Establishment of primary health care in Vietnam

asic demographic and epidemiological data relevant to health problems in Vietnam are described in this paper. Existing health service arrangements are referred to, with particular emphasis on the strategy for development of primary health care. The establishment of the paediatric centre in Ho Chi Minh City is reported, and examples of its valuable work in primary health care development are described

PRIMARY CARE ABROAD

CHRISTOPHER A BIRT

SUMMARY Basic demographic and epidemiological data

relevant to health problems in Vietnam are described in this

paper Existing health service arrangements arereferredto,

withparticular emphasis on the strategyfor development

of primary health care The establishment of thepaediatric

centre inHoChiMinhCityisreported, andexamplesofits

valuable work in primary health care development are

described

Introduction

V IETNAMisoneof thepoorestofdeveloping countries.Its

state of comparative under-development is largely

at-tributableto ahistory ofwargoing backoverabout40 years,

atfirst with the French andsubsequentlywith theAmericans,

which resulted in devastation of the country Despite an apparent

desire for peace,military spendingremainshigh, owingto

ten-sion with Chinain theNorth,and on accountof Vietnam's

re-centinvolvementinCambodia However, itwasalso inevitable

that, following the1975liberation,anumber ofinexperienced

individualswere thrustinto seniorpositionsin the country The

last party congress of the Vietnamese communist party

acknowledged sucherrors,and itis hopedthatVietnam isnow

enteringa new phase of development

Officialfigures claimthat thepopulationofVietnam in 1986

was61 661220 However, other researchinstitutes in the

coun-try estimate that in 1988 the population was approximately

66 000 000 According to statistics issued by the Vietnamese

Ministry of Hetlth, after takingaccountof thebirth rateand

mortalityrate, thepopulation growth ratein 1987was21.5per

1000population.Moreover,46%of thetotalpopulation ofthe

country is under theageof 15 years, and 0-4 year olds

con-stitute 14% ofthetotalpopulation Theinfantmortality rate

wasstated to be 35 per 1000livebirths, andthe maternal

mor-talityratebetween 1.0% and 1.4% Lifeexpectancy wasstated

tobe 63yearsformenand61yearsforwomen.However, surveys

carriedoutby thepaediatric centre inHoChi MinhCitycast

sonme doubtonthesefigures.These suggest ahigher infant

mor-talityrate ataround50-60per 1000 live birthsinurbanareas,

andhigher stillinsomeremotedistricts.Mainlyon accountof

thishigher infant mortality rate, thepaediatriccentrecalculates

thatlifeexpectancy isnearer to 55 than63 years formen

Despitethese morepessimisticfigures,thefactremains that

health status forthepopulationinVietnamappears tobe

con-siderablybetter than the meanforallAfricancountries,for

ex-ample, and isno worse than thatexperienced in someother

developing countrieswhere thegrossnationalproductperhead

is much higher InVietnam,.this figure isUS$ 210perhead,

and health spending per person per yearis theequivalent of

US$ 1.9

Morbidity and mortality

As in manydeveloping countries,the commonest cause ofdeath

isinfectious disease.Inadults, themaininfectious diseasesare

CABirt, MA,MSc, FRCP,FFPHM, consultant inpublichealthmedicine,

Royal NorthernInfirmary, Inverness

Submitted: 26July 1989;accepted: 8 September 1989

© British JournalofGeneralPractice, 1990, 40, 341-344

malaria, tuberculosis,avarietyof bowelinfestations,andvarious

chestinfections.HepatitisBis alsocommon.Nextcomes

cardio-vascular disease (mainlystrokes), with cancerbeing the third commonestcause ofdeath.Among cancers,theincidenceof cervicalcancerandgastriccancer seems tobeparticularly high

