Health Care in the South Central Coast Region – Implementation Results of the Project Ethnic Minority Development Plan

Social Monitoring Report

01 Semi Annual Report October 2014

VIE: Health Care in the South Central Coast Region – Implementation Results of the Project Ethnic Minority Development Plan

Prepared by the Center for Environment and Health Studies, and Center for Community Health and Injury Prevention, for the Ministry of Health, Socialist Republic of Viet Nam, and Asian Development Bank.

This social monitoring report is a document of the borrower. The views expressed herein do not necessarily represent those of ADB's Board of Directors, Management, or staff, and may be preliminary in nature.

In preparing any country program or strategy, financing any project, or by making any designation of or reference to a particular territory or geographic area in this document, the Asian Development Bank does not intend to make any judgments as to the legal or other status of any territory or area.

A JOINT VENTURE BETWEEN THE CENTER FOR ENVIRONMENT AND HEALTH STUDIES AND THE CENTER FOR COMMUNITY HEALTH AND INJURY PREVENTION

Ngo Tuan Dung Sarah-Jane Clarke Nguyen Thi Toan Pham Duc Muc Vuong Tien Hoa Ninh Van Minh Nguyen Thien Nga Nguyen Thi Thu Thai Thi Thu Ha

The joint venture between the Center for Environment and Health Studies and the Center for Community Health and Injury Prevention would like to express our gratitude to the Central and Provincial Management Units of the Health Care in the South Central Coastal Region Project for their provision of secondary data, and the coordination and support from our experts in developing the province-level EM action plans. Thanks also goes to the Central Project Management Unit and the Asian Development Bank for their technical and financial support for this activity.

2 Table of contents

1. Introduction 6 1.1 Background 6 1.2. Objectives 8

2. Methodology 9 2.1. Review of secondary data 9 2.2. In-depth interviews 9 2.3. Consultations with related partners 9

3. Implementation Results 10 3.1. Update and analyze the implementation results of the Project EM development plan according to each Project output 10 3.2. Updated results of implementing strategies according to indicator framework 26 3.3. Analysis of Project strengths, weaknesses, lessons learned and concerns related to EM 28

4. Conclusion 32 5. Recommendations 33 6. References 34 Annex 35 Annex 1. UPDATED PROJECT RESULTS ON EM IN INDICATOR FRAMEWORK 35 Annex 2: Provincial summary 41

3 List of tables

Table 1: Total number of health workers and number of EM health workers trained by the project in each province by June 2014 13

Table 2: Percentage of EM participating in IEC activities implemented by PPMUs 21

Table 3: Number of iEC films translated into minority languages 22

Table 4. Percentage of women using all reproductive health care services by ethnic group, in 33 villages, 2013 23

Table 5: Updated achievements of key monitoring indicators, 31 June 2014 27

Table 6: Remaining activities and task assignment towards the end of the Project 31

List of Figures

Figure 1: Proportion of population that is ethnic minority, by province. 6

Figure 2: Largest ethnic minority populations in the South Central Coast region, by percentage of total population 7

Figure 3: Propotion % of utilization of surveyed outpatient services and health seeking behavior of EM in the Project provinces over the last 4 weeks in 33 poor and EM comunes in 11 districts, 2013 12

Figure 4: Proportion of EM health workers trained and granted scholarships by the Project in each province 14

Figure 5: Percentage of training courses at all levels within the Project provinces that included EM participants 15

Figure 6: The number and percentage of EMs attending VHW training courses organized by the Project 18

Figure 7: Proportion of surveyed VHWs in 33 communes trained by the Project and others courses, 2013 18

Figure 8: Characteristics of VHWs in 12 districts with high EM populations in six Project provinces, 2013 19

Figure 9: Percentage of EM from 11 districts in 6 Project provinces who were satisfied with VHW, 2013 20

Figure 10: Percentage of people with HI cards by ethnic group in survey sites, 2012 25

4 Abbreviations

ADB Asian Development Bank CHC Commune Health Center CPMU Central Program Management Unit DHC District Health Center DOH Department of Health EMDP EM Development Plan FGD Focus Group Discussion EM EM HF Health facility HI Health insurance HRD Human resource development HW Health worker IDI In-depth interview IEC Information, education, communication MCH Maternal and child health MOH Ministry of Health

PPC Poiial People’s Coittee PPMU Provincial Program Management Unit PSC Provincial Steering Committee ToT Training of Trainers VHW Village health worker

5 1. Introduction

1.1 Background Implementation background

Viet Nam is home to 54 different ethnic groups. The majority ethnicity is Kinh who make up approximately 86.2% of the out’s population. The other ethnic groups are small - and sometimes very small - in number and are officially ko as ethi ioities (EM).

The South Central Coastal Region is one of five regions in the country with a high proportion of EM. In this region, approximately 7.4% of the population is EM. Of the eight project provinces – Binh Dinh, Binh Thuan, Da Nang, Khang Hoa, Ninh Thuan, Phu Yen, Quang Nam and Quang Ngai – the proportion of EM population ranges from 0.5% in Da Nang to 23.5% in Ninh Thuan (Figure 1).

Figure 1: Proportion of population that is ethnic minority, by province. In 1,024 communes of 84 25 23.5 districts in the South Central Coastal region, 20 there are 423 remote communes with a high 15 13.3 proportion of EM,

10 8.1 accounting for 38.2% of the 7.4 Percentage (%) Percentage 5.9 5.3 population, as well as 223 5 2.3 communes classified as 0.5 poor. In the eight provinces 0 Ninh Quảg Quảg Bình Phú Yên Khánh Bình Đà Nẵg of South Central Coastal Thuậ Ngãi Nam Thuậ Hòa Địh region, the most populous EM groups are Cham, Hre and Raglai (1.4-1.5% of the total population of the region). Other EM including Bana, Co Tu, Cor, Ede, Gie Trieng, Hoa, Tay and Xo Dang make up much smaller percentages (all below 0.7%) (Source: Statistics, 2009).

6 Figure 2: Largest ethnic minority populations in the South Central Coast region, by percentage of total population

1.5 1.5 1.4

1 0.6

Percentage (%) Percentage 0.5 0.4 0.3 0.3 0.3 0.2 0.2 0.2 0.1 0 Cham Hre Raglai Xo Dang Co Tu Cor E De Ba Na Khac Gie Hoa Co Ho Tay Trieng EM in the South Central Coastal region normally live in remote and mountainous areas with difficult living conditions and little economic development. They face many barriers to accessing health services due to significant poverty, limited knowledge of health care services, an inability to speak the majority Kinh language, long distances and time-taken to travel to hospitals and other health centres, and a preference of traditional approaches to health, such as delivering babies at home. In addition, the health system in mountainous areas is sub-optimal and lacks medical equipment. EM health sector workers are limited in quality and quantity, especially at district and commune levels as well as in management positions. These vulnerabilities are further exacerbated by EM failing to fully benefit from development projects and programs.

Objective of the Health Care for South Central Coastal Region Project and its EM Development Strategy

The Health Care for South Central Coastal Region Project is led by the Ministry of Health (MOH), financially and technically supported by the Asian Development Bank (ADB) and was implemented in eight South Central provinces from 2009 to 2014. The goal of the Project is improve the quality of health care while improving access to and use of health services of the people, especially the poor, ethnic minorities, women, and children, thereby contributing to improving the health status of the people in the eight South Central Coastal provinces.

To ensure that any potential negative impacts to EM due to the Project are resolved according to the ADB Policy on Indigenous Peoples and relevant Vietnamese regulations, the Project developed a common strategy for developing and supporting EM in the eight provinces. Its objectives were: (i) provide guidelines to evaluate potential impacts on EM, with evaluations completed by each province during the implementation process; (ii) support the preparation of specific actions to resolve such impacts; (iii) propose interventions to improve basic health services for EM people, including at village level; (iv) propose interventions focused on gender to meet the needs of EM women and children; (v) ensure EM participate in training activities at all levels; and (vi) provide guidelines for the

7 development of information, education and participation approaches to meet the needs of EM in a culturally appropriate and sustainable way.

Based on the Pojet’s basic EM strategy, the eight provinces implemented activities based on strategic indicators integrated with Project components and outputs. From 2009 to 31 June 2014, the Project achieved tangible results in the improvement of EMs’ access to quality health services, enhanced the capacity of EM health workers (HW) at different levels and upgraded health facilities in mountainous areas for poor and EM beneficiaries.

The Central Program Management Units (CPMU) and the Provincial Program Management Units (PPMU sought technical assistance (TA) through Component C25 to collect and analyze the results of implementation of the Project EM strategy and to support Project provinces to develop sustainable Ethic Minority Development Plans (EMDP) based on lessons learnt from the Project. The outputs of the TA were to (i) develop a report on the results of implementation of the Pojet’s EM development strategy, (ii) develop a EMDP template for the health sector in eight provinces, and (iii) support the eight provinces to complete the EM health sector development plan for 2015-2017.

1.2. Objectives

General objectives: Update, analyze and supplement the implementation results of the EM development strategy from 2009 to 31 June 2014 and provide technical support to the PPMU to develop Provincial EM Development Plans and support each PPMUs to complete a EM Development Plan for 2015 - 2017.

Detailed objectives:

 Update, analyze the activity results related to the Pojet’s EM development plan to the end of June 2014  Supplement and complete remaining Project EM development strategy activities  Update the Pojet’s EM deelopet pla monitoring indicator set  Develop a EMDP template for provinces for 2015-2017  Provide technical support to the PPMU to complete development of EM development plans for each province for 2015-2017.

8 2. Methodology

2.1. Review of secondary data

The TA Consultant will review and analyze data based on the Pojet’s EM-related secondary data up to 31 June 2014, including Project documents, EM strategy, annual plans of CPMU and PPMU, annual reports on Project implementation results on CPMU, report on research results from the C23 and C25 consultants related to EM in 33 communes with a high percentage of poor and EM in 11 districts of six project provinces.

2.2. In-depth interviews

In-depth interviews were conducted with CPMU and PPMU leaders in eight project provinces, HWs at provincial, district and commune levels, ethnic minority health workers, and patients to collect information related to EM issues.

2.3. Consultations with related partners

Consultations were undertaken with leaders and staff in charge of CPMU and PPMUs, provincial EM committees, Women’s Unions and Health and Nutrition Centers on solutions to implement remaining Project EM strategy activities and propose province-specific plans after the project completion.

9 3. Implementation Results

3.1. Update and analyze the implementation results of the Project EM development plan according to each Project output

From the early stages and throughout the Project’s implementation process, EM development strategy activities were integrated with those of the four Project components. The EM stateg’s implementation results were summarized and analyzed according to four Project outputs: (i) Improved Health Facilities, (ii) Strengthened Provincial Human Resources, (iii) Improved Access to Health Care for the Poor and (iv) Strengthened Provincial Health Systems Management.

3.1.1. Output 1: Improved Health Facilities

By 31 June 2014, all six indicators related to the poor and EM was integrated into Output 1 activities to achieve 100% of the target. The Pojet’s results and have delivered benefits to EM through access to newly invested and equipped health facilities (HFs), minimized adverse social-economic and environmental impacts on vulnerable people in resettlement areas as well as ensured the voices and interests of EM in affected areas were addressed in equal measure to Kinh people.

HFs in poor and EM districts were prioritized for upgrading construction and medical equipment

According to the database of the baseline survey in 2009, many HFs in Project districts with EM populations were in bad condition and lacked medical equipment. In response, the Project developed criteria to prioritize investment in the construction and supply of medical equipment for HFs in poor, disadvantaged areas with many EM.

Of the 25 HFs upgraded by the Project, 17 (68%) particularly focused on poor and EM people in disadvantaged areas. Given that the proportion of EM in the Project provinces is only 7.4%, this indicates a strong focus on EM. Essential medical equipment was also distributed to 47 HFs in disadvantaged areas.

