reasonable low birth rate, reproductive health care for youth and minors, protection and development of ethnic groups at risk of racial degradation [26].
In the coming period, the health sector will continue to develop and submit to the National Assembly legal documents to increase resources and provide guidance for health activities in general and for health insurance in particular. Submit to the National Assembly for approval the Law amending and supplementing a number of articles of the Law on Health Insurance; Submit to the National Assembly for comments on the draft Law amending and supplementing a number of articles of the 2005 Law on Pharmacy, the Law on Blood and Stem Cells, the Law on Population, the Law on Prevention and Control of Harmful Effects of Alcohol Abuse. Complete the draft Decrees guiding the Laws issued in 2014, the Circulars guiding the implementation of the Decrees, especially the Circulars guiding the implementation of Decree 85, the Circular on the list of drugs and technical services covered by health insurance, the Circular guiding referrals in the field of medical examination and treatment, referrals under health insurance.
1.2.5. Socialization, inter-sectoral coordination and international cooperation
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Mobilize widely all sectors, socio-political organizations, and communities to participate in communication, education, and provision of population and reproductive health services. Develop and implement a roadmap to gradually reduce the level of state subsidies. Gradually shift the method of payment for population and reproductive health services from funding service providers to payment through intermediaries. Strengthen international cooperation, proactively participate in international organizations and programs on population and reproductive health; actively seek financial, technical, and experience assistance from other countries and international organizations [26].
According to the Department of Medical Examination and Treatment Management, there are currently 170 private hospitals nationwide with 8,627 beds, accounting for 11% of the total number of hospitals nationwide, more than 30,000 private clinics and medical service facilities. The rate of private hospital beds accounts for 4.2% of the total number of hospital beds, reaching about 1 bed/10,000 people [10]. Most of these hospitals have quite good facilities and equipment; dedicated and attentive medical staff. The development of private hospitals will contribute greatly to increasing the number of hospital beds and the capacity to meet the medical examination and treatment needs of the people. However, the results of inspection and supervision also show that there are still some limitations in the implementation of the socialization policy. Some units have not followed the correct procedures and processes such as: not developing a project, not discussing publicly and democratically, not reporting to the superior management agency for monitoring and management; Some units have not yet developed a service price structure according to regulations, and have not yet made prices public for people to know and choose; some units tend to find many ways to increase revenue, which can easily lead to the abuse of techniques, drugs, tests, and low service efficiency; the arrangement of examination rooms and treatment areas on demand is not reasonable, leading to patients feeling discriminated against and not feeling secure about the transparency between public and private sectors in medical examination and treatment on demand. There are not many private hospitals with brands, so the rate of medical examination and treatment in this sector is still very low, accounting for only nearly 7% of outpatient treatment and 6% of inpatient treatment; 56.9% of hospitals have a bed occupancy rate of less than 60% [5]. In particular, private hospitals only serve about less than 4% of health insurance examinations [8].
1.2.6. Finance
It is necessary to increase investment from the state budget; promote the diversification of investment sources from the community, businesses and private sector for population work, control of gender imbalance at birth, and reproductive health care. The state budget ensures to meet the essential needs of population work,
CSSKSS and policy implementation for subjects paid by the State [21]. In the period 2001-2008, the total investment capital for population and family planning work was 4,428 billion VND, an average of 554 billion VND per year (including central and local state budgets, foreign aid loans, development investment capital, including capital for basic construction investment and career capital). In particular, many localities with difficulties in balancing revenue and expenditure have also added local budgets to invest in faster implementation of population and family planning policy goals in the area [19].
Prioritize investment of resources in densely populated areas with high birth rates, mountainous areas, remote areas, areas with many difficulties, high birth rates, low education rates and the poor, adolescents and young people, in order to improve the quality of health care, especially reproductive health care, to reduce birth rates. Develop a Population-Reproductive Health Strategy for the 2011-2020 period as a basis for planning socio-economic development, investing enough funds, equipment, facilities and conditions to ensure good implementation of national target programs, approved projects and plans on population and family planning for the period up to 2010 and after 2020 [26].
