Stakeholder perceptions of a total market approach to family planning in Viet Nam

Abstract

Abstract

Viet Nam has high modern contraceptive prevalence (68%), with most services received through the public sector. As the country transitions to middle-income status, Viet Nam's donors have ceased donations of contraceptive supplies, causing a large projected shortfall in the family planning budget. In response, the Ministry of Health has decided to prioritize free or subsidized contraceptives for poor and vulnerable groups, while enhancing social marketing and sales of contraceptives in the free market. To support planning for this “total market approach”, a descriptive exploratory study was conducted with 38 public and private sector family planning stakeholders to gain their perceptions of the proposals. There was a high level of support for government leadership of public-private coordination and stewardship of the entire family planning system. Key information gaps were identified regarding how the reforms can promote equitable access to family planning and financial sustainability in pricing. The government's experience with this transition may yield valuable guidance for other settings.

Résumé

Le Viet Nam connaît une prévalence élevée de contraceptifs modernes (68%), la plupart des services étant assurés par le secteur public. Alors qu'il passe à un statut de pays à revenu intermédiaire, ses donateurs ont cessé les dons de contraceptifs, ce qui a causé un vaste déficit dans les projections budgétaires de la planification familiale. Pour y répondre, le Ministère de la Santé a décidé d'accorder la priorité aux préservatifs gratuits ou subventionnés pour les groupes pauvres ou vulnérables, tout en renforçant le marketing social et la vente de contraceptifs sur le marché libre. Pour soutenir la planification de cette « approche globale du marché », une étude exploratoire descriptive a été réalisée auprès de 38 acteurs de la planification familiale du secteur public et privé pour savoir ce qu'ils pensaient des propositions. On a constaté un degré élevé de soutien pour le leadership gouvernemental de la coordination du secteur public-privé et l'administration générale de l'ensemble du système de planification familiale. Des carences essentielles en information ont été identifiées sur la façon dont les réformes peuvent promouvoir un accès équitable à la planification familiale et la viabilité financière des prix pratiqués. L'expérience du Gouvernement dans cette transition peut procurer des enseignements précieux pour d'autres pays.

Resumen

En Vietnam existe una alta prevalencia (el 68%) de uso de anticonceptivos modernos; la mayoría de los servicios son recibidos por medio del sector público. Según el país se acerca al estatus de ingreso medio, los donantes de Vietnam han dejado de donar anticonceptivos, lo cual ha causado un gran déficit previsto en el presupuesto de planificación familiar. Por consiguiente, el Ministerio de Salud decidió priorizar los anticonceptivos gratuitos o subsidiados para grupos pobres y vulnerables, a la vez que mejora el mercadeo social y las ventas de anticonceptivos en el mercado libre. Para apoyar la planificación de este “enfoque de mercado total”, se realizó un estudio exploratorio descriptivo con 38 partes interesadas en planificación familiar de los sectores público y privado para conocer sus percepciones de las propuestas. Hubo un alto nivel de apoyo para que el gobierno dirigiera la coordinación y administración pública-privada de todo el sistema de planificación familiar. Se identificaron las brechas clave en información en cuanto a cómo las reformas pueden promover acceso equitativo a los servicios de planificación familiar y sostenibilidad financiera en la fijación de precios. La experiencia del gobierno con esta transición podría aportar orientación valiosa para otros entornos.

Key Words:

• family planning services
• equity and access
• health policy and programmes
• privatisation
• Viet Nam

Viet Nam, with an estimated population of 87 million people in 2010, is attaining middle-income country status. The past decade has seen important progress for health, with many of the goals of the national population strategy for 2001–10 achieved earlier than planned. These achievements include an increase in female life expectancy of more than five years, with the current average at more than 73 years; a more than 50% decrease in infant mortality, to 16 per 1,000 live births; a 40% decrease in malnutrition rates amongst children younger than five years; and a one-third increase in average years of schooling.¹

