MINISTRY of HEALTH Public Disclosure Authorized

Home , Gio Linh District, Hue, Muong people, North Central Coast

The Assessment Social Impacts Report IPP380 V3

MINISTRY OF HEALTH Public Disclosure Authorized

Central North Health Support Project

Public Disclosure Authorized The Social Impact Assessment Report

Public Disclosure Authorized

October.2009 Public Disclosure Authorized

Table of Contents The Assessment Social Impacts Report

Chapter 1: INTRODUCTION...... 1 1.1. The project background...... 1 1.2. The objectives and contents of the report of the social impact Assessment...... 6 Chapter 2: SOCIAL IMPACT ASSESSMENT FRAMEWORK...... 10 2.1 Legal and Policy Framework...... 10 2.2 Determining stakeholders in social assessment and coordination...... 14 2.3 Social impact Assessment framework...... 15 Chapter 3: THE SOCIO-ECONOMIC SITUATION OF THE PROJECT AREA 16 3.1. The Socio-economic situation of the project area.... 16 3.2. Healthcare situation...... 24 3.3.Diseases burden...... 26 3.4. Accessibility and utility by local people of health services...... 29 Chapter 4: THE IMPACTS OF THE PROJECT TO ETHNIC MINORITY... 34 4.1. Identify the level of positive impacts of the project to the poor, near poor and ethnic minority people...... 34 4.2. Socio- Economic condition of some Ethnic minorities in the Project areas...... 41 4.3. Identify the level of negative impacts of the project’s activities to the living and healthcare to the poor, near poor and ethnic minority people...... 47 4.4. Propose the solution to minimize or avoid the negative impacts of the project to the vulnerability targets...... 48 4.5. Constraints that limit ethnic minority people to access public health care services...... 48 Chapter 5: THE RESETTLEMENT...... 50 5.1. The planning and reclaiming land for constructing the PHCs...... 50 5.2. How the project have been affected on cultures, religions and beliefs...... 55 5.3 Procedure of issuing the land use certificate...... 55 5.4. The project impacts to the living and production of the households...... 56 5.4 Results of consultation of affected households...... 57 Chapter 6: THE CONSULTATION OF THE STAKEHOLDERS OF PLANNING THE SOCIAL IMPACT ASSESSMENT...... 60 6.1. Ideas and viewpoints of the stakeholders during preparing the project workplan...... 60 6.2. Proposing the workplan of social impact evaluation during the project implementation in the local...... 63 CONCLUSION...... 66 The Assessment Social Impacts Report The Assessment Social Impacts Report

List of Tables Table 1.1- List of 30 District Preventive Health Centers for project investment ...... 4 Table 3.1. Some features on natural and socio-economic situation of six provinces of the Project ...... 16 Table 3.2. Monthly income per capita by sources of income quintile ...... 17 Table 3.3. Socio-economic situation of district selected of project Thanh Hoa province ...... 18 Table 3.4. Socio-economic situation of district selected of project Nghe An province ...... 19 Table 3.5. Socio-economic situation of district selected of project Ha Tinh province ...... 20 Table 3.6. Socio-economic situation of district selected of project Quang Binh province ...... 21 Table 3.7. Socio-economic situation of district selected of project Quang Tri province ...... 22 Table 3.8. Socio-economic situation of district selected of project Thua Thien Hue province ...... 23 Table 3.9. Percentage of illness or injuies in year 2006 by province ...... 24 Table 3.10. Malnutrition in weight by age among children under 5 years (%) in Central North and 6 provinces 2007 ...... 25 Table 3.11. Mortality pattern in the six selected provinces 25 Table 3.12. Percentage of illness or injuies in year 2006 by urban rural, region, income quintile, sex, age group and ethnic ...... 27 Table 3.13. Rate (%) Sick cases not treatment during 4 weeks before survey ...... 29 Table 3.14. Percentage of in-patient treatment in year 2006 by type of health facilities, region, sex, age group ...... 30 Table 3.15. Distribution of rounds of medical consultation and treatment during 4 weeks before the survey (%) ...... 31 Table 3.16. Use of public hospitals in 6 project provinces. 32 Table 4.1. Percentage of people having treatment in the last 12 months in year 2006 by urban rural, region, income quintile and sex ...... 34 Table 4.2. Percentage of out-patient treatment in year 2006 by type of health facilities, urban rural, region, sex, age group and ethnic ...... 35 Table 4.3. Percentage of in-patient treatment in year 2006 by type of health facilities, urban rural, region, sex, age group and ethnic ...... 36 Table 4.4. Percentage of people having treatment in the last 12 months in year 2006 by age group and ethnic ...... 37 Table 4.5. Percentage of poor, near poor and ethnic minority of districts prioritised for project investment ...... 38 Table 5.1 List of the PHCs prepared the document of land certificate ...... 54 The Assessment Social Impacts Report

Table 5.2 The households and people affected by the project 56 The Assessment Social Impacts Report

ACRONYMS

EG Ethnic group FS Food Safety GH General Hospital HC Health Center HD Health Department HI Health Insurance HMIS Health Management Information System HS Health services HW Health worker MoH Ministry of Health NCR North Central Region NHS National Health Survey GoV Government of Viet Nam PC People’s Committee PH Preventive Health PHC Preventive Health Center PMU Project management Unit PPMU Provincial Project Management Unit SC1 Specialist Class I TM Traditional medicine WB World Bank The Assessment Social Impacts Report

Chapter 1: INTRODUCTION 1.1. The project background 1.1.1. Introduction The Central North Health Support project is designed to follow the government’s regional approach to health system development by targeting the northern region of the central coastal area, referred to as Central North region. The region, with a population of 10.7 million, is the second poorest among the eight regions of Vietnam; 25% and 30% of the population is classified as poor and near poor respectively (2006). Average per capita income in the Central North is 317,000 VND (2004) compared to the national average of 445,000 VND (2004). The inhabitants of the region (approx. 85% of them) live in rural areas and make their living from self-employed agriculture and fish farming; the share of self employment is 79.5% in the total employment structure according to 2004 data. Overall, the health status of the region is poor. Average Infant Mortality Rate is 22 (ranging from 15 to 36) compared to the national average of 16, and Maternal Mortality Rate is 200 compared to the national average of 75. The leading causes of morbidity are associated with respiratory conditions and diseases of the digestive system.

With its regional focus and design, the Central North region project is fully aligned with the government’s strategy to strengthen the health systems in disadvantaged regions by relying on three pillars: (a) reducing demand-side barriers to health services for the economically vulnerable population, (b) improving the quality of pro-poor health services, and (c) reducing the shortage of competent health care professionals in underserved areas. The project will reduce demand barriers by increasing affordability of health insurance to the near poor population by providing significant subsidies towards health insurance premiums, above what is currently offered by the government. This will be complemented by a strong Information and Education Campaign, social marketing, and a number of incentive mechanisms to increase enrollment of the target population in the health insurance scheme. In order to improve the quality of pro-poor health services, the project will invest in district hospitals and DPHCs in the most disadvantaged districts, thereby making basic health care available at a lower cost and closer to the communities. Most of the investment will go into equipping hospitals with most basic medical equipment and refurbishing the DPHCs. This will be combined with a Results Based Financing pilot to test some innovative mechanisms to promote better performance, accountability and client-orientation of health services. The project will address the human resource constraint in the Central North region by training specialists that are in short supply and creating stronger local medical training institutions for more sustainable results. .

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1.1.2 Legal justification

On April 14th, 2009, the Prime Minister released document 551/TTG-QHQT giving approval for the World Bank supported “Central North Region Health Support Project”.

For a long time, WB has been assisting the health system with various major Projects in Vietnam. Such as, National Health Support Project, HIV/AIDS Prevention Project, Mekong Health Support Project, Regional Blood Transfusion Center, Northern Uplands Health Support Project etc. Assisting socio-economically disadvantaged regions, supporting health care facilities utilized by the poor, near-poor and etchnic minorities, and reducing poverty through human development efforst is the top priority of WB.

WB has been assisting various countries in developing their health system. This has given the WB a significant experience in designing projects in a way that can maximize the impact for the poor and prevent any possible negative impact on marginalized societies.

1.1.3. Objectives of the project

The project development objective is to strengthen district level curative and preventive health services and improve their accessibility for the economically vulnerable population. Intermediate objectives are: - Increasing health insurance coverage among the near poor population; - Upgrading capacities of district hospitals and DPHCs; - Improving supply and quality of health care personnel.

1.1.4- Direct project beneficiaries The project beneficiaries will include the following three groups: (i). Local people: especially the near poor and the ethnic minority people are the most important and beneficiaries of the project. While the project provides direct demand- side subsidies to the near poor, it also benefits the poor and ethnic minorities by making affordable and improved health services available at the local level, close to their communities. . (ii). Health care service provision network: District hospitals will receive medical equipment and District Preventive Health Centers will receive new buildings (technical and administration blocks) and medical equipment. Health care personnel will benefit from improved working conditions as a result of infrastructure investment. They will also receive training. (iii). Administration agencies: District Health Offices and district branches of Vietnam Social Security Administration will receive training and support for institutional

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capacity building. They will also benefit from improved working conditions and as well as from the innovative pilots for improving the efficiency of managing the health system.

1.1.5. The project components The project has four components including:

Component 1: Providing health insurance to the near-poor people

1. This component aims to expand access to health insurance for near poor households in the Central North region and to improve the system’s capacity to manage health insurance. It will do so by (i) subsidizing health insurance for the near poor, (ii) conducting a social marketing and Information and Education Campaign, and (iii) strengthening institutional capacities for the administration of health insurance. Specifically, this component will finance the bulk of the out-of-pocket price faced by near poor households with the objective of increasing the take-up of health insurance among this group. In addition, it will entirely sub-contract the social marketing component to a qualified local TA firm that will provide technical assistance on social marketing techniques to the Health Information and Education Centers (HIEC) and Vietnam Social Security Office (VSS). The project will also provide limited support to VSS with additional administrative operating costs resulting from expected increased enrollment of the near poor. This will start as a pilot incentive scheme whereby the VSS will receive a fixed per-capita amount (2% of the premium) for each additional near poor enrolled in the scheme. Finally, a Joint Working Group on Health Financing will be established in order to foster national level engagement with key stakeholders on health reform issues, facilitate dialogue and knowledge exchange between the project provinces and the center, and support capacity-building.

Component 2: Assistance to strengthen the district-level health service The objectives of this component are to: (a) improve the capacity of district hospitals to provide basic curative health services to the population, and (b) strengthen the capacity of District Preventive Health Centers to carry out basic public health functions. The component will achieve its objectives through investing in upgrading medical equipment in the district hospitals, building and equipping District Preventive Health Centers where they do not have adequate functional space, and piloting performance-based financing mechanisms to incentivize health care providers to perform better and more efficiently.

Sub-component 2.1 – Upgrading capacities of district hospitals The Government of Vietnam is paying significant attention to district level health facilities because they are physically most accessible and also pro-poor. In 2008 the government launched a large scale investment of the funds generated from the sale of State bonds into district hospitals. This amount (approximately seven thousand billion VND) has been already distributed among the districts. However the funding is not sufficient to address all equipment needs and to cover all districts. The government funding was used mostly for civil works. In addition to these

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resources, some district hospitals have received funding from international donors. For example KfW has invested in 18 district hospitals in Thanh Hoa and Nghe An provinces.

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

It was decided that the project will only support construction of technical and administrative blocks of District Preventive Health Centers with a size of 500-600 square meters. These are the two essential functional blocks in district preventive centers. It is expected that the local governments will finance building of supporting blocks, such as stores, gardens, garages, etc. It is estimated that the construction of one administrative and technical block will cost approximately $200,000. The project will provide equipment based on the MOH’s standard list of essential equipment for District Preventive Health Centers, the current stock of equipment, and the capacity of each District Preventive Health Center. After being separated from the hospital, no preventive center has had its own vehicle, making it extremely difficult for it to perform epid-surveillance, sanitary control and other functions. The project will provide one off-road vehicle to each district preventive health center under its ambit. It is estimated that about $200,000 will be required to provide the necessary set of medical equipment to each preventive health center.

Table 1.1- List of 30 District Preventive Health Centers for project investment Province District Province District Lang Chánh Qu Phong Thanh Hoá Th ng Xuân Ngh An T ng D ng Quan Hóa K S n Quan S n Ngh a àn Cam Thuy Qu nh L u Nh Xuân Thanh Ch ng H u L c Nam àn Nghi Xuân L Th y Hà T nh K Anh Qu ng Bình Tuyên Hóa H ng S n B Tr ch H ng Khê Qu ng Tr ch Qu ng Tr aKrông Th a Thiên-Hu Phong i n

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Gio Linh Phú Vang H i L ng H ng Trà V nh Linh Phú L c

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

Component 3: Improving supply and quality of human resources for health

The objectives of this component are: (a) to strengthen the capacity of existing medical educational institutions so that they can produce more and better trained medical personnel for the region, and (b) to improve skills and knowledge of already practicing medical personnel so that they are better equipped to provide quality health care to the population. The component will apply a mix of short-term and long-term solutions to health workforce problems faced by the region. These problems include: shortage of doctors, pharmacists, nurses and technicians; low quality of training of nurses, technicians, midwifes, and assistant doctors; outdated clinical skills of medical personnel; poor management skills of health service managers. The short-term solutions include on-job training, refresher courses, workshops, etc. Long-term solutions include strengthening the capacities of medical colleges to increase quality and supply of health care professionals, specialty training of doctors, upgrading of assistant doctors into full-fledged doctors, etc. Sub-component 3.1 – Strengthening medical education system. This sub-component will support the Central North region in transforming Nghe An medical college into a medical university, and in improving teaching facilities in four other medical colleges. This will be achieved through upgrading teaching equipment and materials, and training of trainers Sub-component 3.2 – Training of district health workforce This sub-component will support training of clinical staff of district hospitals, personnel of District Preventive Health Centers, as well as hospital administrators. Only in Quang Tri province the training plan will include the provincial general hospital, which will be upgraded under the project. All other provincial health facilities will be excluded from the training plan, on the grounds that other donors have/will support province level training activities.

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

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Monitoring and Evaluation arrangements: Monitoring and evaluation (M&E) is a critical function for the project. The main objective of M&E is to generate reliable and accurate information about the project implementation progress and statistics for measuring the achievement against the project result indicators. The project will rely, to the extent possible, on existing health information systems and data collection mechanisms in the MOH and in provinces in order not to impose an unnecessary burden on the country. However, for certain statistics it will be necessary to design specific data collection instruments and conduct independent data collection (e.g. small scale household surveys, patient exit interviews, hospital surveys, hospital audits). M&E will consist of two components: (a) monitoring of project implementation process, and (b) monitoring project results indicators and performance of the pilots.

1.2. The objectives and contents of the report of the social impact Assessment 1.2.1. The objectives of the report The present report was prepared with the aim to evaluate and assess the posible social impacts from the Project activities on the population, especially the ethnic minoritie, and to make a plan to prevent posible negative social impacts of the Project and maximize its benfits to the socially vulnerable population groups, with the focus on ethnic minorities. The objectives of the report are - To asssess the key impacts (negative and positive) that can be caused by the Project activities. - To identify appropriate measures to reduce the posible negative social impacts. - To consult with the stakeholders and reflect their views and conerns.

