Describing the primary care system capacity for the prevention and management of non communicable diseases in rural vietnam

THE INTERNATIONAL JOURNAL OF HEALTH PLANNING AND MANAGEMENT Int J Health Plann Mgmt (2013) Published online in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/hpm.2179 Describing the primary care system capacity for the prevention and management of non-communicable diseases in rural Vietnam Hoang Van Minh1*, Young Kyung Do2, Mary Ann Cruz Bautista2 and Tran Tuan Anh1 Center for Health System Research, Hanoi Medical University, Hanoi, Vietnam Program in Health Services and Systems Research Duke-NUS Graduate Medical School Singapore Singapore SUMMARY Background The primary care system in Vietnam has been shown to play a crucial role in disease prevention and health promotion This study described the primary care system in a selected rural area in Vietnam in terms of its capacity for prevention and control of non-communicable diseases (NCDs) Methods The study was conducted in 2011 in Dong Hy district, Thai Nguyen province—a rural community located in northern Vietnam Mixed methods were used, including quantitative and qualitative and literature review approaches, to collect data on the current status of the six building blocks of the primary care system in Dong Hy district Selected health workers and stakeholders in the selected healthcare facilities were surveyed Results A description of Dong Hy district’s primary care capacity for NCD prevention and control is reported (i) Service delivery: The current practice in NCD prevention and treatment is mainly based on a single risk factor rather than a combination of cardiovascular disease risks (ii) Governance: At the primary care level, multi-sectoral collaborations are limited, and there is insufficient integration of NCD preventive activities (iii) Financing: A national budget for NCD prevention and control is lacking The cost of treatment and medicines is high, whereas the health insurance scheme limits the list of available medicines and the reimbursement ceiling level Health workers have low remuneration despite their important roles in NCD prevention (iv) Human resources: The quantity and quality of health staff working at the primary care level, especially those in preventive medicine, are insufficient (v) Information and research: The health information system in the district is weak, and there is no specific information system for collecting population-based NCD data (vi) Medical products and technology: Not all essential equipment and medicines recommended by the WHO are always available at the commune health centre Conclusion The capacity of the primary care system in Vietnam is still inadequate to serve the NCD-related health needs of the population There is an urgent need to improve the primary care capacity for NCD prevention and management in Vietnam Copyright © 2013 John Wiley & Sons, Ltd KEY WORDS: non-communicable diseases; health system; primary care; rural; Vietnam *Correspondence to: H V Minh, Center for Health System Research, Hanoi Medical University, Hanoi, Vietnam E-mail:hoangvanminh@hmu.edu.vn; chsr@hmu.edu.vn Copyright © 2013 John Wiley & Sons, Ltd M V HOANG ET AL BACKGROUND Chronic non-communicable diseases (NCDs) are well-known leading causes of global mortality, representing 60% of all deaths worldwide Of the 57 million global deaths in 2008, almost two thirds (36 million) were due to NCDs, mainly cardiovascular diseases, cancers, diabetes, and chronic lung diseases (WHO, 2009) Chronic NCDs cause premature deaths and adversely impact the quality of life of affected individuals, creating considerable adverse economic effects on families, communities, and societies in general (Strong et al., 2005) Four of the most important chronic NCDs—cardiovascular diseases, cancers, chronic obstructive pulmonary disease (COPD), and diabetes—are linked to modifiable risk factors, such as high blood pressure, tobacco use, alcohol consumption, unhealthy diet, and physical inactivity These risk factors increasingly impact impoverished populations particularly in lowincome and middle-income countries, reflecting the possible underlying socioeconomic determinants of NCDs (Armstrong and Bonita, 2003; WHO, 2011a) Like other developing countries, Vietnam is undergoing a rapid epidemiological transition that results in an increased burden of chronic diseases In 2004, the World Health Organization (WHO) estimated that two out of three deaths in Vietnam (317 000 of 514 000 total deaths) were due to NCDs (Bonita and Beaglehole, 2008) Hospitals across the country have reported chronic NCDs as the major cause of morbidity and mortality Between 1986 and 2008, hospital admissions due to chronic NCDs increased from 39% to 66.2% as chronic NCD deaths rose from 42% in 1986 to 63.3% in 2009 (Ministry of Health of Vietnam, 2009) Risk factors for chronic NCDs are also common in Vietnam In 2002, 16.8% of Vietnamese aged 25–64 years were shown to have hypertension (National Heart Institute of Vietnam, 1996) The prevalence of cigarette smoking in men and women was 56.1% and 1.8%, respectively (Ministry of Health of Vietnam, 2003) In 2004, WHO data showed that the prevalence rates of heavy and hazardous alcohol drinking among men and women were 5.7% and 0.6%, respectively (WHO, 2004) Moreover, a recent study reported a sharp increase (from 2.0% to 5.7%) in the prevalence of overweight in Vietnam between 1992 and 2002; the significant increase was observed across gender and age groups, in both urban and rural areas (Nguyen et al., 2007) In an effort to address the NCD epidemic, the Vietnamese Prime Minister issued Decision No 77/2002/QD-TTg in 2002—a ratification of the national programme on the prevention and control of certain chronic NCDs (Viet Nam Prime Minister’s Office, 2002) The programme focuses on four major chronic conditions (i.e heart disease, cancer, diabetes, and mental health) The responsibility over activities related to each disease is devolved to the respective