MINISTRY of HEALTH Central North Health

The Central North Health Support Project Ethnic Minority Plan (EMP)

IPP380 V2 MINISTRY OF HEALTH

Public Disclosure Authorized

Central North Health Support Project

Ethnic Minority Plan

Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized October 2009

1 The Central North Health Support Project Ethnic Minority Plan (EMP)

TABLE OF CONTENTS ACRONYMS...... 3 Executive Summary...... 4 I. INTRODUCTION ...... 8 1.1. Project Introduction ...... 8 1.2. Ethnic Minority Plan (EMP) ...... 13 II. SOCIO-ECONOMIC SITUATION OF ETHNIC MINORITIES IN PROJECT LOCATIONS...... 14 2.1. Socio-economic features and population structure in project locations ...... 14 2.2. Ethnic minorities in project locations ...... 14 2.3. Socio-economic conditions of 10 ethnic minority groups in Project locations ...... 18 III. POLICY FRAMEWORK ...... 22 3.1. World Bank’s Policy toward Ethnic Minorities (0P 4.10) ...... 22 3.2. GoV’s Policy ...... 22 IV. CONSTRAINTS THAT CAUSE LIMITED ACCESS TO PUBLIC HEALTHCARE SERVICES BY ETHNIC MINOTITIES...... 24 4.1. Geographical and transportation constraints .. 24 4.2. Customary constraints ...... 24 4.3. Economic constraint ...... 25 4.4. Language and educational constraints ...... 25 V. COMMUNITY CONSULTATION...... 25 VI. ETHNIC MINORITY ACTION PLAN ...... 26 VII. ORGANIZATION AND IMPLEMENTATION ...... 28 VIII. MONITORING AND EVALUATION ...... 29 IX. COST ESTIMATION...... 30

2 The Central North Health Support Project Ethnic Minority Plan (EMP)

ACRONYMS

CPC Commune People’s Committee CPMU Central Project Management Unit EMP Ethnic Minority Plan HC Health Center HD Health Department HI Health Insurance HS Health services MoH Ministry of Health NCR North Central Region GoV Government of Vietnam PC People’s Committee PH Preventive Health PHC Preventive Health Center PMU Project Management Unit PPMU Provincial Project Management Unit WB World Bank VSS Vietnam Social Security

3 The Central North Health Support Project Ethnic Minority Plan (EMP)

Executive Summary 1. Introduction 1.1. Project Background The Central North Health Support Project has been promoted by the Government of Vietnam (GoV) to enhance the equity and effectiveness of the health finance and health services provided in 6 provinces in the North Central region (Thanh Hoa, Nghe An, Ha Tinh, Quang Binh, Quang Tri, and Thua Thien Hue provinces). The Project aims to provide better access and improve the healthcare for local people, especially the poor, the near-poor, and ethnic minorities. The priority will be given to the district-level curative and preventative health centers (DPHCs).

The project development objective is to strengthen the district-level curative and preventive health services and improve their accessibility for the economically vulnerable population.

The intermediate objectives are: - Increasing health insurance coverage among the near-poor population; - Upgrading capacities of district hospitals and DPHCs; - Improving supply and quality of health care personnel.

1.2. Ethnic Minority Plan (EMP) The goal of this EMP is to ensure better healthcare services for ethnic minorities who have limited access to healthcare services. This EMP is prepared with careful consideration of the cultural practices of the ethnic minorities, and the constraints that cause limited access to healthcare services by people in the region.

The framework of this EMP is based on the World Bank (WB) Indigenous People Policy (OP4.10; 7.2007) which is applied in all WB-Funded Projects in the ethnic minority areas. The policy aims to: (i) mitigate any potential negative impacts; and (ii) provide prioritized supports for local ethnic minorities.

2. Socio-Economic Situation of Ethnic Minorities in Project Locations 2.1. Socio-economic features and population structure in project locations The Central North region stretches along the coastal line with complicated topography and harsh climate, and consists of 6 provinces, namely: Thanh Hoa, Nghe An, Ha Tinh, Quang Binh, Quang Tri and Thua Thien Hue. The natural land of Central North region accounts for 15.6% of total country area and its inhabitants make up 12.6% of the country’s population, only smaller than that of Red River Delta and Mekong Delta regions.

2.2. Ethnic minorities in project locations The Central North region is the home to over 10 ethnic minority groups that mainly are Thai, Hmong, Muong, Kho Mu, Dao, Tho, Chut, O du, Bru-Van kieu, Co tu, etc. Especially, four of these (Tho, Chut, O du, and Bru-Van Kieu), and two small population groups of O du (351 people) and Chut (3,891 people) only live in Central North region. These groups often live under difficult conditions in the border, remote and isolated areas.

4 The Central North Health Support Project Ethnic Minority Plan (EMP)

3. World Bank’s Policy toward Ethnic Minorities (OP/4.10) The WB has its own policy toward the indigenous/ethnic minority people (OP4.10). It calls upon projects to invest into ethnic minority areas, and to fully respect the preferential rights of the affected ethnic minorities. At the same time, it is expected to mitigate the adverse impacts on the ethnic minorities and promote those activities that aim at bringing benefits and preserving their traditional cultural values. The WB requests that the local people should be sufficiently informed and freely participated in the Project, and the Project should receive the support from most of the affected ethnic minority people. The designed Project must ensure that the ethnic minority people receive the social and economic benefits are culturally appropriate, and gender and inter-generationally inclusive.

4. Constraints that cause Limited Access to Public Healthcare Services by Ethnic Minorities 4.1. Geographical and transportation constraints Currently, infrastructure and transportation in the Central North region are not in very good condition. The distance between villages and district centers is, in some cases, about 50-70 km, while roads are not available or under bad condition, especially during the rainy season. The means of transportation is mainly by bike or on foot.

4.2. Customary constraints As the modern healthcare services are uneasily accessible in various residential areas, the belief still plays an important role among ethnic minorities in the Central North and even drives the decision of selecting the treatment methods. While taking care of the mother’s and children’s health, they assume that worshipping the superpower is very important, and offering a worship to wish the support from the superpower will help the patient recover faster than being treated in the health facilities.

4.3. Economic constraint Given the reality of unstable and low income, healthcare is not the first spending priority given by the ethnic minorities in the area. Most of people do not have their money savings, leading to the fact that the traditional treatment is preferable in case one gets sick. They are not interested in the healthcare and education. Most of ethnic minority families cannot afford their treatment, and often believe in taboos and supernatural forces. In addition, the obstacles of geographical distance, transportation and difficult household living conditions prevent ethnic minorities from going to hospitals.

4.4.Language and educational constraints Among 10 ethnic minority groups in the region, most of them have, with the exception of the Muong, Tho, and Chut, difficulties in using fluent Vietnamese. This is an important factor that disencourages local people to visit district or provincial medical centers for healthcare.

5. Community Consultation *Activity principles Ensuring the participation of the ethnic minorities in the project in order to speed up the smooth project implementation. Disclosure of project information for ethnic minority people is an important part of project preparation and implementation. Making consultation with them,

5 The Central North Health Support Project Ethnic Minority Plan (EMP)

and ascertaining their active participation in the project. These will mitigate the risk of conflicts and project delays. They will also enable the Project to design the resettlement and rehabilitation program as a comprehensive development one, which meets the needs and priorities of the displaced, and thereby maximizing the economic and social benefits of the investments.

*Methods of community participation and consultation The project implementation activities must be consulted with the ethnic minority specialist, especially the one who has experience in project activity areas (healthcare, insurance, etc.) - The CPMU must have close cooperation with the PPMUs, especially those with high and diversified concentration of ethnic minorities. - The PPMUs will monitor the implementation process in order to make sure that equal healthcare services will be provided for ethnic minorities, and financial and legal support will be made available for districts in their provinces. - The DPC must establish the efficient cooperation with other departments/programs in the district, especially those related to ethnic minority development activities.