When last measured, in 2008, the modern contraceptive prevalence rate in Viet Nam was 68%.² Intrauterine devices (IUDs) represented 55% of family planning methods used by married women in Viet Nam, oral contraceptive pills (OCs) 13%, condoms 11%, sterilisation 5%, and injectables and implants 1%.² According to the 2002 Demographic and Health Survey (the most recent source available), almost 86% of contraceptive methods were obtained from the public sector and the rest from the private sector: almost 94% of IUDs were obtained from the public sector, while 57% of condoms were obtained from the private sector. Approximately two-thirds of OCs were obtained from the public sector and one-third from the private sector.³

Data on unmet need for family planning are not available, and an obvious gap is that data are not available for contraceptive use amongst unmarried women. Differences in contraceptive use and abortion rates by region may be an indicator of unmet need. In 2008, modern contraceptive prevalence ranged from 59% of women in the Central Highlands to 72% of currently married women in the densely populated Red River Delta region.² Total abortion rates for rural women were higher than for urban women (0.65 abortions per woman aged 15–49 for the five-year period preceding the survey, compared to 0.49).¹ However, increased contraceptive use may not lead to reduced abortion if high abortion rates reflect inadequate access to counselling and limited choice of contraceptive methods.⁴ Access to and quality of services at commune health centres in Viet Nam have been cited as significant factors supporting modern contraceptive method continuation, especially in rural areas.⁵ It is unclear whether migrants in Viet Nam may also face an unmet need for family planning, due either to adherence to rural norms of childbearing or living out of reach of registration systems and family planning agencies. According to one source, women in migrant populations show lower rates of contraceptive use than their non-migrant counterparts.⁶ Another source found that rural-to-urban migrants actually have lower fertility than their non-migrant urban counterparts,⁷ although it did not assess whether this was due to higher rates of contraceptive use or abortion.

The Ministry of Health network of clinical sites that provides family planning services includes central and provincial hospitals, provincial reproductive health care centres, district hospitals and health centres, inter-communal polyclinics, and commune health centres. Most of the country's communes have their own health centres, which are responsible for providing IUDs, OCs, and condoms. Clinical services are supported by volunteer workers, including members of the Women's Union, a mass organisation. These volunteers make home visits at least once per month to offer and provide information and contraceptive methods, generally OCs and condoms, and to refer women wanting an IUD to mobile teams or health facilities for insertion. Contraceptive methods are generally available in the public sector free of charge, but one survey noted that 30% of the 2,944 women interviewed had been charged a fee for medical services, tests, or essential medicine.⁸ The average amount paid varied by method; women paid about €0.50 for an IUD, less than €0.01 for an injectable, and nearly €30 for an implant. However, in the 2008 national population survey, only 0.04% cited high cost as a reason for not using contraception.²

Several donor-supported non-governmental organisations (NGOs) and social marketing organisations are also involved in provision of family planning services in Viet Nam. VINAFPA, the International Planned Parenthood Federation affiliate, provides direct services to women via 22 clinics nationally. Although a registered NGO, their leadership hold government positions, and most of their contraceptive supplies are donated by the government. Clients pay a fee based on their income; the fees must be approved by local authorities. VINAFPA's stated role is to complement and supplement the government programme. The NGO Marie Stopes International (MSI) has ten clinics providing services, mobile programmes, and partners with 300 commercial providers through a social franchise model to improve services and reach low-income women.⁹ Two international social marketing NGOs also operate: Population Services International (PSI) and DKT International. PSI provides donor-subsidised condoms for HIV programmes. DKT provides donor-subsidised OCs, injectables, emergency contraception, and condoms through private pharmacy and physician networks.¹⁰ DKT is a significant marketing source of OCs, accounting for 20% of monthly pills sold commercially in 2009.¹¹ In 2009, DKT began to provide government-donated IUDs on a pilot basis.

The for-profit commercial sector is highly fragmented. No information is available about the number of private clinics, hospitals, pharmacists, or doctors providing family planning. Professional associations of health care providers are newly formed, and have not been a resource for representing member interests externally or building networks amongst their members. There is one local OC manufacturer. All other hormonal and clinical methods are imported by multiple distributors from more than 20 international and regional manufacturers.

