ĐỔI MỚI HỆ THỐNG Y TẾ VIỆT NAM

PUBLIC HEALTH IN VIETNAM: ACHIEVEMENTS AND CHALLENGES

Prof. Nguyen Cong Khan

Department of Nutrition and Food Safety - HSPH

Department of Science, Technology and Training - MoH

NATIONAL SCIENTIFIC CONFERENCE ON PUBLIC HEALTH “PUBLIC HEALTH IN VIETNAM: CURRENT SITUATION AND FUTURE PERSPECTIVES”

HDI

Source: UNDP 2014

0.473 0.476

0.563 0.598 0.604 0.611 0.617 0.622 0.629 0.632 0.635 0.638

1985 1990 2000 2005 2006 2007 2008 2009 2010 2011 2012 2013

Human development Index (HDI)

Basis health indicators

Results Target 2015 (MDG & 2011-2015 plan of

the MoH)

Life expectancy, 2013 (1) 75.6 74

IMR 2014, (2) 16.21 14.8

U5MR, 2014 (2) 19.7 19.3

Maternal mortality, 2009 (3) 69 58.3

Under nutrition among children under 5, 2013 (4) 15.3 15

Fully vaccinated children, 2013 (4) 91.4 90

Doctor/ 10000 population, 2013 (4) 7.5 8

Beds/population, 2013 (4) 24.2 23

Commune health station with doctor, 2013 (4) 76.9 80

Health insurance coverage, 2013 (4) 68.5 70

(1) WHO 2014; (2) GSO 2014; (3) GSO, 2009; (4) MoH 2014

Health outcomes

70.2 70.5

70.8 71.2

71.5 71.8

72.1 72.5

72.8 73.1

73.4 73.6

73.9 74.1 74.3 74.5 74.6 74.8 74.9 75.0 75.2 75.3 75.5 75.6

1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Life expectancy at birth, total (years)

WHO, 2014

Health outcome

Source: WHO, GSO, UNICEF 2014

37.6 36.4 35.1

33.8 32.5

31.2 30.0 28.7 27.6 26.5 25.5 24.6 23.8 23.0 22.2 21.5 20.8 20.1 19.6 19.2 18.9 18.7 18.6 18.4

16.2

52.6 50.5

48.2 46.0

43.8 41.7

39.7 37.7

36.0 34.3

32.8 31.5

30.3 29.1 28.0 27.1 26.1 25.2 24.5 24.0 23.6 23.4 23.2 23.0

19.7

Mortality rate, infant (per 1,000 live births)

Mortality rate, under-5 (per 1,000 live births)

Source: UNDP 2012

233

69

1990 2009

Maternal mortality (per 100,000 live births )

Health outcome

Health outcomes Malaria cases/ 100,000 population

Source: MoH 2013

728

599

508

446

377

328

233 204

157 119 109

83 70 71 62 49

0

100

200

300

400

500

600

700

800

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2012

Health Facilities

Year 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Hospital 791 821 825 836 833 835 836 842 842 856 878 903 956 974 1002 1030 1040 1042 1069

Polyclinics 1150 1131 1106 1108 1024 936 928 912 930 881 880 847 829 781 682 622 620 631 636

Rehabilitation and Sanatorium

facilities 103 120 121 119 112 92 71 76 77 53 53 51 51 40 43 44 59 59 60

CHS 9670 9935 10014 10078 10109 10271 10385 10396 10448 10516 10613 10672 10851 10917 10979 11028 11047 11049 11055

Health posts in organization 1170 1123 1123 1123 1120 918 891 810 810 789 769 710 710 710 710 710 710 710 710

Others 65 61 59 55 54 50 49 41 38 34 33 30 32 32

TOTAL 12972 13218 13269 1330 13264 13117 13172 13095 13162 13149 13243 13232 13438 13460 13450 13467 13506 13523 13562

MOH, GSO 2014

Health service delivery

MOH, GSO 2014

192.3 196.5 197.9 199.1 195.9 192.0 192.5 192.6 192.9 196.3 197.3 198.4 210.8

219.8 232.9

246.3

266.7 275.1 280.7

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Hospital beds (000)