6. Development Plan From the consultations with local authorities, ethnic minority patients and relevant agencies/bodies, the evaluation indicators of project activities for ethnic minority development will be as follows: 1. Improve the resources of medical workers by supporting medical staff and workers who belong to ethnic minority groups, and selecting young ethnic minority people for their participation in the training. 2. Carry out counseling and communication activities in order to raise the awareness on health examination and treatment, and purchase health insurance cards for local people. 3. Conduct training courses on the organization and management of health examination and treatment activities for the benefits of district hospitals, health centers and regional general clinics. 4. Improve equipment, provide technology transfer for district hospitals in order to meet the needs of medical treatment for the poor, particularly ethnic minorities in remote areas, and make capacity building available for medical staff in the localities.

7. Organization and Implementation As for the performance of the ethnic minority development plan, the CPMU and PPMUs will start up the implementation of project components and carry out the supervision exercise in order to make sure that the project activities are kept on right track. - With regard to those districts which have high concentration of ethnic minority population, documents in their languages should be published, and the engagement of people who have the knowledge of local ethnic minority languages should be made in order to make sure that the communication and consultation with local people will be done during their check-up and treatment exercises in the health facilities. - Qualified doctors will be sent to organize training activities and capacity building for ethnic minority medial workers working in district-level hospitals where there is a high need for the transfer of medical techniques, especially in those districts where there is a high concentration of ethnic minority population.

6 The Central North Health Support Project Ethnic Minority Plan (EMP)

8. Monitoring and Evaluation - Monitoring the implementation of the ethnic minority development plan is a part of monitoring activities within all project components. - An independent supervision agency with qualified and experienced specialists must be in place in order to provide monitoring and evaluation of project activities related to social and ethnic minority development aspects.

The CPMU and PPMUs will undertake monitoring and evaluation of project components. As for provinces which have districts with more than 50% of its population as ethnic minorities, the cooperation should be done in order to provide the monitoring of ethnic minority-related activities.

9. Cost Estimation - The costs of EMP activities are estimated and embedded within project activities. - The costs of training activities will be calculated in detail when these activities are conducted. - In order to make cost savings, EMP-related training and communication activities will be incorporated into other project training and communication activities.

7 The Central North Health Support Project Ethnic Minority Plan (EMP)

I. INTRODUCTION 1.1. Project Introduction 1.1.1. Project Background The Central North Health Support Project is designed to follow the government’s regional approach to health system development by targeting the northern part of the central coastal area, referred to as Central North region. The health sector problems outlined above are more acutely manifested in this region than in other more developed parts of Vietnam. This is, with a population of 10.7 million, the second poorest among the eight regions of Vietnam; 25% and 30% of the population are classified as the poor and near-poor respectively (2006). The average per capita income in the Central North is VND317, 000 (2004) as compared with the national average of VND 445,000 (2004). Most of its inhabitants (approx. 85%) live in rural areas and make their living from self-employed agriculture and fishery. According to 2004 data, the self-employment proportion accounted for 79.5% in the total employment structure. Overall, the region’s health is in poor conditions. The average Infant Mortality Rate is 22 (ranging from 15 to 36) as compared to the national average of 16, and the Maternal Mortality Rate is 200 as compared with the national average of 75. The leading causes of morbidity are associated with respiratory conditions and digestive system-related diseases. With its region-based focus and design, the Central North Health Support Project is fully aligned with the government’s strategy to strengthen the health systems in disadvantaged areas by relying on three pillars: (a) reducing demand-side barriers to health services for the economically vulnerable population, (b) improving the quality of pro-poor health services, and (c) reducing the shortage of competent healthcare professionals in underserved areas. The project will reduce demand-side barriers by increasing the affordability of health insurance to the near-poor by providing significant subsidies for health insurance premiums, above what is currently offered by the government. This will be complemented by a strong Information and Education Campaign, social marketing, and a number of incentive mechanisms to increase the enrollment of the target population in the health insurance scheme. In order to improve the quality of pro-poor health services, the project will invest in district hospitals and DPHCs in the most disadvantaged districts, thereby making basic healthcare available at a lower cost and closer to the communities. The majority of the investment will go into providing the most basic medical equipment for hospitals with and refurbishing the DPHCs. This will be combined with a piloted performance-based financing system in order to test some innovative mechanisms for the purpose of promoting better performance, accountability and client-oriented health services. The project will address the human resource constraint in the Central North region by training specialists that are in short supply and creating stronger local medical training institutions for more sustainable results.

1.1.2. Project Objectives To assist the medical systems of six provinces in the Central North in strengthening district- level curative and preventive health services, increasing the access to and use of the medical system by local people, especially the poor, near-poor and ethnic minorities, and partly improving the health conditions of the local people.

8 The Central North Health Support Project Ethnic Minority Plan (EMP)

Specific objectives The project development objective is to strengthen the district-level curative and preventive health services and improve their accessibility for the economically vulnerable population.

1.1.3. Project Direct Beneficiaries The project beneficiaries will include the following three groups: (i). Local people: The near-poor and ethnic minorities will be the project’s most important and ultimate beneficiaries. The poor, near-poor and ethnic minority people will be provided with better access to healthcare services. In addition, the near-poor will receive some other direct support to reduced financial burdens and better access to healthcare services. Priorities will be given to the district level so that the in-need poor, near-poor and ethnic minority people will be easily supported. (ii). Healthcare service providers: The staff from provincial- and district-level healthcare service providers, especially district hospitals and DPHCs, will be provided with medical equipment, short-term and long-term clinical/hospital management training, and healthcare system management training. District hospitals will receive medical equipment, and DPHCs will be supported to build the technical and administrative blocks with the purpose of meeting the urgent needs of the local healthcare system. (iii). Administrative agencies: Funding will be provided for administrative organizations (Health Departments, district health centers) in order to improve management capacity, monitoring and supervision. Relevant agencies (Departments for Labor, War Invalids and Social Affairs, health insurance/social security and others) which involve in the provision of healthcare services for the poor will be supported to provide better healthcare services to the poor and ethnic minority people.

1.1.4. Project Components The project has four components as follows:

Component 1: Supporting health insurance for the economically vulnerable population This component is to expand access to health insurance for near-poor households in the Central North region and to improve the system’s capacity to manage health insurance. It will do so by increasing the risk-sharing and improving the financial protection of local near-poor households from the catastrophic costs of illness, thus directly contributing to the implementation of the new Health Insurance Law. Vietnam has already achieved reached some important milestones on the road to universal coverage and implementation of the Health Insurance Law, e.g. full health insurance coverage of under-6 children and people living under the poverty line. The next important milestone is to bring the near-poor into the health

9 The Central North Health Support Project Ethnic Minority Plan (EMP)

insurance scheme. The component intends to help the Government achieve this specific milestone. Given the global economic crisis and its impacts on economically vulnerable households in Vietnam, the expansion of such social safety nets for healthcare is in timely manner. However, with its effort to improve the access to healthcare by the near-poor, the Government is determined to keep differentiation between the poor and near-poor in terms of benefits they receive, and to allow the near-poor partially share the cost of their health insurance.

Sub-component 1.1 - Direct subsidies to the health insurance for the near-poor Activities under this sub-component will involve subsidizing health insurance for the near-poor, thus increasing the affordability. This sub-component will finance the bulk of the out-of-pocket price faced by near-poor households with the objective of increasing the take-up of health insurance among this group. Achieving this objective will significantly depend on guaranteed commitments from the Government budget for the 50% of the premium that the State is responsible for. The proportion of the premium that is financed by the project will depend on whether enrolment is for an individual or the whole family. For individual enrollees or a partial family enrollment (family is referred to as parents and children), the sub-component will finance 30% of the premium and the State will finance 50%1, leaving the rest for the individual responsibility. In case the entire family enrolls, the sub-component will finance 40% of the premium instead of 30%. The family will be responsible for the remaining portion of the premium after subtracting 50% subsidy provided by the State and 10% discount applied for each family member. This distinction is made to encourage family enrolment made by near- poor households. Family enrolment is preferred because it increases risk-sharing and reduces the likelihood of adverse selection in the insurance scheme. Encouraging family or group enrolment in the scheme by means of reducing the out-of-pocket price of group enrolment by more than 90% is one way of reducing adverse selection.

