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Overview of Vietnam’s Healthcare System – How best Apollo ca

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Trịnh Phương Thảo

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Transcript of Overview of Vietnam’s Healthcare System – How best Apollo ca

How best Apollo can leverage Healthcare Market in Vietnam?
Overview of Vietnam’s Healthcare System
Market Analysis
mat do dan so - chon dia diem cho Apollo
Overview of Vietnam
Location
: in South East Asia

Capital
: Hanoi

Language
: Vietnamese

Population
: 93,421,835 (July 2014 est.)

Area:
331,210 km2

Currency
: Vietnam Dong (VND)

FX rate
: US$ 1 = VND 21,000
Rs. 1 = VND 350

Largest cities
: Ho Chi Minh City (HCMC), Hanoi, Hai Phong, Can Tho, Da Nang, Bien Hoa, Nha Trang, Hue, Vung Tau


VIET NAM
(MOH, 2008)
GDP on Healthcare:

6.4%, ≈ US$bn 12.9

Private exp on Health:

60.47%, ≈ US$bn 7.8

Gov't exp on Health:

39.53%, ≈ US$bn 5.1

Total exp on Health per capita
:
US$ 139

Health personel per 10,000 peo :
Doctor: 6.45; Nurse: 7.18; Pharmacist: 1.3

Total number of hospitals:
1,108 with 189,855 beds

Pulic hospitals:
1,200 - dominant
Private hospitals + clinics:
>65,000 (108 private hospitals with 6,500 beds)

Beds per 10,000 pop:
22 beds
Health Profile
PESTLE Analysis
2 Healthcare Networks
Hospitals & Clinics
Training & Qualification of Medical Officials
Patients' buying behaviors
Vietnam's Health System Performance
Current Facts of Vietnam's Healthcare System
Public Healthcare Network
Civil & Military Healthcare Network
Government Hospitals
Private Hospitals
Environmental Factors
Black Box Model
Marketing Stimuli
Environmental Stimuli
In Vietnamese people' s opinion
Product
VN patients' chosen services:
- Medical Tourism (Healthcare Check-up)
- Surgeries (Cancer, Heart surgery, General Surgery, Orthorpaedics, Transplants, Neurosurgeries, Plastic Surgery - newly emerging)
Price
Medical treatment in other countries = 3 or 5 times more than in Vietnam More & more patients go abroad
Place
1st choice:
Singapore, Thailand, China
Singapore: 5,000 - 10,000 pts/ yr
Thailand (only Bumrungrad): 80 - 100 pts/ mt
China (only Guangzhou Cancer Hos): 1,000 pts/ yr
Promotion
Ways foreign hospitals doing marketing in Vietnam
Country-wise choice to Vietnamese patients
Recently new choices:
Australia, the USA, Taiwan, South Korea
India : never in the list
For example, price in
Singapore
:
- Liver cancer surgery:
US$ 10,000 - 13,000
- Liver Transplant:
US$ 150,000 - 180,000
- Kidney Transplant:
US$ 60,000 - 70,000
- Heart valve Replacement:
US$ 15,000 - 17,000

Expenses for 1 airplane from Singapore to VN to take patient:
US$ 3,000 - 5,000/hr
India (Apollo): cheaper, but VN patients don't know
Potential
-
Via VNese private hospitals
: Medical tourism, Patient transfer service
Ex: Hong Ngoc Hospital opens medical tours with:
+ Thailand: BNH Hos, Samitivej Sukhumvij Hos, Phyathai2 Hos
+ South Korea: Daegu Fatima Hos
+ Taiwan: Changhua Christian Hos (CCH)
-
Open Representative Office in VN
:
Ex: Parkway Health Hos (Sin), Bumrungrad Int' Hos, Piyavate Int' Hos (Thailand)
-
Via Int' Clinic in VN
:
Ex: Int' SOS Clinic, Columbia Asiana Clinic, Family Medical Practice VN
-
Open website in VNese
:
Ex: Piyavate Int' Hos (Thailand), Parkway Health Hos (Sin)
-
Via marketing campaigns of Embassies
:
Ex: Thailand, South Korea, Singapore
* Other countries: Singapore, Thailand, China, Taiwan, Australia, the USA
Vietnam's Health System Performance is challenged by a changing environment
- Ongoing demographic & epidemiological transitions are likely to increase demand and result in more costly and more diverse healthcare.
- Additional pressure will come from emerging diseases & epidemics like HIV/AIDS, H5N1 (Avian Influenza) & Ebola.
- Reforming of Health Insurance Law on Universal Health Insurance Coverage in Jul/2014 will further increase demand and utilization.
- Low-quality infrastructure of Health System, the overloading situation & bribery in Gov't Hospitals attract special concerns from the Government and community.
Vietnam's population is increasing. It reaches 90 mil in 2014, 3 times as much as that in 1960. It is expected to peak 104 mil in 2050.
But VN's population is aging rapidly. Population growth rate is only 1% (from 2.2% in 1990) & birth rate is 16.26 births/ 1,000 pop in 2014. The share of old people was 6% in 2010 & is forecast to hit 8% in 2020 and 23% in 2050. It means that about 1 in 4 VNese is old in 2050.
(Source: CIA World Factbook)
Age Structure
Children account for 1/4 VN's population in 2014. There is an increasing gender inequality in recent years.
2014 starts the period of "Golden Population" in Vietnam. It is forecast to last until 2042. The 2009-2049 period will also see 2 trends of dependency ratio: at first, the total ratio decreases 'cause the young ratio decreases fast, but from 2017, the total increases 'cause the old ratio increases dramatically and there is no sign of reducing. This demographic transition may provide opportunities for healthcare services.
Source: General Statistics Office of Vietnam (GSO), 2011.
(Source: CIA World Factbook)
Urban population of Vietnam is increasing gradually since 2002, even though it is still much smaller than relatives like Malaysia (>70%). But VN has a relatively high degree urbanization growth rate relative to its peers in SEA (3% vs. < 2% of Indonesia).
(Source: World Bank, "On the Road with Riverwood: Southeast Asia part 2" by Ron Keith, CEO, Riverwood Solutions, in
EMSNow
Aug 27, 2012)
Dependency Ratio
GDP per Capital
> $US 20,000
Vietnam's GDP per Capita has seen an ongoing growth since 2004, increasing nearly 1.56 times in 10 years, reaching $US 5124.64 in 2014. Goldman Sachs forecasts that in 2050, Vietnam will be ranked the 16th (more than $US 20,000 per Capita) among nations having the highest GDP per Capita, above Indonesia, the Philippines and India.

