Describing the primary care system capacity for the prevention and management of non communicable diseases in rural vietnam

Describing the primary care system capacity for the prevention and management of non-communicable diseases in rural Vietnam Hoang Van Minh1*, Young Kyung Do2, Mary Ann Cruz Bautista2 and

Describing the primary care system capacity for the prevention and management of

non-communicable diseases in rural Vietnam

Hoang Van Minh1*, Young Kyung Do2, Mary Ann Cruz Bautista2

and Tran Tuan Anh1

1

Center for Health System Research, Hanoi Medical University, Hanoi, Vietnam

2

Program in Health Services and Systems Research Duke-NUS Graduate Medical School Singapore Singapore

SUMMARY

Background The primary care system in Vietnam has been shown to play a crucial role

in disease prevention and health promotion This study described the primary care system

in a selected rural area in Vietnam in terms of its capacity for prevention and control of non-communicable diseases (NCDs).

Methods The study was conducted in 2011 in Dong Hy district, Thai Nguyen province—a rural community located in northern Vietnam Mixed methods were used, including quantitative and qualitative and literature review approaches, to collect data on the current status of the six building blocks of the primary care system in Dong Hy district Selected health workers and stakeholders in the selected healthcare facilities were surveyed.

Results A description of Dong Hy district’s primary care capacity for NCD prevention and control is reported (i) Service delivery: The current practice in NCD prevention and treatment

is mainly based on a single risk factor rather than a combination of cardiovascular disease risks (ii) Governance: At the primary care level, multi-sectoral collaborations are limited, and there is insufficient integration of NCD preventive activities (iii) Financing: A national budget for NCD prevention and control is lacking The cost of treatment and medicines is high, whereas the health insurance scheme limits the list of available medicines and the reimbursement ceiling level Health workers have low remuneration despite their important roles in NCD prevention (iv) Human resources: The quantity and quality of health staff working at the primary care level, especially those in preventive medicine, are insufficient (v) Information and research: The health information system in the district is weak, and there

is no specific information system for collecting population-based NCD data (vi) Medical products and technology: Not all essential equipment and medicines recommended by the WHO are always available at the commune health centre.

Conclusion The capacity of the primary care system in Vietnam is still inadequate to serve the NCD-related health needs of the population There is an urgent need to improve the primary care capacity for NCD prevention and management in Vietnam Copyright © 2013 John Wiley & Sons, Ltd.

KEY WORDS : non-communicable diseases; health system; primary care; rural; Vietnam

*Correspondence to: H V Minh, Center for Health System Research, Hanoi Medical University, Hanoi, Vietnam E-mail:hoangvanminh@hmu.edu.vn; chsr@hmu.edu.vn

Int J Health Plann Mgmt (2013)

Published online in Wiley Online Library

(wileyonlinelibrary.com) DOI: 10.1002/hpm.2179

Chronic non-communicable diseases (NCDs) are well-known leading causes of global mortality, representing 60% of all deaths worldwide Of the 57 million global deaths

in 2008, almost two thirds (36 million) were due to NCDs, mainly cardiovascular diseases, cancers, diabetes, and chronic lung diseases (WHO, 2009) Chronic NCDs cause premature deaths and adversely impact the quality of life of affected individuals, creating considerable adverse economic effects on families, communities, and societies in general (Strong et al., 2005) Four of the most important chronic NCDs—cardiovascular diseases, cancers, chronic obstructive pulmonary disease (COPD), and diabetes—are linked to modifiable risk factors, such as high blood pressure, tobacco use, alcohol consumption, unhealthy diet, and physical inactivity These risk factors increasingly impact impoverished populations particularly in low-income and middle-low-income countries, reflecting the possible underlying socioeconomic determinants of NCDs (Armstrong and Bonita, 2003; WHO, 2011a)