Sub-component 1.2 - Social marketing to promote health insurance This sub-component will promote awareness of and enrolment in health insurance scheme by the near-poor through social marketing. This is encouraged given the fact that the enrolment in health insurance scheme may remain low due to poor awareness on the insurance benefits, even if the out-of- pocket price is fully subsidized. At present, the Health Information and Education Centers (HIECs) are assigned the task to raise the awareness on health insurance. While these institutions have considerable experience in conducting public health campaigns, additional resources are needed to strengthen their capacity to carry out social marketing campaigns to promote health insurance. The Vietnam Social Security (VSS) will also need additional support to transition from a relatively passive seller of health insurance to an active seller which conducts more efficient marketing of its insurance products.

1 In case of the partial family enrollment, in addition to 50% of State subsidy, 10% discount on the price of the premium will also apply for each family member enrolled.

10 The Central North Health Support Project Ethnic Minority Plan (EMP)

Sub-component 1.3 - Strengthening institutional capacities for the administration of health insurance This sub-component will improve the effectiveness of the health insurance scheme for the near-poor by strengthening the capacity of national-, provincial- and district-level institutions involved in the implementation of health insurance.

An important element of this will be the establishment of a joint working group in the first year of the project to foster national-level engagement by key stakeholders. The Joint Working Group on Health Financing will include the representatives from the VSS, the MoH’s Department of Health Insurance, Ministry of Finance, MOLISA and provincial agencies. The operational costs of the Joint Working Group will be financed by the project although more options for mobilizing additional support will be explored. Component 2: Assistance to strengthen the district-level health services This component aims to: (a) improve the capacity of district hospitals to provide basic curative health services to the population, and (b) strengthen the capacity of DPHCs to carry out basic public health functions. The component will achieve its objectives by investing in upgrading medical equipment in the district hospitals, providing equipment for DPHCs, building additional facilities for DPHCs where there is inadequate functional space, and piloting performance-based financing mechanisms to incentivize healthcare providers to perform better and more efficiently.

Sub-component 2.1 – Improving the capacity of district hospitals The Government of Vietnam is paying significant attention to district-level health facilities because they are most physically accessible and also pro-poor. In 2008, the Government launched a large-scale investment into district hospitals with the funding generated from State bonds. This amount (approximately seven thousand billion VND) has already been distributed to districts. However, the funding has not been sufficient to meet all equipment needs and to cover all districts. The Government fund was mostly used for civil works. In addition to this financial source, some district hospitals have received the financial support from international donors. For example, KfW has supported 18 district hospitals in Thanh Hoa and Nghe An provinces.

Sub-component 2.2 – Strengthening the capacity of DPHCs The objective of this sub- component is to strengthen preventive health services in districts, and thereby scale up the delivery of basic public health services to local people. The project will achieve this by providing 30 districts with new facilities for DPHCs, equipment and training. The project will also implement a performance-based financing pilot to improve the effectiveness of DPHCs.

It has been decided that the project will only support the construction of technical and administrative blocks of DPHCs with a size of 500-600 square meters. These are the two essential functional blocks in DPHCs. It is expected that the local governments will finance the building of supporting blocks, such as stores, gardens, garages, etc. It is estimated that the construction of one administrative and technical block will cost approximately $200,000. The

11 The Central North Health Support Project Ethnic Minority Plan (EMP)

project will provide equipment on the basis of the MOH’s standard list of essential equipment for DPHCs, the current stock of equipment, and the capacity of each DPHC. After being separated from the hospital, no preventive center has had its own vehicle, making it extremely difficult for it to perform epid-surveillance, sanitary control and other functions. The project will provide one off-road vehicle to each DPHC under its ambit. It is estimated that about $200,000 will be required to provide the necessary set of medical equipment to each DPHC. Table 1.1- List of 30 DPHCs for project investment Province District Province District Lang Chánh Qu Phong Thanh Hoá Th ng Xuân Ngh An T ng D ng Quan Hóa K S n Quan S n Ngh a àn Cam Thuy Qu nh L u Nh Xuân Thanh Ch ng H u L c Nam àn Nghi Xuân L Th y Hà T nh K Anh Qu ng Bình Tuyên Hóa H ng S n B Tr ch H ng Khê Qu ng Tr ch Qu ng Tr aKrông Th a Thiên-Hu Phong i n Gio Linh Phú Vang H i L ng H ng Trà V nh Linh Phú L c

Sub-component 2.3 – Performance-based financing pilots The objective of this sub-component is to identify, develop, pilot and evaluate a limited performance-based financing system for district-level health services. The project will develop and test: (a) a set of performance indicators to monitor and evaluate the service provision within district hospitals and DPHCs; (b) methods whereby the performance of these indicators can be incorporated into the calculation of the government budget to be transferred to district health facilities.

Component 3: Improving supply and quality of human resources for health The objectives of this component are: (a) to strengthen the capacity of existing medical educational institutions so that they can produce more and better trained medical personnel for the region, and (b) to improve skills and knowledge of already practicing medical personnel so that they are better equipped to provide quality healthcare to the population. The component

12 The Central North Health Support Project Ethnic Minority Plan (EMP)

will apply a mix of short-term and long-term solutions to health workforce problems faced by the region. These problems include: shortage of doctors, pharmacists, nurses and technicians; low quality training of nurses, technicians, midwives, and assistant doctors; outdated clinical skills of medical personnel; and poor management skills of health service managers. The short- term solutions consist of on-the-job training, refresher courses, workshops, etc. Long-term solutions include strengthening the capacities of medical colleges to increase the quality and supply of healthcare professionals, specialty training of doctors, upgrading of assistant doctors into full-fledged doctors, etc. Sub-component 3.1 – Strengthening medical education system This sub-component will support the transformation of Nghe An medical college into a medical university, and the improvement of teaching facilities in four other medical colleges. This will be achieved through upgrading teaching equipment and materials, and training of trainers Sub-component 3.2 – Training of district health workforce This sub-component will support training of clinical staff of district hospitals, personnel of DPHCs, as well as hospital administrators. Only in Quang Tri province, the training plan will include the provincial general hospital, which will be upgraded under the project. All other provincial health facilities will be excluded from the training plan, on the grounds that other donors have already supported or will support province-level training activities.

Component 4: Project Management, Monitoring and Evaluation Project management: The aim of this component is to ensure an adequate management structure, processes and human resource capacities for the project, and to set up mechanisms for effective monitoring of activities and evaluation of results.

Monitoring and evaluation arrangements: Monitoring and evaluation (M&E) is a critical function of the project. The main objective of M&E is to generate reliable and accurate information on the project implementation progress and statistics for measuring the achievements against the project outcome indicators. In order to avoid imposing any unnecessary burden, the project will rely, to the extent possible, on the existing health information systems and data collection mechanisms within the MOH and provinces. However, it will be, for certain statistics, necessary to design specific data collection instruments and conduct independent data collection (e.g. small-scale household surveys, patient exit interviews, hospital surveys, hospital audits). The M&E will consist of two parts: (a) monitoring of project implementation process, and (b) monitoring the project performance indicators and implementation of pilots.

