Second Health Human Resources Development Project (RRP VIE 40354)

HEALTH HUMAN RESOURCES DEVELOPMENT: POLICY AND STRATEGY CONTEXT

1. National Socio-Economic Development Plans. The Government of Viet Nam recognizes the intricate relationship between inclusive growth and population health and views the health sector as central to the country’s socioeconomic development. The Socio-Economic Development Strategy 2011–2020 prioritizes developing the system of healthcare and improving the quality of health services, including (i) upgrading of health infrastructure at all levels, (ii) improvement of health human resources (HHR), and (iii) strengthening health financing, including universal health insurance.1 The Socio-Economic Development Plan 2016– 2020 reiterates these priorities, and sets national targets to 2020 for hospital beds per population, health insurance coverage, and health staff per population.2

2. The Sixth Plenary Session of the 12th Party Central Committee (October 2017) placed renewed emphasis on the health sector, highlighting amongst the sector’s priorities a need to ensure the adequate supply of qualified health workforce that is responsive to the population’s evolving health needs. The Party Committee’s Resolution on the Protection, Care, and Improvement of People’s Health set updated targets for health workforce coverage to 2030.3 The estimated number of new health staff for key professions required by 2030 in order to meet the targets include (i) 43,250 doctors, (ii) 22,199 pharmacists, and (iii) 249,416 nurses.4

3. The Resolution gave further priority to completing reform of the national health professional education system and framework, establishing a national medical council and national licensing examination, strengthening health practitioner certification and registration, and enhancing the qualifications and continuing professional training of health professionals.

4. Universal Health Coverage. Health workforce development forms a central pillar of the government’s efforts to reach universal health coverage (UHC), as articulated in the National Action Plan for the Implementation of the 2030 Sustainable Development Agenda.5 Ensuring quality human resources for the health sector, in order to meet medical diagnosis and treatment needs of all citizens, is identified as a key area of focus for achieving UHC.6

5. In parallel with the focus on health workforce quality, the government maintains its commitment to redress the imbalance in HHR distribution. The Master Plan on Building and Developing of the Local Health Care (LHC) Network in the New Situation7 recognizes the need to rapidly expand HHR coverage in LHC facilities, particularly in remote and disadvantaged areas. Various Ministry of Finance (MOH) programs, including those for the deployment of graduate doctors to difficult areas and granting preferential access to health education and professional training institutions (HEPTI) for students from disadvantaged regions, have

1 Government of Viet Nam. Viet Nam’s Socio-economic Development Strategy for the period 2011-2020. . 2 Government of Viet Nam. National Assembly Resolution No. 142/2016/QH13 (12 April 2016) on the Five-Year Socio-Economic Development Plan, 2016–2020. Hanoi. 3 Government of Viet Nam. 12th Party Central Committee. Resolution No. 20-NQ/TW (25 October 2017) of the on the Protection, care and improvement of people’s health in the new situation. Hanoi. 4 Sector Assessment (Summary): Health (accessible from the list of linked documents in Appendix 2). 5 Government of Viet Nam, Office of the Prime Minister. 2017. National Action Plan for the Implementation of the 2030 Sustainable Development Agenda. Hanoi. 6 Aligned with SDG target 3c. 7 Government of Viet Nam. Prime Minister. Decision No. 2348/QD-TTg (5 December 2016) on the master plan on building and developing of the LHC network in the new situation. Hanoi. Second Health Human Resources Development Project (RRP VIE 40354) contributed to increasing health workforce coverage in LHC facilities.8 In 2017 the proportion of commune health station (CHS) nationwide served by a medical doctor reached 88.0% from 72% in 2011.9

6. Health Human Resource Development Master Plan. Consistent with the directions of the Soco-Economic Plan 2011-2020 and later resolutions, the MOH issued its human resource development master plan 2011-2020. The master plan includes amongst its four key objectives (i) to develop human resources in terms of quantity, quality, structure and rational distribution; and (ii) to improve the quality of health workforce training to meet the development needs of the society and international integration. Strengthening Viet Nam’s HEPTI is recognized as central to achieving these objectives.