The implementation of financial autonomy of public units is difficult if there is not enough financial balance. The budget allocated to hospitals for autonomy mostly does not cover the human cost. Meanwhile, the current hospital fee framework for 447 new services only includes 3/7 components of service prices. It is planned to add human resources and wages to service prices in 2015, and fully include all components in 2018.
Many provinces approve prices for many services much lower than the service price frame (60-70%) even though the price frame has been calculated relatively close to reality, so the more the hospital implements, the more it has to compensate for losses.
1.2.7. Training, scientific research and data information
Strengthen training and coaching on management and professional skills for staff working in the field of reproductive health care based on planning and technical decentralization, with standardized programs, content and documents. Prioritize the completion of intermediate-level training in population and health for commune-level population and family planning staff; training midwives in villages and hamlets in disadvantaged areas; training in prenatal and newborn screening techniques. Gradually implement specialized training, university and postgraduate training in population, obstetrics, pediatrics and geriatrics. Strengthen scientific research activities, disseminate and apply scientific, technological and technical research results on population, control of gender imbalance at birth, and reproductive health [26].
In order for training interventions to be as effective as expected, it is necessary to avoid potential limitations in the design and implementation process. Accordingly, retraining for service providers is limited due to being too theoretical and not focusing on practice; training materials compiled by the project do not follow or are not consistent with the “standard documents” of the Ministry of Health; in addition, there are limitations in post-training supervision.
The number of medical personnel of all kinds has increased over the years, reaching 7.5 doctors per 10,000 people and 2.01 university pharmacists per 10,000 people. The number of human resources at the district and commune levels has also improved, in 2013, 76.9% of commune health stations had doctors working [5]. The Ministry of Health continues to implement solutions to improve the quality of human resources. The number of training facilities and the training scale of schools continue to increase. Policies to manage and improve the quality of human resources are being implemented, such as granting practice certificates and developing competency standards. A number of policies have been issued and implemented to strengthen the capacity of lower levels and allocate medical human resources reasonably among regions and specialties.
Departments such as Project 1816 (time-limited rotation) and Satellite Hospital Project with technology transfer activities; Project to encourage training and development of medical human resources in some specialties lacking human resources; Pilot project to send young volunteer doctors to work in mountainous areas.
The population and reproductive health strategy for the 2011-2020 period clearly stated the need to improve the quality of collection and processing of information and data on population and reproductive health based on the application of information technology and the completion of the system of indicators and targets; provide complete, accurate and timely information and data to serve the direction, administration and management of population work, control of gender imbalance at birth, and reproductive health care at all levels [26].
The master plan for information system development for the period 2014-2020 with a vision to 2030 was issued under Decision No. 3040/QD-BYT dated August 14, 2014, with the general goal that by 2020, the health information system will contribute to improving people's health, equitably distributing resources, reforming the health sector, improving management capacity, monitoring and evaluating health policies, and strengthening public administrative reform.
1.3. Some information about the research area
1.3.1. General situation
Quang Ninh is located in the Northeast of Vietnam, with a geographical location from 20 to 21.4 North latitude, 106 to 108 East longitude, 145 km northeast of Hanoi. With diverse terrain including mountainous, midland and coastal areas; Quang Ninh has 14 administrative units; including: 4 cities (Ha Long, Uong Bi, Cam Pha, Mong Cai); Quang Yen town, 8 mainland districts and one island district with 186 communes, wards and towns, including 6 border communes. The province is located in a tropical monsoon climate zone, hot and humid [47].
There are 51 ethnic groups in the province, of which the Kinh ethnic group accounts for the majority (88.37%), the rest are ethnic minorities, the largest being the Dao ethnic group: accounting for 5.17%; the Tay ethnic group accounts for 3.06% and the Nung ethnic group: accounting for 0.11%...[47].
The average population of Quang Ninh in 2012 was 1,179,666 people, accounting for 1.34% of the national population. In the period 2000-2012, the population growth rate of the province was 1.24%/year, higher than the average growth rate of the whole country (1.14%/year). The average life expectancy of the province in 2012 was 73.6, higher than the average life expectancy of the whole country. The average population density of the province is 190 people/km2, the population distribution is uneven, the population is mainly concentrated in low-lying districts and inland. The population structure of the province is a golden population structure with 796 thousand people of working age (15-59 years old), accounting for 68% of the population [47].
