Healthcare and the New National Congress in Vietnam
Vietnam ponders privatized healthcare as potential providers look on

by Paul Slusher
Raptorial

During the period of January - March 1996, I had the opportunity, with the gracious support of Southeast Asia Resource Action Center (SEARAC) and the University of Oregon, to engage in research on the current status of Vietnamese national health policies, prior patterns and future trends. The following article is an overview of the "health care issue" as it relates to this crucial time prior to the upcoming 1996 Vietnamese National Congress.

As the 1996 Vietnamese National Congress approaches, which is scheduled for this summer in Hanoi, many within Vietnam and internationally have their attention fixed on the rather uncertain sector of health care and national health policy. Growth during the "Doi Moi" period has been steady. Economic "liberalization" has opened the doors for investment in nearly every national sector of society. One sector, however, that has been quite purposefully isolated from the new "market-socialist approach" has been health care infrastructure and delivery.
Many observers are quietly wondering in what direction will the new National Congress take Vietnam? There are many economic and political forces that are keen to see Vietnamese health care privatized. Private health care providers based in Singapore, the United States and other "developed" nations have been jockeying for political position in the hopes that they may get the jump on the private health care market. There are some within the Party who argue that "market-socialist" policies for the health sector will increase resource productivity and eventually expand the quantity and quality of health care. However, based on my personal observations and conversations with Vietnamese and international health care workers, the predominant view is one of skeptical caution. Many told me that privatization posed a dangerous threat for those who are the most disenfranchised and isolated from the "development process". This includes both rural and urban women and children, as well as whole communities in the rural sector.
Furthermore, According to Dr. Pham Ngoc Len, a project officer for the United Nations Children's Fund (UNICEF) in Hanoi, early signs of some experimental policies regarding private practice hours for government doctors have had mixed results. As of late, doctors have been allowed, albeit in a limited fashion, to engage in "private practice" in their spare time. Dr. Len explained that this relatively new policy has resulted in a growth in the utilization of national medical resources for private gain. 1
It should also be noted that only 3.8% of the 31,389 physicians in Vietnam work at the communal level. The number for pharmacy personnel working at the communal level is a mere 7.3% out of a total 24,1872. With this in mind, expanding current levels of private practice could very well be problematic. Needless to say, capital is at its highest concentrations in the urban centers. Therefore urban migration of educated and skilled medical personnel would logically increase beyond the already lopsided figure mentioned above.
There has also been a wave of new research in the area of income and capital distribution. Income disparities are becoming a very visible problem in this "New Vietnam". The United Nations reports that as of June 1995, HCM City (Saigon) had received 55% of the foreign direct investment capital, while Hanoi had received only 23%. The rest of the nation, the other 84% of the population, subsequently received only 22%. 3
Such macro-geographic disparities are translating directly into regional-class disparities, and as industrial and sales sectors flourish and grow, centers of capital accumulation grow in power and influence (i.e. HCM City and Hanoi). Another concern for many, including some within UNICEF, is that of the growing emphasis on industrial growth as opposed to social spending. Although the budgetary figures show that social spending has not altered drastically over the past 5 years, it is clear that as capital flows into Vietnam at an unprecedented rate, the domestic and international pressure to promote the "pro-market" process may lead to a further marginalization (in regards to resource allocation and policy) for those in rural communities. Such a circumstance will only aggravate already high urban migration patterns. With homelessness estimated to be as high as 1-2 million people in HCM City alone, urban migration poses a very real and powerful problem for the south in particular. 4
Currently there is research taking place in Vietnam in regards to the effect Doi Moi has had on quality of life issues, economic wage differentials and access to capital. The early verdict is that the Doi Moi development process (despite bringing in much needed investment capital) has resulted in some casualties, one of which is general access of health care for women, children, poor, rural and/or marginalized communities.

