Governments role in health care development in vietnam

In the future, it is necessary to consider "health socialization" to be one of the main direction for the development of health sector in Vietnam to mobilize more resources for developme

UPPSALA

UNIVERSITET

U

Students: Bui Tien Phong

Nguyen Viet Cuong Pham Thi Binh

GOVERNMENT'S ROLE IN HEALTHCARE DEVELOPMENT IN VIETNAM

Supenisors:

Prof Dr Ven-Erik Svard

Dr Dana Khac Anh

Hanoi-May 2011

ABSTRACT Thesis title: Government's roles in health care development in Vietnam

Master of Public Management Program

Authors: Bui Tien Phong, Nguyen Viet Cuong, Pham Thi Binh

Supervisors: Prof Sven-Erik Svard, Dr Dang Khac Anh

Date of defense: May/2011

Objectives: Reviewing and evaluating government's role in heath sector in

Vietnam in renovation process; Analyzing the actual situation of Govemment's role in heath care development of Vietnam and proposing some solutions to enhance government's role in heath sector in the future

Outcomes and Conclusions:

In the renovation process since 1986, there has been dramatic changes in Government's role: in stead of taking over every activities in the society centrally planned economy under Soviet Union model, our Govemment has gradually shifted to social management in the macro-management tools such as legislation, policies and other tools, ie moving from the role of the " boat sailing rowing" to the role of "boat controller Health care is a major sector of reform because it influences people's health and the stable development of society During renovation process, the health sector in Vietnam has gained many important achievements, but still exists some shortcomings and weakness

Healthcare service is a special activity and is different with other goods consuming activities in which people, despite of being rich or poor has the right

to get equal minimum benefit of healthcare service quality Only Govemment with its integrated power is able to ensure the equity of providing healthcare service quality to everyone

Govemment plays an important role in the development of health; ensure the right

to access health care of every citizen Government's role in health development in Vietnam is first shown in the following key aspects: the role of govemment in fonning the legal framework in providing administrative support for private sector

in health services to develop and control the provision of health services which can meet the requirements of the Govemment and the society

Besides the development of govemment health sector, the implementation of

"health socialization" has led to positive results In the future, it is necessary to consider "health socialization" to be one of the main direction for the development of health sector in Vietnam to mobilize more resources for development

Complete legal system on health care, increase resources for the development

of health facilities, improving the quality of staffs working in healthcare, implementation the orientation to ensure healthcare access to every people, strengthening the inspection and examination of the state in the health sector will contribute to the improvement of people's health care, ensuring that every people have equal access to primary health care at minimum level

Recommendations/ Suggestion for deeper study:

It is necessary to study and complete govemment's institution in health sector,

determining specific roles of the Govemment in health sector

Contribution of the thesis:

In theory: Systematizing all flindamental theories on Govemment's roles in health

service supply

In practice:

• Analyze and identity the Govemment's roles in health development in Vietnam ( from the actual situations in Lao cai province and Haiphong city)

• Propose solutions to improve Govemment's roles in health sector in Vietnam in general and in Hai Phong and Lao Cai in particular

Key words: Health; Administration Refonn; Socialization; Govemment's role

Contents

INTRODUCTION 5

CHAPTER 1: THE GOVERNMENT' ROLES FN HEALTH SECTOR 7

1.1 Health care and its roles in the society 7

1.2 Government's management roles in healthcare sector 7

1.2.1 Govemment's role in ensuring the equity in medical service 7

1.2.2 Government's role in ensuring the effectiveness of healthcare service supply 8

CHAPTER 2: GOVERNMENT'S ROLES IN HEALTHCARE DEVELOPMENT IN

VIETNAM 10 2.1 Awareness of the Government's roles in health care 10

2.1.1 Vietnam Healthcare situation and reasons for renovation 10

2.1.2 Government's roles in health care sector in the past years 18

2.2 "Socializing" health care supply in Vietnam 21

2.2.1 Basis for "socializing" health care service in Vietnam 21

2.2.2 Actual situation of socialization in health care in Vietnam: 22

CHAPTER 3: ENHANCING THE GOVERNMENT'S ROLES IN VIETNAM HEALTHCARE

DEVELOPMENT IN THE FUTURE 28

3.1 Vietnam healthcare development orientation in the future 28

3.2 The govemment's roles in health development 30

3.2.1 Improvement of health laws and policy systems 30

3.2.2 Build the development plan for health/medical center systems 31

3.2.3 Complete the socialization for health sector 32

3.2.4 Develop plans for health mechanism renovations and effective usage of health

resources 33 3.2.5 Strengthen health inspection and control 33

3.2.6 Policies of training and education of medical/health moral 34

3.2.7 Building and implementing suitable compensation policy to the medical officers and

statT 36 3.3 Recommendations 36

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3.3.1 To the National Assembly 36

3.3.2 To the Govemment 37

3.3.3 To the judicial organs/orhanizations 37

3.3.4 To Ministry of Health and Departments of Health 37

3.3.5 To the municipal people's committee 37

CONCLUSIONS 38 REFERENCE 39 APPENDIX 41

An toan ve sinh thuc pham

An toan thuc pham

Kham chCra benh

Bao ve sue khoe nhan dan

Quan ly nha nuac

Quy pham phap luat

Uy ban nhan dan

Xa hoi chu nghTa

Van ban quy pham phap luat

Ve sinh an toan thuc pham

1

Description in English

Food hygiene and safety

Food safety

Medical examination and treatment

People's health protection

Govemment's management

Legal principles

People's Committee

Socialist

Document of legal principles

Food safety and hygiene

INTRODUCTION

I The necessity of the research

Recently, the Govemment of Vietnam has paid attention to health development to provide better healthcare service to its people Its health network, especially local health centers, has been enhanced and developed; many epidemic diseases have been controlled; the health service is more diversified; health insurance has initially been developed effectively The results show that better health service has been provided to many regions in the country Most general health index

of Vietnam people have higher than that of other countries with the same income per capita

However, Vietnam, together with the achievements, there still exists some problems in health service such as: organizational structure is not appropriate; legal system for healthcare service is limited; healthcare systems have not meet the new requirements of the market economy and changes in diseases structures; health service quality has not met the new increasing and diversified requirement of the people; health service conditions for the poor, and the minorities at remote and mountainous areas are not good; medicine production capacities is limited; the medicines prices arc getting high compared to the income of average person; health service inspection and control is not good enough: some people are not aware of protecting health for themselves; environment hygiene and food hygiene and safety have not strictly controlled

Besides limited resources, there are shortage in quantity and inappropriate in organizational structure It is necessary to enhance socialization activities - the participations of private sectors

in health service - in reform/renovation process in health service It is obvious for the change in the Govemment's role in health service management Both public and private sectors can participate in this service The Govemment's role will change from the sole management entity

to those whose provide directions for the health service activities

Enhancing the quality of the Govemment's management and direction/orientation activities, separating management activities with health service provision will increase the effectiveness of the Government's management This results in the Government's roles as minimum and the private's roles as maximum in health service activities as possible The study of the Govemment' orientation roles in health service are an objective requirement during renovation process Therefore, the group has chosen the thesis: Government's roles in health ser> ice development

in Vietnam today

2 Research objectives and research questions

The research ohjecfives are

• to evaluate the role of Govemment in health service provision and

• to enhance socialization activities in health ser\ ice in order to improve health ser\ ice quality in Vietnam

Research questions

• How do the Govemment's roles change in public service provision during the renovation process?

• What are the roles of Govemment in health service in Vietnam today?

• What should the Govemment do in order to successfully implement their jobs in

health service provision?

