I remember very vividly two of the hospitals I visited in Vietnam, during my first field trip as a global health advisor on the iDSI. In a central hospital in Hanoi, I saw an acute stroke centre that was spotlessly clean and gleaming with the latest equipment, with specialised stroke clinicians offering a range evidence-based treatments matching Western standards. In contrast, in a district hospital a mere two hours away from the capital city, I saw an elderly woman with suspected stroke who had been hospitalised for two weeks, seemingly not getting any better and not receiving any meaningful treatment (and there was no way to confirm the diagnosis as no brain imaging could be done). There was no question as to which hospital I would choose, if I could, if a relative or I were unfortunate to have a stroke.

The reality is that for most people, there is no choice – those who have the means to access the better hospitals, perhaps simply because they live closer to the city, likely get better treatment. This is unfair. Universal health coverage (UHC) is only truly universal if everyone has fair access to good quality health services, irrespective of where they live, what facilities they have access to, their education, income, religion or ethnic background.

Variation in quality is not a phenomenon unique to Vietnam, but is a reality in health systems across the world – even in relatively well-resourced and well-performing UHC systems such as the UK National Health Service. Some variation in quality may be acceptable, but one reason why unacceptable variation occurs is that there is a lack of clarity across the system about what is best practice.

Quality standards

In a bid to address this variation, NICE in the UK introduced Quality Standards (QS). QS are concise sets of statements that describe what is best practice in a given disease area (drawn from existing evidence based guidelines). For instance, what kinds of and how many antenatal checks a pregnant woman should ideally receive; sets out the practical steps required to achieve improvement, *and* most importantly quantifies the improvement. In essence, QS brings everyone together to identify the top 5 or 10 things that need improving nationally, and focus efforts towards raising standards in those areas.

Since 2012, iDSI has been working with India, China, Vietnam and recently Thailand, to develop and implement QS as ways of tackling inequalities in healthcare quality, and to raise overall standards in key areas such as antenatal and maternal health, non-communicable diseases (stroke, hypertension, and diabetes), and antimicrobial resistance. We have drawn on our UK and international experience to create resources section of the site and on our new iDSI Knowledge Gateway.

Thailand, long seen as a success story of UHC, also recognises unacceptable variation in quality among public healthcare providers. In particular, there is now a push to raise and standardise quality in health promotion and disease prevention, beginning with QS in antenatal care. I was privileged to be invited as an international expert to observe and advise on this process. The discussions I heard among policymakers, clinicians and grassroots health volunteers were so rich that I can already anticipate insights and lessons that will go into the next version of the QS guide.

The enthusiasm and expertise of the stroke clinicians I met in the central hospital in Vietnam was unquestionable; the challenge is to sustain those excellent standards of practice and to ensure that all healthcare services across a country can reach those standards. iDSI’s vision is that everyone has fair access to quality healthcare, and we hope that our efforts in introducing and localising the QS model is a small step in the right direction.

Better policymaking for universal health coverage (UHC) requires different actors in the health system to have the right capacities to generate and use evidence. Led by HITAP, in Vietnam iDSI has been supporting the Health Strategy and Policy Institute (HSPI), a technical unit under the Ministry of Health, to build capacity for generating policy-relevant health economic evidence. Through 2016 we have supported HSPI to provide advice to Ministry of Health on reviewing its Basic Health Services Package, identifying high-cost interventions that are inappropriate or poor value for money among the 17,000 drugs and services currently reimbursed by Vietnam Social Security (VSS), the implementing agency for Vietnam’s social health insurance scheme.

As this work draws to a close in January 2017, HITAP and Imperial College visited Hanoi to plan the next phase of iDSI activities with HSPI. iDSI is now also engaging with VSS to explore practical ways of issuing a revised benefit package (based on both clinical and cost-effectiveness evidence) as a national healthcare payer, in order to achieve efficient, fair and high quality UHC.

Dr Netnapis Suchonwanich, Adviser, HITAP (former Deputy Secretary General of National Health Security Office) shares the Thai experience of implementing efficient UHC

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

The workshop focused on developing Quality Standards and indicators for AMR. It was jointly organised by the Department of Medical Services Administration (MSA) of the Ministry of Health and the National Hospital for Tropical Diseases and attendees included members of the AMR subcommittee programme as well as representatives from relevant MoH institutes and universities.

A  plan for developing standards to improve AMR management in hospitals in Vietnam has now been drawn up and will be operationalized with relevant partners over the next 12 months.

Dr Cluzeau with AMR workshop participants

NICE International staff and representatives from the British Medical Journal Technology Assessment Group (BMJ-TAG) presented on topics including:

• an overview of NICE, its functions, core principles and practices,
• the nature of and the methods underlying HTA,
• NICE International’s work demonstrating the application of HTA in a Vietnamese setting,
• the role and work of those contracted to conduct HTA for NICE.

