After independence, the Vietnamese government made efforts to construct a comprehensive health care network from the central down to the grass roots levels. Nonetheless, the health situation of the population has not improved as much as was expected. The most fundamental cause is poverty, as it is in other developing countries. Inefficient administration due to the sectionalism among different organizations makes the situation worse.
With the introduction of a market policy in 1986, privatization has been introduced into the health sector in order to address some of the inadequacies inherent in the current system. Although privatization might reduce public health expenditures by reducing utilization pressure on public facilities, it deprives the most vulnerable inhabitants of health services.
The setting: a rapidly changing health and economic situation
- Inheritance of the past
During the transition from socialism to private markets in the late 1980s, Vietnam was economically backward but socially advanced. In comparison to other Asian and formerly Socialist countries, Vietnam was extremely poor but enjoyed relatively low mortality levels. Vietnam's average life expectancy of 64 years was nearly one decade longer than Bangladesh's and approached that of the three wealthier countries.
Despite four wars over the past 50 years, Vietnam was able to attain near universal adult literacy (88 percent) and primary school enrolment. Great progress in gender equity was achieved, with women joining men in the labour force and girls as well as boys attending school. Social development, however, could not overcome all of the economic barriers to good health. Food and diet were inadequate, and access to clean drinking water and adequate sanitation and were only 30 percent and 24 percent, respectively.
Under socialism public health was considered a state responsibility implemented by a centralized, hierarchical five-tier health care system. Led by a central ministry, health services were provided free of charge throughout the country's provinces, districts, and over 10,000 communes - extending occasionally down to the brigade level. As private activities were forbidden, legislation and regulations were unnecessary, and the services were financed entirely from state finances generated at the commune, provincial, and central levels.
Health care coverage was extensive and mostly equitable, but problematic were the
system's inefficiency, lack of effectiveness, and poor quality. Indeed, even before the economic reform, Vietnam's health system may have been in trouble due to under financing and bureaucratic rigidity.
- The “doi moi” (1986)
"Doi moi" in 1986 set off a powerful set of interactions between economic reform and the health sector. Economic stability and income gains have probably generated positive health benefits. These advances, however, are being compromised by regional imbalances and the growing economic gap between population sub groups. Those rural farmers with good land and urban entrepreneurs able to exploit new openings are enjoying unparalleled economic opportunities. The disadvantaged live mostly in backward rural areas, especially in the northern mountainous and central highland regions which are also weakest in human and physical infrastructure, markets, and land resources.
The Vietnam Living Standards Survey found significant correlation between income and social welfare. Vaccination coverage, weight of newborns, height and weight of the population had all increased in the higher income quintiles.
Where are we now? Trends and challenges for health policy and reform
- 1st challenge: the collapse of the commune-based social welfare system
Under socialism, the commune cooperative system provided a safety net for the poor, the disabled, the elderly, children, and female-headed households. With the shift from collective to family-based agriculture, the fiscal base of these commune-based social programs collapsed, and the services have been withdrawn, privatized or supported by user charges.
Patriarchal attitudes associated with Confucianism and new commercial tastes are leading to gender inequalities, as reflected by the disproportionate laying-off of female workers, declining school enrolment, especially for girls, the withdrawal of subsidized day-care services, and greater domestic work burdens on women. Moreover, child labor has increased and child school enrolment has dropped. Employment for six-to-fifteen year old school-age children increased 37 percent, and an especially disproportionate number are girls.
- 2nd challenge: an extremely dynamic epidemiologic and health transition
These changing economic and social determinants of health are probably generating an extremely dynamic epidemiologic and health transition. While Vietnam continues to struggle with the first generation of infectious diseases, nutritional deprivation, and reproductive health risks among children and women, a second generation of chronic and degenerative diseases of diet and lifestyle is becoming increasingly more important among adults and the elderly. In addition, a wholly unanticipated third generation of new health threats, mostly behavioural and environmental, is quickly emerging.