The voices and interests of EM in the Project areas were heard equally with those of Kinh

During the preparation for the Project activities, withdrawal and resettlement of land was one of the activities associated with the upgrading and building of HFs in Project provinces. Undertaking these activities caused potential risks that could have adversely impacted on people, as 11 out of 25 districts had clearance and relocation activities as a result of construction of health facilities. District resettlement plans focused on land compensation

10 activities, environmental impacts and mitigation measures for people, especially the poor and EM. Resettlement plans were conducted under the supervision of resettlement experts of central and province levels, with coordination with health units and localities, ensuring the voices and rights of EM were equally heard with Kinh people. For example, many EM in Quang Nam province resettlement areas reported to be happy to be located near a highway and upgraded HFs.

The Project provided essential medical equipment to 47 HFs in eight provinces according to proposal list approved by provinces. This equipment promoted efficiency which helped HFs reduce the percentage of referral patients. This greatly improved the quality and access to health care services as well as reduced financial burdens on the poor and EM in remote areas such as Bac Tra My and Dien Ban (Quang Nam) as well as district health centers (DHCs) at Ba To and Tra Bong (Quang Ngai).

Before and during the implementation of construction projects in eight provinces, PPMUs combined with HFs to deploy activities such as Project introductions and community consultations with people. Ten workshops to introduce the Project at CPMUs and PPMUs were held with the participation of 708 representatives. In addition, PPMUs conducted meetings and discussions with affected households (including EM households). On average, each affected area received radio broadcasts at least three times during the HF construction period to inform residents of Project progress as well as the rights and responsibilities of people in surrounding areas. An estimated 70% of affected EM had accessed the Project information.

The Project arranged funding to check impacts on EM - such as a grassroots-level investigation team to consider resettlement and environmental safety issues - as well as meetings with stakeholders and affected people to find solutions.

EM benefited from newly-invested health facilities

Medical equipment has been allocated and utilized by health workers to enhance efficiency, with a reduction in referrals. In particular, this has increased accessibility and reduced cost burdens on the poor and EM patients, especially in Bac Tra My and Dien Ban (Quang Nam province) and Ba To and Tra Bong (Quang Ngai province).

The results of "Research for participatory surveillance on accessibility to health services quality for the poor/EM people in two aspects: the availability of quality health services and financial barriers i oues ith a EM residents (M’Nog, Co, Baa, Ede, Cha, CoHo) in six provinces except Da Nang and Khanh Hoa in 2014 revealed that poor and EM patients had a 70% level of satisfaction with health care services in district hospitals, u from a baseline measurement of 59.5% The satisfaction rate for diagnosis and treatment was 65.6%, medical staff (70.9%), physical facilities and equipment (70.3%) and procedures during health care (57.0%).

11 Examination/Treatment at HF Self-treatment No treatment

95.8 95 100 91.8 91.3 89 86.6 85.5 85.1 84.6 83.3 84 80.5 78.4 80

15.4 14.3 14 13 20 10 12.3 9.612 5 4.14.1 5.8 7 4 6.5 7.2 21.4 2.52.5 2.9 2.6 0 2.4 2 0.6 0 Kinh Raglai CoHo Hre Mnong Xo Dang Co Tu E De Ba Na Cham Gie Cor Total Trieng

Figure 3: Propotion % of utilization of surveyed outpatient services and health seeking behavior of EM in the Project provinces over the last 4 weeks in 33 poor and EM comunes in 11 districts, 2013

Among survey participants who reported being ill in the past four weeks, the proportion of EM attending HF was very high among Raglai (95.8%), Coho (95%), Hre (91.8%), M'nong (91.3%), and Xo Dang (89%), in contrast to Kinh people (85.5%, figure 3).

Nonetheless, a large proportion of people from some ethnicities select self-treatment when sick, including Ede, Bana and Cham (14-15%), or no treatment (Gie Trieng, Cor and Co Tu, 12- 13%, figure 3), largely because they live in remote mountainous areas which makes it difficult for them to reach healthcare. As such, it is important that efforts to increase EM access to healthcare, through EM development plans and other initiatives continue.

3.1.2. Output 2: Strengthened Provincial Human Resources

EM development activities were integrated into Output 2 to improve the management and planning of human resources at provincial level, including strategies such as increasing recruitment and supporting EM health workers, improving the capacity of EM health workers at provincial level through short-term training courses and programs that support long-term training scholarships. By 31June 2014, the Project completed 82% of its workload according to indicator framework (2/12 indicators exceeded targets, 7/12 indicators finished, 2/12 indicators underway and 1/12 indicator not applicable).

With PMU support, all eight provinces finished 5-year HRD plans (for 2012-2015 and orientation to 2020), including strategies to increase recruitment and support EM health workers. Relevant participants from each province were given training on how to create the plan, before developing a plan to fit their specific local needs. The 5-year HRD plans are a positive step by the provincial health sectors: the baseline survey in 2009 identified only one out of eight provinces with an HRD plan that included targets to train health workers in poor and EM communes, train EM health workers at commune health centers (CHCs) and the VHW network.

12 Nih Thua poie’s 5-year health sector HRD plan included some important indicators related to EM such as More than 30% of female and EM taking on leadership at all levels in the health seto i , ad Every year, there will be a 10-20% increase in EM in all HWs receiving post-graduate training and the percentage of EM health workers receiving training and re-training will not fall under 30%.

However, only half of the eight HRD plans – from Binh Dinh, Binh Thuan, Ninh Thuan and Phu Yen - hae ee appoed Poiial People’s Committees. The other four have not been approved due to local budget constraints, which created limitations for the Project and programs, beyond the control of the Project.

The relative proportion of EM health workers granted scholarships for university, post- graduate study and service training was larger than proportion of EM in the population

Within the eight provinces, 85 EM individuals out of 567 health workers received scholarships for university, post-graduate and service training. The percentage of EM health workers granted scholarships was larger than percentage of EM people in the local population (15% versus 7.4%). This is a source of encouragement for the Project and for EM health workers, and creates better motivation to improve qualifications and better serve the EM population.

Percentage of EM students trained in all levels in eight provinces was larger than percentage of EM people in the population

As of June, 2014, the Project had ended all training courses to improve the capacity and support scholarships for 25,270 health workers in all levels of eight provinces. Of these, 2,567 participants were EM (table 1).

Table 1: Total number of health workers and number of EM health workers trained by the project in each province by June 2014 Total 8 Da Quang Quang Binh Phu Khanh Ninh Binh Information prov. Nang Nam Ngai Dinh Yen Hoa Thuan Thuan Total number of health workers 2,44 1,56 25,270 4,528 1,954 3,687 5,342 2,659 3,056 trained by the Project 6 8 Total number of EM health 2,567 5 1,010 412 160 77 227 560 121 workers trained by the Project

Quang Nam, Quang Ngai and Ninh Thuan had the highest number of trained EM health workers (1,010; 560 and 412, respectively), while Da Nang had the lowest (5).

Baseline data from 2009 on the number health workers disaggregated by Kinh/EM was only available for Quang Nam, Ninh Thuan, Binh Dinh, Da Nang . Comparison between the total

13 number of Kinh health workers and EM health workers in these provinces with EM Project- trained participants (from 2010 to 31 June 2014) showed that in Quang Nam, on average, each EM health worker participated in 1.3 training courses.

Similarly, the average rate of participation was 1.2 in Ninh Thuan and 0.78 in Binh Dinh. Da Nang had very few (five), due to the small number of EM health workers (four), so there was an average of 1.2 courses attended by each EM HW. The PPMU and health facilities were successful in encouraging HW, including EM, to participate in training courses, especially Quang Nam and Ninh Thuan. Other provinces have no baseline data for comparison.

The relative proportion of EM among all health workers trained by the Project to improve capacity to support scholarships exceeded the percentage of EM people in the local population (7.4%) as shown in Figure 4.

Proportion of HS/HW attending the project trainning course of all levels Proportion of EM people in population of each province

25 23.5 22 21 21 20

15 13.3

10 10 7.4 8.1 7.4 5.9 5 5.3 5 4 4 4 2.3 0.2 0.5 0 8 province Quang Nam Quang Ngai Ninh Thuan Phu Yen Binh Dinh Khanh Hoa Binh Thuan Da Nang

Figure 4: Proportion of EM health workers trained and granted scholarships by the Project in each province

Quang Nam and Quang Ngai had the most EM participants, with 22% greater than the percentage of EM people in the provinces (13.3% and 8.1%, respectively). Although Ninh Thuan had the highest percentage of EM trained health workers (21%), it is still slightly lower than its percentage of EM populatoin (23.5%). Binh Dinh, Binh Thuan, Da Nang, Khanh Hoa and Phu Yen did not achieve target indicators because no EM in those provinces met the professional requirements for participation in specialized training courses, especially at provincial and district levels.

14 Percentage of training courses including EM participants was limited at provincial and district levels All Project training courses encouraged EM participation. However, the proportion of training courses for HS and HW at all levels with EM participants in provinces was limited in some provinces (figure 5).

Figure 5: Percentage of training courses at all levels within the Project provinces that included EM participants

60 The percentage of Project 50 43 training courses with EM 40 participation was the highest 28 30 26 in Ninh Thuan (43%), but it 22 was also the province with the

Percentage (%) Percentage 20 15 13 11 highest proportion of EM, 10 followed by Quang Nam (28%) 0.2 0 and Khanh Hoa (26%). The Ninh Quảg Khánh Bình Bình Phú Yên Quả Đà Nẵg lowest was Da Nang (2%), Thuậ Nam Hòa Thuậ Địh Ngãi because it has the smallest percentage of EM (0.2%). The PMU and Quang Ngai Health Department should note that although Quang Ngai has the second highest proportion of EM per population and thus a high number of trained EM participants, the proportion of training course in this province with at least one EM participant was very low (11% of training course) and ranked second to bottom. This highlights the lack of EM health workers at district and provincial levels in this particular province.

Provincial-level training courses had few EM participants: EM participants accounted for 1% of training of trainers (TOT) in health colleges and intermediate schools, and only three EM participant attended a provincial-level TOT course on nursing in communes in Ninh Thuan (accounting for 3.7% of participants). Of the Pojet’s 79 medical master scholarships, one EM person from Ninh Thuan was supported with a scholarship to Malaysia. In bridging courses (exam review assistance for university and master’s ouses), no EM passed the Ministry of Education and Training entrance exams.

Limited EM participation, especially in Quang Ngai, could be due to the lack of health sector human workers at district and provincial levels with sufficient professional qualifications, management skills or foreign languages to participate in training courses and receive training scholarships. This again shows the importance and urgency of HRD plans for long-term health sector development, particularly for EM. The lack of long-term plans will limit EM health workers from benefitting from EM development programs and projects.

15 To help provinces overcome this situation, technical assistance is provided to support each province to build plans for EM health sector development during 2015-2017. This work was completed in September and October 2014.

Training materials and research topics focused on EM factors

Project training materials addressed EM-specific issues, especially in TOT courses on nursing at commune level, obstetric emergencies and communication encompassing postnatal mother and infant care, nutrition for children under 5-years-old, and treatment for sick children. Officials and medical staff received training on health staff attitudes to EM patients. The culture, habits and perceptions of EM people were also highlighted in communication skills training courses.

No training courses used interpreters with multi-lingual skills, because the lowest qualification of health staff was primary school, which means all participants could speak Vietnamese. However, according to the supervision consultant in the health and nutrition communication skills training courses in Phu Yen and Quang Ngai, trainers and participants were willing to use the relevant minority languages to help participants clearly understand new words.

In supporting provinces to conduct health care research, the Project emphasized research criteria related to gender and EM. By 2013, two out of five research projects funded and accepted by the Project focused on gender and EM, including research in Khanh Hoa on Cuet status to provide and use health care services in CHCs of Khanh Hoa island oue i that encompassed EM factors.

3.1.3. Output 3. Improved Access to Health Care for the Poor

The focus on the poor and EM is displayed in Output 3, through a number of activities such as improving skills of VHWs, increased EM awareness of health care and nutrition, as well as strengthened health insurance (HI) for the poor and EM. By 31 June 2014, the Project completed 14 of 15 indicators with one Ongoing indicator, achieving 93% of its workload according to the indicator framework.

