NORRED Project Ethnic Minority Development Plan

WOLD BANK IPP614 NORTH – EAST AND RED RIVER DELTA REGION (NORRED)

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ETHNIC MINORITY DEVELOPMENT PLAN

Public Disclosure Authorized Public Disclosure Authorized

Public Disclosure Authorized

DECEMBER, 2012

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NORRED Project Ethnic Minority Development Plan

INDEX ACRONYMS ...... 4 Chapter 1: INTRODUCTION ...... 5 1.1. Introduction of project ...... 5 1.2. The objectives of the ethnic minority development plan...... 14 1.3. The scope and methods of ethnic minority development plan ...... 15 CHAPTER 2 ...... 16 LEGAL AND POLICY FRAMEWORK ...... 16 2.1 Vietnamese Legal and Policy Framework ...... 16 2.2 Policy of the World Bank ...... 20 CHAPTER 3 ...... 22 SOCIO-ECONOMIC CONDITIONS AND HEALTH CARE CURRENT STATUS OF ETHNIC MINORITIES IN PROJECT AREA ...... 22 3.1. Socio-Economic features of ethnic minorities in project area ...... 22 3.2. Health care current status in the project area ...... 30 3.2.1. Health care system status ...... 30 3.2.2. Health check-up and treatment current status of the ethnic minorities ...... 31 3.2.3. Health insurance card purchase status ...... 33 CHAPTER 4 OBSTACLES IN ACCESSING MEDICAL SERVICES AND POSITIVE IMPACTS OF THE PROJECT ...... 35 4.1. Obstacles of ethnic minority in the project area when accessing health care services ...... 35 4.1.1. Geological distance, terrain, transportation and means of transportation ...... 35 4.1.2. Tradition and custom constraints ...... 35 4.1.3. Language and literacy barriers ...... 36 4.1.4. Low household income obstable ...... 37 4.1.5. Disease obstacle ...... 37 4.2. Opportunities and benefits of the project to the ethnic minorities ...... 39 CHAPTER 5 CONSULTATION AND PROPOSED ASSESSMENT INDICATORS ...... 41 5.1. The opinions and views of the stakeholders on the components of the project ...... 41 5.2. Public consultation principles during project implementation ...... 46 5.3. Project activity assessment index to develop ethnic minorities ...... 47 CHƯƠNG 6 ...... 50 IMPLEMENTATION ORGNIZATION AND FINANCIAL ...... 50 6.1. Implementation orgnization ...... 50 6.2. Monitoring and evaluation ...... 50 6.3. Financial Estimates ...... 51

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TABLE OF CONTENTS

Table 1: List of the beneficiaries of the project ...... 5

Table 2: Distribution of ethnic in project provinces ...... 22

Table 3 : Health system status of provinces with ethnic minoroties residing in project area ...... 30

Table 4: Percentage of persons suffered from illness or injuries by region, age group and ethnicity of household head ...... 31

Table 5: Rate of inpatients base don health centre classification and ethnic minorties in 2008 ...... 32

Table 6: The ratio of Ethnic minority household in the Project area supported with health insurance card purchase ...... 33

Table 7: Estimated cost for ethnic minority development plan ...... 51

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CHS Community Health station EMDP Ethnic minority’s development plan HD Health Department HI Health Insurance HIC Health insurance card HHs House Hold IMR Infant mortality rate MOH Ministry of Health NHS National Health Survey GOV Government of Viet Nam PC People’s Committee PMU Project management Unit PPMU Provincial Project Management Unit WB World Bank

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1.1. Introduction of project

Health care assistance for North-East and Red River Delta Regions Project (NORRED) is at the stage of preparing document to submit to the Bank for aprroval by the World Bank and Ministry of Health. With a total estimated fund of about $ 155 million (including $ 150 million in loans and U.S. $ 5 million counterpart fund of the Government of Viet Nam), the project will add significant resources to the 13 project provinces in implementing plans to upgrade the provincial hospital health system and some districts engaged in satellites and technical transfer model, and support people to access to the package of essential services in the health insurance program. The support of the project, in accordance with the Government's strategies, impact health issues at two levels: central and local. At the central level, the experience gained from this project as well as projects to support health in other regions (Mekong Delta, Northern Uplands, North Central. Etc.) will be drawn, selected to be built into the national policy. On the other hand, at the local level, besides supplementing project resources to address priority issues, investment experience among the provinces in the region will be evaluated and replicated. The regional support method has many advantages compared to the provincial support method, especially in the following aspects: (a) identify the specific needs of each region; (b) improve capacity of each province and the whole region;, and (c) allows the pilot of advanced intervention methods which can be applied and extended to the whole region or country. The project shall cover 13 provinces in the Northeast and Red River Delta region: In Northeast region have 7 provinces: Tuyen Quang, Yen Bai, Phu Tho, Lang Son, Bac Giang, Thai Nguyen and Hoa Bình. Red River Delta region have 6 provinces: Hung Yen, Hai Duong, Thai Binh, Ha Nam, Ninh Binh, Nam Đinh. Table 1: List of the beneficiaries of the project

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Managerial level Name of hospital Note Ministry of Health Thai Nguyen Central General Thai Nguyen province has Hospital. no provincial hospital. - These are the units in Viet Duc Hospital, Bach Mai charge of technology Hospital, Central Obstetrics transfer Hospital, K Hospital, Central Paediatrics Hospital, Cardiovascular Center –E Hospital PPC 1. Nam Dinh Nam Định provincial general Ministry of Health, the Hospital, Nam Đinh obstetric World Bank and provinces hospital; Paediatrics Hospital, Y carried surveys, reviews, Yen district Genral Hospital, Giao building science Thuy, Xuan Truong. technology transfer plan, 2. Ninh Binh Provincial General Hospital, development of satellite Obstetric and Paediatrics Hospital, models and proposed Nho Quan district province, Yen funding. Mo district General Hospital, Yen Khanh distric General Hospital.

Phu Tho Provincial general 3. Phu Tho hospital, Ha Hoa distric General These will be detailed in hospital, Thanh Son, Đoan Hung the elaboration of and Cam Khe feasibility reports and project implementation report. 4. Yen Bai 5. Tuyen Quang 6. Bac Giang 7. Lang Son 8. Hoa Binh 9. Hai Duong 10. Hung Yen 11. Thai Binh 12. Ha Nam 13. Thai Nguyen

Due to short preparation period and there is no funding for project preparation, in the first year, the project will support for at least three provinces, including the following provinces: (i) Ninh Binh: Provincial General Hospital, Obstetrics and Pediatric Hospital , Nho Quan Hospital, Yen Mo, Yen Khanh, detailed in the province’s technology transfer and satellite hospital contruction plan (in the form attached) (ii) Nam Dinh: Provincial General Hospital, Nam Dinh Pediatric Hospital, Hospital

6 NORRED Project Ethnic Minority Development Plan of Obstetrics and 03 district hospitals: Y Yen, Giao Thuy and Xuan Truong. (iii) Phu Tho: Provincial Central Hospital and 04 district hospitals: Thanh Son, Ha Hoa, Doan Hung and Cam Khe. 13 provinces under NORRED project have a total area of 47,909 km2 (equivalent to 14.5% Vietnam area), population of 14.5 million (equal 17% national population). There are significant differences in the level of socio-economic development between the two regions. The average poverty rate in 2008 of the Red River Delta region was 8.6% while the Northeast’s is 21.5%. The health indicator of North Eeast region is lower than Red River Delta region and the national average. The infant mortality rate (IMR) under 1 year of age of the Northeast is 24.5 while the Red River Delta is 12.4 and the national average is 16 (Yearbook of Health Statistics 2009). Among provinces in the same area, there are also significant differences on health indicators. In the Northeast, IMR of Thai Nguyen was 14.8 while Tuyen Quang and Yen Bai were 32 and 28.7, respectively. The provinces and cities under the project are the ones with difficulties in terms of resources invested in developing health systems. Many provinces do not have the ability to mobilize local budget hence depend entirely on the central budget. Capital investment to strengthen the quality of health care facilities is very limited while demand is high. The budget balance between capital investment and administratives, between the budget system for treatment and preventative health encounters difficulties due to limited resources and do not have specific criteria for budget allocation for preventive medicine. State budget is often preferred for the provincial treatment facilities where focus many patient and the health care needs, and then to basic services including targeted programs and health facilities in districts and communes. Investment scheme for bond-funded hospital at district level of the Government (Decision 47/2008/QD-TTg) had a positive impact on improving the quality of health care at the district level, thus contributing to reduce patient has reached the line, causing overcrowding in medical facilities at provincial and central level. However, since the fund is limited, they only focused on investing in certain

7 NORRED Project Ethnic Minority Development Plan equipments and upgrading infrastructure in some hospitals, they haven’t resolved thoroughly the service quality issues at locality. As for provincial level, TB hospital, mentality, oncology, pediatrics and general hospital in these 2 regions have been invested by Government bond (QĐ 930/QĐ-TTg date 30/6/2009 of Prime Minister), however, after 2 years of implementation, only 25% of the needs were met, most of the works did not meet the deadline, and most of the funs was used for ground clearance and construction, they did not have the ability to invest in medical equipment. The provinces in the project do not receive much international aid. Besides projects funded by ODA, the majority of projects are funded by NGO, under the technical support category, not under the infrastructure and equipment support category. Regarding investment project, the most recent project is funded by JICA to Lang Son province to upgrade province’s general hospital equipment. Phu Tho and Ninh Binh are under investment project for the Provincial Hospital equipment by the Italian government loans. Bac Giang, Bac Ninh and Ha Nam are under consideration by the European Union (EU) for supporting equipment for CHS to help meet national standards NORRED project shall focus on the following main components:  Upgrading the basic equipment for the Provincial Hospital and a number of district hospitals in five groups of specialist priority: Obstetrics, Paediatrics, Oncology, Cardiology and Trauma to improve technical, quality health services, contributing to reduce the overload at the front level.  To encourage people, particularly the poor and other group tos participate in health insurance to be protected from the financial risks of illness, and increase the financial sustainability of the insurance fund Direct beneficiary group of the proposed project:

- The PPC will receive additional investment from the project for the local health care. The General Hospital, obstetrics and pediatrics hospital, cancer and oncology hospitals of the province, a number of district hospitals shall be

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invested in upgrading medical equipment, training and development of information technology, improving the quality of services.

