We visited five different types of primary care health clinics, one in central Hanoi and four in the provinces and villages. They were immaculately clean, reasonably well-appointed facilities – with good basic equipment including simple laboratory machines, ultrasound, x-ray, slit lamps, dental chairs, small pharmacies, a room for traditional medicine, herbs and acupuncture and rooms for minor injuries and minor surgery – and appeared to be reasonably staffed by passionate and dedicated workers.

However, there were very few patients in evidence, in marked contrast to my practice in Keighley (northern England) serving a similar population. They were seeing 50 people a week where I was seeing up to 30-60 a day with my partners, and a large team seeing 30 people a day each in up to 10 different rooms. This contrast was stark. The staff were absolutely passionate and knowledgeable at the changes they perceived needing to be made – they knew that with the right support they could offer a good service to their population and talked to us about their understanding of the obstacles in their way. One is that home visits are not covered by health insurance, which is a great barrier in managing their increasing ageing population. Currently the Vietnamese population can opt out of family medicine clinics and chronic disease management, and use their health insurance on a symptom-by-symptom presentation at the hospital and the majority choose to exercise that right.

Proforma for patient referrals from primary care, at a primary healthcare pilot site in Khanh Hoa province

The doctors were all requesting better methods of communication and record keeping – very often there was no computer or only one computer which was used for health insurance management.. They did understand about paper record keeping and had excellent proformas, and used email and mobiles to communicate with their hospital counterparts, but they all felt this could be improved.

Dr Yongyuth Pongsupap (National Health Security Office, Thailand) sharing the lessons from Thailand on ‘matrix’ team working between district hospitals, village health centres, and families, for effective primary care

The week led up to a day long workshop chaired by the Vice Minister of Health, Prof Pham Le Tuan, and convened by the Health Strategy and Policy Institute (HSPI). We made our presentations and then heard from the Vietnamese delegates. The floor was then opened to all for discussion, and delegate after delegate got up and spoke about their perceptions and their solutions. There were multiple points of view and a lively debate, but the Vice Minister made it clear that primary care is going to be developed, that there were potentially many solutions, they knew they had to modify the health insurance system as a lever for progression, and that it would take time. Vietnam is already trying pilots of new primary care in some provinces, and I advised them to evaluate those pilots properly before proceeding to the next steps, something we are not very good at in England.

Discussion chaired by Prof Pham Le Tuan (Vice Minister of Health), Mr Nguyen Minh Thao (Deputy Director of Vietnam Social Security), and Dr Maggie Helliwell

The week culminated in a dinner with the Vice Minister in an outdoors restaurant overlooking the bay in Nha Trang. The dinner reflected the healthy Vietnamese diet I had experienced all week. A great deal of fresh fish and shellfish, and some meat accompanied by fresh vegetables and noodles or rice, followed by chunks of beautiful fresh fruit, watermelon and pineapple. A satisfying end to a very interesting and illuminating week.

One morning early in 2016, an email popped into my inbox from NICE International: Would I like to go to Vietnam in March to help the Ministry of Health develop their primary care strategy? At first I had to say no as the original dates clashed with my long booked annual cross-country skiing trip, but dates were changed and 48 hours after skiing across a Norwegian plateau I was on a plane to Hanoi.

My first impression was that it was a little cooler than I expected – though it never reached the minus 10 degrees of central Norway – and that Vietnam has a whole lot of mopeds and noodles. I had been sent a large file of excellent background reading by Ryan Li, my indefatigable NICE International associate and I instantly understood why road traffic accidents are the greatest cause of death in Vietnam. Driving was dangerous but exciting. I witnessed 2 accidents in my first 2 hours and was nearly involved in a third later that evening. The mopeds were 10 deep and 3 abreast at every intersection and entry to a ‘roundabout’, except there were no roundabouts. The mopeds wove in and out of each other at speed. There were sometimes 3 to a moped and children were carried, without helmets in front of, between or clung on tightly behind 2 adults. The mopeds took short cuts across dual carriageways and also travelled the wrong way on those same carriageways. They carried people, smart female office workers going to work in short skirts and high heels, families, and wave after wave of male workers.  They carried produce, fruit, vegetables, flowers, fodder, huge vases strapped precariously to each side and even large panes of glass carried tightly between the driver and the passenger. They passed multiple shops with rows of mopeds on display out front and carousels of helmets of all shapes, types and genders (pink helmet anyone)? The mopeds were continually honked at by the cars as the taxis were also weaving in and out of the lanes. The honking was continuous and appeared to act as immediate warning of potential danger  or semi-courtesy of presence. My trip to the airport on my final day was coloured by the taxi driver obviously having a loud ‘domestic dispute’ using 2 handheld mobiles simultaneously and accompanied by loud female tirades. I arrived OK!

Different kinds of passengers. Photo by Ryan Li.

The Vietnamese Ministry of Health wants to develop their primary care. Primary care has been a poor relation of hospital-based specialist care for many years. Only 70% of the population is covered by any variety of health insurance, many people can ill afford to pay for any healthcare.  People who are covered, though they often have to add co-payments, can use their health insurance at any centre within their province. They perceive that the quality of the health care in their commune is poor, and as the investment has been skewed towards specialisms they are probably correct. Though the government is trying to rectify this, the prevailing cultural perception is against primary care as a reliable resource. As a result people flock to hospitals as their primary source of help and the queues and the inappropriate use of those resources is compounding the problem. There is also a larger proportion of private healthcare than in England for those that can afford it.