Implications of economic transition for family planning

As Viet Nam attains middle-income country status, the two primary donors, KfW banking group (the German government development bank) and the United Nations Population Fund (UNFPA), have withdrawn their longstanding support for contraceptive supply. According to government estimates, all international donor support provided 84% of the total budget for contraceptives between 1996 and 2006. From 2006 to 2010, the projected national budget need for contraceptives was approximately €35 million, with a shortfall of almost €14 million. For the period from 2011 to 2015, the projected national shortfall is €33 million.¹²

Within this context, the family planning division of the Ministry of Health (the General Office for Population and Family Planning, or GOPFP) has expressed a desire to explore a “total market approach” to family planning in Viet Nam and focus its public sector resources on specific populations.¹³ This approach aims to help bring together the public and private sectors (social marketing groups, NGOs, and commercial organisations) in a coordinated effort to identify segments of the population they are best suited to serve. The draft government Population–Reproductive Health Strategy for 2011–20¹³ states that it will:

“Prioritize free or subsidized supplies of contraceptives for poor, socially and economically disadvantaged and especially disadvantaged areas and, at the same time, enhance social marketing and sales of contraceptives in the free market.”

Family planning is one of the few government health services in Viet Nam still provided (mostly) free, which has been possible due to international donor support.¹⁴ After adoption of Doi Moi (reform and renovation) in 1986 – a policy of controlled economic reforms aimed to spur a transition from a fully subsidized economy to a partially subsidized, partially market economy and greater private sector growth – the government endorsed private practice in health services, commercial sale of pharmaceuticals, and user fees at public hospitals.¹⁵¹⁶ Most health care services and goods provided at public health facilities are charged to users.¹⁷ Beginning in 2003, the government implemented the Health Care Fund for the Poor (HCFP) to provide free health care to poor populations. The HCFP has a number of documented strengths, including the fact that it is clearly supported by a central budget allocation.¹⁸ Additionally, the programme seems to identify the poor effectively, that is, services provided to those who are not poor (leakage) is limited.¹⁸ Estimates of coverage (the proportion of the poor covered by the programme) vary: one estimate reported that 84% of the poor were covered,¹⁹ whilst a different analysis found that 31% of the population in question were eligible and only 14% of the total population (i.e., about half of those eligible) were covered.²⁰ Weaknesses include concerns that knowledge of the programme is limited amongst beneficiaries; delays in issuing benefit cards, especially in remote locations; and an outdated fee schedule for reimbursement.¹⁹²¹ Reaching migrant populations with social insurance can also be a challenge, as their residence may not be registered with the government, and they are more likely to be employed in the non-formal sector.⁷ In 2005, it was determined that HCFP funds would cover private services as well as public. One analysis suggests that improved integration of the private sector is a priority, including through incentives, performance-based contracting, regulation, and training.¹⁸ Experience with the HCFP shows that careful planning for a total market approach in family planning is required to maintain the impressive gains that Viet Nam has achieved in contraceptive prevalence in recent decades, especially to protect populations that already face access challenges under the current health system.

Blood pressure check following tubal ligation at an NGO reproductive health care clinic, Hanoi

PATH is currently working with the GOPFP to help plan for implementation of a total market approach and facilitate the planning process. Specifically, PATH conducted an exploratory, descriptive study designed to help develop a plan for the transitions outlined in the draft Population–Reproductive Health Strategy and involve relevant key stakeholders, address their interests, and account for relevant opportunities and obstacles. This article presents the results of an assessment of family planning stakeholders in Viet Nam and their perceptions regarding a total market approach.

Methods

We developed two sets of questionnaires. Questionnaire 1 was a semi-structured survey to identify influential individual actors in family planning and their roles. Participants were provided with a set list of organisations (identified through a literature review and informational meetings) and asked to provide information on the types and frequency of interaction they had with each organisation. This was followed by open-ended questions regarding influential organisations involved in family planning.

