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Facilitating the development of non-public healthcare in the form of public-private partnerships
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Illustrations. Photo: VNA

Viewpoints, guidelines and policies on healthcare

Man is both the target and the driving force of development. Health is the most precious asset of every person and society. The Party and State of Vietnam have paid attention to people's health protection, care and improvement. Since 1993, the Party Central Committee of the 7th Tenure issued Resolution No. 04-NQ/TW dated 14 January 1993 On urgent issues concerning people's healthcare and protection, which outlined five viewpoints (1), 3 objectives, and 7 major policies and solutions (hereinafter referred to as Resolution 04), and for the first time mentioned private healthcare, giving rise to the development of private healthcare establishments.

After the issuance of Resolution No.04, healthcare was given more concern; documents of Party Congresses from the from the 8th to the 12th tenures devoted one separated part on healthcare; the Politburo, the Secretariat issued Resolution No. 46-NQ/TW dated 23 February 2005 On people's health protection, care and improvement in the new situation and 8 Directives, 3 Conclusions, 4 Notices (hereinafter referred collectively to as Party resolutions) on people's healthcare and some concrete medical fields. In addition, some of the Party's resolutions in other fields also have direct impacts on the health sector, such as social security policy; socialization of public services; renovation of operation and financial mechanisms applicable to public non-business units.

The National Assembly, the Government, the Prime Minister and other ministries and sectors have issued a number of decrees, decisions and circulars guiding the implementation of healthcare and population laws and ordinances. So far, more than 1,500 direct and indirect legal documents regulating activities in the field of health and population have come into effect. It can be said that Vietnam has a relatively complete legal system regulating social relations in the field of healthcare and population, including those relate to healthcare socialization, public-private partnerships and facilitation of non-public health facilities.

Given a long history of people's health protection, care and improvement, the Vietnamese health system including public and private health units has been further renewed and completed towards equity, efficiency and integration, equally providing health services to people.

On 25 October 2017, the Party Central Committee Plenum promulgated 4 resolutions (No. 18, 19, 20 and 21-NQ/TW). Resolution No.19-NQ/TW On continuing renovating the organization and management system, improving quality and efficiency of public non-business units highlighted the viewpoints: "Promote socialization, especially in sectors, fields and areas where non-public sector fares well; mobilize and efficiently use all resources for investment in healthy development of the public non-business service market in the socialist-oriented market economy. Exercise transparency, accountability and non-commercialization. Ensure equity and equality between public non-business and non-public non-business agencies. One of the solutions is “continue to implement public-private partnerships in human resources and branding in the health sector; develop mechanisms for investment cooperation between public and private hospitals and between public hospitals. Make public joint-ventures, public-private partnerships, especially those units operating in domains permitted by the State; preserve and develop state capital and property."

Resolution No. 20-NQ/TW On strengthening people's health protection, care and improvement in the new situation also set out the viewpoints: "Invest in people’s health protection, care and improvement is investing in development. The State gives priority to investment from the State budget and adopts mechanisms and policies to mobilize and efficiently use resources to protect, care for and improve people's health; organize public service delivery, ensure basic services, and encourage public-private partnerships, private investment, and provide on-demand services." One of the important tasks is to "continue promoting socialization and mobilizing resources for developing the health system. Diversify forms of public-private partnerships, ensure transparency, equal competition, regardless of public or private health services. Encourage organizations and individuals to invest in building health facilities (including primary healthcare), focusing on providing high quality, and on-demand services. Non-profit medical establishments and elderly care establishments shall be entitled to tax exemption and reduction according to law."

On the status of the healthcare system

During the 1990s, Vietnam had only a system of public health units providing health services to people. Implementing the Party guidelines on encouraging and facilitating non-public health development, now Vietnam has a health system which includes public and non-public health services, in which public health sector plays the leading role, implementing tasks and areas where private health services cannot do or have less conditions for service delivery, such as preventive medicine, public health, treatment of social and fatal diseases, provision of health services en mass, or to people in mountainous, remote and disadvantaged areas; non-public health services play an additional role, serving those who can pay, and participate in primary healthcare activities.