Like other developing countries, Vietnam is undergoing a rapid epidemiological transition that results in an increased burden of chronic diseases In 2004, the World Health Organization (WHO) estimated that two out of three deaths in Vietnam (317 000 of 514 000 total deaths) were due to NCDs (Bonita and Beaglehole, 2008) Hospitals across the country have reported chronic NCDs as the major cause

of morbidity and mortality Between 1986 and 2008, hospital admissions due to chronic NCDs increased from 39% to 66.2% as chronic NCD deaths rose from 42% in 1986 to 63.3% in 2009 (Ministry of Health of Vietnam, 2009) Risk factors for chronic NCDs are also common in Vietnam In 2002, 16.8% of Vietnamese aged 25–64 years were shown to have hypertension (National Heart Institute of Vietnam, 1996) The prevalence of cigarette smoking in men and women was 56.1% and 1.8%, respectively (Ministry of Health of Vietnam, 2003) In 2004, WHO data showed that the prevalence rates of heavy and hazardous alcohol drinking among men and women were 5.7% and 0.6%, respectively (WHO, 2004) Moreover, a recent study reported a sharp increase (from 2.0% to 5.7%) in the prevalence of overweight in Vietnam between 1992 and 2002; the significant increase was observed across gender and age groups, in both urban and rural areas (Nguyen et al., 2007)

In an effort to address the NCD epidemic, the Vietnamese Prime Minister issued Decision No 77/2002/QD-TTg in 2002—a ratification of the national programme on the prevention and control of certain chronic NCDs (Viet Nam Prime Minister’s Office, 2002) The programme focuses on four major chronic conditions (i.e heart disease, cancer, diabetes, and mental health) The responsibility over activities related to each disease is devolved to the respective specialist hospitals or institutes (i.e Viet Nam Heart Institute, National Cancer Hospital, Hospital of Endocrinology, and the National Mental Health Institute) However, the programme mainly focuses

on disease management/treatment rather than using a common risk factor approach for primary prevention In addition, the programme is beset with poor collaboration among the implementing agencies and a shortage of funding from the national budget Vietnam’s primary care system (at the district and commune health levels) has been shown to play a crucial role in preventing diseases and promoting population health (Ministry of Health and Health partnership group, 2008, 2010)

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Nevertheless, it must be underscored that the primary care system should also play a role in implementing population-wide NCD prevention programmes in particular and serve as the primary access point of health care for the vast majority of people with NCDs Hence, primary care capacities in Vietnam should be strengthened to serve the NCD-related health needs of the population This paper aims to describe the primary care system in a selected rural area in Vietnam in terms of its current capacity for the prevention and control of chronic NCDs

METHODS

Study design

This study involves describing primary care facility and staff Mixed methods were used, including quantitative and qualitative and literature review approaches Quantitative approach based on self-administered questionnaire, checklists, and secondary data analysis Qualitative approach used in-depth interview techniques Study site

The study was conducted in Dong Hy district, Thai Nguyen province (80 km north

of the capital, Hanoi) Dong Hy is located in the northern east side of Thai Nguyen province and consists of 18 communes covering an area of approximately 457.75 km2 Among the districts of Thai Nguyen province, Dong Hy district was selected for this study because it is a typical rural area in Vietnam in terms of demographic characteristics with a population of approximately 114 608 in 2008 The working-age population accounts for 50.8% of the district population; 50.3%

is female Nearly 70% of the Dong Hy population engage in farming The annual GDP per capita in Dong Hy for 2009 was about 700 USD

The public health system in Dong Hy includes both district and commune health facilities Health facilities at the district level include the district hospital, the District Center for Preventive Medicine (DCPM), the District Health Bureau

of the District People’s Committee, and the District Centre for Population and Family Planning At the commune level, there are 18 commune health centres (CHCs) with a network of 272 village health workers (VHWs) Dong Hy district only has 12 registered private clinics All of the facilities are small and only provide outpatient services Most of the facilities are located in Chua Hang Town-ship There are also four military health posts responsible for taking care of soldiers in some military camps The farthest CHC is located about 40 km from the district’s centre Dong Hy district is about 10 km away from referral hospitals (i.e Thai Nguyen provincial hospital or the Hospital of Thai Nguyen Medical University)