1.2.2. The Scope of the report - Review the current regulations of GoV and WB with regard to social safeguards that should apply to the Central North Region Health Support Project. Especially, the WB’s social safeguards policy for the poor, ethnic minorities and other groups in the remote areas. - Assessing the level of poverty and access to health services for the ethnic minorities. - Consulting with the stakeholders of the Project: the beneficiaries (the poor, near- poor, ethnic minority people), the providers (preventive healthcare service system, district hospitals, health management), and other relevant parts (the local authorities and organizations) - Understanding the possible impacts of the project on the attitude and health seeking behavior of the enthic minorities and their awareness of the entitelments and benefits.

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- Collecting the necessary information for designing plan to maximize the Project’s positive impact on ethnic minorities consideirng the available resources from the Project and from the local sources. - Organizing the field survey in the Project provinces to collect qualitative data on the ability of local capacities for implementing social safeguards policies at the local level.

1.2.3. The procedure of the social impact Assessment In order to achieve the Project objectives, the social consultants should employ various approachs to assess the socio-economic characteristics of the beneficiary population – the poor and ethnic minorities - in relation to health care and determine posible impact of the Project in this regard. This shall include the assessment of whether the Project activities could cause any resettlement or loss of land use rights, and if so how this could impact the affected population. - Developing and analytical framewor for understaing legal implicaitons of GoV’s and the WB’s safeguard policies, and analysing the relevant qualitative and quantitative data to better assess possible social impact of the Project on the poor, ethnic minorities and general population who might incur negative or positive effects. - Assessing the impact of the land acquisition for building the District Preventive Health Centers (DPHC) on the households that may have to resettle or whose livelihood might be affected. - Within the Project scope, the social consultants conducted the research in 6 provinces (Thanh Hoa, Nghe An, Ha Tinh, Quang Binh, Quang Tri and Thua Thien Hue). The consultants conducted the field trip/survey; They worked with the Provincial Project Managment Units (PPMUs), held discussions with the managers and leaders of district health service administration, hospitals, local authorities where the DPHCs will be built. In- depth interviews were conducted with the medical staff, consultation and treatment faculties and patients (inpatient and outpatient) in the district-level hospitals. The consultants also interviewed a sample of households who may lose a portion of their land due to the construction of DPHCs. 1.2.4. The outcomes of the social assessment - Identification of the beneficiaries of the Project and affected popualtion. - Identification of posible negative impacts of the Project on the livelihood of the population; - Assessing the the extent of social safety provided to the affected population by the policies of compensation for reclaimed land needed for the construction of the district preventive medicine centers.

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- Development of an Ethnic Minority plan to be mainstreamed into the Project implementaiton. The social assessment will also determine the need for preparation of resettlement plan in case of any adverse impacts on private assets, incomes and livelihood..

1.2.5. The methods of the social impact Assessment In order to achieve the set-out objectives, the social consultants employed proven social impact evaluation methods to identify and evaluate the potential impacts caused by the Project. The key social impact factors were identified and the ways to minimize adverse effects and maximize the positive ones have been explored. The main methods used in this Assessment includ: 1. Studying documents: Based on the Project documents, collecting the secondary data from the different sources from the Central and the Project provinces/districts, policy frameworks and guidelines of the WB to establish an overview database of the current guidelines for social impact evaluation, the policies and legal frameworks as well as the guidelines for the implementation of the health projects, particularly the programs related to the social safeguard policies. 2. In-depth interview to collect the qualitative information. The targets of the in-depth interview were the impacted households, medicial workers who are working or dealing with the policies related to the poor and ethnic minority people in some clinics, authorities and some relevant agencies at province and district levels; and the poor and the ethnic minority people. 3. Group discussion: applied to the following targets: impacted households, medical workers, poor patients and ethnic minority people. 4. Participatory observation: observing the construction sites of the DPHC, the situation of the equipment and treatment performance in some multi-discipline or district hospitals within the Project areas. 5. Questionnaires: Using questionnaires to the medical workers; the affected households, poor patients and ethnic minority to identify the level of impacts to the living of the people and evaluate the real needs of the participants during the Project implementation. 1.2.6. The workplan Time Period Items Place 8/2009 Participating in the meeting of PMU and WB Ministry of Health From 18/8 to Writing the inception report. Collecting the Ha Noi 25/8/2009 relevant documents to the project From 25/ 8 to Surveying in 6 provinces: Thanh Hoa, Nghe An, Some hospital, DPHCs,

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10/9/2009 Ha Tinh, Quang Binh, Quang Tri and Thua Thien surveyed sites for building Hue DPHCs of 6 project provinces From 15/9 to Write the report Ha Noi 10/10/2009 15/ 10/2009 Draft report Ha Noi 15/11/2009 Final report Ha Noi

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Chapter 2 SOCIAL IMPACT ASSESSMENT FRAMEWORK 2.1 Legal and Policy Framework 2.1.1. Vietnamese Legal and Policy Framework Since 1998, the Government of Vietnam has issued the Decision No. 135/1998/QD- TTg approving the Program for Socio-Economic Development in Communes Facing Extremely Difficult in Ethnic Minority and Mountainous Areas. According to the Decision, the whole population living in extremely difficult communes in mountainous and remote areas is eligible to benefit from health care services.

The Resolution of Party Congress IX (April 2001) states the direction for infrastructure development in the health sector by 2010 as “Completion of planning, strengthening and upgrading sub-national health care network; upgrades of provincial and district hospitals; development of inter-district general hospitals in distant places from the province center; upgrades of the two advanced medical centers in Hanoi and Ho Chi Minh City and establishment of an advanced medical center in the Central as well as development of regional medical centers; steady modernization of medical equipment and application of state-of-the-art scientific and technological achievements”.

On Feb. 23, 2005, The Politburo adopted Resolution No. 46-NQ/TW on “protection, nurture and upgrade of the people’s health in the new context”. The Resolution stressed the need for further development and polishing of the public health care system, including (1) continued development and refinement of the preventive health system; and (2) consolidation and refinement of the sub-national health network in terms of physical infrastructure, facilities and human resources. It also emphasized the need to build and upgrade hospitals, particularly provincial and district general hospitals to be able to meet the essential health care need of the local community. To be specific, by 2010, robust investment will be needed to create a breakthrough in upgrading health services, with preference to district and provincial general hospitals. Meanwhile, the medical workforce will need to be streamlined not only in number but quality and structure and training of health workers will be stepped up by means of on-the-job recruitment for the uplands and Mekong River Delta.

Directive 06 – CT/TW, dated Jan. 22, 2002 of the Central Party Executive Committee on “consolidating and polishing the sub-national health network” clearly defined the role of community-based health care and the leadership and direction responsibilities of various 10

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Party and authority levels as well as stressed the need for sensible investment policies to strengthen and streamline the sub-national health network.

Decision No. 35/2001/QD-TTg, dated Mar. 19, 2001 defining the Strategy for public health care and protection, 2001 – 2010, set the targets of “increasing quality of care at all levels of the health care system in terms of preventive care, curative care, rehabilitation and improvement of health status; application of technological advancements for the domestic health sector to keep up with more developed countries in the region...” and elaborated the solutions as “investment for consistent upgrades of the curative care system relevant to the needs of each region and local socio-economic capacity … steady modernization clinical imaging capacity, biochemical and biophysical diagnosing, immunization, genetics and molecular biology; application of advanced technologies in cardiovascular treatment, endosurgery, orthopedics, microsurgery, organ replacement and transplant … development of some standardized laboratories for food safety testing and quality control … and development of three advanced medical centers in the North, Central and South”.

Decision No. 51/2004/QD-TTg, dated Mar. 31, 2004 on the Government’s Action plan in implementing the Resolution of the 9th Congress of the Party Executive Committee IX stated: “The Ministry of Health shall cooperate with related ministries, agencies and local governments to devise plans and recommendations for capital investment, renovation, upgrades for enhancement of the sub-national health network. Provincial and inter-district general hospitals shall be upgraded to be able to offer quality local health services in order to provide over time a radical solution to overloads in central and large municipal hospitals”. Concurrently, the Prime Minister also authorized the Ministry of Health, Ministry of Finance and Ministry of Planning and Investment to draft plans for mobilization of resources and capital to this end.

Considering the vital role of regional socio-economic development strategy, the Prime Minister issued Decision No. 184/2004/QD-TTg, dated Aug. 13, 2004, providing the primary direction for socio-economic development of the Central economic hub by 2010 and vision by 2020. In this Decision, upgrade of local health systems is identified as an important task and solution to achieve the set socio-economic targets, therein it is specified that health programs need to be effectively rolled out in combination with strengthening of facilities and health human resources for various levels, particularly in respect of health protection and care.

On June 30, 2006, the Prime Minister issued Decision No. 153/2006/QD-TTg, in approval of the Master plan for development of the health care system in Vietnam by 2010 and vision by 2020. The master plan identifies direction for investment, restructuring of the curative care

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and rehabilitation network with emphasis on strengthening and refinement of the sub- national health care network and increase of access to essential health services. It also addresses the establishment of the curative care network by level of care in a bottom-up approach to ensure the continuity of clinical capacity. District hospitals and inter-district general hospitals are responsible to provide primary health services and take patients from the local community or community-based health centers while inter-commune general clinics affiliated to district hospitals in uplands and remote areas need to be maintained and developed to ensure provision of primary health services to the local communities.

In its Resolution No. 18/2008/QH12 of the National Assembly on accelerating enforcement of socialization policies and legislations in improving the quality of health services, the National Assembly endorsed increase of annual budget expenditure for health care and maintain a higher pace of spending on health care than the overall average hike in state budget spending, as at least 30% of the health expenditure will be earmarked for preventive health. More funding will also be set aside for health care services for meritorious citizens, the poor, farmers, ethnic group members and dwellers in areas of socio-economic hardship and extreme hardship.

For the near – poor, the Ministry of Labour, Invalids and Social Affairs has issues the Circular No. 25/2008/TT-BLD TBXB dated on 21/10/2008 guides the process to determine near –poor households according to the regulation at Item 4, Article 1, Decision No.117/2008/QD-TTg dated on 27/8/2008 by Prime Minister. Base on this Circular, locally authorities carry out to check near – poor households to prepare the priority policy for the near – poor. The Ministry of Finance and Ministry of Health issued the Circular No. 10/2008/TTLT- BYT-BTC dated September 24th, 2008 for implementing health insurance to the near-poor, stipulated health insurance fee equal 3% minimum salary, in which the budget of State support minimum 50%. The Circular No. 09/2009/TTLT-BTC-BYT dated August, 14th 2009 guides to implement health insurance have stipulated the near-poor will get preferential policy if they join health insurance in Item 20, article 1 of this circular.

On Involuntary Resettlement, the most recent Decree 69/2009/CP, enacted on August 13, 2009 by the Prime Minister provided amendments to Decrees No197/2004/CP, No17/2006/CP, No84/2007/CP and No123/2007/CP, radically extending the duration and/or levels of assistances provided to severely affected people, while giving rooms for local authorities to decide by themselves on specific amount of assistances given to DPs, to reflect local conditions and circumstances. Decree 69/2009/CP gave provisions to deal with non- residential land located in urban/settlement areas or joined the plot of residential land The

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Decree 69/2009/CP also clearly stipulated responsibilities of local authorities and investor in ensuring land or dwelling for relocated people, indicating different modes of compensation and assistances. The content of resettlement and compensation is stipulated on item 3, article 16, 19, 20. The Ministry of Resources and Environment has issued a Circular to guide some regulation in the Decree No 69/2009/ND-CP related to land rental rates, land reclamation, and resettlement and compensation. This draft icludes the guidelines of determining subject, area of agricultural land in order to help people stabilize life and production. Chapter 3 stipulated process, procerdures on land use planning, land rental rates, land reclaimation to subjects including land for head office. 2.2 Social Safeguard Policy of the World Bank The Social Safeguard policies of the WB is issued to ensure that all projects funded by WB will not destroy environment or social safety nets where the project is implemented. In social assessment, the following aspects were looked at carefully: Cultural properties policy: The World Bank’s general policy regarding cultural properties is to assist in their preservation, and to seek to avoid their elimination. Specifically: The Bank will assist in the protection and enhancement of cultural properties encountered in Bank- financed projects, rather than leaving that protection to chance. In some cases, the project is best relocated in order that sites and structures can be preserved, studied, and restored intact in situ. In other cases, structures can be relocated, preserved, studied, and restored on alternate sites. Often, scientific study, selective salvage, and museum preservation before destruction is all that is necessary. Indigenous peoples Policy: The WB’s broad objective towards indigenous people is to ensure that indigenous people do not suffer adverse effects during the development process, particularly from Bank-financed projects, and that they receive culturally compatible social and economic benefits. How to approach indigenous peoples affected by development projects is a controversial issue. Debate is often phrased as a choice between two opposed positions. The other pole argues that indigenous people must be acculturated to dominant society values and economic activities so that they can participate in national development. Here the benefits can include improved social and economic opportunities, but the cost is often the gradual loss of cultural differences. The Bank’s policy is that the strategy for addressing the issues pertaining to indigenous peoples must be based on the informed participation of the indigenous people themselves. Thus, identifying local preferences through direct consultation, incorporation of indigenous knowledge into project approaches, and appropriate early use of experienced specialists are core activities for any project that affects indigenous peoples and their rights to natural and economic resources.

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Involuntary Resettlement Policy (OP 4.12) : Involuntary resettlement may cause severe long-term hardship, impoverishment, and environmental damage unless appropriate measures are carefully planned and carried out. For these reasons, the overall objectives of the WB policy on involuntary resettlement are the following: (1) Involuntary resettlement should be avoided where feasible, or minimized, exploring all viable alternative project designs. (2) Where it is not feasible to avoid resettlement, resettlement activities should be conceived and executed as sustainable development programs, providing sufficient investment resources to enable the persons displaced by the project to share in project benefits. Displaced persons should be meaningfully consulted and should have opportunities to participate in planning and implementing resettlement programs. (3) Displaced persons should be assisted in their efforts to improve their livelihoods and standards of living or at least to restore them, in real terms, to pre-displacement levels or to levels prevailing prior to the beginning of project implementation, whichever is higher.

2.2 Determining stakeholders in social assessment and coordination - Project Management Unit has 2 levels of management (1) Central Project Management Unit and (2) Provincial Project Management Unit under by coordination of Central Project Management Unit. - Provincial Project Management Unit (PMU): Provincial Project Management Unit will manage and coordinate project’s activities at the provincial level, oversee the procurement processes and financiam managmenet procedures, develop implementation plans and will manage relationships with the local stakeholders. Beside that, PMU has responsibility for monitoring and assessing Project result indicators and following up the implementation of the safeguards plan. - Consultants team: Consultant team is setup to strengthen relationship and cooperation as well as monitoring responsibility and assessment of processing of preparation and implementation of the Project. - The clinic staffs at communes who are the first point of care for the population especially for the poor, near poor and ethnica minorities. - The staff working for department of labour, invalids and social affairs, who directly provide health insurance card for the poor. - The managers at the administration levels, who have right on decision of financial budget pay to fund of the exam and treat medically for the poor. - Primary beneficiaries are the poor, near poor, ethnic minority groups, who rarely have opportunity to choose healthcare services in district hospital and local clinic.

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2.3 Social impact Assessment framework

Activities of Collecting Social safeguard Policies Health Support information of of WB, Policies of the project socio- economic Government condition Stakeholders consulting - Impacted households: Resettlement - Adverse Impacts on: the poor, near - Determine – poor and ethnic stakeholders people, - Particitating and consulting on planning in local - Attitude and recommendation of stakeholders

-Impact factors from activities of -Build regulation, determine project to stakeholders advantage and disadvantage - Proposed measures to reduce elements related to safety policies impact level and mitigate adverse for impacted households and imapcts stakeholders - Make plan of social impact assessment.