Skills of village health workers in remote communes were improved

In the provision of health service systems, VHWs play a vital role as they help provide primary health care services to people and act as a bridge, especially poor/EM people who struggle to access quality health services. Therefore, the Project focused on activities to improve capacity for VHWs through training courses of 1 week, 1 month and 3 months. According to the results of component C, as of June, 2014 the Project completed 100% of training and re-training courses for VHWs over 1 week, 1 month and 3 months. A total of 1,105 EM participated in three training courses, accounting for 20.7% of participants. The

16 number and proportion of EM participants trained in three courses by the Project is detailed in Figure 6.

17 Quantity of trained EM HS/HW Proportion of trained EM HS/HW

1000 1 892 900 800 0.8 700 600 0.6 500

400 329 0.4 300 200 144 0.2 94 111 100 66 67 0 0 0 Da Nang Quang Nam Quang Ngai Binh Dinh Phu Yen Khanh Hoa Ninh Thuan Binh Thuan

Figure 6: The number and percentage of EMs attending VHW training courses organized by the Project

Quang Nam had the highest number and proportion of EM participants trained by the Project (892 people, 39%), followed by Quang Ngai (329, 32%), Ninh Thuan (111, 37%), Binh Dinh (114, 7%) and Khanh Hoa (94, 12%). Da Nang had no EM training participants.

In 2013, a Rapid Assessment Survey was conducted among 192 VHWs working in 33 communes with high numbers of poor and EM within six of the eight Project provinces. Of there, 67.8% were EM, 66.7% were female and 55.5% were EM female. The results of this survey indicated that 69% of surveyed VHWs had been trained on village health and midwife skills (1 week, 1 month, 3 months). Of these, 50% were trained on village health by the Project. Details are displayed in Figure 7.

Proportion of VHW receive training on VHW Proportion of VHW receive training on VHW from the project

100% 96% 100% 92% 93% 86% 87% 79% 75% 75% 69% 69% 69% 61% 58% 59% 53% 50% 50% 50% 47% 50% 33% 25% 24% 23% 25% 18% 17%

00% 0% Kinh Gie Trieng Co Tu Cham Hre Ba Na M Nong Raglai Co Ho Cor E De Xo Dang General

Figure 7: Proportion of surveyed VHWs in 33 communes trained by the Project and others courses, 2013

The proportion VHWs from Co Tu, Cham, H're and Gie Trieng ethnicities trained by the Project was high, around 50% of total number of surveyed VHWs. This suggests that the

18 training program for VHWs made a substantial contribution to providing training for VHWs in general and EM VHWs, in particular.

Network of EM health workers, VHWs of CHCs in remote areas strengthened and extended

Project training activities for VHWs made important contributions to localities expanding and consolidating VHW networks, particularly EM VHWs. The results of the 2013 RAS, undertaken in 33 communes in 12 high EM population districts in six Project provinces, showed that virtually all surveyed villages had a VHW, most of whom were EM. In addition an increasing number of VHW in these districts now meet MOH guidelines in terms of training and qualification (figure 8).

% surveyed village having VHW % surveyed VHF having EM VHW % surveyed VHW met MOH requirements on qualification

1.2

100%100% 100%100% 100% 100%100% 100%100% 100%100% 100% 100% 100% 100% 100% 100% 99% 1 93% 95.200%95% 92% 90.00% 89.100% 83.300%83% 83.300% 0.8 75% 68% 64% 59.100% 57% 55% 0.6 50% 39% 0.4

0.2 6%

0 Nam Giang Tay Giang Bac Ai Song Hinh Son Tay Vinh Thanh Tra Bong Phuoc Son Son Ha Ham Thuan Ninh Phuoc General Bac

Figure 8: Characteristics of VHWs in 12 districts with high EM populations in six Project provinces, 2013

Further work is needed, however, in districts such as Son Tay in Quang Ngai province. Son Tay idstrict is home to many Xo Dang. While 100% of their village health workers are EM, only 5.9% of the VHW meet MOH guidelines, and no one participated in the Project VHW training courses.

Some 1,665 people including both Kinh and EM 11 districts in six Project provinces were surveyed in 2103 to assess their satisfaction with about their satisfaction with VHW. The popotio of of EM ho ee satisfied ad e satisfied ith VHW atiit as e high, especially for Co Tu, Co Ho, Gie Trieng, Hre and Raglai. The percentage of those dissatisfied as e lo, aoutig fo less tha % aog a ethi goup.

19 Dissatisfied Satisfied Very satisfied

100.00%

75.00%

76.900% 73.600% 82.900% 79.300% 92.400% 88.500% 88.200% 88.00% 87.400% 85.800% 85.800% 50.00% 98.400% 93.600%

25.00%

18.800% 22.400% 25.700% 10.900% 11.800% 10.900% 10.700% 12.600% 15.800% 13.300% .00% .800% 6.400% 7.600% Hre Gie Co Tu Co Ho Kinh E De Cor Ba Na Xo Dang M Nong Cham Raglai General Trieng

Figure 9: Percentage of EM from 11 districts in 6 Project provinces who were satisfied with VHW, 2013 Information, Education, Communication (IEC) program on health and nutrition with a focus on EM

The IEC program on health and nutrition, implemented under the C25 service package, focused on the specific needs of needs of EM. The IEC program included an IEC needs- assessment of EM on health and nutrition, development of IEC strategy based on needs of EM and Project targets, development of IEC materials with key messages, determination of IEC targets and suitable IEC forms, development of IEC training materials and manuals for educator networks, pretest of the model IEC program in areas with high rates of EM, organization of TOT training courses on IEC skills on health and nutrition with integration of EM languages in provinces. It also included the supervision of training courses on IEC skills on health and nutrition with integration of EM language implemented by PPMUs for health workers who participated in IEC activities at commune and district levels, supported some PPMUs to implement workshops on mobilization of communities in improving reproductive health care and nutrition for the poor and EM, development of commune level IEC plans and implementation of an IEC strategy.

The IEC consulting firm held eight TOT workshops for PPMUs representatives and IEC trainers of eight Project provinces with 20 trainees per course. The PPMUs then trained educators and VHWs (two courses per province) and an IEC advocacy workshop (one workshop/province) with the number of EM members displayed in Table 2.

20 Table 2: Percentage of EM participating in IEC activities implemented by PPMUs

Total Total EM Percentage of EM Content participants participants participants Training on IEC skills on improving health and nutrition integrated with EM language (eight 646 239 37% provinces) Workshop on mobilization of communities in improving health and nutrition for the poor and 587 88 15% EM (in Khanh Hoa, Ninh Thuan, Phu Yen, Quang Nam and Quang Ngai)

The percentage of EM who participated in the IEC skills training courses was highest of all Project training courses and proved a central part of the IEC program for EM. According to the consulting firm assessment on IEC training courses in Quang Ngai "the IEC trainers of the province complied with the IEC program and materials designed by the consulting firm, the training classes were lively". The H're and Cor participants reported finding the training methods understandable, the trainers enthusiastic, the examples diverse, the content practical and consistent with EM people.

IEC materials are diverse and suitable to EM

IEC materials were diverse and suitable to EM with the communication methods and target objects, including science education films, five types of flipcharts and communication handbooks.

The science education films in DVD form were translated into ethnic languages such as Bana, Bonong, Hre, Kotu, Kadong, Kor and Raglai by all Project provinces, except Da Nang which has a very small EM population. Each DVD included five films about women’s health care during pregnancy and delivery, postpartum and infant care, and nurturing children under 5 years old. A IEC center leade said: The H’re ad Kor fil at Quang Ngai was viewed by EM health workers who had worked for a long time in the medical and culture sector, and received quite good feedback. The content of the films were culturally appropriate and presented in the relevant minority language. The flims were presented at CHC and village communal centres. In total, 4,237 DVD films were distributed to all levels, with 2,536 DVDs (60%) translated into ethnic languages such as Bana, Bonong, Dadong, Hre, Kor, Kotu and Raglai in Quang Nam, Quang Ngai, Binh Dinh, Khanh Hoa and Ninh Thuan (table 3).

21 Table 3: Number of iEC films translated into minority languages Translated DVD Province Language Number of DVDs Five types of flipcharts conveyed Quang Nam Kotu, Bonong, Kadong 1,305 messages related to health care for EM 470 including properly complementary Quang Ngai H’e Kor 197 feeding for children, treating children Binh Dinh Bana 88 with diarrhea and respiratory Khanh Hoa Raglai 350 infections, maternal health care, Ninh Thuan Raglai 126 raising child fully breastfed and infant 2,536 Total care. The flipcharts were assessed by participants to be closely meeting the needs of EM, as they were innovative and culturally appopiate. Some 451,985 flipcharts were distributed to districts and communes at communication meetings.

The communication handbook was designed as a manual to be useful for health workers, VHWs, population and nutrition collaborators and Project communications staff. The handbook was assessed by participants as useful for planning and implementing communication activities on health care and nutrition for the poor/EM. Some 20,172 handbooks were printed and distributed to communicators by eight PPMUs at all levels.

Regular communication methods and campaign for EM

Regular communication activities for EM included direct communications (visiting households, group communication in communities and at CHCs) and indirect communication through radio broadcasts to districts and communes. Beside, communication programs included irregular activities such as communication campaigns (cultural exchanges for mothers on health care topics, for mothers and children on health care topics and communication at EM festivals).

A local challenge was Project communication activities were only implemented at district and commune levels through training communication networks, designing communication programs for communities and cloning leaflets. Connecting CHCs to EM communities requires integrating Project communication content into national and provincial programs after the Project’s opletion.

Survey results showed there were still awareness gaps in ethnic groups using health care services as in Table 4.

22 Table 4. Percentage of women using all reproductive health care services by ethnic group, in 33 villages, 2013 ANC at least Have enough Multi-vitamin Deliver with Deliver at HFs Ethnic three times Tetanus doses supplement tablets HW support (%) (%) (%) (%) (%) Kinh 79.6 83.3 70.4 96.3 96.3 Cham 84.8 79.7 65.8 86.1 98.7 Ba Na 79.2 61.1 43.1 70.8 73.6 Raglai 74.7 70.9 69.6 82.3 83.5 Co Tu 56.1 74.4 59.8 87.8 87.8 M’Nong 55.0 92.5 60.0 87.5 87.5 Co Ho 55.4 67.5 77.1 60.2 60.2 Cor 55.2 81.6 47.1 52.9 54.0 Hre 52.4 84.1 63.5 69.8 69.8 E De 51.3 53.8 20.5 73.1 74.4 Gie Trieng 25.4 78 50.8 69.5 81.4 Xo Dang 58.9 71.4 35.7 28.6 32.1 Total 61.2 73.8 55.3 71.8 74.6

Despite good achievements among most ethnic groups, there is still only a low proportion of Xo Dang women delivering at HFs and with HW support, and the proportion of these women who take multi supplement tablets or have three ANC appointments is also low. There is an oppotunity for ongoing efforts amonth this community to build on the achievements of the Project.

Reduce financial barriers and enhance participation to health care services for the poor and EM households

During the Pojet’s implementation, the Government changed policies to support the poor adn EM to access health care services. The changes included the transfer from Health Care Fund 139 to Health Insurance Law 25/2008/QH12 from 2009 and Decision No.14/2012/QD- TTg on amending and supplementing some articles of Decision No.139/2002/QD-TTg on providing support to the poor for incidental expenses related to helath care and hospitalization, such as for food and transportation. when having treatment in hospitals. To support provinces to implement this policy, in 2012 the CPMU in collaboration with Viet Nam Social Insurance and Health Insurance Department (MOH) conducted training on health insurance laws and payment methods for 60 leaders of the department of health (DOH), provincial/district hospitals and staff in charge of health insurance in eight provinces.