3 Research target and scope

• Research target: Government's roles in health sector in Vietnam today

• Research scope: the research group investigate the practical health service situations

in Lao Cai province and Haiphong city to understand the actual health service situations in Vietnam

• Analyze and identity the Govemment's roles in health development in Vietnam (

from the actual situations in Lao Cai province and Haiphong city)

• Propose solutions to improving the Government's roles in health service in Vietnam, today

6 (\)nclusions

Apart from introduction, and conclusion, the research has 3 chapters

Chapter I Rationale of Govemment's roles in healthcare sector

Chapter 2 Real situation of Government's roles in the development of health sector of

Vietnam

Chapter 3 Improving Govemment's roles in the development of health sector of Vietnam in

the future

CHAPTER 1: THE GOVERNMENT' ROLES IN HEALTH SECTOR 1.1 Health care and its roles in the society

Health care involves with the caring and protecting people's health People's health is affected

by the nature, environment, and society Therefore, health care and protection sector also has to change together with social development and people's awareness According to the decree issued

by the Vietnam Government on functions, responsibilities, accountabilities, and organizational structure for the Ministry of Health, the healthcare service areas include preventive health, medical care, health recovery, traditional/herbal medicine, people treatment, harmful cosmetics control, food hygiene and safety, and medical equipment"

The healthcare, hence, is viewed as specific and direct activities of people and society in applying sciences in disease prevention, and treatment and protecting people's health The Government is an entity both managing healthcare activities, and carr>ing out its Govemment management roles in this sector.^

Health investments are related to human resource development Therefore, every nation in the world considers healthcare service is an indispensible pari of its national economy structure The product of health service are caring and protecting people's health The Govemment management in healthcare sector is belonged to entities of the Govemment mechanism (executive bodies), adjusting behaviors of individuals and organizations in healthcare service provision (disease prevention, treatment, and people health care and protection) in order to meet the people's legitimate requirement for healthcare and protection

1.2 Government's management roles in healthcare sector

Healthcare service has great impact on people's health and social development It is a public service provided by the Government Government's roles in healthcare sector are detailed as below:

1.2.1 Government's role in ensuring the equity in medical service

i luman beings are born with the rights of living healthy and pursuing happiness They can use healthcare service and health protection to ensure their living activities Therefore, the Government should ensure that every person in the society basically use minimum healthcare service

' Decree No 49/2003/ ND - CP on 15.5.2003 by the Government on functions, responsibilities, aaccountabilities for the Ministry of Health (Article 1)

' Prof Do Nguyen Phuong, Strategic orientation in people's healthcare protection activities from 2000 to 2020,

Hospital Management, Medical Publishing Mouse Ha Noi 2001

Implementation the equity by ensuring faimess for all people to health care, consistent with the economic capacity of society and Govemment policies on free health care and reduce costs for the poor, living in areas with difficult people and ethnic minorities

According to the current statistics, there are 350 health service centers in Vietnam Healthcare service is a special activity and is different with other goods consuming activities in which people, despite of being rich or poor has the right to get equal minimum benefit of healthcare service quality Only Government w ith its integrated power is able to ensure the equity of providing healthcare service quality to everjone

Nowadays, the process of economic renovation in Vietnam has led to the increase of income gap between the rich and the poor, social stratification is becoming bigger and bigger among social classes According to specialists' calculation, the imbalance between high income individuals and low income individuals is at 8 times The number of people living under poverty line in our country accounts for 6% of the population and is allocated in all provinces and districts all over the country but mainly gather in rural and mountainous area Those groups of people mainly take medical service at grass root levels because they can not afford medical services in hospitals at upper level Nearly 80 per cent of Vietnam populations who are living in rural area do not buy healthcare insurance and they are not capable of paying for their treatment when they get diseases

In order to deal with this issue, the Government has issued and performed a wide range of regime and policy on medical examination and treatment for poor people, but because of limited Government budget and limited contribution of social resources, there should be effective solutions to mobilize more social resources for healthcare development

1.2.2 Government's role in ensuring the effectiveness of healthcare service supply

7.2.2./ The Government should apply unified criteria to ensure quality of healthcare service

supply

Criteria of the quality standard in providing healthcare service consists of a system of laws and regulations set by the Government and Government bodies in healthcare sector It is stated in the Constitution, Law and regulations, Resolution and other legal documents

Legal documents that are directly regulating and managing health performances including: Law

on Protection of People's Health (1989); Pharmacy Law (2005); Law on Food Hygiene and Safety (2011); Ordinance on Medical and Pharmaceutical Practice (2003) Other legal documents have many articles relating to heath sector such as: Law on Children Protection, Care and Hducation (2004); Marriage and Family Law (2000); Population Ordinance (2003)

With the purpose of efficiently developing healthcare service, Govemment's regulation should

not rely solely on regulations stated in standard legal documents which directly infiuence

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medical activities but also need to consider other terms and conditions in legal documents relating to healthcare

Govemment regulations on health has strong connection to Govemment management on health (in terms of management process, and activities in health sector ) which are related to Govemment management subjects (Govemment agencies, officials and employees) and subjects engaged in health sector (entity and individual) and citizen (rights and duties of citizen in health sector- health care and protection for public) Moreover, the Govemment strictly and consistently legalize on professional, technology, specialist skill and knowledge related to activities in health sector including: regulation on professional and technical conditions and standards of medical treatment and examination, care, physics, and rehabilitation, aesthetic, nursing, orthopedic, assessment

7.2.2.2 Government management, monitoring and controlling the operation of medical

centers nationwide

Health service is a major public service of the Government There is a fact that Government health authorities focused only on the types of specific health services that society needs but lack

of service provider or unwilling to provide and in many cases provide ineffective services

For instance, it should be the Govemment's responsibility to provide medical examination and treatment for poor people in poor areas However, because of the fact that the Govemment is not able to cover all the works, it is recommended that the Govemment uses private sector's service but the Government should cover all expenses or ensure the preventive medical service, health protection and treatment

Public health service must be under government's management, supervision to ensure the efficiency of these activities

Inspection, testing, monitoring is an important step in the process of managing the health sector The purpose of the inspection and supervision is to promptly find out mistakes and fix them timely

The development of various types of medical services requires the govemment to manage and go through inspection and examination activities to better control the operation of these facilities ensure the quality of health examination and treatment and meet healthcare requirements of the people

The inspection and monitoring of health activities focus on key issues such as conducting regular inspections of health professional competence; focus on the regimes and expert rules, medical techniques, the administrative procedures of examination and treatment, the activities of private health and pharmaceutical establishments It is necessary for health inspection bodies and health inspectors to treat violations of laws on medical and pharmacy sector seriously and promptly once it is detected to ensure the order and discipline in medical activities

CHAPTER 2: GOVERNMENT'S ROLES IN HEALTHCARE

DEVELOPMENT IN VIETNAM

M Awareness of the Government's roles in health care

M.l Vietnam Healthcare situation and reasons for renovation

lealthcare is one of the key sectors which have drawn the great attention of the Vietnam 3ovemment in the process of Doi Moi (reform) Vietnam's health sector has undergone many :hanges to meet the increasing requirements of the protection, caring and improving people's lealth Compared to 1986 (the year started the renovation process in Vietnam), the quality of health care has made significant progress, specifically:

• Indicators which reflect people's health status has improved remarkably Epidemics and infectious diseases is tightly controlled, the infection rate and death rate is declining due

to the successful implementation of many national health policy

• The healthcare service has met the requirements of health examination and treatment of majority of people across the country with increasing quality services with reasonable costs so that people can afford, fhe number of people benefit from medical treatment is increasing considerably in which there is a significant proportion from poor people, poor areas and areas under the preferential policy of the Govemment According to a survey data of the Ministry of Health, in 2009, there were 40.5 million hospital visits for medical examination at commune level and 132.6 visits to hospitals and clinics People take health examination and treatment 2.2 times per year on an average

• System of health centers have strongly developed at commune level: there are health workers and medical centers at every commune There is an increase in number of doctors, medical obstetric and midwives annually Rural health network is invested, funds for health facilities at grassroots level is also invested by the Government and the contribution of the community to pay for medical centers in coinmunes and villages

• There is also a big improvement in the supply of medicines for people; the situation of

medicines shortage or no medicines at local level has been terminated In 2008,

pharmaceutical industry has met 40% of the requirement of domestic demand for drugs, drug export has increased more The proportion of fake and poor quality drugs has been reduced prevented and will be eliminated in the future

• Renewing the financial mechanism in the implementation of health services: In addition

to the financial resource mainly taken from the Govemment budget like before, leaders of health sector have proposed and successfully carried out strategies to raise fund for health sector Currently, the Government budget for health care ensures only about 60%, the rest

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(40%) is from collection of charges for hospital services at 13%, health insurance payments at 14% and 13% by aids

• Pursuing the model of preventive medicine, developing national traditional medicine, along with consolidating the network of medical facilities at grassroots level to serve public health

The success of the health sector in recent years is shown in the following main aspects: legal requirements for medical operations have been improved; system of medical facilities is developed; capacity and quality of medical staff, especially medical staff, doctors is significantly improved, material resources and equipment is supplemented and upgraded, in particular:

a) Building a legal framework on health and health ser\ ice supply:

