PROJECT PLAN ENHANCING GRASSROOTS HEALTH CARE IN THE NEW CONTEXT

1. PROJECT PLANENHANCING GRASSROOTS HEALTH CARE IN THE NEW CONTEXT Hà Nội, December 10, 2013

2. Outline • Concept & role of grassroots health care (GHC) • Achievements • Challenges • Experience gained from some GHC models • Project plan on enhancing GHC in the new context • Objectives • Perspectives • Solutions

3. PART 1CONCEPT AND ROLE OF GRASSROOTS HEALTH CARE

4. Health service delivery system 39 Cen hos. • - 150 hospitals • 35.000 clinics • 39.000 phar, drug outlets Central level 382 Prov hosp. 63 Provinces 561 Dist hosp. 686 Poly-clinics 698 Districts 11.112 CHCs 96.534 VHWs 11,138 Communes Public Private (199.011 beds, 95%) (9.611 beds, 5%)

5. Concept & Role of GHC • GHC is the foundation of Vietnamese health care system • The health care level which is closest to the people and easiest to access (esp. in rural, mountainous, disadvantaged areas) • Addressing most needs of common health care service. • Reasonable costs and low indirect cost/expenditure. • Ensuring that all people can access basic health care service (universal health care coverage). • Contributing to achievement of health and social equity. • Complete and sustainable solution to the overcrowding in hospitals

6. Scope of GHC level • From the commune level and lower levels, because: • At present, many District Hospitals (DH) are able to perform specialized techniques and medical specialized services. • Planning draft: Hospitals are arranged by residential clusters+ Hospital grading (DH can be graded as Grade 2 or Grade 1 hospital) • The scope of the Project plan will be huge with inclusion of district level, which is not feasible due to lack of resources. • Decision No. 58/TTg dated 03/02/1994 stipulating that GHC is from commune level downwards (MOH is developing Gov. Decree to replace Decision No. 58. To get a commonality among project plans, GHC is counted from the commune level downwards). • During the consultation process, most Ministries/sectors and localities are supportive to the scope of GHC to be from the commune level downwards.

7. PART 2RECORDED ACHIEVEMENTS

8. 1. GHC network developed far and wide • 11,112 CHCs across the country • 98,9% of communes having CHCs • Nearly 100.000 VHWs • Communes achieving national standards in health care increased by 35,7% (2005)  nearly 80% (2011).In the disadvantaged region such as the North western area 40,2% of CHCs achieved the standardsand the Central Highlands - 57,6% (old standards).

9. 2. GHC human resource development • After 10 years, the percentage of Commune HWs increased by 11%; the percentage of highly qualified HWs (MDs) increased by 40%. • 74,4% of communes being staffed with MDs (including those who work >3 days/week) • 95,3% of communes being staffed midwife or Ass. Doctors in obstetrics/pediatrics • 88% of villages having HWs (mountainous areas: 96,9%). • Percentage of communes/wards having full-time staff on population – family planning in CHCs accounting for 82,1%. • Allowance/incentives for GHC staff has been substantially improved.

10. 3. Improvement in physical facilities andequipment • 2010: 55% of CHCs were built with solid brick wall and concrete roof; 39% of CHCs with solid brick wall and tile roof; CHCs with one-of houses accounting for 6%. • Some localities receiving international support in building CHCs with 2 storey-buildings – clean and spacious. • Improvement in medical equipment, overcoming part of the serious shortage of ME in the previous time. • Some CHCs were provided with ultrasound, electrocardiograph, apparatus for blood, urine, bio-chemical testing, blood sugar level meter, simple dental chair, etc....

11. 4. Implementation of activities • PHC activities are effectively implemented in Viet Nam. • Some NTPs have been implemented with high effectiveness (EPI, malnutrition prevention, MCH, Pop-FP...), promptly containing epidemics. • For medical services, in provinces with developed GHC, each CHC can have 50-100 patients/day. For national average, medical services at CHC accounted for 30-50% of total episodes of medical examination and treatment • About 80% of CHCs provide HI reimbursed medical services; about 20% of HI card holders registered for primary care at commune level. • ,In provinces with developed GHC, no serious overcrowding was found at higher level hospitals.

12. 5. Health indicators • Average life expectancy increased (73,2 years). • Good health indicators • One of 8/74 countriesachievingprogress in MDGsonreducingchildmortalityrate; • One of 9/74 countriesachievingprogress in MDGsonreducing maternal mortalityrate • One of 3 countriesachievingover 75% in reducing MMR during 1990 – 2010 period.

13. PART 3CHALLENGES

14. 1. Low concern in giving leadership, direction • Concern in giving direction is not regularly and comprehensively given. • GHC has not been given with sufficient allocation of resources. • Non-proactive mobilization of resources for GHC and dependence on the central level investment are found in localities . • No clear assignment of stakeholders, and loose oversight and supervision mechanism. • Limited involvement of sectors, organizations and the public, considering that it is the task of the sole health sector. • Organizational structure and operational activities of the People’s health care board is superficial, not effective.