7. Viet Nam has 36 universities offering bachelor and postgraduate health professional training programs, eighteen of which offer medical programs. 10 Of these Hanoi Medical University (HMU) and University of Medicine and Pharmacy at (UMP) are recognised as the country’s leading HEPTI. Under the master plan, HMU and UMP are assigned to be developed as National Health Sciences Universities, capable of increasing graduate numbers and diversifying degree and specialty programs in response to the country’s evolving health needs and disease burden. The development of HMU and UMP is listed in the Health Human Resources Development Master Plan as a priority project for Prime Minster approval.11

8. The master plan further emphasizes reform of the system of health professional education, including training program curricula, teaching methods, and systems for quality assurance and accreditation. MOH, through the Administration of Science, Technology and Training (ASTT), oversees the reforms in consultation with the Ministry of Education and Training (MOET). A draft roadmap prepared by ASTT identifies four priority reform areas (i) developing a competency-based curriculum to produce practice-oriented graduates, suited to the changing health needs of Viet Nam; (ii) developing faculty to increase the quantity and quality of trained medical educators in universities and hospitals, to deliver profession-oriented medical education; (iii) developing a national quality framework for medical education to support standardization, quality assurance, and program accreditation; and (iv) regulating health professionals through certification and licensing.

9. In addition to ASTT, various departments within MOH assume a role for HHR development and management. The Department of Manpower oversees HHR recruitment policy, salaries and incentives. The Medical Services Administration is in charge of licensing for health professionals and health facilities. The Council of Rectors of medical and pharmaceutical universities and colleges serves as an advisory body to the Minister on policy, training plans and scientific research in HEPTI. MOH has established a taskforce group on Human Resources for Health composed of MOH staff and representatives of other ministries. The taskforce provides

8 The local health care system encompasses the network of (i) commune health stations, (ii) district health centers providing public health and preventive services, and (iii) district hospitals providing inpatient and outpatient curative services. 9 Government of Viet Nam, Ministry of Health (MOH). Report 1499/BC-BYT (29 December 2017) on review of performance in 2017 and the key directions, tasks, and solutions in 2018. Hanoi; and Government of Viet Nam, MOH. 2017. Joint Annual Health Review 2016: Towards Healthy Aging in . Hanoi. 10 World Health Organization. 2016. Human Resources for Health Country Profiles: Viet Nam. Manila. 11 Section V. 5.1 specifies a project for establishing two universities of Health Sciences: one in the North based on the present Hanoi Medical University and another in the South based on the University of Medicine and Pharmacy Ho Chi Minh City. Second Health Human Resources Development Project (RRP VIE 40354) policy and strategy advice to the Health Minister and facilitates coordination between MOH, related ministries, and partner organizations.

10. Development Coordination. The government’s reform agenda is supported by a core group of development partners, including the Asian Development Bank. 12 ADB’s strategic engagement in HHR development commenced with the Health Human Resources Sector Development Program (HHRSDP), which marked a shift from project-based HHR trainings to investment for HHR institutions, systems, and policy. Co-financed by the Government of Australia, the HHRSDP delivered key reforms to policy and regulatory frameworks governing HHR training, planning, and management. Complementing the reforms, HHRSDP supported investments for infrastructure and strengthening teaching capacity and management in 17 HEPTI, including HMU and UMP. The proposed Second Health Human Resources Development Project consolidates and extends the achievements of HHRSDP through focused support to develop HMU and UMP as health sciences universities and replicable models of best practice in health professional education.

11. Complementing ADB’s support, the World Bank financed Health Professionals’ Education and Training for Health System Reforms Project, co-financed by the European Union, focuses investment in the areas of HEPTI quality assurance, accreditation, and curriculum reform. The Partnership for Health Advancement in Viet Nam’s (HAIVN) IMPACT MED Alliance provides technical assistance to five HEPTI, including UMP, on the development of competency-based curricula for the undergraduate medical program. HAIVN further supports post-graduate training reform, including technical assistance to a three-year hospital based surgical residency program to be piloted at Viet Duc Hospital. The Japan International Cooperation Agency supports the development and piloting of a standardized clinical training program for nursing graduates. The World Health Organization provides technical assistance to curriculum reform and the proposed establishment of a national medical council and national licensing exam. HMU and UMP are further supported through direct bilateral relationships, including with health professional training and research institutions in Japan.13

12. HMU and UMP-Medium-Term Development Plans. The MOH has issued medium- term development plans for HMU and UMP for the period 2011-2020, with a vision to 2030.14 Each university’s plan includes amongst the key objectives to: (i) complete the organizational structure of a Health Science University; (ii) establish new schools and faculties and diversify degree and specialty programs to respond to the country’s epidemiological and demographic transition; (iii) increase annual student enrolment and graduate numbers to meet future health workforce need; (iv) meet domestic and international accreditation through upgrading of teaching programs, faculty teaching and research capacity, and university management and operational systems; and (v) establish each university as a leading center in medical science research and technology transfer.