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CHAPTER 3 THE SOCIO-ECONOMIC SITUATION OF THE PROJECT AREA

3.1. The Socio-economic situation of the project area The Central North Coast includs six provinces - Thanh Hoa, Nghe An, Ha Tinh, Quang Binh, Quang Tri, and Thua Thien Hue. It is one of the eight ecological regions of Viet Nam, it has narrow streches along the coast with the complicated topography and harsh climate marked with high temperature, prolonged rains, storms and floods. The North Central Coast accounts for 15,6% of the whole country’s territory, while its population accounts for 12,6% of Vietnam’s population, only ranking right after the Red River Delta and Mekong Delta regions. This region is the habitation of various ethnic minorities including Thai, Hmong, Muong, Khmu, Tho, Chut, O du, and Bru-Van Kieu groups. Four of whom, Tho, Bru-van Kieu, O du and Chut groups found only in the North of the Central, the latter two have a small population of 351 peoples and 3,891 people, respectively. These minority groups often live in the bordering remoted areas under extreme living conditions. In term of socio-economic situation, the project provinces have not been economically developed yet and have poor infrastructure.The poverty rate is higher than the average level of the country. The economic structure is relied on the agricultural and aquatic productions; the contribution of the industrial production to the economy is still low. Due to the harsh climate and weak socio-economic conditions, the diseases have often occurred to the people (petechial fever, infections, and respiratory infections) and the raising animals (foot and mouth diseases, bird flu).

Table 3.1. Some features on natural and socio-economic situation of six provinces of the Project Thanh NgheA Ha Quang Quang TT Items Total Hoa n Tinh Binh Tri Hue Area (Km2) 11,136 16,488 6,055 8,065 4,760 5,065 51,569 Population (1.000 people) 3,702 3,122 1,290 854 639 1,144 10,751 Number of districts 27 20 12 7 10 9 85 Number of communes 634 481 262 159 139 152 1,827 Number of comunes within Program 135 94 166 30 73 27 15 405 The poorest districts/62 poorest districts of the whole 7 3 0 1 1 0 12

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country Rate of ethnic minorities (%) 14,4 13,4 1% 10,5% Poverty rate under Policy 139 (%) 31% 29% 17% 28% 40% 12% 26,16% Source: GSO, Data Social- Economic provinces and citties, 2006 The poverty rate of the provinces of the North Central Coast is quite higher than the other provinces in the country. The monthly income per capita of the regions is lower than the average level of the country, particularly in the below poverty and nearly poor line groups. In comparison to the other provinces in the region, the income of the poorest group in Ha Tinh, Nghe An and Thanh Hoa provinces is ranking at bottom level, which is only higher than those of the extremely difficult provinces such as Lai Chau (VND 96.000 per capita per month), Dien Bien (VND 114.000 per capita per month) and Dak Nong (VND133.000 per capita per month). According to the new poverty criteria issued by the Ministry of Labor, Invalid and Society Affairs that regulated that the households which have the monthly income per capita under VND 300.000 will be the poor households; as a result, the poverty rate has been increased certainly in the North Central Coast provinces. The main incomes of the households in the North Central are mainly from salary and agricultural and aquatic productions.

Table 3.2. Monthly income per capita by sources of income quintile Unit:1000 VND

Quintile 5 Quintile Quintile Quintile compare to Total Quintile 2 Quintile 5 1 3 4 Quintile 1 (times)

636.5 184.3 318.9 458.9 678.6 1541.7 Whole country 8.4 418.3 148.3 231.9 321.5 456.2 933.8 North Central Coast 6.3 Thanh Hoa 395.0 145.4 216.4 294.2 407.6 911.5 6.3 Nghe An 413.0 135.0 222.6 313.5 458.4 935.5 6.9 Ha Tinh 400.0 125.9 205.4 285.5 412.0 971.2 7.7 Quang Binh 420.0 151.5 243.2 346.9 483.2 875.2 5.8 Quang Tri 436.0 155.7 232.3 318.3 472.4 1001.3 6.4 Thua Thiên Hue 517.0 171.5 301.0 409.0 602.5 1101.1 6.4 Source: General Statistic Office, A census on household living standard, 2006

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The data from Table 3.2 showed that the incomes of the poor and near poor households in six provinces of North Central Coast are lower than the average income of the groups of the country. In term of household’s expenditures, most of the expense items are spent to buy foods. The expenses for medicines and healthcare are still limited (only account for 6.4% of household’s expenditures). For the poor and near poor households, this expense reach to 6.8% of the household’s expenditure and it is only 5.8% for the well-being household groups. Thanh Hoa province Thanh Hoa province has its natural areas of 11,136 square kilometres with 3.7 million people and 27 districts and 634 communes; the distance from the center of Thanh Hoa city to the remotest district, Muong Lat, is above 300 kilometre long; it has 12 mountainous districts and seven of which are under the list of 62 poorest districts of the country. There are 28 ethnic groups live in the province including Kinh group (2,898,311people, account for 85.6% of the province population), Muong group (328,744 people, 9.4%); Thai group (210,908 people, 6%); Hmong group (13.320 people, 0,38%); Tho group (9.890 people, 0,25%); Dao group (5,077 people, 0.14%); Kho Mu group (607 people); Tay group (444 people); Hoa group (327 people); Nung group (131 people) by ranking as the population. The ethnic minorities often live in the upland and bordering areas. In 2008, the poverty rate following the Decision 139 is 21.53%. The rate of the near poor in 2008 was estimated as 12.82%.

Table 3.3. Socio-economic situation of district selected of project Thanh Hoa province District Area(km2) Populatio Population Ethnic Commune Health hospital Health n density minorities s/wards care beds workers (persons) (persons per establish (Persons) km2) ments

M ong 808,7 30.784 38 Thai, 8 10 83 44 Lat Hmong, Kho mu, M ong

Quan Hoa 996,5 43.549 44 Thai, 18 21 220 76 Hmong, Muong

Ba Th oc 777,2 103.189 133 Thai, 23 26 225 128 Muong

Quan S n 931,1 34.311 37 Thai, 12 15 165 44 Muong

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Muong

Lang 586,3 45.702 78 Thai, 11 13 180 78 Chanh Muong

Source: GSO, Data Social- Economic 671 district and citties, 2006

Nghe An province This is the largest province of the North Central Coast, with the natural areas of 16,488.45 square kilomters and the population of 3,122,405 people. It has 20 districts/cities and 481 communes. Ten of which are the mountainous districts (244 mountainous comunes). The distance from Vinh city to the remotest districts, Ky Son and Que Phong, are 300 km and 250km long, respectively. The poverty rate following the Decision 139 is 29%. There are 20 ethnic groups in the province and the Kinh people is the majority group with 2,477,332 people and accounts for 86.65% of the province population. The populations of other ethnic groups are 269,491 Thai people (9.42%); 56,345 Tho people (1.97%); 27,014 Kho Mu people (0.94%); 20.045 Hmong people (0.91%); 532 Muong people (0.018%); and 0.092% other groups. The poverty rate in 2008 was 17.31% and the near poor households are estimated as 8.89%.

Table 3.4. Socio-economic situation of district selected of project Nghe An province District Area(km2) Populati Population Ethnic Communes/w Health hospital Health on density minorities ards care beds workers (persons (persons per establish (Persons) ) km2) ments

Qu 1,895.4 60,398 32 Thái, 13 16 135 301 Phong Hmông

K S n 2,094.8 63,895 31 Thái, 21 25 180 118 Hmông, Kh mú

T ng 2,806.4 74,313 26 Thái, 21 26 190 257 D ng Hmông, u

Ngh a 737.7 190,580 258 Th 32 35 365 338 àn

Qu nh 607.1 358,906 591 Kinh 43 48 375 276 L u

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Yên 546.9 269,129 492 Kinh 37 41 387 322 Thành

Thanh 1,127,6 232,812 206 Kinh 38 45 365 260 Ch ng

Nghi L c 379.1 216,881 572 Kinh 34 39 330 255

Nam àn 293.9 158,872 541 Kinh 24 28 226 208

Source: GSO, Data Social- Economic 671 district and citties, 2006

Ha Tinh province Ha Tinh province has 6.055,7 square kilometres natural area account for 1.8% of whole country area and 1.227.554 people, accounts for 1.7% population of country (total population census on April 1st, 2009). The population density is 203 people per square kilometres. The majority ethnic group is the Kinh people and the Chut people live in the mountainous area with about several thousand people. Ha Tinh province has one city, one township and ten districts with 262 communes including five mountainous districts. It has complicated topography and difficult transportation, particularly in the remote and isolated communes. The economy of the province is slowly developed, ranking at the group of the poor provinces of the country. The economic structures are mainly agricultural, forestry and aquatic production (contributes to 42.5% budget revenues) while industry and construction only contributes to 21.5%. The infrastructure system has not been developed; the total annual revenue only covers about one fourth budget expenditures. The livings of people are quite difficulty with the capital income is lowest level compared to the other provinces of the North Central Coast.

Table 3.5. Socio-economic situation of district selected of project Ha Tinh province District Area(km2) Populati Population Ethnic Communes/w Health hospital Health on density minorities ards care beds workers (persons) (persons per establish (Persons) km2) ments

Nghi 220 99,478 452 Kinh 19 22 225 316 Xuân

H ng 1101 127,830 116 Kinh 32 35 280 347 S n

c Th 203 117,930 581 Kinh 28 30 300 304

C m 636 154,562 243 Kinh 27 30 275 355 Xuyên

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Xuyên

H ng 1299 108,010 83 Kinh, 22 26 260 300 Khê Ch t

K Anh 1.058 170,351 161 Kinh 33 37 315 291

Source: GSO, Data Social- Economic 671 district and citties, 2006 Quang Binh province Quang Binh province, with 8.065 square kilometres natural area, has its narrow and sloppy topography from the west to the east, and 85% of the total land area is criss-crossed by the mountains and rivers. The great part of the western zone of the province is the mountains at the height from 1.000-1.500 m where the Phi Co Pi, at 2017m above sea level, is the highest top of the area, and the long lower mountains are distributed as the dome-shaped top. Near by the littoral is the small and narrow delta. The later is the crescent or fan tail sand bank running along the littoral. With a narrow and sloppy topography and located in the monsoon tropical zone, Quang Binh is always impacted by the North and South climates and annual floods and storms. According to the total census of population on April 1st, 2009, Quang Binh has 846.924 people that the Kinh is the majority. The ethnic minorities include Chut (including local groups of Ruc, Sach, May, and Arem) and Bru-Van Kieu (including local groups of Khua, Ma Lieng and Van Kieu) concentrated in the western communes of Bo Trach, Quang Ninh, Le Thuy districts and in two mountainous districts of Minh Hoa and Tuyen Hoa. It has 7 districts and 159 communes. The poverty rate following the Decision 139 was 28% and the rate of near poor households was estimated as 24.3% in 2008.

Table 3.6. Socio-economic situation of district selected of project Quang Binh province District Area(km2) Population Populatio Ethnic Communes/w Health hospital Health (persons) n density minorities ards care beds workers (persons establish (Persons) per km2) ments

Minh Hóa 1,410 438,41 31 Ch t, 16 18 128 147 Kinh

Tuyên 1,149 79,465 69 Ch t, 20 23 167 168 Hóa Kinh

Qu ng 612 200,459 328 Kinh, 34 35 337 282 Tr ch Bru- Vân Ki u

B Tr ch 2,123 172,616 81 Kinh 30 32 260 254

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L Th y 1,411 144,543 102 Kinh, 28 29 250 247 Bru- Vân ki u

Source: GSO, Data Social- Economic 671 district and citties, 2006 Quang Tri province Quang Tri province has 4,745.7 square kilometres natural area. According to the total census on April 1st, 2009, its population was 597,985 people. Quang Tri has one city, one township and 8 districts including 139 communes with population density of 104 people per square kilometer. In addition to the Kinh people, there are two ethnic groups, Bru-Vankieu and Ta oi people, live in Dakrong, Huong Hoa, Gio Linh and Cam Lo districts. The administrative center of the province is Dong Ha township, 598km far from Ha Noi city toward the south and 1112 km from Ho Chi Minh city toward the north. The climate in Quang Tri is very harsh with the south-west dried hot wind namely as “Lao wind” from Laos blowing to. The storm season is annually from July to November, which focuses on the September to October. A record in 1998 showed that there were 75 storms crossing to Binh Tri Thien zone; and it is in average of 0.8 storm per year affecting directly to Quang Tri, rainfall caused by a storm is about 300-400 mm, evenly, to 1000mm. The poverty rate is 16% and the near poor rate is estimated 7.85% in 2008.

Table 3.7. Socio-economic situation of district selected of project Quang Tri province District Area(km2) Populati Population Ethnic Communes/w Health hospital Health on density minorities ards care beds workers (persons) (persons establish (Persons) per km2) ments

V nh 626,4 90,695 145 Kinh 22 25 245 178 Linh

Gio Linh 473 76,336 161 Kinh, Bru 20 22 136 143 – Vân Ki u

Dak 1223,3 32,615 27 Bru- Vân 14 17 77 96 Krông Ki u, Tà Ôi

H i L ng 489,5 102,281 209 Kinh, 21 24 144 131 Bru- Vân Ki u

Source: GSO, Data Social- Economic 671 district and citties, 2006

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Thua Thien-Hue province Belonging to the economic focal area of the Central of Viet Nam, Thua Thien Hue is located at the important site of the north- south roads (national road no.1, Ho Chi Minh road, and national railway) and east-west economic lobby that connects Thailand, Laos and Vietnam. Hue has its rich potential in tourism and diversity material and non-material cultural heritages. It has 5,053,99 square kilometers land area, 9 districts and 152 communes; it is specialized by the mountainous districts with a high poverty rate and ethnic minority groups, the area around the Tam Giang embayment, and the districts extended along the littoral. Its population is 1,087,579 people (April 1st, 2009), with the population density of 215 people per square kilometres. The ethnic minority groups are …, including Co tu, Bru-Vankieu, and Ta oi people concentrate in mountain districts of A Luoi and Nam Dong. Thua Thien Hue often suffers from the damages to both human livings and assets by the annual floods and storms. Disease prevention and providing healthcare for the people after floods is always the hard works to the medical offices in Thua Thien Hue. The infrastructures of healthcare including medical equipment and facilities and the quality of healthcare services, however, is very poor, particularly in the remote mountain districts. This is also the only province without the hospital at province level in the country.

Table 3.8. Socio-economic situation of district selected of project Thua Thien Hue province District Area(km2) Populati Population Ethnic Communes Health hospital Health on density minorities /wards care beds workers (persons) (persons per establish (Persons) km2) ments

Phong 953.8 105,134 110 Kinh 16 20 128 146 i n

Phú Vang 280.3 180,059 642 Kinh 20 25 170 180

H ng 520.9 116,066 223 Kinh, Tà 16 20 148 160 Trà Ôi

Phú L c 728.1 149,875 206 Kinh 18 23 179 179

TP Hu 71 321,498 4.529 Kinh 25 43 2404 1990

Source: GSO, Data Social- Economic 671 district and citties, 2006

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3.2. Healthcare situation With regards to disease pattern and mortality, statistics from the six North Central provinces show that infectious and communicable diseases are the most popular diseases among the North Central communities. Diseases with the highest incidence and mortality include respiratory infection like pharyngitis, pneumonia, bronchitis and disorders associated with intestinal tract and parasitic worms. Mortality from all causes remains generally high in the six North Central provinces at 6.2/1,000, higher than the country rate of 5.3/1,000. Mortality is highest in Quang Tri province at 8.0/1,000; followed by Ha Tinh at 7.0/1,000 in second, Thanh Hoa in third at 6.9/1,000. This typical disease pattern is proof of the underdeveloped economic conditions, living standards and education level in the North Central region.