Increasing GDP per Capita of VNese people will increase demands of high-quality life like education, tourism and especially healthcare...
Annual health service contacts per Capita, 2002 - 2010
Data analysis of 5 rounds of the Vietnam Household Living Standard Surveys from 2002 to 2010 show that the number of households using health services has increased overtime.
Vietnam is at the final stage of epidemiological transition. Non-communicable diseases are now the principal cause of premature death and ill-health. This transition is increasing and diversifying the demands of healthcare further.
(Source: WHO-Vietnam Chronic Disease Report)
Due to the urbanization and changing of lifestyle, rate of obesity is rising fast. Increased prevalence of risk factors will change the burden of disease, especially modern diseases like diabetes, cardiovascular diseases and cancer.
Increasing the need for preventive measures.

Vietnam's Health Delivery System
VN's healthcare network includes a wide range of facilities from hospitals, polyclinics, specialized clinics and commune health stations.
Despite being a developing country, VN has achieved wide coverage of its healthcare network, including some facilities performing dual functions of curative and preventive care.
(Source: Joint Annual Health Review 2012. Data until Dec 31st, 2010)
An already stretched healthcare delivery system will be put under more further pressure due to increasing demands from ongoing demographic and epidemiological transitions as well as Vietnamese Government's plan towards Universal Health Coverage.
- Vietnam's health infrastructure, despite reaching wide coverage of network, does not have sufficient beds or health workers with professional service to meet this increasing needs.
- Pharmaceutical supplies are reasonable, but most of Vietnamese patients have to suffer from expensive medicine and most expenditures are out of pocket.
- There is a pressing need for human resource distribution in quantities and quality.
There has been a significant growth in the number of private hospitals in Vietnam since the Gov't allowed private investment in the health sector (1999). The number of private hospitals was more than double from 2004 to 2008 to reach 82 in 2008. However, this number only constitute only 7% of total hospitals, 4.4% of total hospital beds and are unlikely to reach the target of 20% hospital beds (5 beds/ 10,000 pop) by 2020. They were located mainly in urban and wealthy areas like HCMC, Hanoi, Da Nang, Nghe An, Thanh Hoa.
(Source: Private Hospitals in Vietnam - Recent growth & Role in the Health Sector by the University of Melbourne & Ministry of Health, Vietnam & JAHR 2012)
THAILAND
SOUTH KOREA
TAIWAN
SINGAPORE
THAILAND
Infrastructure
Hospital Overcrowding
is the most concerned issue in VN's healthcare, nowadays. To face it, MOH's Project on Satellite hospitals (2013) has set up a network of 50 satellites hospitals linked to 14 hub hospitals & added 7150 beds for 5 overcrowded specialties. No. of patient beds has increased remarkably, but has not kept up with the growth in the no. of outpatients & inpatients. Therefore, hospital overcrowding has not been improved to any clear extent. Overcrowding in tertiary hospitals, particularly in some specialties such as
oncology, pediatrics, cardiology, gynecology, orthopedics and endocrinology
, remains widespread.

Bed Occupancy Ratios
Bed Occupancy Rates (BORs) have decreased gradually, Average BORs in 2009 & 2010: 103.4% & 98.8%. However, BORs of central hospitals remain extremely high.
Some causes of this situation are:
- The increasing demand for the healthcare service by the people
- Improved access to higher level facilities by the people
- Low differentials in user fees between levels of facilities
- The policy of hospital financial autonomisation that encourages hospitals to attract more patients to increase revenues
- The low effective of referral system between state hospitals and private hospitals.
Human Resources
Government health worker numbers have been rising overtime, especially doctors, nurses & midwives. But the no. of university level pharmacists remained low and saw no increase over years due to low enrollment.
When compared with the gov't health workforce of other Asian Pacific & Western Pacific countries, the ratio of doctors per 10,000 pop in VN is at the middle level, higher than Thailand, Indonesia, Cambodia & Laos, but lower than the Philippines, China and Malaysia. The ratio of nurses and midwives to pop is on par with Indonesia and Cambodia, but much lower than other countries. The ratio of pharmacists in VN is not low compared to other countries.
Gov't health workers are available throughout the country
. The state health system is organized from the grassroots level to the provincial & central levels. But quantity & structure of health workforce in each district, region & area varies. Pharmacists & medical technologists account for a very small segment of health workers.
There is a relatively even distribution in the no. of gov't health worker across regions
. Thanks to the increase in no. of gov't health workers & wide distribution, health service continue to develop. The vast majority of pop can access healthcare service of reasonable quality. Many epidemics have been controlled in time.
HR - Quantity
VN's health system is facing a general shortage of HR. According to the draft
Master Plan for development of HR for health and the medical training system to the year 2020
, VN would need 478,000 health workers by 2020.
The clear change in disease patterns from communicable diseases to non-communicable diseases & accidents/injuries results in attention on training health workers in non-communicable & trauma specialties, e.g: cardiovascular disease, oncology, endocrinology, injuries/accidents.
Shortage of health workforce in curative care