specialist hospitals or institutes (i.e Viet Nam Heart Institute, National Cancer Hospital, Hospital of Endocrinology, and the National Mental Health Institute) However, the programme mainly focuses on disease management/treatment rather than using a common risk factor approach for primary prevention In addition, the programme is beset with poor collaboration among the implementing agencies and a shortage of funding from the national budget Vietnam’s primary care system (at the district and commune health levels) has been shown to play a crucial role in preventing diseases and promoting population health (Ministry of Health and Health partnership group, 2008, 2010) Copyright © 2013 John Wiley & Sons, Ltd Int J Health Plann Mgmt (2013) DOI: 10.1002/hpm PRIMARY CARE SYSTEM FOR NCDs IN VIETNAM Nevertheless, it must be underscored that the primary care system should also play a role in implementing population-wide NCD prevention programmes in particular and serve as the primary access point of health care for the vast majority of people with NCDs Hence, primary care capacities in Vietnam should be strengthened to serve the NCD-related health needs of the population This paper aims to describe the primary care system in a selected rural area in Vietnam in terms of its current capacity for the prevention and control of chronic NCDs METHODS Study design This study involves describing primary care facility and staff Mixed methods were used, including quantitative and qualitative and literature review approaches Quantitative approach based on self-administered questionnaire, checklists, and secondary data analysis Qualitative approach used in-depth interview techniques Study site The study was conducted in Dong Hy district, Thai Nguyen province (80 km north of the capital, Hanoi) Dong Hy is located in the northern east side of Thai Nguyen province and consists of 18 communes covering an area of approximately 457.75 km2 Among the districts of Thai Nguyen province, Dong Hy district was selected for this study because it is a typical rural area in Vietnam in terms of demographic characteristics with a population of approximately 114 608 in 2008 The working-age population accounts for 50.8% of the district population; 50.3% is female Nearly 70% of the Dong Hy population engage in farming The annual GDP per capita in Dong Hy for 2009 was about 700 USD The public health system in Dong Hy includes both district and commune health facilities Health facilities at the district level include the district hospital, the District Center for Preventive Medicine (DCPM), the District Health Bureau of the District People’s Committee, and the District Centre for Population and Family Planning At the commune level, there are 18 commune health centres (CHCs) with a network of 272 village health workers (VHWs) Dong Hy district only has 12 registered private clinics All of the facilities are small and only provide outpatient services Most of the facilities are located in Chua Hang Township There are also four military health posts responsible for taking care of soldiers in some military camps The farthest CHC is located about 40 km from the district’s centre Dong Hy district is about 10 km away from referral hospitals (i.e Thai Nguyen provincial hospital or the Hospital of Thai Nguyen Medical University) According to Dong Hy district statistics, NCDs are the second leading cause of morbidity in the district hospital During the first months of 2011, more than 500 patients were admitted to the district hospital because of NCDs A WHO study (2009) involving people aged 40 years and over in a commune in Dong Hy district also showed that NCD morbidity was quite common The prevalence of Copyright © 2013 John Wiley & Sons, Ltd Int J Health Plann Mgmt (2013) DOI: 10.1002/hpm M V HOANG ET AL hypertension (i.e blood pressure >140/90 mmHg) was 21.8%; the gender-specific prevalence was 29.9% among men and 14.5% among women The proportion of people who had elevated blood cholesterol (≥5 mmol/L) was 11.8% (16.4% among men and 8.1% among women), whereas increased blood glucose levels (≥7 mmol/L) were reported in 0.8% of the study population (1.1% among men and 0.4% among women) Risk factors for NCDs were also prevalent Among the surveyed population, 9.5% reported a body mass index of ≥25 kg/m2 (8.8% among men and 10.0% among women) The prevalence of daily smoking and daily alcohol consumption among men was 52.2% and 80.4%, respectively The corresponding figures for smoking and alcohol consumption among women were 0.8% and 12.1% Study subjects Health facilities and staff of the primary care system in Dong Hy district (at the district and commune levels) were studied Study scope We described the capacity of the primary care system for the prevention and control of NCDs based on the following six building blocks of the primary care system: (i) service delivery; (ii) policy/governance; (iii) healthcare financing, (iv) human resources; (v) information and research; and (vi) medical products and technology Study tools Self-administered questionnaire, checklists, and guidelines for in-depth interview were developed by a team of researchers The multidisciplinary research team is composed of professionals with PhDs (2), master’s (2), and bachelor’s degrees (5) in the field of public health, statistics, and health economics The tools were pilot tested before official use Data collection Using the study tools, the research team visited all the selected facilities to collect the necessary data Relevant health staffs were interviewed An inventory of facilities was conducted using the checklists developed Data management and analysis EpiData 3.1 and Stata10 were used in entering quantitative data and conducting descriptive statistical analyses, respectively Qualitative data were analyzed by content analysis techniques Copyright © 2013 John Wiley & Sons, Ltd Int J Health Plann Mgmt (2013) DOI: 10.1002/hpm PRIMARY CARE SYSTEM FOR NCDs IN VIETNAM RESULTS Service delivery Various population-based NCD prevention