Questionnaire 2 was a structured survey (mainly using Likert scale responses) of stakeholders' perceptions of the national family planning programme and a total market approach. The survey included questions about the existing family planning programme, policies, and strategies; levers that facilitate or hinder the success of public- and private-sector family planning; challenges and perceived benefits of a total market approach; roles, responsibilities, and capacity of the public sector in establishing coordination mechanisms and implementing a total market approach; and potential interventions to enhance access, quality, and sustainability of family planning in Viet Nam. A total market approach was defined as:

“Government stewardship of the total family planning system by mobilizing and coordinating all sectors – public, private, and commercial – to identify the most appropriate family planning client population for each and to support appropriate contraceptive method mix provision for each sector's population of responsibility.”

Key informants working in family planning in Viet Nam were initially identified through a literature review of government policies, regulations, and guidelines related to family planning services and preliminary informational meetings in country. Additional informants were identified through a snowball approach. Interviews were conducted from January through April 2010 by two interviewers native to Viet Nam who were trained by an expert in health policy research on data collection tools, the informed consent process, and interview methodologies. Interviews were conducted in Vietnamese, with the exception of one interview in English (the interviewers were fluent English speakers). To protect confidentiality of stakeholders, informants are presented by stakeholder category; this required that at least two representatives for each stakeholder category were interviewed.

Data from Questionnaire 1 were transcribed and translated into English for data analysis using a spreadsheet database. We used PolicyMaker 4.0²² to assess positions of support for and opposition to a total market approach taken by key players, and to initiate the design of strategies for managing the politics of a policy shift, including identification of opportunities and obstacles relevant to the key players. For PolicyMaker, prior to the interviews, the project team developed and entered overarching policy goals for a total market approach in Viet Nam to define the policy content for analysis (Table 1). After the interviews were completed, using previous knowledge, questionnaire responses and interview notes, the interviewers discussed and entered information for each respondent's power, position (level of support or opposition, or lack thereof), opportunities, and obstacles with respect to the pre-identified policy content. In PolicyMaker, power is interpreted as the level of power a player has over whether the policies defined will be adopted or implemented, and power can be classified as high, medium, or low. A person with high power generally has substantial, but not total, influence over the fate of a policy, while someone with low power has limited influence. For example, responses to questionnaire 1 regarding key stakeholders in family planning informed the determination of each respondent's power. Responses to questionnaire 2 regarding challenges and key benefits of a total market approach helped to determine each respondent's position. Strategies to improve the feasibility of the policy goals were subsequently identified based on analysis and discussion among the co-authors. Data entry, which took place in English, was an iterative process; data were revisited and updated as team discussions progressed. After all interviews were completed, the project team also identified key questions from Questionnaire 2 that were most important to the policy goals. Participant responses were entered in a spreadsheet database and basic statistical analysis was conducted.

short-legendTable 1

Findings

A determination of non-human subject research was granted by PATH's Research Determination Committee. Using the questionnaires, the team conducted interviews with 38 individuals from 11 stakeholder categories (Table 2).

short-legendTable 2

Family planning stakeholders

When interviewees were asked to nominate individuals and/or organisations in a position to make decisions or influence decision-makers in family planning, the top ten responses were all governmental bodies, led by the GOPFP plus UNFPA and “NGOs". UNFPA was identified by 71% of respondents as a financer of family planning compared to government, which was identified by 45% of respondents. Other groups that featured prominently were the Women's Union, provincial-level government stakeholders, national government agencies responsible for planning and finance, and other national programme divisions of the Ministry of Health responsible for family planning service provision and HIV/AIDS.