In the renovation process from 1986 up to now, the Govemment has issued a number of legal

documents on health, such as the Law on Protection of People's Health adopted by the National Assembly dated 30/06 /1989; Ordinance on private medical and pharmaceutical practice in

1993, Health Insurance Law , Law on Medical Examination and Treatment, and Resolution No I8/2008/QH12 dated 03/06/to promote the implementation of law policies and socialization to improve people's health care; Decree No 69/2008/ND-CP dated 30/5/2008 of socialization policy for relating activities in the field of education, vocational training health, culture, sports and environment Decision No 47/2008/QD-TTg dated 02/4/2008 and Decision No 930 /QD- TTg dated /06/30/2009 on using fund from government bond to invest in health development Currently, the Ministry of Health has been urgently completing the Draft of Medicine Law, the draft Ordinance Amending and Supplementing a number of articles of the Ordinance on private medical and pharmaceutical practice; Draft Ordinance on Food to submit to the National Assembly and National Assembly Standing Committee for approval

Building and issuing many legal documents on inspection activities, conducting the inspection and examination on law implementation and obedience, the performance of expertise jobs, hospital regulations, health insurance, medical morality, the safe efTective and rational use of medicine, anti-smuggling, trade fraud, illegal manufacturing and trading of prevention and treatment drugs , the management of toxic drugs, psychotropic medicines, food hygiene, work safety, the implementation of policies, regulations and duties assigned the management of funds, materials and equipment In 2001, 3892 medical stations (in which 407 health facilities found violated): 8986 medical stations of private pharmaceutical practice and 198.490 food hygiene facilities and environment were inspected

Encouraging, guiding and well managing the operation of private medical centers, preventing from disobeying registration license and negative manifestations of these facilities

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b) Building strategy and plan in providing medical service:

Ministry of Health has developed and submitted to the Govemment for approval many programs and plans related to the development of health sector such as the strategy for people's health care and protection in each period, national health programs includes tuberculosis, leprosy, malaria and expanding immunization programs, development strategy of Vietnam Pharmaceutical Industry, Currently, the Ministry of Health is conducting the research and building of a project on organizational restructuring of the Ministry of Health under Resolution

16 of the Government "on the reorganization and downsizing "

c) Building and developing a system of healthcare facilities

In recent years, public health systems continue to be strengthened and developed as a core factor

in the work of caring and protecting people's health Quality of human resources in health care sector and professional services are continually being improved Government medical system is widely developed by an administrative system from the central to grassroots level and divided into four routes which is mainly from central to provincial, district, and communal level

Basically, the medical system which is organized according to four levels of administration is very convenient for the management and implementation of health activities This system has worked effectively in disease prevention, health care for all citizens and organizations; especially people in remote areas, ethnic minorities have the opportunity and ability to access to better health care services Within this system, healthcare at grass root level needs to be more concerned, strengthened and developed because at this level, the healthcare sector has the earliest and direct connection with people and is the pioneer in the primary healthcare treatment and disease prevention

Health facilities are shifting from the management mechanisms of centrally planned economy into a self-control mechanisms in providing health services and self-responsible for task performance, organization and finance

Socialization of health care is carried out in 1997 under Resolution 90/NQ-CP on promoting the socialization on health care, culture and education and is specified by Resolution No 05/NG-CP

in 2005 and Resolution No 53/2006/ND-CP in 2006, the Resolution has brought an important change to health service supply Besides public medical establishments, the private health facilities have gradually set up a system of service supply which are complementing and competing with state/public medical establishments in people's healthcare.^ According to statistics of the Ministry of Health, there were 66 private hospitals and thousands of private health facilities granted license and began operation by February, 2008 In 2008 particularly

^ hiip; medinet.hochiminhcitv.t!Ov.\n updated March 20'^ 2011

12

there were 22 new hospitals in operation, in which, there were 10 foreign - invested hospitals

with over 1000 beds on a largest scalệ

Table 1: Public health system 1995-2004

Source: Vu Thanh Son (2009), p 173

From a management mechanism of a centrally planned economy, health centers are gradually shifting to self-control mechanism, self - providing services, self - responsible for task performance, structure organization, staffing and finances Health care socialization is carried out

in 1997 under Resolution 90/NQ-CP on promoting socialized health care, culture and education, and is specified by Resolution 2005 and Resolution 05/NQ-CP 53/2006/ND-CP in 2006 This has brought an important change in health services supplỵ Besides public health center, a system

of private health service centers is developing They support and compete with public health care centers According to a statistics of the Ministry of Health b\ February/2008, there are 66

private hospitals and thousands of private medical facilities granted licensẹ Particularly, there are 22 new hospital registrations in which 10 foreign- invested hospitals with foreign a scale of

more than 1000 hospital beds ^ in 2008

^ V u Thanh Son (2009) p.173

13

Table 2: Private medical and pharmaceutical centers

Source: Le Chi Mai (2004), p 159 and Lao Cai Department of Health

According to the above statistics, it should be noted that there are 24 foreign - invested private general hospitals, 289 limited companies Joint Stock Company, medicine selling and buying enterprises and 4 foreign - invested medicine manufacturing enterprises

Table 3: Statistics of visit turns for health examination and treatment at private health

centers (2000) Provinces

Ha Noi

Ho Chi Minh City

Hui Phong city

Government Medical Centers

2074350

18721762

1264827

Private Medical Centers

Source: Le Chi Mai (2004) p 160; Haiphong Department of Health

The statistics show that the number of people come for medical examination and treatment at non-governmental medical centers is increasing , account for nearly 50%, thanks to having locations close to people's living area and in accordance with people's needs, hence, reducing the burden for public hospitals

Fhis trend also shows that the role of Vietnam Govemment is shifting from "boat people" - in which the Govemment provides its own medical services to the role of "boat controller" that providing orientation, guiding medical service suppliers rather than providing medical services itself

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d) Resources to implement health services:

It is the Govemment's roles to provide health care services to every people: therefore, health

sector still relies on the Government budget Under the current financial mechanism, the Ministry of Health is responsible for funding activities of units under the Ministr>' of Health, People's Committees at all levels shall provide funding for local medical activities However, because of the facts that Govemment budget is too limited, it is unable to meet the requirements

of minimum operations of the health sector

Considering the total budget, the expenses for health care sector is too little In 2011 the spending on health care rose 30.9% compared to 2010 estimates, but only reached 43,200 billion VND In particular, the spending of health care budget focuses on medical care, disease prevention and control, spending on reciprocal capital when receiving ODA (official development assistance) projects; expenses for the implementation of health programs related to prevention of social diseases and diseases epidemics, HIV / AIDS, food hygiene and safety , ; allocate funds to purchase health insurance cards for the poor, children under age six in line with the roadmap to implement the Law on Health Insurance ; support poor people to buy health insurance card and ensure funding for the implementation of health policies by adjusting the poverty line; allocate sufficient funding to carry out preferential policies for vocational secondary health sector; business additional costs incurred to support the purchase of health insurance cards for the poor and people near poverty line by adjusting the standard of poverty line,

Besides the Govemment budget, the govemment also carries out partly collecting hospital charges and health insurance, mobilize aid and foreign borrowing These revenues have contributed to the increase of revenues for health sector's activities, but in fact, it is unable to meet the actual needs of the health sector

The main financial source for hospitals is from the Govemment budget, hospital fees and health insurance, in which the Government budget is the main source and accounts for the highest proportion of total revenue at 3 routes of hospital lines (central: 40%, provinces: 37%, districts: 61%), followed by hospital charges and health insurance at a rate of 36%, 10.6% in the central route, 4 5 % and 17% in provincial route and 39% in district route including hospital fees and health insurance There is a big difference in revenue by routes, by region and hospital characteristics Proportion of the total revenue budget is high at the district hospitals compared with the ones at provincial and central level, hospitals provide free for tuberculosis and mental patients than other hospitals at central level Budget allocations in hospitals is still unreasonable mainly base on number of patient beds but not mention capacity use of hospital beds, the ability

to collect hospital fees and health insurance and heavily depend on the ability of local financial

