Takashima et al. Environmental Health and Preventive Medicine (2017) 22:74 Environmental Health and DOI 10.1186/s12199-017-0682-z Preventive Medicine REVIEW ARTICLE Open Access A review of Vietnam’s healthcare reform through the Direction of Healthcare Activities (DOHA) Kyoko Takashima1†, Koji Wada2*†, Ton Thanh Tra3 and Derek R. Smith4 Abstract Objective: This article provides a comprehensive review of the healthcare reform process driven by the Vietnamese Ministry of Health’s Direction of Healthcare Activities (DOHA) scheme. Methods: We reviewed policy documents relating to DOHA, along with historical literature and background information describing its formation. Results: DOHA (Chỉ đạotuyến in Vietnamese) literally means guidance line or level in English. It requires healthcare facilities at higher government administration levels to support those at lower levels (the four levels being central, provincial, district, and commune), to help lower level hospitals to provide medical services for local communities in primary care settings and reduce the number of patients in higher level (central and provincial) hospitals. Since the 1990s, there have been too many patients attending higher level hospitals, and DOHA has therefore focused on technical skills transfer training to help alleviate this situation. Designated core central hospitals now provide technical skills transfer to provincial hospitals. Professional technical lists for each level of health facility have enabled strong commitment and proactive ownership of the process of training management in both higher and lower level hospitals. Conclusion: The DOHA scheme has accelerated the necessary up-skilling of healthcare at lower level public hospitals across Vietnam. These reforms are highly relevant for other countries with limited healthcare resources. Keywords: Direction of Healthcare Activities (DOHA), Health system, Quality, Referral, Vietnam Background changing, with the main societal health problems shift- Alongside rapid economic development, the health sta- ing from maternal and child care and infectious diseases tus of people in Vietnam has significantly improved in to non-communicable diseases and traffic-related injur- recent years, with the life expectancy at birth increasing ies [5]. Vietnam also has one of the most rapidly aging from 71 years in 1990 to 76 years in 2015 [1]. Infant populations in the world [6, 7], with an increasing de- mortality rates (under 5 years of age) decreased from 58 mand for quality healthcare services and new issues deaths per 1000 live births in 1990 to 18 in 2015 [2]; likely to emerge in the health sector in future years [4]. and the proportion of under-five-year-olds who were The country’s government is now being forced to con- underweight decreased from 37% in 1993 to 14% in sider not only a plan for developing healthcare man- 2015 [3, 4]. However, wide disparities remain in core power and improving health infrastructure such as health indicators between rural and urban residents, facilities and equipment, but also for better management across different regions, and among population groups of limited healthcare resources and reforming health fi- [4]. Disease patterns in contemporary Vietnam are nancing to improve overall efficiency [4]. The healthcare workforce in Vietnam is currently insuffi- * Correspondence: [email protected] cient to meet manpower norms and practical needs [4], with †Equal contributors 2Bureau of International Health Cooperation, National Center for Global the number of physicians in 2015 (around eight per 10,000 Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo 162-8655, Japan population) [4] being quite low when compared to other Full list of author information is available at the end of the article © The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Takashima et al. Environmental Health and Preventive Medicine (2017) 22:74 Page 2 of 7 countries in Southeast Asia [8]. Healthcare resources should three patients sharing a bed becoming common in many be appropriately distributed to meet needs [9], but there is central and provincial hospitals [17]. Bed occupancy currently an imbalanced distribution of human resources rates have reached 120–160%, especially in the central and a shortage of manpower in Vietnam, especially of highly hospitals of some large cities [4]. Overcrowding in specialized physicians in fields such as cancer, palliative care, higher level healthcare facilities may have several causes, and mental health [10, 11]. Mountainous and remote areas including limited healthcare quality in lower level facil- have severe shortages of healthcare workers [12], with the ities in districts and communes, and even in provincial number of physicians per population in the North West, hospitals; increasing expectations of service quality; im- Central Highland, and Mekong Delta Regions being lower provement in convenience of transportation from re- than the national average [4]. Most healthcare workers in re- mote areas to central areas; and limited differences in mote areas manage with a shortage of medical equipment hospital fees at different administrative levels [13]. This and training. They have limited opportunities to use ad- may lead to a drain on resources in higher level hospitals vanced diagnosis and treatment methods and maintain and and subsequent wastage at lower levels. If the current improve their professional ability [4]. The quality of health- situation is not improved, this situation will eventually care services is therefore lower in remote areas than more result in major inefficiencies across the entire Vietnam- urban regions. ese health care system. Healthcare facilities in Vietnam are divided into four levels The Ministry of Health in Vietnam has managed by administrative structure: central (Level I); provincial healthcare provision through a system known as the (Level II), covering a population of 1–2 million; district Direction of Healthcare Activities (DOHA) since 1961 (Level III), covering 100,000–200,000; and commune (Level [18]. This system requires health facilities at higher IV), covering around 5000–10,000 [13]. This structure is set administrative levels to support those at lower levels out in Article 81 of Chapter VIII of the 2009 Law on Exam- to enable them to deliver medical services for local ination and Treatment [6], which covers the organizational communities in primary care settings. The contents system of medical examination and treatment establish- of DOHA have been modified and adjusted over time ments. Level I hospitals include central hospitals owned by based on the need for medical care, but the word theMinistryofHealthandcityhospitals owned by munici- “DOHA” has been retained in the context of medical palities such as Hanoi or Ho Chi Minh City. Level II, III, care reform [18]. DOHA currently focuses on redu- and IV hospitals are owned by local provincial governments, cing the burden on higher level hospitals, particularly such as the people’s committee responsible for allocating fi- central hospitals, which still have too many patients nance and human resources. The provincial or district seeking health care. The healthcare system in health department is responsible for their professional man- Vietnam is not well known outside the country and agement under the Vietnamese Ministry of Health. information regarding DOHA is rarely available in The healthcare system has a mixture of public and pri- English, and as such, the aim of this article was to vate provision. The number of private hospitals is in- review the health reform process through the DOHA creasing, but as of 2014, only 6% of all healthcare scheme in contemporary Vietnam. facilities were privately owned [14]. Private hospitals, however, now provide more than 60% of outpatient ser- Methods vices and have become an important component of the We reviewed appropriate policy documents setting out the national health system [15]. A health insurance system concept of DOHA, the historical background and informa- was introduced in 1993, and the government has made a tion regarding the formation of DOHA. One of the authors considerable effort to achieve universal coverage, reach- (KT) is bilingual (Vietnamese and English) and spent several ing 77% of the population in 2015 [4]. Recently, the gov- years working on a project to enhance DOHA activities with ernment has announced a target of 90% health staff from the Ministry of Health, Vietnam, funded by the insurance coverage by 2020 [16]. Reform of the Japan International Cooperation Agency (JICA). During this organizational structure of healthcare at all levels is cur- project, a number of official documents were translated into rently underway, as set out in the master plan for Viet- English. The JICA project also supported provincial hospi- nam’s health system development to 2025 [4]. The plan tals in the northwestern part of Vietnam to obtain basic data explains that having too many facilities