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User-friendly healthcare? Public health services in Vietnam after economic reform

Vietnam’s public health system reaches far into the countryside through a network of commune health stations. However, the rural poor often prefer the user-friendly services of more expensive private practitioners. How can the public primary healthcare system, a legacy of the planned economy delivering preventative as well as curative care, more effectively meet the needs of poor Vietnamese?

The UK Institute of Development Studies and the Hanoi Institute for Health Strategy and Policy, Vietnam, investigated ways to improve rural access to affordable and effective healthcare. They report on two intervention case studies: public-private collaboration in commune health services, and development of a village health worker (VHW) system in remote mountainous areas.

Before economic reform most communes had a network of VHWs who were mainly elementary nurses working under the guidance of the commune health station. Paid by agricultural co-operatives, the VHWs were a convenient and low-cost response to the basic healthcare needs of rural people. However, the system collapsed after decollectivisation when the funds to support VHWs disappeared. Resurrection of the system is now a priority for the Ministry of Health. But what is the best way to implement this in the post-reform period?

One option is to involve the private sector. With public sector downsizing, many former public health workers are now practising privately in communes. They are popular with households as they provide a convenient and responsive service and are flexible about payment. A pilot scheme in four rural lowland communes involved collaboration between public health services and private practitioners, who became a type of post-reform VHW. The success of the scheme was due to:

negotiation of an acceptable deal between the parties
agreement by the private practitioners to participate in preventative healthcare and have their clinical work monitored, in exchange for a licence to practise legally
light regulation of private fee levels
external support for implementation of the scheme.

The second case study set up a public outreach VHW network in two mountainous communes inhabited by ethnic minorities. There are few retired public health workers in these remote communities, so most VHWs were specially trained to the elementary nurse level. As a result of its success, the scheme is now being extended to other communes. Essential elements included:

co-operation from the communities, who selected the VHWs
focus on local decision-making and participation
support from political leaders and health authorities
VHWs who share the culture and language of the communities they serve
short but frequent training courses by experienced supervisors.

The report concludes that the main obstacle to the success of a VHW scheme of this type is finance. It suggests that:

While external agencies may assist in initial costs, a VHW network must be sustainable from local sources.
A household tax may be needed and this would require the goodwill of the community.
A performance-related element to pay could give VHWs an incentive to carry out preventive work.
Different forms of payment could be used, such as agricultural goods or subsidised healthcare for families of VHWs.

Source(s):
‘Economic Reform, Poverty and Equity in Access to Health Care: Case Studies in Vietnam’ by M. Segall, G. Tipping, D. X. Vinh and D. L. Huong, IDS Research Report 34 (1999)

Funded by: The European Commission

id21 Research Highlight: 29 January 2001

Further Information:
Malcolm Segall
Institute of Development Studies
at the University of Sussex
Brighton BN1 9RE
UK

Tel: +44 (0)1273 678674
Fax: +44 (0)1273 621202
Contact the contributor: m.segall@ids.ac.uk

Institute of Development Studies (IDS), UK

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