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resources

There is big difference in expenditure between hospitals Expenditures from the Govemment budget: district hospitals accounted for the highest proportion at 67.2%, 44.4% is at Central Hospital and Provincial Hospital was 38.1%; expenditure from hospital charges and health insurance, hospitals at provincial level account for the highest proportion at 62% central hospitals: 56% and district hospitals: 32.8% Hospital fees and health insurance plays a key role

in expenditure for expertise performances directly involve with patients caring, accounting for 65%, while only 12% is spent on human resources, the rest of expenditure is spent on repairing, purchasing fixed assets In contrast, the allocated Govemment budget is mainly for people, accounting for 57%, expenditures for professional activities accounts for 14.4%, the remaining 28.6% is for administration costs and repairing and purchasing fixed assets Spending on hospital beds in central hospitals is approximately 112 million, nearly twice the provincial hospitals and district level

Source: Report from Ministr>' of Health

e) Officials and staffs in health sector:

According to the statistics of Department of Organization and Personnel - Ministry of Hcalth^ there are 212.000 health officials working in health sector across the country, of which, there are 42,721 graduates and, I 19,634 personnel graduated from high school The ratio of Doctor per 10.000 is 6.5 %, a very modest rate compared to other countries

The allocation of staff in route, according to professional fields, according to the private sector was relatively fair, ensuring the care and protection of people's health in all localities and all levels

Most of medical staffs have high professional standards, good ethics, commitment to job good, dedicated attitude to patients, but besides that, there are still some officials and staffs in health sector shows a decline in morality, awareness of responsibility and performance manner toward patients which results in lessening people's trust in Health Sector

0 Covernment management in medical service supply

In recent years Government management activities in health service supply in Vietnam have

focused on efficiency and budget savings by mobilizing the entire society to participate in people health caring and protection A lot of Govemment management activities focused on:

"'^ Report of health socialization No 557/BYT-XHH on 20/2/2011 page 6

16

• Strengthening Govemment management on health, especially for the private health sector

by building a fairly complete legal system and professional regulations on health

• Research and propose the pilot implementation of mechanism, the new fiscal policies in some public hospitals in major cities

• Renovate administrative procedures in health examination and treatment; create favorable condition for patients to get quick access to those services

• Strictly control the full implementation of the regimes, rules of professional in medical treatment facilities

• Perform well financial management; quickly conduct the annual draft budget for healthcare units with timely guideline to the implementing units Carry out the settlement

of Govemment budget to make report to the Ministry of Finance timely and in accordance with approved laws and regulations Well manage the financial aid and public asset management, major repairs, and annual budget estimates and settlement in accordance with current regulations

g) Propaganda and education on health law

\fter the issuance of medical regulations, the Ministry of Healthcare has directed the Center of lealth Communication and Education, Health and Life Newspaper, magazines, specialized )rinting papers, conducting propaganda and dissemination of the contents of the documents pecified on health, particularly the Law on Protection of People's Health Health Insurance Law, )rdinance on medical and pharmaceutical Ordinance on HIV/AIDS Prevention and Control; at

he same time coordinate with public inedia agencies in propaganda and guidance activities for ifficials and civil servants in health sector, propagation of health documents to all social classes, nterprises , raising people's awareness in health care for themselves, their families and ncourage iheiti to participate in community activities in health care

* General comments: Besides accomplishments, there still exist some shortcomings and weaknesses in health care protection activities in Vietnam, shown in the following aspects:

• Slow renovation of medical system, still not consistent with the socialists oriented market economy and the change in disease structure; quality of health services fail to meet the growing diversified people's; have difficulty in medical care for the poor and in remote and ethnic minority regions a and remote areas, medicine production capacity and supply

is weak, prices of medicines are high in comparison w ith people's incomes

• In sufficient organization and operation of preventive health care A majority of people may have not formed the self-awareness and habit of health caring and protection

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Environmental hygiene, food safety has not been strictly controlled The work ethics violation of some health workers has been slowly treated

The main cause of these weaknesses are due to insufficient Govemment management in the health sector, some health care policies are no longer appropriate, but slowly amended or supplemented; the management of medical examination and treatment at private medical and pharmaceutical practice is not good, Govemment investment for health sector is low, the distribution and use of resources is not rational and less efTectivẹ There are no effective measures for mobilizing resources from the community and society for health protection and caring activities There is a shortage and weakness in medical staffs besides an irrational structure and unsatisfactory remuneration A number of officials in party committees and govemments are not really interested in leadership and direction of the protection, caring and improvement of peoplés health, many healthcare units still rely on Govemment subsidies

Along with these weaknesses, the protection, caring and improvement of peoplés health in our country is facing enormous challenges:

• Many social problems arise, such as environmental pollution and social evils affecting peoplés health; peoplés differences in income are posing major challenges in ensuring the equity in peoplés examination and treatment, and doctor's noble moral value is being threatened by the negative side of market economỵ

• Population size of our country will be increasing in the coming years; peoplés demand for health care is growing and diverse, while the ability to satisfy peoplés needs of health care system is still limited

• Costs for health care is increasing, while our country is basically still a poor country, investment in the health care is low

• Globalization and intemational economic integration has brought us new opportunities, at the same time, brought the risks of transmission of dangerous diseases and challenges in drug manufacture and applications of high technology in medicinẹ

2.1.2 (Government's roles in health care sector in the past years

Today, Government plays an important role in the development of society The Govemment intervention in the development of socio-economic firstly is to overcome the limitations of the market and ensure social justicệ In this context, the minimum functions of the Govemment are

to provide public goods and pure services and implementing policies to ensure social stability and social equitỵ Government intervention also helps to limit the negative impact of the market

^ World Eiank(l997), p.27

^ Vfi Thanh Sim (2009) pagẹ31

18

to people's life especially for vulnerable individuals in society such as the poor, children, the elderly, and the unemployed.^

Also Government also intervened on a supporting basis which helps to maintain profitability for private sector development that is stimulated market factors which creates an environment for

widespread development ^, The Govemment regulates the socio-economic development first

through the legal system, the system of govemment policies (public policy), through the inspection and monitoring activities and provide services system, regulatory tools such as subsidies, grants, the Govemment should provide public services itself only when private sectors can not, or they do not want to or not have the chance to undertake these services (under provisions of the Govemment)

The development of the health sector in Vietnam over the years shows that, the role of the Govemment is shown on the following key aspects:

a) Building a legal framework for health services supply

It is compulsory for individuals or organization operating in a country to obey laws and regulation of that country Through the legal system, the Government determined the legal framework for activities of all individuals and organizations, giving orientation for social behavior towards in a way that the Governtnenl aims The promulgation of such a framework cannot be assigned to non - state units

Health is an important field that requires the specific Government's regulation and supervision specific to best serve the healthcare needs of people in the society Previously, because of the fact that most health services are provided by the Govemment, not much attention is paid to the identification of the legal framework for these activities Nowadays, the draw - up of a legal document system with the aim to management by law and under the law building Govemment legal system, ensuring justice and equality among all economic sectors is an essential requirement for improving the quality of Govemment management and improve quality of service providers This legal framework will build up a legal framework for the operation of health service providers and identify the essential support from the Govemment for these activities

The health service supply in Vietnam has become more competitive when the Decree No 90/CP dated 21/8/1997 on the orientation and socialization of education, health, culture takes effect There are many participants in health service supply, including Govemment entities, private and mixed ownership entities The number of private hospitals is not significant in comparison with

"Vu Thanh Son (2009) p.31

19

he huge scale of public health, but the participation of the private competitors in term of quality

md health care services will be improved^

b In addition to strengthening the capacity of public health units, the Government ihould support non - state medical facilities by providing professional training information

3ecause of the fact that Vietnam is still in transition period from centrally planned economy to narket oriented economy under Government management, most of public services in general ind medical service in particular is still under Government management State health service

:)roviders still play a key role because there still exist dependant attitude and rely on the

Govemment like it was ^ Besides, health care in private sector has not strongly developed in erm of financial capacity and management capacity to replace Govemment's health services in

he process of providing services In that context, it is an urgent and objective requirement to Jevelop public health supply in health sector in the coming time

lowever, it is impossible for the Government to meet society requirements if it is the only service supplier The fact has shown that, in recent years, the mobilization of financial resources For health sector has been carried out through various models such as: Policy to partially :olleclion of hospital fees (since 1989); health insurance policy (since 1992 ); and has achieved practical results and those policies needs to have more concern from the Govemment in the

:oming years The development of non- public service providers has set a new requirement to the

