UNIVERSITY OF TOKYO AND MANAGEMENT SCIENCES FOR HEALTH

　A wide network of health centers was designed around the commune cooperative system. Of the 9,929 communes in the country,

　

　

　Prior to 1986 there were in the villages brigade nurses who were supported by their production brigades. Since the introduction of the market economy as a result of the “Doi Moi Renovation" in 1986, the cooperative system has collapsed. This led to the dismantling of production brigades and the collapse of the brigade nursing system. However, the CHCs endured, as there were physical structures that had to be run and maintained. The ownership of CHCs was thrust upon the commune people's committees. However, from the financial and management perspectives, the commune people's committees were ill-equipped and unprepared to run the CHCs. Supporting the CHC infrastructure has placed a severe strain on the health budget. Though 9,243 communes have CHCs, 686 do not. An overwhelming number of communes without CHCs (445) are in the northern mountainous region.

　

　The Vietnam project has reached a crucial turning point.

　

　Accordingly, assessing the impact of project activities since its inception and the finding of appropriate indicators and relevant baseline information about the performance of the RDFs emerged as a critical need. The present study was designed to provide the necessary information to all involved partners, to improve project management and implementation during the next phase and also to assist the Nippon Foundation and other interested donors to determine the nature and future direction of their support.

1986	Doi Moi Reform inaugurated
1989	Bamako Initiative started and drug user charges introduced
1991	Acute shortage of drugs recognized
1992	Support for drugs and pharmaceutical sector development solicited
1993	Support of US$2 million per annum for three years to MOH Vietnam and UNICEF proposed by NF, which asked to develop program with MOH
1994	In response to UNICEF request, technical assistance of US$300,000 per annum for three years approved by Nippon Foundation for baseline surveys (50,000), training (150,000) and social mobilization (100,000)
1995	First batch of drugs procured through UNIPAC and sent to MOH, destined for all communes in all districts in eight provinces selected by MOH/UNICEF
1995	Program review carried out by the University of Tokyo's Department of Health Policy & Planning and the Nippon Foundation
1996	Review/evaluation of the RDF/Bamako Initiative initiated and funded by MOH
1996	Second batch of Nippon Foundation drugs procured through a Japanese procurement agency and sent to MOH Vietnam for a second lot of eight districts
1997	Formal study of the RDF project (MOH/UNICEF/MSH/University of Tokyo)

　

　From 1986 to 1994, there was a notable shift from the provision of free care to partial/full cost sharing. From the launching of the Doi Moi Initiative in 1986 till the start of the implementation of the Nippon Foundation RDF project in 1994, a number of key events occurred. These were:

　

　

　The momentum of change was slow and the events were spread out over almost a decade. During this period, the assumptions underlying the Doi Moi Initiative gradually permeated the service sectors allowing for the cost sharing principle to become the norm rather than the exception. The MOH conceded that there were acute shortages in the areas of pharmaceutcals, medical equipment and quality of care and began to develop an approach to address these.

　The basis of increased donor participation in the development of the health sector and in the consolidation of gains made during the pre-Doi Moi period was also put in place during this time.

　

　From 1994 to 1996, the pace of change in policy development and structural reorganization within the Ministry of Health and the Government of Vietnam was astonishingly rapid. Key events that occurred during these two years include:

　

　

　Around this time, other donors also started to take an increasing interest in supporting the health sector as a result of the development of a health sector support proposal by the World Bank, the intensification of SIDA support, more focused UNICEF and UNDP support, closer collaboration between donors and the Ministry of Health, and close scrutiny by the MOH of its own performance and the reorganization required to change the rhetoric of PHC into reality.

　

　During the first half of 1997, the momentum for change continued to accelerate with the following events occurring:

　

　

　The MOH has recognized that with the rapidly developing pharmaceutical sector, growing at an average rate of 10% per annum, and the increasing awareness among the general population about health care quality, it needs to reform and reorganize in order to respond more adequately to the new challenges, particularly with regard to the costs of providing health care and the improvement of the quality of care. Therefore, during 1997, the momentum of change within the MOH has accelerated and significant changes in the structure of the Ministry are being initiated. That there is no longer a shortage of drugs appears to have shifted the focus from resolving shortages and increasing access to essential drugs to promoting rational drug use and improving the quality and equity of care. It is expected¹ that the pace of change will continue to intensify and expand in scope. It will include expansion and the scaling-up of the RDF scheme but with the inclusion of rational drug use, increased community co-management of health services rather than just RDFs, and strengthening management capacity at the district and commune levels through more effective implementation of decentralization. The role of international donors in assisting the development of health care in Vietnam and the coordinating role of the MOH will also expand, providing new opportunities and presenting new challenges.