activities in Dong Hy district are implemented by the Dong Hy DCPM, the CHCs, and a network of VHWs These activities include special event campaigns (e.g the World No-Tobacco Day) and routine information, education, and communication activities such as meetings, loud-speaker announcements, and distribution of posters and leaflets Table shows key NCD prevention activities within the primary care system in Dong Hy district in 2010 Whereas tobacco control activities are implemented in all 18 communes in the district, health promotion activities on the reduction of salt intake are only implemented in seven communes Only three of the 18 communes have prevention initiatives for alcohol misuse; a small project by a non-governmental organization is in place in the said communes Health promotion initiatives to encourage physical activity have not been conducted in Dong Hy district Table Key NCD prevention activities in the primary care system, Dong Hy district (2010) Services Health promotion to reduce tobacco use Health promotion to reduce salt intake Health promotion to reduce alcohol Health promotion to promote physical activity Early detection of people at high risk of disease DCPM DH CHC VHWs Yes Yes Yes No No Yes Yes Yes No No Yes (18/18) Yes (7/18) Yes (3/18) No Yes (7/18) Yes Yes Yes No Yes DCPM, District Center for Preventive Medicine; DH, district hospital; CHC, commune health centre; NCD, non-communicable diseases; VHWs, village health workers In seven of the 18 communes, CHCs and VHWs conduct screening activities for early detection of individuals at high risk for chronic diseases However, individuals are only screened for hypertension The diagnoses of diabetes and high cholesterol conditions are made at the district level, whereas COPD and cancer diagnoses could only be confirmed at the provincial or central level The aforementioned health promotion/education activities in Dong Hy are usually managed and implemented independently Only seven of the 18 communes (i.e.CHCs included in the WHO project or the national NCD program) have implemented the prevention activities in an integrated manner that simultaneously addresses salt consumption, smoking, and other cardiovascular risks Table presents information on key treatment services available at the primary care level in Dong Hy in 2010 At the district level, services for early treatment of hypertension, diabetes, and COPD are available and provided at the General Internal Medicine Department of the district hospital The department has 24 staff members, four of whom are doctors of specialization level However, none of these doctors have specialized in NCD management and treatment In general, NCD patients who have health insurance receive treatments for free However, these patients have to be referred by CHCs Patients who have health insurance but bypass CHCs for some reason will have to pay for the treatment costs as those patients without health insurance would Copyright © 2013 John Wiley & Sons, Ltd Int J Health Plann Mgmt (2013) DOI: 10.1002/hpm M V HOANG ET AL Table Key NCD management and treatment services available in the primary care system, Dong Hy district (2010) Services Early treatment for hypertension Early treatment for diabetes Early treatment for COPD Early treatment for people with high cholesterol Early treatment for cancer Rehabilitative and palliative cares DCPM DH CHC VHWs No No No No No No Yes Yes Yes No No No Yes No No No No No No No No No No No DCPM, District Center for Preventive Medicine; DH, district hospital; CHC, commune health centre; VHWs, village health workers; COPD, chronic obstructive pulmonary disease; NCD, non-communicable diseases Like other areas in Vietnam, CHCs in Dong Hy are considered as the NCD patients’ access point to the healthcare system However, at the commune level, only treatments for mild cases of hypertension are available Only the seven communes where the WHO project or the national NCD programme is in operation are implementing active and continuous management and treatment of hypertension The current treatment practice in the district and commune levels is mainly based on a single risk factor (i.e high blood pressure) rather than a combination of cardiovascular disease risk factors (i.e age, gender, blood pressure level, smoking status, total blood cholesterol, and the presence or absence of diabetes mellitus) The role of the private health sector in the management and treatment of NCDs in Dong Hy is limited as it is mainly focused on acute care services Governance Vietnam has a national programme on the prevention and control of certain chronic NCDs (according to Decision No 77/2002/QD-TTg in 2002), which mainly focuses on disease management/treatment rather than using a common risk factor approach for primary prevention In addition, the programme is beset with poor collaboration among the implementing agencies and a shortage of funding from the national budget Furthermore, the role of primary care system remains unclear Non-communicable disease prevention activities in Dong Hy are mainly managed by the DCPM and implemented by the CHCs that tap a network of VHWs The DCPM is responsible for planning the prevention activities (based on the CHC’s plans and the Thai Nguyen Provincial Health Bureau guidelines), assigning prevention tasks to CHCs, and supervising the implementation of activities CHCs in Dong Hy district are in charge of conducting national health programmes (including NCD and tobacco control programmes), as well as monitoring and notifying diseases (including NCDs) among the populations The network of VHWs is chosen by the locals in each village; the CHCs and the DCPM subsequently approve the selection Although there are primary care committees with memberships from different sectors in the district, inter-sector collaborations are limited and are lacking a clear Copyright © 2013 John Wiley & Sons, Ltd Int J Health Plann Mgmt (2013) DOI: 10.1002/hpm PRIMARY CARE SYSTEM FOR NCDs IN VIETNAM vision/strategy for NCD prevention