Table 3.9. Percentage of illness or injuies in year 2006 by province Unit: %

In the past 4 weeks In the past 12 months Of which: Stay in bed and need some one to Local take care of

whole country 17.95 49.10 10.45

Red River Delta 15.37 44.37 10.95

North East 17.30 42.23 10.24

North West 15.68 37.19 11.02

North Central Coast 15.13 39.10 12.07

Thanh Ho¸ 12.80 35.79 13.16

NghÖ An 16.38 37.44 9.03

Hµ TÜnh 27.54 69.18 16.92

Qu¶ng B×nh 9.79 27.08 11.43

Qu¶ng TrÞ 14.24 37.58 13.28

Thõa Thiªn HuÕ 9.06 28.36 10.70

Source: General Statistic Office, A census on household living standard, 2006

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Table 3.10. Malnutrition in weight by age among children under 5 years (%) in North Central and 6 provinces 2007 Unit: %

Regions 2005 2006 2007

North Central 30.0 24.8 25.0

Thanh Hoa 31.3 29.1 27.3

Nghe An 28.9 26.7 24.8

Ha Tinh 30.5 27.9 25.1

Quang Binh 34.4 32.1 30.6

Quang Tri 25.9 24.3 22.5

Thua Thien – Hue 23.0 21.2 19.8

Sources: Nutrition Institute, 2007

According to Table 3.10, Malnutrition is also common among children in the North Central. Child malnutrition rate here in 2007 was recorded at a high 25% against the country average of 21.2%. special in Quang Binh (30.6%), Thanh Hóa (27.3%).

Table 3.11. Mortality pattern in the six selected provinces

Infectious diseases of highest mortality Non-infectious diseases of highest mortality

Respiratory tract inflammation Cardiovascular disorders

Diarrhea Traffic injuries

HIV/AIDS Tumor, cancer

Intestinal infections and parasitic disorders Other injuries, traumas

Gastroduodenitis Pregnancy/labor accidents, obstetric incidents

Hepatitis Malign hematic disorders

Hematic infections Neural system disorders

Reproductive tract inflammation Poisoning

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Fever of unknown causes Perinatal traumas*

Paralytic ileus*

Congenital diseases*

Source: Survey of health status in North Central region, 2006; Provincial health statistic review, 2006; Most lethal diseases among children, Health Year Book of statistics, 2007

Of the infectious diseases, the highest rates belong to acute respiratory inflammation and diarrhea while HIV/AIDS is becoming an alarming issue in the selected provinces. Although the rate of new HIV infections in 2005 in the region was lower than the country average, the unaccounted for actual data may be higher. HIV/AIDS is the third highest killers in the provinces, only behind pneumonia and diarrhea.1 Sales and use of drugs are widely popular in the region and tourism-related inflow of immigration, among others, may make the situation even worse in the near future. Non-infectious causes of death include cardiovascular disorders at 25%, cancer at 15% and injuries at 12% In summary: the basic health indicators of local people in project provinces have shown to be the lowest nationwide, especially health indicators of mothers and children, reflecting limited socio-economic conditions and health care capacity compared to other provinces. The basic disease pattern shows that of less developed regions, with high rates of infectious diseases and contageous diseases. Although tuberculosis, malaria, bronchocele have been put under control, the risk of the development of these diseases is still high. Besides, non- infectious diseases, accidents, injuries, tend to increase, creating a “double burden” in providing health care services for the public. What is more, unhealthy life styles such as the above-nationa-average rate of drinking alcoholic drinks, popular drug use in some localities which are on the rise, create new health risks. The above data indicate that the Central North provinces have a very high demand for health care.

3.3.Diseases burden The objective of morbidity burden analysis is to describe the population’s health status, by types of diseases and specific health conditions. The methodology used for describing general health status in project provinces is analysing the burden of diseases. This method focuses on the comparison of morbidity burden between the project provinces and national level, and the identification of typical diseases and disease pattern of project provinces, as

1 Health Yearbook, 2007 26

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well as target population (including rural population, the poor, the ethnic minorities, women and children). The national analytical data on morbidity burden using DALY method (counting the number of years lost due to illnesses and Mortality) indicate that 22% of morbidity burden is caused by infectious diseases, nutritious problems; 54% by uncommunicable diseases. An important characteristics of national health situation is that accidents and injuries counted for 23% of the burden. Accidents and injuries can cause morbidity burdens at similar levels to that cuased by traditional infectious disesases. More in-depth analysis may be implemented on the health status of the local population in the project provinces, by comparing the morbidity burdens born by the urban and rural population with those born by the poor in the same provinces. Analytical results on the morbidity burden pattern of urban, rual and the poor areas in project provinces show remarkable differences in the health status among these 3 groups of population, and also suggest necessary inteventions to mitigate the unfairness in terms of health conditions.

Table 3.12. Percentage of illness or injuies in year 2006 by urban rural, region, income quintile, sex, age group and ethnic Unit: %

Of which: Stay In the In the past in bed and need Total past 12 4 weeks some one to months take care of

whole country 49.10 17.95 49.10 10.45 Income quintile for whole country Quintile 1 45.81 19.45 45.81 12.75 Quintile 2 46.81 17.97 46.81 10.80 Quintile 3 49.11 17.37 49.11 10.40 Quintile 4 50.96 17.46 50.96 9.66 Quintile 5 52.85 17.47 52.85 8.64 Sex Male 45.53 16.00 45.53 9.37 Female 52.54 19.83 52.54 11.49 Age group 0-4 63.34 30.64 63.34 19.84 5-14 48.08 15.66 48.08 8.47 15-24 35.10 9.30 35.10 5.64 25-39 43.59 13.10 43.59 7.36

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40-59 53.40 20.37 53.40 10.33 60+ 72.22 36.22 72.22 24.77 Ethnic of household head Kinh 50.04 17.98 50.04 10.29 Tay 41.41 18.51 41.41 8.82 Thai 33.19 14.17 33.19 11.78 Hoa 51.78 20.48 51.78 7.11 Kho me 45.82 17.48 45.82 8.84 Muong 43.48 22.11 43.48 14.30 Nung 41.26 18.69 41.26 11.53 Hmong 31.09 10.22 31.09 12.07 Dao 34.67 11.04 34.67 6.79 Others 51.36 18.61 51.36 14.32 Source: General Statistic Office, A census on household living standard, 2006 The disease burben of urban area in the project provinces are same as the national pattern. The major differences are found in higher morbidity burdens of the elderly in urban area of the project provinces and the lower morbidity burden of urban children in the project provinces than the national indicators. The results also are relevant to the fact that urban people have better health. The basic difference in morbidity burden pattern in project provinces relate prioritized groups of population (including women and children). The pattern of children’s morbidity burden in urban area is 216/1,000, 618/1,000 in rural area and 1.042/1,000 in the poor rural area. The figures reflect the fact that rural children’s health is 3 times worse than that of urban children, and rural poor children’s health is even upto 5 times worse. It is poverty that caused 90% of the morbidity burden in the poor rural area, and 80% in other rural areas. The same situation is also seen among women aged from 15 to 44, and even worse among the poor rural women. In general, women’s morbidity burden (between 15-44 years of age) in the rural area is 70% higher than in the urban area. If we compare morbidity burdens of women who live in the rural poor area with urban women, the difference is even greater (3.5 times). The morbidity burden is mainly associated with pregnancy and child delivery. In this regard, severe cases have been caused by limited access by the rural poor to available medical treatment services the North Central region. What is more, child birth delivery at the local health facility is a difficult job due to long distance from local residence, and financial constraints of the households.

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3.4. Accessibility and utility by local people of health services Due to geographical conditions, regular floods and storms every year, isolation of some locations in flood season, the North Central region face with difficult accessibility to health care services, even at commune level. The average distance from commune health station to the nearest provincial health facility in the region is 58 km, which is relatively remote compared to other regions in the country (Northern Eastern region: 57km, Red River delta area: 24km, Southern Central region: 35km, Central Highland: 58km, Southern Eastern region: 33km, Mekong Delta Area: 29km). It is the long distance that leads to very low accessibility to provincial hospitals for the local people in general, and for the poor in particular. Whilst, the demand for health care services among the North Central population is higher than in other regions, the number of inpatient and outpatient visits in the region is 3.5 times/person/year, lower than the national average (4.2 times/person/ year). During the 4-week-interval of 2 survey interviews conducted in North Central region, 39.5% of the local population used health care services or bought medicines with their pocket money, which is lower than the data found in Red river delta, Southern Central region and Mekong delta area. Average total times of using health care services by one local resident in North Central region during 12 months (9.6 times) is lower than that found in the above other areas. North Central region population use provincial in-patient care half as much as other regional population do (National Health Survey). When seriously ill, the local people mainly use the health care services at district level and regional general hospitals, commune health stations, or contact hamlet health workers. According the National Health Survey data of 2002, the rate of sick people who received no treatment throughout the country during 4 weeks before the survey was 4.2%. This rate among ethnic minorities in Central and Central Highland regions is very high, upto 22.3%, compared to the national rate of 4.2%.

Table 3.13. Rate (%) Sick cases not treatment during 4 weeks before survey Male Female Urban Rural Area General Sick cases Area General 4.4 4.0 3.3 4.4 4.2 66.795 Ethnic minorities in Central region and Central Highland 21,5 13,0 10,9 23,0 22,3 1.579 Regions total 66.795 Red River Delta 4.2 4.5 4.1 4.4 4.4 13.695 North Central Region 6.4 5.5 7.2 5.6 5.9 8.150 Northern Western 12.7 10.2 4.9 12.4 11.4 2.522 Central Highland 12.6 11.9 4.8 14.7 12.2 4.028

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Male Female Urban Rural Area General Sick cases Area South Eastern 2.7 2.9 2.2 3.2 2.8 8.618 Mekong Delta 2.1 1.7 1.3 2.0 1.9 15.793 Source: National Health Survey, MoH, 2002

The pattern of using health care services (for both in-patient and out-patient care) was also analyzed during the National Health Survey by region. On the average, total use of health care services in commune health stations for medical consultation and treatment compared to that in regional general hospitals is 21.9% (21.5% for outpatient care, 0.4% for inpatient care), 8.2% compared to district hospitals and 8.6% compared to provincial/national hospitals. In North Central provinces, the rate between the use of provincial hospitals and the use of national hospitals is lower than that nationwide (6.6% versus national 8.6%). Meanwhile, health care services at district hospitals (11.8%) and commune health stations (34.1%) are utilized more often than national average. This shows that the local people in the North Central provinces mainly use their local health facilities (at district and commune levels). In particular, the ethnic minorities in Central region and Central Highland use health care (out-patient and in-patient) services of district hospitals for medical consultation and treatment quite a lot (11.3%, where 4.7% of in-patient services and 6.6% of out-patient services)

Table 3.14. Percentage of in-patient treatment in year 2006 by type of health facilities, region, sex, age group Unit: %

Of which Governm Commune Regio Private Tradition ent health n health medical hospital centre poly- facility practitio Total clinic ner Others

Whole country 100 78.05 14.01 5.04 1.62 0.34 0.93 Urban - Rural Urban 100 88.88 2.78 4.77 2.53 0.18 0.85 Rural 100 74.21 18.00 5.13 1.30 0.40 0.96 Region

Red River Delta 100 84.17 11.01 2.94 0.47 0.44 0.97 North East 100 74.33 17.31 6.56 0.40 0.32 1.09 North West 100 64.06 23.80 9.89 0.50 0.24 1.51

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North Central Coast 100 71.21 21.51 3.55 1.68 0.87 1.18 South Central Coast 100 80.55 12.26 3.74 2.57 0.05 0.82

Central Highlands 100 75.31 12.63 6.11 4.43 0.25 1.25 South East 100 85.78 5.43 4.98 2.62 0.21 0.98 Mekong River Delta 100 76.00 15.13 6.43 1.75 0.19 0.49 Sex Male 100 79.93 12.96 4.62 1.26 0.18 1.05 Female 100 76.55 14.86 5.37 1.91 0.47 0.84 Age group 0-4 100 70.65 20.57 7.45 0.96 0.04 0.33 5-14 100 70.23 21.34 6.10 1.31 0.19 0.83 15-24 100 76.41 15.31 4.75 2.25 0.13 1.15 25-39 100 76.70 13.89 5.93 1.71 0.97 0.80 40-59 100 80.88 11.69 4.58 1.61 0.21 1.04 60+ 100 81.89 11.18 3.97 1.61 0.32 1.03 Source: General Statistic Office, A census on household living standard, 2006

According to the GSO statistics, (findings of Households Living standard survey conducted in 2006), the times of using public hospital in-patient care services by Northern Central people are the least the times of using commune health station inpatient care services by the same people are the second highest (after North Western region) nation wide.

Table 3.15. Distribution of rounds of medical consultation and treatment during 4 weeks before the survey (%) Provincial /Central District hospitals Regional General Private Other hospitals Clinic/ CHC/ Hamlet health public Total health facilities services facilities Inpatient Outpatient Inpatient Outpatient Inpatient Outpatient General 1.2 7.4 0.9 7.3 0.4 21.5 58.7 2.6 100 Ethmic minorities in Central region and Central highland 0.9 2.0 4.7 6.6 1.2 49.4 34.4 0.9 100 Red River Delta 0.9 7.4 0.8 7.5 0.3 21.9 56.4 4.9 100 North Eastern region 1.6 7.4 1.7 12 1.2 35.2 35.9 5.0 100 North Western region 0.8 6.4 0.7 12.1 1.0 49.1 26.4 3.6 100 North Central region 1 5.6 1.5 10.3 1.4 32.7 45.8 1.7 100

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South Central region 1.2 6.2 1.6 7.5 0.4 15.1 66.8 1.2 100 Central Highland 1.4 5.9 1.6 7.5 0.2 21 59.6 2.8 100 South Eastern region 2 11.5 0.3 6.1 0.1 11.4 66.6 2 100 Mekong River Delta 1 6.5 0.7 5.1 0.2 19.4 66.3 0.8 100 Source: National Health Survey, MoH, 2002

The use of private health care services in North Central provinces is lower than national use (45.8% versus 58.7%), being the third lowest region across the nation. Among cases of using private health care services, the majority use traditional medicine, Vietnamese traditional medicine and medicines made from leaves. This means the private health care facilities in the North Central region are in small numbers and less developed. The rate of users of traditional health care services and traditional treatment methods is the highest in North Central region, where there is also the highest rate of Chinese traditional medicine users, upto 28%. Thus, health care for local people in the region mainly rely on public health facilities, especially at commune and district levels. Regarding the use of hospital services, the national rate of use of hospital beds in 2006 was 103.1% (including beds in commune health stations). On the average, stays in hospitals last 7.82 days nationally.