The event was well received, particularly with respect to HTA’s workings, application, and regulation. A one-to-one discussion between Professor Phạm Lê Tuấn and Kalipso Chalkidou yielded an agreement for NICE International to continue its collaboration with Vietnam under the international Decision Support Initiative (iDSI), specifically developing Quality Standards on Antimicrobial Resistance.

July 2014

NICE International was pleased to host a delegation from the Vietnamese central and provincial governments as part of the EU-funded Health Sector Capacity Support Project. The delegation consisted of members of the Ministry of Finance, Ministry of Planning and Investment, and representatives from the health services departments in the Bac Ninh, Bac Giang, and Ha Nam provinces. Vietnam is proposing substantial health reform over the coming years and the delegates learnt about the role of NICE in the NHS and also the importance of primary care to delivering high quality, efficient and equitable services.  Representatives from Monitor and the London Procurement Partnership also addressed the delegation providing invaluable insights into the regulation of hospitals and procurement mechanisms in the NHS. NICE International is currently working with the Vietnamese Ministry of Health on a series of in-country projects, and this visit highlighted the importance of engaging across government departments and on a central and provincial level.

Health Minister Madame Tien visits NICE

October 2013

In the second visit to NICE by the Ministry of Health, Vietnam, Health Minister Madame Tien led the delegation and learned about the role of GPs and primary care in the NHS from Dr Maggie Helliwell, the Vice Chair of NICE and a GP. Primary care will be an important part of Vietnam’s healthcare reform strategy. The Ministry of Health and NICE engaged in dialogue about opportunities to strengthen our ongoing collaboration (in quality improvement and HTA capacity-building) into a long-term partnership covering broad strategic areas, to create sustainable institutions that deliver improved health for the population of Vietnam.

Vietnamese Ministry of Health visits NICE

July 2013

A delegation from the Ministry of Health of Vietnam and affiliated organisations, led by the Vice Minister for Health, Madame Xuyen spent five days with NICE to help inform the Ministry’s strategy for quality improvement.

The group learnt about the structure of the NHS, NICE HTA processes, the development and Implementation of guidelines, Quality Standards including pay for performance schemes and the role and structure of Primary Care in the UK. They visited the Health and Social CareInformation Centre and the stroke Unit at St Thomas’ hospital in London. The Study Tour was funded by the Joint Learning Fund. Summarising her experience of the Study Tour Madame Xuyen said: “this is one of the most interesting and useful trip they have ever participated in.

The group has met twice bringing together participants including;

• senior individuals and advisors from Colombia, Ghana, Philippines, Thailand and Vietnam health ministries
• executives from Eli Lilly, GlaxoSmithKline and Janssen Pharmaceuticals (Johnson & Johnson)
• priority-setting experts from NICE International, the Health Intervention and Technology Assessment Program and the Center for Global Development.

As a result of the discussions, the group drafted a set of principles which could form the starting point of future collaborations between industry and policy makers in LMICs.

 Hanoi stakeholder meeting

On 22 April 2015, the Vietnamese Ministry of Health hosted the multi-stakeholder high level Groundwork meeting, in Hanoi. The meeting brought together the Groundwork participants, ministers, academics, donors, and representatives from Indonesia and Singapore. The objective of the meeting was to present the principles developed as part of the Groundwork project to key stakeholders involved in healthcare priority-setting and discuss areas for future collaboration.

Professor Pham Le Tuan, Vietnamese Vice-Minister of Health, gave an opening address, welcoming the participants to Vietnam and highlighted the importance of the Groundwork project.

Sir Andrew Witty, CEO of GlaxoSmithKline (GSK), gave a talk during which he expressed GSK’s support of the Groundwork project and highlighted the importance of building a trusting relationship with policy makers from LMICs.

Sir Andrew Dillon, Chief Executive of NICE, chaired a panel of representatives from:

• Ministries of Health, Professor Pham Le Tuan,
• Vice Minister of Health, Vietnam, Dr Victor Asare,
• Deputy Minister  of Health, Ghana and
• Dr Siswit Titarado, Chief Advisor to Public Health Minister, Thailand,

All conveyed their support of the of the Groundwork project and the draft principles.

The principles will be finalised and published by Meteos in the coming months, following a final consultation with the Groundwork participants.

April 2015

NICE International coordinated two events in Hanoi on health benefits package design in partnership with the Health Strategy and Policy Institute and the Vietnamese Health Economics Association.

A health benefits package is the range of technologies and services that are available at a free or subsidised rate to the insured population, and the methods, processes and policies that contribute to its design and inclusions or exclusions are central to achieving and maintaining universal health insurance coverage. The events included a meeting to share international experiences of decision making for health entitlements and benefits package design, and a workshop focusing on the status and future direction for benefits package design in Vietnam.