13. The development plan of each university includes enrolment targets. HMU’s plan specifies a target of 18,000 students by 2020 and 23,000 students by 2028. UMP projects an increase of 10%–20% annually with a target of 25,000 students a year by 2020. Currently, each

12 Development Coordination (accessible from the list of linked documents in Appendix 2). 13 The institutions are detailed in the Second Health Human Resources Development Project Grant document (accessible from the list of linked documents in Appendix 2). 14 Government of Viet Nam. MOH. Decision No. 3680/QD-BYT (2 October 2009) on approval of the overall plan for development of HMU until 2020, with a vision to 2030. Hanoi; and Government of Viet Nam. MOH. Decision No. 2670/QD-BYT (27 July 2009) on approval of the overall plan for development of UMP until 2020, with a vision to 2030. Hanoi. Second Health Human Resources Development Project (RRP VIE 40354) university is operating at maximum capacity–11,095 students at HMU and 11,727 students at UMP. The breakdown of the 2017 student body by degree program for HMU and UMP is detailed Tables 1 and 2. Despite strong enrolment demand both universities face constraints meeting enrolment targets within their current campus infrastructure. In 2017, only 7%–8% of total applicants for undergraduate medicine at each university could be offered places. Development of new campuses is a priority for both universities.

14. Hanoi Medical University. HMU operates one main campus over an area of approximately 10.78 hectares and three small campuses, each with a few working rooms. The university has a separate practice hospital located within the precinct of the main campus. HMU’s existing campus does not meet the land area requirements for its development as a Health Sciences University. Lack of available neighboring land limits options for expansion of the existing campus.

15. The medium-term development plan for HMU proposes investment in the construction of a second campus over an area of 40 to 50 hectares by 2030. In 2011 the University signed a Memorandum of Understanding with the People’s Committee of Ha Nam Province on the hand- over of land in Duy Tien District for construction of the 2nd campus.15 The land area sits within the 800-hectare University Zone, an area designated by the Prime Minister for the relocation of universities and colleges from the inner city of Hanoi.16

16. University of Medicine and Pharmacy at Ho Chi Minh City. UMP’s campus is spread over ten locations across four districts of Ho Chi Minh City (HCMC). The largest area is the Faculty of Medicine with 2.5 hectares, followed by the Faculty of Pharmacy with 1.6 hectares. The smallest of the ten locations is a 340m2 facility. The university’s development plan proposes a second campus in the Northwest Urban Area of HCMC. However, the development has been hindered by a lack of reserved land and a subsequent decision by the Peoples Committee of HCMC directing the development of new university facilities to locations outside of HCMC.17

17. In line with the People’s Committee directive UMP has secured land within the 320- hectare University Village zone of Nhon Trach District, Dong Nai Province. The University Village zone sits within a 41,078-hectare site assigned for development under the Nhon Trach New Urban Area Master Plan. 18 Approved by the government in 2016, the Master Plan encompasses housing, commercial and cultural centers, a university village, ecotourism destinations, and an industrial park. The Master Plan envisions the area as providing education, training, health, trade and other services for the Ho Chi Minh City Region.

Table 1: Student numbers by degree program - HMU (2017) Degree Program Students Undergraduate General Medicine Doctor 3450 Dentistry 550

15 Memorandum of Understanding between Ha Nam People’s Committee and HMU, signed on 12/9/2011 in Ha Nam regarding construction of HMU’s 2nd campus in Ha Nam. 16 Government of Viet Nam, Prime Minister. Decision 1748/QĐ-TTg (27 September 2013) approving the construction project of Nam Cao University Zone in Ha Nam Province. Hanoi. 17 Government of Viet Nam, People’s Committee of Ho Chi Minh City. Decision No. 5209/QD-UBND (22 October 2014) approving the planning tasks for the building of universities and colleges in Ho Chi Minh City to the year 2025. Hanoi. 18 Government of Viet Nam, Prime Minister. Decision 455/QD-TTg dated 22 March 2016 approving the Master Plan of the Nhon Trach New Urban Area in Dong Nai Province to 2035 with a vision to 2050. Hanoi. Second Health Human Resources Development Project (RRP VIE 40354)

Traditional Medicine Doctor 300 Preventive Medicine Doctor 480 Bachelor Nursing 370 Bachelor Pubic Health 100 Bachelor Medical Technology 250 Bachelor of Optometry 173 Bachelor of Nutrition 187 Bachelor (work and study stream) 1000 Preventive Medicine Doctor (inter-system) 465 Preventive Medicine Doctor (second degree) 150 Advanced Program 100 Postgraduate PhD 580 Master 950 Medicine Specialization I 1100 Medicine Specialization II 240 Resident Doctor 650 TOTAL 11095 PhD = Doctor of Philosophy. Source: Hanoi Medical University.