The CPMU engaged consultants under component C23 and C25 of the Project to conduct research and provide recommendations related to EM access and use of health care services, communication with EM and the role of VHWs. The surveys included: - Rapid assessment on status of providing and use of community health care services, especially for the poor and EM and women in the South Central Coastal region 2014

23 - Research on the status of quality health care services access of the poor and EM in the South Central Coastal region 2013 - Research on status of village health workers and their role in improving access to health quality services for the poor and EM in the South Central Coastal region 2013. - Research on conversion of the healthcare fund for the poor to the healthcare insurance fund and impacts to healthcare service access of the poor/EM in the South Central Coastal region 2013 - Report on communication needs of communities on reproductive health and nutrition in the South Central Coastal region 2013 - Research the status of health care access for the poor and EM in the South Central Coastal region 2013. - Assess the status of reproductive health services for EM mothers and ability to meet the needs of CHCs and DHCs/district hospitals in eight provinces in the South Central Coastal region 2012-2013.

The Poposal fo tial iteetios to ehae ualit of health ae seies at distit hospitals in South Central Coastal egio was conducted at Nam Giang district hospital in Quang Nam. The aim of the trial was to (i) establish and strengthen the hospital’s quality management system, (ii) train key staff on quality management, patient safety, infection control as well as develop, and (iii) supplement and update specific regulations on professional and technical guidelines at the hospital. Work was also done to improve instruction services, reception and guidelines for patients, especially for the poor and EM.

The results of research and Project trial intervention were widely shared among relevant stakeholders in eight provinces through workshops and trainings, as well as two regional workshops in September 2014 to provide information and data to develop annual EM development plans for 2014-2016.

Enhance knowledge of the poor and EM on their rights when insured

The report Research on conversion of healthcare fund for the poor to healthcare insurance fund and impacts on healthcare service access of the poor/EM in the South Central Coastal egio, covering 33 EM communes in six project provinces in 2013 showed that the percentage of EM with health insurance cards in the survey site was high and more than 90% for Gie Trieg, Raglai, CoHo, M’og, He, Baa, Co (figure 10).

24 Figure 10: Percentage of people with HI cards by ethnic group in survey sites, 2012

95.8 94.9 94.6 94.2 94.2 100 93 91.2 89.9 84.9 84.7 80.4 80

60 52.9 52.3

0 Gié Triêng Raglai Cơ Ho M'Nông Hre Bana Cor Cơ Tu E Đê Xơ Đăng Kinh Chăm Tổng

According to this study, the percentage of people with HI cards in 2012 in poor/EM communes in the South Central Coastal region was quite high compared to the regional and national average (84.7% compared with 62.3% and 67%). In addition, 74% of poor and EM interviewed at the survey sites, kne aout the right to health examinations and teatet.

3.1.4. Output 4: Strengthened Provincial Health Systems Strengthened Provincial Health Systems Management

To improve health system management and better meet EM needs, the CPMU organized study tours for a number of management staff and leaders from eight provinces. One tour to China focused on health system, hospital and project management, another to Germany and Sweden covered health system and hospital management as well as HI innovation. The PMU also organized study tours to China, Korea, Sri Lanka and Thailand for 49 management staff from the provinces, PMU, MOH, Ministry of Planning and Investment and Ministry of Finance representatives. These tours were well received by DOH leaders to improve management capacity.

The Project also gave scholarships to 11 HWs for master’s courses on public management and public health.

All eight provinces updated 5-year plans and brought mid-term target frameworks into the Pojet’s EM strategy including specific targets and activities for EM with provincial annual action plans. However, only half of the eight plans have been approved by PPCs.

Strengthened Hospital Management

Hospital management and financial management training was evaluated as practical by local participants to help hospitals effectively implement Decree 43’s financial autonomy mechanism. Only a very small percentage (1-2%) of EM HWs participated due to few in health sector management positions (table 6).

25 Better Health Management Information Systems

In 2012 and 2013, the Project provided Health Management Information System (HMIS) and Medical Information System MIS for 40 hospitals in provincial and district levels. These management systems provide accurate information on human resources, finance and take- up of services. This helps hospital management and clinical staff improve service quality and operational efficiency to meet EM health care needs.

Effective Project Management Support

Right from the start of Project implementation, eight PPMU and one CPMU were established. PMU members received capacity building through workshops, with training on planning and monitoring, including gender and EM issues. However, there was only one EM from Ninh Thuan PPMU and Provincial Steering Committee (PSC) present as few met professional and work position requirements for PPMUs and provincial PSCs.

A resettlement expert (8 person-months) was recruited by CPMU. An international consultant on gender and social development and a national consultant on social development were contracted by the CPMU to support the PPMUs to develop gender and EM action plans.

The CPMU initially organized one workshop for each of eight provinces on EM and gender development to guide provinces’ Project implementation. Khanh Hoa and Ninh Thuan held workshops, with the participation of 580 stakeholders (EM: 3%).

C23 Consultant is currently provide technical assistance to eight PPMUs to develop EM development plans for 2015-2017, based on lessons learned from Project implementation in each province. This process was supported by workshops and trainings for eight provinces in implementing and monitoring these plans, held in October 2014.

3.2. Updated results of implementing strategies according to indicator framework

The results of implementing EM development strategies were integrated into four Project components. The evaluation of the implementation strategy is based on the pre-defined monitoring indicators (table

26 Table 5: Updated achievements of key monitoring indicators, 31 June 2014 Total On- Not Not Project output Exceeded Completed indicators going completed applicable 1 Output 1: Improved Health 6 6 0 0 0 Facilities 2 Output 2: Strengthened 12 2 7 2 0 1 Training Capacity 3 Output 3: Improved Access to 15 0 14 1 0 0 Health Care for the Poor 4 Output 4: Strengthened 15 0 11 0 0 0 Provincial Health Systems Total 48 2 42 3 0 1

In total there were 48 target indicators for the strategy

Two indicators (4%) exceeded targets

. Percentage of EM health workers receiving scholarships for graduate, post- graduate, specialization education equivalent to the percentage of EM in the community (15% compared with 7.4%) and

. A 50% increase in the percentage of EM knowing how to use HI cards.

42 indicators (87%) met evaluation criteria.

Three remaining indicators (6%):

. Four out of eight provinces have developed 5-year plans and the medium-term expenditure frameworks, including Project EM strategies and had been approved thei Poie People’s Coittee.

. Development activities to connect poor and EM communities with commune and district HFs, PPMU and local partners having information on health care and risks to ethnic groups. Communication materials printed and distributed at grassroots level. Communicator networks trained and local partners pledged support.

. Provinces with specific targets and activities for EM, including annual action plans. Eight provinces have completed EM development plans for 2015-2017, with technical support through component C23.

Two indicators achieved on in only Ninh Thuan were: PMU established with an EM representative and involved in the Project steering committee because PPMU and PSC employees need to meet professional requirements outlined in the Project terms of reference.

One indicator (2%) as deeed ot appliale due to lo dead

27 . Number of training courses with EM participants using multi-language interpreters. For further details see Annex 1. 3.3. Analysis of Project strengths, weaknesses, lessons learned and concerns related to EM 3.3.1. Project strengths related to EM

The results of the EM strategy have significantly contributed to the Pojet’s goal: To improve the quality of health care services and access to and use of health care services for people, especially the poor, EM, women and children, thereby contributing to improve health status of people in eight provinces of South Central Coastal region.

EM development issues were prioritized from the Pojet’s initial stage as shown in the EM strategy and monitoring indicator framework.

HFs received investment and medical equipment, prioritized for less developed districts with large EM populations, to reduce referrals, increase access to quality health services and reduce cost burdens on poor and EM patients. These investments contributed to increasing the reported satisfaction with health services among poor/EM patients from 59.5% at baseline to 70% by the end of the Project. This shows that Project investment made positive contributions to improving grassroots level HFs in the Project area.

All training courses, scholarships for graduate and post-graduate studies were prioritized for EM to strengthen health sector human resource capacity in the eight provinces. All training materials highlighted EM issues and were well received by participants.

Project training and re-training activities for VHWs, especially for EM VHWs, were highly appreciated by local partners in terms of quantity and quality. This helped strengthen capacity building and expand CHC/VHW networks in remote areas to ensure each remote EM communities had at least one trained VHW.

All communication activities, including TOT courses and training courses on communication skills to enhance health care and nutrition received active support from technical consultants, with the participation of CPMU and local partners. Communication materials were highly appreciated for their diversity, cultural sensitivity and ability to support EM. Communication materials distribution to grassroots levels, communication networks properly trained, health sector leaders, Government and related organizations’ commitments to implementation will ensure communication programs remain effective after the Project’s completion.

PPMUs were trained on Project management in EM areas to implement activities, enhance management, and to monitor Project impacts on EM. Information management software

28 helped manage, update and analyze information about ethnicity and income of HS/HWs and patients.

3.3.2. Project weaknesses related to EM

The 5-year HRD plans for 2011-2015 (including specific targets and activities for EM and annual action plans) in four out of eight provinces were not approved by PPCs due to budget constraints. This had a significant impact on the implementation of annual EM health care development plans in the South Central Coastal region.

To overcome this problem, in September 2014 technical assistance was provided to eight project provinces to develop and submit EM development plans for 2014-2016. Eight workshops and trainings will be organized to introduce and guide implementation of the plans in each province and 2 another regional workshops will be held in October 2014.

The technical assistance through components C23 and C25 were mobilized more slowly than expected, limiting the effectiveness of activities. If implemented on schedule, communication activities would have more effectively connected with EM communities and would likely have increased the achievement of certain indicators, including the proportion of pregnant women who had three or more ANC appointments, proportions who gave births at CHCs, or a decreased proportions of EM children under 5-years-old with malnutrition within the Project area.

3.3.3. Lessons Learned EM development should be include in the project at the design stage

The EM strategy and monitoring indicator framework were designed by the Project and distributed to provinces form an early stage of the Project. This helped CPMU and provinces undertake implementation, monitoring and reporting of strategy results.

The EM development strategy and Project objectives were consistent and EM development activities were integrated into all Project components and outputs. This allowed EM development activities to positively contribute to the Pojet’s success.

EM development priorities are specified in the criteria of the project

All Project criteria - such as selecting HFs for upgrades, providing essential medical equipment, trainings, workshops, national and international scholarships and research support - followed specific Project regulations to prioritize EM development based on the monitoring indicators. This meant EM development activities were implemented by eight PMU and the majority of indicators were fully implemented by 31 June 2014.

29 Focus on improving health sector professional capacity and social development regarding poverty, EM and gender

Aside from focusing on specialization training and providing national and international scholarships for HWs in the eight provinces, the Project also engaged in research activities on social issues related to women, poverty and EM. The research assessed access and use of health care services and issues related to HI from the perspective of the poor and EM, the role of VHWs and trial interventions to improve the quality of HF services. The research results will be widely shared with stakeholders in the eight Project provinces to improve EM health care in the South Central Coastal region. Provinces can now utilize gender and EM research results and data to develop, implement and monitor annual EM development plans to ensure the Pojet’s sustainability.

Establish Central to PPMU monitoring system

In addition to general Project supervisors, CPMU staff were in charge of monitoring Project activities related to gender and EM. In each of the provinces, PPMUs also assigned staff to regularly monitor and update information related to this work. The recruitment of professional consultants to conduct research and provide social development bidding packages were important factors in implementing and monitoring EM development activities carried out in a systematic way from central to province levels and in HFs.

3.3.4. Project issues needing greater focus on EM Some key EM issues needing continued Project focus include: 1. Approve all provincial 5-year HRD plans including specific targets and activities for EM: The PPMU and DOHs of four provinces need to pay more attention to the approval process. 2. EM development plans: None of the eight provinces have such plans. PPMUs and DOHs will quickly develop EM development plans for 2015-2017 by September 2014, with the appropriate technical support. 3. Communications between CHCs and EM communities: Community program communications have strategies, materials, communication testing and TOT for provincial communication lecturers already developed within the Project. The grassroots communication staff was trained by eight PPMUs on health and nutrition communication skills. Communication materials in Kinh and EM languages were distributed at all levels. Related partners committed to participate and support such communication activities. Such community program communications will enhance awareness and change EM people’s behavior to enhance their ability to search, access and benefit from quality health services.