　

In the pharmaceutical sector,² there are:

PREPARED BY MOHAN NARULA, MARIA MIRALLES, TOMOKO FUJISAKI, WITH THE ASSISTANCE OF MOH AND UNICEF

　

　

　A finding from this study is that for the twenty tracer drugs selected, although availability was slightly better in comparison groups at all levels, the relative difference between availability in the DPS and CHC groups was approximately the same (16%). However, with no other information on drug availability prior to the Nippon Foundation study project, it is not possible to determine if drug availability has improved or declined since inception of the project. What is clear, though, is that there is a greater availability of the same set of tracer drugs in the private sector.

　

　Similarly, prices to consumers in the study and comparison groups were on average higher than prices offered in the private drug outlets. These products, however, are typically not generic and are not necessarily on the National Essential Drugs List. The expanding role of Vinapharm, the para-statal pharmaceutical company, should be evaluated in this light. With the new management of Vinapharm, together with recent approbation of RDFs by the central government, access to and availability of generic, essential medications at competitive prices may be further improved.

　

　According to the World Bank and to key informants, there has been an increase in the utilization of public sector services since 1995. This is most likely due to a combination of factors including the return of health care professionals to the public sector and to efforts to improve incentives (or wages). The perceived quality of care, it is suggested, has improved.

　

　Utilization may have improved with successful RDFs because of the perception that the quality of public sector medicines is good. The targeted populations of the CHCs with limited resources are likely to feel satisfied with the quality of drugs supplied by RDFs. Indeed, there were few reports by the CHCs of poor quality drugs. During the period of declining public health services, a sharp increase in self-medication meant that people were spending a significant amount of household income on drugs available in the private sector. This was at a time when private pharmacies were expanding rapidly while the Ministry of Health had extremely limited capacity to conduct inspections.

　

　The CPCs and district and provincial health authorities have continued to express interest in RDFs and, in particular, in learning how to expand them to meet unmet demand. Suggestions included finding additional seed stock or capital. Other alternatives for some RDFs may be a re-evaluation of their pricing strategies and certainly for most, tighter accounting and record keeping methods.

　

　Among the activities UNICEF has been promoting through the Nippon Foundation support for RDFs is the training of health workers on rational drug use. This is a very responsible and reasonable activity to accompany the provision of seed stock.

　This study provides the baseline for a follow-up study that may be undertaken in the future.

　

　The findings indicate little difference between the study and comparison groups on standard indicators of average number of drugs prescribed per encounter, and the percentage of antibiotics and injectables prescribed. There is some evidence that the practitioners in the study group were less likely to prescribe potentially inappropriate combinations of antibiotics than those in the comparison group.

　

　The Ministry of Health is well on the way to assuring improved drug information, prescribing reviews and treatment guidelines for the inpatient setting. Similar efforts for the outpatient setting would be beneficial.

　

　RDFs are one model for community-based drug cost recovery. This model has been applied in Vietnam for several years and has met with some success or it would not have endured. As record keeping of RDF activity has not been uniform, universal or transparent, the data collected was incomplete and unreliable. Despite these limitations, some definitive results were obtained measuring the performance of RDFs.

　

　RDF performance is often measured only by the number of times a fund is able to revolve, and by relatively simplistic, unidimensional measures of financial well-being. In this study, measures typically used in the private sector allowed for a richer understanding of how well CHCs are able to manage the resources at their disposal and generate revenues.

　

　Most of the RDFs in both the study and comparison groups showed both positive and negative signs in financial performance. A careful case by case evaluation could help individual RDFs to identify weaknesses and find ways to eliminate or overcome these.

　

　The recent sanctioning of RDFs by the Vietnamese government is likely to give a boost to their performance as it provides explicit guidelines on what is expected from RDFs in terms of services and accountability.