Govemment, that is, it is necessary for newly - established units to have Govemment support in :apacity building, especially support from service providers units which has strong capacity and experience (in term of human resources and facilities) strength This issue will be analyzed in its 3wn section about the socialization of medical services

c) Conducting quality control activities among health units, especially the non-state ones to ensure service quality

The main purpose of private health care facilities is to eam profits; therefore, it will be impossible for them to meet Government and society's requirements once they are operating by their own It is an urgent task of the Govemment to manage and control these service providers

so that they are able to perform all of government's requirements in a right manner Currently, in Vietnam, it is popular to realize that after obtaining Govemment's operation license for non-government service providers, the Govemment is unable to collect necessary information to supervise the operation of these service providers." The lack of necessarv' information as well as bad management has led to the unordered operation of these facilities, thus, service quality

'^ Vu Thanh Son (2009) p 172

'*^LeChiMai(2004), p.193-194

" Refer to L.e Chi Mai (2004), p.230

20

provided to the society is not guaranteed, and there is no control in setting level of service charges, collecting charges

Govemment's control of non-government health facilities is carried out by a system of specialized control agencies such as Ministry of Health Inspectors and Department of Health inspectors and administrative inspection activities The inspection and testing activities has achieved relatively good'*^ over the years However, there still exists some inappropriateness in inspection and testing activities such as low quality, improper concentration and too formal

2 2 " S o c i a l i z i n g " health c a r e s u p p l y in Vietnam

2.2.1 Basis for "socializing" health care service in Vietnam

"Socialization" here can be understood as the process of mobilizing and encouraging people's participation and the entire society in public service supply in order to gradually meet the higher requirements of service of the people and organizations in society

Socialization trend in health sector was mentioned since the Vlll Congress of the Communist Parly of Vietnam and is detailed in the Resolution 90/CP dated August 21, 1997 of the Govemment on orientation and socialization trend of education, health, culture activities In this Resolution, socialization is defined as the building of community responsibilities among social classes in the setting and improvement of a good socio- economic environment which creates favorable conditions for educational, health and cultural activities It is also the responsibility of Govemment agencies, people's organizations, economic organizations, enterprises locally and of each citizen in each province

There is a close relationship between socialization and diversifving models of medical activities Besides the strengthening of Government institutions, it is necessary to widely develop type of activities for groups and individuals in line with Party's policy and Govemment's laws Diversification has created opportunities for social classes to actively and equally participate in these activities

Socialization is the expansion of investment sources, exploiting the potential of human and material resources and financial resources in the society Making the efficient use of people's

resources and create favorable conditions for faster development of medical activities with

higher quality It is also our Party and Government's long-term policy and orientation for implementation of social policies, but not a temporary measure in the context of fund shortage of these activities Despites people's high income or redundant Govemment budget, it is still necessary to perform socialization in health care activities, because health is a long career of the entire people which will grow continuously with huge resources of the entire population

' - Refer to Le Chi Mai (2004) p.244-245

'^ Refer to Governments Resolution No 90/CP dated 21/8/1997,

21

Socialization does not mean to mitigate Govemment's responsibility and reduce the Govemment budget, but in contrast, the Govemment often looks for more sources for revenues to increase budgets for these activities, at the same time, well managing to improve the efficient use of such funds

Socialization of health activities is an important solution of our Party and Govemment in the implementation of social justice policies in economic development strategy Social justice is not only expressed in terms of enjoyment, that is, people are taken care by the society and Govemment, but also mean in terms of people contribution and dedication to the society according to their ability

In the implementation of Resolution 90/CP, dated 19/8/1999, Vietnam Govemment has issued Decree 73/1999/ND-CP on encouraging policies to promote the socialization of education, health, culture, sports, activities, in which identified'*^: Along with the strengthening of public institutions, the Government encourages the extensive development of non-public facilities consistent with Government planning in the field of education, health, culture, sports and activities with non-commercial purposes

Our Government and the society respect and provide equal treatment for products and services

of non-public facilities as well as the products and services of public facilities Non-public institutions also have the responsibility to partly receive and provide services to people under social policy as well as public establishments

The above documents have grounded the main legal basis for socialized activities in health care in Vietnam today

2.2.2 Actual situation of socialization in health care in Vietnam:

In order to implement socialization policy, the Ministry of Health has tried the solution to

"mobilize resources for investment in developing public health system." in which "encourage health care facilities, nursing and rehabilitation to mobilize funds besides the Govemment budget, cooperate and associate with individuals and enterprises to invest in infrastructure development, upgrading equipment and providing medical services accordance with the approved plan"" In order to implement this policy, resources mobilization for investment in the development of public health facilities is being implemented in two main forms:

Cooperating and collaborating in the investment of medical equipment in public hospitals

'•* Article 2 Decree 73/1999/ND-CP

'^ Resolution 2194/QD-B^ I on 21/6/2005 Ministry of Health approved on socialization development on health scr\'ice care and improvement of people's health, page 2

22

fhe fact has shown that, the cooperation and collaboration at public hospitals has brought fruitful esults and has met the demand for innovating medical technical equipment, especially high-tech equipments in the field of people's health care and treatment while the Govemment budget :annot provide sufficient equipments The mobilization of private investment resources under lifferent forms of health care have brought in positive changes in the mobilization of social esources and has made a step forward in quality and quantity of providing health care services

o people According to a Govemment's report'^ so far, public hospitals have succeeded in nobilizing about 3,000 billion to make the use of high-tech equipments, in w^hich more than 500 )illion dong is from hospitals under the Ministry of Health, 1,000 billion dongs is from luthorities and agencies of Ho Chi Minh city by borrowing stimulus fund; over 100 billion nobilized from Ha Noi authorities and agencies, nearly 50 billion comes from Quang Ninh irovince

Vith the current low level of investment in health care ( account for about 29% of the total lospital revenues),' the promotion of cooperation and collaboration in public hospitals could aad to an increase in medical charges that people have to pay if there is no control mechanisms

3 specify and use high-tech equipment According to a report from the Treatment Department, Ministry of Health among 731 hospitals in 2007, hospital revenue mainly coines from charges, ccounting for 59.4% of revenues and increase 26.5% compared with 2006 The increasmg ledical expenses that people have to pay will lead to the limit access to medical examination

nd treatment of the poor and people at sub - poverty -line

)n the other hand, according to a study on the status of medical equipment at clinic hospitals at rovincial level, there is a relatively high rate of medical equipment which is not in fully - used apacity (approximately 20%)'"^ It proves that the efficiency of investment capital from the ocialization is not high and there is an inconsistency between equipment investment and staff

•aining of equipment usage

besides, the cooperation and collaboration in the investment of medical equipment in public ospitals while lacking the Health Ministry's regulations on technical standards of current ledical test may lead to the abuse of testing at many health facilities whose goal is to regain

^ Report No 65/BC-CP, on 05/5/2008 of The Govemment on "status on the implementation of legislation and olicies on people health socialization (Report by the health minister Nguyen Quoc Trieu, on behalf of the Prime

linis teron meeting session 3 on National Assembly XII) p.9

Report on hospital examination, health treatment division 2007, p.5

** Report on health check and trcamcnt 2007 and action plan orientation 2008, Health treamnet division Ministry

f Health, p.4

"^ Health Technology Assessemenl: An inventor> and asessment of status of diagnosis equipment in provincial eneral hospitals 2006

23

invested capital, making it difficult for people to afford their medical examination and treatment Therefore, it is necessary to develop and implement regulating mechanisms in the use of high-tech equipment to ensure medical care quality in line with economic efficiency

Reports from various health facilities in the implementation of socializing health care have shown a lack of specific guidelines making it difficult for public hospitals in cooperation and association in the use of medical devices Results from a study evaluating the impact of the implementation of financial autonomy of hospitals of Health Strategy and Policy Institute shows that most of provinces are facing issues in the implementation process due to lack of detailed direction and guidance on the determination of land prices in cooperating and collaborating:

"The cooperating party only takes cares of the installment of medical equipment but the real estate belong to the Government The basis for profit calculation still gets stuck because we have not found out the basis for profit calculation yet^^ 'Thus, public hospitals should be synchronically invested by the Government to become more modem:

The change in hospital investment shows clearly in public hospitals These hospitals plan to build more service facilities by developing "on demand services" in which more investment is in diagnostic machines such as image scanners, color ultrasound, digital X-rays, endoscopy