Table 3.16. Use of public hospitals in 6 project provinces Average days in Times of using Out- Number of in- Province hospital patient care / 1000 patients people admission/ 1.000 people Thanh Hoa 6.9 416 120 Nghe An 6.6 380 114 Ha Tinh 6.9 611 143 Quang Binh 6.2 330 132 Quang Tri 5.4 26 133 Thua Thien Hue 6.8 217 53 Nation wide 6.72 284 108.7 Source: Health Year Book of statistics, 2007; Reports provided by Provincial Health Departments, 2008

The average number of days of in-patient stay reflect the quality of treatment, the longer the stay is, the better quality the treatment is. The number of days during an average in-patient stay in North Central provinces is less than the national number. However, in poor provinces where health care quality is low, the short in-patient stay indicates the contrary finding (which can be read through higher rate of referrals than other areas). One reason of short stays is also due to the local families’ unaffordability, in terms of food, accommodation and

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economic conditions, for sufficient stay till their health recovery, they have to work daily to earn their living. This can be considered typical feature of the poor areas with low quality of health care services.

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Chapter 4 THE IMPACTS OF THE PROJECT TO ETHNIC MINORITY

4.1. Identify the level of positive impacts of the project to the poor, near poor and ethnic minority people Since reform policy has been implemented, health situation of most Vietnamese people has improved. In the fact, ethnic people has get free of charge on health treatment from different finance resources.

Table 4.1. Percentage of people having treatment in the last 12 months in year 2006 by urban rural, region, income quintile and sex Unit: % Of which Percentage of Of which: Percentage Of which: having inpatient having health of health insurance treatment insurance or outpatient or free health care Total free health treatment certificate care certificate

whole country 35.24 6.30 3.96 32.61 18.58 North West 28.91 8.39 7.49 24.30 20.96 North Central Coast 27.13 6.80 4.78 23.39 15.40 South Central Coast 35.41 7.09 4.81 32.56 20.85 Central Highlands 41.26 6.64 4.75 38.76 27.33 Income quintile Quintile 1 33.81 7.13 5.33 30.36 21.51 Quintile 2 34.38 6.16 3.59 31.71 16.62 Quintile 3 35.19 6.35 3.48 32.52 15.79 Quintile 4 36.49 6.02 3.60 34.11 18.14 Quintile 5 36.32 5.85 3.82 34.34 20.84 Sex Male 31.61 5.58 3.73 29.10 17.26 Female 38.73 7.00 4.19 35.98 19.85 Resource: General statistic office, living standard survey, 2006

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According to 4.1. data table, people get benefit from the recent health care programs are poor people and ethnic people; lowest income group has 7.13% patients get free of charge treatment while group 5 has highest income get lower benefit (5.85%).

Table 4.2. Percentage of out-patient treatment in year 2006 by type of health facilities, urban rural, region, sex, age group and ethnic Unit: % Of which Governm Commune Region Private Tradition Total ent health poly- health medical hospital centre clinic facility practitioner Others

whole country 100.00 28.83 25.87 3.59 31.98 2.43 7.31 North Central Coast 100.00 32.06 39.94 3.13 12.92 4.41 7.55

South Central Coast 100.00 34.64 23.38 3.43 30.50 2.64 5.41 Central Highlands 100.00 26.25 31.33 5.11 32.93 0.74 3.64 Sex Male 100.00 29.14 25.93 3.45 31.99 2.44 7.06 Female 100.00 28.61 25.82 3.70 31.96 2.42 7.49 Age group 0-4 100.00 19.97 38.45 3.58 31.97 0.42 5.61 5-14 100.00 20.86 33.40 3.63 33.55 0.73 7.83 15-24 100.00 28.14 26.12 4.14 32.73 1.26 7.60 25-39 100.00 29.33 24.69 3.10 32.48 2.32 8.09 40-59 100.00 33.38 21.90 3.44 30.74 3.51 7.03 60+ 100.00 30.99 22.39 3.87 32.01 3.36 7.39 Ethnic Kinh 100.00 29.55 23.87 3.47 33.29 2.50 7.32 Tµy 100.00 28.03 49.66 7.85 8.93 1.97 3.56 Th¸i 100.00 28.08 52.29 3.65 8.61 0.11 7.26 Hoa 100.00 28.90 7.15 2.92 52.06 4.32 4.65 Kh¬ me 100.00 23.22 41.51 1.34 24.80 1.19 7.94 M êng 100.00 20.43 53.83 5.26 10.77 1.85 7.86 Nïng 100.00 27.36 42.14 2.45 20.93 2.29 4.82 Hm«ng 100.00 4.60 83.84 0.70 5.01 0.82 5.01 Dao 100.00 29.00 49.11 2.78 1.06 8.98 9.07 Others 100.00 14.72 54.11 6.99 13.39 0.75 10.04

Resource: General statistic office, living standard survey, 2006

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For boarding hospital treatment, due to weak infrastructures, difficult transportation so most ethnic people choose clinics and hospitals in commune and district levles. Due to low income, ethnic people can not afford sufficiently finance when moving to hospitals in central and provincial levels.

Table 4.3. Percentage of in-patient treatment in year 2006 by type of health facilities, urban rural, region, sex, age group and ethnic Unit: % Of which Governme Commune Region Private Tradition nt health poly-clinic health medical Total hospital centre facility practitioner Others

whole country 100.00 78.05 14.01 5.04 1.62 0.34 0.93 North West 100.00 64.06 23.80 9.89 0.50 0.24 1.51

North Central Coast 100.00 71.21 21.51 3.55 1.68 0.87 1.18

South Central Coast 100.00 80.55 12.26 3.74 2.57 0.05 0.82 Central Highlands 100.00 75.31 12.63 6.11 4.43 0.25 1.25 Sex Male 100.00 79.93 12.96 4.62 1.26 0.18 1.05 Female 100.00 76.55 14.86 5.37 1.91 0.47 0.84 Age group 0-4 100.00 70.65 20.57 7.45 0.96 0.04 0.33 5-14 100.00 70.23 21.34 6.10 1.31 0.19 0.83 15-24 100.00 76.41 15.31 4.75 2.25 0.13 1.15 25-39 100.00 76.70 13.89 5.93 1.71 0.97 0.80 40-59 100.00 80.88 11.69 4.58 1.61 0.21 1.04 60+ 100.00 81.89 11.18 3.97 1.61 0.32 1.03 Ethnic Kinh 100.00 80.37 11.82 4.60 1.83 0.37 1.01 Tµy 100.00 71.85 17.09 8.89 0.58 0.21 1.37 Th¸i 100.00 69.67 25.27 4.05 0.26 0.25 0.50 Hoa 100.00 95.51 2.58 1.91 - - - Kh¬ me 100.00 83.85 12.89 3.26 - - - M êng 100.00 64.77 24.45 9.14 0.59 0.26 0.78 Nïng 100.00 65.57 25.29 7.37 1.41 - 0.36 Hm«ng 100.00 41.04 51.88 7.09 - - - Dao 100.00 78.84 19.30 1.86 - - - Others 100.00 53.25 35.48 10.02 0.68 0.27 0.30

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Resource: General statistic office, living standard survey, 2006

Rate of Hmong, Thai, Muong, Nung ethnic people having treatment in commune clinics are higher than ethnic groups living in lowland like Kinh, Kho me, Cham...

Table 4.4. Percentage of people having treatment in the last 12 months in year 2006 by age group and ethnic Unit: % Of which Percentage of Of which: Percentage of Of which: having inpatient having health outpatient health insurance Total treatment insurance or free treatment or free health care health care certificate certificate

Age group 0-4 50.52 8.25 7.50 47.20 41.85 5-14 31.82 3.86 3.18 29.93 24.10 15-24 21.71 4.08 2.24 19.74 10.90 25-39 30.84 5.73 2.78 28.49 11.79 40-59 39.53 6.82 3.96 36.77 16.83 60+ 58.86 14.01 9.15 53.78 28.53 Ethnic Kinh 35.82 6.19 3.65 33.34 18.00 Tµy 28.26 6.61 5.25 25.01 19.10 Th¸i 30.62 8.59 8.15 25.46 23.33 Hoa 33.46 4.15 1.88 32.29 13.00 Kh¬ me 33.82 6.00 3.55 31.02 17.95 Mêng 29.68 7.57 6.47 25.43 20.66 Nïng 27.43 5.37 4.44 24.31 19.60 Hm«ng 29.05 6.95 6.82 24.45 23.87 Dao 18.84 3.51 2.21 16.64 10.40 Others 37.92 8.29 7.51 34.24 29.74

Resource: General statistic office, living standard survey, 2006. According to table 4.4, Thai, Muong, Hmong ethnic minorities have health care credits and free of charge treatment credits are higher than other ethnic groups including Kinh group. Number of Thai, Hmong and Muong patients get boarding hospital treatment are higher than other ethnic minorities. According to project design, patients in hospitals at district level are poor, people have health care insurance cards and villagers in project area. In 3 components in the project including 2 components serving directly for poor benefit, near poor line and ethnic people

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that invest hospital equipments for hospitals at district levels, building constructions and upgrading offices for PHCs district level and component to buy health care insurance cards for people near poor line. For ethnic people, poor households get health care insurance cards, the remain will get health care insurance funded by projects according to policies for poor people.

Table 4.5. Percentage of poor, near poor and ethnic minority of districts prioritised for project investment Unit: % District Rate of Poor Rate of neer Rate of Ethnic Ethnic Minority households Poor minorities households (estimate 2005) (estimate 2008) Thanh Hóa province 21,53 12.82 16.4 Lang Chánh district 45,0 28.48 51.58 Thái, M ng Th ng Xuân district 49,9 17.26 55.0 Thái, M ng Quan Hóa district 43,5 40.57 51.5 Thái, M ng, Hmông Quan S n district 47,3 43.64 55.0 Thái, M ng, Hmông M ng Lát district 63,0 34.42 70.0 Hmông, Thái, M ng Nh Xuân district 43,0 28.99 52.3 M ng, Th Bá Th c district 54,8 20.27 60.0 M ng C m Th y district 24,3 20.61 34.0 M ng, Dao H u L c district 20,8 12.06 0 T nh Ngh An 17,31 8.89 13.4 Nam àn district 12,88 5.80 0 Qu nh L u district 11,95 7,17 0 Thanh Ch ng district 18,98 11.39 0 Ngh a àn district 22,24 13.35 20.8 Th Qu Phong district 46,57 23.28 89.4 Thái, Hmông T ng D ng district 57,85 23.14 89.5 Thái, Hmông, u K S n district 57.97 23.19 95.4 Hmông, Thái, Kh mú T nh Hà T nh 0.2 H ng S n district 11.76 22.10 0 Nghi Xuân district 13.57 28.59 0 c Th district 7.14 10.81 0 C m Xuyên district 14.30 19.47 0 H ng Khê district 14.57 24.67 0.2 Ch t, M ng K Anh district 16.97 15.29 0.1 M ng T nh Qu ng Bình 27.5 1.,8 1.9 Minh Hóa district 57.5 21.3 0.6 Ch t

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Tuyên Hóa district 34.5 23.3 14.9 Ch t, Bru Vân ki u B Tr ch district 16.9 14.3 1.3 Bru Vân Ki u,. Ch t L Th y district 18.6 12.6 2.6 Bru Vân Ki u,. Ch t Qu ng Tr chdistrict 25.7 17.8 0.1 Ch t T nh Qu ng Tr 13.9 7.85 9.1 Dakrong district 8.0 10.4 75.7 Bru Vân Ki u, Tà ôi Gio Linh district 17.3 8.5 2.5 Bru Vân Ki u H i L ng district 18.2 10.5 0 V nh Linh district 12.2 8.1 2.6 Bru Vân Ki u Th a Thiên Hu 3.6 Bru Vân Ki u, C tu, Tà ôi Phong i n district 8,60 5,11 0.5 Bru Vân Ki u Phú Vang district 9,20 4,87 0 H ng Trà district 9,72 6,66 0.3 Bru Vân Ki u Phú L c district 11,32 4,95 0.4 Bru Vân Ki u Souces: Provincial reports in 2008 Data in table 4.5, shows that the rate of poor people, people near poverty line and ethnic minorities people in the project area are quite high, special in Thanh Hoa and Nghe An where Chut, o du, Co tu and Bru- Van kieu people live and getting many prioritized policies of Vietnamese Government. According to the project design, the target groups of the hospitals at district level are the poor, health insurance holders and local people. Two of three investment items of the project that serve directly to the benefit of the poor, near poor and ethnic minority people are the investment in equipment for the hospitals at district level, constructing and upgrading the working offices for the district preventive health centers, and support to buying of health insurance for the near poor people. The investment of upgrading the medical system for the North Central Coast province, especially at district level, will impact directly to improve the health status for the people, particularly the poor, near poverty line and ethnic minority househoulds. ƒ The healthcare system in general, especially at the district level in the provinces where project is invested for training the healthcare workers and upgrading facilities and supplies of medical equipment. This investment will change significantly in treatment capabiliities and quality of the healthcare services in the district hospital level. ƒ The people, particularly the poor, near poverty line and ethnic minority people in the project provinces have accessed mainly to the treatment services at district level. The treatment services have improved both in quantity and quality will help the people have the better treatment services right in the local, which reduce the

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transportation of the patients to upper levels and the expenses of treatments, and the poverty to the people. ƒ The improved healthcare service at district level will contribute to ensure the equity of healthcare services and provide a better condition for the poor, near poor and ethnic minority people that they do not or only pay partly for the treatment expenses. That is very suitable with the living condition and healthcare needs of the poor, near poor and ethnic minority people. ƒ The patients are treated timely and qualifiedly right in the district level will reduce the presures to the upper levels, the provincial hospitals. District hospital will attract more patients that contributes to the effective and harmony operation of the medical system. ƒ In addition to the investment of medical system, the project will invest directly to the service users (the poor, near poor and ethnic minority people), which bring the realistic effects to the target groups and increase the effectiveness of the operation of the medical system in general. In term of the sustainability of the project, the investment items of the project are highly sustainable. The project components were designed simultaneously including staff training and medical human resource development, upgrading facilities and supplying equipment and health insurance cards for the near poor households, and changing communication behavior. Therefore, the project is not only to improve the quality of treatment services and supporting to the near poor households, but also to strengthen and develop the medical system at grassroot level to provide the better services to the local people. In difference with the projects in other zones, this project has firstly focussed on training medical workers and developing human resource for the project provinces and investing medical equipment. This investment item is to develop sustainably the medical system in the project provinces. The supplied equipment will be employed to provide the medical services to the local people. The Provincial People’s Committees have already made their committments to contribute fully the co-finance budget to implement the project and to maintain and reserve the machines during and after the project ending. The medical workers will have trained to use the supplied equipment. - For the poor people, because most of them live in the remote and mountain or littoral vertical plain, they have a few chance to take the patients to the large medical clinics in the city or the center. When the project running, the healthcare services at the ditrict level will be enhanced and help the poor households to save their expenses of travelling and caring of the patients and increase the opportunities to access to the healthcare services. - For the households just above the poverty line, the project will support 30% of payment in addition to the 50% payment from the Government. As a results, the near poor households

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will be supported by 80% of payment for the health insurance card. The income of the near poor households is not higher much more than that of the poor; therefore, this is a very good chance for them to improve access to the healthcare and treatment services. Besides, the project has supported to the sale agents of the health insurance and communication to change the behaviors of seeking healthcare services of the near poor people. - For the ethnic minorities, it is very difficult to access to the high quality healthcare services because most of them live in the remote area with a difficult travelling. The investment for upgrading the medical facilities at district level is very appropriate and it creates the better chances to the ethnic minority to access to the healthcare and treatment services. The project running will increase the number of patients receiving the healthcare services including the ethnic minority people, especially in the mountain and border districts. For the ethnic minorities, apart from the poor who received the health insurance, the remain households will receive the health insurance under the supports of the project by the policy for the near poor households. In 30 hospitals have been invested health care equipments including 18 mountainous districts, 7 poor districts in 62 poor districts list. 16 mountainous districts PHCs have been invested equipments and buiding offices including 7 poor districts in 62 poor districts list in the whole nation. The survey results show that, opportunities for ethnic minorities get benefit from health care Projects is positive. Thanks for the hospitals in district levels have been invested on equipments, health care workers have been trained and capacities for health care workers in PHCs’ have enhanced so the health care for ethnic minorites have improved clearly. There are more than 20 ethnic minorities in the North coastal area so the projects will support to provide health care insurance cards for near poor households, to enhance health care workers capacities for hospitals in district level are suitable and positive for people’s health care, special for ethnic minorities in the mountainous district, remote and isolated districts.