and control The role of the private health sector in the management and treatment of NCDs in Dong Hy is mainly centred on acute care services There is very little interaction between the private health facilities and the public health services Financing Dong Hy DCPM receives funding from the Thai Nguyen Provincial Health Bureau (government budget) to pay for staff salary (at the DCPM and CHCs) and other recurrent expenditures (i.e electricity, water, meetings, and duty travels) The government allocates about 85%–90% of its total annual expenditure on preventive health activities in the district Dong Hy DCPM receives a number of in-kind contributions (e.g vaccines, supplies, posters, and leaflets) from the different national programmes (for immunization, nutrition, and TB) The DCPM also receives direct funding from international projects on reproductive health, HIV/AIDS, and tobacco control The local government funding for prevention activities in the district (District People’s Committee) is inadequate and intermittent (with very modest funding for small health campaigns and meetings) Even though the NCD programme has been implemented for almost 10 years today, a specific national budget for NCD prevention activities at the primary care level remains to be put in place In 2011, Dong Hy DCPM received very few NCD-related health education materials from the Thai Nguyen Provincial Center for Preventive Medicine These materials were sufficient for NCD health promotion activities in only a few locations in the district At the commune level, no specific financial resource is regularly available for NCD prevention activities CHCs rely on either external project support or the government budget for their recurrent activities Apart from funding for staff salary, each CHC in Dong Hy district receives VND 20 million (about 1000 USD) a year for other recurrent activities; some CHCs use a small share of this budget for NCD-related health campaigns on special events such as the World No-Tobacco Day, New Year’s festivals, and the VHW competition on heath education knowledge and skills The local government (Commune People’s Committee) also provides a small amount of funding for similar activities within community organizations such as the Women’s Union and the Youth’s Union Despite playing important roles in disease prevention programmes in general and NCD prevention activities in particular (i.e being responsible for the additional task of early detection and monitoring of hypertension cases), VHWs receive very little remuneration from the DCPM, if any VHWs in the mountainous areas in Dong Hy receive VND 415 000 (21 USD) per month, whereas those in other rural areas receive VND 250 000 (12.5 USD) per month VHWs working in urban areas/townships not receive any financial incentives At the district level, there is no budget specifically allocated for the management and treatment of NCDs In 2010, more than 54% of the district’s total expenditure for treatment-related activities at the district hospital came from the government budget through the Thai Nguyen Provincial Health Bureau User fees and health insurance correspondingly contribute to 28% and 18% of the district’s total expenditure The district hospital uses part of its revenues from user fees and health insurance Copyright © 2013 John Wiley & Sons, Ltd Int J Health Plann Mgmt (2013) DOI: 10.1002/hpm M V HOANG ET AL reimbursements to pay for additional staff salary and other activities to improve hospital care services Unlike prevention services, treatments for NCDs at CHCs are not always free and available Health insurance scheme only covers a limited type of treatment services and causes bypassing problems Human resources Health workers who officially engage in preventive medicine include VHWs and staff members from the Dong Hy DCPM and CHCs Of the 31 health workers in Dong Hy DCPM, four personnel (two medical doctors, one bachelor of public health, and one administrative person) are assigned to take care of all the 10 national programmes, including the national NCD programme Only one of them received prior training on the epidemiological transition towards a mix of communicable diseases and NCDs Given the volume of workload for a limited health workforce, these four health personnel often need to work overtime but receive very little incentive The health staff at the DCPM expressed the need to increase their knowledge and skills to perform better NCD-related prevention activities; however, there are limited NCD training opportunities for them (e.g only one of the four personnel received training on the management of hypertension in 2011) In addition, supporting materials for NCD prevention are not completely available A total of 104 health workers are assigned across the 18 communes Only one CHC in Dong Hy district had no doctor In 2011, staff from seven of the 18 CHCs had the opportunity to participate in training courses on counselling services for behavioural change and lifestyle improvements, and the prevention and management of hypertension In addition, Dong Hy district has 272 VHWs The VHWs are selected by the community and managed by the CHCs As mentioned earlier, VHWs receive little, if any, remuneration despite having important roles in disease prevention programmes and NCD prevention activities (i.e being responsible for the additional task of early detection and monitoring of hypertension cases) Only VHWs from seven of the 18 communes are trained on counselling services for behavioural change and lifestyle improvements Health workers from both the district hospital and CHCs are involved in the diagnosis, management, and treatment of NCDs In the district hospital, eight staff (three of whom are general practitioners) from the Outpatient Ward and 24 personnel (four general practitioners) from the General Internal Medicine Department work on the diagnosis, management, and treatment of NCDs Although NCDs ranked second in the list of leading causes of morbidity in the hospital, none of the doctors