30 3.4. Develop a plan to implement remaining activities

To continue supporting PMUs to address EM issues, the following activities are planned towards completion of the Project:

Table 6: Remaining activities and task assignment towards the end of the Project Activities Time Responsibility Finalize results report on EM strategy implementation. 5/9/2014 C23 consultant Update indicator framework Develop provincial EM health sector development plan 5/9/2014 C23 consultant framework Support eight provinces to develop EM health sector 15/8 to 5/9/2014 8 PPMU + consultants development plans Complete provincial health sector EM development plans 8/9/2014 C23 consultant Receive CPMU and ADB comments on the implementation 9/9/2014 C23 consultant ADB, report and provincial health sector EM development plans CPMU Receive atioal epets’ comments on the 17-18/9/2014 C23 consultant implementation report and provincial health sector EM International development plans consultant Workshop to presenting results (integrated with C23 consultant CPMU workshops): International - Regional workshop - one in Da Nang 17-18/10/2014 consultant PPMUs - Regional workshops - two in Ninh Thuan 29-30/10/2014 Local representative Workshop and training on Gender and EM Development 10/2014 C23 consultant CPMU Plans, in Da Nang International consultant PPMUs Local representative

31 4. Conclusion

The CPMU and provinces implemented EM strategy activities and integrated them into components as shown in Project outputs. The successful implementation of EM development activities significantly contributed to the Pojet’s overall objective to Ipoe the quality of health care services, and improve access to and use of health care services for people, especially for the poor, EM, women and children, thereby contributing to improve the health status of people in eight provinces in the South Central Coastal egio. Project investment was targeted and consistent with Government priorities to enhance grassroots level HFs in remote and EM populated areas.

The Project took an innovative approach to meet the needs of people, especially the poor and EM. The prioritization of EM development was integrated into training activities to improve capacity at all levels, with investment to upgrade HFs and provide equipment, while improved communication channels atiulated the Pojet’s true benefits to the poor and EM through improved access and use of quality health care services.

Updated indicator framework results show the Project completed 93% of monitoring indicators. Two indicators exceeded expectations: (i) Percentage of EM health workers receiving scholarships for graduate, post-graduate, specialization education equivalent to the percentage of EM in the community (target 7.4%, achievement 15%) and (ii) the percentage of EM who have an HI card, know their rights around HI, and know how to use HI cards in increased significantly from the project baseline in 2009. Some 42 indicators were completed (87% of all indicators), with three remaining indicators (6% of all), and one indicator that was deemed to be not applicable.

The Pojet’s prominent EM-focused activities encompassed infrastructure investment with equipment supplied for district hospitals in disadvantaged areas, capacity building training for EM health workers especially for VHW networks and strengthened medical system management capacity. Training and communication materials effectively engaged EM in a culturally appropriate manner. Research topics relating to gender and EM were prioritized for support.

Research to evaluate and enhance access to and use of health care services and HI for women, children, the poor and EM were supported and results will be widely disseminated with stakeholders to help provinces fully understand EM health sector development issues.

Technical assistance has been provided within the C23 component to support the implementation of remaining activities such as developing the EM development plans (EMDP) for the health sector in the period 2015-2017. These plans had been completed and approved by all eight PPMUs and the CPMU in October 2014.

32 5. Recommendations

For ADB and CPMU: - Greater policy impacts on Project PPCs are required, with an accelerated approval process for 5-year provincial HRD plans, including EM HRD plans - Widely disseminate lessons learned from the Project’s EM development to stakeholders. This includes research results from the evaluation of access to health care services to enhance EM access to quality health care services in the South Central Coastal region. For PPCs: - Work towards approving 5-year health sector HRD plans, including EM HRD plans and allocate budgets for implementation.

Direct departments and relevant Government agencies, including mass organizations in each province to coordinate implementation of EM development plans to improve EM quality of life and narrow the development gap between EM and Kinh. DOHs and HFs should: - Complete EM health sector development plans for 2015-2017 and implement such plan at all levels to develop EM health human resources in quantity and quality, with lessons learned from the Project. - Prioritize investment to upgrade and provide equipment for HFs in disadvantaged areas to improve access to quality health services for the poor and EM. - Study appropriate policies to attract a more highly qualified workforce to HFs in mountainous and remote areas. Prioritize training for EM workers at all levels. - Coordinate solutions to increase the proportion of people with HI cards, to ensure 100% of poor/EM people have HIs. Enhance communication to expand HI coverage of the poor and EMs. Implement policies to support indirect fees for the poor/EM during inpatient treatment at hospitals, especially provincial ones. - Increase communication with communities on safe motherhood practices, with special attention to births at HFs or with HWs’ support. Enhance training on delivery techniques for VHWs in areas with high percentages of home deliveries, including areas with high populaitons of Xo Dang, Cor and CoHo. Integrate Project communication programs into national and provincial communication programs in mountainous areas to enhance EM awareness of health care. - On an annual basis refresh training and update professional knowledge for VHWs (treatment of common diseases, mother and child health care, abortions, reproductive infections/STDs), with enhanced health education and nutrition communication skills and related information/knowledge (such as VHW duties, HI, information on health services at provincial/district hospitals). Provide sufficient equipment, tools, supplies and materials for VHWs. - Mobilize the active participation of Government and mass organizations to change EM customs and practices harmful to health with support from VHWs.

33 6. References

1. Report of the Provincial Social Insurance Agencies in (2012) 2. Baseline study report on access of health services quality of the poor and EM in South Central Coastal region (2013) 3. MOH, Planning on health protection, promotion and human protection (2011-2015) 4. MOH, Health Statistics Book (2011) 5. MOH, Hospital work-load reduction project (2012–2020) 6. MOH, Healthcare Support Project in South Central Coast region (2013). Research Report on status of village health workers and their role in improving access to health quality services for the poor and EM in South Central Coastal region 7. MOH, Healthcare Support Project in South Central Coastal Region (2014). Rapid Assessment Report on status of providing and use of community healthcare services, especially for the poor and EM and women in the South Central Coastal region (2014) 8. MOH, Healthcare Support Project in South Central Coastal Region (2013). Research Report on conversion Healthcare fund for the poor to healthcare insurance fund and impact to healthcare service access of the poor/EM in the South Central Coastal Region (2013) 9. General Statistics Office, Survey of Household Living Standards (2012) 10. Prime Minister, 2013 Decision No. 2405/QD-TTG for approved list of special difficult communes, bordering communes and safety zones covered by Program 135 in 2014 and 2015 11. General Statistical Office, Statistical Yearbook (2012) 12. Prime Minister, 2013 Decision No. 122/QD-TTg issued in 10 January 2013 approving the national strategy for health protection, care and improving people's health in period 2011-2020, and vision 2030 13. General Statistics Office, Census of Population and Housing (2009) 14. MOH, Healthcare Support Project in South Central Coast region (2012). Initial Survey Report of Healthcare Support Project in South Central Coast region 15. Institute of Strategy and Health Policy - MOH (2010), situation analysis and proposal for allowance amendments for health officials, Sept. 2010, Ha Noi.

34 Annex

Annex 1. UPDATED PROJECT RESULTS ON EM IN INDICATOR FRAMEWORK

Anticipated Anticipated Proposed Actions to Enhance Impacts and Mitigate Risks Achieved by 31 June 2014 Evaluation Impacts Risks Output 1: Improved Health Facilities - New and Upgraded Health Facilities and Equipment Improved Water, Sanitation, and Waste Management ● Improved ● Minor: Budget made available for (i) screening potential impacts on Budget was available for (i) screening potential impacts on Complete facilities and Ethnic ethnic groups, mitigating impacts, managing risks, and ethnic groups, mitigating impacts, managing risks, and equipment for minorities not developing enhancement measures; and (ii) monitoring and developing enhancement measures; and (ii) monitoring and hospital services in accessing evaluation activities disaggregated by gender, ethnicity, and evaluation activities disaggregated by gender, ethnicity, and ethnic minority upgraded income. income. areas facilities  Iopoate ADB’s idigeous people heklist as pat of Sub-project preparation procedures was referred the ADB’s Complete  Improved access the overall sub-project preparation procedures. indigenous people checklist to health facilities Consult with EM communities during sub-project preparation - 10 workshops organized with 708 participants at all levels Complete for ethnic and before the start of sub-project construction. - 11 resettlement plans well implemented ensuring the rights minorities of EM people are equally upheld with Kinh people. ● After upgrading, ensure ethnic minorities are informed of - Estimated 70% of affected EM accessed information on new Complete the new facilities and their rights to free health care at HFs and on their rights to free health care in HFs facilities. - 68% of invested HFs in poor and EM populated districts. Output 2: Strengthened Provincial Human Resources - Improved Provincial Human Resource Planning and Management - Improved Provincial Training Capacity - Improved Quality and Availability of Staff HRD Policy Studies Conducted Increased number  Minor: HRD plans include strategies to increase the recruitment and - Eight provinces completed 5-year HRD plans (for 2012-2015 On-going of women and EM Individuals promotion of EM staff. and orientation to 2020), including strategies to increase

35 Anticipated Anticipated Proposed Actions to Enhance Impacts and Mitigate Risks Achieved by 31 June 2014 Evaluation Impacts Risks health workers in from smaller recruitment and encourage EM staff. targeted ethnic groups - HRD 5-year plans in four provinces (Binh Dinh, Binh Thuan, communities did not meet Ninh Thuan and Phu Yen) approved by PPCs requirements  Ensure provinces establish and reach training course - Total of 2,557 EM trained and received scholarships (10%), Complete to participate targets for women and EM at all levels. higher than percentage of EM per population of eight in training. provinces (7.4%)  Health workers trained to recognize and understand health- - HWs trained on health-seeking behaviors of EM during Complete seeking behaviors of EM. training courses on VHW, communication skills and HIV.  Teaching materials will be gender and ethnically sensitive. - Ethically sensitive and comprehensive training materials for Complete EM in TOT courses on: nursing at commune level, obstetric emergency and training course communication skills to enhance health care and nutrition with EM languages.  Use of interpreters with multilingual skills as necessary and - N/A for training courses due to no demand. N/A feasible. Improved quality of  Health workers from and/or serving EM communities given - Some 1,106 EM HW (20%) out of 5,322 HWs trained on Complete health workers priority for training. VHW courses. serving ethnic  Participation records to be disaggregated by gender, - 239 EM (37%) trained on communication skills to enhance minorities ethnicity and other appropriate information. health care and nutrition with EM languages - Participation records disaggregated by gender, ethnicity and other appropriate information.  Targets for percentages of training participants and - 15% of training participants and scholarship recipients were Complete scholarship recipients from EM groups are proportional to EM, proportional higher than EM in local populations the ethnicities of the local populations. (7.4%).  Ensure that EM are targeted for scholarships to upgrade to - 85 EM were targeted for scholarships to bachelor level, Complete bachelor level and receive post-graduate and pre-service post-graduate and pre-service training. training.  Ensure HRD planning capacity development specifically - HRD planning capacity development plans to address EM On-going addresses EM issues. issues for 2015-2017 are being developed by PPMU and technically supported by C23 consultant and will be completed in October 2014.