According to the Master Plan, the projected need is for 47,035 people (if calculated by admin hrs) or 80,774 people (if calculated by shifts).
Shortage of nurses in the public sector
The ratio of nurses and midwives to doctors is 1.6, lower than the Government's Regulation at 3.5 nurses per doctor. At 9.0, the no. of nurses and midwives per 10,000 people is lower than other regional countries (12.2 for Southeast Asian countries and 12.9 for Western Pacific region).
Severe shortage of health workforce in preventive medicine
Among preventive medicine staff, the main shortages are doctors and preventive medicine technicians.
Health workforce needs in selected specialties
-
Odonto-Stomatology
:
The ratio of odonto-stomatology doctors/pop is
1/25,000
, which is
too small
compared to the need. At present, VN has
1
university,
3
odonto-stomatology faculties, and some schools that train technicians in dentistry. Given a pop of >90 mil, this no. of schools/specialties in VN is too small
(Source: JAHR 2009, Interview with Prof. Tran Van Truong, Chairman of the Vietnam Odonto-Stomatology Assoc., 2009)
- Tuberculosis & Pulmonary Disease
:
There is a
very severe

shortage
of health workers in this specialties, especially doctors. Experts and professionals are lacking, even at central level. Insufficient continuing education and the "brain drain" in the TB specialty are the causes of this situation.
(Source: JAHR 2009, Interview with Prof. Tran Van Sang, Chairman of the Dept. of TB, Hanoi Medical School, Vietnam Tuberculosis & Respiratory Disease Assoc., 2009)
- Dermatology:
There is a
very severe shortage
of doctors, nurses & technicians in dermatology. Compared to other countries in the region, the ratio of dermatology health workers per pop is very small.
(Source: JAHR 2009, Interview with Assistant Prof. Tran Hau Khang, Chairman of the Dermatology Dept. , Hanoi Medical University, Vietnam Dermatology Assoc., 2009)
- Paediatrics:
There is a
very severe shortage
of paediatricians, specialized in paediatric nurses (neonatal nurses) and a shortage of health workers in adolescent health to provide care for 22 mil children and adolescents.
(Source: JAHR 2009, Interview with Prof. Nguyen Gia Khanh , Chairman of pediatrics Dept., Hanoi Medical University, Vietnam Tuberculosis & Respiratory Disease Assoc., 2009)
- Pathology:
In recent years, due to increasing needs for diagnosis involving histology & cytology, training of various levels of health workers of pathology has been promoted. However, due to
increasing demands to screen and detect cancers early
, the pathology specialty should develop a plan for a cytology-based diagnosis.
(Source: JAHR 2009, Interview with Prof. Nguyen Vuong, Former Head of Pathology Dept., Hanoi Medical University, Vietnam Pathology Association, 2009.)
- Oncology:
According to Vietnam Cancer Association, Vietnam has
a shortage of all types
of health workers in Oncology, i.e: specialized oncologists, radiotherapy engineers, chemotherapy professionals, nurses and technicians.
HR - Quality
Quality of HR is a problem, whose resolution needs prioritization in the coming years
. According to Health Statistics Yearbook 2000, 2005, 2008, the proportion of commune health workers with correct knowledge & skills for first aid, diagnosis, treatment of illnesses, epidemics is very limited.
- Only
17.3%
doctors & assistant doctors with correct knowledge & skills for first aid
- Only
17%
doctors & assistant doctors could identify risk factors during pregnancy
-
50.5%
of health workers knew how to diagnosis hypertension
-
15.6%
knew how to do with an epidemic
- Only
54.3%
doctors having correct knowledge about diagnosis and treatment for dehydration due to diarrhea

It's
common for newly graduated doctors to lack practical skills
. The medical training currently has been assessed as lacking professional practice opportunities, particularly clinical skills.
- Only
45%
knowing how to make an early diagnosis & provide appropriate initial treatment for communicable disease
- Only
50.9%
knowing how to implement some simple technical procedures
- Only
37.6%
having ability to implement monitoring & mgnt of chronic disease in the community
Why is the Bed Occupancy Rate of private hospitals is low? Only 60% !?
- Joint ventures & business partnership between public and private hospitals can easily lead to
side effects of over prescription of drugs, tests & high-tech services -
inequity in patient care
. The policy allowing provision of medical examination & treatment services of higher quality for a higher fee within public hospitals
lack clear regulations, easily leading to conflicts
.