specialized in any NCD area Only four of the personnel had the chance to participate in the training course on the prevention and management of hypertension in 2011 At the commune level, CHC staff members, under the supervision of a district hospital staff, are trained to manage and treat certain types of NCDs, including mild hypertension and diabetes Once more, only the staff from seven CHCs received training on the prevention and management of hypertension in 2011 Copyright © 2013 John Wiley & Sons, Ltd Int J Health Plann Mgmt (2013) DOI: 10.1002/hpm PRIMARY CARE SYSTEM FOR NCDs IN VIETNAM Information and research The health information system in Dong Hy district is generally weak Mortality and morbidity data are mainly collected from health facilities and reflect only a small part of the health status of the total population A specific information system for collecting population based data on NCD mortality, morbidity, and risk factors has yet to be developed and implemented VHWs and CHCs collect mortality data, but the information on the cause of death is usually not available In addition, the primary care system in Dong Hy district does not have a disease registry Because of inadequate research funding, and limitations in data generation capacity and data usage among healthcare staff, only four research studies were conducted by the district health staff in 2011 (all were completed within the period of the staff’s higher degree studies); staff from CHCs did not engage in any research work The information system in the primary care system in Dong Hy district is heavily dependent on paper-based formats Different vertical programmes require CHCs and the DCPM to complete several reports/forms However, the information obtained from these reports/forms is not always consistent Patient records at the district hospital are not organized in a way that can facilitate patient management Information on patient referrals and back referrals are usually missing from the system Medical products and technology Although all the CHCs in Dong Hy district are regarded as National Standard CHCs, medical products and technology related to NCD prevention and treatment not meet the WHO Package of Essential Non-communicable (WHO PEN) disease interventions criteria for primary health care in low-resource settings (WHO, 2010b) The following WHO PEN-recommended equipment (i) thermometer, (ii) stethoscope, (iii) blood pressure measurement device, (iv) measurement tape, (v) weighing machine, (vi) peak flow metre, (vii) spacers for inhalers, (viii) blood glucose test strips, (ix) urine protein test strips; (x) glucometer, and (xi) urine ketones test strips are available at the district hospital but not at CHCs There is limited availability of blood glucometers, urine ketones test strips (not available in any CHC), urine protein test strips (only available in two CHCs), and peak flow metres (only available in four CHCs) The WHO/International Society of Hypertension (WHO/ISH) risk prediction charts are only available at the district hospital and in five of the 18 CHCs that are included in the WHO project; the tool was reported to be rarely used Medicines are essential components of the treatment of cardiovascular diseases, diabetes, COPD, and many cancers The WHO-recommended essential medicines are always available at the district hospital However, this is not the case in the CHCs As diabetes, COPD, and high cholesterol conditions are rarely treated at the CHCs, only a few CHCs had medicines for treating these conditions Antihypertensive medications are more readily available in CHCs, especially in the communes included in the WHO project However, not all types of medications for hypertension are available: none of the CHCs had statins, and only three communes had betablockers (Table 3) Copyright © 2013 John Wiley & Sons, Ltd Int J Health Plann Mgmt (2013) DOI: 10.1002/hpm M V HOANG ET AL Table Availability of essential WHO-recommended medicines in CHCs, Dong Hy (2010) Medicine Thiazide diuretic Calcium channel blocker (Amlodipine) Beta-blocker (Atenolol) Angiotensin inhibitor (Enalapril) Statin Insulin Metformin Glibenclamide Isosorbide Glycerin Furosemid Spironolacton Salbutamol Prednisolone Beclometas Aspirin Paracetamol Number of CHCs with available medicines Medicine Number of CHCs with available medicines 18 12 Ibuprofen Codein 10 Morphine 10 11 Penicillin 18 0 0 11 10 18 18 10 18 Erythromycin Amoxicillin Hydrocortison Epinephrine Heparin Diazepam Magnesium sulfate Promethazine Senna Dextrose Glucose Sodium Oxy 15 18 13 16 15 18 18 CHC, commune health centre; WHO, World Health Organization At the district level, protocols for diagnosis and treatment of hypertension, diabetes, and COPD are available At the commune level, however, only seven of the 18 CHCs have protocols for the diagnosis and treatment of hypertension, whereas only five CHCs have protocols for the diagnosis of diabetes None of the CHCs follow protocols for the treatment of diabetes and COPD Other important protocols/guidelines for health education and counselling on tobacco cessation, keeping a balanced diet, and the early detection of NCDs are either unavailable or underutilized in the primary care facilities in Dong Hy district DISCUSSION To our knowledge, this is the first study that described the primary care system capacity for prevention and management of NCD in rural Vietnam The findings from our study showed that the primary care system in rural Vietnam has not been well prepared to respond to the rising NCD epidemic in the country Service delivery In Dong Hy district, NCD prevention activities have been implemented according to the NCD-specific national health target programme However, these activities are implemented without proper collaboration and integration, which may reduce Copyright © 2013 John Wiley & Sons, Ltd Int J Health Plann Mgmt (2013) DOI: 10.1002/hpm PRIMARY CARE SYSTEM FOR NCDs IN VIETNAM effectiveness NCD prevention should use an inter-sectoral approach that requires