Childhood infections and malnutrition still dominate in the national burden of disease. The major causes of death continue to be diarrhea and acute respiratory tract infections, exacerbated by malnutrition. Tuberculosis remains common, and cutbacks in mosquito spraying has contributed to a resurgence of malaria, some of which is resistant to routine chemoprophylaxis. Meanwhile, the burdens due to chronic and degenerative diseases are likely to grow given changing diets, increasing consumption of tobacco and alcohol, and more sedentary lifestyles.
- Trend: a ‘twilight zone’ of policy transition between an outdated past and a uncertain future
Whereas socialism acknowledged health as a universal entitlement and the obligation of the state, present economic reforms are clearly shifting responsibility for health to the individual and his/her family. Health transactions between providers and consumers are changing from public bureaucratic provisioning to market exchanges. The major challenge that Vietnam faces is that the social sector may be increasingly starved for funds if other priorities take precedence over social welfare. Economic reform has made financial resources available for health reform, but only if the political will exits to use these resources for health advancement.
For further information: some references and articles to come on this blog
Adams S. (2005), Vietnam’ Health Care System: a Macroeconomic Perspective, Paper Prepared for the International Symposium on Health Care Systems in Asia, Hitotsubashi University, Tokyo.
Chen L., Hierbert L. (1994), From socialism to private markets: Vietnam’s health in rapid transition.
Dapice, D. (1993), "Vietnam at the Starting Point: Just another Successful Asian Economy?", The Challenge of Reform, Cambridge, Harvard University Press.
Matsuda S. (1997), “An introduction to the health system in Vietnam”, Environmental Health and Preventive Medicine, 2, 3.
Data available on healthcare in Vietnam:
Asian Development Bank: http://www.adb.org/default.asp
General Statistics Office of Vietnam: www.gso.gouv.vn
World Bank (see Data and Research): http://www.adb.org/default.asp
World Health Organization, Website for Vietnam: http://www3.who.int/whosis/country
→ We will publish soon on this blog a summary of the existing evidence on countries like Vietnam that achieve good health at low cost (i.e. Costa Rica, China, Indian state of Kerala or Sri Lanka).
* The aim here is not to write an exhaustive presentation of the Vietnamese health care system but to put in perspective historical facts and some recent trends.
With the introduction of a market policy in 1986, privatization has been introduced into the health sector in order to address some of the inadequacies inherent in the current system. Although privatization might reduce public health expenditures by reducing utilization pressure on public facilities, it deprives the most vulnerable inhabitants of health services.
The setting: a rapidly changing health and economic situation
- Inheritance of the past
During the transition from socialism to private markets in the late 1980s, Vietnam was economically backward but socially advanced. In comparison to other Asian and formerly Socialist countries, Vietnam was extremely poor but enjoyed relatively low mortality levels. Vietnam's average life expectancy of 64 years was nearly one decade longer than Bangladesh's and approached that of the three wealthier countries.
Despite four wars over the past 50 years, Vietnam was able to attain near universal adult literacy (88 percent) and primary school enrolment. Great progress in gender equity was achieved, with women joining men in the labour force and girls as well as boys attending school. Social development, however, could not overcome all of the economic barriers to good health. Food and diet were inadequate, and access to clean drinking water and adequate sanitation and were only 30 percent and 24 percent, respectively.
Under socialism public health was considered a state responsibility implemented by a centralized, hierarchical five-tier health care system. Led by a central ministry, health services were provided free of charge throughout the country's provinces, districts, and over 10,000 communes - extending occasionally down to the brigade level. As private activities were forbidden, legislation and regulations were unnecessary, and the services were financed entirely from state finances generated at the commune, provincial, and central levels.
Health care coverage was extensive and mostly equitable, but problematic were the
system's inefficiency, lack of effectiveness, and poor quality. Indeed, even before the economic reform, Vietnam's health system may have been in trouble due to under financing and bureaucratic rigidity.