- The study "Private Hospitals in Vietnam - Recent Growth and Role in the Health Sector" by the University of Melbourne & MOH, Vietnam showed that private hospitals tended to
provide a higher proportion of diagnostic and laboratory services than expected
from their proportion of beds which
ruins the belief of patients
on them.

- Social Health Insurance doesn't cover treatment in private hospitals so patients have to be
out-of-pocket
for many costly and unreasonable medical treatments.

- Private hospitals rarely had reciprocal referral or transfer arrangements with state hospitals. After "
Financial Autonomy" Policy
is applied, state hospitals don't want to share patients with private hospitals to
protect high revenue
and to
attract investment
to improve facilities or open satellite hospitals.

- Private hospitals have
difficulties to attract skillful and reputed health workers
, especially doctors from state hospitals working overtime 'cause difficulties about paperwork... They also don't attract newly-graduated doctors. So, they couldn't cure complicated cases.

-
Mass media
with many bad news about cases happening in private clinics and hospitals destroys patients' belief in private hospitals.
Vietnam's Health System Performance measured in term of health outcomes, equity and overall assessment of health care quality.
- Vietnam scores highly on
































































































Health Outcomes
Communicable Disease Prevention Activities
"Communicable Disease Prevention Projects"

Results
:
- No cases of cholera or plague reported; incidence & deaths due to rubella, malaria, rabies, streptococcus suis in humans reduced & no epidemic outbreaks; typhoid fever, viral encephalitis, meningitis, anthrax effectively controlled.
- Maintain achievements of eradicating polio, neonatal tetanus
- Reduce incidence of diseases preventable via vaccination in the national expanded immunization program; try to achieve the immunization rate of >90%, limit side effects
- Control Influenza A (H5N1 + H1N1)
Shortcomings
:
In 2012, VN still underachieved targets in the areas of control of hand-foot-mount disease and dengue fever, which both had high incidence & prevalence over a wide area.
Communicable Disease Prevention Activities
"
The Tuberculosis Control Program
"
- Tuberculosis prevalence fell from 375/100,000 people (2000) to 225/100,000 (2011)
- Successfully treat 90% of these cases
- Control program covers 100% of the nation's territory

"
The HIV/AIDS Control Program
"
- Reduce the incidence & deaths from HIV/AIDS starting in 2008
- 69 882 people nationwide were benefiting from ARV treatment
- The free condom distribution & the needle exchange program have been implemented in all 100% & 88% of provinces, corresponding
- HIV voluntary counseling and testing has been expanded to 485 counseling units in all 63 provinces
- Prevention of HIV transmission from mother to child is being implemented nationwide
Implementing Communicable Disease Prevention Activities
Difficulties & Shortcomings

- Tuberculosis, Dengue fever, and Hand-Foot-Mouth disease has still not been controlled.

- Tuberculosis control is the major challenge.
Vietnam is ranked 12/22 countries with high tuberculosis-related disease burden.

- The main difficulties: living environment & understanding of prevention and control among people
Non-Communicable Disease Prevention Programs
"
The Hypertension Control Program
"
- Prevalence among adult is high, but % of hypertensive aware, treated & controlled is unacceptable low
- Program only been implemented for 2 years, not yet scaled up nationwide
- Exceeding targets: training about 20,000 health workers, managing 41,984/ 71,972 patients screened since 2010
"
The Diabetes Control Program
"
- Being implemented nationwide
- Establishing the organizational network from the national to the commune health station level
- Community-based screening & pre-diabetes and diabetes surveillance primarily been undertaken since 2010
Screening: 1983 communes (18.5% of all communes), 1.6% of population, 668,476 people receiving blood glucose testing
Non-Communicable Disease Prevention Programs
"
The Blindness Control Program
"
Results up to 2012 showed that performance on targets has been inadequate:
- Cataract surgery: only 1764 cases/yr (target: Min 2000 cases/ mil people by 2013)
- Entropion surgery: only 10,000 cases/yr (target: 30,000-40,000 cases/yr), backlog > 200,000 cases (target: eradication of entropion by the end of 2014)
"
Chronic Obstructive Pulmonary Disease (COPD) & Asthma Prevention Programs
"
- By 2012, only been implemented in 10 provinces from Nghe An on north
- All other goals have not yet been achieved for 2012
Detecting so far only 3575/ 4000 cases as target through screening 48 395 individuals
- Organizing 92 skills training courses for 5106 health worker trainees
- Implementation was ineffective due to delays in funding
Implementing Non-Communicable Disease Prevention Programs
Difficulties & Shortcomings
- Not reach the majority of the set targets like: detection & screening, patient management at primary care facilities, criteria for building organizational networks & HR training for the program

- Reasons:
+ Inadequate investment in programs for NCD prevention
+ Absence of standardization in organization and management of service providers network
Health Outcomes (Cont.)

Vietnam's life expectancy has increased from 1980, even longer neighbors like China, Thailand
Maternal Mortality Ratio decreased significantly since 1990
Under-5 mortality rate has increased fast since 1990, but has showed unchanged & higher than the regional average's lever since 2005
VN
Regional Avr
General fertility rate decreased significantly with skilled attendance at birth rate reaching 93.4%
% of ARVs is still small, although double to 2007
% of Underweight & Stunting halved from 1988 to 2011. However, % of exclusive breastfeeding showed unchanged (<20%) in a long time.
Equity
-
Inequalities
continue to persist in:
+
MMR
(> in illiterate, ethnic minorities, farmers, disadvantaged districts)
+
Adolescent birth rate
(> in rural mountainous areas, ethnic minority women, low education)
+
% of birth attendance by health workers
(lowest in mountainous, rural areas, ethnic minorities and the poor)
etc.

