of health services remain low. Both the direct and opportunity costs of health care combined with traditional attitudes and practices and limited services and quality of care are some of the reasons why.

Better quality of care; new and upgraded facilities; subsidized food and transport costs for women attending health facilities; the institutionalization of gender-responsive and patient-focused approaches to providing health care; high levels of participation by women health workers in project training; and increased access to health services by women, particularly for antenatal care, are some of the critical achievements of ADB's Health Care in the Central Highlands (HICH) Project in Viet Nam. Implementation of the gender and ethnic minority action plan (GEMAP) and attention to the non-medical barriers to women’s use of health services produced important gender equality results.

The Project

The Viet Nam Health Care in the Central Highlands Project (HICH) aimed to improve the health status of the poor and disadvantaged in the four Central Highlands provinces. The project design included a gender strategy and provided for a part-time gender specialist to provide technical guidance to implement and monitor the strategy. Implementation of the gender strategy was included as a covenant in the loan agreement, which also required that priority be given to women when selecting participants for all training activities, to achieve at least the same proportion of women trainees as in the overall pool of the targeted staff. Performance indicators on maternal mortality, the proportion of deliveries attended by trained health workers and the coverage of antenatal care were included in the design and monitoring framework.

Based on gender analysis of the social, economic and cultural barriers to women seeking health care, the project gender and ethnic minority action plan (GEMAP) provided several strategies to increase the capacity of the health system to better respond to the needs of women, understand their health-seeking behavior, and reduce their burden of disease. While the Government’s Decision 139 provided for free health care for the poor through issuance of health care cards, the indirect costs of health care remained a significant barrier to accessing health care. The project's “health care funds for the poor” (HCFP) was designed and included to complement Decision 139 by defray the indirect and opportunity costs. HCFP provided supplementary food and travel allowances, assistance with direct treatment costs and mobile health outreach services. Hence, the project addressed the direct, indirect and opportunity costs of health services for the poor, especially women.

Practical Benefits for Women

Increased use of health services by women was the direct result of strategies and design features that improved the quality of services and reduced the direct and opportunity costs of care. 

The construction of new health facilities reduced distance to health services and facilitated proximity and physical access. This meant that more women were able to get to and be treated in district health centers and hospitals. New obstetric and pediatric wards, new equipment, separate delivery rooms, separate toilets for women, and the construction of canteens strengthened the capacity of hospitals to better respond to women’s needs. The canteens provided women patients and their children to be fed while they were in hospital.

A 20-year old Kinh woman was at the hospital waiting to give birth. She came to the hospital with her mother from a commune about 30 kilometers from the hospital. This is her first pregnancy. She came to the hospital because it is her first birth, there is no hospital in her district and she felt Lam Ha's services were better than her local health clinic. As a result of access to the new ultrasound equipment the doctors were also able to determine the size of her baby and advised her to deliver at the hospital due to potential complications.

The HCFP provided outreach health services to ethnic minority communities and covered the costs of transport to health facilities and food while in hospital, all of which significantly reduced the direct and opportunity costs of accessing heath services.

The skills and qualifications of female health staff were upgraded, resulting in increased confidence and capacity of health staff serving these communities. The GEMAP required at least one staff member to be trained in women’s health at each medical facility–this was achieved and staff at all levels had improved understanding of women’s health needs.

The IEC activities were well targeted and made women aware of their entitlements to free health care under Decision 139 and the special allowances provided under the HCFP. The information, education, and communication (IEC) materials focused on health topics that directly affected women and children, such as diarrhea prevention, breastfeeding, reproductive health, immunization and safe pregnancy. The activities encouraged women to improve their own health-seeking behavior. All these factors combined to increase women’s confidence in the health system, their understanding of the importance of accessing health care during pregnancy, and their use of health services.

In Madrak District Hospital in Dak Lak patients were aware of their entitlements. A woman from the Ede ethnic minority group with four children was boarding at the hospital so that she could care for her 4-year old son. Because of the health insurance cards issued by the village head, she and her family were able to have regular health checks. Each of her births had been at the local health clinic and she reported having a lot of trust and confidence in the doctors.

Evidence suggests that there was an increase in the use of health services by women. Data available for one HICH province shows that 95% of pregnant women had accessed health services and 67% had three health checks during pregnancy, compared with a baseline of 45% of pregnant women accessing antenatal care. Many of the women reported improved quality of care provided by hospitals.

Participation of Women in Project Activities

The project achieved high participation by women health workers in project trainings with most GEMAP targets achieved. Women made up 77% of midwife trainees and 52% of primary health care trainees. Women participated in the development and distribution of IEC materials (48% of trainees) which helped to improve their effectiveness and impact. Women made up 32% of provincial staff trained in planning and management, 62% of those trained in financial management, and 43% of district staff trained. Sixty percent of commune health workers trained were women, 42% of hospital management staff, 26% of post-graduate doctor trainees, and 21% of doctors who received refresher training.