The success of Vietnam's health care infrastructure since 1975 to treat, prevent and monitor the health of its population of over 70 million people, despite its relative poverty, is worthy of praise. However Vietnam still suffers greatly in certain aspects. In a survey conducted from 1987 to 1989, it was discovered that Vietnam had a higher proportion of underweight and stunted children (25% and 56.5% respectively) than any other country in Asia except Bangladesh and perhaps Mynamar. 5 In the same survey it was discovered that 47% of all rural children were "severely underweight for their age." For urban children this number was 45% and was a surprisingly low (in comparison) 37% for children located in the mountainous regions. 6 There are, however, signs of remarkable improvement in areas such as maternal, infant and neo-natal mortality.
Vietnam, it should be noted, has also made remarkable progress in the areas of immunization and primary care education. This is due in large to the efforts of numerous government-NGO cooperative efforts. The Ministry of Health and the Vietnamese Women's Union have worked together well to address primary and family health issues in many rural sectors. International aid has been utilized to fund many rural development and education projects. I was told by Francis Cosstick of the UNICEF office in HCM City that just such a program involving the creation of fresh water wells was in the works between UNICEF and SEARAC.
However, despite these recent efforts, there are still visible problems in area of long-term malnutrition. This is due to a lack of several key vitamins and protein in the diet. It is estimated that 40-50% of Vietnamese pregnant women are anemic7. The prevalence of anemic pregnancies has also be attributed to the cultural practice of dieting during the last phases of pregnancy. However Anemia goes well beyond simple birthing patterns. Iodine and vitamin deficiencies also seem to be visible at extraordinary levels, especially for the rural communities.
Chronic malnutrition is, especially for women and children, a very real social issue that finds its roots in various related issues, such as capital access, income distribution and the rising cost of health care. With the ongoing dismantling of the medical subsidy system, over 67% of all out-patient care is now handled in the private sector. 8 It was also reported by the Ministry of Health that in 1992 approximately 30% of all communal health clinics had declined in the level of care since the previous survey of 1990. This has been attributed to a decreasing emphasis on resource allocation at the communal level. 9
Policy in health care has, in general, reflected these problem areas and important improvements have been made. However as the Vietnamese government goes into the next National Congress, the issue of long-term malnutrition must be addressed. Unfortunately in order to fully attack such malnutrition, inevitably one must first tackle the aforementioned issues of income distribution, insurance and subsidies, and privatization within this sector.
One project that many within Vietnam have been singing praise for is that of the rural-based "revolving credit scheme". This project has been detailed in the Fall/Winter 1995 issue of The Bridge 10 by Diep N. Vuong. One person I found to be very excited by the early successes of this credit scheme was Dr. Nguyen Kim Cuc, the Head of the International Relations Department within the Vietnamese Women's Union. She stated that the capital recovery rate is nearly 98-99%. The model effectively gives credit at 1-2% interest to families who may be able to utilize the funds to develop a sustainable income. Examples of the uses of the available credit have been animal husbandry, small-scale production and investment into various other small-scale enterprises. According to Dr. Cuc, this project has been one of the more successful rural development programs in recent years.
However the question remains, is it enough to offset the macroeconomics shifts that are taking place? Perhaps more importantly, how much further will policy shift in the area of health care? This upcoming Congress is arguably a very crucial time in the area of health within Vietnam. It is a time when crucial infrastructural decisions must be made in order to maintain Vietnam's honorable pattern of providing as many resources to national health as is possible. It is also a time when crucial theoretical issues about state, society and social need are to be hammered out in Hanoi. Where Vietnam will go next remains to be seen, however no doubt there will be strong debate within the party in regards to this sector.

Paul Slusher recently completed a three-month research internship for SEARAC in Vietnam. Paul is also currently researching and writing a Master's Thesis on the Vietnamese health care system for the University of Oregon.

Footnotes
1- Interview with Dr. Pham Ngoc Len took place 13 Jan, 1996, in Hanoi, Vietnam.
2- UNICEF. Women and Children: a situation analysis 1994. Hanoi, Vietnam.: 1994, p 45.
3- United Nations (joint UNDP, UNFPA & UNICEF document). Poverty Elimination in Viet Nam. Hanoi, Vietnam: 1995, p xii.
4- Accurate homelessness levels are rather difficult to ascertain. Many Vietnamese from rural communities come to the larger cities and many of those migrating are not "officially recognized" as living in HCM City. Some return to their home villages after a short period, but many also remain, living either in the streets, in alleys, or renting out very small living quarters in order to sleep under shelter. Official census often do not include these individuals. This problem, as I observed and confirmed with several UNICEF personnel, is much more extreme in the southern region, namely HCM City. Hanoi also has a growing level of homelessness, however the problem is much less visible and is arguably much less extreme.
5- Witter, Sophie. Doi Moi and Health: the effect of economic reforms on health and nutrition in Vietnam. University Leeds-United Kingdom (thesis): 1995, p 28.
6- UNICEF. p70.
7- Ibid., p 29.
8- Gellert, George A. "The Influence of Market Economics on Primary Health care in Vietnam." The Journal of the American Medical Association. V 273, n 19, p 1498.
9- Ibid. p 1499.
10- The Bridge is the quarterly newsletter of SEARAC, and is published out of Washington, D.C. SEARAC contact: 1628 16th Street, NW - 3rd Floor, Washington, D.C. 20009.