Health service delivery (Fully vaccinated children)

NEPI 2013


Coverage of OPV3 and polio 1985 – 2011

NEPI 2013


Coverage of vaccine UV2+ among pregnant women and child tetanus, 1991-2012

NEPI 2013

Paper “30 years of vaccination in Vietnam: impact and cost-effectiveness of the national Expanded Programme on Immunization” (Accepted for publication in Vaccine 2014)

“National surveillance data suggests that up to 5.7 million diseases cases and 26,000 deaths may have been prevented by EPI”


GSO UNICEF, 2014

Birth attendance by professional staffs


GSO 2013

18.9

34.3 35.2 34.2

40.9 39.2

5.7 7.1 6.3 6.5

8.1 7.3

14.2

30.9 32.6

31.0

37.1 36.0

2002 2004 2006 2008 2010 2012

Utilization rate (%) Utilization of inpatient service (%)

Utilization of outpatient service (%)

Health financing

Source: National Health Account, Vietnam

7.4 7.1

6.5

7.9 7.5

6.6 7.0

6.3 6.0 5.5 5.2

7.5

9.2

8.0 8.5

10.1 10.1 9.5

5.2 5.1 4.9 4.9 4.9 5.3

5.6 5.1 5.2

5.5 5.9

6.5 7.1

6.0 6.5

6.9 6.8 6.9

0

2

4

6

8

10

12

Health expenditure, public (% of government expenditure)

Health expenditure, total (% of GDP)

Health Insurance coverage

Source: National Health Account, Vietnam

5 6 10

12 12 13 13 14 15 17

20.7 22.8

28.8

44.7 43.8 47.1

58.2 59.6

64.3 68 68.5

1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Health human resource

Source: Health Statistics Year Book

3.2 3.5 3.6

3.9 4.0

3.6

4.4 4.1 4.2

4.4 4.4 4.4 4.7

5.1 5.4 5.4

5.7 5.9 5.9

6.0 6.2

6.5 6.5 6.6

7.2 7.3 7.3 7.5

0.9 1.0 1.0 1.1 0.9 1.0 0.9 0.8 0.8 0.7 0.7 0.7 0.7 0.8 0.8 0.8 0.8 0.8 0.8

1.3 1.3 1.2 1.2

1.8 1.8 1.9 2.0

1.8

Doctor/10,000 population Pharmacist/10,000 population2

Health human resource

Source: Health Statistics Year Book

4.6 9.4

17.7

23.2

33.9

51.1 56.1

61.5 65.4

69.2 69.4 65.1

67.4 65.9 67.7 70.0 71.9

76.5 76.9

% CHS with doctor

Medical universities/schools

Source: Ministry of Health

0 1 5

2

46

1 1

6 2

68

5 1

10

2 5

1

11

2 6

1

13 16

7

14 16

44

74

0

10

20

30

40

50

60

70

80

Trường đào tạo

YTCC

Trường đại học

Dược

Trường Đại học Y

và Y dược

Trường đào tạo cao

đẳng Y, điều dưỡng

Trường trung học y

dươc

Năm 1985 Năm 1995 Năm 2001 Năm 2005 Năm 2010 Năm 2014

Medical students


11,479 8,304

21,950

60,526

Năm 1990 Năm 1995 Năm 2005 Năm 2010

Thành tựu khác của hệ thống y tế

• Preventive medicine: Good controlling of dangerous transmitted

diseases such as SARS, flu A/ H5N1, flu A/H1N1.

• Development of high technologies at a similar level of regional and

international development (interventional treatments, laparoscopic

surgery, organ transplants…).

• Population and Family Planning: Natural population growth of Vietnam

has been reduced and restricted stably

• Pharmaceutical products: In 2012 domestic medicine met 234/314

active elements in the list of essential medicines with all 29 groups

of pharmacological effects as recommended by WHO; 100% of

pharmaceutical production facilities achieved GMP; 100% drug-

testing facility achieved GLP; 39% of drugstores achieved GPP

• Development of traditional medical network from central to

provincial, districts and communes

Conclusion

Thành tựu:

1. Vietnam's health system has made great efforts and achieved many impressive and important accomplishments in protecting and improving the health of people.