4.2. Socio- Economic condition of some Ethnic minorities in the Project areas 1. The Hmong Ethnic minority - Location: Hmong people in Viet Nam consists of four local subgroups as white Hmong (Hmong ), black Hmong (Hmong uz), flower Hmong (Hmong l nhz) and blue Hmong (Hmong suaj). Hmong people often live in the high and remote comunes. In Thanh Hoa and Nghe An provinces, Hmong people live near the bordering region between Viet Nam and Laos (Muong Lat, Quan Son, Ky Son, Que Phong and Tuong Duong) district.

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- Economic activities: The main economic activity of the Hmong people in North Central Region is upland cultivation. Relevant crops are maize and one-crop drought rice so that their living is still in difficult situation. The income of the people is rather low and unstable because of their heavy dependence on the natural and climate conditions. - Community relations: Each Hmong village consists of several dozens houses spaserly buidt on mountains’ side. The Hmong kinship system is very well organized and supportive. Each kinhship has its own worship rituals. Their houses are often not concrete with thatch roof and wooden walls. There is high humidity and darkness inside the house. - Family and marrige system: The Hmong rarely marry to people from other ethnic groups. Men have more dicision powever, especially in community interactions. Women are responsable for housework. - Language: Hmong language belongs to Tibet-Chinese linguistic family. Today, the writing system has been latinized and popularly used by the whole community. Most of Hmong women do not speak Vietnames, and it is a constraint for them to access to social services in general, health care in particular. - Education: Living in the upland and rather remote areas, educational level of the Hmong is still very low. Given the language constraint and the burden of farming and housing work, many of Hmong women and girl are illiterate. Children often go to school late and there is high drop out rate. Very few complete high school. 2. The Thai Ethnic minority - Location: The Thai population in the North Central contrentrate in upland districts of Thanh Hoa and Nghe An province . - Economic activities: Traditional economic production of the Thai include upland farming and wet rice cultivation. Recently, they have some other long term crops such as bamboo and rubber. Food security is obtained.. - Community interaction: Thai villaje often located in valley areas, near river, or stream where there is availabity of productive land. Each Thai villaje consists of hundred of houses dividing into kinship. Most of Thai villaje have limited accessibility to district and provincial health care centers upon the difficulty of transportation - Family and marriage system: Thai people live in extended patrilineal family. Under each Thai house-on-stilt roof, there are often number of couples. Each couple is allocated a seperated bedroom and the distribution of bedroom among couples follows age principle: - Language: The Thai people are more fluent in Vietnamese language comparing with people from other linguistic groups.

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- Education: Given better transportaion system (comparing with the Hmong for instance) and stable economic considtion, education level of the Thai is high with low illiterate rate.

3. The Muong Ethnic minority - Localtion: In North Central Region, Thai population concentrates in lowland areas in Thanh Hoa Province. - Economic activities: Besides wet rice, the Muong also have some other industrial crop such as sugarcane, rubber, and ground nut. In general, they have médium living standard. - Community interactions: Muong villages are often located in Midland with small rate in mountainous areas. Each Muong villaje consists of hundred of houses dividing into kinship. Kinship relations are very well integrated that assist to maintained a community cooperative network. - Family and marriage systems: Muong people are free to decide their own marriage. Though Muong households follow patrilineal system, men and women are quite equal in all terms. - Language: Muong language is very similar to Viet language so as they could easily speak Vietnamese. Almost Muong people are bilingual. - Education: Given the advantage of transportation system, the Muong have better accessibility to educational, and other social services. There is very low illiterate rate. 4. Khmu Ethnic minority - Location: In North Central Region, Khmu people residence concentrates in Ky Son and Que Phong districts of Nghe An province, and Muong Lat district of Thanh Hoa province. These sidence are the border districts of Viet Nam and Laos and in difficult traveling. Khmu households often live scaredly in the hillsides so that each Khmu Hamlet often consists of tens of households. - Economic production: The Khmu heavily dependon upland crops such as dry rice, maize and cassava. Their income is very low though besides farming they have some income from non-timber resources gathering. The average income of a Khmu household is lowest among the ethnic minoirty groups in the region. According to the surveyed data by the Institute of Ethnology in 2007, rate of hunger households of Khmu people in Nghe An province accounted for over 80% of households, the household’s average income only reached to VND 120.000 per people per month (Nguyen Quang Tan et all, Newspaper of Ethnology, 2008).

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- Community interaction: Khmu villages are often sparsely on upland area. Each village consists of several dozens of households so as community relations in a village is quite integrated. - Family and marrige system: The Khmu marry quite early and diverse rate is pretty high. Men have more power than women. - Language: The Khmu language belongs to Mon- Khmer family. They do not have writing system and not yet latinized. Speaking fluent Vietnamese is still a constraint for many people, especially for women and children. - Education: Given economic difficulty, low rate of Kho Mu people could send their children to school. There is high drop-out at primary 5. The Tho Ethnic minority - Location: The Tho mostly live in low land area in Thanh Hoa and Nghe An province where transportation condition is pretty good. - Economic production: main crops of the Tho are: wet rice and maize In Nghia Dan (Nghe An) and Nhu Xuan (Thanh Hoa), the Tho have some other industrial tree crops such as rubber, sugercane... - Community relations: marriage and neighbor relations are foundation of Tho community relations. - Family and marriage system: The Tho follow patrilineal system, but women have relevant voice in decision making. - Language: Tho language belongs to Viet-Muong group so as they have no difficulty in speaking fluent Vietnamese. - Education: Education level of the Tho is quite high. Most of children complete popular education, and there are high rate go to higher education. 6. The O Du Ethnic minority. - Localtion: The O Du live in Tuong Duong district, Nghe An province only, with very small population. - Economic production: There is combination between local land and upland cultivation. Income from these production is low with roughly 200 kg of rice per individual per year. - Community relations: Because of small population and sparsely residence, O Du village’s integration is very loose, some live with the Thai. - Family and marriage: The O Du often marry to people from other ethnic groups, especially the Thai.

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- Language: O Du language belongs to the Mon-Khmer so as they have more difficulty in learning Vietnamese. However, most of them could speak Thai language. - Education: Given economic difficulty, few O Du students go to school. There is high rate of illiteration.

7. The Chut Ethnic minority - Location: As one of the ethnic minority with a little population and residing mainly in the North Central region, Chut people live concentratedly in the mountainous areas of the western of Quang Binh province. Their habitation are often in the remote and isolate areas close to the border between Vietnam and Laos. Chut ethnic group has many subgroups such as: Sach, May, Ruc, A rem, Ma Lieng, ... residence concentrated in the districts of Minh Hoa, Tuyen Hoa, Le Thuy, Quang Trach district of Quang Binh province. - Economic production: Upland farming and non-timber production gatheringa are two main activities. Households’ income is not stable, highly depent on forestry resources. - Community relations: Previously, the Chut live a wandering life from forest/cave to forest/cave. At the present, they have settle in government built villages. The role of elderly and of village leader is highly respected in Chut community. - Family and marriage: Chut people live in nuclear family. Marriage relations are loose with only prohibition among siblings. - Language: Chut language is in Viet Muong family so as they could speak Vietnamese quite fluently. -Education: Education level of the Chut is very low. Very few people have have complete high school level, especially female studendts. 8. Bru – Van Kieu Ethnic minority - Location: Bru – Van kieu group has quite big population concentrated in the North Central with different subgroups such as Bru, Ma Cong and Khua in the districts of Tuyen Hoa, Minh Hoa and Bo Trach (Quang Binh province), Gio Linh, Vinh Linh and Huong Hoa (Quang Tri). The Bru-Van kieu’s language is quite similar to those of Co Tu and Ta Oi groups. - Economic production: There is combination of uplan and wet rice farming. Main crops are: rice, maize, cassave, coffe and pepper. Income leve lis mostly average and near por line.

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- Community relations: Each Bru Van Kieu village is integrated with solid integration of Mu (kinship- on father side). Neighboring relation is important. Kinship head role is repected and village leader is responsable for village management.. - Family and marriage: Bru- Van Kieu follow patrilineal system with neuclear family. The younth when get to marriage age often overnight in village house. They can make friend here. - Language: Bru- Van Kieu language belongs to the Mon-Khmer linguistic family, and is quite similar the Co Tu and Ta Oi language. They do not have writing system yet. Speaking fluent Vietnamese is still constraint for some people. -Education: In- school rate of Bru- Van Kieu student is pretty high with low drop out rate. 9. The Ta oi Ethnic minority - Location: Ta Oi people residence concentrates in the west mountainous areas of Quang Tri, Thua Thien Hue provinces with local sub-groups as Pa Koh, Ba Hi and Ta Oi. Their language is belong to Mon – Kho me linguatic group. - Community relation: The Ta Oi’s village is arranged in the circle, with a Rong community cultural house in the center. The Ta Oi’s village is arranged in the circle with a Rong community cultural house in the center. The Ta Oi’s house type is length floor with tilts, usually 100m, is the residence of many couples under open family. Cutting of teeth and body and face tattoos are also the traditional customs of Ta Oi people. In each hamlet, there are distinct residence and foresta reas and Roong house is a common place for the community’s activities. - Family and marriage: The Ta Oi’s marriage relation is quite similar to the Co tu’s and Bru- Van Kieu’s. In their customs, they believe. The customs and habits, the Ta Oi people believe in traditional belief systems with the system of Yang (gods) and souls. They think that each person has his/her soul, and their health and sickness depend on the soul (representation of each soul of a member in family is a bowl, the bowl is considered as sacred objects and used when conducting rituals). - Language: Ta Oi language belongs to the Mon-Khmer linguistic family, They do not have writing system yet. Speaking fluent Vietnamese is still constraint for some people. - Education: Percentage of Ta Oi’s children dropout of class is highly because they reside in remote areas. Number of illiterated people in Ta Oi’s community has reduced alot in recently years

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10. Co Tu Ethnic minority -Location: Co Tu people concentrated reside in Quang Nam and Da Nang. In the north central area, Co Tu people live in Phu Loc, A Luoi districts (Thua Thien Hue province) -Economy activities: Similarly with other ethnic people communities on Truong Son mountain, the Co Tu people is living by upland cultivation. In history, they lived as shifting cultivation so they were very poor. Now, they have settled in villiges along Ho Chi Minh Road. - Community relation: Co Tu people resides in the circle, with the a community cultural house in the center (Guol). There is 50 houses in each village, and a fence arrounding. Locality of residence of the Co Tu are highly dangerous mountains. The Co tu’s village is arranged in the circle with a community house (guol) at the center with a pillar used to force the existential animal to do ritual divine of village. Each village has fifty to hundreds of rooftops. A fence is around the village. The type of house is the high floor with a round roof. Practice tooth sawn is quite common in The Co Tu and buffalo stabbing festival is held with the participation of the whole community. In the customs and habit, the Co Tu people has a lot of taboo, specially to women and children. - Language: Co tu language belongs to the Mon-Khmer linguistic family, They do not have writing system yet. Speaking fluent Vietnamese is still constraint for some people. However, Co Tu’s language more popularly, and it is used in broadcasting communication in this area. - Education: Percentage of Co Tu’s children dropout of class is highly because they reside in remote areas. However, number of illiterated people in Co Tu’s community is still high.

4.3. Identify the level of negative impacts of the project’s activities to the living and healthcare to the poor, near poor and ethnic minority people. - The project activities will not cause any negative impacts to the living and healthcare activities to the poor, near poor and ethnic minority people. - The target groups for treatment in the district hospitals are available to all people without gender or age discrimination.

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4.4. Propose the solution to minimize or avoid the negative impacts of the project to the vulnerability targets. Thank to the positive impacts of the project, the target groups as poor, near poor and ethnic minority households have benefit by increasing oppotunities to access to the healthcare and treatment services; the project activities will not affected negatively to these target groups. Therefore, the target of consultation did not propose the solution to limit the negative impacts of the project from upgrading, investing equipment and training medical workers.

4.5. Constraints that limit ethnic minority people to access public health care services

- Geographycal constraint and transportation Infrastructure and transportation condition in the North Central Region is not very good at the moment. The distance between villages and district centers is sometime about 50-70 km, while roads are not available, or under bad condition, especially in rainy season. Means of transportation of the people are mainly bike or on-foot.

- Customary constraint Regarding health care, because the residential area are so difficult to access to the modern health services, by now the Hmong people is still a few ethnic group which preserves various traditional knowledges on taking care of community health. The health care of the Hmong people are mainly relied on the indigenous knowledges of health prevention and treatment. Due to different reasons, most of Hmong people have not accessed adequately to the modern health care services, particularly by the impacts of anthological cultural elements many people are used to select the method of homecare and using indigenous medicines. Treatment in accompany with belief also plays an important role, even driving the decision of selecting the treatment methods. Hmong woman always is accompanied by their husband when go to the clinic for treament and it is important thing that they do not give birth at the health facilities because of the belief that the children must be suported and sponsored by a superpower (home ghost). The pregnant woman must be received the supports from other members of the family. An very important abstain of the Hmong people is unexpecting their family members have accident or being died outdoor without the supports by the home ghost. Therefore, too long distance from house to health faicilities, difficult conditions of household’s economy and some customs and habits are the important obstacles make a majority of the people have not accessed to the modern health care services. In the customs and habits, the Khmu people has remained traditional habits of daily activities, especially the ceremonials of the worship. By now, the Khmu people still think that sickness is due to superpower (hroi), the family has to offer a worship to wish a protection and recovery of health when a member of the family is being sickness. In taking care of health for the mother and children, they assume that worshiping the superpower is

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very important and offers a worship to wish the supports from the superpower to recover the patient’s health as soon as posible when the patient has been treated in the health facilities. In the customs and habits, the Mon- Khome Ethnic group such as: Bru-Van Kieu, Co Tu, Taoi still maintain many ceremonies in marriage and health care. During pregnancy period, the mother has to abstain a lot of things, it often offer to worship when the children being sickness. In the ceremony of worship, they emphasize the offerings to land, forest, and sun, buffalo meat, spritual rice ceremonies, etc... Residence in high and remote areas, the Bru- Van Kieu people have not approach fully to the medincine and health care services due to the household’s income is low, barriers of language, customs and habits are obstacles to people when access to modern medicine and health care services. The customs and habits, the Ta Oi people believe in traditional belief systems with the system of Yang (gods) and souls. They think that each person has his/her soul, and their health and sickness depend on the soul (representation of each soul of a member in family is a bowl, the bowl is considered as sacred objects and used when conducting rituals).