- In addition, managers, health workers will be trained on the lines of knowledge and management skills, expertise. Health officials participating provincial PMU improved project management skills through short-term training and the implementation of the tasks assigned

- The poor are supported health insurance card, increase the rate of health insurance coverage to the beneficiary provinces by conditions whole families involved; some people with serious illness and high medical cost shall be provided with free medical assistance.

Project’s objectives:

1. Overall objective Support the implementation of national health strategies to improve access of the population in the project provinces to essential health care services in accordance with the national policy and strategy on health system development, especially against overload and universal health insurance policy. 2. Development objective: improve the supply of quality health services at provincial and district levels, and enhance access to this service of the people, especially the groups with difficult economic conditions in the North East and Red River Delta 3. Specific objectives: - Strengthening of the health service delivery system at provincial and district levels to improve the quality of services in five specialty groups: oncology, cardiology, obstetrics, pediatrics and trauma - Expand coverage of health insurance for the near-poor object - Improve management ability, direct routes, technical transfer of the Health Sector. Main output of the projects:

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Expected output of the project under each component: 1. Component 1: Investment support strengthening provincial hospitals, district in 5 priority specialty areas (oncology, obstetrics, pediatrics, cardiology, trauma): - Capacity perform tricks and technical expertise in accordance with the Ministry of Health (technical identifier in accordance with the technical distribution). - Number of patients with treatment related to five specialists at provincial hospitals, district increase. - Reduce patients with diseases related to 5 specialist referral, pass on the central line Support the Investment in capacity building support provincial hospitals, district 5 priority specialty areas (oncology, obstetrics, pediatrics, cardiology, trauma) - Capacity building for professional expertise in accordance with the Ministry of Health (under technical identifier in accordance with the technical distribution). - Number of patients with treatment related to five specialties at provincial hospitals, districts increase. - Reducing the number of patients with diseases related to 5 specialties on referral, transfer to the central line. Content: This component is expected to support the implementation of the scheme to reduce hospital overload through extended support deployment of new health services to provincial hospitals and district hospital with the support of specialized hospitals at central level. The support is made in the form of "integrated satellite hospitals", was developed based on a model of satellite hospital of the Ministry of Health, which has been effectively piloted with a number of specialists in recent years. This activity is consistent with the Satellite Hospital Development Model that the Ministry of Health Hospital has submitted to the Prime Minister for approval, contributing to reduce overcrowding in hospitals. This component will be implemented through the support package for the hospital medical equipment, including equipment used for remote medical consultation and treatment (telemedicine), short-term training, long-term training and training in team, to ensure that the receiving unit can pferform the identified services and techniques. In addition, this component can also provide technical assistance (consulting,

10 NORRED Project Ethnic Minority Development Plan training, study tours) to allow for the establishment of new service delivery models, such as the day-care hospital model. Investment site selection criteria:

1) Selection of medical technology transfer to suit epidemiological model: mortality rate and disability related disease, can be basicly treated at the provincial level (based on the current technical distribution -Circular 23/2005/QD-BYT date 30/8/2005 by the Ministry of Health): essential obstetric care; Newborn; Trauma, Pediatric, Screening of cancer (breast, cervical, lung, stomach, colorectal); Anesthesiology and emergency. The invested equipment must be included in the list of essential health equipment issued by the Ministry of Health. 2) Infrastructure is eligible to receive investment support of the project (the project does not support basic construction investment) 3) Supported by leading central hospital and sign the contract of responsibility 4) Suitable population and resident structure 5) There is limited capacity to implement the techniques within their route scope: inability to perform, weakness in performance, high referral rate 6) Can select at least three district hospitals which will act as satellites for provincial hospitals with criteria: distance from the center, appropriate infrastructure conditions and personnel to receive technology transfer.

2. Component 2: Health insurance - Increase coverage of health insurance, especially in the near-poor: 95% of poor health insurance card; - Raise awareness and understanding of people on health insurance in general and the poor in particular, raise the level of use of health services by the poor and near- poor to 5 specialty areas at the provincial and district level

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-Reduce the rate of-pocket spending on health of the people. - Reduce the rate of health expenditures of a catastrophic nature (severe, prolonged, costly) of the people. To support the implementation of the scheme towards universal health insurance, applying the approach of the previous successful project, and directly assisting to reduce the cost of health care in the people in project area, NORRED project will focus on supporting health insurance coverage expansion in the following activities: - Supports more than 20% of the face value of health insurance card for thenear- poor (the state budget shall support 70% and the people pay 10%) provided that the whole families are involved. In the case only individual members of the household participate, they will not be supported. - Support commision campaign to increase incentive to sell health insurance of agents (about 2% of the face value of the card). This activity has been carried out effectively in the North Central Health Support project. - Support directly the cost of treatment for patients with difficult economic circumstances for the high-cost diseases, major technique. - Support to raise awareness about health insurance (benefits, responsibilities, and procedures) of people through information, education and communication. Ministry of Finance commented that supporting the poor access to health insurance within the scope of the project should closely follow the current regulations and directions of the Government, to ensure consistency of the Government. According to the new draft policy that the Ministry of Finance has submitted to the Prime Minister, the budget only supports 100% for the near poor in the districts under the Government's Resolution 30A and the near- poor who just escaped poverty with a support period up to 1-5 years after poverty. But in fact the implementation of health insurance policies for the poor to this point has not been 5 years, most of the near poor are poor people who just escaped out of poverty, therefore eligible for assistance. Besides, this will require a system and process to verify / track the status of the poor and near-poor households but the construction of the system and the process takes time. Therefore, the Ministry of Health recommended the Ministry of Planning and Investment submit to the Prime Minister to approve the loan and assign

12 NORRED Project Ethnic Minority Development Plan to the Ministry of Health and the Ministry of Finance, these two bodies will come to an agreement after the policy is issued and in the case of the state budget is able to support allocate Government's budget, funding for this component of the project can be reallocated or canceled. 3.Component 3: Technical assistance, capacity building for projects management and operation ($ 6 million ODA fund) Content: Activities of this component is to ensure that the project organization structure and activities are appropriate, have sufficient financial resources, facilities and human resources to implement, monitor, and evaluate project, to meet the requirements of the Government and the donors. Management structure of the project will be designed to reduce the cumbersome organizational structure for project management. Due to the nature of the project being investment and developing training activities, monitoring, technology transfer, the establishment of a provincial project management units is essential.Once selected, at each phase, the participating units will be trained on the process for funding and reporting regime to use aid. At the central level, a lightweight project management unit will be founded by the Minister of Health with the task of coordinating all activities of the project from planning, implementation of activities, monitoring and evaluation and the activities of the central hospital support sub-component (due to diiferrent mechanisms for implementation of the local hospital). The structure will be described in detail in the project management model Guide. The main activities of Component 3 include: - The activities for preparation, construction of feasibility report, preparation of effective conditions (Manual of implementation ...) of the project. - Support for program development, education and training, technology transfer; - Support training and teaching facilities, consultation, remote monitoring for a number of central hospitals; - Support Central hospital in supervision and technical guidance; - Capacity building for project management (domestic training and abroad). - Capacity building for results assessment, results-based financing.

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- The annual and mid-term, final term review conference workshop - The technical consultant - A number of contract employees working for the project. - Essential Office equipment - Vehicles for Working: 02 units (due to the area of large projects, the mountainous province of Yen Bai, Tuyen Quang and Hoa Binh, Lang Son and technical assistance activities, large support deployments); - Monitoring - Inspection and monitoring of the technical system invested - Auditing (internal and independent). - Finalization of the project 1.2. The objectives of the ethnic minority development plan 1. The objective of ethnic minority development plan is to implement equitable policies in health care for ethnic minorities, those who have no or little financial conditions for access to and use of health services. Therefore, a number of project activities contribute to and facilitate more for ethnic minority beneficiaries of the project. Ethnic minority development policy of the project is set up with a specific plan based on cultural features, traditions and the factors that limit access to health services of minorities in order to determine project activities to minimize barriers to health care needs of ethnic minorities. 2. Ethnic minority’s development plan reports (EMDPs) are prepared based on policies for local people of the World Bank. The World Bank has a specific policy for local people/ethnic minorities (OP4.10; 7.2005). The Bank calls for investment projects for ethnic minorities and fully implements preferential rights for those who are ethnic minorities that are affected by the project, limiting negative impacts on local people and strengthen activities to benefit and preserve the value of their traditional culture. World Bank requires people to provide complete information and freedom to join the project and the project must be largely agreed by ethnic minorities affected by the project. The project is designed to ensure that ethnic minorities enjoy the socio-economic benefits in accordance with the cultural identity, including gender issues and multi-generational attributes.

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1.3. The scope and methods of ethnic minority development plan

- To review and determine the index and prepare ethnic minority development plan from NORED Project documents; assess the need and the benefits enjoyed by ethnic minorities in the project design. - To identify and respond to the opinions of the project stakeholders during project construction to support ethnic minorities have greater access to the services of the project.

- Collect the necessary information for project design with possible resources from the national data, the project provinces. - To field-investigate provinces in the project area to collect data base and understandings of the financial institutions, implementation of safety policies at the local level. Use research tools such as: + In-depth interview: to gather qualitative information, subjects of in-depth interviews are: managers, health workers in some health care facilities, government at all levels of districts, provinces, people performing health care services and other services related to ethnic minorities. + Group discussion: Medical staff performing health care services, management team and ethnic minorities. + Method of participant observation: on the field survey of the provincial and district hospitals, observe the status of equipment and clinical practice in a number of provincial hospitals, district hospitals in the project scope.