2. Most of the millennium goals have been achieved or will be achieved in 2015

3. Vietnam’s health indicators are at a level similar to or better than the countries with similar levels of economic development

Epidemiological transition (hospital cases)

59.2

37.6

24.9 19.8

39

50

62.4

71.6

1.8

12.4 12.7 8.6

0

10

20

30

40

50

60

70

80

1986 1996 2006 2010

Communicable diseases Non-Communicable diseases Injuries, poisoning

Epidemiological transition (DALYs)

Hypertension (%)

Source: JAHR2012

Diabetes (%)

Source: JAHR2012

Food safety Food poisoning in 2015

• 179 food poisoning cases

– 5552 patients contracted

– 5147 patients hospitalized

– 23 dead.

• Food poisoning tends to be complicated such as FP in collective kitchens at industrial zones, FP due to poison mushroom or natural toxins

Number of facilities violated food safety rules: 78.413

Behavioral risk factors (%)

27.4

37

54.9

69.6

1.7 5.6

Smoking Alcohol use (in the last 30 days)

Overall Men Women


Ageing problems

7.2 8.1 8.7

11.8

21.4

1989 1999 2009 2019 2039

% aged 60+

Source: General Statistics Office

Emerging diseases

Measles outbreak


6584

11235

14431

18817

11942

6720 8160

528

19287

7554

4180 10

3 1 0 0 0 0

136

0

20

40

60

80

100

120

140

160

0

5000

10000

15000

20000

25000

sè m¾c tö vong

Dengue fever and weather in Hanoi

20

40

60

80

10

0

0

10

02

00

30

04

00

50

0

01 Jan 0701 Apr 0701 Jul 0701 Oct 0701 Jan 08thang

case rainfall

temp humid

20

40

60

80

0

20

04

00

60

08

00

10

00


case rainfall

temp humid

20

40

60

80

0

10

00

20

00

30

00

40

00


case rainfall

temp humid

20

40

60

80

10

0

0

20

04

00

60

08

00


case rainfall

temp humid

20

40

60

80

10

0

0

10

02

00

30

04

00


case rainfall

temp humid

20

40

60

80

10

0

0

20

04

00

60

08

00


case rainfall

temp humid

2005 2006

2007 2008 2009 2010

Antibiotic treatment and antibiotic resistance

Research by TDH in 2009-2010 in 19 hospitals in Hanoi, HCMC and Haiphong

74%67%

84%

26%33%

16%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Total E.coli or Klebsiella Acinetobacter or Pseudomonas

Appropriate Inappropriate

Inappropriate antibiotic use was 74% and appropriate use was 26%

(Similar to research result of Kollef et al 1998 (73.3%))

IMR

JHAR, 2014

16.0 16.0 15.9 16.0 15.8 15.5

10.0 9.8 9.5 9.4 9.2 8.5

-

2.0

4.0

6.0

8.0

10.0

12.0

14.0

16.0

18.0

2006 2007 2008 2009 2010 2011

Pe

r 1

00

0 li

ve b

irth

s

Rural Urban

IMR 2011

MICS 2011

23

17

12

23

11

10

30

No education

Primary

Secondary and higher

20% poorest

20% richest

Kinh

Ethnic minorities

(per 1000 live births)

Malnutrition

MICS 2011

6

13.9

22.4

13.2

9.5

20.6

3.1

10

22

Urban

Rural

No education

Primary

Secondary…

20% poorest

20% richest

Kinh

Ethnic…

Malnutrition among under 5 children (%)

Health care utilization

MICS 2011

81.6

50.5

5.6

44

69.3

27.2

88.7

67

59.6

Urban

Rural

No education

Primary

Secondary and…

20% poorest

20% richest

Kinh

Ethnic minorities

Pregnant women had >=4 antenatal examinations (%)

Health care utilization (% used in the last 12 months)

VLSS 2002-2012

16.5

32.4 33.8 34.2 37.5 36.6

22

36.7 36.3 35.4

45.5 42.2

2002 2004 2006 2008 2010 2012

20% poorest 20% richest

Một số vấn đề khác • Quản trị hệ thống y tế còn nhiều bất cập: phối hợp

liên ngành; y tế dự phòng và điều trị; Đầu tư cho y tế dự phòng, hệ thống y tế…

• Bao phủ bảo hiểm ở nhóm lao động phi chính thức còn thấp, thanh toán “Theo phí dịch vụ” vẫn là chủ đạo; Chi cho thuốc chiếm tỷ trọng lớn.