- Economic constraint Given the reality of unstable and low income, health care is not the first priority in spendings of ethnic minority in the regions. Most of people do not have savings so as traditional treatment is preferable in case one get sick. They are not interested in demand on healthcare and education. Most of ethnic people families do not have saving for treatment so they often believe to taboo, spirit. Beside that, the obstacling of distance and transportation, household living condition also are difficulties for ethnic people go to hospital.

- Language and educational constraints Among 10 ethnic groups in the regions, with the exception of the Muong, Tho, and Chut, most of other ethnic groups have difficulty in using fluent Vietnamese. This is an important factor that discourage the people to go to district or provincial medical center for health care.

To overcome this constraint, CPMU and PPMUs should: (i) Give priority to hire health workers (both males and females) who can speak languages of the local ethnic minority in the areas to participate in the project. (ii) Have consultation with NGOs who have experience in working with ethnic minority in Vietnam, particularly in the project areas such as PLAN, OXFARM. The relevant experience should learn from these organiztions include: community consultation policy; community participation, mechanism that help ethnic minority people to overcome cultural barriers, and to accept modern medicial treatment over their traditional systems.s

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Chapter 5 THE RESETTLEMENT

5.1. The planning and reclaiming land for constructing the PHCs Through the fieldtrip from 15th August to 7th November, the social consultants of the Project Office had conducted a survey in six project provinces and assess the progress of preparing land acquisition and resettlement documents for constructing the PHCs. In general, the provinces have implemented quickly the project activities to complete the land ownership documents to receive the project of constructing offices for the PHCs. It is described in detail as follows: 1. Thanh Hoa province: The province project management board (PPMU) has directed actively the district to prepare the land documents. At present, 7 districts already have red book for the land designated for construction of PHCs. The province has a policy to limit using farming land, particularly two-crop rice land to build the infrastructure or works. The local cannot arrange the suitable land for the hospital construction, the PMB suggested the district authority to intervene and arrange the land area to build the PHCs by limit to use farming land and not damage to the living of the people. For example, in Thuong Xuan and Lang Chanh districts, the district authorities changed the acquisition of farm land for the purpose. Unused land area of the district’s agencies is instead being arranged for building the PHC. The remaining PHCs have employed the planned land area for the medical purpose which has been approved for long- term use by the District People’s Committee. 2. Nghe An province According to the Decision No. 806/QD UBND-VX issued by the Nghe An Provincial People’s Committee, the district PHCs were established based on the preventive medicine and family planning teams under the district healthcare centers. The Province Project Management Board has directed the districts to use the planned land resource for the PHC and prepare the land document to receive the project. Provincial People’s Committee has issued the Circular no. 3149/UBND-CN on establishing the investment project of building the district healthcare centers that requires the departments in cooperation with the Department of Health and district healthcare centers to prepare the document to submit to the Provincial People’s Committee for approval and Decision no. 2689/UBND-CN issued by the PPC that approves the investment project of building the PHC facilities and office by the

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funding of the project of Supporting to the Medicine in North Central Coast region or the Government’s bond. PPMU has directed quickly the districts in preparing land documents and the investment plan. By the time of this report, seven districts have obtained the red book for the construction of the PHC in whole province. Most of PHCs use the land area within the precinct of the district hospital or planned land area for long-term use to build the offices of the district. Some districts have plans to compensate agricultural land and resettle effected households like in Nghia Dan district (20 households), Thanh Chuong district (4 households) to build PHCs. All the effected households have committement to give land so all the necessary documents have been completed on November 20th, 2009. Compensation and other assistance to all the affected households (DPs) would be provided in accordance with the provisions of the RPF.

3. Ha Tinh province Up to the survey period (from August 30th to September 1st), two districts, Nghi Xuan and Huong Khe, have already red books (land use certificate) for the land area to build the PHCs. Remaining districts, Huong Son and Ky Anh, have completed actively the document to submit to the Provincial People’s Committee to issue the land use certificate. The PHC of Huong Son district has prepared actively the document of compensation and ground release for the farming land. This is newly planned land area to build the offices of the district including District Communist Party, District People’s Committee, Taxation and Bank office, so that the DPC took its task to deal with the compensation of ground release. Most of people have agreed to receive the compensation and made their commitment to transfer land ground to the project. Compensation and other assistance to all the affected households (DPs) would be provided in accordance with the provisions of the RPF. Ky Anh district has prepared the proposal of issuing land use certificate for the construction of PHC. The district also made its plan of compensation, releasing land ground and compensating crops in the land. The reclaimed area to build the PHC is the farming land where the farmers are cultivating crops (peanut and sesame). Through the interview, the people agreed to transfer land area to the PHC but they required to receive the compensation cost equal to those of the Taiwan project beside (the compensation cost is twice or three times to the cost-norm of Ha Tinh province). Up to September 24th, Ky Anh district sent its letter of committing to take compensation, releasing land ground and transferring land area to the preventive health center as soon as possible. District authorities are committed to provide compensation and other assistance the DPs are entitled to in accordance with the provision of the RPF.

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In term of the preparation of investment document, the districts have been completed the procedure of issuing land use certificate, compensated to the affected households, and handed over the land ground for investment. 4. Quang Binh province After two serveys, Quang Binh province has basically completed the necessary procedures to issue land to build the PHCs. Some districts have already the land use certificate such as Bo Trach and Quang Trach; Tuyen Hoa and Le Thuy have been completing the documents to submit to the authorities for approving and issuing land use certificate. In Tuyen Hoa district, the land area reclaimed is forest land where there are not much plants and assets, located in the development plan of Dong Le town and affected not much to the living of the people. The district is actively preparing the proposal of issuing the red book. In Le Thuy district, because of late information (substituting to the Minh Hoa district that has other funding source of the Government), the district authority has conducted quickly the procedure of the investment to submit to the authorized agencies. By the survey period, the document of compensation and ground release were completed. The preventive health center of Le Thuy district has the land allocation document and compensation letters signed by the affected households, the minutes of meeting between the Xuan Thuy commune authority and 7 affected households in Phan Xa village, extracted document of land situation authorized by the District Department of Resource and Environment, detailed plan of the work construction of the Preventive health Center of Le Thuy district, and the proposal document of land allocation that is waiting for the approval of the chairman of the DPC to submit to the province for issuing land use certificate. During the implementation phase of the project, the Bank will conduct due diligence to check if the compensation already provided to the DPs is consistent with the provision of the RPF. Additional assistance/compensation will be paid to the DPs in case of any gaps.

5. Quang Tri province: The management board of Quang Tri province has actively directed the districts to complete the land document for the procedure of investing of the project. The PHC of Dakrong has already the red book while Hai Lang, Gio Linh and Vinh Linh districts have approved the investment plan of building the PHC within the planned area of the districts and have received the certificate of planning. Hai Lang and Gio Linh districts have allowed using forest land within the planned areas for building the offices of the district center. Vinh Linh district which reclaimed farming land of six households has completed the compensation document. The district authority has made

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its commitment to implement the compensation, releasing ground and constructing the road with 150m long from the National Road No. 1A to the construction site of the preventive health center. Compensation and other assistance to all the affected households (DPs) would be provided in accordance with the provisions of the RPF. 6. Thua Thien Hue province By the survey period, only three PHCs have prepared well the investment procedure of the project. Phu Vang and Phu Loc districts have an adequate certificate of land planning for building PHC. The PHCs have planned within the precinct of the land area for the medicine, long-term use and without ground release. The consultants have spent a day to work with the Health center of Phong Dien district. Although the certificate of land planning has expired date on December 2009 for the PHC of Phong Dien, the PHC of Phong Dien district will be built in the current precinct of Phong Dien hospital so it has not compensated and released land ground. The Phong Dien hospital received the project of hospital construction with the funding from the Government’s bond so that the technical design was completed and it is preparing the construction. The land area for building the PHC does not impact to design of the construction of the hospital and without the conflicts, compensation and ground release. The consultants advised the PHC to complete quickly the necessary document on land situation (certificate of planning or extract of construction site in the former precinct of the hospital authorized by the District Department of Environment and Resources; the planning of hospital and PHC construction of Phong Dien district) By the survey time, Huong Tra district has only the introduction letter on land position. At the meeting with the consultants, director of PHC invited Mr. Tran Duy Tuyen, Deputy Chairman in charge of culture and social affairs of Huong Tra district to join in the meeting. In reply to the requirement of the project, Mr. Tuyen committed to submit the document of certificate of land planning issued by the DPC. It will be built in the public land, according to Mr. Tuyen, this area is a reserve land under the planning of the district. The district has committed to provide the land area the district preventive health center. Up to September 20th, 2009, in Thua Thien Hue four PHC have completed the land documents following the requirements of investment procedure of the project and are available to receive the project implementation. Through the survey results in 6 provinces, the locations basically completed or are completing the document of proposing land use certificate for the PHCs. All of PHCs in Thanh Hoa and Nghe An provinces have the red books and are preparing for investment; the other provinces have directed actively the completion of the land allocation documents and

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will take on time the transfer of land area to build the PHCs of the districts of the investment items of the project.

Table 5.1 List of the PHCs prepared the document of land certificate District Area Red Book No. of PAHs Land use situation Thanh Hoa province Lang Chanh 3,237 Yes N/A Public vacant land Thuong Xuan 851.6 Yes N/A Public vacant land Quan Hoa 4,000 Yes N/A Public vacant land Quan S n 2,359 Yes N/A Public vacant land Nh Xuân 1,705 Yes N/A Public vacant land H u L c 3,132 Yes N/A Public vacant land C m Th y 3,659 Yes N/A Public vacant land Nghe An province Que Phong 4,235 Yes N/A Public vacant land Tuong Duong 2,100 Yes N/A Public vacant land Ky Son 1,667 Yes N/A Public vacant land Nghia Dan 6,312 Yes 20 Public vacant land Quynh Luu 2,873 Yes N/A Public vacant land Thanh Chuong 1,887 Yes N/A Public vacant land 450 4 Productive land Nam Dan 1,572 Yes N/A Public vacant land Ha Tinh province Nghi Xuan 2,735 Yes N/A Public vacant land Ky Anh 3,663 Ongoing 25 Short-day crop farming land Huong Son 5,000 Ongoing 25 Productive land Huong Khe 3,000 Ongoing N/A Public vacant land Quang Binh province Le Thuy 3,600 Ongoing 07 Productive Tuyen Hoa 2,930 Ongoing 05 Forest land Bo Trach 4,350 Yes N/A Public vacant land Quang Trach 2,400 Yes N/A Public l vacant and Quang Tri province Dakrong 2,975 Yes N/A Public vacant land Gio Linh 2,496 Ongoing 02 Forest vacant land Hai Lang 5,790 Ongoing 04 Forest land Vinh Linh 2,500 Ongoing 06 Productive land Thua Thien Hue province Phong Dien 5,000 Yes N/A Public vacant land Huong Tra 1,400 Ongoing N/A Public vacant land Phu Vang 3,600 Ongoing N/A Public vacant land Phu Loc 4,000 Ongoing N/A Public vacant land Total 95,478,6 98

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5.2. How the project have been affected on cultures, religions and beliefs The consultants have conducted survey on all the districts having PHCs, the survey results show that all the lands have plans to be used to build PHCs that will not have effects on any local cultural constructions, religions constructions therefore these constructions have not listed in the compensation lists.

5.3 Procedure of issuing the land use certificate Where LURCs have already been issued to the district authorities, the procedure of certificate document has been performed legally to the current laws. The procedure of issuing land use certificate includes following steps: - Propose the document on preparing investment project of building the district PHC - The District People Committee’s document on introducing land position. - The documents include land document extract, minutes of land measure and setting up landmark and addressing the position by the district environment resources department and authorized by the district People’s Committee. - The minutes of ground release and resettlement compensation, minutes of land area allocation of the DPC. - Letters of Department of Construction, Department of Planning and Investment submit to the Provincial People’s Committee for approval. - The land use certificate authorized by the Chairman of PPC.

Some locations that are in process of completing the documents of land use certificate have finished the following works: - The letter introduces the land use position - The minutes of setting up landmarks and addressing position attached by the land extracted map. - The documents of compensation, ground release, minutes of land transfer (Huong Son, Le Thuy districts); some locations are preparing the compensation document and commitment of releasing land ground of the DPC (Ky Anh, Vinh Linh, Gio Linh, Hai Lang and Huong Tra districts).

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- The certificate of land planning, the land positions selected are all addressed as the perennial use and constructing the offices. In several provinces as Quang Binh, Quang Tri and Thua Thien Hue, the procedure of issuing land use certificate has required the officially approved project. However, the documents have been completed and submitted to the PPC for the final approval. According to the process of issuing land use certificate, the districts have to complete the procedure within September and receiving the Decision of issuing land use or land use certificate in October or November 2009. During the implementation phase of the project, the Bank will conduct due diligence to check if the compensation already provided to the DPs is consistent with the provision of the RPF. Additional assistance/compensation will be paid to the DPs in case of any gaps.

5.4. The project impacts to the living and production of the households Among 30 PHCs of the investment list, 19 districts have land area ready for contruction of PHCs, mainly in Thanh Hoa and Nghe An province. The remaining 11 districts will have to acquire land for the contruction of PHCs. In general, the levels of project impact on the people’s living are not seriously affected. Numbers of affected households are concentrated in Huong Son and Ky Anh districts of Ha Tinh province. In other provinces, numbers of affected households are not much.

Table 5.2 The households and people affected by the project District Area (m2) No. of PAHs Land use situation Nghe An Province Thanh Chuong 1,887 4 Public vacant land 450 Productive land Nghia Dan 6,312 20 Forest land Ha Tinh Province 1. Ki Anh 3,663 25 Productive land 2. Huong Son 5,000 25 Productive land 3. Huong Khe 3,000 0 Public vacant land Quang Binh 4. Le Thuy 3,600 07 Productive land 5. Tuyen Hoa 2,930 05 Forest land Quang Tri 6. Gio Linh 2,496 02 Forest land 7. Hai Lang 5,790 04 Forest land 8. Vinh Linh 2,500 06 Productive land Thua Thien- Hue 9. Huong Tra 1,400 - Productive land

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10. Phu Vang 3,600 0 Public vacant land 11. Phu Loc 4,000 0 Public vacant land Total 95,478.6 98

For the sources of income of the affected households, they come from retailed salary (45 households), non-farming (6 households), and mainly rice cultivation (47 households) among 98 surveyed households (100% of affected households). In term of damage level, the damage level is not high in Vinh Linh, Gio Linh and Hai Lang districts (Quang Tri province), Tuyen Hoa district (Quang Binh province) because the planned land areas are located in the forest land with a few and worthless perennial trees. In the provinces where there are a numerous affected households in the project, we carried out a focused study in Ky Tan commune (Ky Anh district), Son Giang commune (Huong Son district) in Ha Tinh province, and in Xuan Thuy commune (Le Thuy district, Quang Binh province). The detail impact levels are follows: In term of compensation price, the locations have made their compensation plan based on the current price by the regulation of laws. In Huong Son district, DPC applied the Decision no. 3737/QD- UBND issued by the Ha Tinh PPC dated 25th December 2008 on the Ban hành the price of different land in Ha Tinh province. The Annex 6 attached to this Decision regulated clearly the compensation price of VND 80,000 to VND 130,000/m2. According to the Decision no. 01/2009/QD-UBND dated 13th January 2009 on issuing unit cost of house, architect, comb, plants and crops compensation when the authority reclaims land in the province, the Part II of this decision regulated clearly the unit cost of compensation for the different plants including crops and perennial trees. Based on the Decision No.3737/QD- UBND and Annex 9 issued by the Ha Tinh PPC regulated the land price in Ky Anh district, Ky Anh DPC applied to the reclaimed land for building PHC at price of VND 700.000 – 750.000/m2. In Le Thuy and Tuyen Hoa districts (Quang Binh), Vinh Linh, Gio Linh and Hai Lang districts (Quang Tri), the authorities have announced the compensation price issued by the province, the quantity of affected plants and crop area to each affected households. The affected households have agreed at the compensation price and signed the commitment of land area transferring after receiving the money of the ground release.