Lung canceris knowntobe fairlycommon,butmaybemore

soowingtofailuretoSiakethe correctdiagnosisin manycases

ofchestdisease Breast cancerincidenceislow,which may be

associatedwiththe low fatcontentin theVietnamesediet In children,amongthe infectiousdiseases,the diarrhoeal diseases arethecommonest causes ofdeath, followedbydengueand malaria.Nowadays,uptakeof immunization for childrenis

en-couraging Malnutrition is the next most common problem

amongchildren

Thecities of Vietnam havemanyoftheproblemscommon

incentresofpopulation in developing countries.Theseproblems areseen attheirworstinHoChiMinhCity This conurbation

has a population of over 4000 000 (compared with around

500 000livinginthesame areain1940),of which3 000 000are resident in thecrowded centralarea(Saigon) Here the problems

posed by lack of sanitation andpoorhygieneareparticularly exacerbated Pollution isa problem and this takes three main forms: pollution ofthe air fromtraffic fumesand factories;

humanpollutioncausedbypoorsanitation; and pollution from industry intowater courses(mainly chemicalsincludinginone particulararea, heavy metals) Afurther problemin HoChi

MinhCity is infectious diseaseasalready describedfortherest

of Vietnam

Amongthemostdisturbing health problemsfacing Vietnam

is thelegacy of the chemicalwarfare agents usedduringthe Viet-nam war Duringonephase of thiswaritwasUSApolicy to drive ruralpeopleawayfrom theirvillages,using defoliantsto destroycrops.Certainhighly toxic dioxinswereincludedin the

defoliantsused There have beenanumber of documented in-creases in morbidity and mortality which appear to be at-tributabletodioxinexposure,includinganincreased incidence both of livercancerandchorioncarcinoma Inthecaseof this lattercondition,over recentyears,between 45and51 pregnan-ciesresultinginchorioncarcinomahavebeenobservedfor every

1000live births in HoChiMinhCity These healthproblems

are,generallyspeaking, onlyseenin SouthVietnam(especially

aroundHo Chi MinhCityand theMekongdelta),aschemical

warfare agentswere notused in North Vietnam;

Diet and drugs

Asalreadystated, malnutrition remains anidentifiable health problem,especiallyinchildren.There appearstobeaplentiful

supplyofmany foodstuffsthroughoutthe country (although

recently shortageshave been-reportedinsomeareas, following

poorharvests),andit hasbeenclaimedthatthereisnolonger

anyrealproblemofmalnutrition However, there is evidence

thatit remains aprobem inchildren, and relates not to the

overallsupplyoffood, buttothequalityof the dieteatenby

thepeople,which is deficientinfats, especiallycertain essen-tialfatty acids suchaslinoleic acid."Notsurprisingly, vitamin deficienciescausedbydeficiencyof fatsoluble vitaminsare

par-ticularlycommon.AsfarasvitaminDisconcerned,this situa-tion is madeworsebythefactthatmotherstendtowrpchildren

up,believingthatitisnotpropertoleavechildren's skin

expos-edto sunlight

So far Vietnamesehealthworkers have hadlittletimretothink aboutdiseases ofaffluence, althoughthereisalreadyconcern

C A Birt r 'I Primary.,care abroad

about alcoholism and drugs of addiction There were large Health centres and heplth education

numbemftof heroin addictU remnininginSouth VietU after Theb6 re mos than 3000healtcetre InVieinam sevng

responded totreatment, heroin addiction remainsaproblem.

Many Vietnamese people now smoke and it is fearedthiat in throughout the countryside The author was able to visit one

a few yearstime,anepidmicofsmok.ingrelated diseases w.ll particularhealth centre in thecountryside of'SouthVietnam, addtoeaxistimghealth care problems r serving a population of 19 500 Most of this population lived

inalarge village,whichprovidedthe labour forabig factory

Organization of services nearby The,staff ofthehealthcentre includedanadministrator, Hospital servicesweredeveloped duringtheperiodof French adoctor,-a medical auxiliary,midwivesandcommunity health

colonialism and the furtherperiod before liberation in 1975 work Themedc auiliaries,whoaretrainedfor three years,

