NATIONAL SCIENTIFIC CONFERENCE ON PUBLIC HEALTH “PUBLIC HEALTH IN VIETNAM: CURRENT SITUATION AND FUTURE PERSPECTIVES”
PUBLIC HEALTH IN VIETNAM: ACHIEVEMENTS AND CHALLENGES
Prof. Nguyen Cong Khan Department of Nutrition and Food Safety - HSPH Department of Science, Technology and Training - MoH
HDI
Human development Index (HDI)
0.622 0.629 0.632 0.635 0.638 0.598 0.604 0.611 0.617 0.563
0.473 0.476
1985 1990 2000 2005 2006 2007 2008 2009 2010 2011 2012 2013
Source: UNDP 2014 Basis health indicators
Results Target 2015 (MDG & 2011-2015 plan of the MoH)
Life expectancy, 2013 (1) 75.6 74 IMR 2014, (2) 16.21 14.8 U5MR, 2014 (2) 19.7 19.3 Maternal mortality, 2009 (3) 69 58.3 Under nutrition among children under 5, 2013 (4) 15.3 15 Fully vaccinated children, 2013 (4) 91.4 90 Doctor/ 10000 population, 2013 (4) 7.5 8 Beds/population, 2013 (4) 24.2 23 Commune health station with doctor, 2013 (4) 76.9 80 Health insurance coverage, 2013 (4) 68.5 70
(1) WHO 2014; (2) GSO 2014; (3) GSO, 2009; (4) MoH 2014 Health outcomes
Life expectancy at birth, total (years)
75.6 75.3 75.5 75.0 75.2 74.8 74.9 74.5 74.6 74.1 74.3 73.9 73.6 73.4 73.1 72.8 72.5 72.1 71.8 71.5 71.2 70.8 70.5 70.2
1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
WHO, 2014 Health outcome
Mortality rate, infant (per 1,000 live births) Mortality rate, under-5 (per 1,000 live births)
52.6 50.5 48.2 46.0 43.8 41.7 39.7 37.7 36.0 34.3 32.8 31.5 37.6 36.4 30.3 35.1 29.1 33.8 28.0 32.5 27.1 26.1 31.2 25.2 24.5 30.0 24.0 23.6 23.4 23.2 23.0 28.7 27.6 26.5 19.7 25.5 24.6 23.8 23.0 22.2 21.5 20.8 20.1 19.6 19.2 18.9 18.7 18.6 18.4 16.2
Source: WHO, GSO, UNICEF 2014 Health outcome
Maternal mortality (per 100,000 live births ) 233
69
1990 2009
Source: UNDP 2012 Health outcomes Malaria cases/ 100,000 population 800 728 700 599 600 508
500 446 400 377 328 300 233 204 200 157 119 109 83 70 71 100 62 49 0 1996199719981999200020012002200320042005200620072008200920102012
Source: MoH 2013 Health Facilities
Year 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Hospital 791 821 825 836 833 835 836 842 842 856 878 903 956 974 1002 1030 1040 1042 1069 Polyclinics 1150 1131 1106 1108 1024 936 928 912 930 881 880 847 829 781 682 622 620 631 636 Rehabilitation and Sanatorium facilities 103 120 121 119 112 92 71 76 77 53 53 51 51 40 43 44 59 59 60 CHS 9670 9935 10014 10078 10109 10271 10385 10396 10448 10516 10613 10672 10851 10917 10979 11028 11047 11049 11055 Health posts in organization 1170 1123 1123 1123 1120 918 891 810 810 789 769 710 710 710 710 710 710 710 710 Others 65 61 59 55 54 50 49 41 38 34 33 30 32 32 TOTAL 12972 13218 13269 1330 13264 13117 13172 13095 13162 13149 13243 13232 13438 13460 13450 13467 13506 13523 13562
MOH, GSO 2014 Health service delivery
Hospital beds (000)
275.1 280.7 266.7 246.3 232.9 219.8 210.8 192.3 196.5 197.9 199.1 195.9 192.0 192.5 192.6 192.9 196.3 197.3 198.4
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
MOH, GSO 2014 Health service delivery (Fully vaccinated children)
NEPI 2013 Health service delivery
Coverage of OPV3 and polio 1985 – 2011 NEPI 2013 Health service delivery
Coverage of vaccine UV2+ among pregnant women and child tetanus, 1991-2012 NEPI 2013 Paper “30 years of vaccination in Vietnam: impact and cost- effectiveness of the national Expanded Programme on Immunization” (Accepted for publication in Vaccine 2014)
“National surveillance data suggests that up to 5.7 million diseases cases and 26,000 deaths may have been prevented by EPI” Health service delivery