Economically, Quang Ninh has always been one of the localities with a high GDP growth rate compared to the whole country. The economic growth rate in 2012 reached 7.4%, higher than the national average (5.2%) [47].
Along with the general economic and social development in the whole province, the Quang Ninh Health sector has made many positive contributions to improving the health status of the people. Many health indicators of the population in the province have been achieved at a higher level than the average of the Red River Delta and the whole country: the number of doctors/10,000 people: 9 (the national average is 7.4), 100% of villages/hamlets have active village health workers (the whole country: 87%); 96% of children under 1 year old are fully vaccinated (the whole country: 95%); maternal mortality rate 65/100,000 (the whole country: 64/100,000); infant mortality rate under 1 year old: 10.7/1000 (the whole country: 15/1000); infant mortality rate under 5 years old: 13.8/1000 (the whole country: 22/1000)... [47]. However, there are still some targets that have not been achieved compared to the whole country: 72% of health stations have doctors working (74% nationwide); 22.04% of commune health stations meet national criteria on health (45% nationwide); Population growth rate: 1.29% (1.03% nationwide) or Gender ratio when
Birth rate: 115 boys/100 girls (nationwide 112.3 boys/100 girls, Red River Delta 122.4)
boys/100 girls).
In addition to the achievements, the Quang Ninh health system is still facing many difficulties and challenges such as: Overload due to increasing medical demand, especially in provincial hospitals. The bed occupancy rate is always >100%, leading to the situation of 2-3 patients having to share a hospital bed. Medical facilities in the province are currently lacking in facilities and medical equipment suitable for research and application of advanced techniques. In mountainous districts, remote areas, and islands, ambulance services are still limited. The population continues to increase, the quality of the population is still limited. The disease structure is clearly changing, the need for health protection of the people is increasing, especially medical examination and treatment, health check-ups on demand, high-quality medical examination and treatment in the context that some provincial and district hospitals have not met the requirements in terms of technology and facilities. Low income and the difference in living standards between population groups are posing major challenges in ensuring fairness in medical examination and treatment. Although planning has been focused on, it has not achieved uniformity and unity. The health system has been innovated but has not yet adapted to the development of the market economy. Health sector development policies have been implemented in many aspects but have not achieved uniformity. The plan for training and fostering human resources for primary health care has not been closely linked to the needs of use. The quality of medical staff is still limited compared to service requirements. Primary health care lacks the conditions to carry out activities, especially the lack of highly qualified human resources and facilities. On the other hand, the model of health organization at the grassroots level is not unified, causing many difficulties and inadequacies in organizing and implementing professional activities. State policy mechanism
and of the province are not complete and slow to innovate, not strong enough to attract a team of medical staff with high professional qualifications, deep expertise in key specialties and staff working in some specific fields. Due to the lack of coordination mechanism, the effectiveness of health care activities has not been as expected [47].
1.3.2. Reproductive health care
In Quang Ninh, the work of reproductive health care in the province is increasingly focused. The province's orientation on reproductive health care is to prioritize the main contents: Focus on further reducing the rate of maternal and child mortality, prioritizing mountainous areas, remote areas to narrow the gap between regions. Improve the nutritional status of mothers and children, reduce the rate of malnutrition in children, control the increase in overweight and obesity in children. Gradually improve the quality of reproductive health care services, fully meet the family planning needs of all subjects, not only to control population growth but also to create conditions for women to increase birth spacing. Significantly reduce unwanted pregnancies, basically eliminate unsafe abortions. Better prevent and control reproductive tract infections including HIV, promote prevention of HIV transmission from mother to child; Improve sexual and reproductive health of adolescents, young people, men, the elderly and other specific groups such as migrants, people with disabilities, people with HIV; proactively prevent and treat cervical cancer and breast cancer early; increase access to prevention and treatment of infertility... [47].
In addition to strengthening and improving the capacity of the obstetrics and pediatrics departments of the district general hospital, the reproductive health care department of the district health center; improving the quality of services at commune health stations, it is necessary to continue investing in strengthening the capacity (expertise, facilities) of district-level hospitals; at the same time, improving the quality of services at commune health stations.