Crowds at a provincial hospital in Vietnam. Photo by Ryan Li.

This situation is also not helped by the tensions in status between hospital and primary care. The specialism and philosophy of family medicine and the potential of primary care is currently poorly recognised. The training is very short by English standards and almost entirely hospital and lecture based. We met a pioneering Professor of Family Medicine from Hanoi Medical University who was passionate about developing the family doctors that Vietnam needs and she was hoping that she will be given the support to carry out her plans. In England 90% of daily work within the NHS is carried out in primary care for 9% of the NHS budget. In Vietnam the ratio is probably reversed.

Continued in Part 2

Cuba’s reputation for producing dedicated health workers who are prepared to work in difficult or remote health contexts is well known and was profiled by Jose Luis de Fabio, Director of the Pan American Health Organisation in Cuba. Since the 1970s Cuba has been a major producer of health workers with a commitment to international solidarity in health and provides doctors to countries facing severe shortages of health workers. The selection process for entry to Cuban medical education focuses on social skills and competencies as much as academic ability which has helped overcome the mal-distribution of health workers, common in most countries, which leave major  gaps in service provision for poor and marginalised populations.

But perhaps the Cuban experience is not all it seems.  Jimmy Volmink, Dean of the Medical School of Stellenbosch University in South Africa laid out the advantages and disadvantages of a long-standing scheme that trains African students in Cuba with the aim of providing doctors for rural areas. Volmink highlighted the culture shock that awaits rural black African students in Cuba, the language problems, the lack of internet to enable easy communication with relatives back home, and problems of re-integration with South African trained students when they return home for ‘top-up’ courses on malaria,   HIV/AIDS, neonatal infections – preventable diseases that are not common in Cuba.  One returning student said: “if you buy a cat, don’t expect it to bark!”  The culture shock and the process of adaptation experienced by these students may be essential components that makes the Cuban approach so powerful.  Incubating Cuban approaches within Africa – a potentially more logical and less disruptive plan – but without the experience in Cuba may not work so well.

These optimistic and pessimistic views of the transferability and utility of Cuban medical education arise because of different contexts and ways of implementing the Cuban approach – which is very flexible and is modifiable depending on the resources available.  All systems of medical education produce ‘pluri-potential’ doctors who may become family doctors, eye surgeons or psychiatrists. So the cat-dog analogy doesn’t work for me.  Neil Squires, Deputy Director, Public Health England, asked whether the global shortage of family doctors and an imperative for universal health care, would leverage medical schools to focus their core curriculum on graduating functional family doctors.  John Ashton, President of the Faculty of Public Health, described such a scheme operating in the rural mid-west states of USA.

Jim Campbell, Director of WHO’s Health Workforce Department, described the WHO Initiative on transforming and scaling up health professionals’ education and training which has compiled regional case studies.  These provide a substantial evidence base from which to work.  WHO’s commitment to universal health coverage and the new sustainability development goals that will do away with targets, replacing them, for example, with zero acceptance of neonatal and maternal deaths and 100% access to primary care provide compelling reasons for solving the primary care workforce crisis.  The massive growth in health care in high income countries is likely to suck markedly large flows of doctors from low income countries.[Crisp & Chen, 2014] Global action to create primary care doctors and community health workers on an industrial scale is needed now to offset workforce crises in primary care, which in turn provide fertile soil for epidemics of preventable communicable and chronic diseases.

Evaluations of the Cuban model have been conducted in the past but questions of selection of students, training of faculty, competences at graduation, impact on distribution and retention of doctors in disadvantaged and rural communities need to be answered to provide better evidence for policy making.  A DfID funded policy programme grant has been awarded to support Cuban, African and UK collaborative research on the Cuban approach.  In the UK, NICE International, Public Health England and LSHTM are involved.  The research aims to answer these questions:

• Does the Cuban system of medical education result in more equitable distributions of doctors? And in stronger retention of doctors in rural and disadvantaged communities?
• Are doctors trained in the Cuban model equipped with an appropriate set of skills and competencies for primary care? Are they better equipped than doctors trained in conventional ways?
• What lessons can we learn for health professional capacity building from a development perspective? And what can we learn for the NHS here in England?

Medical schools should be capable of assimilating and retaining the lessons learned over the last 40 years: redesigning selection processes to improve access for disadvantaged students; early and long-term contact with patients and their families; shifting teaching into primary care; integrated core training of doctors, nurses and other health professionals. [Frenk et al, 2010]  General Medical Councils may make accreditation more difficult for highly innovative education but they are not the barrier.  Deans of medical schools have more room for initiating change as demonstrated by the Training for Health Equity network (THEnet) and other networks, one of them arising in Africa,  the Consortium of New Southern African Medical Schools.  Once again we have to “turn the world upside down”, asking rich countries to learn these lessons from Cuban medical schools which show how doctors with vision, resilience, relevant competencies and the motivation to work with the most disadvantaged people can be created.

Prof Shah Ebrahim, Honorary Professor of Public Health at LSHTM, is collaborating with NICE International, Public Health England, PAHO and the Cuban Ministry of Health on the DfID-supported project on Cuban medical education model for Africa.

References

Nigel Crisp, Lincoln Chen. Global supply of Health Professionals. N Engl J Med 2014;370:950-7

Julio Frenk, Lincoln Chen, Zulfiqar A Bhutta, Jordan Cohen, Nigel Crisp et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet 2010;376:1923–58