government action such as tobacco and alcohol control, and ensuring environmental safety (UN Health Partner Group, 2005) Internationally, a study from Ghana showed that in order to make services more responsive to local needs, the integration of service delivery at the district level with more decentralized planning and improving the flexibility in central government regulations are needed A focus on prevention alone disregards the needs of current and future patients, and may diminish the impact of prevention policies, given that people may be reluctant to test for a disease for which there is no prospect of effective treatment (Maher et al., 2009) However, the current study found that not many treatment services for NCDs were available in the Dong Hy health system For example, diabetes medication was not available in the community; a possible reason for the limited availability of diabetes medication is the very low incidence of diabetes (0.8%) in Dong Hy district, which in turn may be due to the lack of a health screening policy for diabetes at the commune level In addition, there were no special wards for NCDs at the district hospital; existing doctors have no specialization in NCD diagnosis and treatment These observations are consistent with findings from previous studies that reported that the primary care system for NCDs in developing countries remains oriented towards acute problems and communicable diseases (Maher et al., 2009; Robinson and Hort, 2012) Additionally, service delivery models in Dong Hy district were also characterized by over-centralization and limited interaction between the public and private sectors (Mills et al., 2002) WHO suggested that action towards NCD prevention and control requires support and collaboration from government, the civil society, and the private sector (Maher et al., 2009) Governance The WHO defines governance as “ensuring strategic policy frameworks exist and are combined with effective oversight, coalition building, the provision of appropriate regulations and incentives, attention to system-design, and accountability” (WHO, 2010c) For NCDs, Vietnam has a national programme on the prevention and control of certain chronic NCDs, but the programme mainly focuses on disease management/treatment rather than using a common risk factor approach for primary prevention Using a common risk factor approach for NCD prevention has been suggested primarily because NCDs have shared characteristics; for example, tobacco use, unhealthy diets, physical inactivity, and harmful use of alcohol are common risk factors for NCDs that are potentially amenable to behavioural modification (Magnusson, 2008); NCDs can be detected using simple tests available (or potentially readily available) in primary care settings in low-income countries; and they can be managed in typical primary care settings in middle-income and low-income countries Therefore, having a national programme on chronic NCDs orientated towards a common risk factor approach should be promptly addressed In Dong Hy, inter-sectoral collaborations for NCD prevention and control have been very limited and lacking in a clear vision/strategy The United Nations High-Level Copyright © 2013 John Wiley & Sons, Ltd Int J Health Plann Mgmt (2013) DOI: 10.1002/hpm M V HOANG ET AL Meeting on NCDs highlighted that “addressing NCDs require interventions, not only from the health sector, but many other sectors, such as agriculture, education, urban development and transport” (Bermejo, 2011) Health financing We found that funding for NCD prevention activities in Dong Hy district is not always regularly available and often relies on external project support or government budget However, funding priority seems to be given to treatment and management activities (like its counterparts, more than 80% of NCD-related funding in Dong Hy is spent on clinical care for treatment and management of disease complications, and less than 20% is spent on health promotion, prevention, and community-based care) (WHO, 2012) Many NCD-related healthcare interventions have been shown to be cost effective, relative to costly procedures Cost-effectiveness may be necessary in case of delayed detection and treatment, and when a patient is in an advanced disease stage (Samb et al., 2010) Nonetheless, NCD prevention is as important as NCD treatment and management and, therefore, should be given more attention and adequate financing Limitations in financial protections, combined with the long-term nature of chronic disorders, particularly put NCD patients and their families at a high risk of incurring catastrophic healthcare costs, especially those who are already poor (Xu et al., 2003) Out-of-pocket expenditure in Dong Hy is rather high for NCD patients: a 2011 survey in one commune showed that about 10% of households with NCDs experienced catastrophic health expenditure (monthly health spending more than 40% of the capacity) Globally, an estimated 100 million people each year are pushed into poverty because they have to pay directly for health services in the world (WHO, 2010a) In India, one in four families with a family member who has cardiovascular disease reported catastrophic expenditure; as a result, 10% of these families are driven into poverty (German Foundation for World Population and Action for Global Health, 2011) In Kenya, although private spending (including out-of-pocket expenditures) declined between 2001/2 and 2005/6, treatment costs continue to limit access to care, especially for the poor It is estimated that 16% of the sick not seek care because of financial barriers, whereas 38% must dispose of their assets or borrow money to pay for medical bills Because of the need to directly pay for health services at the point of consumption, 4.1% of households face catastrophic expenditures (2.7% of non-poor and 7.7% of poor households); 1.5% of households were pushed below the poverty line (Luoma et al., 2010) In Nigeria, more than 63% of cancer patients failed to adhere to chemotherapy partly