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2.1 Vietnamese Legal and Policy Framework Since 1998, the Government of Vietnam has issued the Decision No. 135/1998/QD- TTg approving the Program for Socio-Economic Development in Communes Facing Extremely Difficult in Ethnic Minority and Mountainous Areas. According to the Decision, the whole population living in extremely difficult communes in mountainous and remote areas is eligible to benefit from health care services. The Resolution of Party Congress IX (April 2001) states the direction for infrastructure development in the health sector by 2010 as “Completion of planning, strengthening and upgrading sub-national health care network; upgrades of provincial and district hospitals; development of inter-district general hospitals in distant places from the province center; upgrades of the two advanced medical centers in Hanoi and Ho Chi Minh City and establishment of an advanced medical center in the Central as well as development of regional medical centers; steady modernization of medical equipment and application of state-of-the-art scientific and technological achievements”. On Feb. 23, 2005, The Politburo adopted Resolution No. 46-NQ/TW on “protection, nurture and upgrade of the people’s health in the new context”. The Resolution stressed the need for further development and polishing of the public health care system, including (1) continued development and refinement of the preventive health system; and (2) consolidation and refinement of the sub-national health network in terms of physical infrastructure, facilities and human resources. It also emphasized the need to build and upgrade hospitals, particularly provincial and district general hospitals to be able to meet the essential health care need of the local community. To be specific, by 2010, robust investment will be needed to create a breakthrough in upgrading health services, with preference to district and provincial general hospitals. Meanwhile, the medical workforce will need to be streamlined not only in number but quality and structure and training of health workers will be stepped up by means of on-the-job recruitment for the uplands and Mekong River Delta.

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Directive 06 – CT/TW, dated Jan. 22, 2002 of the Central Party Executive Committee on “consolidating and polishing the sub-national health network” clearly defined the role of community-based health care and the leadership and direction responsibilities of various Party and authority levels as well as stressed the need for sensible investment policies to strengthen and streamline the sub-national health network. Decision No. 35/2001/QD-TTg, dated Mar. 19, 2001 defining the Strategy for public health care and protection, 2001 – 2010, set the targets of “increasing quality of care at all levels of the health care system in terms of preventive care, curative care, rehabilitation and improvement of health status; application of technological advancements for the domestic health sector to keep up with more developed countries in the region...” and elaborated the solutions as “investment for consistent upgrades of the curative care system relevant to the needs of each region and local socio-economic capacity … steady modernization clinical imaging capacity, biochemical and biophysical diagnosing, immunization, genetics and molecular biology; application of advanced technologies in cardiovascular treatment, endosurgery, orthopedics, microsurgery, organ replacement and transplant … development of some standardized laboratories for food safety testing and quality control … and development of three advanced medical centers in the North, Central and South”. Decision No. 51/2004/QD-TTg, dated Mar. 31, 2004 on the Government’s Action plan in implementing the Resolution of the 9th Congress of the Party Executive Committee IX stated: “The Ministry of Health shall cooperate with related ministries, agencies and local governments to devise plans and recommendations for capital investment, renovation, upgrades for enhancement of the sub-national health network. Provincial and inter-district general hospitals shall be upgraded to be able to offer quality local health services in order to provide over time a radical solution to overloads in central and large municipal hospitals”. Concurrently, the Prime Minister also authorized the Ministry of Health, Ministry of Finance and Ministry of Planning and Investment to draft plans for mobilization of resources and capital to this end.

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Considering the vital role of regional socio-economic development strategy, the Prime Minister issued Decision No. 184/2004/QD-TTg, dated Aug. 13, 2004, providing the primary direction for socio-economic development of the Central economic hub by 2010 and vision by 2020. In this Decision, upgrade of local health systems is identified as an important task and solution to achieve the set socio- economic targets, therein it is specified that health programs need to be effectively rolled out in combination with strengthening of facilities and health human resources for various levels, particularly in respect of health protection and care. On June 30, 2006, the Prime Minister unleashed Decision No. 153/2006/QD-TTg, in approval of the Master plan for development of the health care system in Vietnam by 2010 and vision by 2020. The master plan identifies direction for investment, restructuring of the curative care and rehabilitation network with emphasis on strengthening and refinement of the sub-national health care network and increase of access to essential health services. It also addresses the establishment of the curative care network by level of care in a bottom-up approach to ensure the continuity of clinical capacity. District hospitals and inter-district general hospitals are responsible to provide primary health services and take patients from the local community or community-based health centers while inter-commune general clinics affiliated to district hospitals in uplands and remote areas need to be maintained and developed to ensure provision of primary health services to the local communities. In its Resolution No. 18/2008/QH12 of the National Assembly on accelerating enforcement of socialization policies and legislations in improving the quality of health services, the National Assembly endorsed increase of annual budget expenditure for health care and maintain a higher pace of spending on health care than the overall average hike in state budget spending, as at least 30% of the health expenditure will be earmarked for preventive health. More funding will also be set aside for health care services for meritorious citizens, the poor, farmers, ethnic group members and dwellers in areas of socio-economic hardship and extreme hardship. For the near – poor, the Ministry of Labour, Invalids and Social Affairs has issues the Circular No. 25/2008/TT-BLD TBXB dated on 21/10/2008 guides the process to determine near –poor households according to the regulation at Item 4, Article 1,

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Decision No.117/2008/QD-TTg dated on 27/8/2008 by Prime Minister. Base on this Circular, locally authorities carry out to check near – poor households to prepare the priority policy for the near – poor. On 24 Sep 2008, Ministry of Finance and the Ministry of Health issued Circular No. 10/2008/TTLT- BYT-BTC guiding the implementation of health insurance for near- poor HHs which regulated health insurance premiums equivalent to 3% of the minimum wage, including the state budget at least 50% of health insurance, the rest to be paid by the poor households. Joint Circular between the Ministry of Finance and the Ministry of Health No 09/2009/TTLT-BTC-BYT dated 14 August 2009 provided guidance on health insurance implementation. In particular, in Clause 20, Article 1 regulates that the near-poor under the provisions of the Government shall be entitled to incentives to participate in health insurance. On 26 June 2012, Prime Minister issued Decision No. 797/QD-TTg on raising the level of support for health insurance of people in the near-poor HHs. According to this decision, the state budget supports at least 70% of health insurance premiums for people in near-poor households under the national poverty line since 01 Jan 2012; Funding support is from the central budget (70% of face value of health insurance card) for the provinces that are not able to balance their budgets; 35% of face value of health insurance cards for the people in the near- poor households in the local where regulation rate on the central budget revenues is below 50%. The remaining provinces allocated from local budgets. Currently, the Strategy for Protection, care and improvement of people's health in the 2011-2020 period, towards 2030 and the master plan to develop health systems up to 2020 and vision to 2030 is being submitted by Ministry of Health to the Prime Minister for approval, which identified priority health sector management innovation, increase investment in health facilities, improve service quality, reduce the load for front level.

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2.2 Policy of the World Bank The Social Safeguard policies of the WB is issued to ensure that all projects are invested by WB will not destroy environment or social where the project implementing. In these polices, the process of project implementation and preparation make sure to mimimum or avoid risks (if have) by project to the life and development in area of project. In social assessment, it is necessary to consider some issues are following: Cultural properties policy: The World Bank's general policy regarding cultural properties is to assist in their preservation, and to seek to avoid their elimination. Specifically: The Bank will assist in the protection and enhancement of cultural properties encountered in Bank-financed projects, rather than leaving that protection to chance. In some cases, the project is best relocated in order that sites and structures can be preserved, studied, and restored intact in situ. In other cases, structures can be relocated, preserved, studied, and restored on alternate sites. Often, scientific study, selective salvage, and museum preservation before destruction is all that is necessary. Indigenous peoples Policy: The WB's broad objective towards indigenous people. Specifically, the objective at the center of this directive is to ensure that indigenous peoples do not suffer adverse effects during the development process, particularly from Bank-financed projects, and that they receive culturally compatible social and economic benefits. How to approach indigenous peoples affected by development projects is a controversial issue. Debate is often phrased as a choice between two opposed positions. The other pole argues that indigenous people must be acculturated to dominant society values and economic activities so that they can participate in national development. Here the benefits can include improved social and economic opportunities, but the cost is often the gradual loss of cultural differences. The Bank's policy is that the strategy for addressing the issues pertaining to indigenous peoples must be based on the informed participation of the indigenous people themselves. Thus, identifying local preferences through direct consultation, incorporation of indigenous knowledge into project approaches, and appropriate early use of

20 NORRED Project Ethnic Minority Development Plan experienced specialists are core activities for any project that affects indigenous peoples and their rights to natural and economic resources. 2.3. Consistency between the objectives of the project with the policies and priorities of donors The World Bank (WB) for many years has engaged with the goal of reducing poverty in the Asia-Pacific region through support sustainable economic development, social development. Project NORRED is completely in line with the national partnership strategy (CPS) for the period of 2007- 2011 between the World Bank and the Vietnamese Government. 2nd pillar of the CPS emphasizes the importance of "strengthening social integration" in order to ensure sustainable growth with the strategic support of the poor and near-poor approach to quality education and health services. In this strategy, the CPS pays special attention to the areas of: Demand side effects, improving access to quality health services through expanded coverage of health insurance to the poor, near-poor, minorities and improve the quality of services in health facilities. Project NORRED will contribute to improve access to services sector and to meet the health care needs of vulnerable groups: the poor, the near-poor, ethnic minorities, mothers and children.