- The “doi moi” (1986)
"Doi moi" in 1986 set off a powerful set of interactions between economic reform and the health sector. Economic stability and income gains have probably generated positive health benefits. These advances, however, are being compromised by regional imbalances and the growing economic gap between population sub groups. Those rural farmers with good land and urban entrepreneurs able to exploit new openings are enjoying unparalleled economic opportunities. The disadvantaged live mostly in backward rural areas, especially in the northern mountainous and central highland regions which are also weakest in human and physical infrastructure, markets, and land resources.
The Vietnam Living Standards Survey found significant correlation between income and social welfare. Vaccination coverage, weight of newborns, height and weight of the population had all increased in the higher income quintiles.
Where are we now? Trends and challenges for health policy and reform
- 1st challenge: the collapse of the commune-based social welfare system
Under socialism, the commune cooperative system provided a safety net for the poor, the disabled, the elderly, children, and female-headed households. With the shift from collective to family-based agriculture, the fiscal base of these commune-based social programs collapsed, and the services have been withdrawn, privatized or supported by user charges.
Patriarchal attitudes associated with Confucianism and new commercial tastes are leading to gender inequalities, as reflected by the disproportionate laying-off of female workers, declining school enrolment, especially for girls, the withdrawal of subsidized day-care services, and greater domestic work burdens on women. Moreover, child labor has increased and child school enrolment has dropped. Employment for six-to-fifteen year old school-age children increased 37 percent, and an especially disproportionate number are girls.
- 2nd challenge: an extremely dynamic epidemiologic and health transition
These changing economic and social determinants of health are probably generating an extremely dynamic epidemiologic and health transition. While Vietnam continues to struggle with the first generation of infectious diseases, nutritional deprivation, and reproductive health risks among children and women, a second generation of chronic and degenerative diseases of diet and lifestyle is becoming increasingly more important among adults and the elderly. In addition, a wholly unanticipated third generation of new health threats, mostly behavioural and environmental, is quickly emerging.
Childhood infections and malnutrition still dominate in the national burden of disease. The major causes of death continue to be diarrhea and acute respiratory tract infections, exacerbated by malnutrition. Tuberculosis remains common, and cutbacks in mosquito spraying has contributed to a resurgence of malaria, some of which is resistant to routine chemoprophylaxis. Meanwhile, the burdens due to chronic and degenerative diseases are likely to grow given changing diets, increasing consumption of tobacco and alcohol, and more sedentary lifestyles.
- Trend: a ‘twilight zone’ of policy transition between an outdated past and a uncertain future
Whereas socialism acknowledged health as a universal entitlement and the obligation of the state, present economic reforms are clearly shifting responsibility for health to the individual and his/her family. Health transactions between providers and consumers are changing from public bureaucratic provisioning to market exchanges. The major challenge that Vietnam faces is that the social sector may be increasingly starved for funds if other priorities take precedence over social welfare. Economic reform has made financial resources available for health reform, but only if the political will exits to use these resources for health advancement.
For further information: some references and articles to come on this blog
Adams S. (2005), Vietnam’ Health Care System: a Macroeconomic Perspective, Paper Prepared for the International Symposium on Health Care Systems in Asia, Hitotsubashi University, Tokyo.
Chen L., Hierbert L. (1994), From socialism to private markets: Vietnam’s health in rapid transition.
Dapice, D. (1993), "Vietnam at the Starting Point: Just another Successful Asian Economy?", The Challenge of Reform, Cambridge, Harvard University Press.
Matsuda S. (1997), “An introduction to the health system in Vietnam”, Environmental Health and Preventive Medicine, 2, 3.
Data available on healthcare in Vietnam:
Asian Development Bank: http://www.adb.org/default.asp
General Statistics Office of Vietnam: www.gso.gouv.vn
World Bank (see Data and Research): http://www.adb.org/default.asp
World Health Organization, Website for Vietnam: http://www3.who.int/whosis/country
→ We will publish soon on this blog a summary of the existing evidence on countries like Vietnam that achieve good health at low cost (i.e. Costa Rica, China, Indian state of Kerala or Sri Lanka).
* The aim here is not to write an exhaustive presentation of the Vietnamese health care system but to put in perspective historical facts and some recent trends.