Thesehospitalsare nowdilapidated and relatively poorly equi have an areaof special training In this case the auxiliary has

ped.Therehas beensome newhespiUd development since1975 owntreatmeim vithi thehealthcntre(arate to that

Superimposedonthishospital serviceisadecentralizedsystem used bythedoctor), and is'an expert in traditionalremedies,

Of care (establishedinthe North in1954and in the South fo - includingvarious herbsandacupuncture She stated that itwas ing 1975)extendingfrom the national level (MinistryofHealth) mainly old people who requested traditional therapies, younger

to thecities and provinces and soondownto local communties people being more likely to seek 'modem' medicine Primary TheMinistry isresponsible for providing schools of medicine care health centres have at least two midwives on the staff, who

and pharmacy, andfor supportingresearchinstitutes, as well provide a basicmaternityservice There are also a number of

asfordirect administrationof;hospitals.Thehealthservies comniunityhealth worerson the aff who outposted within

citiesandprovinces provideschools for otherhealth personnel the local community, living intheirown homes, from which they (for example nurses and paramedical staff), provide provideabasic service of health advice and fistlinetreatment

epidemiological and public health services, and run;some The author visitedonesuch workerinhishome.He hada plea-hospitalsand research centres.District healthoffices, ofwhich santhouse andabasic butspaciouseonsulting rooxn, set inan

thereare several in eachcity,or -province, provide polyclnics, attractivegarden Althoughhe ispaid for hiswork, he is

ex-dispensaries, and also employ theequivalentofenvironn pectedtoprovidehisownconsultingroom athisownexpense health officers. Health centres are provided in all local Much ofthe workofoutposted community health rkers

apparent-Health policyin Vietpam, and themanner in which this is ly wellAdministered and coordinated health educationservice, being developed, ismostimpressive, especially consideringthe providedby thelocalcityorprovincialhealth service The

direc-overal levelofeconomicdevelopmentin thecouIntry.Itshould torof healtheducationsericbsof HoChiMinhCity, and his

bestated thatsomeVietnamesedoctorsarecritical ofcurrent staff,arecohcernedwith the production of information and the

healthpolicy, seeingitastoomuchconcerned withthetraining holding of monthlyseminarsfor community healthw6rkers,the

ofhealthprofessionalsandtheprovisionof healthservices,and provision of health information to thepopulationibymeansof toolittle concerned with theimprovementof the determinants television, newspapers, radio,as well as bymeansof a health,

ofillhealth, namely the Qverallsocial andeconomic environ- newsletter,and for the supply ofappropffate infoationto all ment within which most people live, taking account oftheir heH1thservicepersonneL Howeve,theapproachto

health'educa-housing, diet andso on Nevertheless, muhprogressixbeing tion issomewhatpaternalistic, withlittleattemptkt

encourag-madewithinthehealtkcarefielditself.Thereisalradyonedoc- ing the self-empowerment of tthe' people He$th education torforevery18000populationa(a highfigure forathird world depaents areinvolVedinprovidii,g vtal supportto other ser-country), andthere;are now six medicalschools opera ngin vices, such as theprovisionofcalibrated spoonsfor measuring

medical studentsper year sl~~~t'andsugarto help peopletocopeWith dehydration

follow-ing diarrhoe These departmen%arealsoinvQlvec inascheme Primary health care strategy forproviding malnourished childrenin rfanilies, with some Since January 1986, the Ministry of Health for Vietnam has basic foodstuffs, and withvAtaninAandDsupplements (fish

madethe establishmentofeffective primaryhealthcarein the oil)free ofchargeSHealtheducationworkersstressthat in many

wholecountry by 1990 its firstpriority. Basedon the declara- casessuch mauttioniscausedmore;by lackof education of tionofAlma-Ata,the Ministry has established 10 special mothers thanby unavailabilityof fqod.Accordinly theVare

trionities ofAhma-Ata, base primary health care poliQ in making considerable effortsto teach mothers the essentials of

priorities on which to base primary health.care policy in

-Establishment of healthcare servicesinlocalcommunities, City

-Establishment ofadequate clean drinkingwatersuppliesfor

the whole population, and of effective sanitation ices In 1982, this centre was set up asa, isearch instituiteassociated