because of the cost of the drugs (Samb et al., 2010) Human resource The effective delivery of good quality care for NCDs in primary care settings depends on a strong health workforce that is properly educated and trained (WHO, 2011b) However, it is likely that qualified NCD health professionals in Dong Hy province are insufficient to meet rising demand Of the 31 health workers in Dong Hy DCPM, four personnel are assigned to take care of all the 10 national programmes including national NCD programme, and only one received prior training on the epidemiological Copyright © 2013 John Wiley & Sons, Ltd Int J Health Plann Mgmt (2013) DOI: 10.1002/hpm PRIMARY CARE SYSTEM FOR NCDs IN VIETNAM transition towards a mix of communicable diseases and NCDs Additionally, although NCDs ranked second in the list of leading causes of morbidity in the district hospital, there were no doctors who specialized in any NCD area In order to respond to NCDs in Dong Hy district, the health workforce needs a range of personnel starting from primary care health workers and extending to public health specialists who can deliver inter-sectoral prevention strategies (WHO, 2006) In Uganda, rural districts still lack the required number of health workers trained for NCD prevention and treatment (Ministry of Health and Health Systems 20/20, 2012) The limited NCD training opportunities not help district health workers who are facing difficulties in NCD diagnosis and treatment NCD training courses on counselling services for behavioural change and lifestyle improvement and the prevention and management of hypertension should be frequently organized for all relevant staff of CHCs and district hospital It takes decades to build a qualified health workforce A population-based approach to healthcare and a multidisciplinary team of health professionals—including clinicians, nurses, and community health workers—and public health leaders and workers are required Urgent attention to training approaches for CHCs is needed (Bangdiwala Shrikant et al., 2010) The primary care system should consider providing adequate incentives and better working conditions to ensure the retention of health workers for NCDs Given that NCDs require prolonged treatment and a continuum of care, more health personnel may be distributed across the stages of prevention, detection, management, and treatment The shortage of skilled health workers in any of these stages will be a considerable obstacle in the fight against NCDs The public health sector in Vietnam, particularly in Dong Hy district, has always been plagued with issues of low wages and inadequate incentives, which led to difficulties in retaining staff for preventive medicine and spurred the so-called “brain drain” of doctors and other health workers to the private sector (Chua and Cheah, 2012) Information and research Information systems are increasingly important for measuring and improving the quality and coverage of health services for NCD patients However, until now, a specific information system for collecting population-based data on NCD mortality, morbidity, and risk factors has yet to be developed and implemented in Dong Hy district Paper-based health records were exclusively used as the means of data storage, despite being known as a time-consuming method that overburdens health staff and being prone to error that hampers rapid retrieval of information In the study that evaluated the health management information system (HMIS) in Uganda based on interviews with doctors and nurses, the introduction of a computerized HMIS resulted in health workers putting greater value to the data generated; the HMIS supported programme planning and decision making, while improving the quality of and access to health care (Fenenga, 2007) Medical products and technology Medical products and technology related to NCD prevention and treatment in the Dong Hy district health system not meet the criteria of the WHO PEN WHO PEN is a Copyright © 2013 John Wiley & Sons, Ltd Int J Health Plann Mgmt (2013) DOI: 10.1002/hpm M V HOANG ET AL conceptual framework for strengthening equity and efficiency of primary health care in low-resource settings WHO PEN is considered as an important step for integrating NCDs into primary health care and initiating reforms that need to cut across the established boundaries of the building blocks of national health systems (WHO, 2010b) To advance towards the universal coverage of NCD care and promote the efficiency and equity aspects of NCD services in Vietnam, various ministries particularly the Ministry of Health, professional bodies, and other developmental partners urgently need to work together to ensure that the WHO PEN criteria are met at all primary care settings in Vietnam Limitations of the study This study was conducted in one district in northern Vietnam; hence, the results cannot be any more than a snapshot of the primary care system in a rural setting, which limits the generalizability of our findings Inherent limitations of the reporting system did not allow for a more detailed assessment of the relevant elements of the health system CONCLUSIONS The primary care system capacity in rural Vietnam is still inadequate to serve NCDrelated health needs of the population There is an urgent need to improve the primary care capacity for NCD prevention and management in Vietnam An appropriate approach to address the NCD problem should be consistent with the Regional Strategy for Health Systems based on the Values of Primary Health Care (WHO, 2011c) as well as other existing health system strategies These findings offer insights on the current primary care system capacity for NCD control and management in a low-resource setting, which in turn, highlight gaps that need to be addressed in order to strengthen health system capacity at the primary care level AUTHORS’ CONTRIBUTIONS H.V M designed the study and developed the questionnaire in discussions with Y K D H.V M supervised the data collection, analyzed the data, and wrote the paper