According to a result from Health Strategy and Policy Institute'' '4 out of 14 clinic hospitals at provincial level has strongly expanded their service types while 6 out of 14 hospitals at district level has slowly expanded their service types In the process of applying autonomy, the majority

of hospitals are interested in developing on - demand services

rhere are 3 types of medical on-demand services: "on-demand hospital room", "on-demand surgery" or "non-office hour service"" According to a survey at 14 hospitals at provincial and district level of Health Strategy and Policy Institute, there are two types of service charges: normal service price and on-demand service price There was a social reaction when people have chance to witness the difference between on-demand service areas with large and fully-fumished hospital rooms and other areas when 2-3 patients share a bed in public hospitals Therefore, there

is no consensus in the impleinentation of on-demand examination and treatment and cooperating and collaborating public hospitals

•^* Impact assessment oon self finance hospitals in health service supply and heahh service pa>'ment Institute of health stategics and policies 2008, page 12

•' Impact assessment oon self finance hospitals in health service supply and health service pa>Tneni Institute of health stategies and policies 2008, page 13

'^ Surveyed data on Binh Dinh General hospital on the first 6 moths of 2008 Revenues from on requested healh

check 913.067.000 d; requested surgery 506.772.500d and part time health check 247.362.000d This revenues are partly used for direct payment to medical statT the remaining is used for hospital budget

24

Development of private hospitals and medical check centers and voluntary health insurance:

In order to implement the socialization policy, private hospitals and private clinics are open every year in provinces across the country to meet the growing needs of the people; the data is

Source: Le Chi Mai (2004), p 159 va Lao Cai

Due to high cost of medical treatment in private hospitals and private clinics, those services mainly spend for high income people; patients with low income often buy services in public hospitals On the other hand, these private hospitals mainly locate in big cities where people have the ability to pay to gain inore benefits and they often attract outpatients

2.2.2 L Real situation of heahh care socialization in Lao Cai province

lmpleir»enting the policy of "socialization" in health care, the health care system in Lao Cai is continually strengthened, widened and gradually improved from provincial to grassroots level; medical staffs are trained and retraining, supplementing high professional staffs, reaching the rate of 7.7 doctor and 0.7 pharmacists doctor per thousand people The investment of facilities and medical equipments is focused, provincial hospital are renovated, expanded, upgraded 100% clinics at regional level is firmly constructed Especially, a multifunctional hospital is largely invested with 500 hospital beds will solve the overcrowded situation currentlv Besides, Lao Cai health sector should focus on developing traditional medicine by combining oriental and western method in examination and treatment Medicine supply is developing continuously, ensuring the needs for prevention and treatment Health insurance sector is expanded, 90% of people in Lao Cai province possess health insurance cards It should be noted that, despite being

a mountainous province, people are getting closer access to health serv ices, quality is improved

•»s

poor people and children under 6 years are taken care of Number of examination and treatment has been high; it reaches an average of 2.6 times per person per year in 2010*^^

Nowadays, medical staffs are not only required to operate well modem medical equipments but also need to improve their professional skills to catch up with the development of advanced medicine There are now 3275 medical staff and employees in health sector, including 479 doctors, reaching 7.7 doctors per thousand people (increase 2.3 doctors per thousand people compared to 2005) 100% of staffs working at health centers at commune level graduated from

high school " In order to perform this task effectively, the medical training should be

implemented synchronously from village to provincial level under various models such as professional training classes, collaborating with universities in training Doctors and nurses, encouraging staff to study at postgraduate level The training in technology transfer is a major success of health sector in recent years Since 2005, Lao Cai has invited the top experts from Central hospitals like Bach Mai Hospital, Vietnam, Viet Due Hospital, Psychiatric Hospital, the National Hospital of Traditional Medicine, E Hospital, to transfer technology for health workers

in the province After receiving technology transfer from the central hospital, doctors at provincial hospitals will support those at district level and doctors at district level will support those at commune level

In term of private health development: Currently, Lao Cai province has 52 private health centers

in operation, mainly private clinics and concentrated in urban areas; in 2010 these units had medical treatment for 18,500 visitors, mostly inpatients But the medical treatment at private clinics often have a high cost, therefore, only high-income people can afford services there Low

- incoine people in remote areas often take medical services at public hospitals People also concern about Voluntary health insurance in 2010, 6578 people buy voluntary health insurance cards, the rest mainly buy the compulsory health insurance The Govemment budget also supports poor people and children under 6 years old to buy health insurance

2.2.2.2 Actual status of Hai Phong heahh care

According to general assessment of Hai Phong Department of Health, after more than 20 years of innovation, the protection, care and improve people's health Hai Phong city has made remarkable achievements

In comparison with health system nationwide, Hai Phong health system is rather complete from

the city to communes, wards and towns, including fw'i main activities: prevention, health

examination and treatment, manufacturing and supplying medicines, medical equipment, and training and health economics

'^ Report of Lao Cai Department of Health in 2009 p 3

•^•* Report of l.ao Cai Ocpatlmcnt of Health in 2009 p 5

Hai Phong health sector has positive contribution to people's health caring and protection Health network is strengthened and developed widely from city to communes, wards, towns infrastructure improved, type of health services in disease prevention, treatment and supply is very diversified

So far, there have been permanent doctors in health centers at every commune, most of health centers are newly - built or renovated, and 100% of communes meet national standards of health care The capacity of medical staffs and medical facilities at district and grass root levels has been strengthened; there is improvement in both in expertise and management

Health center also actively take part in the mobilization, propaganda and education in hygiene and disease prevention, epidemic prevention, actively implementing the projects, programs and disease prevention, epidemiological surveillance ; the national health program is well conducted achieving set objectives They are: the expansion of vaccination to prevent dangerous infectious disease to children always reach 99% - 100% annually, level 11 leprosy and neonatal tetanus is eliminated, controlling measles, tuberculosis, dengue fever, malaria and initially control the rate

of HIV / AIDS infection, well manage food safety and sanitation, prevention of malnutrition; prevention of disorders caused by iodine deficiency

Haiphong has 9 hospitals and 12 health centers The care and protection of the city people's health is improved one step Average life expectancy of urban dwellers rose to 74.6 the percentage of malnourished children under age 5 falls below 19%~ Some health indicators of Hai Phong have reached the level of countries of which its people's incomes are much higher than ours Epidemic and infectious diseases are tightly controlled On average, each person does medical check 3 times per year Antenatal women take medical check 5 times per year on average

In terms of private health development: currently Haiphong has built 102 private health centers, meeting the medical requirements for people, every year; these centers provide medical service for 31% of patients in need of treatment 40% of the population living in rural areas of Hai Phong buys voluntary health insurance

It is the point of view of Hai Phong Department of Heath to consider: health is the greatest treasure of people and the entire society is an important factor in the strategic development and national defense, Hai Phong health sector continues to perform the orientation in caring, protecting and improving people's health It is also the effort of Hai Phong Department of Health

to bring opportunities to every people to access to quality primary health care Everyone benefit from a safe living coinmunity, well developed physically and mentally

'^Report of Hai Phong Department of Health in 2010 p.4

27

CHAPTER 3: E N H A N C I N G T H E G O V E R N M E N T ' S ROLES IN VIETNAM

H E A L T H C A R E D E V E L O P M E N T IN THE FUTURE

^.\ Vietnam healthcare development orientation in the future

lealthcare is a particular activity that strongly impacts to each person's health and sustainable levelopment in particular, and to the society in general The Government's roles play an mportant one in ensuring that healthcare service is provided to every person in the society; and

re responsible for managing the overall healthcare sector However, it is not necessary for the ovemment to directly provide the health service Besides public health centers/organizations managed, established, sponsored, and operated by the Govemment); it is necessary to develop rivate health service centers/organizations It is required to separate the Govemment's roles of verall health management from their role of providing direct health - one of the Govemment's indamental orientations of government management in their reform process from "centrally lanaged economy'' ( The Government managed all the economic activities directly) to "market :onomy with the Government management"

he Government needs to reform and improve health systems effectively and efficiently in order

» provide better service quality to every person in the society; and to catch up the :onomic development of the country

socio-he Government provide nation-wide socio-health insurance to obtain tsocio-he equal socio-health service to every :rson - rich and poor, children, working and elderly persons.,

he Govemment diversifies health service to meet the different requirements from different )cial classes This results in better health service to different people in the society: regardless

e rich or the poor, rural and urban areas General and special health service should be

;veloped both in Oriental and Westem medicines

le Government, together with public investment, enhances private health service - as a