-
Reasons
:
+ Geographic disparities in resources
+ Rapid medical cost escalation
+ Inadequate financial protection

-
Policy orientation
:
+ Compulsory insurance coverage towards the near poor & self-employed
+ Direct recruitment of students from mountainous & disadvantaged areas to medical schools with commitments to return origin area
+ Easy access to basic primary & preventive healthcare services
Overall Assessment of Healthcare Quality
Technical Competence
- Remain limited in lower level facilities
- The excessive overcrowding in tertiary hospitals and some specialties is an obvious result of the low level of technical competences in responding to the people's health care needs.
District Hospitals' share of surgeries is much lower than Provincial Hospitals
Access to Service
- In 2011, health insurance coverage reached 64.9% of the population
A rising trend of health care seeking at higher level facilities.
Health insurance has helped increased access to health care services.
Effectiveness of Healthcare Provision
- Effectiveness is accessed through use of clinical standards & guidelines.
- Over years, MOH developed many technical standards & treatment protocols, although
updating of guidelines has been limited.
-
No mechanism
for assessment or verification of compliance with guidelines by external agencies.
- Risk of over prescription of unnecessary drugs, diagnostic tests and imagining results from
Financial Autonomy Mechanism, Lack of External Quality Control
- Overuse of deliveries by C-section was
30.1%
(2011) - double to WHO's recommendation below 15%
Overall Assessment of Healthcare Quality (Cont.)
Professional Ethnics
Violations of medical ethics are prevalent in both public and private sectors.
Poor communication, Indifference, Coldness, Lack of enthusiasm
Expression of anger when interacting with patients
Taking envelopes from patients during inpatient treatment or prior to medical interventions
Collusion between physicians & pharmaceutical representatives/ pharmacies: commissions to doctors for prescribing certain drugs, private clinic sales of drugs without prescriptions
Abuse of authority & power to defraud the health insurance fund

Medical ethics violations & misconduct of health workers are often criticized & condemned by the press and public opinion.
These caused negative impacts on the physician-patient relationship.
Reason of patients' seeking medical treatments in foreign countries
Efficiency
Due to resource constraints, optimal use of healthcare services requires managerial attention.

Overcrowding at high level facilities (including mild cases that could be treated at lower level, but patients prefer care at higher level) negatively affects quality of care

As Health technology assessment is not practiced in VN health system, drugs with low effectiveness, ineffective technology & intervention technique are still used - waste

Lack of a mutual recognition arrangement for lab test results across hospitals
Amenities for Patients
- Basic amenities for patients has been paid little attention, negatively affecting service quality especially in public hospitals.
Some hospitals still use sedge mats rather than mattresses.
Many wards don't ensure coolness in summer, warmth in winter, or inadequate ventilation.
Toilets and bathrooms are neglected.
Overcrowding in tertiary hospitals forcing patients to share beds
- Meals for hospital inpatients are generally not provided. Because the cost of feeding patients are not included in the charges for hospital bed days, it's impossible to force hospitals to provide food for all patients.
- Nutrition dept. is considered as a source of potential increased revenues rather than ensuring hospital service quality.
- Providing therapeutic nutrition has been neglected.
Sedge mats
2 or 3 patients/ bed
No ventilation
Other reasons for patients seeking medical treatment in foreign countries
Disease Prevalence
Vietnam's Burden of Disease (BoD) will be divided into 4 parts.
Overview Disability Adjusted Life Years (DALYs)
+ General Information
+ By sex
+ By age
+ By cause

Sex & Age patterns of BoD

Specific diseases

Determinants of Health
BoD of Vietnam is calculated by the DALYs (Disability Adjusted Life Years)
DALY = YLL + YLD
= N*L + I*D*L
YLL: Years of Life Lost
YLD: Years Lived with Disability
N: the age & sex-specific no. of deaths
L: the age & sex-specific standard life expectancy
I : the no. of incident cases in the period
DW: the disability weight
L: the avr duration of disability (in years)