Birth attendance by professional staffs
GSO UNICEF, 2014 Health service delivery
Utilization rate (%) Utilization of inpatient service (%) Utilization of outpatient service (%)
40.9 39.2 37.1 36.0 34.3 35.2 34.2 32.6 30.9 31.0
18.9 14.2
7.1 8.1 7.3 5.7 6.3 6.5
2002 2004 2006 2008 2010 2012
GSO 2013 Health financing
Health expenditure, public (% of government expenditure) Health expenditure, total (% of GDP) 12
10.1 10.1 10 9.2 9.5 8.5 7.9 8.0 8 7.4 7.5 7.5 7.1 7.0 7.1 6.9 6.9 6.6 6.8 6.5 6.3 6.5 6.5 6.0 5.9 6.0 5.6 5.5 5.5 6 5.2 5.3 5.2 5.2 5.1 4.9 4.9 4.9 5.1 4
2
0
Source: National Health Account, Vietnam Health Insurance coverage
68 68.5 64.3 58.2 59.6
47.1 44.7 43.8
28.8 22.8 20.7 17 14 15 12 12 13 13 10 5 6
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Source: National Health Account, Vietnam Health human resource
Doctor/10,000 population Pharmacist/10,000 population2 7.5 7.3 7.2 7.3
6.6 6.5 6.5 6.2 6.0 5.9 5.9 5.7 5.4 5.4 5.1 4.7 4.4 4.4 4.4 4.4 4.1 4.2 3.9 4.0 3.5 3.6 3.6 3.2
1.9 2.0 1.8 1.8 1.8
1.3 1.3 1.2 1.2 1.1 0.9 1.0 1.0 0.9 1.0 0.9 0.8 0.8 0.7 0.7 0.7 0.7 0.8 0.8 0.8 0.8 0.8 0.8
Source: Health Statistics Year Book Health human resource
% CHS with doctor
76.5 76.9 71.9 69.2 69.4 67.7 70.0 65.4 65.1 67.4 65.9 61.5 56.1 51.1
33.9
23.2 17.7 9.4 4.6
Source: Health Statistics Year Book Medical universities/schools
Năm 1985 Năm 1995 Năm 2001 Năm 2005 Năm 2010 Năm 2014 80 74 70 68
60
50 44 46 40
30
20 16 16 14 13 10 11 10 5 5 6 7 5 6 0 1 1 1 1 1 1 2 2 2 2 0 Trường đào tạo Trường đại học Trường Đại học Y Trường đào tạo cao Trường trung học y YTCC Dược và Y dược đẳng Y, điều dưỡng dươc
Source: Ministry of Health Medical students
60,526
21,950 11,479 8,304
Năm 1990 Năm 1995 Năm 2005 Năm 2010
Source: Ministry of Health Thành tựu khác của hệ thống y tế
• Preventive medicine: Good controlling of dangerous transmitted diseases such as SARS, flu A/ H5N1, flu A/H1N1. • Development of high technologies at a similar level of regional and international development (interventional treatments, laparoscopic surgery, organ transplants…). • Population and Family Planning: Natural population growth of Vietnam has been reduced and restricted stably • Pharmaceutical products: In 2012 domestic medicine met 234/314 active elements in the list of essential medicines with all 29 groups of pharmacological effects as recommended by WHO; 100% of pharmaceutical production facilities achieved GMP; 100% drug- testing facility achieved GLP; 39% of drugstores achieved GPP • Development of traditional medical network from central to provincial, districts and communes
Conclusion
Thành tựu: 1. Vietnam's health system has made great efforts and achieved many impressive and important accomplishments in protecting and improving the health of people. 2. Most of the millennium goals have been achieved or will be achieved in 2015 3. Vietnam’s health indicators are at a level similar to or better than the countries with similar levels of economic development
Epidemiological transition (hospital cases)
Communicable diseases Non-Communicable diseases Injuries, poisoning 80 71.6 70 62.4 59.2 60 50 50 39 40 37.6
30 24.9 19.8 20 12.4 12.7 8.6 10 1.8 0 1986 1996 2006 2010 Epidemiological transition (DALYs) Hypertension (%)
Source: JAHR2012 Diabetes (%)