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3.1. Socio-Economic features of ethnic minorities in project area In the project area, the ethnic minorities reside mainly in the north-eastern provinces. Particularly, Ninh Binh province is located in the northern plains, but there is a part of Cuc Phuong National Park area and the area of residence of the Muong (adjacent to Hoa Binh province). The Tay, Nung, Muong, Dao are the most populous ethnics and account for the majority in the provinces of Yen Bai, Hoa Binh, Lang Son, Yen Bai. Table 2: Distribution of ethnic in project provinces Unit: Person Tuyên Hoà Thái Lạng Bắc Ninh Quang Yên Bái Bình Nguyên Sơn Giang Phú Thọ Bình Total 724,821 740,397 785,217 1,123,116 732,515 1,554,131 1,316,389 898,999 1. Kinh 334,989 342,880 207,557 821,077 124,433 1,356,011 1,108,991 875,579 2. Tày 185,464 135,314 23,089 123,197 259,532 39,939 3,526 354 3. Thái 348 53,104 31,386 928 116 454 657 172 4.Mường 725 14,619 501,956 1,687 319 461 184,141 22,614 5.Hoa(Hán) 5,982 597 156 2,064 2,147 18,539 231 - 6.Nùng 14,214 14,821 207 63,816 314,295 76,354 1,067 - 7.Hmông 16,974 81,921 5,296 7,230 1,224 325 866 - 8.Dao 90,618 83,888 15,233 25,360 25,666 8,751 12,986 - 9.Sán Chay 61,343 8,461 43 32,483 4,384 25,821 3,294 - 10.Sán Dìu 12,565 2 42 44,134 213 27,283 - - Source: General Department of Statistic, General Population and Housing Survey 1 April 2009

3.1.1. Tay ethnic - Place of residence: The Tay are the main residents in the Northeast. The Tay are presented in most of the provinces in the Northeast, taking the high proportion of the population in the provinces: Lang Son (35.38% of the province's population), Tuyen Quang (25.55%), Yen Bai (18, 24%), Thai Nguyen (10.95%). Area of residence of the Tay concentrated in the rice fields in between the hills and mountains. - Method of production and economic life: the traditional economy of the Tay is terrace and upland cultivation ... Main crops are rice, cassava, maize and some

22 NORRED Project Ethnic Minority Development Plan vegetables. The Tay since their early days, have resided stably and ensured food security in life. - Community Relations: Villages of Tay people are often collective with many families. Each Tay village has typically from tens to hundreds of households. Tay people usually reside along the main roads. However, due to living in areas where the terrain is fragmented, traffic of the Tay encounters many difficulties. - Marriage and Family: The marriage of the Tay are open, boys and girls are free to date. Tay families are under patriarchy, men have the right to decide in the family, but the discussion also involves the woman's opinion. Living in the family of the Tay has many similarities with the Thai people. - Languages and writting: Tay language belongs to the South Asia language group (language group Tay - Thai). Due to the relatively large population in the Northeast and residing in low areas along the major roads, the Tay has easier access to Viet language than other ethnic groups. Most Tay women and children can speak and communicate fluently in national language. - Education: The education level of the Tay is the highest among ethnic minorities in Vietnam. By residing in low-lying regions, there is tradition in education in the community; Tay children soon developed academic sense. Illiteracy rate is low and children go to school at the right age. 3.1.2. Hmong ethnic - Place of residence: In the project area, the Hmong reside quite concentrated in Mu Cang Chai, Tram Tau (95% of the district population) of Yen Bai province; Yen Son (7074) by Tuyen Quang; Dong Hy district (3400), Vo Chew (3700) in Thai Nguyen; Mai Chau (7500) in Hoa Binh province. Area of residence is mainly highland, which is deep, and extremely difficult. Most of the Hmong villages are located away from roads and there is no road for cars, so transportation is mostly rudimentary, by walking and other basic means.

-The method of production and economic life: Main economic activities of the Hmong in the Northeast is now shifting cultivation on slopes. Crops are mainly corn and rice varieties, only 1 crop/year so the life of the people is very difficult. People have low income and rely on unstable natural climate conditions.

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- Community Relations: Each Hmong village usually contains only a dozen of roofs and scattered on the mountain slopes. In public relations, the Hmong have close relationships among clan, family and villagers. Each clan, Hmong families often have relationships with each other through worshipping, mutual financial and mental support. The Hmong live in not-so-solidly-built houses with grass roof and covered with wood panels. Their houses are low, humid and lack of light. - Marriage and Family: In a marriage relationship, the Hmong preferred the form of internal marriage among the ethnic group. Only in a few cases the Hmong married to other ethnic. In the family, the man has the right to decide in all activities; especially the diplomatic relations with the community and society, the woman is in charge of housework and family expenditure management. So far the status of early/child marriage still is pretty common in the Hmong people, especially for those communes in remote areas. - Spoken and written language: Language of the Hmong belongs to Sino - Tibetan language. Currently Hmong language is Latin transcribed and used widely in the community. Hmong language is used mainly in the community. Most women do not know how to use common language; this is the major obstacle for Hmong women in the access to social services in general and modern health care in particular. - Education: Since residing in the high, remote area, education level of the Hmong is generally very low. Due to limited communication and strenuous working conditions, children do not go to school, the vast majority of Hmong women and girls are illiterate. Children do not go to school at the right age and leave school early. There are very few children in middle school and high school. 3.1.3. Nung ethnic - Place of residence: Nung people account for a high percentage of population in the Northeast. Nung residents concentrated in the provinces: Lang Son (35.38% of the province's population), Tuyen Quang (25.55%), Yen Bai (18.24%), Thai Nguyen (10.95%). Area of residence of the Nung concentrated in the rice fields in between the hills and mountains. - Method of production and economic life: Nung's traditional economy is rice cultivation. Main crops are rice, cassava, maize and some vegetables.

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- Community Relations: The Nung usually reside in the large village, from a few dozen to a few hundred households. Community relations are close and intimate; community members have close ties between families, clans and villages. - Marriage and family: The Nung preserved many traditions in marriage. There are many wedding rituals imbued with cultural features of the ethnic groups. Previously, the Nung’s common practice is child marriage, in recent years this has changed a lot. In families, there is equality between men and women. - Languages spoken and written: Nung language is close to the Tay language which belongs to the Tay-Thai. Due to the low-land residence, most of the Nung people are able to communicate fluently in national language. Nung language is still widely used in village communities. - Education: The Nung are very interested in their children's learning. However, due to the economic conditions of poor households, a part of them could not finish school program. In recent years, the percentage of Nung children going to school is ascending, they are well aware of learning and going to school at the right age.

3.1.4. Thai ethnic - Place of residence: Thai northeastern residents concentrate in the province of Yen Bai, Hoa Binh and scattered in several provinces. Area of residence is rather condensed in the valley with vast rice fields in Van Chan district (Yen Bai) and Mai Chau (Hoa Binh province). - Method of production and economic life: Thais traditional economy is shifting cultivation on terraces ... Main crops are rice, cassava, maize and some vegetables. Food security is ensured in the life of the Thai people due to rice cultivation. - Comunity relations: Thai villages are concentrated in the valley area, near major rivers, streams and areas where there is agricultural land. Each Thai village often has hundreds of families residing in the family clan and large extended family. However, most of the villages of Thai people are usually far away from medical facilities as residence area stretches along the river bank and mountains. Transportation is very difficult. - Marriage and family: Marital relations of Thais are relatively free, there is no pressure to marry in marriage. Thai family is patriarchy, men have the right to decide

25 NORRED Project Ethnic Minority Development Plan in the family, but the discussion also involves the woman's opinion. In every Thai family there are often many couples living in stilt houses, every couple has a separate sleeping space and is arranged in order from the oldest to the youngest daughter. - Languages spoken and written: Thai language belongs to South Asia language group. So, Thais has easier access to Viet language than people who speak Sino- Tibetan languages and Mon-Khmer. Thai ancient writing has been circulated for a long time, however, the current written language of the Thai people have been Latin and widely used in the community. The majority of Thai women and children can speak and communicate fluently in Viet national language. - Education: Since they stay in the valley, there are roads and favorable economic conditions for family stability, education of the Thais is relatively even. Illiteracy rate is low and the children go to school at the right age. 3.1.5. Mương ethnic - Residence area: Muong residents are rather concentrated in Hoa Binh province (accounting for 63.8% of the population of the province) and Phu Tho provinces (accounting for 13.9% of the population of the province and focus in Thanh Son District). A part of Muong people reside in the buffer zone and the core zone of Cuc Phuong National Park in Ninh Binh province. Area of residence of the Muong people is in low area with many water fields. Economic conditions in the Muong are more favorable than other ethnic groups residing in the area. - Method of production and economic life: Due to residing in the low land area, the production of the Muong is quite stable. In addition to 2-crop-paddy rice cultivation, Muong people in Hoa Binh and Ninh Binh also grow many crops such as sugar cane, bamboo, peanuts, ... However, the income of the households is at average only and there are not many rich households. - Community Relations: The village of Muong concentrated mainly in the midlands and a small proportion resides in the mountain. Each village of the Muong has from one to several hundred households. In the community, family and clan relationship is very close, creating an effective network of community assistance. The members of the family, the clan often help each other for food, work and visit and encourage each other when sick or at risk. - Marriage and family: The concept of marriage of the Muong are not bound by traditions, boys and girls are free to date and choose who to marry. Muong family is patriarchy but the division of labor in the family is relatively equal between husband

26 NORRED Project Ethnic Minority Development Plan and wife. Previously Muong people live in stilt houses, they recently moved to live in level-4 houses or ones that are built solidly. - Language and writing: The Muong language is very close to Vietnamese, although Muong people do not have their own writing but they have fairly easy access to national language. Almost all Muong can use fluently the native and national language, there are no obstacles in life and communication of the Muong. - Education: With the advantages of terrain, traffic infrastructure conditions and quite set in the low-land residence, the Muong have more favorable conditions when access to educational services and other social services. The percentage of children going to school at the right age is high, very few people are illiterate.