5.4 Results of consultation of affected households The survey results in the districts showed that most of affected households were agreed at transferring land area to build the office of PHCs. 100% interviewees gained clearly the information on land reclaim to build the PHC which source of information from

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the local authorities to the people was 80.3%, from the district/commune medicine workers was 12%; from both the local authority and medicine workers was 87%, and 3.8% from the meeting of local communist party. Through the consultation, all affected households interviewees will transfer land area to the project whenever they receive the decision of land reclaim and the compensation. 100% ideas were agreed that the building of PHC is necessary and will bring the benefit of healthcare to their family and community. 17.3% of the ideas suggested the project has to protect the environment hygiene during the work construction. For the compensation plan and cost-norm of the local authority, most of the people are all agreed at the regulation issued by the PPC. However, 42.3% interviewees suggested to enforce this regulation by the end of 2009 and early 2010; therefore, it is suggested to the local authorities to apply the compensation cost-norm following the new one for the year 2010. “The commune authority has already measured and counted the crops/tree in the ground. We met together here and agreed to transfer the land to the project. However, it is several months from now to the time when the project has reclaimed officially the land while the compensation price is increasing; the local people propose the local authority to update the compensation cost for the farmers to reduce the disadvantages” (Mr. Pham Trong Than, the affected household in Son Giang commune, Huong Son district, Ha Tinh province) “We have been informed and learnt about the plan of extending to construct the functional offices of the district. Rice crop was harvested; we are agreed to transfer land area to build the office of PHC. We have no comment on the application of compensate price following the regulation of the authority” (Le Ngoc Thang, the affected household in Xuan Thuy commune, Le Thuy district, Quang Binh province)

In Ky Anh district, most of farmers have received the compensation from the Formosa project of Taiwan at very high price; they also suggested applying the appropriate price as the market price. However, the affected households agreed at the compensation price issued by the province and compensation plan of the district by the explanation of reclaiming land areas for building the offices for the district’s agencies unlike the foreign investment project (The Formosa project of Taiwan has investing the vocational training school and reclaimed 30 hectares farming land of Ky Tan commune, the project of building Vung Ang port also reclaimed over 100 hectare farming land).

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“ We agreed at transferring land to the project, however, we had lost variously the farming land by other projects, we have expected to this project should construct the Preventive medicine Centre and conduct the compensation following the current price in a suitable way”. (Nguyen Van Tinh, an affected household in Ky Tan commune) “The local people have very low income that mainly comes from agricultural production. This project did not reclaim the large of farming land but we have suffered from the disadvantage of the landless. We have supported to this project of constructing the medical office, however, we wish the local authorities implement a suitable compensation” (Tang Loi, a poor household in Ky Tan commune) Thus, through the survey and consultation in the locations where there are many households impacted by the project, in general, the level of project impact to the households is not serious. Only in Ky Anh and Huong Son districts of Ha Tinh province, the number of affected households is quite big (50 out of 74 affected households) because of reclaiming farming land. In fact, these areas have been already planned for building the office of the agencies of two districts where the preventive healthcare center is one of the agencies has been allocated the land area and prepared the constructive project. In all locations, the planning of compensation and ground release has been prepared carefully such as inventory, applying compensation price, organizing the meeting and announcing the numbers of damages and levels of compensation to each affected households. Through the direct consultation, the affected households agree to transfer their land to the project when the decision of reclaiming land area and implementing project has issued.

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Chapter 6

THE CONSULTATION OF THE STAKEHOLDERS OF PLANNING THE SOCIAL IMPACT ASSESSMENT

6.1. Ideas and viewpoints of the stakeholders during preparing the project workplan Provincial Project Management Unit (PPMU)

The technical support project has completed to submit to the Government and the World Bank (WB) for considering and approval. In the locations, the preparations for the project implementation have been implemented positively, particularly in some locations are completing the land document for building the office of PHC. For the components of the projects, all PPMUs agree at and ready to wait the approval for implementing continuously the project activities.

“The project has been prepared in a quite long time, the project activities are ready, and so we are waiting to continue the project implementation. The project components are very suitable to the investment needs of the local. For the district PHCs that have the basic constructions, we have determined to complete the necessary requirements and suggest the PPC to direct the relevant agencies for issuing the red books to the PHCs for receiving the investment”

(The director of Department of Health of Ha Tinh province)

In monitoring and supervising the social safeguard policy, PPMUs have continuously sent the letters to require the provincial agencies and districts to finish the documents for land allocation and releasing ground to the PHCs and compensating to the impacted households.

“The local authorities have worked directly to the land allocation and releasing ground to the PHCs that will be invested are the great advantages to the medicine department. Although the preparation was delayed, the leader of DPCs took the responsibility of releasing land ground and compensations to the impacted households; the

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procedure of land allocation to the PHCs were basically solved and ensured the progress of the project”

(PPMU of Thua Thien Hue)

Through the consultation to the PPMUs, most of ideas suggested the project to be approved and officially implemented as soon as possible. The planning of the project was finished in the locations.

For the workplan of the project, the Provincial Steering Committee (PSC) includes one leader of PPC will act as the head, the director or vice director of Department of Health will act as deputy head and some officials from the relevant departments as the members. During the project implementation, PSCs directed the agencies in the local implement some activities as bellow:

- Conduct quickly the document of land allocation to the PHCs that have not received the land use certificate;

- Make a cooperation plan with the Department of Labor, Invalids and Social Affairs, revising the beneficiaries of treatments and identifying the near poor households receive the support of health insurance that ensure the benefits to the poor, near poor and ethnic minority people.

- Implement the management, equipment investment supervision and staff training in accordance with the needs of each local.

For the hospital at district level, the needs of treatments of the people are now increasing that lead to overload of the medical bed and equipment and the urgent needs for training medical workers. Through the survey, some hospitals in Cam Xuyen and Ky Anh districts (Ha Tinh province), Gio Linh and Vinh Linh districts (Quang Tri province), are always overload from 120- 130% to the bed efficiency. In the hospitals in the mountain districts, the investment of equipment is very necessary; however, the training on the operation of this equipment is also very important. Many hospitals have not enough the doctors and technical workers to provide the treatment and healthcare services to the people. Therefore, some district hospitals proposed the project to make a detail training plan to every participant, for example, 61

The Assessment Social Impacts Report

- It should have the detail plan of training programs on master, doctor, specialization I, II for the long-term trainees.

- For the short course, it should be organized in the province and open flexibly the courses following the needs of each local.

- For the capacity building course, the training should be organized at the local to reduce the travelling time and the organization of the training will attract more target groups to join and will not affected so much to the treatment plan of the hospital.

Medical workers

In reply to the question on the situation of the equipment of the hospitals, most of ideas assumed that these equipment are old, backward or damaged. The investment of the equipment is very necessary and meeting the needs of increasing treatment of the people. The survey results in 12 district hospitals of six project provinces showed that 70% ideas think that the equipment of the hospitals do not serve well the needs of treatment; 25% ideas assumed that it is lacking of some specialized equipment, and 35% ideas assumed that it should be organized the training course on equipment operation to the medical workers.

In term of training activities, most of medical workers would like to join in the continuous training courses, especially the capacity building to the doctors, nurses and medical workers who are working in the hospitals.

The proposal on work plan of the project, some ideas think that it is necessary to take the regular monitoring to evaluate the effectiveness of the project to withdraw the lessons learnt and suitable to the real needs of every local. Some medical workers in the hospitals in Ky Anh (Ha Tinh province), Huong Tra and Phong Dien (Thua Thien Hue province) suggested that the hospital has to build the medical waste treatment system, particularly the solid waste burner and improving waste water system to limit the pollution, especially in the rainy season that the flood will influence on the epidemic prevention to the community.

As for supporting to issue health insurance card to the near poor people, some ideas assumed that the local should revise and promote the cooperation of the health agency and the relevant agencies to deliver timely and rightly HICs to the targeted groups and to avoid the 62

The Assessment Social Impacts Report

missing of name, age and address information, and to limit the shortages and inconveniences to the patients during using the health insurance card.

The poor patients

Through the consultation, all interviewed patients were welcome to the project implementation. Capacity building for the district hospitals is very in accordance with the expectations and benefits of the people, especially the poor, near poor people and those in upland and remote districts.

As for the near poor target, the support of 30% of health insurance expenses is in accordance with the expectations and benefits of the poor. The survey results in some hospitals revealed that many patients did not use the health insurance because of having no money to buy the health insurance. The component of partly supporting the health insurance fee to the households and strengthening communication, social marketing to health insurance promotion is very in accordance with and meeting the expectations of the people. Contributing to increase the number of beneficiaries of healthcare and to implement the financial equity to help all patients could have expense for treatment.

6.2. Proposing the workplan of social impact evaluation during the project implementation in the local * The plan ensures the social safeguard policies during ground release compensation The Central Project Management Unit (CPMU) shall be sent the supervisor/social evaluation specialist during the project life: - To supervise the ground release compensation in the locations where the compensation and ground transfer has not been completed yet to ensure the implementation of the safeguard policy to the impacted households. - To address all the severe impacts due to the land acquisition or other losses from the project, he RP has been prepared in accordance with the provision of the RPF. - To supervise the activities during the project implementation to keep on track the true beneficiaries of the policy of free treatment for the poor and the target group to the health insurance support.

The Assessment Social Impacts Report

PPMU must have the detailed plan to ensure the safeguard policy to the impacted households, particularly in the locations have not finished the compensation, releasing ground and transferring land to the PHC: - Deliver the letter to suggest the local authorized agencies to compensate to the impacted households, - Supervise and suggest the local authorities compensate suitably to the impacted households, particularly the poor and the households losing over 10% of cultivated land, it should have the policy to support the living and transfer the job to the impacted households following the regulations of safeguard policy - Prepare the supervise plan to the construction of PHCs that do not affect to the environment and living of the surrounding people. * Workplan for the participation of the stakeholders to the project activities The Central Project Management Unit will implement the project activities, prepare the workplan and supervise the project activities in the provinces, and support and cooperate to implement the components of the project. PPMU: during the project implementation, the Department of Health has to cooperate with the relevant agencies to conduct bidding, budgeting and taking liquidities yearly. It also chairs and implements the project activities in the local, cooperating with CPMU in regularly supervising and evaluating the project implementation, providing alternated work plan and suitable adjusts to ensure the requirements and promoting the effectiveness of the project activities. District level: In each hospital, PHC has one staff to manage and implement the project activities, particularly the construction, treatment for the poor and near poor people, and supporting to buy health insurance cards to the near poor people. The Department of Health, besides giving priority to employ health workers who can speak local languages and be able to communicate with ethnic minority people, will cooperate with the following organizations: + The Department of Resources and Environment to complete the necessary documents and procedure to the PHCs and build the environment protection plan. + The Department of Labor, War Invalids and Social Affairs, Department of Finance, Department of Planning and Investment and Social Insurance Agency to list and review the

The Assessment Social Impacts Report

near poor people, the agents of health insurance, and the Centers for health education to plan the social marketing and support to buy the health insurance to the near poor groups. + The Department of Cultural Affairs to provide necessary understanding about ethnic minority cultural practices that help the ethnic minority to over come their cultural barrier and to accept modern medicinal methods over their traditional systems. + The Broadcast Station to widely inform and explain about the benefit of the project in both Kinh and ethnic minority languages. During the project implementation, CPMU in cooperation with PPMUs to send the supervisors and social impact evaluation specialists to ensure that the invested components of the project bring the benefits to the poor, near poor and ethnic minority people and will not impact negatively to the living and treatments of the people.

The Assessment Social Impacts Report

CONCLUSION The North Central Coast provinces are densitied population region (in average of 207 people per square kilometres) that is quite high than the density of the country. North Central Coast is also located in the harsh climate region with a lot of storms and floods occurred yearly that caused the serious consequences impacted to the health status of the people and socio- economic situation of the locations. The poverty and near poor rates of the region are also higher than those of other regions of the country. This is a complicated topograph, difficult travelling region and is the homeland of various ethnic minorities including O du, Chut, Ta Oi, and Co tu groups. The rates of poverty and near poor households in the North Central Coast provinces are still high. The monthly income per capital is low and distributed irregularly among income quintile, the different levels of the income between the rich and the poor is high (6.3 times). These provinces are very poor in intrastructure and slow economic growth while they are often suffered from the damages of natural calamity and diseases. The popular diseases are the transfer diseases, infections caused by the harsh climate of the region. Therefore, the liability of diseases that the people in North Central Coast region have to suffer is heavier than the people in other regions of the country do, particularly the poor, near poor, ethnic minority, disadvantage people due to the orrange poision and war, and children and women. In that condition, the people have a little opportunity to take care of their health that the equipment and facilitities of the hospitals are not enough to requirement of consultation and treatment; and the medicine workers did not satisfy the increasing requirement of treatment of the local people both in quantity and quality. The North Central Coast Medicine Supports Project was designed based on the investment needs of the local and met the expectations of most of the people who have no a chance to receive the treatment and healthcare services through the Government’s and local’s policies. The implementation of the Project will bring the benefit to many people such as the poor, near poor and ethnic minority people. The Project activities do not cause any negative impacts to the living and the treatment of the poor, near poor and ethnic minority people. In term of building the offices of the DPHCs, it has not caused any negative impacts to the living of the people in some locations that arranged the planned land area for the medicine purpose and have already red book and without compensation, land ground release and resettlement. In some locations where there no land fund for building the offices of the agencies or planning of expanding the town, the authorities have to reclaim farming land of the farmers to build the DPHCs. These reclaims did not affect to the houses, cultural works and graves. The locations reclaimed farming land are actively making the compensation and ground release plan and completing document of issuing land use certificate.

The Assessment Social Impacts Report

In term of the damage levels to the affected households, through the survey and consultation, there were a few affected households were reclaimed to 40% of cultivated land; most of households were reclaimed from 10% to 20% farming land. The reclaimed land, hill land and poor fertilizer land for food crops, did not bring so much economic effects to the households. The local authorities committed compensating to the affected households following the regulation of the State and supporting to vocational training to change the job to the households that are impacted seriously in farming land area. 100% affected households agreed at transferring land area to the PHCs to receive the investment of the project. The locations that are conducting the compensation and transferring land area, have committed to complete the land document during two months (lastest in November 2009) before the Project has officially implemented. The consultation results showed that the stakeholders of the Project have agreed at and cooperated to each other to make the workplan of the Project. For the beneficiaries including the poor, near poor people; medicine workers, district hospitals are very welcome to the Project and expected to implement early the Project in the location. All ideas did affirm that the Project activities will bring the benefits to the poor, near poor people and supporting the local medicine clinnics in providing better healthcare services to the local people.