This section presents the description overview of Vietnam and Thai Nguyen, health care system and policy of health, as well as stroke care in Vietnam.
2.2.1 Description of Vietnam and Thai Nguyen
Vietnam is an S shape, lying in the Indochina peninsular, and borders with China, Laos, Cambodia, and the Gulf of Tonkin in the east. With a surface area of more than 330.000 km2 and the distance from the northernmost point to the southernmost point of 1650 km (see Figure 2.1). Vietnam is a country with a diversified eco-system. There are 57 provinces and 5 centrally controlled cities.
According to General Statistical Office Vietnam (GSO, 2013) the population was approximately 90.7 million in 2015, with 54 ethnic minority groups (GSO, 2013). The country is divided into six geographic-socioeconomic regions: Northern Midlands and mountain areas, Red River Delta, North Central area and Central coastal area, Central highlands, South East and Mekong River Delta. Hanoi is the capital of Viet Nam, located in the Red River Delta. Ho Chi Minh City is the largest city located between the South East and Mekong Delta regions.
Vietnamese cultural values build on the principles of Confucianism.
Contrary to the Western idea of individualism, Vietnamese culture emphasizes the
importance of family and community, and its core values are harmony, duty, honor, respect, education and allegiance to the family (Pham, 2011). Family is the cornerstone of the Vietnamese society. Vietnamese family follows the extended multi–
generational pattern. Vietnamese household includes the parents, the sons and their wives (in some instances, daughters and their husbands), grandchildren, and unmarried siblings. In fact, the Vietnamese perceive society as a whole as one big extended family. In a typical Vietnamese family household, the father is the central figure and is responsible for the well-being of every member of his family (Pham, 2011). The children paid more attention to their elderly parents, and had more knowledge about caring for their elderly parents (Le, 2015).
Figure 2.1 The map of Vietnam
Thai Nguyen is located in the North of Ha Noi capital, being the center of the highland and mountainous region in the North of Viet Nam, also the third largest educational center in the country and the regional health center with a system of quality disease examination and treatment facilities. Thai Nguyen Province has a population of 1.3 million people, including eight ethnic groups, with 650 thousand
Thailand
Cambodia Lao
China
Myanmar
people of working age. Thai Nguyen has a natural area of 3,541 km2 divided into 9 administrative units: Thai Nguyen City, Song Cong city, Pho Yen town, 6 districts and 180 communes and wards. Thai Nguyen city has long been famous throughout Vietnam for the quality of its green tea, with Tan Cuong Commune producing the most widely recognized brand. In addition, Thai Nguyen is also known as a center of education and training of scientists and technical staff of Northern midland and mountainous provinces. It is the 3rd largest educational center with 21 universities, colleges and vocational training to educate tens of thousands of students. Nowadays, Thai Nguyen is one of the cities in Vietnam that has several modern health services including: Thai Nguyen National General Hospital, 9 Provincial Hospitals, and 14 District Medical Centers (GSO, 2013).
2.2.2 Health care system in Vietnam
The current health system in Vietnam is a mixed public-private provider system. The public system, the largest part, is organized under an administrative hierarchy, with the central level under the Ministry of Health and local levels under provincial and municipal authorities. There are basically four levels of health administration: central, provincial, district, communal levels with the Ministry of Health at the central level. The provincial hospitals provide technical assistance to the district hospitals, and district hospitals supervise commune health centers (see Figure 2.2) (Dao, Waters, & Le, 2008; Le et al., 2010). At each level, there were two-track systems. One focuses on prevention, which includes the public health system and another focuses on mother and child health care; together they may be called the
“public health center” system. The other is devoted to clinical acute care. These two tracks are distinct and different systems, but they collaborate closely. They are sometimes housed in the same hospital, and sometimes separately.
The Ministry of Health manages a number of health institutions including national hospitals, research and Pasteur institutes, universities and colleges. The most national general and specialty hospitals are concentrated in Hanoi and Ho Chi Minh City. These are the highest referral hospitals of the provincial hospitals in each region and are also the teaching hospital for nearby medical universities. The research institutes include Health Strategy and Policy Institute, Institute of Hygiene and Epidemiology,
National Institute of Nutrition, Institute of Occupational Medicine, and Pasteur Institutes in Ho Chi Minh City and Nha Trang. Research institutes offer postgraduate education and provide preventive services. The health professional education institutions include several medical and pharmaceutical universities and medical colleges offering program in medicine, nursing, midwifery, pharmacy and medical technology, among others.