Stakeholder perceptions of the total market approach

Basic statistical analysis of responses to questionnaire 2 revealed fairly strong support for a TMA in Viet Nam. Twenty-eight respondents agreed and an additional nine strongly agreed that public-private partnerships would create equitable and sustainable access to family planning services in Viet Nam (only one respondent disagreed). Additionally, most respondents perceived that a total market approach would improve accessibility, quality, and sustainability of family planning for low-income populations to a great extent (Table 3); however, eight respondents said they did not know. Additionally, when respondents were asked to name the most useful or appropriate aspect of a total market approach for Viet Nam, 23 had no response, and 27 provided no response in terms of the least useful or appropriate aspect.

short-legendTable 3

Obstacles and opportunities for implementing policy goals

Analysis of each of the policy goals listed in Table 1 yielded more specific insights regarding the network of stakeholders and key obstacles and opportunities for implementation.

• Goal 1: Engender public sector leadership of public-private coordination

All but one respondent strongly agreed or agreed that strengthening the government's role to coordinate and mobilise public and private sectors was an effective way to improve family planning programmes. We categorised all respondents as supporters of this goal (20 strong supporters, 12 medium supporters, and 4 low supporters), with the exception of two who did not support or oppose this policy goal. Five respondents, including donor, government planning and finance, and provincial government interviewees, expressed concerns about the logistical challenges of establishing a coordination mechanism, and/or the fact that many cross-sectoral groups already exist for other purposes (e.g., reproductive health coordination groups or groups in other health areas). Eighteen respondents, including government planning and finance and community group interviewees, as well as private providers, manufacturers, and distributors, said that engaging the private sector in policy and planning should be a priority.

Ten respondents from a range of stakeholder categories thought that a key obstacle to government leadership of a multi-sectoral coordination mechanism was the transition of the family planning programme from an autonomous programme on a par with the Ministry of Health (the National Committee on Population and Family Planning) to a division within the Ministry – the GOPFP. The GOPFP's power to convene a group that would include representatives of other government ministries, e.g. Finance or Planning and Investment, could therefore be somewhat diminished. In addition, the roles of the GOPFP and the Department of Maternal and Child Health, the division of the Ministry of Health responsible for clinical family planning service provision, were still being clarified.

• Goal 2: Expand public sector role from primary service provider to steward of the total family planning system

No respondents were identified as opponents. Of the 11 government stakeholders, ten were supportive of this goal; one did not take a position. All other categories of respondents were supportive.

In terms of opportunities, 27 interviewees from a range of categories noted that clear regulations from the government would be needed regarding the involvement of the private sector in family planning. An obstacle mentioned by 20 stakeholders from various categories was that the quality of family planning services needs to be improved – strengthening counselling and provider attitudes in the public sector and reducing unnecessary procedures in the private sector.

• Goal 3: Promote equitable access to family planning services and products

In contrast with previous goals, there were relatively fewer supporters of this goal and more respondents who took no position. Their relative lack of strong support was related to an important obstacle that emerged from the analysis: 14 respondents from a range of stakeholder categories felt that it was unlikely that a total market approach would be implemented in Viet Nam. Of these, nine cited government views or leaders' capacity as the reason. This in part relates to the structural obstacle raised, that the GOPFP may have limited convening power, and its relationship to other Ministry of Health divisions was still in transition. Additionally, respondents expressed the need to engage provincial government for policy implementation to be successful.

Government respondents also expressed concern that the private sector does not serve low-income populations. In contrast, other respondents thought that private providers had helped to improve access to family planning for low-income populations; 33 respondents said that not-for-profit private providers had helped improve access for this group to a great, moderate or some extent (Table 4). For-profit private providers and manufacturers/distributors were identified by 22 and 21 respondents, respectively, as being moderately or somewhat helpful, and by 15 and 12, respectively, as being helpful to a small extent or not at all (Table 4).

short-legendTable 4

For implementing this goal, 16 of 38 respondents suggested that research regarding consumer market segments in family planning was needed to develop a family planning targeting strategy.

• Goal 4: Promote financial sustainability of family planning

Again, there were relatively fewer high-support respondents and several respondents who neither supported nor opposed the goal. Amongst respondents who were commercial and NGO providers and manufacturers/distributors, four named pricing competition between the public and private sectors as an obstacle to achieving this goal. Information gaps identified as obstacles included knowledge of who could afford to pay, commercial products and pricing, and how fees would be determined in government facilities.