-Achievement of high uptake of ;mmuniation against witha majorchidrens hospital;it was given theresponsibility diphtheria,tetanus,whooping cough, poliomyelitis,measles and of researching the health needs of children and newimprovred

tuberculosis, > systems fordeliveryof health care toclikren. Since its

establish-Prevention andcontrol of local epidemics. ment its director has been Dr DuongQuynh HoA,arespected

-Adequate nutrition. paediatricianwho' had her original medical education in France

-Establishment ofadequate family planning services, in the1950s DuringtheVietnamwarDr HRoi wastheMinister

Provisionof a adequatesupply ofessentialdrugs including of Health in theprovisional revolutionarygovernment of South

traditional meines, becaueofte increasi useoftraditonal Vietnam.She is thereforenotonlyaspecialistdoctorinherown therapiessuch as acupuncture andmassage field, and onewho is informed abbut atiageofhealth

pro Promotion ofhometreatmentofillneSs. blems outside herownfield,butshe is also well versed in

Viet Improvedsystemsofhealth caremanagement. namesepolitics.

BritshJoumal of Generl Practice, Augulst1990

342

Primary care abroad

Dr Hoa does not believe that the health services alone can

answer the needs forprimaryhealth care for children or for any

otherage group She has been demonstrating in the work of

thepaediatriccentre that solutions to healthproblemsin

Viet-nam (as elsewhere) can only be addressed satisfactorily on a

multidisciplinary approach, involving education, agriculture,

forestry,foodsupply,andindustryin healthproblems- an

'in-tersectoral' approachas the World HealthOrganizationwould

describe it She insists thatprimaryhealth careworkerscanonly

be successful whenthey trulyunderstandthesocial and economic

determinants of health.

Theobjectives for thepaediatric centre, as agreedwith the

MinistryofHealth,can be described as follows.First,tostudy

the family as a single unit, rather than to concentrate on

in-dividuals Thepaediatriccentre would collaborate withparticular

primaryhealth carecentres,which would hold a file for each

family, providingsocioeconomic information as well as an

in-dividual health record for each member of thefamily.

Second-ly,to collaborate with health centres in thetrainingin new skills

forcommunityhealth workers and inplanningthreeparticular

directions of work: (1) involvement of primary health care

workers in environmentalhygiene (dealing with the problems

of clean water supply, human waste disposal and rubbish

disposal as a priority); (2)involvement in the stabilization of

social conditions(raisingthe socioeconomic and cultural level

of thepeople);and(3)involvement intackling employment

pro-blems,vocationaltraining,andimprovementin economic

con-ditions(giving particularattention toimprovingnutrition and

general living standards)

Wherever it becomes involved in aproject,thepaediatric

cen-tre insists thatprimary health care must be partof an overall

community developmentprogramme.Every attemptis made to

change attitudes towards the doctor as being the onlysource

of health care.Development requirementsare of course different

for rural and urban areas and for communities with different

cultures and levels of socioeconomic development There is

therefore nosinglemodel forprimaryhealth care which can be

prescribed for everyarea.

Twoof theprojectswith which thepaediatriccentre has been

associated will now be described in greater detail.

Primary health care centre in quartier 6, district 4, Ho

Chi Minh City

This is apoorquarter close to the dock area of thecity It is

built on oldswampland,and theremainingswamps are

gradual-ly beingfilled in with the rubbishgenerated bythecity.The area

covers about 20 hectares, of which seven are still stagnant

swamps.There are four residentialzones,which range from some

quitecomfortable houses withrunning water, electricity, latrines,

andregular rubbishdisposal, to huts built in a swampy area,

withoutanyrunning water,nopublic stand-pipes,water which

is fetched from one kilometre away, noelectricity, andpublic

latrines over the ponds and the river.