DALYs - General Info
DALYs - By Sex
DALYs - By Age
DALYs - By Cause
In 2008, the total BoD in Vietnam amounted to 12.3 mil. Non-communicable diseases were responsible for more than 3-quarters of the total disease burden, followed by Injuries.
The burden due to premature death (YLL) in Vietnam 2008 is larger than the burden due to illness (YLD).
Neuropsychiatric conditions & Cardiovascular diseases were the leading cause groups for disease burden in VN, 2008, each responsible for 18% of total DALYs. Unintentional injuries & Cancers ranked 3rd and 4th, accounting for 14% and 13% of total DALYs, respectively.
The total no. of DALYs in men was 6.8 mil and 4.5 mil in women. NCD was the main cause for the total BoD in both men (77%) and women (66%). The contribution of Communicable diseases of 2 genders was almost similar, but the percentage of injuries in men was 2 times higher than that in women.
In men, unintentional injuries were the leading cause of BoD. Cardiovascular diseases ranked 2nd, followed by neuropsychiatric conditions and cancer. Together, these 4 disease groups contributed abt 2/3 of the total BoD.
Similar to men, those 4 disease groups were responsible to 2/3 of all DALYs in women, but there was differences in order. The leading cause was neuropsychiatric conditions (22%), followed by cardiovascular diseases (18%), and then cancer and unintentional injuries.
The lowest burden was experienced in the age group 0-14. After that the BoD in men increased fast with age, peaking in the 45-59 age group. The total BoD in early childhood was predominantly due to communicable diseases. After 15, NCDs were leading causes, though injuries contributed significantly at ages 15-59.
Infectious diseases were the main causes of burden in men under 15. Between ages 15-44, unintentional injuries & neuropsychiatric conditions dominated the BoD in men. Cardiovascular disease & Cancer were the main cause of burden in older men.
Similar to men, before the age of 14, the burden decreased gradually with age groups in women. After that, the burden in women peaked again at age 79 due to NCDs.
Pattern of burden in women under 45 was different to men. Unintentional injuries were the main cause in young girls. Neuropsychiatric conditions & injuries were the most important cause to young adult women. Similar to men, cardiovascular diseases and cancer contributed most to the burden in older women.
Stroke was the leading cause of DALYs in men (10%), but it was depression (12%) for women. Road traffic accidents, alcohol use disorders, liver cancer & HIV/AIDS were the next main causes in men. Meanwhile, they are stroke, vision loss, diabetes, traffic accidents for women.
Sex & Age Patterns of BoD
Children aged 0-14 years
Males & Females aged 15-44 years
Males & Females aged 45-69 years
Adults aged 70+ years
In 2008, the BoD in VN's 0-14 year children was 1.3 mil DALYs, accounting for 11% of the total BoD. Unintentional injuries, congenital anomalies, respiratory infections combined were responsible for 1/2 of the total burden in this age group.
Pneumonia was the leading specific cause of BoD in children, followed by drownings, falls and road traffic accidents.
In men aged 15-44, unintentional injuries was the leading BoD & neuropsychiatric conditions ranked 2nd. These 2 disease groups contributed 1/2 of total DALYs. Infectious & cardiovascular diseases accounted for 1/5 of total BoD in men of this age range.
In women of a similar age group, neuropsychiatric conditions (40%), unintentional injuries (13%), infectious diseases (8%) & musculoskeletal diseases (7%) were the leading disease burdens.
Road traffic accidents were the leading cause of BoD in 15-44 aged men. The next leading causes, HIV & alcohol use disorders, combined & accounted for 17%. For women, depression was the leading cause, followed by road traffic accidents (8%) & anxiety disorders (7%). Liver cancer, falls & drug use disorders were top-ten causes of BoD in men but not in women which were anxiety disorders, vision loss and diabetes in women but not in men.