All authors contributed to the analyses and interpretation of the findings as well as the revision of the manuscript All authors read and approved the final manuscript ACKNOWLEDGEMENTS The authors acknowledge the funding support from the World Health Organization, Viet Nam Dr Hai-Rim Shin and Dr Cherian Varghese of the World Health Organization’s Regional Office for the Western Pacific provided invaluable comments on an earlier version of the manuscript Alexander Hargrave provided editorial support for this paper The authors declare no competing interests Copyright © 2013 John Wiley & Sons, Ltd Int J Health Plann Mgmt (2013) DOI: 10.1002/hpm PRIMARY CARE SYSTEM FOR NCDs IN VIETNAM REFERENCES Armstrong T, Bonita R 2003 Capacity building for an integrated noncommunicable disease risk factor surveillance system in developing countries Ethn Dis 13(2 Suppl 2): S13–8 Bangdiwala Shrikant I, Sharon F, Osegbeaghe O, Stephen T 2010 Workforce resources for health in developing countries Public Health Reviews 32 Bermejo R 2011 Non-communicable diseases in Southeast Asia The Lancet 377(9782): 2004 DOI: 10.1016/ S0140-6736(11)60863-5) Bonita R, Beaglehole R 2008 Noncommunicable disease (NCD) prevention and control in Vietnam: report to WHO on a review of the Integrated model of NCD prevention World Health Organization Chua HT, Cheah JC 2012 Financing universal coverage in Malaysia: a case study BMC Public Health 12 (Suppl 1): S7 Fenenga C 2007 Health management information systems as a tool for organizational development Cordaid IICD Health Programme Uganda German Foundation for World Population and Action for Global Health 2011 Health spending in India: the impact of current aid structures and effectiveness Luoma M, Doherty J, Muchiri S, et al 2010 Kenya Health System Assessment 2010 Health Systems 20/ 20 Project Abt Associates In: Bethesda Magnusson R 2008 Developing a global framework to address non-communicable diseases 53: 9–12 Maher D, Harries AD, Zachariah R, Enarson D 2009 A global framework for action to improve the primary care response to chronic non-communicable diseases: a solution to a neglected problem BMC Public Health 9: 355 Mills A, Brugha R, Hanson K, Mcpake B 2002 Public Health Reviews What can be done about the private health sector in low-income countries? 80: 325–30 Ministry of Health and Health partnership group 2008 Joint Annual Health Review 2008: health financing in Vietnam pp 149 Hanoi Ministry of Health and Health partnership group 2010 Joint Annual Health Review 2010: Vietnam’s health system on the threshold of the five-year plan 2011–2015 pp 254 Hanoi Ministry of Health and Health Systems 20/20 2012 Uganda Health System Assessment 2011 Kapala, Uganda Ministry of Health of Vietnam 2003 Vietnam National Health Survey 2001–2002 Ministry of Health Vietnam: Hanoi Ministry of Health of Vietnam 2009 Health Statistics Year Book National Cancer Institute: Hanoi National Heart Institute of Vietnam 1996 Preparatory Document for the VIIth Party Congress; Situation of Cardiovascular Disease Ministry of Health: Hanoi Nguyen MD, Beresford SAA, Drewnowski A 2007 Trends in overweight by socio-economic status Copyright © 2013 John Wiley & Sons, Ltd in Vietnam: 1992 to 2002 Public Health Nutr 10(02): 115–121 Robinson HM, Hort K 2012 Non-communicable diseases and health systems reform in low-andmiddle-income countries Pac Health Dialog 18(1): 179–190 Samb B, Desai N, Nishtar S, et al 2010 Prevention and management of chronic disease: a litmus test for health-systems strengthening in low-income and middle-income countries Lancet 376(9754): 1785–1797 Strong K, Mathers C, Leeder S, Beaglehole R 2005 Preventing chronic diseases: how many lives can we save? Lancet 366(9496): 1578–1582 UN Health Partner Group 2005 A Health Situation of Assessment of the People’s Republic of China WHO Representative Office in China: Beijing Viet Nam Prime Minister’s Office 2002 Decision 77/ 2002/QD-TTg: ratification of programme of prevention and control of certain noncommunicable diseases for the period 2002–2010 WHO 2004 Global Status Report on Alcohol 2004 Department of Mental Health and Substance Abuse: Geneva WHO 2006 The World Health Report 2006—Working Together for Health WHO Press: WHO, Geneva, Switzerland WHO 2009 World Health Statistics 2009 World Health Organization: Geneva WHO 2010a Global Status Report on Noncommunicable Diseases World Health Report WHO Press: WHO, Geneva, Switzerland WHO 2010b Package of Essential Noncommunicable (PEN) Disease Interventions for Primary Health Care in Low-resource Settings Geneva WHO 2010c Western Pacific regional strategy for health systems based on the values of primary health care WHO 2011a Global Status Report on Noncommunicable Diseases World Health Organization: Geneva WHO 2011b Noncommunicable Diseases in the Southeast Asia Region: 2011 Situation and Response World Health Organization: Geneva WHO 2011c Regional Strategy for Health Systems based on the Values of Primary Health Care World Health Organization: Geneva WHO 2012 Intercountry Consultation on Improving Access to Essential Medicines, Diagnostics and Medical Devices for the Management of Noncommunicable Diseases M Report, pp 48 WHO Western Pacific Region: Manila Xu K, Evans DB, Kawabata K, Zeramdini R, Klavus J, Murray CJL 2003 Household catastrophic health expenditure: a multicountry analysis Lancet 362: 111–117 Int J Health Plann Mgmt (2013) DOI: 10.1002/hpm ... describe the primary care system in a selected rural area in Vietnam in terms of its current capacity for the prevention and control of chronic NCDs METHODS Study design This study involves describing. .. readily available) in primary care settings in low-income countries; and they can be managed in typical primary care settings in middle-income and low-income countries Therefore, having a national... snapshot of the primary care system in a rural setting, which limits the generalizability of our findings Inherent limitations of the reporting system did not allow for a more detailed assessment of the