Primaryhealth care, based on the model describedby the

paediatric centre,isbeingestablished in thisquarter.Wherever

possible,the assistance of outsideagencieshas been obtained.

As a result of a survey of the community, the following

priorities wereagreed The firstobjectivewould be the active

participationof thepeopleandcommunityleaders. ftaining

ses-sions arebeing organizedwith thehelpof UNICEF aspartof

aprogrammeof environmentalhygiene Secondlya programme

for theprovisionof thesupplyof cleandrinkingwater has been

launched with the assistance of UNICEF This will involve

pro-vidinganadequatewatersupplyto twolarge apartment blocks,

the repair and cleansing of the public stand-pipes, and the

establishmentof furtherpublic stand-pipes The third aim isto

establisha properprimary healthcare centrefor the

communi-ty.Onepartis reserved for maternal and childhealth,and this has beensponsored and financedbyaBritishcharity.Aseparate partof thecentreisdesigned for servicestoadults, and finan-cialsupport has been obtained froma Frenchcharity Other Frenchsourceshaveprovidedfundingforimmunization

cam-paigns, improved recordsystems, supportformidwifery train-ing, and the provision ofa creche

Anew programme tocontrolintestinalparasites isplanned,

following an appropriate training programme provided by

UNICEF.This followsadiarrhoearesearchprogrammewhich hasoperatedin theareasince1987, financed by the WHO This has shownthat childreninvolved in thestudy have lessdiarrhoea,

fewer seriousrespiratory infections, and fewer parasites than those who did not participate It is assumed that this is

at-tributabletohealtheducationand the practicalapplication of simple and cheap hygiene practices by families From thisthe

paediatriccentrehas concluded that healthpromotion should

be continuedevenwherethesocioeconomic conditionsare not

alwaysfavourable Improvement in socioeconomic conditions

is clearly animportant component of health promotion, but education andtrainingcannotalwayswait for thesetoimprove.

Primary health care in Talai, Dong Nai Province

Talaizoneisanoldvolcanicarea, 170kilometres northeastof

Ho Chi MinhCity Itwasbadly affected by the bombs, napalm anddefoliantsin'theVietnamwar, and thevirgin forests have been reducedto one or twolonelytrees onbarehilltops Soil erosionis seriousandstreams aredryingup.Erosion is

exacer-batedbyuncontrolledfelling of thosetreeswhichremainby the ethnicminority people resident in thearea.

Thereareapproximately 2000 inhabitants resident in thezone,

and therearethree separateracialgroups.Asan areaofsparse

population,Talaihasbeen asettlementareafor ethnicminorities since 1981

Rice cultivationis theprincipal economic activity ofthese ethnicminority peoples Part of theareapermits irrigated rice cultivationwithtwoharvestsper year,butdryricecultivation predominates.Thereisgenerallya verylow standard ofliving, withhunting, fishinginthe streams,and thecollection ofresin (used for boatbuilding) beingthe other mainactivities Surveyscarriedoutbythepaediatriccentre atlTlai showed

that whiletherehasneverbeenfamine,thereis permanent under-nutritionwhichaffects thechildrenearlyintheir lives These

surveyshave shownthatprevalenceofmalnutritionandstunted growthinchildrenofallages up totheageof 15yearsisvery

high.Associatedcommonproblemsareprematuredelivery, low birthweight (over20% ofneonates arebornweighing less than

2500grammes),andtheinabilityofmanymotherstoproduce sufficient milk forbreast feeding

Malaria is themost commonseriousdisease in thisarea,but othercommonproblemsincludenutritionalanaemia, respiratory diseases, diarrhoea and dysentery, intestinal parasites, skin diseases, deficiencyof vitaminA, tuberculosis and leprosy