1.2. Ethnic Minority Plan (EMP) 1. The goal of this EMP is to ensure better healthcare services for ethnic minorities who have limited access to healthcare services. This EMP is prepared with careful consideration of the cultural practices of the ethnic minorities, and the constraints that cause limited access to healthcare services by people in the region. 2. The framework of this EMP is based on the Ethnic Minority Planning Framework (EMPF) prepared for the project and World Bank’s (WB) Indigenous People Policy

13 The Central North Health Support Project Ethnic Minority Plan (EMP)

(OP4.10; 7.2007). All WB-Funded Projects in the ethnic minority areas are requested to: (i) mitigate any potential negative impacts; and (ii) provide prioritized supports for local ethnic minorities. 3. It is requested by World Bank that people must be properly consulted and provided with prior, free and informed consultation and information of the proposed project. The proposed Project must (i) receive support from the majority of affected ethnic minority people, and (ii) must ensure that socio-economic benefits brought to the people by the project will be culturally appropriate, and gender and multi-generationally inclusive. 4. To achieve these goals, the CPMU and PPMUs has, during the project design period, carefully selected Project sites that will not affect the residential land, cultural and religious buildings, and cultivation land.

II. SOCIO-ECONOMIC SITUATION OF ETHNIC MINORITIES IN PROJECT LOCATIONS 2.1. Socio-economic features and population structure in project locations The Central North region stretches along the coastal line with complicated topography and harsh climate, and consists of 6 provinces, namely: Thanh Hoa, Nghe An, Ha Tinh, Quang Binh, Quang Tri and Thua Thien Hue. The natural land of Central North region accounts for 15.6% of total country area, and its inhabitants make up 12.6% of the country’s population, only smaller than that of Red River Delta and Mekong Delta regions.

Table 2.1. Situation of North Central Region’s population by location Location Population Area (km2) Pop. Density Proportion (thousand (persons/km2) of ethnic people) minorities Whole country 85,154.9 331,211.6 257 16.3 Central North Region 10,722.0 51,551.9 208 7.89 Thanh Hoa 3,697.2 11,136.2 332 16.4 Nghe An 3,103.0 16,498.0 188 13.4 Ha Tinh 1,290.0 6,026.0 214 0.2 Quang Binh 854.0 8,065.0 106 1.9 Quang Tri 626.3 4,760.1 132 9.1 Thua Thien –Hue 1,150.9 5,065.3 227 3.6 Source: General Statistics Office, Annual Statistics Book 2007

The proportion of ethnic minorities in the Central North accounts for 9.2% of total national ethnic minority population and 7.89% of the Central North region’s population.

14 The Central North Health Support Project Ethnic Minority Plan (EMP)

Table 2.2. Ethnic minorities in Central North region Ethnic Minority 2005 estimated The main habitation in Project locations Groups population (people) Hmong 31,300 Thanh Hoa (Muong Lat, Quan Son, Quan Hoa) Nghe An (Ky Son, Quy Chau, Tuong Duong) Thai 429,300 Thanh Hoa (Lang Chanh, Thuong Xuan, Ba Thuoc); Nghe An (Tuong Duong, Quy Chau, Que Phong, Ky Son) Muong 312,500 Thanh Hoa (Cam Thuy, Thuong Xuan, Ba Thuoc, Quan Son, Quan Hoa, Muong Lat) Ha Tinh (Huong Khe) Khmu 27,800 Thanh Hoa (Muong Lat, Quan Son), Nghe An (Ky Son, Tuong Duong, Que Phong) Tho 55,800 Thanh Hoa (Nhu Xuan, Thuong Xuan) Nghe An (Nghia Dan, ...) Chut 3,820 Ha Tinh (Huong Khe), Quang Binh (Tuyen Hoa, Le Thuy)

O du 351 Nghe An (Tuong Duong) Bru- Van Kieu 47,400 Quang Binh (Le Thuy...) Quang Tri (Huong Hoa, Dakrong) Co tu 11,200 Thua Thien Hue (Dakrong, Phú Loc) Ta Oi 30,600 Quang Tri (Huong Hoa); Thua Thien Hue (Phu Loc), Source: General Statistics Office. Annual Statistics Book 2005, and Institute of Ethnology’s Data

Thanh Hoa province Thanh Hoa province has a total natural area of 11,136 square kilometers with 3.69 million people. The province has 10 ethnic minority groups who live in 12 mountainous western districts, making up 16.4% of the whole province’s population. (Specifically, there are 328,744 Muong people, accounting for 9.4% of the province’s population; 210,908 Thai people, making up 6%; 13,320 Hmongs, making up 0.38%; 9,890 Tho people, making up 0.25%; 607 Khmu people; 444 Tays; 327 Chinese people; and 131 Nungs).

Nghe An province This is the largest province among project locations with the total area of 16,488.45 square kilometers. Its total population is 3.1 million people with 20 ethnic minority groups of approximately 600,000 people, accounting for 13.4% of the province’s population. The ethnic minority groups their population of over 100 people include: Thai with 269,491 people, making up 9.42%; Tho with 55,345 people, making up 1.97%; Khmu with 27,014 people, making up 0.94%; Hmong with 20,045 people, making up 0.91%; and Muong with 532 people, making up 0.018%

15 The Central North Health Support Project Ethnic Minority Plan (EMP)

Ha Tinh province Ha Tinh province has 6,026 km2 of total natural area, and its total population of 1,290,000 people. The number of ethnic minorities accounts for only 0.2% of the province’s population, including: Thai (295 people), Chut (190 people), and Muong (150 people). These ethnic minority groups mainly live in Huong Khe and Huong Son districts.

Quang Binh province The geography of the province is narrow and sloppy from the west to the east with total areas of 8,065 km2. Its total population is 846,924 people with 1.9% of ethnic minorities, including: Chut (3,534 people with sub-groups of Ruc, Sach, May, Arem, etc.) and Bru-Van Kieu (11,200 people with sub-group of Ma Lieng and Van Kieu). They concentrate in the west communes of Bo Trach, Le Thuy, Minh Hoa and Tuyen Hoa districts.

Quang Tri province Quang Tri province has its natural area of 4,745.7 km² and population of 597,985 people. The ethnic minority groups account for 9.1% of the province’s population, including Bru – Van kieu (41, 200 people) and Ta Oi (11, 000 people) who live in Dakrong, Huong Hoa, Gio Linh and Vinh Linh districts.

Thua Thien-Hue province Thua Thien – Hue province has 5,053.99 square kilometers of its natural area, and the population of 1,087,579 people (Data from the Population Census dated 1 April 2009) with the population density of 215 people per square kilometer. The ethnic minorities account for 3.4% of the province’s population, including Co Tu (12,000 people), Bru- Van kieu (780 people), and Ta Oi (24,600 people) who live concentratedly in the mountainous districts of A Luoi and Phu Loc.

Table 5. Percentages of poor, near-poor and ethnic minority people in the selected districts for project investment Unit: % District Poor Near-poor Ethnic minorities Note (estimated (estimated in in 2008) 2005) Thanh Hoa province 21.53 12.82 16.4 Lang Chanh 45.0 28.48 51.58 Thai, Muong Thuong Xuan 49.9 17.26 55.0 Thai, Muong Quan Hoa 43.5 40.57 51.5 Thai, Muong, Hmong Quan Son 47.3 43.64 55.0 Thai, Muong, Hmong Muong Lat 63.0 34.42 70.0 Hmong, Thai, Muong Nhu Xuan 43.0 28.99 52.3 Muong, Tho Ba Thuoc 54.8 20.27 60.0 Muong Cam Thuy 24.3 20.61 34.0 Muong