Cancer contributed 23% of the total burden in men and was the main burden for 45-69 aged men. Cardiovascular diseases & neuropsychiatric conditions ranked 2nd & 3rd, accounting for 22% & 11%, respectively.
Meanwhile, neuropsychiatric disorders were the leading burden group for women in this age group, followed by cancer, cardiovascular diseases. Together, all three contributed to >50% DALYs.
Stroke was the leading specific cause of BoD for men & ranked 2nd for women. The next 3 leading causes for men were liver cancer, road traffic accidents, lung cancer. For women, depression (13%) was the 1st cause, followed by stroke, vision loss & diabetes.
Cardiovascular diseases were the leading BoD for men, up to 40% of DALYs. Cancer was the next significant one with 20%, followed by respiratory diseases.
Like for men, cardiovascular diseases and cancer were the 2 leading BoDs for women, accounting for 53% totally, followed by neuropsychiatric conditions.
Stroke was the 1st cause for both older men & women, 22% & 24%, respectively. COPD, lung cancer & IHD were the next 3 leading causes in older men while dementia, COPD, diabetes held that position in women.
Sense Organ Diseases
Cardiovascular Diseases
Chronic Obstructive Pulmonary Diseases
Musculoskeletal Disorders
Unintentional Injuries
Infectious & Respiratory Diseases
Cancer
Diabetes
Neuropsychiatric disorders
Specific Diseases & Injuries
Most of the burden of cancer, cardiovascular disease, unintentional injuries & infectious diseases were causes of premature deaths. In contrast, disability were resulted from sense organ disease, mental disorder & musculoskeletal disease
Overall, the BoD caused by infectious diseases was higher in men than in women. DALYs caused by HIV/AIDS in men were 4 times higher than in women. The pneumonia was similar in both sexes.
Pneumonia was the main cause of the respiratory infection burden in young boys. HIV/AIDS was the main one in the next age range. The major of burden for men at 60+ was due to TB. Pneumonia, Upper respiratory infections were important from 70+.
Similar to men, the rate of infectious disease in women was dominated by pneumonia in 0-4 & 70+ age groups. In adulthood, besides pneumonia, TB was the main cause for a sharp rise in the rate of burden
The burden of cancer differs between men & women. It was higher in men for most cancers. These are particularly for lung, liver & mouth cancer, which were almost twice in men. But, some cancers that exist common in women such as ovary, uterus & breast cancer, showed significant %.
The DALY rate for cancer increased steadily with age, up until 70 years old.
Stomach, liver and lung were the most common cancer types in both men and women.
The burden of diabetes amounted to 358,000 DALYs with a greater burden in women than men. Disability was cause of 46% of DALYs from diabetes
DALY rates rose gradually to a peak at about 3.8 thousand per 100,000 pop in the 60-69 age group in both sexes.
There was an increasing trend of no. of deaths from 4 main NCDs (cancer, diabetes, heart diseases & chronic respiratory diseases), especially in men.
In 2008, mental disorders contributed >2.1 mil DALYs to VN's BoD. Burden of mental disorders in women was higher in men due to a higher burden of depression, anxiety, dementia, & schizophrenia. But drug & alcohol use disorder caused a greater burden in men than women.
DALY rates for mental disorders in males rose sharply from 5-44 age, followed by a plateau during age 45-60. In young & middle aged men, alcohol abuse dominated BoD, followed by depression. Dementia contributed most to +60 age range.
DALY rates in women were higher than in men. It increased steadily to a peak at the oldest age group, mainly due to dementia. Depression was the greatest contributor to BoD at ages 15-60 years.
Overall, the burden of vision loss & hearing loss in women was higher than in men
The pattern of DALY rates for hearing & vision loss were similar in men & women. During childhood, DALY reached a peak at 5-14 age, followed by a small dip in early adulthood, & then a steep rise with age. The contribution to the burden of vision loss was much greater than that of hearing loss.
In Vietnam, 2008, cardiovascular disease was one of the largest contributors to the total BoD. Contribution of Stroke & IHD to the total heart disease burden was similar among men & women while other heart diseases among men made up a greater proportion.
DALY rates for cardiovascular diseases increased with age in both genders with stroke being the dominant cause of burden.
Compared to women, men made a greater contribution to the total burden of COPD.
DALY rates for COPD and other respiratory disease increased steadily with age in men and women
The contribution of osteoarthritis to the total burden in women was about 2 times higher than in men (4% vs. 2%)
DALY rates per 100,000 population among women were almost doubled that among men and focused on +15 age range in both genders.
DALYs due to unintentional injuries were 2.5 times higher in men than in women. Road traffic accidents contributed most with 4% in women, 8% in men.
DALY rates in men for unintentional injuries showed a peak in young adults. In women, the rate peaked in young adults & again in the elderly. Drowning was the most common cause in young children of both sexes. At the 15-69 age range, road traffic accidents dominated the rates of both sexes. From +70 age, falls are the largest cause of burden.
Lifestyle Factors
Environmental Factors
Health
Determinants
Socio-Economy & Population Factors
- VN has escaped from less developed country status to a lower middle income country with GDP per capita increased.
- Shortcomings in social & cultural factors,especially education, training & healthcare.
- Ethics, lifestyles of some groups have deteriorated.

Population
- Population density is high (259 people/km2), 2 times higher than Asian continent, higher than China.
- Shares of pop in the working age group & the +60 age group have increased from 59%, 8% (2009) to 65.8%, 9.4% (2010).
- Age group of entering reproductive ages is also very large.

- Social infrastructure development tends to lag behind pop growth in urban areas.
Urban environmental pollution
- Air pollution caused by transportation vehicle exhaust (70%)
- Water pollution, solid waste, man-made disasters...

Food safety & Hygiene
- Food poisoning: remain complicated
(every yr: abt 200 cases with abt 30 incidents involving >30 people affected)
- Use of illegal chemicals & additives: fairly common

Climate change
- 1 of countries most heavily affected by climate change & increasing ocean levels.
- Avr temperature increasing causes negative results on human health: the elderly, newborns, especially about cardiovascular diseases, mental illness, allergies.
- Increase of outbreak & spread of epidemic diseases like H1N1, H5N1, diarrhea, cholera...
Tobacco consumption
- VN: 1 of countries with the highest male smoking prevalence, though declining 56.1% (2002) - 47.4% (2010)
- % of VNese people exposed to 2nd-hand smoke is very high at home, work & public places
- Law & fines show little effects.

Alcohol abuse
- Large impact on health via 3 ways: intoxication, alcoholism, alcohol poisoning.
- High in groups with high education
- Increase over years

Illicit drug use
- A large no. of illicit drug users & no sign of declining

Unsafe sex
- Big cause of increasing HIV/AIDS & sexually transmitted diseases
- Increasing % of abortions
Health Financing Reform
Vietnam's government is committed to implementing the reform and assuring all Vietnamese citizens access to quality health services and financial protection against the impoverishing effects of unpredictable medical care costs.

Fulfilling this commitment will require the development, implementation, and monitoring of policies affecting all aspects of the health system.
Health Care Financing
Until end of 1980s: healthcare was funded & provided by the Gov't, but very limited resources.
1989: User fees introduced at public health facilities
1992: Introduction of social health insurance
2002: Set up Health Care Fund for the poor
2005: Free care for children under 6
2008: Law on SHI passed, in effect on July 1st, 2009
Since the "Doi Moi" (Renovation) policies, 1986, VN health financing made a transition from a tax-based system to a system with multiple sources of financing.
Today, the major sources of financing are general government revenues, SHI funding, OOP payments of households. Other minor sources are external aid, overseas development assistance & private health insurance.
Financing for Health is still heavy reliance on direct Out-Of-Pocket spending!
Besides, compared to other countries in the neighboring are, Vietnam ranked 2nd in the Health Expenditure per Capita (102.50 in current US$), right after Indonesia (107.75 in curren US$).
Social Health Insurance - SHI
Summary of SHI's Development in VN
Piloted in early 1990s