Most of these institutions are directly managed by the Ministry of Health. Most medical universities have been training hospitals with about 200 beds to implement training missions, scientific research and health-care provision (MOH, 2013).
Provincial health institutions include state-level departments of health, the medical services institutions such as general and specialized hospitals. The provincial hospitals usually have a size of 500 beds. The specialized hospitals include maternity, obstetric, pediatric, traditional medicine, and tuberculosis and lung disease hospitals.
The specialized hospitals are organized according to the population size of each province. In the provinces with high population, some provincial regional hospitals are the referral level for neighboring district health centers. Provinces often also have specialized in medical centers managed by the Department of Health in reproductive health, preventive medicine, HIV/AIDS prevention, forensics, eye disease, communication and health education, and food safety and population agencies. These medical centers provide medical services as well as management of their specialty and have no inpatient beds. Each of the provinces usually has a medical college or secondary medical school offering programs in medicine, nursing, midwifery, medical technology and pharmacy according to the province‟s needs (MOH, 2013).
Viet Nam has 419.542 employees working in the public health system. The health workforce consists mainly of doctors, assistant doctors, nurses, midwives, medical technicians and traditional medicine practitioners. These professions account for 83.55% of all health workers (GSO, 2014). Other cadres include pharmacists, engineers, accountants and technicians. The density of doctors in Viet Nam was 7.34 per 10 000 people in 2012 and 7.61 per 10 000 in 2013 (MOH, 2015). The nurse-to-doctor ratio increased from 1.19 to 1 in 2008 to 1.34 to 1 in 2012. The number of employees in the health system has remained stable in recent years. Highly qualified human resources such as PhD, master and specialists, work mainly at the national level including hospitals, research institutes and universities (GSO, 2013).
Vietnam‟s health system continues to make great progress in improving its capacities and performance. However, despite the many significant achievements that have been made, Vietnam‟s health care system still faces many challenges. These include an emerging double burden of non-communicable diseases and infectious diseases, an ageing population, etc. (MOH, 2015). In addition, there are some specialty hospitals in the big city like Hanoi and Ho Chi Minh City, including those for oncology, cardiology, surgery, and pediatrics frequently overloaded patients.
Sometimes there was two, three, or four people in the same bed. Overcrowding did not happen at the provincial, district, and commune levels. To reduce hospital overcrowding, recently the government spent about 1 billion dollars building new hospitals and renovating existing ones in the provinces and districts so the overall number of beds has increased. Moreover, Ministry of Health has implemented some other policies to reduce overcrowding at the central hospitals by the "core hospitals"
introduced the satellite hospitals policy. Under this policy, provincial hospitals were selected based on their human resources capacity, availability of medical equipment and devices, and infrastructure. Health staff at these hospitals receive clinical skills training from their colleagues at core hospitals to help them perform their work at higher quality, thereby reducing the number of patients who bypass the provincial or district hospitals and go directly to the large core hospitals for care. Similarly, Ministry of Health has provided additional training for family doctors to provide higher-quality basic services to the community, thereby preventing patients from going to hospitals for only basic services.
Vietnam‟s national health insurance was established in 1992 to manage insurance throughout the country with two forms of insurance: compulsory and voluntary. In 1999, 10.5 million people had health insurance, of which 6.9 million had compulsory insurance (66% of all insurers) and 3.6 million had voluntary insurance (34% of all insurers) (Dao, Waters, & Le, 2008; Le et al., 2010). In 2012, almost 61.8 million Vietnamese people or 68 % of the total population was covered by the health insurance. 90% of them are covered by the compulsory insurance and 10% is covered by the voluntary insurance. The government wants to reach a coverage level of 80%
by 2020 and 100% by 2030 (Nguyen et al., 2012).
The number of health workers in Vietnam has increased substantially over the past 10 years, but there are still severe shortages in remote and disadvantaged areas. Nguyen (2015) reported the most disadvantaged parts of the health workforce are those working in difficult mountainous and rural environments with limited resources coupled with little opportunity to practice to maintain and develop professional competencies and with poor supervision. In addition, Hinh and Minh (2013) reported that generally low levels of work-related satisfaction among of primary health care staff, particularly regarding salary and incentives, equipment, and the working environment.
Official management Professional supervision
Figure 2.2 Structure of the Vietnamese health care system (Le et al., 2010)
2.2.3 Stroke care in Vietnam
Vietnam is a developing country and low and middle income countries in south-east Asia and like other Asian countries. Vietnam is facing an enormous socio- economic burden caused by many people with chronic illness such as stroke. The numbers of stroke victims hospitalized are steadily increasing. Accounting for this phenomenon is the growing older population. In addition, along with the economic and society growth that increasing middle class, who has a more inactive lifestyle and increased access to fatty food, but with relatively low public awareness of hypertension and smoking as stroke risked factors (Cong, 2007; Yamanashi et al., 2016).