3.1.6. San Chay ethnic - Place of residence: San Chay residents concentrated in the province of Tuyen Quang (61,343 person-accounting for 8.42% of the province's population), Thai Nguyen (32,483 people) Bac Giang (25,821 people) and a few scattered in the province of Yen Bai, Phu Tho and Lang Son. Area of residence of the San Chay is in low coastal hills and midlands. The San Chay has two groups: Group Cao Lan- residents concentrate in Yen Son and Son Duong district, Tuyen Quang Province, Luc Ngan Son, Luc Nam (Bac Giang), San Chi group focus in district of Bac Giang, Thai Nguyen. - Method of production and economic life: The main economic activities of San Chay households is farming on 2-crop field. People's lives and stable food supply is ensured in place. In Bac Giang province, the San Chay also plant many fruit trees such as longan, litchi, ... provide a stable source of income for the family. - Public Relations: Villages of the the San Chay residence are quite close to each other. In Tuyen Quang, there are many big villages of Cao Lan group. Community relations retain many traditional features, emotional intimacy and attachment between family members, family and community. Supportive relationships in the community are maintained and become a social support network, which is very efficient especially when there are crop failures, floods or the risk of illness. - Marriage and Family: The San Chay have open marriages and relationships based on the concept of love. Boys and girls are free to date and choose mates. San Chay family is patriarchy but relatively equal between men and women. Previously the San Chay live in stilt houses, in recent years, due to economic growth and

27 NORRED Project Ethnic Minority Development Plan urbanization, the majority of households the San Chay turned to permanent or land houses. - Language and writing: San Chay Ethnic has two groups: Cao Lan with Tay - Thai language and San Chi group with Chinese language. Due to the low residence area, San Chay people can speak Viet national language fluently. - Education: The educational level of the San Chay is fairly even in the community and achieves fairly good level in the ethnic community in Vietnam. 3.1.7. Dao ethnic - Place of residence: Dao ethnic has 7 local groups, residing scattered in the northern mountainous provinces. In the Northeast, there are many Dao residents, especially in the province of Tuyen Quang, Yen Bai, Lang Son. In Tuyen Quang province, the presence of 7 Dao groups accounts for 12.5% of the population of the province, Yen Bai province with 11.2% of the population being Dao. In Lang Son province, there are several groups of Dao residents such as Dao Thanh Phan, Lo Gang, ... The Dao reside on the high mountains, their villages scatter. Each village has from a few to several dozen rooftops. In some area, the distance between the houses is very long; sometimes every house is on a mountainside. - Method of production and economic life: farming method of the Dao is mainly shifting cultivation. Upland farming did not bring high economic efficiency, which pushed a lot of Dao households into the food shortage situation. In recent years, with the support of the state, the Dao have extended terraces cultivation area, rice cultivation, which has brought clear economic efficiency. Households’ economy is stable and the rate of poverty is reduced over the years. - Public Relations: The Dao have a tradition of community cohesion. Members of the community are always in the spirit of sharing, helping each other. Villages of the Dao in the Northeast are usually in the high land and middle slopes so the coherence relations are not as close as in the villages of minority residents in the valley. - Marriage and Family: The Dao has early marriage practices, with the highest rates of child marriage, especially in the remote communes. In the Dao family, retains many traditional customs and practices as Thanh Dinh (grown-up rituals for sons), Awarding ceremony (rise) to the shaman, in the funeral ceremonies, weddings, ... - Languages spoken and writting: Dao language belongs to the Chinese. In the Dao community, people keep communication primarily in Dao languge and Nom Dao writing. Nom Dao is used primarily in the paper at rituals, date of birth or the family

28 NORRED Project Ethnic Minority Development Plan and clan's genealogy. However, Dao women and children have good ability to use common language so it is quite favorable when communicating with other people in the area. - Education: The Dao’s education level is fairly even. Dao children are eager to learn and have good academic tradition. However, due to economic conditions, family difficulties, there is still a part of the Dao children with no full access to education, especially higher levels of education and professional level, University level. 3.1.8. San Diu ethnic -Place of residence: San Diu residents scattered in several provinces in the Northeast, most concentrated in the provinces: Thai Nguyen, Tuyen Quang, Phu Tho, Bac Giang, ... San Diu residents are rather collective in the villages at the foot of high mountains. - The method of production and economic life: Economic activities of the San Diu are mainly the cultivation of fields and farms. Main crops are rice, maize, cassava and other crops, vegetables... In many places, San Diu people also planted fruit trees, providing a significant source of income for households. - Community Relations: San Diu people reside collectively, hence there is a very close relationship among village community. Family and clan relationships are always strengthened and maintained. Mutual assistance between the members of the community are maintained and developed. - Marriage and Family: Marriage of the San Diu is quite modern and has many variables. The traditional ceremony of marriage is now no longer reserved; much affected by a lot of modern elements and urbanization. San Diu family is patriarchy, they reside in husband's side but not too strict in gender discrimination. - Language and writing: The San Diu has their own language. Writing is based on Chinese characters. Currently, most of the San Diu use common language in the community and communicate with the outside. Traditional language is only used in the home or while conducting the ritual traditions. - Education: The education level of the San Diu is high and even for all subjects in the community. Most children go to school. Very few people are illiterate or do not go to school.

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3.2. Health care current status in the project area Although there have been quite a lot of attentions of the Government by the State budget, the health care situation of the people in the project faced many difficulties. In addition to the difficulties in socio-economic conditions, infrastructure and medical equipment are also challenges given the growing healthcare needs of the people.

Health care system is being strengthened at unit level. Health facilities were basicly invested in. However, in practice, the need for training and retraining of health workers are emerging. According to statistics, the current ratio of villages with health workers only reached 89.80%. In particular, the Red River delta’s is lower than the national rate (88.52%). Especially in some localities such as Yen Bai province, on average there is only 0.66 doctors / 10,000 people, much lower compared to other provinces in the region. Northeast provinces are the regions with a high number of communes where health stations have not been built solidly such as Tuyen Quang (6.06%), Thai Nguyen (4.17%),Yen Bai (3.77%). Table 3 : Health system status of provinces with ethnic minoroties residing in project area No of Commune Number No of communes No of comunes with of communes with with health Information health doctors/ with prívate stations not station 10.000 health health solidly built (%) (%) ppl staff (%) facilities (%) Nationwide 99,34 1,8 0,97 89,80 36,90 Ninh Bình 0,80 0,98 Tuyên Quang 6,06 1,13 Yên Bái 3,77 0,66 Thái Nguyên 4,17 2,07 Lạng Sơn 0,97 2,17 Bắc Giang 0,49 1,35 Phú Thọ 0,40 1,71 Hoà Bình 1,08 Source: General Department of Statistic, General Rural Survey, 2007

For the northeastern provinces, the health infrastructure has not been invested in. Some provinces such as Lang Son, Bac Giang, Tuyen Quang, Yen Bai hardly get the support of international organizations on the health infrastructure. Most of general

30 NORRED Project Ethnic Minority Development Plan hospitals, regional hospitals are built by the local budget and the central budget, while the budget is very limited.

On the clinical situation, according to the survey data of the General Statistics Office in 2010, the proportion of people seeking medical treatment in the past 12 months tended to increase in both regions and income groups. In Northeast region, where there are high rates in the population being ethnic minority, patient rate increased faster than the national rate and the Red River Delta. Compared with 2008, in 2010, in the North East, the proportion of patients seeking health care is increased by 7 percentages, on par with the South Central Coast and these are the two areas with the fastest growing rate of patients between these two investigations. With preferential policy which excempts treatment charge to the poor and ethnic minorities, the number of poor people health insurance cards tend to increase, especially in mountainous and ethnic minority and rural areas. For the Northeast region, the percentage of poor households using health insurance cards in health care tends to increase rapidly. Regarding the disease status, in the Northeast region, the proportion of patients with diseases with inpatient treatment, long-term therapy tends to increase. Regarding trauma patients, in some provinces of Ninh Binh, Hoa Binh, Phu Tho, the proportion of patients increased according to the statistics in 2006 and 2008. Table 4: Percentage of persons suffered from illness or injuries by region, age group and ethnicity of household head Unit: % 2006 2008 Of which: Of which: In the In the past Stay in bed and In the past In the past Stay in bed and past 12 months need some one to 4 weeks 12 months need some one to 4 weeks take care of take care of Nationwide 18.0 49.1 10.5 16.3 51.6 10.1 Ninh Bình 19.6 48.2 11.5 20.2 59.1 13.3 Tuyên Quang 26.2 47.4 11.9 25.2 47.2 13.2 Yên Bái 25.1 54.0 10.3 20.7 51.8 11.3 Thái Nguyên 23.4 51.0 12.3 15.5 43.4 9.1 Lạng Sơn 16.0 36.0 9.1 14.9 32.1 6.4 Bắc Giang 11.2 30.2 7.5 10.6 40.0 9.6 Phú Thọ 18.2 40.1 9.9 15.0 42.6 11.3 Hoà Bình 23.9 50.5 14.3 20.7 52.1 12.1

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Kinh 18.0 50.0 10.3 16.6 53.1 9.9 Tày 18.5 41.4 8.8 16.4 41.2 11.0 Thái 14.2 33.2 11.8 10.7 34.4 9.7 Mường 22.1 43.5 14.3 16.2 44.2 13.9 Nùng 18.7 41.2 11.5 14.5 37.6 10.4 Hmông 10.2 31.1 12.1 7.1 25.9 7.4 Dao 11.0 34.7 6.8 13.7 50.0 9.3 Source: General Department of Statistic, Household Living Standards Survey, 2010