16 The Central North Health Support Project Ethnic Minority Plan (EMP)

Hau Loc 20.8 12.06 0 Nghe An province 17.31 889 13.4 Nam Dan 12.88 5.80 0 Quynh Luu 11.95 7.17 0 Thanh Chuong 18.98 11.39 0 Nghia Dan 22.24 13.35 20.8 Tho Que Phong 46.57 23.28 89.4 Thai, Hmong Tuong Duong 57.85 23.14 89.5 Thai, Hmong, O du Ky Son 57.97 23.19 95.4 Hmong, Thai, Khmu Ha Tinh province 0.2 Huong Son 11.76 22.10 0 Nghi Xuan 13.57 28.59 0 Duc Tho 7.14 10.81 0 Cam Xuyen 14.30 19.47 0 Huong Khe 14.57 24.67 0.2 Chut, Muong Ky Anh 16.97 15.29 0.1 Muong Quang Binh 27.5 16.8 1.9 province Minh Hoa 57.5 21.3 0.6 Chut Tuyen Hoa 34.5 23.3 14.9 Chut, Bru Van Kieu Bo Trach 16.9 14.3 1.3 Bru Van Kieu, Chut Le Thuy 18.6 12.6 2.6 Bru Van Kieu, Chut Quang Trach 25.7 17.8 0.1 Chut Quang Tri province 13.9 7.85 9.1 Dakrong 8.0 10.4 75.7 Bru Van Kieu, Ta Oi Gio Linh 17.3 8.5 2.5 Bru Van Kieu Hai Lang 18.2 10.5 0 Vinh Linh 12.2 8.1 2.6 Bru Van Kieu Thua Thien Hue 3.6 Bru Van Kieu, province Co Tu, Ta Oi Phong Dien 8.60 5.11 0.5 Bru Van Kieu Phu Vang 9.20 4.87 0 Huong Tra 9.72 6.66 0.3 Bru Van Kieu Phu Loc 11.32 4.95 0.4 Bru Van Kieu Sources: Provincial Reports, 2008

17 The Central North Health Support Project Ethnic Minority Plan (EMP)

2.3. Socio-economic conditions of 10 ethnic minority groups in Project locations 1. The Hmong - Location: The Hmong group in Viet Nam consists of four sub-groups of white Hmong (Hmong ), black Hmong (Hmong uz), flowery Hmong (Hmong l nhz) and blue Hmong (Hmong suaj). Hmong people often live in the high mountains and remote communes. In Thanh Hoa and Nghe An provinces, Hmong people live close to the border areas between Viet Nam and Laos (Muong Lat, Quan Son, Ky Son, Que Phong and Tuong Duong districts). - Economic activities: The main economic activity of the Hmong in Central North region is upland cultivation. The main plants are maize and one-crop rice. Therefore, their living is still in difficult situation. The income is rather low and unstable because of their heavy dependence on the natural and climate conditions. - Community relations: Each Hmong village consists of several dozens of houses built on the mountain’s sloppy sides. The Hmong kinship system is very well-organized and supportive. Each kinship has its own worship rituals. Their houses are often not permanent with thatch roof and wooden walls. There is high humidity and darkness inside houses. - Family and marriage system: The Hmongs rarely marry people from other ethnic groups. Men have more decision power, especially in community interactions. Women are responsible for housework. - Language: The Hmong language belongs to Tibet-Chinese linguistic family. The writing system has been Latinized and widely used by the whole community. Most of Hmong women do not speak Vietnamese, and this brings barriers to social services in general and healthcare in particular. - Education: Living in the upland and rather remote areas, the educational level of the Hmong is still very low. Given the language barriers and burden of farming activities and housework, many of Hmong women and girls are illiterate. Children often start their schooling very late with high drop-out rate. Very few of them are able to complete high schools.

2. The Thai - Location: The Thai people in the Central North concentrate in upland districts of Thanh Hoa and Nghe An provinces. - Economic activities: Traditional economic activities include upland farming and wet rice cultivation. Recently, they have planted some other long-term crops such as bamboo and rubber. Food security is maintained. - Community interactions: Thai villages are often located in valley areas close to rivers or streams where there is production land available. Each Thai village consists of a hundred of houses divided into kinships. Most of Thai villages have limited access to district and provincial healthcare centers due to the difficulties in transportation. - Family and marriage system: Thai people live in extended patriarchal families. Under each Thai house-on-stilt roof, there are often a few couples. Each couple is allocated a separate bedroom, and the distribution of bedrooms among couples follows age-based principles. - Language: The Thai people are more fluent in Vietnamese language than other ethnic minority groups. - Education: Given better transportation system (as compared with the Hmong, for instance) and stable economic conditions, the education level of the Thai is high with low illiterate rate.

18 The Central North Health Support Project Ethnic Minority Plan (EMP)

3. The Muong - Location: In Central North region, Muong people concentrate in lowland areas in Thanh Hoa Province. - Economic activities: Besides wet rice, the Muong also have some other industrial crops such as sugarcane, rubber, and ground nuts. In general, they have medium living standards. - Community interactions: Muong villages are often located in the midlands with a small part in mountainous areas. Each Muong village consists of a hundred of houses divided into kinships. The kinships are very well-integrated and help maintain a community cooperative network. - Family and marriage systems: Muong people are free to make their marriage decisions. Though Muong families follow patriarchal system, men and women are quite equal in all terms. - Language: Muong language is very similar to the Vietnamese language. Therefore, Muong people can easily speak Vietnamese. Most of them are bilingual. - Education: Given the advantage of transportation system, the Muong people have better access to educational and other social services. There is very low illiterate rate.

4. The Khmu - Location: In the Central North, Khmu people concentrate in Ky Son and Que Phong districts of Nghe An province, and Muong Lat district of Thanh Hoa province. These are the border districts of Vietnam and Laos with traveling difficulties. Khmu people often live scatteredly on the hillsides, and each Khmu hamlet often consists of tens of households. - Economic production: The Khmu people are heavily dependent on the upland crops such as dry rice, maize and cassava. Their income is very low though they also have, besides farming, some additional revenues from gathering activities of non-timber resources. The average income of the Khmu household is the lowest among the ethnic minority groups in the region. According to the survey data collected by the Institute of Ethnology in 2007, the percentage of Khmu hunger households in Nghe An province accounted for over 80% with the average income of only VND 120,000 per month (Nguyen Quang Tan et all, Ethnology Newspaper, 2008). - Community interaction: Khmu villages are often scattered in upland area. Each village consists of several dozens of households, so the relationship within a village is quite integrated. - Family and marriage system: The Khmu have early marriages, and the proportion of exogamous marriages is pretty high. Men have more power than women. - Language: The Khmu language belongs to Mon-Khmer family. It does not have writing system. Speaking fluent Vietnamese is still a constraint for many Khmu people, especially for women and children. - Education: Given economic difficulty, very few Kho Mu people are able send their children to schools. There is high drop-out rate at primary level.

5. The Tho - Location: The Tho group mostly lives in lowland areas in Thanh Hoa and Nghe An provinces, where transportation condition is pretty good. - Economic production: The main crops are wet rice and maize. In Nghia Dan district (Nghe An province) and Nhu Xuan district (Thanh Hoa province), the Tho have some other cash crops such as rubber, sugarcane, etc.

19 The Central North Health Support Project Ethnic Minority Plan (EMP)

- Community interactions: marriage and neighbor relationships are the foundation of the Tho community interactions. - Family and marriage system: The Tho group follows patriarchal system, but women have their voices in decision-making. - Language: The Tho language belongs to Viet-Muong group. Therefore, Tho people have no difficulty in speaking fluent Vietnamese. - Education: The education level of the Tho is quite high. Most of children complete general education, and there is a high rate participating in further education.

6. The O Du - Location: The O Du only lives in Tuong Duong district, Nghe An province with very small population. - Economic production: There is combination between lowland and upland cultivation. The income from this activity is low with roughly 200 kg of rice per individual per year. - Community relations: Because of small population and scattered distribution, O Du village’s integration is very loose; some live with the Thai. - Family and marriage: The O Du people often marry people from other ethnic groups, especially the Thai. - Language: The O Du language belongs to the Mon-Khmer. Therefore they have more difficulty in learning Vietnamese. However, most of them can speak Thai language. - Education: Given economic difficulty, a few O Du children go to schools. There is high illiterate rate.