Table 2: Student numbers by faculty and degree program - UMP (2017) Degree Program Faculty Undergraduate Specialty I Specialty 2 Master PhD Total Medicine 3037 1159 215 497 69 4977 Pharmacy 1658 93 26 234 16 2027 Nursing 1800 0 0 106 0 1906 Dentistry 759 127 12 47 5 950 Public Health 818 2 2 54 2 878 Traditional Medicine 915 41 6 25 2 989 TOTAL 11727 PhD = Doctor of Philosophy. Source: University of Medicine and Pharmacy at Ho Chi Minh City.

18. Health Sciences University - Campus Master Plans. In consultation with each university, MOH has prepared master plans for the health sciences university campus of HMU in Ha Nam province and UMP in Dong Nai province. The master plans, approved by the Health Minister in 2018, propose three phases of development for each campus.

19. Phase 1 of the HMU campus will develop the teaching infrastructure for microbiology, microscopy, physiology, physics, chemistry, biochemistry, pharmacology, laboratory skills, traditional medicine, nursing, pharmacy, public health, and dentistry. The facilities include an auditorium, a main administration and library building, laboratory rooms, a teaching medical center, a sports hall, dormitories, parking, a socio-cultural space, a canteen and a technical cluster. Once operational, the phase 1 campus will to receive up to 5,540 students. Approximately 20% of the students will be housed inside of the campus, with the remainder housed in the surrounding areas and communities.

20. Phase 1 of the UMP campus will put into operation undergraduate and graduate teaching. The development covers the construction of sixteen buildings, including a main administrative building, an auditorium, six lecture/laboratory buildings, a canteen, a medical center, four dormitory buildings, a staff residence and a sports administration building. Additional facilities include outdoor sports areas, recreational green space, a car parking area, and internal roads. The provincial government will construct external access roads to the south and west of the campus. Once operational, UMP’s phase 1 campus will receive up to 6,050 Second Health Human Resources Development Project (RRP VIE 40354) students and approximately 200 staff.

21. Phases 2 and 3 of each campus development will expand teaching, research, dormitory, and sports center facilities, construct a university hospital, and develop the medical technology, pharmaceutical and other commercial centers of the universities. Intake capacity at the HMU campus will increase to 12,140 students at the completion of phase 2 and up to 23,000 students following completion of phase 3. Phase 2 of the UMP campus is projected to accommodate up to 15,870 students and 500 staff. The intake capacity for UMP phase 3 is unknown at this stage.

22. Financing Campus Master Plan Development. MOH has requested ADB loan financing of $80 million to support the phase 1 construction under each master plan. Following government regulations on the use of official development assistance, each university is required to absorb on-lending of 20% of the loan amount.19

23. HMU and UMP currently operate under a hybrid financing model, whereby two-thirds of their operating costs are covered by cash flows from rate-controlled tuition, training, hospital, and other revenues and one-third from the State Budget. Since 2015, the universities have been governed by updated regulations on the autonomy of public administrative units. 20 Under the regulations, HMU and UMP are assigned responsibility for planning and execution of their functions as education and training institutions, independence in determining the university’s organizational, workforce and finance structures, and autonomy in determining service price and charging. Increases in tuition fees are subject to incremental caps through to 2025 from which time both universities will set their own tuition rates. State budget support will be incrementally phased out over the same time period.

24. A financial assessment was undertaken in accordance with ADB guidelines for financial management and analysis of projects. The assessment forecast the planned increase in tuition rates coupled with the projected increase in enrolments, offset by the projected reduction in state budget support, would enable each university to generate sufficient cash flows to sustain new campus operations while satisfying principal and interest payments at a 3.25% on-lending financing rate. The sensitivity analysis found tuition fee levels as the variable posing the greatest risk to sustainability. Should the projected fees under autonomy not be realized, it is assumed that state budget support will continue to allow HMU and UMP to breakeven rather than risk institutional failure.

19 Government of Viet Nam. Decree 16/2016/ND-CP (16 March 2016) on management and use of official development assistance and concessional loans for foreign donors. Hanoi. 20 Government of Viet Nam. Decree 16/2015/ND-CP (14 February 2015) on the mechanism for exercising the autonomy of public administrative units. Hanoi.