Health sector reforms and HRH in the grass-roots network: case study of Vietnam

1. Health sector reforms and HRH in the grass-roots network: case study of Vietnam Nguyen Lan Huong. MPH Department of Manpower and Organization MOH, Vietnam

2. Background • Grass-root healthconsists of health facilities at district and commune levels (district preventive health centers, district hospitals and commune health centers). It’s most important component of the health care system. • In 1986, Vietnam initiated a reform policy, focused on economic reform; from planned, centralized into a market economy • In 1989, this policy applied to the health sector. Most important was the implementing of user fees for health services at central level hospitals, and legalization of private practice. • Since 1990, with the Government’s public administrative reform, grassroots health network has undergone reform process .

3. Public Health system in Vietnam Government - Hospitals: 30 - Institutions: 15 - Medical colleges: 14 MOH 16 Departments In 1998 1. Central level Provincial People’s Committee (Local Gov.) 2. Provincial level - Hospitals: 350 - Provincial Prevention Centers: 64; Malaria Centers: 28; infection disease control: 22 - Secondary medical schools: 53 Provincial Health Office 6-8 Departments 3. District level District Health Centers: 667 4. Commune level Commune Health Centers:10, 886 Direct management ( funding, manpower) Indirect management (Providing guidelines on professional practice and supervision)

4. Public Health system in Vietnam Government - Hospitals: 30 - Institutions: 15 - Medical colleges: 14 MOH 16 Departments In 2004 1. Central level Provincial People’s Committee (Local Gov.) 2. Provincial level - Hospitals: 350 - Provincial Prevention Centers: 64; Malaria Centers: 28; infection disease control: 22 - Secondary medical schools: 53 Provincial Health Office 6-8 Departments District People’s Committee 3. District level District Health Office 3-5 staffs - District Health Hospitals: 667 - District Preventive Centers: 667 4. Commune level Commune Health Centers(CHC):10, 886 Direct management ( funding, manpower) Indirect management (Providing guidelines on professional practice and supervision)

5. Advantages Administrative agencies at district level , responsible for monitoring, supervision and evaluation Involve local authorities and coordinate others sectors in health activities Strengthen capacity of preventive services in the grass-roots health network Disadvantages Administrative management skills are poor Shortage staffs in DHD In remote areas, difficult to follow this model because shortage of HRH. Coordination between DHD and District Preventive Centers in management CHC Public Health system in VietnamChanges:-Setting upDistrict Health Divisions(DHD): administrative health agencies -Separating curative and preventive services at district level. - Moving function on management CHC to the DHD

6. Health workforce status in Vietnam • Workforce size is increasing (229, 887 in 2001 and 259, 583 in 2005). In June 2007, Government have issued the staffing norm Number of staffs will be increased about 58, 769. • Distribution: 82, 5% at local ; 12, 20% at central level, and 5, 25% in other sectors.By geography, health staffs concentrate in the better off regions (North delta region 18.39%; North West 3, 91% ). • Qualification is poor( 25% had university degree including 1.24% Master and 0.44% PhDs;65% had secondary and primary degree). • Health workforce structure is inappropriate. Shortage pharmacists, nurses and midwife; surplus assistant doctors. (Doctor: 18. 98%; assistant doctor: 18.82%; nurse: 19.74%; pharmacist 8.27%; midwives: 6.94% ; technician :3. 77%)

7. Health workforce production • 11 medical colleges produce university and postgraduate degree.Annually, about 6,200 graduated including medical doctors, pharmacists, nurses, technicians and public health workers. • 70 training institutions from 64 provinces produce secondary and primary degree. About 18,000 graduated. • This number is insufficient to meet the demand for health system.

8. Health workforcein grass-roots health network Preventive service provision • Shortage of staffs, especially doctors:Averagely, 21.8 staffs per Preventive center (According to Standard at least there are 25-30 staffs). • Difficult to recruit, especially qualified staffs. Almost prefer to stay in the hospitals • Low qualification: 72.65% was secondary degree; few had been trained preventive medicine. • Brain drain issues. Qualified doctors move to upper level or curative services • Inappropriate health workforce structure • District Preventive Centers have been allocated new function on reproductive health provision and food safety control. It needs more midwives, technicians.

9. Health workforcein grass-roots health network Medical service provision • Number almost got the standard • Qualification: better than preventive services

10. Health workforcein grass-roots health network Administrative agency (District Health Division) • Shortage staffs: In some districts, 1-2 staffs • Poor administrative management skills. • Incapacities to control/manage commune health centers

11. Lessons learnt • Health sector reform impacts HRH and HRH influence its implemetation • Appropriate incentive policy to attract and retain health personnel in grass-roots health network • In-service training • Involve health personnel in design and implement reform.

12. Thank you very much