7. The Chut - Location: Being one of the ethnic minority groups with small population, Chut people live concentratedly in the mountainous areas in western Quang Binh province, close to the border of Vietnam and Laos. The Chut group has many sub-groups such as: Sach, May, Ruc, A rem, Ma Lieng, etc, and lives in Minh Hoa, Tuyen Hoa, Le Thuy and Quang Trach districts, Quang Binh province. - Economic production: Upland farming and non-timber production are the two main activities. The household income is not stable and highly dependent on forest resources. - Community relations: In the past, the Chut people had mobile life, moving from forest/cave to forest/cave. At present, they settle in Government-built villages. The old people and village leader are highly respected in Chut community. - Family and marriage: Chut people live in nuclear families. Marriages are allowed for people in their own group, except for siblings. - Language: Chut language belongs to Viet-Muong linguistic family. Therefore, Chut people can speak Vietnamese quite fluently. -Education: The education level of the Chut is very low. Very few people have completed high schools, especially females.

8. Bru – Van Kieu - Location: Bru – Van kieu group has quite large population who concentrates in the Central North with different sub-groups such as Bru, Ma Cong and Khua in Tuyen Hoa, Minh Hoa and Bo Trach districts (Quang Binh province), and Gio Linh, Vinh Linh and Huong Hoa districts

20 The Central North Health Support Project Ethnic Minority Plan (EMP)

(Quang Tri province). The Bru-Van kieu language is quite similar to those of Co Tu and Ta Oi groups. - Economic production: There is combination of upland and wet rice farming. The main crops are rice, maize, cassava, coffee and pepper. The income level is average and close to the poverty line. - Community relations: Each Bru-Van Kieu village has strong ties of Mu (the kinship on father’s side). Neighboring relations are important. The head of each family name is respected, and the village leader is responsible for village management. - Family and marriage: The Bru-Van Kieu group follows the patriarchal system with nuclear families. When the young people reach their marriage age, they often stay overnight in the village house. They can make friends there. - Language: The Bru- Van Kieu language belongs to the Mon-Khmer linguistic family, and is quite similar the Co Tu and Ta Oi languages. It does not have a writing system. Speaking fluent Vietnamese is still a problem for some Bru- Van Kieu people. -Education: Attendance rate among Bru- Van Kieu students is pretty high with low drop-out rate.

9. The Ta oi - Location: Ta Oi people concentrate in the western mountainous areas of Quang Tri and Thua Thien Hue provinces with the local sub-groups of Pa Koh, Ba Hi and Ta Oi. Their language belongs to Mon – Khmer linguistic family. - Community relation: The Ta Oi village is arranged in a circle, with a Rong - the community cultural house - at the center. The Ta Oi’s house has long floor on stilt (usually 100m long), and is the living place of many couples within one extended family. Teeth cutting, and body/face tattoos are also the traditional customs of Ta Oi people. In each hamlet, there is a distinction of residence and forest areas, and Rong house is a common place for the community’s activities. - Family and marriage: The Ta Oi’s marriage relation is quite similar to the Co tu’s and Bru- Van Kieu’s. Ta Oi people believe in traditional belief with the system of Yang (gods) and souls. They believe that each person has his/her soul, and their health and sickness depend on the soul (The soul of a family member is represented by a bowl which is considered as a sacred object and used for ritual activities). - Language: The Ta Oi language belongs to the Mon-Khmer linguistic family and does not have writing system. Speaking fluent Vietnamese is still a problem for some Ta Oi people. - Education: The drop-out rate of Ta Oi children is high because they live in remote areas. The number of illiterate Ta Oi people has significantly reduced in recently years.

10. Co Tu -Location: Co Tu people concentrate in Quang Nam and Da Nang. In the Central North, they live in Phu Loc and A Luoi districts (Thua Thien - Hue province). -Economy activities: Similar to other ethnic minority communities on Truong Son mountain range, the Co Tu people live on upland cultivation. In the past, they had shifting cultivation, leading to very poverty condition. At present, they settle down in villages along the Ho Chi Minh Road. - Community relation: The Co Tu’s living place is normally on highly dangerous mountains. Co Tu village is arranged in a circle, with the community cultural house (Guol) at the center

21 The Central North Health Support Project Ethnic Minority Plan (EMP)

with a pillar used for binding animals for village ritual activities. There are 50 houses in each village which is surrounded by a fence. The house type is with a round roof. Tooth cutting is quite common among the Co Tu people, and buffalo stabbing festival is held with the participation of the whole community. According to customs, the Co Tu people have a lot of taboos, especially women and children. - Language: The Co Tu language belongs to the Mon-Khmer linguistic family without a writing system. Speaking fluent Vietnamese is still a problem for some Co Tu people. However, Co Tu’s language is more popular, and used for broadcasting purposes in the area. - Education: The drop-out rate of Co Tu children is high because they live in remote areas. And the number of illiterate Co Tu people is still high.

III. POLICY FRAMEWORK 3.1. World Bank’s Policy toward Ethnic Minorities (0P 4.10)

The WB has its own policy toward the indigenous/ethnic minority people (OP4.10; 7.2005). It calls upon projects to invest into ethnic minority areas, and to fully respect the preferential rights of the affected ethnic minorities. At the same time, it is expected to mitigate the adverse impacts on the ethnic minorities and promote those activities that aim at bringing benefits and preserving their traditional cultural values. The WB requests that the local people should be sufficiently informed and freely participated in the Project, and the Project should receive the support from most of the affected ethnic minority people. The designed Project must ensure that the ethnic minority people receive the social and economic benefits are culturally appropriate, and gender and multi-generationally inclusive.

The WB’s objective on ethnic minorities is to ensure that the development process will foster a full respect for their dignity, human rights, and cultural characteristics. The focus of the planning framework is to ensure that ethnic minorities will not be affected during the development process, especially under projects using the WB’s loan. At the same time, it is also to make sure that the ethnic minorities will receive their corresponding socio-economic benefits.

The WB’s strategy for addressing the issues pertaining to ethnic minorities must be based on the participation and informed consultation of the ethnic minority people themselves. Thus, identifying local preferences through direct consultation, incorporation of indigenous knowledge into project approaches, and appropriate early use of experienced specialists are core activities for any project that affects ethnic minority people and their rights to natural resources

3.2. GoV’s Policy

The GoV made its Decision No.135/1998/QD-TTg dated 31 July 1998 on the approval of the “socio-economic development program for the extremely difficult mountainous and remote communes". Accordingly, those people who live in the extremely difficult mountainous and remote areas will be entitled to preferential health examination and treatment.

22 The Central North Health Support Project Ethnic Minority Plan (EMP)

The National Assembly’s Resolution No. 18/2008/QH12 stipulates the accelerated performance of socialization policies and laws to promote the quality of healthcare services. The National Assembly approves the directions to increase the share of annual health budget expenses, and to ensure that the increased health expenses are higher than the average increased expenses of the national budget. It is planned to spend at least 30% of health budget for the preventive health. The attention will also be paid to the budget line allocation for the healthcare for the poor, farmers, ethnic minorities and those living in difficult and extremely difficult socio-economic situation.

On 15 October 2002, the Government promulgated the Decision No.139/QD-TTg on "medical check-up and treatment for the poor", which states that all people who are the poor, live in extremely difficult areas under Program 135, and ethnic minorities will receive free medical check-up and treatment. The budget of this program will be allocated from the national and local budgets (accounting for 75%), and mobilized from various organizations and individuals. The payment levels will be in accordance with the regulations.

Thanks to the enforcement of Decision 139, the healthcare for the poor and ethnic minorities has been significantly improved. Provincial governments has issued regulations on the fulfillment of medical check-up and treatment for the poor, and established their funds for medical check-up and treatment for the poor. In extremely difficult provinces in the Central North, the number of beneficiaries who are entitled to preferential treatment as indicated in Decision 139 is quite large due to the high proportions of ethnic minorities and those living in Program 135 areas. Since the implementation of health check-up and treatment for the poor, the number of patients visiting health facilities has significantly increased. This also is a great challenge to the extremely difficult provinces in the Central North due to their limited public budget in the context of the poor’s increasing demands for health check-up and treatment.