- Public health facilities have been strengthened and improved in terms of quantity, quality and scale, ensuring the system synchronization: the number of health establishments rapidly increased from 12,884 in 1993 to 13,337 in 2005 and up to 13,725 in 2014. Implementing the policy of streamlining focal points, many inter-communal polyclinics were merged with district hospitals. The health sector now boasts 13,541 public medical examination and treatment establishments, (including more than 11,000 communal health stations) and more than 2,400 units for preventive medicine, education, communication and training. The system of public non-business health units is professionally managed from the central to local levels throughout the country and subjected to leadership and direction of local Party committees and authorities.

The grassroots health network (2) has been gradually strengthened and intensified with renewed mode of operation. Up to now, 100% of the communes have health workers, 99.4% have separate health stations (3) (the remaining 0.6% have their health facilities located jointly with other establishments); 78.5% of communal health stations have doctors; 98.2% have midwives or pediatric physicians; 74.3% of villages and people groups have health workers, (in rural areas 98% of villages have health workers), 80% of communal health stations provide health check-up and treatment to patients with medical insurance, pilot treatment of chronic diseases, such as asthma, hypertension, and diabetes, contributing to reducing referral cases and reducing costs for people. The number of preventive medicine facilities has increased; the capacity of forecasting, monitoring and preventing epidemics of preventive medicine facilities has been improved; the public hospital system has received breakthrough investment from the state budget and thus is being renovated and upgraded. The Government has given priority and provided ODA and government bonds to the health sector, implemented many new and investment policies, such as allowing hospitals to borrow capital, enter into joint ventures, invest in building new hospitals thus the number of hospital beds per 10,000 people increased from 17.9 in 2005 to 25 in 2016, basically meeting the increasing demand for medical examination and treatment of people. (4)

The non-public health facilities have made great stride, playing an important role in providing health services to people.

The number of non-public hospitals and hospital beds has increased. In 2005, there were only 36 hospitals in 9 provinces and cities with 2,538 beds. In 2014, the numbers were 169 hospitals with 11,762 beds (1.2 beds/10,000 people), 30,000 pharmacies, 35,000 general and specialized clinics, providing 43% outpatient services and 2.1% inpatient services. Some 100% foreign-invested hospitals with modern equipment have been put into operation). By June, 2018, the country had 222 private hospitals with 14,900 inpatient beds, accounting for more than 16% of the number of hospital beds nationwide. Many businesses have invested in developing private hospitals, considering it an important solution in branding large corporations. Thus a number of hospital groups has been formed, initially implementing the model of "non-profit hospital."

At present, the Government continues to issue many policies to encourage private health service development, enabling public-private partnerships to call for investment in developing the health system to meet the increasing demand of people. However, there remain constraints and limitations in the implementation of the Party and State policies on social mobilization and development of private health services, specifically:

- The implementation of policies and laws on socialization and mobilization of economic sectors to invest in health development has not yet been on par with potential, so the implementation of three strategic breakthrough is limited (currently there are only 1.4 private hospital beds per 10,000 inhabitants while the target is 5 beds per 10,000 inhabitants by 2020). Besides positive achievements, public hospitals’ implementation of socialization policy has had weaknesses, intransparency, indirectly resulting in negative phenomena, abuse of high tech and tests, collection of fees higher than service quality, increasing the cost of medical examination and treatment.

- Mechanisms and policies supporting land, capital and human resources for private health sector are still inadequate, not really encouraging the private sector to invest in the construction of medical facilities and facilities for the elderly.

- The management mechanism has still followed subsidized mechanism and has not yet been facilitating. The management agencies (due to current law) have directly intervened in many activities of the public service units which have basically been given financial autonomy at different levels (full autonomy, partial autonomy and no autonomy) and not yet fully financial and human resources autonomy. The management and administration of health establishments, especially of the public hospitals have slowly reformed and not yet kept pace with the development of the society. The capacity of managing finance, human resources, administration, services has been weak, not yet bringing into full play the potentials of high-qualified human resources.