Source: JAHR2012 Food safety Food poisoning in 2015 • 179 food poisoning cases – 5552 patients contracted – 5147 patients hospitalized – 23 dead. • Food poisoning tends to be complicated such as FP in collective kitchens at industrial zones, FP due to poison mushroom or natural toxins
Number of facilities violated food safety rules: 78.413 Behavioral risk factors (%)
Overall Men Women
69.6
54.9
37
27.4
5.6 1.7
Smoking Alcohol use (in the last 30 days)
Source: Ministry of Health Ageing problems
21.4 % aged 60+
11.8
8.1 8.7 7.2
1989 1999 2009 2019 2039
Source: General Statistics Office Emerging diseases Measles outbreak
25000 160 136 140 19287 20000 18817 120
14431 100 15000 11942 11235 80
10000 8160 7554 60 6584 6720 40 5000 4180 10 20 3 1 0 0 0 0 528 0 0
sè m¾c tö vong
Source: Ministry of Health
Dengue fever and weather in Hanoi
100 100
400
800
80
80
300
600
60
60 200
2005 400 2006
40
40
100
200
20
20
0 0
01 Jan 0501 Apr 0501 Jul 0501 Oct 0501 Jan 06 01 Jan 0601 Apr 0601 Jul 0601 Oct 0601 Jan 07 thang thang
case rainfall case rainfall
temp humid temp humid
100
500
100
1000
800
80
80
4000
400 800
80
80
600
3000
60
60
300 600
60
60
400
2000
200 400
40
40
40
40
200
1000
100 200
20
20
20
0 0
20
0 0
01 Jan 0701 Apr 0701 Jul 0701 Oct 0701 Jan 08 01 Jan 0801 Apr 0801 Jul 0801 Oct 0801 Jan 09 01 Jan 0901 Apr 0901 Jul 0901 Oct 0901 Jan 10 01 Jan 1001 Apr 1001 Jul 1001 Oct 1001 Jan 11 thang thang thang thang
case rainfall case rainfall case rainfall case rainfall temp humid temp humid temp humid temp humid
2007 2008 2009 2010 Antibiotic treatment and antibiotic resistance
90% Appropriate Inappropriate 84% 80% 74% 70% 67% 60% 50% 40% 33% 30% 26% 20% 16% 10% 0% Total E.coli or Klebsiella Acinetobacter or Pseudomonas
Inappropriate antibiotic use was 74% and appropriate use was 26% (Similar to research result of Kollef et al 1998 (73.3%))
Research by TDH in 2009-2010 in 19 hospitals in Hanoi, HCMC and Haiphong
IMR
Rural Urban 18.0 16.0 16.0 15.9 16.0 15.8 15.5 16.0
14.0 12.0 10.0 9.8 9.5 9.4 9.2 10.0 8.5 8.0 6.0
Per 1000 live births live 1000 Per 4.0 2.0 - 2006 2007 2008 2009 2010 2011
JHAR, 2014 IMR 2011
(per 1000 live births)
Ethnic minorities 30
Kinh 10
20% richest 11
20% poorest 23
Secondary and higher 12
Primary 17
No education 23
MICS 2011 Malnutrition
Malnutrition among under 5 children (%)
Ethnic… 22 Kinh 10 20% richest 3.1 20% poorest 20.6 Secondary… 9.5 Primary 13.2 No education 22.4 Rural 13.9 Urban 6
MICS 2011 Health care utilization
Pregnant women had >=4 antenatal examinations (%)
Ethnic minorities 59.6
Kinh 67
20% richest 88.7
20% poorest 27.2
Secondary and… 69.3
Primary 44
No education 5.6
Rural 50.5
Urban 81.6
MICS 2011 Health care utilization (% used in the last 12 months)
20% poorest 20% richest 45.5 42.2 36.7 36.3 37.5 36.6 34.235.4 32.4 33.8
22 16.5
2002 2004 2006 2008 2010 2012
VLSS 2002-2012 Một số vấn đề khác • Quản trị hệ thống y tế còn nhiều bất cập: phối hợp liên ngành; y tế dự phòng và điều trị; Đầu tư cho y tế dự phòng, hệ thống y tế… • Bao phủ bảo hiểm ở nhóm lao động phi chính thức còn thấp, thanh toán “Theo phí dịch vụ” vẫn là chủ đạo; Chi cho thuốc chiếm tỷ trọng lớn. • Chất lượng và phân bố nhân lực y tế: bất cập. • Hệ thống thông tin y tế thiếu đồng bộ • Nhận thức về xã hội hoá y tế (XHH) chưa thống nhất • Lạm dụng dịch vụ và kỹ thuật y tế