Changes in Gender Relations

Women’s burden of care was reduced when looking after sick family members in hospital due to food allowances paid under HCFP. Further, women reported that they were less dependent on husbands and families to cover the transport costs to hospitals and health centers as a result of the transport allowance.  As a result, more women were attending health centers for pre-natal check ups and childbirth. These elements have the potential to contribute to changes in gender relations.

Institutional Changes

In Viet Nam, provincial project managers were aware that the GEMAP strategies had assisted to implement government policy on women’s health and ethnic minorities and indicated that the experience gained from HICH would be applied to future health projects and other provinces.

In Conclusion

There was a clear correlation between the implementation of the GEMAP, consistent monitoring and reporting of gender equality results, the use of gender expertise on the project team during implementation, and the achievement of the range of practical and strategic gender benefits. Effective strategies that contributed to the achievement of results were the involvement of women in the development and targeting of IEC materials; training at least one staff member from each health facility and provincial program management unit in women’s health needs; capacity building for project staff on key gender issues; and focusing on the non-medical barriers to women’s access to health care. In addition, broader, institutional changes were facilitated when the GEMAP was well-implemented and project staff could see how gender equality results contributed to loan outcomes and assisted implementation of Vietnam government policy.

Summary of Gender Equality Results

The following table provides a brief summary of the gender and ethnic minority action plan (GEMAP) provisions and the results achieved by the project:

Project components
GEMAP provisions

Gender equality results

Goal: improved health status

  • Women’s participation and increased access to health services by women and children were identified as a priority
  • Project outcomes focused on maternal and child health
  • Loan covenant required implementation of the GEMAP and achievement of training targets

Increased access to health services by women and children:

  • More women attending health centers for antenatal check-ups and childbirth (e.g. access to antenatal care increased from 45% to 67% for one clinic near Da Lat).

Upgrading facilities and equipment
Curative and preventive services

  • At least one staff member to be trained in women’s health in each medical facility
  • Upgraded and new facilities to provide adequate visual and auditory privacy for women
  • New and upgraded medical facilities and equipment (including obstetrics and pediatrics wards and ultrasound machines) strengthened the capacity of health services to respond to women’s needs.
  • Provincial hospitals and communes had at least one staff member trained in women’s health; staff had a good understanding of women’s health issues.
  • Separate toilets for women at hospitals.
  • Canteens at hospitals provided food for patients and their families.

Human resource development
Clinical training; primary health care training; medical schools; and IEC

  • 33% target for women’s participation in training, or a proportion equivalent to the number of female staff employed
  • 20% target for female trained doctors to be trained
  • Measures to increase the number of female medical staff including ethnic minority women
  • Capacity-building to focus on gender-specific health areas
  • IEC materials on health care to integrate gender equality messages; materials to be developed in consultation with women; IEC to prioritize health issues that disproportionately affect women
  • Increased skills of female staff due to high women’s participation in training: 77% of midwife trainees ; 52% of primary health care trainees; 48% of IEC trainees; 26% of post-graduate doctor trainees; and 21% of doctors in refresher training. Priority was given to women and ethnic minority people.
  • Patients’ confidence in hospital staff and services increased.
  • Increased gender awareness of health staff at all levels.
  • IEC campaigns targeted topics that directly affected women including diarrhea prevention, breastfeeding, reproductive health, immunization and safe pregnancy.
  • Women participated in the development and distribution of IEC materials.
  • Construction workers received HIV training.

Strengthening financing and management
Capacity building for project staff; management information system

  • One female member trained in gender-specific issues in all PPMUs
  • Gender capacity building for project implementation staff
  • Gender equality in recruitment and priority to ethnic minority women
  • Sex-disaggregated data to be collected and reported
  • Progress reports and reviews to consider gender equality issues
  • PPMUs had a gender focal point with responsibility for implementing the GAP.
  • Gender training undertaken at PPMU level: women’s participation in training was: 32% for provincial planning and management training; 62% for financial management training; 43% for district training; 60% for commune health worker training; and 42% for training of hospital management staff.
  • No sex-disaggregated data were available on recruitment.
  • Sex-disaggregated data on women’s participation in training were regularly collected.

Health care fund for the poor

  • Staff capacity-building on health care fund for the poor to be gender-sensitive
  • Measures to reduce direct and opportunity costs of accessing health care to be targeted to poor women and me—including food and travel allowances, direct treatment costs and mobile outreach services
  • Men and women were aware of their rights under Decision 139 regarding free health care; outreach work was successful in communities.
  • Food and travel allowance reduced the cost for women of accessing health services.
  • Reduced burden of care for women when looking after sick family members in hospital.

* Some male doctors also participated in this training.