Orientations and solutions for development of non-public healthcare

In the present period, the development of private health services is essential and consistent with the socialist-oriented market economy. However, the private health sector in our country has not yet developed in line with potential and needs of the society. So, renovation of private health service management is of decisive significance to promote private healthcare in the coming period. To continue developing private health units to help them share the burden with the public health facilities, reduce state budget allocation and provide more options for healthcare, it is necessary to strengthen the management and rectification of deviations and solve difficulties and obstacles. In the coming time, the health sector should focus on the following tasks:

First, strengthen the state management effectiveness and efficiency of people's health protection, care and improvement, in which the private health sector is an integral part of the health system in general. It is necessary to set up mechanisms, policies to encourage and create conditions for private healthcare services to develop in line with approved plans and law. In addition to guidelines, specific policies are needed to encourage, especially non-profit services and small profit businesses. In reality, healthcare is not an attractive area for investors because of its low profit and high risks. Along with incentive policies, the State needs to develop policies to support private healthcare, especially in poor areas, disadvantaged areas, at grassroots level.

Second, develop synchronously and create an equal environment to support and transfer technical expertise between public and private health facilities. Policies must be made to encourage non-profit private health facilities, such as policies on taxation, capital and land support; facilitate their full access to demand stimulus programs, especially those with specialized facilities, advanced and modern technical equipment. Non-profit health facilities in disadvantaged areas, vulnerable to potential epidemics must enjoy the State's incentive policies concerning investment on equipment, land, facilities, and human resources. Only by so doing can we limit negative aspects of private healthcare services, the tendency of profit making, and bring into play the positive aspects of private healthcare.

Third, study and perfect the system of legal documents regulating the operation of private health services. Specific regulations for private medical management include regulations on registration and licensing of practicing establishments, regulations on self-control of professional practice, regulations on verification of medical examination and treatment facilities, regulations on information and regulations on finance, among others. Attention is paid to complete documents on management of medical examination and treatment fees. Currently, private health facilities set their own fees including all costs and profit, covering also salaries and depreciation. Thus, there is a fairly large fee difference between private and public health facilities; patients in private health facilities have to pay the difference. Therefore, it is necessary to issue normative documents regulating fees for each type of service, each group of disease, floor and ceiling levels, based on the ranking of medical examination and treatment establishments. In addition, legal documents on protection of professional activities in the private health sector, regulations on dissolution and bankruptcy in investment in private health care services must be developed.

Fourth, renovate investment structure and mode of investment from the state budget, step up the socialization and mobilization of resources for development of the health system. Diversify forms of public-private partnerships, ensuring transparency and equal competition, regardless of public, private services in the provision of healthcare. Encourage organizations and individuals to invest in building health facilities (including primary healthcare), focusing on providing high level, high-tech and on-demand services.

Fifth, rearrange the organizational apparatus and network of streamlined, efficient health facilities engaging in international integration and harmoniously develop public and private health services.
Sixth, health workers in public health facilities come to work in private health facilities to transfer advanced technologies and develop a contingent of high-qualified health workers in private hospitals. Strictly punish violations, and actions which damage dignity and health of physicians; ensure security, order and safety of public and non-public health establishments.

(1) The Resolution of the 4th Plenum, 7th Tenure identified five basic viewpoints on people's health protection and care: 1. Health is the most precious asset, an important factor in the national construction and defense; 2. Proactive and active prevention; 3. Combine modern with traditional medicine; 4. Healthcare is the responsibility of the community, of each people, party committees and authorities, mass organizations and social organizations in which the health sector plays the core role; 5. "The State and people join hands" to diversify forms of healthcare, in which state healthcare plays the key role.

(2) According to Directive 06-CT/TW of the Party Secretariat, the grassroots health network includes village, commune, ward, district and town health facilities

(3) Ministry of Health Statistical Yearbook 2014

(4) The Government decided to invest VND55,061 billion in government bonds in 766 hospitals from the central to district levels and hundreds of regional polyclinics of which 610 hospitals, including 103 provincial and central hospitals, such as K Hospital, Children Hospital, Endocrine Hospital, Geriatric Hospital, Dermatology Hospital, among others, 507 district hospitals, 103 regional polyclinics have been completed and put into operation.

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This article was published in the Communist Review, No. 913 (November 2018)

Associate Professor, Nguyen Thi Kim Tien, PhDMinister of Health