According to Dong Hy district statistics, NCDs are the second leading cause of morbidity in the district hospital During the first 6 months of 2011, more than 500 patients were admitted to the district hospital because of NCDs A WHO study (2009) involving people aged 40 years and over in a commune in Dong Hy district also showed that NCD morbidity was quite common The prevalence of

hypertension (i.e blood pressure >140/90 mmHg) was 21.8%; the gender-specific prevalence was 29.9% among men and 14.5% among women The proportion

of people who had elevated blood cholesterol (≥5 mmol/L) was 11.8% (16.4% among men and 8.1% among women), whereas increased blood glucose levels (≥7 mmol/L) were reported in 0.8% of the study population (1.1% among men and 0.4% among women) Risk factors for NCDs were also prevalent Among the surveyed population, 9.5% reported a body mass index of ≥25 kg/m2 (8.8% among men and 10.0% among women) The prevalence of daily smoking and daily alcohol consumption among men was 52.2% and 80.4%, respectively The corresponding figures for smoking and alcohol consumption among women were 0.8% and 12.1%

Study subjects

Health facilities and staff of the primary care system in Dong Hy district (at the district and commune levels) were studied

Study scope

We described the capacity of the primary care system for the prevention and control of NCDs based on the following six building blocks of the primary care system: (i) service delivery; (ii) policy/governance; (iii) healthcare financing, (iv) human resources; (v) information and research; and (vi) medical products and technology

Study tools

Self-administered questionnaire, checklists, and guidelines for in-depth interview were developed by a team of researchers The multidisciplinary research team is composed of professionals with PhDs (2), master’s (2), and bachelor’s degrees (5) in the field of public health, statistics, and health economics The tools were pilot tested before official use

Data collection

Using the study tools, the research team visited all the selected facilities to collect the necessary data Relevant health staffs were interviewed An inventory of facilities was conducted using the checklists developed

Data management and analysis

EpiData 3.1 and Stata10 were used in entering quantitative data and conducting descriptive statistical analyses, respectively Qualitative data were analyzed by content analysis techniques

M V HOANG ET AL.

Service delivery

Various population-based NCD prevention activities in Dong Hy district are implemented by the Dong Hy DCPM, the CHCs, and a network of VHWs These activities include special event campaigns (e.g the World No-Tobacco Day) and routine information, education, and communication activities such as meetings, loud-speaker announcements, and distribution of posters and leaflets

Table 1 shows key NCD prevention activities within the primary care system in Dong Hy district in 2010 Whereas tobacco control activities are implemented in all 18 communes in the district, health promotion activities on the reduction of salt intake are only implemented in seven communes Only three of the 18 communes have prevention initiatives for alcohol misuse; a small project by a non-governmental organization is in place in the said communes Health promotion initiatives to encourage physical activity have not been conducted in Dong Hy district

In seven of the 18 communes, CHCs and VHWs conduct screening activities for early detection of individuals at high risk for chronic diseases However, individuals are only screened for hypertension The diagnoses of diabetes and high cholesterol conditions are made at the district level, whereas COPD and cancer diagnoses could only be confirmed at the provincial or central level

The aforementioned health promotion/education activities in Dong Hy are usually managed and implemented independently Only seven of the 18 communes (i.e.CHCs included in the WHO project or the national NCD program) have implemented the prevention activities in an integrated manner that simultaneously addresses salt consumption, smoking, and other cardiovascular risks

Table 2 presents information on key treatment services available at the primary care level in Dong Hy in 2010 At the district level, services for early treatment of hyperten-sion, diabetes, and COPD are available and provided at the General Internal Medicine Department of the district hospital The department has 24 staff members, four of whom are doctors of specialization level 1 However, none of these doctors have specialized in NCD management and treatment In general, NCD patients who have health insurance receive treatments for free However, these patients have to be referred by CHCs Patients who have health insurance but bypass CHCs for some reason will have to pay for the treatment costs as those patients without health insurance would

Table 1 Key NCD prevention activities in the primary care system, Dong Hy district (2010)

Health promotion to reduce tobacco use Yes Yes Yes (18/18) Yes Health promotion to reduce salt intake Yes Yes Yes (7/18) Yes Health promotion to reduce alcohol con Yes Yes Yes (3/18) Yes Health promotion to promote physical activity No No No No Early detection of people at high risk of disease No No Yes (7/18) Yes DCPM, District Center for Preventive Medicine; DH, district hospital; CHC, commune health centre; NCD, non-communicable diseases; VHWs, village health workers.