36 Anticipated Anticipated Proposed Actions to Enhance Impacts and Mitigate Risks Achieved by 31 June 2014 Evaluation Impacts Risks Output 3: Improved Access to Health Care for the Poor - Better Skilled VHWs in Remote Communes - Health and Nutrition Promoted in EM Communes Reduced Barriers to the Health Care Funds for the Poor Improved basic Ensure one trained and fully resourced VHW is present in - Ensured almost 100% of villages in the 33 poorest Complete health care for every remote EM community. communes have VHWs remote communes - 69% of VHW in the 33 poorest communes trained, 50.1% and EM VHW trained by the Project  Expanded and - 3,700 VHWs equipped with VHW Equipment Bags by the strengthened Project. network of CHS  Develop and implement activities to link poor and EM - 239 EM VHWs (37% participants) attended training and 88 On-going staff, VHWs and communities with commune and district health facilities. EM health staff (15% participants) attended workshops on other volunteers in  Trainings and workshops open to all ethnic groups, and health and nutrition. The percentage of participants from remote areas participation records disaggregated by gender and ethnicity. small EM groups was higher than the proportion of EM in  Improved The percentage of participants from small EM groups should the local population (7.4%). capacity of CHS be proportional to the ethnicity of the local population. - Pilot communication campaigns organized for EM staff, VHWs, communities by C25 consultant members of mass - Other communication campaigns, training and workshops organizations, and will be organized by VHW in national and local others to promote communication programs. the health and  Teaching materials will be gender and ethnically sensitive - Teaching materials were gender and ethnically sensitive and Complete nutrition of women and inclusive. inclusive. and children. Ethnic minorities will be specifically targeted and included - EM specifically targeted and included in participatory Complete Reduced financial  in the participatory approaches. approaches. barriers and Complete increased  Development of innovative, creative, and culturally - Health promotion materials evaluated as innovative, enrollment in appropriate health promotion materials. creative and culturally appropriate by local participants. health  Development of innovative, context-specific information, - Five IEC messages were viewed as innovative and Complete care services for education, communication messages and media. context-specific. The messages related to poor and EM complementary feeding for children, children with diarrhea and respiratory infections, maternal health

37 Anticipated Anticipated Proposed Actions to Enhance Impacts and Mitigate Risks Achieved by 31 June 2014 Evaluation Impacts Risks households care, raising children fully breastfed and infant care.  Public health materials translated into the relevant EM - Some 2,536 DVD films were converted to Kotu, Complete languages, where appropriate. Boog, Kadog, H’e, Ko, Baa, Raglai languages.  Budget provided for (i) screening of potential impacts on - Project budget available for research on potential Complete ethnic minorities, mitigating impacts, managing risks, and impacts on EM, mitigating impacts, managing risks, developing enhancement measures; and (ii) monitoring and developing enhancement measures and monitoring and evaluation activities. evaluation activities.  Increasing awareness of Decision 139 among the intended - 60 leaders of DOH, provincial/district hospitals, staff in charge Complete beneficiaries and other local stakeholders. of HI in eight provinces benefitted from heightened awareness of Decision 139 during a training organized by CPMU and Viet Nam Social & Health Insurance Department (MOH)  Provide data and analysis to inform future policy-making by - Data provided and analyzed by PPMU to inform future MOH Complete the MOH related to Decision 139. policy-making related to Decision 139 ● Provide support to strengthen capacity in South Central Training on health insurance laws and payment methods for Complete Coastal region provinces to manage the provincial human 60 leaders of the department of health (DOH), care funds for the poor./EM provincial/district hospitals and staff in charge of health insurance in eight provinces. Several research on health access of the poor and EM in poorest communes in the project areas was conducted by Consultant C23 in 2012 – 2013. Output 4: Strengthened Provincial Health Systems - Strengthened Provincial Health Systems Management - Strengthened Hospital Management - Better Health Management Information Systems Effective Project Management Support  PMUs, with EM None  All provincial and district plans to incorporate programs  All provincial and district plans were incorporated into On-going representation, will and activities to meet health care needs of EM groups. programs and activities to meet the health care needs of EM be established  Updated 5-year provincial plans and medium-term groups.  Capacity epeditue faeoks to ilude the Pojet’s EM  Updated 5-year provincial plans and medium-term development of strategy. expenditure frameworks included in the Pojet’s EM strategy

38 Anticipated Anticipated Proposed Actions to Enhance Impacts and Mitigate Risks Achieved by 31 June 2014 Evaluation Impacts Risks the PMUs and  Specific activities and targets for EM to be included in  Specific activities and targets for ethnic minorities were PPMUs provincial annual operating plans. included in provincial annual operating plans.  Better  But only HRD plans in four provinces (Binh Dinh, Binh information on Thuan, Ninh Thuan and Phu Yen) approved by PPCs. health care and  Teaching materials will be gender and ethnically sensitive  Teaching materials were gender and ethnically sensitive and Complete risks for EM and inclusive. inclusive.  Target participation of EM in training for provincial health  Percentage of EM participants only reached 1-2% of all Complete officials, hospital managers and staff. participants due to few EM HWs in health sector management positions.  Improve health management information systems to better  40 hospitals in provincial and district level were supplied Complete meet the health care challenges and needs of marginalized with HMIS and MIS systems EM groups and ensure data collected through those systems  83 health staff trained on application of information is disaggregated by gender and ethnicity. technology in hospital management.  Ensure PPMU training includes topics relevant to  PPMU training included topics relevant to management in Complete management in Project EM areas. Project EM areas.  Ensure project surveys collect, analyze and disseminate  Project research and survey results collected, analyzed and Complete data disaggregated by gender and ethnicity. disseminated data disaggregated by gender and ethnicity.  By midterm, develop health sector gender and EM  Health sector gender and EM development plans for each of On-going development plans for each of the provinces, based on the provinces based on lessons from Project implementation lessons from project implementation. are being developed and will be completed in October 2014.  An international social and gender development specialist  An international social and gender development specialist Complete (4 person-months) and a national social development (4 person-months) and a national social development specialist (12 person-months) will support the Government specialist (12 person-months) supported the CPMU in Project in Project implementation. implementation.  A resettlement specialist (8 person-months) will assist the  A resettlement specialist (8 person-months) was contracted to executing agency to protect the land and user rights of ethnic assist the executing agency to protect the land and user rights of groups during land acquisition and resettlement. ethnic groups during land acquisition and resettlement.  Representatives from the Provincial Committee of EM will  Only Ninh Thuan province had a EM representative from Complete be invited to participate in the Project steering committee. the Committee of EM in the Project steering committee.

39 Anticipated Anticipated Proposed Actions to Enhance Impacts and Mitigate Risks Achieved by 31 June 2014 Evaluation Impacts Risks  All progress reports, internal and external, will report  The Project’s mid-term evaluation, internal and external Complete Project impacts on EM groups. progress and research reports, detailed Project impacts on EM groups.

40 Annex 2: Provincial summary

1. Name of Province: Binh Dinh

Population:

Kinh (97.7%) Ba Na (1.2%), H Re (0.6%), Cham (0.4%) Other (0.3%)

Province Profile

Binh Dinh is a province of Vietnam South Central Coastal Region. Area is 6050.6 km. Administrative boundaries of Binh Dinh including 1 city, 2 county towns and 9 districts and 159 communal units consisting of 21 wards and 12 towns and 127 communes. There is a total of 43 special difficulty and poor communes and 49 ethnic minority communes in province. The rate of near poor and poor households of the province is 17%, of which 70% of poor ethnic minority households.

Key Project indicators

Behavior seeking outpatient care services when sick in the last 4 weeks of the Hre, Ba Na, Cham: the rate of health care at the health facilities is quite high, respectively: 91.8%, 83.3%, 84.0%; the rate of self-treatment is respective 4.1%, 14.3%, 14.0% and the rate of no treatment is 4.1%, 2.4%, 2.0%.

The rate of women who ANC at least 3 times of the Hre, Ba Na, Cham is quite low, respectively, 52.4%, 79.2%, 84.8%; the rate of women who delivery at home is respective 30.2%; 29.2%; 13.9%. The rate of children under 5 years old suffering from malnutrition (weight/age) is 15.7%. The rate of EM people with health insurance among total number of EM people is 100%. (Source: Research reports on the current status of health service access quality of the poor/ethnic minority people in the South Central Coast Region, 2013)

Summary of achievements and shortcomings/challenges

In the period 2009 - 2014, in addition to investments from the Government, the Ministry of Health, and localities also invested in the health fields, the health sector in the province has received a lot of support from the Project of Health care Support in the South Central Coastal Region with the goal of strenghening the quality and quantity of health care activities for people in general, and for ethnic minority people in particular. The support activities of the project including: investment to upgrade and build health facilities (Clinic of general hospitals in Binh Dinh Province, Binh Dinh Traditional Medicine Hospital, Phu My Medical Center) with a total investment of 108, 184, 368, 000 VND and supply essential health equipment for a number of health facilities; strengthen the management capacity of health systems through training courses on management and organization of study tours in domestic and abroad; by 6/2014, up to 3687 health staff visits (EM accounting for 4%) to participate in training courses, seminars and universities, postgraduates and service training. Number of trained and re-trained people on VHW (1 week, 1 month, 3 months) is 1623 people (EM: 9%). The project has supported the activities of IEC about health and nutrition for the ethnic minority people of the province through training activities for media lecturers, design media materials and provide media handbook for propagandists. Building a 5-year human resource development plan in the health sector, including EM human resource development plan for the period 2011-2017 was approved.

Province specific Strengths

PMU staff, Department of Health and health units are very enthusiastic, responsible, good coordination in EM development activities. The rate of CHCs with doctors is 95% (higher than the average rate of region is 60%); The rate of CHCs with Ob/Ped assisstant doctors/midwives is 96.2% and the The rate of villages with health workers who working is 98.6%. The rate of VHWs from ethnic minority people is 8.7%. The rate of VHWs with qualifications that meets the requirements of the Ministry of Health is 82%.

Province specific Weaknesses

Limited budget for investing activities for the health sector. Proportion of health workers per 10,000 people is 30%, lower than the whole region (36%); proportion of ethnic minority health workers is very low, only 1.3% of total of health workers of province;

Province specific Lessons Learned

EM development is oriented from the beginning by Project. EM development priorities are reflected in the criteria of the project: the choice health facility for investing in renovating, supplying essential medical equipment, training, seminars, international and national scholarships, supporting research...Focus on improving the professional capability and social development, including the poor and EM, gender for the health sector. Establish the system of monitoring from the central to the provincial PMU.

Province specific Next Steps Forward Develop and implement the Gender Action Plan, EM Development Plan for health sector of Binh Dinh in the period 2015 – 2017

42 2. Name of City: Da Nang

Population:

Kinh (99.54%), Co Tu (0.11%) E De (0.03%) Tay (0.03%) Other (0.19%) Province Profile Da Nang is a big center of economy, culture, education, science and technology in Central – Highlands Region. Da Nang is one of 15 grade 1urbans and is one of five cities under central authority in Vietnam. The total natural area of the city is 1285.4 km2. Da Nang now has eight districts and five communal units with 119 villages

In 2011, Danang city has 69 medical facilities under the Health Department, of which 12 hospitals, 1 nursing and and rehabilitation hospital and 56 CHCs. The number of hospital beds under Health Department of Da Nang is 3,442 beds. Danang also has a system of hospitals, private clinics that are gradually developing: Cancer Hospital (scale of 500 beds), Tam Tri hospital, Hoan My general hospital...

By the end of 2012, Danang has completed target of universal health insurance 2 years ago compared with the country (2014), with 91.6% of the population participating in health insurance. With the formation of the University of Medicine and Pharmacy and University of Medical Techniques in the city, Danang is aiming to become a major medical center of Central - Highland regions and the whole country. http://vi.wikipedia.org/wiki/%C4%90%C3%A0_N%E1%BA%B5ng - cite_note-186Key Project indicators

Rate of health workers per 10,000 populations is 35% (the regional average rate of 36%); rate of CHCs with doctors is 37.5% (much lower than the regional average rate of 60%); rate of CHCs with Ob/Ped assisstant doctors/midwives and Rate of villages with health workers working are 100%. Rate of CHCs meets national standards and Rate of villages with health workers working are 100%.

Summary of achievements and shortcomings/challenges

The activities supported by the project including: investment to upgrade and build two health facilities (Hoa Vang hospital, nursing and and rehabilitation hospital) with a total investment is 57,076,457,220 VND and supply essential medical equipment for some health facilities; strengthen the management capacity of health systems through training courses on management and organize learning tours at home and abroad; by 6/2014, there were 2,446 staff visits and medical staff (EM accounted for: 0.2%) are

43 participated in the training courses, workshops and university, postgraduate and and service training. Number of people trained and re-trained on health village (1 week, 1 month, 3 months) is 248 people (EM: 0%). The project has supported the IEC activities about health and nutrition for EM people of the province through training of trainer, designing media materials and providing media manuals for propagandists. A 5-year human resource development plan of the health sector that developed by PPMU and Health Department, including EM human development plan period 2011-2017 was approved.