Especially, Decision 139 also stipulates the provision that eligible people will be granted with Health Insurance Cards, benefits of non-advance payment medical examination and treatment, and refundable medical examination and treatment in the healthcare establishments which are not the originally registered ones. The eligible people include are those living under the poverty line, those living in extremely difficult communes (under Program 135), and ethnic minorities.

The preferential medical examination and treatment given to the poor as stipulated in the Government’s Decision 139 has significantly contributed to the improved healthcare for the poor, especially those living in mountainous areas and ethnic minorities. However, the access to healthcare services by the poor and ethnic minorities in the Central North is still difficult. The poor cannot go to healthcare units because they cannot afford the transport or the patients’ caring costs, or access to modern healthcare services at provincial and central healthcare establishments. Meanwhile, the district-level medical equipment and facilities are inadequate, and the personnel are not satisfactory in both quantitative and qualitative terms in order to provide ensured examination and treatment for local people in general and for the poor and ethnic minorities in particular.

23 The Central North Health Support Project Ethnic Minority Plan (EMP)

IV. CONSTRAINTS THAT CAUSE LIMITED ACCESS TO PUBLIC HEALTHCARE SERVICES BY ETHNIC MINOTITIES 4.1. Geographical and transportation constraints Currently, infrastructure and transportation in the Central North region are not in very good condition. The distance between villages and district centers is, in some cases, about 50-70 km, while roads are not available or under bad condition, especially during the rainy season. The means of transportation is mainly by bike or on foot.

4.2. Customary constraints As the modern healthcare services are uneasily accessible in various residential areas, the Hmong is, by now, still one of a few ethnic minority groups which preserve traditional knowledge of the community healthcare. The healthcare performed by the Hmong mainly relies on the indigenous prevention and treatment knowledge/experience. Most of Hmong people have not adequately accessed to the modern healthcare services due to various reasons, especially the impact of cultural elements that cause many people to select the homecare method and use traditional medicines. The belief-based treatment also plays an important role and even drives the decision on the selection of treatment methods. A Hmong woman is always accompanied by her husband while going to the clinic for treatment. And it is important thing that a Hmong woman cannot have delivery at the clinic as it is believed that a new-born child must be supported and sponsored by a superpower (home god). A pregnant woman must be supported by other members of her family. The important belief is that Hmong people do not expect their family members to have accident or die outside their homes without being supported by their home god.

Therefore, geographical distance from home to health facilities, difficult economic conditions of households, and traditional customs/habits are the important obstacles that prevent the majority of people from having access to modern healthcare services.

In their customs and habits, the Khmu people have still maintained the traditional habits of their daily activities, especially the worship ceremony. By now, the Khmu people still believe that the sickness is caused by the superpower (hroi), and the family has to offer a worship to wish health protection and recovery when a family member is sick. While taking care of the mother’s and children’s health, they assume that worshipping the superpower is very important, and offering a worship to wish the support from the superpower will help the patient recover faster than being treated in the health facilities.

In their customs and habits, the Mon-Khmer ethnic minority groups of Bru-Van Kieu, Co Tu and Ta Oi have still maintained many ritual ceremonies for their marriages and healthcare. During the pregnancy period, a pregnant woman has to do a lot of things. Worshiping is practiced when a family member gets sick. During ceremonies, people prepare the offerings such as water buffalo meat and sticky rice to the God of land, God of forest and the Sun with much hope that their family/crops/stocks will be protected.

Living in high and remote areas, the Bru- Van Kieu group does not have full access to modern medicine and healthcare services because of the poor transportation system in their areas.

24 The Central North Health Support Project Ethnic Minority Plan (EMP)

Some other obstacles include financial burden, language barriers, and many other cultural factors.

Traditionally, Ta Oi people believe in traditional belief with the system of Yang (gods) and souls. They believe that each person has his/her soul, and their health and sickness depend on the soul (The soul of a family member is represented by a bowl which is considered as a sacred object and used for ritual activities).

4.4. Language and educational constraints Among 10 ethnic minority groups in the region, most of them have, with the exception of the Muong, Tho, and Chut, difficulties in using fluent Vietnamese. This is an important factor that disencourages local people to visit district or provincial medical centers for healthcare.

V. COMMUNITY CONSULTATION *Activity principles

Ensuring the participation of the ethnic minorities in the project in order to speed up the smooth project implementation. Disclosure of project information for ethnic minority people is an important part of project preparation and implementation. Making consultation with them, and ascertaining their active participation in the project. These will mitigate the risk of conflicts and project delays. They will also enable the Project to design the resettlement and rehabilitation program as a comprehensive development one, which meets the needs and priorities of the displaced, and thereby maximizing the economic and social benefits of the investments.

The objectives of the public information and consultation program for ethnic minority people are as follows:

a) To ensure that local authorities, as well as representatives of ethnic minorities, will be included in the planning and decision-making processes. b) To fully share information about the proposed project components and activities with the ethnic minority. c) To obtain information about the needs and priorities of the ethnic minorities, as well as their reactions to the proposed policies and activities. d) To ensure that ethnic minorities are able to make fully informed decisions that will directly affect their incomes and living standards, and that they will have the opportunity to participate in activities and decision-making on the issues that will directly affect them. e) To establish the cooperation and participation of ethnic minority people and communities in various activities necessary for resettlement planning and implementation.

25 The Central North Health Support Project Ethnic Minority Plan (EMP)

*Methods of community participation and consultation

The main methods which are used in community - based resettlement management include: - Public disclosure: through the communication campaigns associated with the public media such as television, commune-based radio, posters, leaflets. - Community meetings at project sites - Formation of groups/group discussion in order to establish the information channel to facilitate the participation of ethnic minorities in project planning and implementation. - Face-to-face interviews of household representatives to reach agreements on their benefits/interests. - Establishment of a council represented by the stakeholders to facilitate the project planning/monitoring and community participation. - Development of complaint procedures and solutions

In the process of strengthened consultation and community/stakeholder participation, the following should be considered: - Identification and participation of all stakeholders, including beneficiaries and affected people. - Development of a strategy for community–based project planning, implementation, and monitoring and evaluation. - A complete and comprehensive list of requests for communication campaigns and information disclosure, the establishment of steps to provide better access to project goals for ethnic minority people. - Development of a timeframe for the completion of activities/items such as information campaign, compensation levels, solutions and conditions, and resettlement areas and plans. - Seeking for the assistance from public organizations (e.g. women association, farmer’s association, veteran’s organization, Fatherland Font, etc.) to address various issues related to community consultation and participation. - The project implementation activities must be consulted with the ethnic minority specialist, especially the one who has experience in project activity areas (healthcare, insurance, etc.). - The CPMU must have close cooperation with the PPMUs, especially those with high and diversified concentration of ethnic minorities. - The PPMUs will monitor the implementation process in order to make sure that equal healthcare services will be provided for ethnic minorities, and financial and legal support will be made available for districts in their provinces. - The DPC must establish the efficient cooperation with other departments/programs in the district, especially those related to ethnic minority development activities.

VI. ETHNIC MINORITY ACTION PLAN From the consultations with local authorities, ethnic minority patients and relevant agencies/bodies, the evaluation indicators of project activities for ethnic minority development will be as follows:

26 The Central North Health Support Project Ethnic Minority Plan (EMP)

1. Improve the resources of medical workers by supporting medical staff and workers who belong to ethnic minority groups, and selecting young ethnic minority people for their participation in the training. 2. Carry out counseling and communication activities in order to raise the awareness on health examination and treatment, and purchase health insurance cards for local people. 3. Conduct training courses on the organization and management of health examination and treatment activities for the benefits of district hospitals, health centers and regional general clinics. 4. Improve equipment, and provide technology transfer for district hospitals in order to meet the needs of medical treatment for the poor, particularly ethnic minorities in remote areas.