Presently in Vietnam, although more than 20 Stroke Centers/Stroke Units have been taking care of stroke patients together with other specialized departments.
The Ministry of Health attempts to develop unified guidelines about Quality Standards Committee for hospital care of stroke. These Quality Standards aim to establish quality of services for care to people with stroke by healthcare staff during the course of diagnosis and initial management, acute phase care, rehabilitation and management after acute phase throughout Vietnam (MOH, 2015). However, according to the Vietnam Association of Neurology (2015), stroke treatment and care in Vietnam necessitate further improvement due to hospitals' limited infrastructure and resources. Although, the number of patients who died decreased, the number of people experiencing after-effects was on the rise. About 90 per cent of patients have been after-effects, the severity of which depended on when the patients were hospitalized and how they were treated. Most of the patients missed the
"golden hour" to go to the hospital, which is about three hours after experiencing stroke symptoms such as numbness in face, arms and legs, speaking difficulties and vertigo. Moreover, hospitals still lack modern equipment for diagnosis and treatment. The medical schools and universities lack a stroke faculty so most doctors gather their professional knowledge from their working experience. In commune medical stations, where there are no doctors, giving emergency aid and treatment to stroke patients is also difficult.
Besides the problem of inadequate equipment, the biggest problem facing stroke care in Vietnam, as in other developing countries, is that the number of stroke victims is excessive and continuously increasing. Sickbed management becomes
problematic and the capacity to sense the stroke patients are limited. As a result, stroke patients are generally discharged within one to two week of admission, and they mostly return to their homes where most caring for stroke patient‟s rehabilitation by family caregivers and little health care resources are available.
Family members responsible for the care of chronically persons have been described in Vietnam literature (Hayashi, Hoang, & Nguyen, 2013; Ngo, Pornpat, &
Wanne, 2011; Truong, 2015). In the Vietnamese culture, women are assumed to be the primary caregivers compared to other persons in the family. Ngo and colleagues (2011) investigated a study related to burden among caregivers of patients with schizophrenia in Thai Nguyen, Vietnam. The finding found that majority of caregivers were females (80%) and mothers had a prominent role in caregiving. In a study of Truong (2015) about caregiving for dementia patients in Ha Noi, the researcher found that more daughters offered their care for parents that sons (62.5% and 37.7%). A smaller number of husbands were taking care of their wives, compared with wives taking care of their husbands (29.3% and 70.3%) (Truong, 2015). In addition, traditionally, children have to take care of their parents, and wises/husbands have to look after their spouses. It fact, children show their love and feelings by looking after their parents when the parents are sick or unable to do things by themselves. Children taking care of a parent who has had a stroke accept this task, because taking care of parents has been accepted in Vietnamese culture as one of the prime responsibilities of the children (Meyer et al., 2015; Pham, 2011).
Hayashi and colleagues (2013) conducted a study about needs of caregivers for stroke survivors in Da Nang. They showed that the family caregivers mostly are women, including wives, daughters, and daughters-in-law. The care provided includes activities of daily living, giving medication, and providing for other needs. Most family members providing care scarcely knew how to care for the stroke patients. They are depending on the hospital or the institution in which acute care was given (Hayashi, Hoang, & Nguyen, 2013). Interestingly, the evidence in Vietnam showed that lack of home care guideline for stroke caregivers, less attention in issues supporting, and educating for caregivers before the patient is discharged from hospitals that lead to caregivers frequently lack of knowledge and skills required to provide home care for stroke patients (Hayashi, Hoang, & Nguyen, 2013). In addition, in some health care
facilities in remote areas, family members may not receive any information about caregiving at home because of insufficiently knowledgeable health care professionals.
Under such circumstances, caregivers of the stroke patients have to find their own ways to manage problems regarding the care they provide to their loved ones when they occur (Hayashi, Hoang, & Nguyen, 2013).
Overall, the number of cases of stroke is expected to increase in the near future because of the growing older population. However, stroke treatment and care in Vietnam necessitate further improvement due to hospitals' limited infrastructure and resources. As a result, stroke patients are generally discharged within one to two weeks of admission, and not surprisingly, the caregiving role is a big responsibility for family members of stroke survivors because most of them return to their homes.