Province specific Strengths

PMU staff, the Health Department and health units are very enthusiastic, high responsible, good coordination of EM development activities.

Rate of CHCs with doctors is 95% (much higher than the regional average rate of 60%); rate of CHCs with Ob/Ped assisstant doctors/midwives is 96.2% and and rate of villages with health workers working is 98.6%. Rate of EM VHWs is 8.7%. Rate of VHWs with qualifications that meet the requirements of the Ministry of Health is 82%.

Province specific Weaknesses

The gap in the provision of and accessibility to health care services of ethnic minority people do not have much difference compared to the Kinh people due to geographical distance between communes, districts the farthest is 20km from the city. The only Hoa Vang district has ethnic minority people and prioritized to invest much more.

Province specific Lessons Learned

EM development is oriented from the beginning by Project.

EM development priorities are reflected in the criteria of the project: the choice health facility for investing in renovating, supplying essential medical equipment, training, seminars, international and national scholarships, supporting research...

Focus on improving the professional capability and social development, including the poor and EM, gender for the health sector. Establish the system of monitoring from the central to the provincial PMU.

Province specific Next Steps Forward

Develop and implement the Gender Action Plan, EM Development Plan for health sector of province in the period 2015 – 2017

44 3. Name of Province: Khanh Hoa

Population:

Kinh (94.7%), Raglay, Ede, Gie Trieng, Cham… (5.3%)

Province Profile Mountainous areas in Khanh Hoa Province with a total natural area is 290.500ha (63.5% of the province's natural area), including 53 communes and towns. Of these five communes in Region III, 17 communes in Region II and 31 communes in Region I. The province has 33 ethnic minorities (EM) living (accounting for 5.3% of the provincial population). Each ethnic group has language, place of residence area, customs, habits bring unique identity. The average rate of poor households in mountainous and ethnic minority areas (according to national standards periods 2011-2017) accounted for 20.64%, much higher than average rate of poor households of the whole province (9.4%). Rate of EM poor households accounted for 61.67% compared to the total number of poor households

Besides the largest Kinh in the ethnic minority group, Raglay accounted for the largest proportion (74.55% of EM people) concentrated in two mountainous districts of Khanh Son, Khanh Vinh and mountainous communes of province (over 90%) and the rest scattered in plain communes, towns

Key Project indicators Rate of EM to health facilities for outpatient care when sick in 4 weeks of Gie Triêng, Cham, Raglai is respective 80.5%, 84.0%, 95.8%; Rate of Self-treatment of 2 ethnic groups is respective 6.5%, 14.0%, 2.8% and no treatment is respective 13.0%, 2.0%, 1.4%. Proportion of ANC women at least 3 times of Gie Triêng, Cham, Raglai is respective 25.4%, 84.8%, 74.7%; proportion of pregnant women who gave birth at home of three ethnic above is respective 30.5%, 13.9%, 17.7%.

The province has 4091 health workers at all levels, including EM health workers accounting for 2%, lower than the percentage of EM in the total population of the province. 86% of CHCs with doctors; 86.3% of villages with VHWs. Number of health workers from ethnic minority accounted for 10.2%. Percentage of children under 5 years old were malnourished (weight/age): 10.51%.

Summary of achievements and shortcomings/challenges

The activities supported by the project including: investment to upgrade and build 3 health facilities with total investment of $ 3,275,400 (Cam Ranh regional general hospital, Van Ninh District Hospital, Ninh Hoa district health center) and supply essential medical equipment for some health facilities; strengthen the management

45 capacity of health systems through training courses on management and organize learning tours at home and abroad; by 6/2015, there were 5,342 visits and medical staff (EM accounted for: 4.2%) are participated in the training courses, workshops and granted university and postgraduate scholarships at home and abroad. The project has supported the IEC activities about health and nutrition for EM people of the province through training of trainer, designing media materials and providing media manuals for propagandists. A 5-year human resource development plan of the health sector that developed by PPMU and Health Department, including EM human development plan period 2011-2017 was approved.

Province specific Strengths

PMU staff, the Health Department and health units are very enthusiastic, high responsible, good coordination of EM development activities.

Rate of CHCs with Ob/Ped assisstant doctors/midwives in 2012 is 98%. Percentage of poor and EM people are granted health insurance cards and the percentage of poor people use health insurance cards in total of poor people to health facilities for health care is 100%.

Province specific Weaknesses

Obstacles caused a number of ethnic minority people are difficult to access to health care services quality such as: financial barriers (high rate of poor, lack of money for health care), cultural (a part of the population does not know Kinh language, limited awareness of health care), geography (in remote areas, difficult traveling, away from the hospital), backward (backward customs (when sick self-treatment at home with all traditional medicine and ritual; habits of giving birth at home and abstinence ...)

Province specific Lessons Learned

Province specific Next Steps Forward

Develop and implement the Gender Action Plan, EM Development Plan for health sector of province in the period 2015 – 2017

46 4. Name of Province: Ninh Thuan

Population:

Kinh (76.5%), Cham (11,9%) Raclay (10,4% ) Co ho (0,5%) Nung (0,1%) Churu (0,1%) Khac (0,3%)

Province Profile

The average population of Ninh Thuan Province in 2013 was 587,377 people, the percentage of ethnic minority accouned for 23.5%. Ninh Thuan Province has 7 administrative units, including 1 city and 6 districts, 65 communal administrative units. In which poor communes accounted for 31% and EM communes accounted for 20%. Rate of poor households of province is 11%. Cham people in Ninh Thuan accounted for nearly 50% of the Cham in Vietnam.

Key Project indicators 100% of the poor, ethnic minorities are granted health insurance cards. Percentage of Cham and Raglai to health facilities for outpatient care when sick in the past 4 weeks, respectively 84% and 95.8%; proportion of the self-treatment of Cham is quite high (14.0%) compared with Raglai (2.8%) and proportion of no treatment of the two ethnics is respective 2.0% and 1.4%. The proportion of women who gave birth at home of Cham, Raglai is respective 13.9% and 17.7%.

In 2013, there were 03 maternal deaths from ethnic minorities, the maternal otalit atio: . ateal deaths/, lie iths (tagets ≤ ateal deaths/100,000 live births). In the first 7 months in 2014, there are 04 maternal deaths (EM: 50%), mortality rate: 59.3 maternal deaths/100,000 live births. The percentage of malnourished children in 2013 dropped 20% compared to in 2012 21.4%, decreased 1.4% (nationwide 15.3%)

Summary of achievements and shortcomings/challenges

47 1,635,668 USD and supply essential health equipment for a number of health facilities; strengthen the management capacity of health systems through training courses on management and organization of study tours in domestic and abroad; by 6/2014, up to 2.659 health staff visits (EM accounting for 21%) to participate in training courses, seminars and universities, postgraduates and service training. The project has supported the activities of IEC about health and nutrition for the ethnic minority people of the province through training activities for media lecturers, design media materials and provide media handbook for propagandists. Building a 5- year human resource development plan in the health sector, including EM human resource development plan for the period 2011-2017 was approved.

Province specific Strengths

The health sector has 2,522 staff, achieves 42.7 staff/10,000 population, with 471 staff are ethnic minorities (provincial level has 136 staff, district level has 191 staff, communal level has 144 staff), accounting for 18.7% of health workers throughout the sector, of which the Cham accounted for 96.4% (402/471); other ethnic minorities accounted for 14.6% (69/471).

In 35 ethnic minority communes, there are 19 communes with doctors working regularly, achieveing 54.3%, the province is 43.1%; 11/28 CHCs with doctors from ethnic minority, accounting for 39.3% of total of CHCs with doctors. Proportion of CHCs with Ob/Ped assisstant doctors/midwives and VHWs working is 100%. The province has 322 VHWs in which ethnic minority accounting for 50%. VHWs with qualifications meet the requirements of the Ministry of Health is 55%.

In 2013, Health sector has focused on professional training for Inter-university: 30 people (07 doctors, 11 pharmacists and 12 Bachelor of Nursing, laboratory, physiotherapy, health public), ethnic minorities accounted for 10% (30/03). Postgraduate: 14 (09 doctors specialty I, 01 doctor specialty II, 04 Masters), ethnic minorities accounted for 14.3% (14/02). Professional training: 04 people (03 doctors, 01 technicians), ethnic minorities accounted for 25% (01/04). State management training: 19 people (15 specialist category, 04 main specialist category), ethnic minorities accounted for 21.1% (04/19). Political theory senior: 05 people; Political College: 06 people, ethnic minorities accounted for 16.7% (01/06).

In addition, in 2013 has developed many training courses to improve professional capacity on HIV, TB, Malaria, Maternal Health Care - Children, statistics reports for all districts/cities and all CHCs. (Source: report of PPMU and Ninh Thuan Province Health Department, 2015)

By 6/2014, the province has 63.28% of the population participating in health insurance, including: poor, near poor, EM people are 136,970 HI cards; children under 6 years olds are 67,353 HI cards. The management and allocation of health insurance

48 cards for poor, near poor, EM people and children under 6 years old are the responsibility of the Department of Labour, Invalids and Social Affairs and city/district PC.

Province specific Weaknesses

 Most of ethnic minority people in Ninh Son and Bac Ai to health facilities for health care did not bring their health insurance card. Health facilities performed free health care regime but there is no basis to pay for social insurance agencies.

 Knowledge, qualification and consciousness about the disease of ethnic minority people in mountainous areas are limited. They are less concerned about the rights and obligations of people who are entitled to health insurance, as well as the place of registration of the initial medical examination, the expiry date of the card...

 The implementation of the co-payment 5% of the cost of medical examination and treatment under the health insurance law caused difficulties for poor/ethnic minority patients in remote areas and this increased burden for health facilities because most of the hospital has supported the cost of both medical care and food for the poor patients and caregivers so many health facilities currently still balance funds that did not pay for social insurance agencies

 The life of health staff in the remote and ethnic minority communes remains many difficulties and has not yet enjoyed appropriately preferential regimes

 Infrastructure and human resources of the CHCs in the remote and ethnic minority communes is still lack and.

Province specific Lessons Learned

EM development is oriented from the beginning by Project.

Province specific Next Steps Forward

Develop and implement the Gender Action Plan, EM Development Plan for health sector of province in the period 2015 – 2017

49 5. Name of Province: Phu Yen

Population:

Kinh (94%), Ede (36,5%), Cham (36,2%), Other EM: Ba Na, Hro, Mnung, Raglai Province Profile Phu Yen is a province having natural area of 5,060 km2; the northern borders with Binh Dinh province, the southern with Khanh Hoa and the westen with Dak Lak, Gia Lai provinces, the eastern with East Sea. The province has 09 administrative units including 1 cities and 8 districts with 112 communal units, including 38 ethnic minority communes (34%) and 18 poor communes. There are 30 ethnic minority groups, accounting for about 6% of the provincial population and living mainly in the mountainous districts (over 90%). The average poverty rate in mountainous and ethnic minority areas (according to national standards periods 2011-2017) accounted for 59.12%, much higher than average poverty rate of the whole province (17%). Poverty rate of ethnic minorities is 17.05% accounted for the total poor. Key Project indicators The percentage of sick EM people using outpatient health services in the past 4 weeks in M'Nông ethnic groups, Hre, E De, Raglai was quite high (91-95%) while the Ba Na, Cham, reaching lower than the 83% - 86%. Self-treatment percentage of Ede, Bana and Cham was from 14.0% - 15.4%. The percentage of sick EM people without treatment of Hre was 4.1% and the rest of the group was from 1.4% - 2.9%. Percentage of women prenatal care at least 3 times of the Raglai, Ba Na, Cham was respectively of 74.7%, 79.2%, 84.8%; of Ede, Hre, M'Nông was from 51.3% - 55%. The percentage of delivery birth at home of Ede, Bana and Hre was rather high (from 26.9% - 30.2%); of M'Nông, Care and Raglai was from 12.5% - 17.7 %. Proportion of underweight (weight/age) children under age 5 is 10.51%. In 2013, the province had 3,560 health workers in which the percentage of minority workers was 2%, lower than the percentage of EM in total population of the province. 86% of village health centers (VHC) have doctors; 86.3% village have VHW. Number of EM VHW accounted for 10.2% of total VHWs. The percentage of VHC having midwives/obstetrical physicians in 2012 was 100%. Percentages of the poor and EM people recieved health insurance card and using health insurance card in total the poor and EM using health services were 100%. Percentage of children under age 5 were underweight (weight/age): 10.51%

50 Summary of achievements and shortcomings/challenges The provincial health sector had received a lot of supports from the Health Care Support Project in South Central Coast region, including: investment to upgrade and build 4 health facilities (General Hospital in Tuy An; General district hospital in Tay Hoa; General Hospital in Song Cau; Town Hospital in Song Cau) with a total investment of VND 58,029,065,780; supply essential medical equipment; strengthening health systems management; organize study tours in domestic and abroad. By June 2014, total 1568 health workers/health officers (EM accounted for 5%) was attended training, workshops, recieved scholarships for university, master training programs. The number of trained and re-trained VHW was 573 people (EM: 12%). The project has supported the activities of IEC about health and nutrition for the ethnic minority people of the province through training activities for media lecturers, design media materials and provide media handbook for propagandists. Building a 5-year human resource development plan in the health sector, including EM human resource development plan for the period 2011-2017 was approved.