Key indicators inlude: (i) Professional training: 11 intensive 4-year doctor and pharmacist trainings for the ethnic minority staffs and medical workers who work in those selected districts (ii) Communication: (a) prepare flyers to provide for related organizations/stakeholders in 15 districts having the presence of ethnic minority people; (b) through local broadcast systems in ethnic minority languages in 15 districts having the presence of ethnic minority people (iii) Management training for local staffs in the 15 districts having the presence of ethnic minority people (iv) Facilities operation training for local technicans in the 15 districts having the presence of ethnic minority people

From the consultations with local authorities, ethnic minority patients and relevant agencies/bodies, the evaluation indicators of project activities for ethnic minority development will be as follows: 1. Improve the resources of medical workers by supporting medical staff and workers who belong to ethnic minority groups, and selecting young ethnic minority people for their participation in the training. - Provide intensive 4-year doctor and pharmacist trainings for the ethnic minority staffs and medical workers who work in those selected districts with at least 50% ethnic minority population. The number of proposed trained doctors and pharmacists will be 11 people in the project areas. - Provide short-term training on district-level medical examination and treatment for the ethnic minority staff and medical workers who work in those selected districts with at least 50% ethnic minority population. The number of proposed short term training staffts will be 11 people in the project areas

2. Carry out communication activities in order to raise the awareness on health examination and treatment, and purchase health insurance cards for local people. The performance of communication activities can be seen through the: - Use of a friendly and affective approach which helps ethnic minority people obtain adequate information and good knowledge of the project activities.

27 The Central North Health Support Project Ethnic Minority Plan (EMP)

- Various methods of communication, including: + Direct information on project activities provided by medical workers at district health centers and district hospitals. + Communication campaigns aimed at public media such as television, commune- based radios, posters, and leaflets written in ethnic minority languages. + Use of communication means and diversification of communication products which are appropriate with the customs and cultural values of ethnic minority groups in order to raise the poor’s awareness as well as to encourage the take-up of patients in hospitals.

3. Conduct training courses on the organization and management of health examination and treatment activities for the benefits of district hospitals, health centers and regional general clinics. - Organize training courses on health insurance for ethnic minorities. - Organize training courses on monitoring the implementation of health insurance for ethnic minorities. - Identify and select beneficiaries, provide 30% of health insurance card fee for the near- poor ethnic minorities.

4. Improve equipment, and provide technology transfer for district hospitals in order to meet the needs of medical treatment for the poor, particularly ethnic minorities in remote areas. - Organize training courses for medical workers working in district hospitals; utilize modern medical equipment in order to improve the capacity for the treatment of local people. - Provide support to the purchase and transfer of technical equipment for hospitals in districts where there is high concentration of ethnic minorities. - Provide support to the purchase of health insurance cards for the near–poor ethnic minorities who are not the beneficiaries of the Government’s Decision 139.

VII. ORGANIZATION AND IMPLEMENTATION As for the performance of the ethnic minority development plan, the CPMU and PPMUs will start up the implementation of project components and carry out the supervision exercise in order to make sure that the project activities are kept on right track. - With regard to those districts which have high concentration of ethnic minority population, documents in their languages should be published, and the engagement of people who have the knowledge of local ethnic minority languages should be made in order to make sure that the communication and consultation with local people will be done during their check-up and treatment exercises in the health facilities. - Qualified doctors will be sent to organize training activities and capacity building for ethnic minority medial workers working in district-level hospitals where there is a high need for the transfer of medical techniques, especially in those districts where there is a high concentration of ethnic minority population.

28 The Central North Health Support Project Ethnic Minority Plan (EMP)

Table 6. Languagues should be publish of Ethnic minority people in the selected districts for project investment

District Ethnic minority Languages Thanh Hoa province Lang Chanh Thai, Muong Thai, Muong Thuong Xuan Thai, Muong Thai, Muong Quan Hoa Thai, Muong, Hmong Thai, Hmong Quan Son Thai, Muong, Hmong Muong, Hmong Muong Lat Hmong, Thai, Muong Hmong, Thai Nhu Xuan Muong, Tho Muong Ba Thuoc Muong Muong Cam Thuy Muong Muong Nghe An province Nghia Dan Tho Tho Que Phong Thai, Hmong Thai Tuong Duong Thai, Hmong, O du Thai, Hmong Ky Son Hmong, Thai, Khmu Hmong, Khmu, Thai Quang Binh province Minh Hoa Chut Chut Quang Tri province Dakrong Bru Van Kieu, Ta Oi Bru- Van kieu Thua Thien Hue province Phu Loc Bru Van Kieu Bru – Van kieu

VIII. MONITORING AND EVALUATION - Monitoring the implementation of the ethnic minority development plan is a part of monitoring activities within all project components. - An independent supervision agency with qualified and experienced specialists must be in place in order to provide monitoring and evaluation of project activities related to social and ethnic minority development aspects. The implementation of EMP shall be constantly supervised and monitored by respective PPCs, CPMU, PPMU in co-ordination with the local People’s Committees.

An independent consulting agency will be entrusted with external monitoring tasks. The external monitoring agency/agencies would be selected and contracted by CPMU immediately after EMP approval and shall begin supervision and monitoring activities from the beginning of the implementation phase.

29 The Central North Health Support Project Ethnic Minority Plan (EMP)

The evaluation should be carried our into two phrases: (i) Phase 2: Will be carried out 2 years after the implementation of the project Requirement of the evaluation and report: (1) to identify how all proposed activities prepared in this EMP that have been facilitated in the first two years implementation of the project; (2) to identify what activities are relevant/useful/suitable for the ethnic minority people in the project areas; (3) to identify what activities are not relevant/useful/suitable for the ethnic minority people in the project areas; (4) to propose recommendation (if any) for better project implementation in the following stages:

(ii) Phase 2: Should be carried out right after the completion of the project. Requirement of the evaluation and report: (1) to assess the effectiveness of all proposed activities prepared in this EMP during the project implementation (2) to assess the participation of related organizations/partners/stakeholders in the implementation of proposed activities prepared in this EMP

IX. COST ESTIMATION - The costs of EMP activities are estimated and embedded within project activities. - The costs of training activities will be calculated in detail when these activities are conducted. - In order to make cost savings, EMP-related training and communication activities will be incorporated into other project training and communication activities.

Table 7: EMP’s Estimated Budget Unit: USD No. Items Budget Source of Total Budget 1 4-year training of doctors 11 pax x UDS 6,000/pax Project budget 66,000 and pharmacists 2 Short-term and mid-term 11 pax x USD 1,500/pax Project budget 16,500 training for the staff and medical workers who are from ethnic minority groups 3 Training on medical 11 pax x USD 1,500/pax Project budget 16,500 equipment management

30 The Central North Health Support Project Ethnic Minority Plan (EMP)

and maintenance 4 Printing communication USD 4,000 x 11 districts Project budget 44,000 documents for the ethnic where the proportion of minorities ethnic minorities is over 50% of district population 5 Training on USD 5,000/district x 15 Project budget 75,000 communication and districts assistance 6 Granting health insurance (estimated 10,000 Project budget 58,500 cards for the near-poor people) x USD 5.85/pax people who are from ethnic The near-poor ethnic minority groups minorities in the lowland districts who have not benefited from the Decision 139 Total 276,500

31 The Central North Health Support Project Ethnic Minority Plan (EMP)

APPENDICES Appendix 1: Public consultation pictures (available in hard copies) Appendix 2: Public consultation in Project area communities (available in hard copies and in Vietnamese) a. 06 sessions of public consultations in Th ng Xuân, C m Th y, M ng Lát, Quan S n, Quan Hóa and Nh Xuân districts, Thanh Hóa Province b. 04 sessions of public consultations in K S n, T ng D ng, Qu Phong and Ngh a àn districts, Ngh An Province c. 01 session of public consultations in DakRong district, Qu ng Tr Province