Aprimaryhealthcare centrehas been established inlTlai,

and it hasbeenequipped withFrenchassistance.Healthworkers have beenrecruited fromthe local ethnicgroups,witha

Viet-namesemedicalauxiliary giving technicalsupport.Furthersocial

surveys arecontinuing.Aprogrammeofimmunization, family planning, andsanitary improvement is being started with the helpofaFrenchcharity.ADutchorganizationisassisting with

a programmeof nutritioneducation andwith theestablishment

ofvegetable gardens, fruittrees, and fishponds.The

interna-tionalRed' Cross isassistingintheprovision ofanappropriate

British Journal of General Peatice,August 1990

C A Birt

343

Primary care abroad

trainingprogramme for community healthandhealth

educa-tion workers

The paediatriccentreconcludes that thetwomainobstacles

tomakinganimpactonthehealthstatusof the peoplearound

Talai are the lack of understanding of the special needs of

thepeople and lack of cooperation by the authorities, and the

inertia and lack of participation inanyhealth promotion

ac-tivitiesonthepartofthepeople The paediatriccentretherefore

feels that the basis for healthpromotion in this community

mustbearaising of the level ofconsciousnesswithin the

com-munity of the possibilities for and advantages of improved

health

Achievement of primary health carein Vietnam

Thepaediatriccentrein Ho Chi Minh Cityis basicallyaresearch

organization, but it has led the way in demonstrating the

possibilities for the development of primary healthcarein

Viet-nam.Aprimary healthcarecommittee, chaired byavice-minister

forhealth has beenestablished, and has been given the

respon-sibility for supervising the introduction of primary healthcare

and evaluating ittoidentify themostuseful aspects. Ineach

area,thecommunity itself will be responsible for the

introduc-tion and implementation of its own primary health care

programme.

Itis estimated that eachprimary healthcareproject will

re-quire basic capital of around US$ 80 000-100 000 However, it

is alsounderstood that thegovernmentwill be responsible for

purchase of land, supply of locally available construction

materials,fundingbasic construction and labour, and funding

materialsnecessaryforcertaineconomic developments (for

ex-ample, fishingnets,seeds, seedlings, chickens, fish) The

govern-mentwouldalso, ofcourse,continuetoprovide the salaries of

health service personnel

Inaddition, donor organizations indeveloped countries will

be askedtoprovide US$ 50 000-60 000tobe usedmainly for

thepurchase ofimported goods Where malnutrition remains

aproblem, someofthis moneywillbespent onfood aidfor

small children and for pregnant and lactating women, until

economicimprovements make this unnecessary.

Anewmedicalschool, thefirst.to specialize in training for

primary healthcare, wasestablished in 1989 In additiontoits

training function, it will provideaforum whereforeign donors

and experts can be briefed, where they can research precise

requirements, and wherecooperation canbe established with

Vietnameserecipients charged-with the establishment of primary

healthcare.Vietnam isawareof theneedtointroduceaprimary

healthcarestrategyaspartof the World HealthOrganization's

'Health for all by theyear2000'programme. Theaim istoenable

Vietnamto useprimary healthcarein itsoveralldevelopment

inaccordance with the principles of self-sufficiency

Acknowledgements

This paper is based on theexperienceobtained during two visits to

Viet-nam, and also on a paperdescribing developmentsinprimaryhealth

care in Vietnamprepared byDr DuongQuynhHoa I amgratefulto

many Vietnamese friends and colleagues who havehelpedto inform

me about their country InparticularI amgratefulto DrDuongQuynh

Hoaherself,DrNguyenThiNgocPhuong, Mr Nguyen Tholtuong,

Dr DuongQuangTrung, Dr Do HongNgoc, as well as many others

who cannot be namedindividually

Address forcorrespondence

Dr C ABirt, RoyalNorthern Infirmary, Inverness IV3 5SF.

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