According to the results of the Household Living Standards Survey 2008, usually when in sickness, minorities often go for a check-up, take drugs and apply home self- treatment. Most of the Hmong and Dao selected outpatient medical care. According to survey data, there are 80.2 of the Dao and 77.5 of the Hmong ethnic chose outpatient options at CHS, only 7.9% the Dao and 12.3% Hmong chose outpatient examination in the State hospitals. The main reason is due to the long distance from home to the state hospital, people preferred health care close to home. Meanwhile, the percentage of people selecting outpatient at state hospital of the Muong is 27% and the Nung is 26%. These results clearly reflect the influence of geographical distance and ethnic traditions to choose health care place of ethnic minority people in the Northeast in particular, the northern mountainous region in general. Table 5: Rate of inpatients base don health centre classification and ethnic minorties in 2008 Unit: % Regional Private Overal State Ethnic Information CHS health health Others l hospital doctor clinic centre Nationwide 100 83,2 6,9 3,8 5,4 0,2 0,5 Northest region 100 80,8 11,0 4,7 2,2 1,0 0,4 Red river delta area 100 88,5 5,0 4,4 1,7 0,1 0,3 Kinh 100.0 85.9 7,4 3,6 2,3 0,2 0,7 Tày 100.0 81.7 10,8 5,5 1,6 0,1 0,5 Thái 100.0 73.8 13,1 12,5 0,4 - 0,2 Mường 100.0 72.0 22,5 3,4 1,8 - 0,2 Nùng 100.0 79.3 14,0 6,0 0,3 - 0,4 Hmông 100.0 53.5 43,1 2,8 - 0,6 - Dao 100.0 62.0 17,2 20,8 - - - Source: General Department of Statistic, Household Living Standards Survey, 2010

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For inpatient medical care, ethnic minorities choose more state hospitals with better health conditions. However, there are differences between some ethnic groups. Lowland ethnic residents (Tay, Nung, Muong)’s rate to inpatient medical care in state hospitals is much higher than with the people residing in the uplands such as Hmong, Dao. For the highland provinces of Yen Bai, Tuyen Quang, the proportion of health care options in the state hospital was 62% and 75%. Some provinces have high proportion of patients choosing health care at the state hospital in the Northeast such as Thai Nguyen(87%), Phu Tho (88%), Bac Giang (87%) . According to the survey results in 2008 of the General Department of Statistics, for the Red River Delta, the proportion of people selecting inpatient medical care in state hospitals is very high (the rate for the region is 90%, the highest is Hung Yen province -97%, the lowest is Ha Nam province with 76%). Proportion of people who choose medical inpatients in CHS is very low, only 6.5%. Ha Nam province has the highest rate of 13%. In Ninh Binh, only 7.3% of health care options are at CHS. In the situation that health workers at unit level have not been trained, the average ratio of doctors per 10,000 populations is too low, the selection of health care in large hospitals is a legitimate demand of the people.

To assist in health insurance card purchase, in recent years with the support of the State, the poor and a part of near- poor households have been supported with health insurance card. However, the comparison between the regions shows that Red River Delta region has the lowest rate of households supported to buy HIC (5.3%). Poor and near-poor households have not been fully with health insurance card. Table 6: The ratio of Ethnic minority household in the Project area supported with health insurance card purchase Unit: % Region 2009 2010 Nationwide 10.3 10.2 Northeast 14.9 14.9 Northern central region 15.1 14.6 Tay Nguyen 10.2 9.6 Kinh ethnic (Viet) 7.6 7.5 Other Ethnic minorities 28.7 28.5 Source: General Department of Statistic, Household Living Standards Survey, 2010

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According to the results of Table 6, the proportion of ethnic minority households supported with health insurance card is too low compared with the total number of households. In the Northeast, only 14.9% of households are the beneficiaries of government subsidies to buy health insurance. A large proportion of households at the poverty line and the poverty threshold were only encouraged to voluntarily purchase health insurance card, many near-poor households and average income HHs can not afford to buy health insurance because they do not have sufficient financial capacity and another reason is that they are not fully aware of the role and meaningful use of health insurance.

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4.1. Obstacles of ethnic minority in the project area when accessing health care services

The Northeast region is mountainous, complex terrain with storms and floods regularly every year. Many localities often suffer flash floods, landslides as Yen Bai, Tuyen Quang, Phu Tho, Lang Son, .... Average distance from CHSs to the nearest provincial hospital in the northeastern province is 57km. Meanwhile, the condition of the roads infrastructure investment has not been synchronized so ethnic minorities face many obstacles in terms of transportatition and means of transportation. Annually, there is flooding, landslides, seriously impacting on daily life and production of the ethnic minorities in the North. Distance from the village to the district center is far, sometimes can be from the 50 - 70 km and there are no traffic roads. Main means of transportation is walking and cycling. Between the villages, the distance can be from a few kilometers to tens of kilometers. Therefore, the geographic distance constraint is a big challenge for minority ethnic groups in accessing health care services.

So far, in daily life activities, the ethnic minorities in the Northeast region still maintain the traditions and customs, especially the rituals, taboos related to health care. It can be said that this is one of the major obstacles that make a sizable part of the ethnic minorities in the Northeast unable to access to modern health care services. In health care, due to residence condition encoutering many difficulties to gain access to modern health services, ethnic minorities also save a lot of traditional experience in health care among the communities. Due to various reasons, a division of ethnic minorities, especially in some ethnic groups: Hmong, Dao, Nung, ... did not have adequate access to modern health services, it is the impact of ethnic cultural factors, many people have a habit of self-selecting forms of medical care at home and mainly by ethnic prescriptions. Treatment associated with belief also held dominant importance, even deciding method of treatment for ethnic minorities.

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Hmong women going to health care centre must be accompanied husband and especially they do not choose to give birth in health centre due to the conception that child birth must be blessed, sponsored by a supernatural force (house ghosts). Women during pregnancy, childbirth must have the help and support of family members. An important taboo to the Hmong is that they do not want their loved ones in danger, and death in the street without house ghost‘s bless. The habit of the Dao ethnic is medicinal use, with very little medical care in the health centre. In addition, they also have a habit of worshipping when they are sick, this practice has much influence on the issue of treatment and the patient's health care. Thai, Nung, San Chay, San Diu, since residing in low-lying regions, have more access to health care services. However, due to the influence of many factors in the cultures and customs, ethnic minorities are less likely to benefit from the modern health care services. Many traditions still affected heavily in maternal and child health care. During pregnancy women have to work a lot with the concept for easy birth-giving, ... some ethnic groups believe that women during labor have to lie near the fire, after the birth, the mother and newborns have to be located next to the fire for the first month to prevent gynecological diseases. Children after birth must have spirit offerings ritual. These practices are still quite heavy influence on choice behavior of forms of health care of ethnic minorities in the North.

Among the ethnic minorities residing in northern region, only the Hmong have the biggest obstacles of language communication. Most Hmong women and children in the districts of Mu Cang Chai, Tram Tau (Yen Bai) and in some other localities can not communicate in common language and do not know how to read and write. This is the key reason for a large segment of Hmong women not going for medical care at the health facility or encountering difficulty when exposed to medical personnel in the treatment process. For people such as Tay, Nung, Dao, San Chay, San Diu, their communicating in common language is not so fluent but they can make themselves understood between patients, family members and medical staff. Therefore, the barrier of language and communication is not a priority for this minority.

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Since residing in the mountains, living on upland farming, household's income is very low and uncertain, dependent on natural factors. Financial viability of the ethnic minorities are limited, only enough to cover the needs of daily food. The demand for health care, investment in education has not been focused. Most ethnic minority families do not have reserve funds. Meanwhile, a number of people residing in remote areas such as the Hmong, Dao lived self-sufficient, household economy is heavily dependent on natural conditions. When sick, they do not have enough money for long-term therapy in the hospital. According to the General Statistics Office in 2010, the average income of one person in 1 month in the Northeast region is 1.054.000VND (approximately 50 USD), that of the Red River Delta is 1.568.200VND (equivalent70 USD). If by HH income, the poorest household average income reached 369.000d/person/month, group 2 (near- poor) is 668.500d/person/month. With such meager incomes, people in the Northern Delta area, especially mountainous province, ethnic minority areas in the Northeast have just enough to cover the purchase of food. There is no spending on health care. In the case of a family illness, disease, if the state does not support, the poor in the project area can not afford to pay the expenses related to health care and treatment.

In the difficult socio-economic conditions, the people living in the project area are also affected by many issues, including the impact factor from natural disasters, epidemics, living conditions ... With living standards being too low, meager income of the people can only meet part of the need to ensure food security, health problems and disease burden are always set out with the poor, the ethnic minorities. Burden of disease were analyzed to see that people in the project area are suffering from the burden brought about by disease, in which, if supported and given timely health care, they would not have to suffer severe unwanted consequences as such Burden of disease is much more severe for poor and the near- poor ethnic minority families. Through in-depth interviews and group discussions in Yen Bai and Tuyen Quang, it is common that ethnic minority patients leave the hospital without full

37 NORRED Project Ethnic Minority Development Plan treatment because they do not have money, especially diseases related to trauma, cancer, heart disease, blood related diseases .. "Hmong patients here are looking forward to the surgery at the district hospital because they are poor and do not have money to go elsewhere. In many cases they would not want operation because there is no money, they ask for home self- treatment with ethnic medicinal prescription. There is no ability to pay for buying more drugs and supplies for surgery or even food, poor ethnic minorities in Mu Cang Chai is very vulnerable and very frightened when relatives fall ill "(deep interview- hospital director Mu Cang Chai district). At the provincial and district hospitals in Yen Bai and Tuyen Quang, a lot of poor people, the near poor and ethnic minorities do not have money for treatment at large hospitals. When people get sick, they only cure for a short time, and when they do not have enough money, they have to ask the doctor to allow them to go home for self-treatment with medicinal herbs and traditional folk experience. Besides, the poor, the near-poor still have to pay part of the treatment prescribed. Even though the pay is very low, but for the sick poor, this payment will exceed the financial capacity of the family (group discussion results in Yen Bai province hospital, Hospital Son Duong district, Tuyen Quang). In many cases, pregnant women only go to health centre for childbirth under critical condition. For some, it was too late because people are afraid to pay a sum of money to the hospital, while their habits are often to give birth at home with the help of relatives. In some cases of premature birth that needs long-term therapy, pregnant women and families depend on hospital to cure the child without the money to pay for the support services for both mother and child (Deep interview-Obstetrical Dean, Mu Cang Chai hospital, group discussion at Son Duong hospital). Thus, the socio-economic conditions of the province in the project area are still difficult. People still face many obstacles when accessing to health services and health care. In particular, though the poor, near-poor and ethnic minorities have received the support of the state, the network coverage is not comprehensive. Still a large proportion of poor households, low-income households do not benefit from the support of the state policy.

