فرآیندهای سیاست سلامت در ویتنام: مقایسه سه مورد مطالعات موردی بهداشت مادران Health policy processes in Vietnam: A comparison of three maternal health case studies

In the area of reproductive health, the Vietnam government has developed nationwide strategies and implemented activities to strengthen reproductive health. In particular the Ministry of Health (MOH) has developed the Reproductive Health Strategy (2001–۲۰۱۰), which addressed for the first time the issue of adolescent reproductive health and gender equality. It led to a National Safe Motherhood Plan for period 2003–۲۰۱۰ to address the continuing high rates of maternal mortality, as well as a National Master Plan of Action (2006–۲۰۱۰) and Vision (to 2020) for Adolescents and Youth to address the issue of adolescent reproductive health. The government has also, with the active involvement of the MOH, developed a law in 2008 on Domestic Violence prevention and control. Such policy is important for guiding activities in the health system, yet the processes which develop and implement such policies are not well-researched particularly in a changing society and economy such as Vietnam. Health policy processes are generally accepted as being led by government though increasingly there is recognition of the reality and importance of the involvement of actors outside both the government sector and the health system. In recent years, under the influence of factors such as globalization, health sector reform, decentralisation and the development of public-private partnerships, health policy processes have become less top down and more consultative, involving more actors and networks, and taking into account people’s understanding, values and beliefs [1,2]. Understanding how policies are developed and implemented is critical if the appropriateness and robustness of such policies is to be enhanced. This paper reports on research conducted in Vietnam on such policy processes. The research was part of a wider project,2 which aimed to enhance health policymaking processes through a comparative study of three Asian countries – Vietnam, India and China – using a casestudy approach in the field of maternal health (HEPVIC). In Vietnam the policies studied related to safe birth attendance (SBA), adolescent reproductive health (ARH) and domestic violence (DV). A conceptual framework which focuses on policy processes and their relationships with key elements—the policy content, the overall context and the actors involved (Fig. 1) is used [3]. This framework draws on a well-known way of describing the public policy process, the stages heuristic [4,5], which analyses policy processes as a series of different stages. Whilst in practice policy processes are messy and iterative, and such stages are not clearly delineated, this approach is often seen as a helpful way of analyzing the different elements [6] and in this research we focused on three key stages, agenda-setting, development and implementation. The paper describes and analyses the policy processes related to maternal health in Vietnam focusing on the differences and similarities between the three cases and possible explanations for these, taking into account the relationships between the actors, context, content and processes. Such policy processes occur against a changing context in Vietnam. In 1986 it instituted a major political reform (Doi Moi) with greater orientation to a market economy. However, despite a recent high annual economic growth rate [7], the health sector has suffered from low public funding and high out-of-pocket payments by households [8], with negative equity implications. The private health sector is playing an increasing role in providing outpatient services (32% of total visits), but still has only a very modest share of inpatient services (1.7% of visits) [9]. The numbers of qualified health staff, and their level of qualifications have increased significantly in recent years. However, the ratio of health worker/population in mountainous and remote areas remains low. The shift of health workers from the public to the private sector and from poor provinces to big cities has exacerbated the maldistribution of human resources. There is a reported a lack of doctors specialized in obstetrics and gynaecology [10]. The MOH is seeking to introduce a policy to redistribute health workers more equitably and improve the standards of service delivery. In the rest of this paper we outline the methods deployed in the research and then the key findings followed by a discussion of their significance.