• Chất lượng và phân bố nhân lực y tế: bất cập.

• Hệ thống thông tin y tế thiếu đồng bộ

• Nhận thức về xã hội hoá y tế (XHH) chưa thống nhất

• Lạm dụng dịch vụ và kỹ thuật y tế

Other issues • Limitation in governance of health system. Lack of inter-

sectoral collaboration in diseases prevention. Cooperation between prevention and treatment is still not good. Investment for prevention and related networks still remain limited.

• Health insurance coverage within informal sector keep at low level. “Fee for service” keep the role as the main payment method. Expenses for drug still account as high proportion in total health expenses.

• Quality and distribution of human resources for health: inappropriate

• Health system information: inconsistent

• Awareness of socialization in health is not unitized

• Overuse of medical and technical services

Conclusion • Key challenges:

1. Health: an increase of NCDs and its risk factor, aging trend, new emerging diseases or relapse, climate change related health issues

2. Health system: Health system have not yet been prepared well to respond issues mentioned above. While central hospitals always suffer from overloading, health facilities at lower level have not yet been invested appropriate. Impacts of health policy in financial protection are still limited, especially health insurance. Payment methods still remain inappropriate.

3. Inequity in health and healthcare: Among different population groups, the poor, people with low level of education and minority people.

Health system: priorities for research and change

• Health system organization and governance: combine prevention and treatment.

• Universal health coverage together with health equity.

• Invest for preventive medecines, implement PRIMARY HEALTH CARE elements in new context.

• Equip health system with new capabilities to respond to new health problems and to the changes in climate, population and socio-economic status.

• Develop a sycronizied health informatics system.

• Planning and projection capacities.

HIV, TB, malaria

Other infectious

Mat//peri/nutritional

CVD

Cancers

Other NCD

Road traffic accidents

Other unintentional

Intentional injuries

0

5

10

15

20

25

30

2004 2015 2030 2004 2015 2030 2004 2015 2030

Dea

ths

(mill

ion

s)

High-income countries

Middle-income countries

Low-income countries

Mortality: global projection, 2004-2030

Effective multi-disciplinary collaboration

• In policy making.

• In planning and projection

• Disease control

• Response to climate change

• Food safety control

• Appropriate nutrition: in treatment and prevention

• Deal with new public health issue (such as antibiotic resistance, etc.).

One health

Innovation in HRH training

• Capacity-based training

• Training

• Need-based training

• Redistribution of HRH: policies and attraction.

• Training for health system reform: Public health, Family health care.

• Health management

Science based Problem based Systems based

Scientific

curriculum

University based

Problem based learning

Academic

centers

Competency driven:

local-global

Health

education

systems

Inst

ruct

ion

al

Inst

itu

tio

nal

1900 2000+

Three generations of reforms

Inter- and Trans-Professional Education

Higher income countries Lower income countries

Inter-

Professional

Education Inter- & Trans-

Professional

Education

Program innovation

Enrolment source

Multidisciplinary and cross-sectoral

approach

Capacity-based and job-

descrition-based

approaches

Public health training

SYSTEM INNOVATION

Need for multi-stakeholder approaches in countries…

Completing health policy system and health law

• Laws (such as revision of health examination and treatment law, etc.).

• Develop professional standards and norms in health sector.

• Innovation of payment methods, improve financial protection for vulnerable groups.

• Socialization in the direction of openness, transparency and quality of health services.

Trân trọng cám ơn!

ĐỔI MỚI HỆ THỐNG Y TẾ VIỆT NAM

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