»ciali/ation process The govemment provides better health care service and protection for the )orand special persons

:> develop health sector to meet the new demand of the people and the society, it is necessary to irry out the following urgent activities:

• Develop and improve the activity quality of the health service centers in the whole country by

o planning, arranging and strengthening the health service network throughout the country to ensure equit> among different areas;

28

o keeping strengthening and improving local health service centers in terms of facilities, equipment and medical staff in order to meet the people's health service requirement and provide fundamental health services such as optical, dental, otorhinolaryngology problems, reproductive health and children health

o strengthening the organization, and professional activities of commune health centers so that the following target are met: 80% of commune health service centers having doctors; 100% of plateau health service centers having midwives and 60% of mountainous health/medical centers having doctors 100% commune medical center having midwives, reproductive physicians, children physicians, in which 80% are secondary midwives, 80% commune medical centers having officers of traditional/oriental medicine; on average, one commune medical officer serves from 1,000 to 1,200 people; ensuring at least 5 medical staff having titles defined by Ministry of Health to one commune center

• Improving the quality and morality, duties of medical staff and officers, especially doctors and nurses

• Provide appropriate financial mechanism for different health service models, encouraging the health service provision from different sectors in the society At the moment, Vietnam's medical spending is small, so the renovation of hospital financial mechanism should be considered under the views of the whole medical system, of the hospital and from the people's benefits

• Finance for health care service and medical treatment is an important factor ensuring enough capital for allocating in health/medical activities to help the people, especially the poor who have financial difficulties for dealing with health problems Therefore, health insurance is a fundamental trend for equality in health service The health insurance for the poor is paid by the Govemment However, for the people who want high quality health/medical service, they will have to pay some part of the fee as proposed

Besides financial mechanism renovation, financial resources for health/medical serv ice should be effectively used

29

3.2 The government's roles in health development

3.2 L Improvement of health laws and policy systems

To ensure the health development in a right direction: national development aim: the first and foremost important task of the government is develop a legal corridor for health service provision done and monitored, and regulated by the Govemment To achieve this end public management entities should:

a) Regularly review, improve, and amend health policy/legal

At the moment, the reviewing and amending legal regulations are just focused on some fields such as: HIV/AIDS prevention, injuries prevention, private medical professional, and children's right for health care service it is necessary to regularly review legal health/medical regulations

in all fields in health care and medical service for the people

The review and combination of the documents of health/medical legal regulations are just only focused on a single statistical data collection The activities should be focused on reviewing the out of date regulation and in confiict ones to propose to the Ministry of Health for amending and giving up the obsolete documents and making and supplementing the new ones

h) Identify the most important health principles and regulations for developing and enforcing

It is necessary to identify the key legal areas for the cause of health/medical service for the people The legal areas should be developed and enforced in the near future The legal documents include: Pharmaceutical laws, hospital fee regulations, health insurance for the poor hospital professional compensations, epidemic diseases prevention in the direction of health/medical innovations

c) Strengthen the roles of professional institutions in health/medical legal development

It is suggested to have policies for attracting qualified experts in legal and professional areas to participate in the process of studying, evaluating, appraising drafts of legal health/medical documents such as ordinances, regulations, decrees, and principles ; and to coordinate with the Ministry of Health and other health institutions and universities in developing health/medical legal documents

d) Enhance the effectiveness and efficiency in health/medical regulations implementation

r:flcctiveness and efficiency in health/medical regulations refiect actual capacities of public health organizations To enhance the eft'ectiveness and efficiency of the work, the following measures should be implemented

30

Firstly, dealing with legal rights and benefits of the patients and the citizens in health care and

medical service is dealt with administrative procedures between health/medical organizations and the people Therefore, it is necessary to study health/medical administrative procedures to renovate basing on the principles: giving up all the autocratic, troublesome medical administrative procedures; simplifying the administrative procedures, improving legal health regulations in the way that is open, simple and convenient to the people while ensuring the Government's strict management

Second, solving patients and people' claims relating to health care services The patients and

people' claims should be solved promptly, quickly and legally on the principles: Unifying one place of resolution, combining with the relevant entities for claim resolution

e) Use policy tools to regulate the behaviors of the providers' health care service

Health policies and legislations are the two management tools used by the Govemment in health/medical services While the legislation is imposing and coercive to the objects, the policies are more fiexible, encouraging the changes in behaviors of the adjusted objects In health field, the Govemment should develop and improve the policies for encouraging private sectors to invest in health service centers by reducing the lax, providing building sites, giving professional supports to new ly established centers

3.2.2 Build the development plan for health/medical center systems

Health service provisions can be well implemented only if there is a complete and appropriate health center system The Government needs to build a comprehensive plan for developing the health center system in the directions that:

• Health system ensures to provide comprehensive health service Besides providing health check, medical treatment, the health centers system should be developed and improved National programs on health care awareness and diseases prevention, food hygiene and safety, and physical exercises should be developed and multiplied effectively by the health centers Timely forecasting and preventing to minimize negative impacts of the changes in living style, environment and working conditions in industrialization and

modernization to the health; improving the ability of monitoring, identifving and

controlling the epidemic diseases, especially HIV/AIDS and newly arising ones; strengthening professional diseases prevention; enhancing and developing school health care: and focusing on the health care for women, children and die elderly as well as rehabilitation activities

• Develop plans for enhancing health service qualitv at all levels, from local to the central health centers: Building and upgrading hospitals, especially municipal/ district and provincial general hospitals to have enough capacities to meet the needs of medical examination and treatment of the people right there; gradually developing sanatorium

31

system and rehabilitation centers: planning the local health center system geographically; continuing investing and deploy the existing professional medical centers effectively; and developing more professional medical centers

• Having plans to strengthen the studies, inheritance, preservation and development of traditional medicine into a scientific field Mobilizing, encouraging and instmcting the people to grow herbal trees for making herbal medicines

• Building development strategy for the pharmaceutical business to become a key economic - technological field; enhancing the capacity of domestic medical manufacturers; prioritizing high tech pharmacy; planning and developing herbal cultivation areas, and herbal medicine suppliers; strengthening pharmaceutical distribution networks to stabilize pharmaceutical market and treat the people's diseases; pushing the studies and production of vaccines, medical products and developing the industry of medical equipments

• Strengthening scientific studies; applying modem technology and scientific achievements, especially in biological and information technology; gradually putting Vietnam's medical science into advanced level in the region and the world

• Widening the medical cooperation, and taking advantages of the intemational support and resource investment; acquiring technological and scientific achievements as well as management experiences to serve the cause of caring, protecting and improving the people's health

3.2.3 Complete the socialization for health sector

I lealth care socialization is an the Parly and the Government to mobilize financial resources from

the whole society during the new situation: to reduce the Government's budget burden; to increase the imitativeness and activeness of different social classes in health care service to provide health/medical services to meet the people's requirements

At the current, health/medical service socialization has been widely implemented and achieved several benefits: non public health service networks have been established and developed strongly This partly contributes to ensure health service provision for the people, reducing pressures for public health centers as well as the Govemment's health budget

However, the policies and activities of the non public health centers are weak, that needs further improvement, fhe monitoring mechanism for the sectors has not been completed so that the health service quality is not ensured

The Government needs to build mechanism for encouraging different economic entities/individuals to coordinate with the Government in opening new health/medical service centers to meet the health service requirement of the pei>ple

32

Health socialization does not mean that the Govemment does not care for the health sector In contrast, the Govemment is still the biggest investor in developing health/medical service centers from local to the central levels for the people's health care requirements as the purpose of the Party and the Govemment Public health must play a major role in the health sector, having enough capacities in meeting basic health care and medical services, health protection of the people

3.2.4 Develop plans for health mechanism renovations and effective usage of health resources

The Govemment's roles are to indentify comprehensive renovation policies for the public hospitals activities; renewing macro-management and applying management measures to avoid potential wastes of resources in buying and using hi-tech medical equipment; studying suitable compensation policies for medical staff on their performance, but not relating to their hospitals

"benefit"; quickly implementing health insurance for the entire people; gradually crossing out payment method by service fee and implementing the payment methods by fixed fee for specific disease; quickly and stably develop health insurance as a sources for medical fee The health care sector should coordinate with other related entities to ensure the implementation of nationwide health insurance policies Health/medical financial policy needs renewing and improving under the rapid increase of the proportion of public financial source (including national budget and health insurance), reducing the direct fee from the patients Suitable hospital fees should be built accurately and sufficiently The Government should have policies to support the poor and special persons Hospital fee should be published clearly