38 NORRED Project Ethnic Minority Development Plan

4.2. Opportunities and benefits of the project to the ethnic minorities According to the design of the project, the provincial hospitals and some district hospitals will be invested in medical equipment and medical training for high technical level staff, which will bring practical benefits forethnic minorities. Thus, if project invests in the provincial hospitals and some district hospitals, it will be a good opportunity for ethnic minority patients to have access to modern health care services. In the situation that ethnic minorities are facing many obstacles on geography, customs and income constraints, strengthening the capacity of provincial and district hospitals will help them significantly reduce the pay such as accommodation cost for people to take care, travel expenses, etc. In addition, the psychological barrier of traditions and customs shall be resolved satisfactorily when the medical staff has the same ethnic with the local people, they can use the native language to communicate with the patient, understand and share with patients about obstacles in customs (in case the district hospitals of the province of Yen Bai, Tuyen Quang, Lang Son, Thai Nguyen, etc.). For inpatient medical care, ethnic minority patients often want their health care centre to be close by to reduce the travel costs, convenient for care, visit ... Therefore, they often choose health care at district and provincial hospitals. Most of the poor and near poor, ethnic minorities do not have the financial ability to pay when moving to central hospitals. Inpatient health care opportunities in the state health facilities for ethnic minorities in mountainous areas are lesser than the populations in the delta area. The proportion of ethnic minority in highland regions such as the Hmong, Thai, Muong and Nung taking healthcare at commune health stations is many times higher than that of the Kinh. The support for costs for the patient with servere disease, prolonged duration of treatment is necessary. According to the project design, a part of the funding of the project will support the poor, the near poor and minority pay expenses exceeding their economic capabilities. This is a content of enormous human significance of the project for the poor and

39 NORRED Project Ethnic Minority Development Plan ethnic minorities. In addition, the project will support the purchase of health insurance card for the near-poor object to expand health insurance card coverage for the near poor who have not benefited from the policy of the State. With regard to the ethnic minorities, because most of the people reside in the remote areas with difficult travel conditions, the access to high quality health services encounters many difficulties. The investment in upgrading district health facilities is very appropriate and creates better opportunities for ethnic minority to access to health care services and health care. Projects in operation will increase the number of patients who receive health care services, including ethnic minorities especially in mountainous district, deep-lying, remote, border area. Thus, from the fact of the investigation, the opportunity for ethnic minorities to benefit from the project in health care is very positive. District and provincial hospitals will be invested in terms of equipment, training and capacity building of health preventive medicine; the health care for ethnic minorities is raised much more. For the northern region, the residence area of many ethnic minorities, in addition to supporting insurance cards for poor households, upgrading the capacity of the health care for district hospitals is very suitable and positive for the care of people's health, especially for people residing in the mountainous districts, poor districts, and remote areas which are facing many barriers to health care and access to modern health care services. Regarding equipment provided by the project, the Ministry of Health will request the project provinces to be committed to ensuring funding for the operation of equipment, and maintenance, machinery maintenance during and after the project. The project components are designed in sync, including staff training and development of human resources for health, provide health equipments, health insurance card for the poor, behavior change media ... therefore, the project will not only improve the quality of health care services, support for the near poor, but also strengthen and develop the health system at the unit level in order to provide better health care for people.

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The aim of ethnic minority development plan is to implement equitable policies in health care for ethnic minorities, those who have no or little financial conditions for access to and use of health services sectors. Therefore, a number of project activities contribute to and facilitate more for those who are ethnic minority beneficiaries of the project. Ethnic minority policy of the project is set up with a specific plan based on cultural traits, traditions and the factors that limit access to health services of minorities to the determination of the project activities in order to minimize barriers to health care needs of ethnic minorities.

5.1. The opinions and views of the stakeholders on the components of the project From experience in implementing other aid projects, the Ministry of Health identified, health care capacity building for provincial and district hospitals is the most important focus of the project. The direct training under professional surgery and treatment team pays special attention to five majors: Cancer, trauma, obstetrics, pediatrics and cardiology. The training activities are defined as direct training in the form of "learning by doing", capacity building practice for the team doctors and medical staff who directly perform medical care at provincial hospitals and districts. Enhance communication to raise awareness of people about the use of health insurance. Encourage people, especially the near-poor group and other groups participate in health insurance to protect them from the financial risks of illness, and increase the financial sustainability of the insurance fund. Support the purchase of health insurance, support patients in paying costs that exceed the financial capacity of the poor and minorities. Ministry of Health and the World Bank agreed on the importance of capacity building for PMU staff at all levels. Therefore, in the process of preparing and implementing projects, training activities, domestic training and abroad training on knowledge, project management skills, financial management, and procurement for PMU staff will be given priority. Thus, project management capacity of the health

41 NORRED Project Ethnic Minority Development Plan sector, from the Ministry of Health, Department of Health and the medical establishment will be improved. According to the leaders of the medical centers, the content of this project is fully consistent with the practical needs of the locality. In some provinces, the hospital's infrastructure construction has been invested by the government's budget, but not medical equipment investment. This is a good opportunity to improve the health care capacity of the provincial and district hospitals in order to reduce the load of patients on referral. "Tuyen Quang Hospital really is a satellite hospital of the region. Many patients from Ha Giang, Yen Bai, Lao Cai, Phu Tho moved on here for treatment. We have received some training team of the major hospitals in Hanoi as Bach Mai, Viet Duc, but because there is no funding should only train a small number of the technical team. Now this project is really needed for general hospital in Tuyen Quang province "(Deep interview Tuyen Quang provincial hospital leaders). "Ninh Binh Hospital is also looking for promotion opportunities for investment in equipment. Infrastructure of the provincial hospitals has been invested but we are lacking equipment. We have ensures that each patient has one private hospital bed, but the equipment, treatment machinery has not been ensured since the cost is too much compared to the local budget. We also need training for highly qualified doctors for timely surgical intervention for patients "(Group discussion, leaders of Pediatric hospital, General Hospital of Ninh Binh) For district hospitals, the current health care needs of the population is growing, leading to overcrowding in hospital beds, medical equipment and urgent need for training of health workers. Actual survey shows that a number of district hospitals as Mu Cang Chai (Yen Bai), Son Duong (Tuyen Quang), Nho Quan (Ninh Binh), ... always overloaded with hospital bed capacity up to 120 - 130%. For the district hospital in mountainous areas, the investment in equipment is necessary; however, training of human resources using equipment is also very important. "Mu Cang Chai Hospital does not have enough doctors to do the surgery. If we move patients to Van Chan or Yen Bai, we fear the patients cannot make it. On the other hand, their patients do not want to go so far because there is none to take

42 NORRED Project Ethnic Minority Development Plan care, no money for meals, medication ... ( in-depth interview, hospital leaders Mu Cang Chai, Yen Bai) "Nho Quan Hospital is currently lacking good qualified surgical doctors. There are more and more patients, everyone wants surgery at the district hospital, so hospital leaders have to mobilize maximum doctors to serve patients "(In-depth interview, hospital leaders Nho Quan, Ninh Binh). "Son Duong Hospital urgently needs investment, especially medical equipment and training of doctors. In 2012, we have treated an average of 250 obstetrical cases per month. But there are many cases of pediatric patients in need of blood, but we did not have enough blood reserves, so the blood transfusion could not be done, in many cases we transferred the patients to the provincial hospital but we had to send them home mid-way since patients could not stand it. We do not know many high-tech skills since we are lack of training, lack of laboratory equipment such as ultrasound color, biochemical tests, ... many births showed signs of premature or complications that need to be moved the provincial level, but it will be very dangerous for the patient "( group discussion- hospital staff of Tuyen Quang, Son Duong). The fact is that many hospitals do not have enough doctors, technical staff in the health care service to people. Therefore, the management staff and medical staff agreed with the training plan of the project, which is learning by doing and training highly qualified technical team. - Experts invited to attend the training courses are industry experts at large central hospital, has professional experience in expertise and direct teaching experience to be able to impart knowledge and experience in the best way for those students. - Capacity building training should be organized locally to reduce travel time, the organization of training workshops locally will attract more participants and do not affect much to the hospital's health care plan. (Group discussion Results in provincial and district hospitals).