Like other areas in Vietnam, CHCs in Dong Hy are considered as the NCD patients’ access point to the healthcare system However, at the commune level, only treatments for mild cases of hypertension are available Only the seven communes where the WHO project or the national NCD programme is in operation are implementing active and continuous management and treatment of hypertension

The current treatment practice in the district and commune levels is mainly based on a single risk factor (i.e high blood pressure) rather than a combination of cardiovascular disease risk factors (i.e age, gender, blood pressure level, smoking status, total blood cholesterol, and the presence or absence of diabetes mellitus) The role of the private health sector in the management and treatment of NCDs in Dong Hy is limited as it is mainly focused on acute care services

Governance

Vietnam has a national programme on the prevention and control of certain chronic NCDs (according to Decision No 77/2002/QD-TTg in 2002), which mainly focuses

on disease management/treatment rather than using a common risk factor approach for primary prevention In addition, the programme is beset with poor collaboration among the implementing agencies and a shortage of funding from the national budget Furthermore, the role of primary care system remains unclear

Non-communicable disease prevention activities in Dong Hy are mainly managed

by the DCPM and implemented by the CHCs that tap a network of VHWs The DCPM is responsible for planning the prevention activities (based on the CHC’s plans and the Thai Nguyen Provincial Health Bureau guidelines), assigning prevention tasks to CHCs, and supervising the implementation of activities CHCs

in Dong Hy district are in charge of conducting national health programmes (including NCD and tobacco control programmes), as well as monitoring and notifying diseases (including NCDs) among the populations The network of VHWs

is chosen by the locals in each village; the CHCs and the DCPM subsequently approve the selection

Although there are primary care committees with memberships from different sectors in the district, inter-sector collaborations are limited and are lacking a clear

Table 2 Key NCD management and treatment services available in the primary care system, Dong Hy district (2010)

Early treatment for hypertension No Yes Yes No Early treatment for diabetes No Yes No No Early treatment for COPD No Yes No No Early treatment for people with high cholesterol No No No No Early treatment for cancer No No No No Rehabilitative and palliative cares No No No No DCPM, District Center for Preventive Medicine; DH, district hospital; CHC, commune health centre; VHWs, village health workers; COPD, chronic obstructive pulmonary disease; NCD, non-communicable diseases.

M V HOANG ET AL.

vision/strategy for NCD prevention and control The role of the private health sector

in the management and treatment of NCDs in Dong Hy is mainly centred on acute care services There is very little interaction between the private health facilities and the public health services

Financing

Dong Hy DCPM receives funding from the Thai Nguyen Provincial Health Bureau (government budget) to pay for staff salary (at the DCPM and CHCs) and other recurrent expenditures (i.e electricity, water, meetings, and duty travels) The government allocates about 85%–90% of its total annual expenditure on preventive health activities in the district Dong Hy DCPM receives a number of in-kind contributions (e.g vaccines, supplies, posters, and leaflets) from the different national programmes (for immunization, nutrition, and TB) The DCPM also receives direct funding from international projects on reproductive health, HIV/AIDS, and tobacco control The local government funding for prevention activities in the district (District People’s Committee) is inadequate and intermittent (with very modest funding for small health campaigns and meetings)