3.2.5 Strengthen health inspection and control

Strengthening the inspection, controlling and strictly treatment of medical violations is one of the most important task of the Government to ensure that the health/medical services can meet the Govemment's standards and requirements, trying to serve best the people and organizations" needs according to the Govemment's direction Ihe renovation of inspection in medical area should focus on:

First, the post check should be strengthened One of the most prominent cases in recent legal

violations is that the Goveminent refused some licenses relating to health care The fields rejected licensing are massage practices, medical equipment business, and health/medical advertising However, the violations increase in those fields Therefore, it is necessary to strengthen the inspection and control of these areas, especially the post-inspection Post-inspection work should be conducted on the basis of reorganizing and supplementing specialized inspection staff for public health

Second, inspection and control methods should be renovated Multi-parties inspection and

control should be enhanced; close cooperation between health/medical inspection, with the People committee organization, the Government management entities and the Parly

33

organizations By doing that, the strength of inspection system will be enhanced for deterring preventing law violations, timely detection and strict handling behaviors violating the health law

Third, inspections and control should be focused on the public govemment health sector To

create equality between the private health sector and the public one, health inspection work should be focused on the public health facilities rather than just only on the private one

Fourth, health/medical violations treatment is partially implemented Medical administrative

violations treatment should be equal among the public and private medical areas During the inspection of govemment health sector, if violations are detected, they must be strictly dealt with promptly regardless who violated the health/medical laws and regulations

The health/medical violations should be promptly done following the procedures, processes and authorities govemed by the laws

Fifth, the medical professional inspection is enhanced

Apart from the inspection section at the ministerial and provincial levels, inspection department should be expanded to district and commune levels in order to have a wide inspection network to work effectively

In order to well implement the health/medical inspection and control, one of the key tasks is to improve the quality of medical inspection team: those who have morals and professional ethics qualification to ensure that medical inspection organizations strong and transparent In addition

to increase the quantity and quality of inspection staff at the provincial level, each health department must have a minimum of 20-30 inspectors, depending on population and geographical conditions for successful impleinentation the assigned inspection duties It is necessary to supplement legal and administrative knowledge, and professional knowledge of health, inspection skills in order to improve their capacity of health inspectors

Besides, the improvement of their capacit\ it is necessary to upgrade the infrastmcture and means for health/medical inspection, such as capital investment to vehicles, cameras and recorders, especially the laboratories, quick and accurate testing means to detect the breach/violations of foods safety, medicine and cosmetics which directly affect the people's health

3.2.6 Policies of training and education of medical/health moral

The Government need to have a master plan on health/medical training centers at all levels: rearranging the network, expanding and upgrade training and education center to meet the medical staffs requirement and the development of the health sector; establishing health training centers as advanced as those of other countries in the region

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In order to improve the medical capacities for district and grass root level centers, especially in remote and difficulty regions, it is necessary to train medical officers under qualified candidates The training and education should be focused on managing officers, especially hospital managing officers Training and education and compensation benefits should be emphasized for talented persons

It is encouraged to send qualified officers overseas for training and development based on the Govemment's budget or self support budgets for demanding professions

Based on the new requirements and tasks as well as the weakness of the staff, the training and development should be focused on the following areas

Training types, content and methods:

• Training types: Training, seminars, links, and coordination among the related departments

• Contents: different training and development programs given to specific staff:

• Leaders and managers, planned as high-ranking officials, should attend full time training

• Doctors, working in hospitals, should be trained on psychology, and health regulations on part- time or full-time basis

• Ihe reform program must derive from the needs of leamers to meet the current work requirements The training program should be comprehensive and suitable with the professional areas of the health staff and officers

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3.2.7 Building and implementing suitable compensation policy to the medical officers and

staff

At the present, the compensation policies for the national staff in general and medical staff in particular are quite low This is one of the causes of lowering the medical moral and increasing corruption and bureaucracy in health care service

To deal with the problem, there should be a suitable incensement in salary policy, equal being to other professions and ensuring the health/medical officers" living

Social insurance and health insurance should be given to those who work in commune medical centers Work rotation should be implemented Attractive compensation should be given to those who are willing to work in the mountainous and remote areas

Besides, strengthening medical staff should be absolutely implemented on the basis of structure

of quantity and quality of public officers by scales, grades, titles, reasonable professional standards, improving the regime recruitment, appointment, training, and downsizing Wages and salaries schemes of public health officials are fundamentally reformed, as a driving force of the civil service, ensuring the living of officials, public employees and their families in order to raise their responsibility and professional ethics

An aim of the renovation in public financial usage is to allow revenue generating institutions to

be initiative, self-financed and self-responsible for their assigned by the Govemment These results in suitable organization structure, leadership, and good income and allowances for the health/medical staff and officers

Compensation policies for doctors should be revised not only on incomes but also on recognition such as awards, and appropriate overtime payment

Facilities and equipment are fully provided to help doctors to carrv out their work successfully Hquipment maintenance and repair should be regularly implemented on schedules so that no interruption happens during its operation periods

3.3 Recommendations

3.3.1 To the National Assembly

Reviewing law and under law documents on medicine to gradually comprehend and improve the quality of medical services

Druing the supervising work of the implementation of legal documents on medicine and solving the supervising proposals

In annual budget distribution plan, leaving a suitably regular part for medical services so that they can ensure their practical etTectiveness

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Totalizing, taking lessons from the implementation of legal policy on medical management recently and urging to instruct such implementation

Strengthening the socialization of medical services

3.3.3 To the judicial organs/orhanizations

Strengthening inspection ability, introducing legal violation in medical sector, strictly treating such violation

3.3.4 To Ministry of Health and Departments of Health

Reviewing, amending, supplementing and publishing the documents under authority in the assigned area

Comprehending inspection team specializing on medicine, combining medical inspector to market managing team, strengthening the inspection, checking and strictly treating the illegal actions to medical quality management

3.3.5 To the municipal people's committee

Timely publishing document of legal principles suitable to local conditions and well organizing the implementation of the documents from higher level; clearly determining medical management in annual action plan

Closely managing the hospitals and medical centers in the local

Well organizing the work of inspection, checking and strictly treating the illegal actions on medicine in the local

Suitably organizing annual budget for medical management, especially at ward and communes Mobilizing the local resources to the activities of developing medical services, upholding public information agency and social organizations' role in supervising and discovering illegally medical actions

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CONCLUSIONS The renovation process in Vietnam initiated in 1996 has led to tremendous changes in every aspect of social life Currently, the renovation is being processed at a deeper level, along with a deeper integration into the world economy in the process of industrialization and modernization Health sector has an important role in ensuring the stable social development; therefore, it has drawn great attention from the Govemment It is necessary to strengthen the govemment's role

in the management of health sector

Government's role in health sector is firstly shown in the following aspects: building a legal framework for the operation of the units providing health services, building an appropriate system of policies to encourage the participation of every individuals of the society in medical services supply, use tools, economic leverage to support health service providers and strengthen the inspection and supervision of these units to make sure that they are following orientation and regulations and meet the requirements of the Government,

Renewing and improving the health system towards equity, efficiency and development will help

to create opportunities for people to access to health care, protection and improvement services with increasing quality and be consistent with socio - economic growth of the country Besides,

it is vital to develop health insurance for every people to gradually achieve equity in health care, implement the sharing between the healthy and the sick, the rich and the poor, people at working age with children, the elderly, and fair remuneration for health workers The Govemment should have solutions to create opportunities for poor people to access to primarv' health care services and high quality health services so that everyone can benefit from a safe communit\, well developed physically and mentally, reduce the incidence of disease, improve physical strength and racial development

It is necessary to promote the socialization of public services in health sector Govemment should "focus on sailing boat", at the same time solve problems of limited resources, both satisfy the need for improving services in health care to ensure people's health

Besides, the development of health economics is very necessary, thanks to that, the Govemment

is able to find out scientific evidences for developing health policy and building efficient supervising and evaluating tools on the impacts of policy implementation Health Economics focuses on the equity, efficiency and development of healthcare, including hospitals finance; health services quality, preventive health care; health improvement Health Care for the poor and health insurance Medical work ensuring the health service for people in Vietnam is an important task and necessarv for social security

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