For health care workers

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When asked about the current status of equipment of the hospital, most of the reviews is that equipment was obsolete, outdated, even damaged. The investment in equipment is necessary and meets the growing health care needs of the people. Surveys at three provincial hospitals in Yen Bai, Tuyen Quang Ninh Binh show that most hospitals are lack of equipments. Departments often have to borrow the ventilator, patient monitor, causing major obstacles in the process of patients active treatment. "We are often lack of some kind of supportive treatment equipment. In one year we had to treat about 800 children, of which three-quarters of the children need to be intervened. Many preterm children were not timely supported and could not be cured. Even in the case of blood transfusion and the tracking equipment, we did not have enough equipment. Many unfortunate events happened. In 2011,10 children died. If hospitals have had the equipment, we should have had the opportunity to save more lives "(In depth interview Head of Pediatrics Department, Tuyen Quang Hospital). “Our kits have been used for over 10 years. Now when there is surgery, we have to pick, pair from 3 sets of surgical instruments to create a complete set. If you have a second surgery, we can’t do anything because there are no instruments; we don’t even have nailing equipment for the limbs, which is very inconvenient for the treatment of patients "(Deep interview. Head of Trauma department, Tuyen Quang hospital). For provincial hospitals, very little amount of equipment is be enough to meet the demand of the department, especially for the Department of Obstetrics and Pediatrics. Particularly at Ninh Binh provincial hospitals, infrastructure is a spacious new building but the area of radiation oncology department has not been invested in equipment, waiting for the opportunity from the project. Regarding training, most health workers have expressed desire to continue training in subjects, particularly open capacity training courses for doctors, nurses, paramedics who are taking direct medical care at the hospital. The direct training towards advanced technical team is essential, especially for provincial and district hospitals which act as the center of the region and of the area.

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Proposed implementation plan of the project activities, a lot of comments look forward to early implementation of the project to support local health facilities to meet the growing health care needs of people On the support of health insurance cards for the near poor, a number of local opinion that the need to review and coordinate the implementation between the health sector and related industries in the issuing of cards for the right audience and promptly, quickly, to avoid errors in the name, age, address ... limit the inadequacies, inconvenience to the patient in the process of using insurance cards. For poor Ethnic patients With the near poor, the project supports 30% of the funds for the purchase of health insurance, which is consistent with the wishes and interests of the poor. Through field surveys in a number of hospitals, many patients do not use because there is no money to buy health insurance voluntarily. The component partially supports to buy health insurance for the near-poor HHs and enhance communication and social marketing to encourage health insurance, which is a great fit and meet the expectations of a majority of people, contributing to increase the number of recipients of health care and fair financial implementation to ensure that all people when ill l are able to cover health care costs. "I seek medical care but I have no health insurance card. I'd love to be 100% state supported but not yet. If we have to pay 20%, we do not have money to buy. Year-round, farmers only have a few pounds of rice, everything needs buying and money. Without health insurance card, we would not go to see the doctor because there is no money. If the project additionally support for our family with health insurance card, that would be good. We will be entitled to medical treatment free of charge "( In-depth interview, 43 year-old patient, Nho Quan hospital, Ninh Binh).

"My child is only 4-year-old but already has cancer (actually pneumonia), I am so scared. The doctor said only provincial hospital can cure this. But my husband and I had no money, if going to provincial hospital, I do not know anyone, no one will come to visit so I do not want to go. If the project can help cure my child, I am very grateful "(In-depth interview, 18 year-old women, Hmong ethnic, Mu Cang Chai).

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"Many poor ethnic patients were hospitalized but they did not have the money to pay the expenses for food, drink, or other materials in the course of treatment (needles, pipes, etc.) when requested to make payment, they request to be discharged and stop the treatment. For many ill people with the inability to pay, we must mobilize the help of the other patients in the room and the medical staff. Currently, there are some premature children treated aggressively but was abandoned because families cannot come to visit, hospitals have to spend money to rescue the children first, then raise the contribution of everyone "(Group discussion, hospital staff of Yen Bai, Mu Cang Chai, Son Duong). According to the preliminary design, the components of the project have received the support of the stakeholders. The components designed in the project are considered feasible and meet the current urgent needs at the provincial and district hospitals in the project area. With innovation and to learn from other projects of the Ministry of Health, NORRED project has received the support and commitment of implementation of stakeholders in the project implementation process.

5.2. Public consultation principles during project implementation In order to achieve the goal of ensuring fairness in health examination and health care for ethnic minorities, expert consultation activities have to be done during the implementation of project and activities of project implementation require the participation of stakeholders. - For the implementation of the project activities, it is necessary to have the advice of experts who have extensive experience in the field of development of ethnic minorities, especially the communication activities, information campaigns to raise awareness of people to buy health insurance, health insurance cards and switching behavior in health care. - The Central Project Management Unit directs and regularly monitors the implementation of components in project provinces. Especially for the provinces with more minority residents, CPMU should closely monitor the

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implementation plan of ethnic minorities in order to achieve the original objectives of the project. - Provincial Project Management Unit deploy implementation plan, allocate and monitor the implementation at base in order to ensure fairness in the implementation of health care policy for ethnic minorities, to create favorable conditions for local financing and other legal basis for the implementation of the project activities. Provincial Project Management Unit collaborates with provincial departments in order to implement the project activities, especially investment program to develop ethnic minority.

- Department of Health, Department of Finance, Social Insurance (Medical Insurance) coordinate with agencies in charge of ethnic, cultural information and insurance agent to deploy media activities at base in order to achieve the highest efficiency.

5.3. Project activity assessment index to develop ethnic minorities Ethnic minority development consultation mechanism is the result from the dissemination of information, public consultation and participation of ethnic minorities and local government. According to the result of consulting with local authorities, patients from ethnic minority groups and other stakeholders, the indicators to assess project activities for the development of ethnic minorities were identified to be: 1. Number of staff, medical staff participating in training capacity building, professional training to improve the capacity of health workers in the mountainous districts, where there is a high rate of ethnic minority. - Prioritize the training of doctors, pharmacists, health workers from ethnic minorities, currently working in hospitals district and province of project area. -Training, short-term training for staff, health workers from ethnic minorities in districts with high concentrations of ethnic minorities in order to improve professional skills. 2.Results of the communication activities are evaluated by the following specific activities:

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- Methods of communication: Use an efficient and friendly community approach, to help ethnic minorities to easily capture information and activities of the project - The communication output include: + Investment in the media means such as television, video sets in the examination and treatment rooms with the information content consistent with the hospital's medical content and information dissemination to raise awareness of people in health care, health insurance cards and the benefits that the poor, near-poor and ethnic minorities enjoy from preferential policies of the state and the project. + The live media at the provincial hospitals, district hospitals on the activities of the project directly conducted by the medical staff by intergrating with the propagation of disease prevention campaigns... + The radio show, broadcast on mass media in common language. For Tram Tau, Mu Cang Chai district in Yen Bai province and some districts with high rates of Hmong people, should build in the Hmong language with the content to raise awareness of ethnic minorities on the purchase and use of medical insurance cards, behavior change in health care and to encourage ethnic minorities to medical examination and treatment at the health centre. 3. Organize training courses on the organization and management of health care for the provincial and district hospitals. There are the places that patients from ethnic minorities select the most. - Organization of training on the management of health insurance, identification of ethnic minorities who have not benefited from the Government's health insurance issuance policy. - Provide training on monitoring the implementation of health insurance for the near poor being ethnic minorities. - Select and support 30% of the remaining amount which is not yet supported to buy health insurance for ethnic minority under near-poor category. 4. Improve equipment and technology transfer for provincial and district hospitals in Project area, satisfied demand of health treatment for the poor, especially ethnic minorites in remote areas, increase the number of patients being ethnic minories with

48 NORRED Project Ethnic Minority Development Plan better access to modern health care services,as well as capacity strengthening for health staff at locality. - Provide training on the use of equipment and machinery for the district hospitals with many ethnic minorities staff. - Implement hands-on training for the medical staff at the hospitals in remote area with many ethnic minority residents about the professional activities and the use of modern equipment. - Communication support for the near poor who are ethnic minorities to raise awareness in the purchase of health insurance cards and use of health insurance cards in health care.

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IMPLEMENTATION ORGNIZATION AND FINANCIAL

6.1. Implementation orgnization Implementing ethnic minority development plan, Central project management unit and Provincial project management units conduct activities for the implementation of project components and monitoring activities to ensure that the eactivities of the project have been made to ensure ethnic minority development plan. - For districts with a high proportion of ethnic minorities, should have the audio-visual communication materials in ethnic languages, communication staff fluent in the ethnic language to implement the communication activities, counselinng and mobilize ethnic minority to have health care at health cantre. - Provide professional qualified doctors to come to training at provincial and district hospitals, improving the capacity of health workers in the district hospitals with many staff being ethnic minorities to the transfer technology for the district hospitals, especially those districts with more minority residents.

6.2. Monitoring and evaluation Monitoring implementation of ethnic minority development plan is part of the monitoring component of the project activity. We need to have an independent monitoring organization: expert with experience to monitor and evaluate the activities of the project in the view of the social and ethnic minority development. Central Project Management Unit and the Provincial Project Management Units need to conduct assessment activities, monitoring of project components. For districts with more than 50% of the population being ethnic minorities, we need to coordinate in monitoring activities related to ethnic minorities.

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6.3. Financial Estimates - Financial costs of ethnic minority development plan is estimated in the project's activities - The cost of training will be calculated in detail when these activities are implemented. - To cut cose, training, communications for ethnic minority development plan will be coordinated with other communication and training activities of project Table 7: Estimated cost for ethnic minority development plan No Category Unit price Budget Total

1 Short-term Direct training 15ppl/ province x 8 Project 20,000 for doctors, pharmacists provinces budget being ethnic minorities

2 direct train staff, medical 15ppl/ province x 8 Project 15,000 staff who ethnic minorities provinces budget

3 Training of staff from ethnic 10ppl/ province x 8 Project 15,000 minorities in management provinces budget and maintenance of medical equipment

4 Develop communication 4,000 USD x 6 Project 44,000 materials for ethnic hospitals budget minorities: documentary disc 2000 USD x 10 district hospital with 50% of population being ethnic minorities

5 media, media support 5,000 USD/ district Project 75,000 training x 15 district budget

6 Support to purchase health (About 10,000 ppl) Project 58,000 insurance cards for the poor x 5.85USD/ppl budget ethnic minority

Total 227,000

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