Governed by Govt's Decree:
First HI Decree
issued in 1992; and there has been amended 2 times in 1998 & in 2005
- Health care for the poor program transferred to SHI in 2005

Two types:
compulsory
+
voluntary

Ministry of Health: policy making, oversight

Implementing Agency: VN Health Insurance (1992-2002),
VN Social Security Agency - VSS
(2003-now): an independent agency (the merger: agency for SHI + agency for pension insurance & short-term allowance benefits - VSS)

The law on health insurance passed in Nov, 2008 and be in effect on July 1st, 2009
- The free care for children < 6 transferred to SHI
SHI schemes and their target population
Health Insurance Law
New phase of HI Development
Preparation started since 2005
Passed on Nov, 2008 by the National Assembly
In effect on
Jul 1st, 2009
"Vietnam Health Insurance's Day"
Goal:
Towards universal coverage of HI
Gov't budget contributes to the poor, ethnic minorities, child < 6, near poor, social protection group...
Ministry of Health: policy making, oversight
Vietnam Social Security - VSS
: implementing agency
Current Situation
HI Fund - 1 of the most important sources of funding for health care services. In 2012, HI disbursed 1.7 bil USD to reimburse medical service costs.
MOH approved the Project to implement the roadmap towards UHI Coverage: by 2015, Min 70% pop covered by insurance
Benefit Packages
- In general, is comprehensive, including:
Inpatient & outpatient care and medical rehabilitation
Screening for some diseases
Drugs, according to the list made by MOH
Transportation costs for people who are the poor & living in mountainous areas.
- Co-payment required: 5% and 20% depending on groups of member
- Health Commune Station is 1st contact without copayment and follows referral lines
- The ceiling is applied for some kinds of high tech services: not exceeding 40 times of Min salary
Purchasing Healthcare Services & Provider Payment Methods
- Mainly by contracts with health care providers, both state-owned and private-owned
- Fee-for-service (FFS) is the most common method used
- Capitation used at mainly district hospitals
- DRG method is being discussed and proposed to pilot
>> There were situations of overuse medical services and drugs due to having no cost control mechanisms and FFS payment.
Challenges
- Around 30 mil people not be covered by health insurance
- The health insurance fund is not used effectively
- Service quality is below expectations
- Coverage rates in the informal sector: low
- Participation in health insurance is not compulsory
- Lack of measures to ensure compliance
- % of avr or higher income people enrolled in HI: very low
v...v...
Other Concerned Issues
Increase public spending on health via increasing state budget on health & expanding health insurance coverage

Reform the operational and financial mechanism in state sector health service facilities

Reform health service provider payments
Health Spending Trend
- Vietnam's health system is functioning efficiently in terms of healthcare outcome indicators.

Increase Efficiency of Available Resources
Resolution No. 18/2008/QH12 clearly stated:
"
At least 30% of the health budget should be allocated to preventive care.
"
Regarding financial allocation, VN has set priorities to the areas that could bring about high efficiency in health care like
preventive care
grassroots healthcare
healthcare for mothers & children
support for healthcare of the poor
.
Priority was also given to remote areas in terms of Gov't budget allocation coefficients set at 1.7-2.4 times in these areas compared with urban areas.
The highest level of budget expenditure for health per capita was found in 2 highland regions
Difficulties & Shortcomings
- Drug costs & utilization:
In VN, drugs account for 42% of total health spending, 70% of total health insurance reimbursements
% of drugs prescribed which are general/from the essential medicines list prescribed much < WHO recommendations, but % of antibiotics drugs is very high
- Over prescription of many unnecessary & duplicative services and tests has been acknowledged by VSS.
- Fee-for-service provider payments are still the most common mechanism >> very difficult to control cost
- Irrationality of health service delivery in the entire health system
Overcrowding at the upper level, low capacity at the lower level
Underuse of outpatient services, overuse of inpatient services
Financial Resources for UHC
The share of state recurrent expenditures allocated for health increased continuously in 2008-2012 but slightly decreased in 2013.The state budget share for health as a portion of GDP increased from 2008 to 2011, but saw a decline in 2012, 2013. This indicator reflects the extent of priority given to the health sector in general budgeting.
State budget
spending on health accounted for 26% of total health spending in 2010. The share of the state budget spent on health has risen 34.2%. But the annual growth rate spending for health in the last 3 yrs sharply declined due to economic hardship & the fiscal restraint policy.
State Budget Spending
Health Insurance
In 2010, with coverage of 60.3% pop, the social health insurance scheme only contributed 18% of total health expenditure of the entire society.
Reasons:
Preventive medicine services are paid by direct state budget subsides, not by insurance.
Expensive private sector services & self-medication are also not covered by health insurance.
Law on Health Insurance stipulates co-payment of 20% for many of the insured.
External Assistance
External assistance for health does not account for a large portion of total health expenditure (approx. 2.3% in 2009).
VN has become has become a lower-middle income country, but external assistance for health remains high.
In 2012, 52 ODA projects were managed by MOH, contributing 1.5 bil US$.
106 health projects are financially supported by NGOs with total commitments of 256 mil US$.
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