Strategies

PolicyMaker provides a set of pre-determined strategies, some of which we selected and adapted. Based on the identified opportunities and obstacles, and the power and support level of respondents for each goal, we established the following three strategies to improve the feasibility of the policy goals:

• Create a new organisation or new partnerships

Specifically, new partnerships proposed include a Total Marketing Approach coordination group led by the GOPFP and comprising government planning and finance and provincial government stakeholders, key community groups, NGOs and donors. In addition, a new commercial manufacturer working group could be convened based on outreach to pharmaceutical manufacturers with sales in Viet Nam.

• Increase the organisational strength of supporters by increasing material or technical resources

A specific action could be to identify regulatory mechanisms and agencies needed to regulate the private sector, including quality, and to address specific quality improvements in the public sector. This work would focus on engagement with government officials at the national and provincial levels.

• Provide information and evidence to supporters

This strategy would be directed toward key, high-power government programme stakeholders and donors. Actions include helping to identify costs of family planning service provision; identifying market segments; recommending targeting methods and mechanisms; assisting with development of commodity needs projections; characterising commercial markets, including pricing and affordability of products; identifying unmet need; and finally, organising the coordination group convened under the first goal in order to develop an action plan based on the relevant information. In addition, providing training for national government officials and other key stakeholders on total market approach concepts could highlight evidence regarding the role of the private sector in achieving equitable access to family planning.

Discussion

Our analysis identified strong support for a total market approach in family planning amongst a set of key stakeholders in Viet Nam (including those from both public and private sectors) and confirmed that the government is a dominant force for family planning policy and programming in Viet Nam. A major potential obstacle to the total market approach was real or perceived government opposition, in spite of documented support for the policy in the new draft Population–Reproductive Health Strategy. In fact, the government stakeholders interviewed expressed support for two of the four components of the policy shift – promoting public-private coordination and establishing government stewardship of the family planning market. Nearly all stakeholders identified the need for a coordination mechanism and for clear regulations for private-sector participation in the family planning market which in our view provides additional support for Goals 1 and 2.

Initially focusing on those elements of the total market approach that garnered the most support from key allies might enable subsequent progression in the areas in which there is more ambivalence, and which are also at the heart of the draft Population-Reproductive Health Strategy – promoting equitable access through market segmentation and targeting, and promoting financial sustainability through private-sector participation and financing and pricing revisions. This approach would also allow time for the information-gathering and research activities identified as strategies under Goals 3 and 4. Additionally, given the importance of government to family planning, making other stakeholders aware of clear government support for Goals 1 and 2 may help to address some of these concerns and mobilise important stakeholders for the other goals. Given that low understanding regarding the total market approach was also identified, training and outreach around key concepts can be tailored to address different stakeholder perceptions around each policy goal.

This analysis had several limitations. Data entry in PolicyMaker, including the determination of project strategies, is largely open-ended and user-directed, based on our interpretation of interview responses. The results and conclusions presented here are therefore fairly subjective and could have been influenced by the biases of team members. We hope this potential was somewhat diminished by the fact that multiple individuals with different experiences, perspectives and expertise participated in the analysis. It remains to be seen if these strategies and actions will be endorsed and implemented by stakeholders. Additionally, we may have overlooked key stakeholders by predetermining the set list of players for Questionnaire 1 at the start of the project, although no additional key stakeholders were mentioned in responses to open-ended questions by our 38 respondents. This was also a time-sensitive analysis that reflected stakeholder views at one specific moment; stakeholders' power and positions are likely to shift over time and thereby result in new opportunities and obstacles requiring revised strategies and/or perspectives.

The government of Viet Nam's priority is to provide free services to the poor, minorities, migrants, and people in remote areas, and to increase access for youth. They will both initiate fees for services in government facilities and encourage commercial provision. Their experience may yield valuable guidance for other settings.

Acknowledgement

This article was developed with support from the Fred H Bixby Foundation.