The events were opened by Professor Pharm Le Tuan, Deputy Minister of Health who advised of the importance of the role of a high quality, nationally accessible and affordable benefits package as Vietnam moves towards Universal Health Coverage. Dr Tran Thi Mai Oanh, Director of the Health Strategy and Policy Institute and Dr Kalipso Chalkidou, Director of NICE International endorsed the Deputy Minister’s comments and highlighted the beneficial role of continuing partnership and joint working between Vietnamese institutions and iDSI

Sir Andrew Dillon of NICE, UK and Dr Yot Teerawattananon of the Health Intervention and Technology Assessment Programme (HITAP), Thailand shared the experience of their country’s approach to determining access to technologies and services.  They were joined by Ursula Giedeon of the Inter-American Development Bank on an international panel who discussed initiatives in different South American countries to establish explicit benefits packages.

Attendees also benefited from hearing experience from Dr Sastroasmoro and Dr Gyansa-Lutterodt who shared early experiences of health technology assessment and benefits package design in Indonesia and Ghana.

At the workshop Amanda Glassman of the Center for Global Development presented a comprehensive overview of key themes in benefits package design and explained how a methodological and strategic approach can optimise health outcomes from within limited resources available for health. The diversity of international experiences provided useful insight into potential opportunities and challenges facing policy makers in Vietnam and was a valuable input to the strategic direction of the Vietnamese benefits package.

Developing capacity for HTA and quality improvement initiatives are key areas where NICE International and HITAP are working with colleagues in the Ministry of Health and supporting institutions in Vietnam.  The benefits package workshop showcased pilot HTAs conducted by technical teams, showing how the information produced through HTA can be a valuable input to benefits package design. Highlighting the importance of the quality component to services patients receive as part of a benefits package, recent work to adapt Quality Standards used in the English National Health Service to the Vietnamese context were also presented and discussed.

Importantly, the events facilitated discussion by local policy makers and stakeholders on the institutional arrangements and strategic direction for benefits package design. Presentations from the Department of Planning and Finance in the Ministry of Health and Vietnamese Social Security in addition to an overview of the status of social health insurance by the World Bank Vietnam office provided a comprehensive overview of the underlying needs and current status of benefits package design and enabled attendees to generate key areas of recommendation for work going forward. Recommendation areas included the need for analytical and administrative capacity development, established process and evidence generation and use, and a focus on communication and implementation activities. Dr Duong Huy Lieu, Chairman of the Vietnamese Health Economics Association closed the events reiterating the importance maintaining the momentum for benefits package reform in Vietnam and continuing dialogue between all major stakeholders.

The meeting and workshop brought together departments of the Vietnamese Ministry of Health, Vietnamese Social Security (the state insurer), local clinicians and academic institutions, policy makers from around the world and international experts in benefits package design.

The events were supported by the Rockefeller Foundation and were part of NICE International’s long-term partnership with the Ministry of Health of Vietnam on their journey towards achieving Universal Health Coverage (UHC).

NICE International supports Vietnamese colleagues in Health Technology Assessment capacity building

July 2014

NICE International staff joined the Health Intervention and Technology Assessment Program (HITAP), Thailand, in the delivery of a week-long training course on health technology assessment in Hanoi, Vietnam. The in depth course covered fundamental aspects of the conduct of health technology assessment including searching for and synthesising evidence, health state evaluation, costing methods and decision rules. The course participants were from the various institutions in Hanoi that are currently engaged in some form of economic evaluation and is part of a wider Rockefeller Foundation-funded initiative to use the results of health technology assessment to informing priority setting and health policy in Vietnam.

Support for basic package design

November 2013

NICE International completed the first phase of its programme to support the design of the basic package of healthcare subsidised at Vietnamese health facilities. This included interviews and group discussions to outline current mechanisms for basic package design and targeted training events in collaboration with the Health Interventions and Technology Assessment Program (HITAP), Thailand.

The “Principles of HTA” training event, held at Hanoi Medical University, targeted researchers and policymakers who will be conducting economic evaluations. The event attracted 40 attendees from universities, the Ministry of Health, and affiliated research institutions. 80% of attendees felt confident or very confident that they could apply the training to their current work.

The “HTA in Policy” training event was held at Hanoi School of Public Health, and primarily targeted policymakers interested in how HTA can inform priority-setting decisions in health. This event featured theoretical approaches to basic package design, and experiences of how HTA is used for priority-setting in the UK and Thailand

HTA in Vietnam conference

Hanoi Medical University and VHEA hosted a conference on HTA in Hanoi on 15 – 16 November. The conference provided a forum for senior Ministry of Health policymakers , healthcare professionals and researchers from across Vietnam, and international partners to discuss current research and HTA developments in Vietnam. NICE International and partners delivered presentations on experiences from the Technology Appraisals programme and incorporation of health economic evidence in NICE Clinical Guidelines, and chaired panels on addressing the challenges to institutionalising HTA in Vietnam.

 Groundwork project

for more information on the Groundwork project, please click here