Even though the NCD programme has been implemented for almost 10 years today,

a specific national budget for NCD prevention activities at the primary care level remains to be put in place In 2011, Dong Hy DCPM received very few NCD-related health education materials from the Thai Nguyen Provincial Center for Preventive Medicine These materials were sufficient for NCD health promotion activities in only

a few locations in the district

At the commune level, no specific financial resource is regularly available for NCD prevention activities CHCs rely on either external project support or the government budget for their recurrent activities Apart from funding for staff salary, each CHC in Dong Hy district receives VND 20 million (about 1000 USD) a year for other recurrent activities; some CHCs use a small share of this budget for NCD-related health campaigns

on special events such as the World No-Tobacco Day, New Year’s festivals, and the VHW competition on heath education knowledge and skills The local government (Commune People’s Committee) also provides a small amount of funding for similar activ-ities within community organizations such as the Women’s Union and the Youth’s Union Despite playing important roles in disease prevention programmes in general and NCD prevention activities in particular (i.e being responsible for the additional task

of early detection and monitoring of hypertension cases), VHWs receive very little remuneration from the DCPM, if any VHWs in the mountainous areas in Dong Hy receive VND 415 000 (21 USD) per month, whereas those in other rural areas receive VND 250 000 (12.5 USD) per month VHWs working in urban areas/townships do not receive any financial incentives

At the district level, there is no budget specifically allocated for the management and treatment of NCDs In 2010, more than 54% of the district’s total expenditure for treatment-related activities at the district hospital came from the government bud-get through the Thai Nguyen Provincial Health Bureau User fees and health insurance correspondingly contribute to 28% and 18% of the district’s total expenditure The dis-trict hospital uses part of its revenues from user fees and health insurance

reimbursements to pay for additional staff salary and other activities to improve hospital care services

Unlike prevention services, treatments for NCDs at CHCs are not always free and available Health insurance scheme only covers a limited type of treatment services and causes bypassing problems

Human resources

Health workers who officially engage in preventive medicine include VHWs and staff members from the Dong Hy DCPM and CHCs Of the 31 health workers in Dong Hy DCPM, four personnel (two medical doctors, one bachelor of public health, and one administrative person) are assigned to take care of all the 10 national programmes, including the national NCD programme Only one of them received prior training on the epidemiological transition towards a mix of communi-cable diseases and NCDs Given the volume of workload for a limited health workforce, these four health personnel often need to work overtime but receive very little incentive The health staff at the DCPM expressed the need to increase their knowledge and skills to perform better NCD-related prevention activities; however, there are limited NCD training opportunities for them (e.g only one

of the four personnel received training on the management of hypertension in 2011) In addition, supporting materials for NCD prevention are not completely available

A total of 104 health workers are assigned across the 18 communes Only one CHC in Dong Hy district had no doctor In 2011, staff from seven of the 18 CHCs had the opportunity to participate in training courses on counselling services for behavioural change and lifestyle improvements, and the prevention and management

of hypertension In addition, Dong Hy district has 272 VHWs The VHWs are selected by the community and managed by the CHCs As mentioned earlier, VHWs receive little, if any, remuneration despite having important roles in disease prevention programmes and NCD prevention activities (i.e being responsible for the additional task of early detection and monitoring of hypertension cases) Only VHWs from seven of the 18 communes are trained on counselling services for behavioural change and lifestyle improvements

Health workers from both the district hospital and CHCs are involved in the diagnosis, management, and treatment of NCDs In the district hospital, eight staff (three of whom are general practitioners) from the Outpatient Ward and 24 personnel (four general practitioners) from the General Internal Medicine Department work on the diagnosis, management, and treatment of NCDs Although NCDs ranked second in the list of leading causes of morbidity in the hospital, none

of the doctors specialized in any NCD area Only four of the personnel had the chance

to participate in the training course on the prevention and management of hypertension

in 2011

At the commune level, CHC staff members, under the supervision of a district hospital staff, are trained to manage and treat certain types of NCDs, including mild hypertension and diabetes Once more, only the staff from seven CHCs received training on the prevention and management of hypertension in 2011