Province specific Strengths The rate of CHCs with doctors was 86%; The rate of CHCs with Ob/Ped assisstant doctors/midwives was 86,3%; The rate of EM people with health insurance among total number of EM people was 100%.

Province specific Weaknesses The percentatage of EM health worker was 2%, lower than the percentage of minorities in the total population of the province. A part of the EM was facing with difficults when accessing quality health care services due to: financial barriers (high rate of poverty, lack of money for going to hospital); culture (a part of EM does not know King language, limited awareness of health care); geography (living in remote areas, difficulty transportation, far from the hospital); backward customs (self treatment at home by traditional medicine or ritual when getting sick; delivering birth at home and abstinence.

Province specific Lessons Learned EM development is oriented from the beginning by Project. EM development priorities are reflected in the criteria of the project: the choice health facility for investing in renovating, supplying essential medical equipment, training, seminars, international and national scholarships, supporting research...Focus on improving the professional capability and social development, including the poor and EM, gender for the health sector. Establish the system of monitoring from the central to the provincial PMU.

Province specific Next Steps Forward Develop and implement the Gender Action Plan, EM Development Plan for health sector of province in the period 2015 – 2017

51 6. Name of Province: Quang Nam Population: Kinh (91.9%), Co Tu (3,2%), Xe Đang (2,7%), Gie Trieng (1.3%), Co (0.4%) Others…

Province Profile Quang Nam is the province located in South Central Coast, Vietnam and the middle of North - South axis of the country. The total nature area of the province is 1,043,836.96 hectares including 72% hills area. The total population of the province is 1,422,319 people, including 91.9% Kinh and 0.9% EM people. The province has 18 administrative units at district-level (16 districts, 2 cities) and 247 communal units (216 communes, 13 towns). The province has 74 EM communes (account 34% of total commune) and 1,709 villages. There are 4 permanent inhabitant EM groups, includes Co Tu (3.2%), Xe Dang (2.7%), Gie Trieng (1.3%), Cor (0.4%) and other small number of new migrants EM. Key Project indicators By 2012, there was 95% of EM in the province recieving insurant card. The percentage of children under age of 5 suffering from malnutrition (weight/age) was 16%. The proportion of outpatient care in 4 past weeks of sick people in Co Tu, Xe Dang and Gie Trieng groups respectively were 80.5%, 89.0% and 78.4%. The proportion of self-treatment of these sick EM groups respectively were 6.5% 7.0% and 9.6%; The proportion of sick EM groups without treatment was rather high and respectively were 13.0%, 4.0% and 12.0% (Source: Information sheet provided by Quang Nam Provincial Health in 2012, Health Care Support Project in South Central Coast region). Summary of achievements and shortcomings/challenges In the period of 2009 – 2014, the province had received a lot of supports from the Health Care Support Project in South Central Coast region, including: investment to upgrade and build 4 health facilities (Bac Tra My District Hospital; Quang Nam General Area Hospital; Dong Giang General District Hospital; Dien Ban District Health Center) with a total investment of USD 4.720.422; supply essential medical equipment; strengthening health systems management; organize study tours in domestic and abroad. By June 2014, total 4528 health workers/health officers (EM accounted for 22%) was attended training, workshops, recieved scholarships for

52 university, master training programs. The number of trained and re-trained VHW was 573 people (EM: 12%). The project has supported the activities of IEC about health and nutrition for the ethnic minority people of the province through training activities for media lecturers, design media materials and provide media handbook for propagandists. Building a 5- year human resource development plan in the health sector, including EM human resource development plan for the period 2011-2017 was approved.

Province specific Strengths The province has received a lot of investment and supports from the State, provincial health sector and local programs/projects.

Province specific Weaknesses The proportion of health workers per 10,000 residents currently is 38% (lower than the rate in the area of 60%). The percentage CHS having doctors was very low of 24.2%. The percentage of CHCs having Ob/Ped assisstant doctors/midwives is 89.3%; the proportion of village having VHW is 97.0% and the number of EM VHWs is 28%. The popotio of VHW’s ualifiatios eet the euieets of MOH is %. The implementation of the provincial Ethnic Minority Development Plan (EMDP) are facing many difficulties due to: difficult of mountainous terrain, literacy, poor infrastructure condition and transportation; limit knowledge of VHW of EM; people still el o state’s suppot, thus iatie i the lao. Ifoatio aesset condition and communication are limited in the villages and remote.

Province specific Lessons Learned EM development is oriented from the beginning by Project. EM development priorities are reflected in the criteria of the project: the choice health facility for investing in renovating, supplying essential medical equipment, training, seminars, international and national scholarships, supporting research... Focus on improving the professional capability and social development, including the poor and EM, gender for the health sector. Establish the system of monitoring from the central to the provincial PMU.

Province specific Next Steps Forward Develop and implement the Gender Action Plan, EM Development Plan for health sector of province in the second period

53 7. Name of Province: Quảng Ngãi Population: Kinh (86,7%), Hre (9,5%), Cor (2,3%), Xo Đang (1,5%), Small percentage of other groups of Hoa, Muong, Tay, Thai.

Province Profile Quảng Ngãi Nam is a coastal province located in South Central Coast, Vietnam with vast territorial waters of 11,000 km 2 and coastline length of about 129 km. Administrative area of the province including 1 cities and 14 districts (1 island district, 1 midland district, 6 plain districts, 6mountain districts). The province has 29 ethnic groups, in which Kinh is the largest (86.7%), the second is Hre (9.5%), Cor (2.3%), Xo Dang (1.5%), and a small percentage of other ethnic groups such as Chinese, Muong, Tay, Thai. Total EM commune of the province is 69 (accounting of 38% total number of communes and wards). Key Project indicators The popotio of outpatiet ae i past eeks of sik people i H’e ad Co respetiel ee ,% ad %. Peetage of delie ith at hoe of H’e oe as ,%; Co: % ad Xơ Đăg: %. Peetage of hilde ude age of 5 suffering from malnutrition (weight/age) was 17%. Summary of achievements and shortcomings/challenges In the period of 2009 – 2014, the province had received a lot of supports from the Health Care Support Project in South Central Coast region, including: investment to upgrade and build 5 health facilities (Ba To, Son Tay, Tay Tra District Hospitals; Mo Duc District Health Center); supply essential medical equipment; strengthening health systems management; organize study tours in domestic and abroad. By June 2014, total 1954 health workers/health officers (EM accounted for 21%) was atteded the pojet’s training, workshops, recieved scholarships for university, master training programs. The number of trained and re-trained VHW was 573 people (EM: 12%). The project has supported the activities of IEC about health and nutrition for the ethnic minority people of the province through training activities for media lecturers, design media materials and provide media handbook for propagandists. Building a 5- year human resource development plan in the health sector, including EM human resource development plan for the period 2011-2017 was approved.

54 Province specific Strengths The province has received a lot of investment and supports from the State, provincial health sector and local programs/projects.

Province specific Weaknesses The proportion of health workers per 10,000 residents of the province is 38% (lower than the average national proportion of 45,9. The percentage CHS having doctors is 24.2%. The percentage of CHCs having Ob/Ped assisstant doctors/midwives is 98,9%; The percentage of EM in poor area having insuarance card is 100%.

Province specific Lessons Learned EM development is oriented from the beginning by Project. EM development priorities are reflected in the criteria of the project: the choice health facility for investing in renovating, supplying essential medical equipment, training, seminars, international and national scholarships, supporting research... Focus on improving the professional capability and social development, including the poor and EM, gender for the health sector. Establish the system of monitoring from the central to the provincial PMU.

Province specific Next Steps Forward Develop and implement the Gender Action Plan, EM Development Plan for health sector of province in the period 2015 – 2017

55 8. Name of Province: Binh Thuan

Population:

Kinh (92,6%), Cham (3%), Ra Glai (1,3%), Co Ho (1%), Tay (0,4%), “all peetage of othe goups of Ê Đ, Cơ Tu, Gi Tig.

Province Profile Binh Thuan is a province of south coastal central area. Its topography is mainly low hills, narrow coastal plain with a total natural area of 7992 km². The provincial population in 2012 was 1,167,023. Binh Thuan has 10 administrative units, including 127 commune units, 1 mountain communes (Da Mi commune, Ham Thuan Bac). There are 34 ethnic groups living in the province.

Key Project indicators The proportion of outpatient of in the last 4 weeks of Raglai group was 95.8%, while Gie Triêng, Cor, E De, Cham, Kotu were less than 80%. The percentage of self- treatment care of Cham and E De groups were from 14 to 15.4%. The proportion of people without treatment of Gie Trieng and Cor higher than other EM groups (12- 13%). Percentatage of antenatal care at least 3 times of EM pregnent women groups were also very different: Cham (84.8%), Raglai (74.7); Xo Dang, E De ranged from 51.3 to 58.9%; Gie Triêng was the lowest of 25.4%. Similarly, the birth rate of EM are also very different: Xo Dang was highest (71.4%), Cor (47.1%), Gie Triêng (30.5%), E De (26 , 9%), Raglai (17.7%), Cham (13.9), Co Tu (12.2%). The proportion of malnourished children under 5 years of age (stunting: 10.4%). (Baseline survey access health services by the poor /EM in the South Central Coast, 2013 - Health Support Project in South Central Coast region).

Summary of achievements and shortcomings/challenges In the period of 2009 – 2014, the province had received a lot of supports from the Health Care Support Project in South Central Coast region, including: investment to upgrade and build 3 health facilities (North Regional General Hospitals; South Regional General Hospitals, Phan Thiet City Health Preventive Center) with total investment of USD 3.961.926; supply essential medical equipment; strengthening health systems management; organize study tours in domestic and abroad. By June 2014, total 3056 health workers/health officers (EM accounted for 4%) was attended the pojet’s taiig, okshops, eieed sholaships fo uiesit, aste training programs. The number of trained and re-trained VHW was 962 people (EM: 7%).

56 The project has supported the activities of IEC about health and nutrition for the ethnic minority people of the province through training activities for media lecturers, design media materials and provide media handbook for propagandists. Building a 5- year human resource development plan in the health sector, including EM human resource development plan for the period 2011-2017 was approved.

Province specific Strengths

The province has received a lot of investment and supports from the State, provincial health sector and local programs/projects.

Province specific Weaknesses

High percentage of EM in population with low awaraness. Percentage of EM self-treatment at home when getting sick and delivery birth at home were rather high, and higher than Kinh minority

Province specific Lessons Learned

EM development is oriented from the beginning by Project.

Province specific Next Steps Forward

Develop and implement the Gender Action Plan, EM Development Plan for health sector of province in the period 2015 – 2017