Other issues • Limitation in governance of health system. Lack of inter- sectoral collaboration in diseases prevention. Cooperation between prevention and treatment is still not good. Investment for prevention and related networks still remain limited. • Health insurance coverage within informal sector keep at low level. “Fee for service” keep the role as the main payment method. Expenses for drug still account as high proportion in total health expenses. • Quality and distribution of human resources for health: inappropriate • Health system information: inconsistent • Awareness of socialization in health is not unitized • Overuse of medical and technical services
Conclusion • Key challenges: 1. Health: an increase of NCDs and its risk factor, aging trend, new emerging diseases or relapse, climate change related health issues 2. Health system: Health system have not yet been prepared well to respond issues mentioned above. While central hospitals always suffer from overloading, health facilities at lower level have not yet been invested appropriate. Impacts of health policy in financial protection are still limited, especially health insurance. Payment methods still remain inappropriate. 3. Inequity in health and healthcare: Among different population groups, the poor, people with low level of education and minority people.
Health system: priorities for research and change
• Health system organization and governance: combine prevention and treatment. • Universal health coverage together with health equity. • Invest for preventive medecines, implement PRIMARY HEALTH CARE elements in new context. • Equip health system with new capabilities to respond to new health problems and to the changes in climate, population and socio-economic status. • Develop a sycronizied health informatics system. • Planning and projection capacities. Mortality: global projection, 2004-2030
30 Intentional injuries Other unintentional 25 Road traffic accidents
20 Other NCD
15 Cancers
Deaths (millions) Deaths 10 CVD
Mat//peri/nutritional 5 Other infectious HIV, TB, malaria 0 2004 2015 2030 2004 2015 2030 2004 2015 2030 High-income Middle-income Low-income countries countries countries Effective multi-disciplinary collaboration
• In policy making. • In planning and projection • Disease control • Response to climate change • Food safety control • Appropriate nutrition: in treatment and prevention • Deal with new public health issue (such as antibiotic resistance, etc.).
One health Innovation in HRH training
• Capacity-based training • Training • Need-based training • Redistribution of HRH: policies and attraction. • Training for health system reform: Public health, Family health care. • Health management Three generations of reforms
1900 Science based Problem based Systems based 2000+
Competency Scientific Problem based driven: curriculum learning
local-global
Instructional
Health University Academic education based centers
systems Institutional Inter- and Trans-Professional Education
Inter- Professional Inter- & Trans- Education Professional Education
Higher income countries Lower income countries Public health training
Capacity- based and job- Enrolment descrition- source based approaches
Multidisciplinary and cross-sectoral approach
Program innovation
SYSTEM INNOVATION Need for multi-stakeholder approaches in countries… Completing health policy system and health law
• Laws (such as revision of health examination and treatment law, etc.). • Develop professional standards and norms in health sector. • Innovation of payment methods, improve financial protection for vulnerable groups. • Socialization in the direction of openness, transparency and quality of health services. Trân trọng cám ơn!