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Information and research

The health information system in Dong Hy district is generally weak Mortality and morbidity data are mainly collected from health facilities and reflect only a small part

of the health status of the total population A specific information system for collecting population based data on NCD mortality, morbidity, and risk factors has yet to be developed and implemented VHWs and CHCs collect mortality data, but the information on the cause of death is usually not available In addition, the primary care system in Dong Hy district does not have a disease registry

Because of inadequate research funding, and limitations in data generation capacity and data usage among healthcare staff, only four research studies were conducted by the district health staff in 2011 (all were completed within the period of the staff’s higher degree studies); staff from CHCs did not engage in any research work

The information system in the primary care system in Dong Hy district is heavily dependent on paper-based formats Different vertical programmes require CHCs and the DCPM to complete several reports/forms However, the information obtained from these reports/forms is not always consistent Patient records at the district hospital are not organized in a way that can facilitate patient management Information

on patient referrals and back referrals are usually missing from the system

Medical products and technology

Although all the CHCs in Dong Hy district are regarded as National Standard CHCs, medical products and technology related to NCD prevention and treatment do not meet the WHO Package of Essential Non-communicable (WHO PEN) disease interventions criteria for primary health care in low-resource settings (WHO, 2010b) The following WHO PEN-recommended equipment (i) thermometer, (ii) stethoscope, (iii) blood pressure measurement device, (iv) measurement tape, (v) weighing machine, (vi) peak flow metre, (vii) spacers for inhalers, (viii) blood glucose test strips, (ix) urine protein test strips; (x) glucometer, and (xi) urine ketones test strips are available at the district hospital but not at CHCs There is limited availability of blood glucometers, urine ketones test strips (not available in any CHC), urine protein test strips (only available in two CHCs), and peak flow metres (only available in four CHCs) The WHO/International Society of Hypertension (WHO/ISH) risk prediction charts are only available at the district hospital and in five of the 18 CHCs that are included in the WHO project; the tool was reported to

be rarely used

Medicines are essential components of the treatment of cardiovascular diseases, diabetes, COPD, and many cancers The WHO-recommended essential medicines are always available at the district hospital However, this is not the case in the CHCs As diabetes, COPD, and high cholesterol conditions are rarely treated at the CHCs, only a few CHCs had medicines for treating these conditions Antihyperten-sive medications are more readily available in CHCs, especially in the communes included in the WHO project However, not all types of medications for hypertension are available: none of the CHCs had statins, and only three communes had beta-blockers (Table 3)

At the district level, protocols for diagnosis and treatment of hypertension, diabetes, and COPD are available At the commune level, however, only seven of the 18 CHCs have protocols for the diagnosis and treatment of hypertension, whereas only five CHCs have protocols for the diagnosis of diabetes None of the CHCs follow protocols for the treatment of diabetes and COPD Other important protocols/guidelines for health education and counselling on tobacco cessation, keeping a balanced diet, and the early detection of NCDs are either unavailable or underutilized in the primary care facilities in Dong Hy district

DISCUSSION

To our knowledge, this is the first study that described the primary care system capacity for prevention and management of NCD in rural Vietnam The findings from our study showed that the primary care system in rural Vietnam has not been well prepared to respond to the rising NCD epidemic in the country

Service delivery

In Dong Hy district, NCD prevention activities have been implemented according to the NCD-specific national health target programme However, these activities are implemented without proper collaboration and integration, which may reduce

Table 3 Availability of essential WHO-recommended medicines in CHCs, Dong Hy (2010)

Medicine

Number of CHCs with available medicines Medicine

Number of CHCs with available medicines Thiazide diuretic 18 Ibuprofen 4 Calcium channel

blocker (Amlodipine)

Beta-blocker

(Atenolol)

Angiotensin inhibitor

(Enalapril)

11 Penicillin 18

Metformin 1 Hydrocortison 13 Glibenclamide 0 Epinephrine 5

Furosemid 11 Magnesium sulfate 6 Spironolacton 0 Promethazine 15

Prednisolone 18 Dextrose 6

CHC, commune health centre; WHO, World Health Organization.

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