15. 2. Many changes with the organizational structure • No uniformity in management of CHCs - under DHC in some provinces or under DH Office in other provinces. • CHC does not have a legal status, having neither stamp nor bank account  Unable to sign contract with HI. • No clear division in function, tasks and directions on investment for GHC  Allocation of human resource and investment in fragmented manner.

16. 3. Insufficient number and poorly qualified health staff • Number of health staff at grassroots level is in insufficient quota. • Problematic distribution and structure of GH staff • Low proportion of trained VHWs as required. • Health staff at urban residential quarter/township do not have allowance as stated in Decision No. QĐ75/2009/QĐ-TTg. • Existence of multiple health care job titles: VHWs, pop collaborators, village birth attendants (VBA), collaborators of some NTPs in health, etc. • Low coverage of TBAs in disadvantaged areas, just meeting 1/5 of the real needs. • Low favorable allowance for GHC staff.

17. 4. Degrading CHC’s physical facility

18. (Assessment of function and task performance of CHCs in 11 provinces, HSPI, 2012) 5. Lack of essential drugs

19. 6. Lack of essential medical equipment As stipulated in Decision No. 1022, BYT, 2004 (Study on situation of HI reimbursed medical services at CHCs in 4 provinces, HSPI 2012)

20. 7. Investment in GHC is very insufficient • Although Directive No. 06 (2002), Decision TTg 950 (2007) are in place , no significant investment for GHC has been made over the past years. • Mainly dependent on the local limited investment sources • Some grant –supported projects (AP, GAVI, GF, EC…) are available but cover some localities and areas that need investment. • Very low regular expenditure (>10 million VND/CHC/year)

21. 8. Supply and utilization of medical services • Difficulties in implementing NTPs in health, especially community-based and preventive activities. • Medical exams and treatment: On average, only 52,2% of l08 services are provided in accordance with technical level decentralization. • 47,8% of services have not been provided, mainly due to lack of health staff or untrained staff (52,7%), no availability of ME or old/broken ME (45,8%). • CHC’s health service quality is limited, without gaining confidence from the users, and as a result, patients by-pass CHC to move to higher level for medical exams and treatment.

22. PART 4EXPERIENCE – LESSONS LEARNT Is it effective to make investment in GHC?

23. Thừa Thiên – Huế • Decent CHC physical facility • Sufficient basic equipment (ultrasound, cardiography, biochemistry, etc...) • Enough staff (5-7 health staff, with MD, some CHCs with Specialization level 1 doctor) • Serving 50-70 patients/day • 50% of medical visits are at commune level • No overcrowding at higher level hospitals

24. Khánh Hòa • Decent CHC physical facility • Sufficient basic equipment (ultrasound, cardiography, biochemistry, etc...) • Enough staff (5-7 health staff, with family doctors) • HI reimbursed medical services • 50% of medical visits are at commune level • No overcrowding at higher level hospitals

25. CHC in Quảng Ngãi CHC in Ninh Bình…

26. Lessons learnt • Investment for GHC and PHC is a short and long-term health care strategy which is cost-effective and most sustainable. • Key role of leadership, direction of Party’s committees, authorities in strengthening GHC; MOH plays its technical/professional key lead and involvement of sectors, organizations and individual citizens. • To develop GHC, adequate and comprehensive investment in physical facility are needed  adequately needed ME Appropriately qualified health staff Appropriately financial mechanism and operational activities • Localities with developed GHC, proper implementation of PHC, community/household-based health management  No hospital overcrowding

27. PART 5PROJECT PLAN “ENHANCING GHC IN THE NEW CONTEXT”

28. Objective To create a breakthrough and comprehensive change in terms of organization, physical facility, medical equipment, health staff and operational mechanism of Grassroots health care in order to improve the quality of PHC, thus to meet the health care need of the people right at the community level, contributing to reduction of overcrowding at higher level hospitals, ensuring equity, effectiveness and development of the cause for People’s health protection, care and promotion.

29. Major tasks and solutions

30. 1. Improving awareness and responsibility of leadership, giving direction of the Party’s committees, authorities • Improving awareness of the Party’s committees from the central level to local level on the special importance of GHC. • Integrating specific objectives, targets, tasks on GHC enhancement into the socio-economic development plans of the country and localities. • Priotizing allocation of adequate resources. • Clearly assigning tasks and responsibility • Conducting regular oversight, monitoring and evaluation. • Mobilizing involvement and collaboration of sectors, organizations, community and individuals in activities for strengthening GHC and PHC in the localities

31. 2. Consolidating organization and renovating operational mechanism • CHC is established according to administrative units of commune, ward, township and residential cluster (communes with wide area and big population can have establishment of sub-CHC). • CHC/Ward HC is under management of DHC. • Categorizing CHC into 3 groups: Mountainous, remote areas; plain-midland areas; and urban areas so as to have appropriate investment • Developing functions, tasks appropriately for each group of CHCs .

32. Consolidating and developing school health, health service in agencies, enterprises, industrial-agricultural-forestry establishment, factories • Scaling up model of civil and military health service combination in the border, island areas; developing the family doctor network in the areas having favorable conditions. • Implementing the direction of “disease prevention is better than disease treatment” and making PHC and GHC strengthening as a foundation strategy ; • Ensuring provision of comprehensive health care, associating preventive care, health study with curative care and rehabilitation. • Urban and hospital proximity areas: enhancing preventive care, implementing NTPs, and IEC in health . • Rural and mountainous areas: conducting well the preventive care function + primary care service/first aid

33. 3. Human resource development for GHC • Identifying needs of human resource (quantity, quality and structure) and staff appropriate to regions, areas. • Diversifying staff competency-based training forms appropriate to each working position, function, task and specific context. • Intensifying training of family doctors, VHWs, VBAs for GHC in extremely disadvantaged areas, with priority given to the local inhabitants, ethnic minorities. • Conducting retraining, continuing training in order to update and improve technical qualifications for health staff at grassroots level.

34. MOH to develop the framework curriculum serving as a basis for DOH to develop specific curriculum appropriate to local needs and qualification level of the local health staff, and functions, tasks of commune health staff, with a focus on essential technical contents for commune level. • Supplementing and perfecting regimes and policies to attract health staff working at grassroots level, especially in mountainous, remote areas. • Encouraging integration of functions of population collaborators, VBAs, collaborators of some NTPs, etc. into functions of village health care. • Increasing mobilization of involvement of private health care, retired health staff in local PHC activities.

35. 4. Increasing investment, creating a breakthrough in physical facility and medical equipment for GHC 4.1. Increasing investment in physical facility • Building new CHCs: • Priority 1: (i) for communes without CHC; (ii) communes with CHC having one-off, roof-leaking, serious degrading houses in disadvantaged, remote, border, island areas. • Priority 2: for communes in other areas having CHC but in bad condition with one-off, roof-leaking, serious degrading houses that need to be rebuilt. • Priority 3: for CHCs that are still in operation but in need of investment for repair, upgrading and expansion • Upgrading and renovating CHCs: depending on the report of current status of infrastructure, physical facility and decision made by the local authorities

36. 4.2. Provision of medical equipment • Based on the ME list issued by MOH, provinces confirm the ME need based on the disease patterns, infrastructure conditions in order to have ME installation and utilization capacity. • Types of ME should be appropriate to CHC’s function and tasks, capcity of CHC staff to ensure effective medical services and safety for the patients. • Providing village health packs to VHWs and clean delivery packs to VHAs in the moutainous, remote, border, island areas.

37. 5. Innovation in financial mechanism • The State is responsible for ensuring funding source on GHC investment and regular expenditure . • Accelerating the process of UHC, expanding HI coverage and HI reimbursed medical services at grassroots level. • Innovating payment methods for health service cost, shifting from FFS to capitation and DRG. • Applying appropriate financial mechanisms to encourage people to use GHC services, and avoiding abuse of health care services. • Continue to support health care of the poor, near poor, ethnic minorities and those who enjoy social privilege/meritorious policies • Increasing mobilization of international resources (ODA, NGO), encouraging domestic and international organizations, individuals to invest in GHC.

38. 6. Improving IEC in health • Strengthening communication activities, innovating contents and method for IEC, creating a substantial change in the awareness of the whole political system for GHC. • Strengthening communication activities to improve awareness of individuals, families on behaviour of disease prevention, health protection and study, and at the same time to improve awareness of the people on their right of health care. • Improving IEC capacity at different levels; knowledge and skill in health IEC for communicators, commune HWs and VHWs. • CHCs having integrated health IEC and counseling sevice room with adequate materials and equipment for operational activities.

39. Investment need and mechanism

40. Investment need and mechanism • Capital sources • For physical facility construction, provision of ME and instruments, training, capacity building: funding source from the state budget allocation • For communication, oversight, supervision, completion of model, management mechanism and policies: funding source from NTPs, aid projects and other legitimate capital sources. • Support mechanism • Two support levels from State budget: 50% for prov./cities with state budget allocation adjustment < 50%, 100% for localities with disadvantaged conditions. • Funding to support training, technical refreshment, provision of village health packs is made with annual local budget allocation. • Funding sources mobilized from other legitimate source includes loan, grant projects, support from domestic and foreign individuals, organizations will be applied in compliance with project documents or signed agreements.

41. Organization of implementation • National Assembly commissions and organs. •  Party’s commission in Government • Vietnam Fatherland Front and its member organizations. • Party’s central popularization and education committee • Party’s committees, commissions and sections in ministries, sectors, organizations: • MOH • MPI • MOF • MOCST • MOIC • MOET • MARD • Committee for ethnic minority affairs (CEMA) • Provincial/Centrally-run city People’s Committees • People’s Health Care Board at different levels

42. Thank you very much!