Access to hypertension care and services in primary health-care settings in Vietnam: a systematic narrative review of existing literature

Figures & data

Figure 1. Organisational chart of Vietnam’s health-care system, illustrating roles and responsibilities of each component

(adapted from the Ministry of Health).

Table 1. Timeline of health insurance and related-government decisions in Vietnam (1986–2016), including health insurance coverage and rate (when available).

1986	Doi Moi Policy for Economic Reforms
1987	No changes
1988	No changes
1989	Pilot for first Voluntary Health Insurance (VHI)
	Introducing user fees, private sector
1990	No changes
1991	Health Insurance Coverage Population: Children <6yrs
1992	Introducing Social Health Insurance (SHI) under Vietnam Health Insurance Agency (VHIA)
	Health Insurance Coverage Population (Rate): Civil servants, employees in state and non-state (>10 employees) enterprises, pensioners, elderly (4%)
1993	No changes
1994	Introducing fee exception scheme for poor
	Health Insurance Coverage Population: Poor in addition to schools and kindergartens
1995	Introducing schemes of Health Insurance Fund (HIF) under Vietnam Social Security (VSS), including VHI
1996	No changes
1997	No changes
1998	Introducing 20% co-payment, special conditions for special groups
	Health Insurance Coverage Population (Rate): PLUS: Government members, preschool teachers, social welfare target groups, dependants of policy and armed forces staff (23%)
1999	Introducing nation-wide fee exemption scheme for poor
2000	Defining health insurance as a non-life insurance business sub-sector
2001	No changes
2002	Introducing Health Care Fund for the Poor (HCFP)
	Decentralising and budgetary autonomy to local provincial agencies
2003	Merging VHIA into VSS; Encouraging VHI by introducing a minimum threshold 30% for total uninsured at the community level
2004	Law on Protection, Care and Education of Children
2005	Implementing the medical insurance regulation; Detailing payment methods: fee for service and training, and prepare for case-based (diagnosis-specific) package payment mechanism; Introducing VHI in every commune with no co-payment and VSS is implementation agency
	Health Insurance Coverage Population (Rate): PLUS: Non-state (>1 employee) enterprises, cooperatives, other organisations, war veterans, poor (46%)
2006	Expansion of accountability and rights of public hospitals
2007	Raising contribution rates of VHI; Increasing premiums of individuals enrolled in VHI; Transferring the responsibility of some health insurance duties to MoH
	Local administrations cannot raise taxes without legal grounds and act on their sole discretion; Developing Vietnam’s pharmaceutical industry; Introducing first law on personal income tax; Implementation guidelines for the Law on Insurance Business (issued in 2000), however, it did not touch on health insurance business activities
2008	Increasing premiums of individuals enrolled in VHI; At least 50% of government subsidies on health insurance premiums to enrol in the VHI scheme for members of ethnic groups, social-welfare targeted, poor and near-poor households
	Investing in construction, improvement, upgrading of district-level general hospital for period 2008–2010
2009	Health Insurance Law/Law on Health Insurance
	Health Insurance Coverage Population (Rate): PLUS: Children <6yr, near poor (60%)
2010	Health Insurance Coverage Population (Rate): PLUS: Students (65%)
2011	No changes
2012	Health Insurance Coverage Population (Rate): PLUS: Farmers (66%)
2013	Accelerating the implementation of health insurance policies and legislation for universal health coverage
	Regulations on division of medical care by level for health-care facilities
2014	Revised Health Insurance Law/Law on Health Insurance (amendment and supplementation of several articles)/Amended Health Insurance Law
	Health Insurance Coverage Population (Rate): PLUS: Dependants of labourers and cooperative members; Compulsory participation by 2016 (70%)
2015	Introducing a roadmap to develop and implement basic health service package paid by health insurance in Vietnam
2016	Health Insurance Coverage Rate: 82%

Figure 2. Framework on people-centred access to health care with definitions and examples for each component, modified from Levenseque [24].

Figure 3. Flow diagram for study selection process.

Table 2. Characteristics of included peer-reviewed articles.

No.	First author	Objective	Population	Sampling technique	Sample size
Accessibility of system
	Cross-sectional
1.	Tuan, 2005	To gather evidence about the availability and quality of the community health system in general, and private health services in particular	Health centres in one commune	Multistage stratified cluster	CHSs: n = 30 HC providers: n = 126 Private providers: n = 234
2.	Mendis, 2012	To evaluate the capacity of primary care to implement basic interventions for prevention and management of major NCDs, including CVDs and diabetes	Health centres in one district	Random	n = 15
3.	Hoang, 2014	To describe the primary care system in a selected rural area in Vietnam in terms of its current capacity for the prevention and control of chronic NCDs; collecting data on the current status of the six building blocks of the primary care system.	Health centres in one district	All centres	Districts centres: n = 2 CHSs: n = 18
	Literature review
4.	Hoang, 2009	To report and discuss currently available evidence on economic aspects of chronic diseases in Vietnam	NA	NA	NA
5.	Alwan, 2010	To review the capacity of countries to respond to NCDs	NA	NA	NA
6.	Abdul Rahman, 2015	To discuss the growing problem of hypertension in the Asia-Pacific region, and to develop consensus recommendations to promote standards of care across the region	NA	NA	NA
	Intervention
8.	Barzin, 2012	To investigate a charity’s medical programme focusing on its impact on the public health system	Patients & HC providers	Non-random clinic recruitment	NS
9.	Sundberg, 2012	To describe an education and training programme for health practitioners in Vietnam on prescribing physical activity	HC providers	NS	NS
10.	Islam, 2014	Summary from a talk in the Symposium titles as: Health systems and NCDs in developing countries: experience from Vietnam	HC providers	NA	NA
11.	Markuns, 2015	To develop systems to effectively train, support and integrate competent primary care physicians for health systems as part of an effort to address human resource development of primary care staff.	HC providers	NA	NA
12.	Do HTP, 2016	To evaluate the effectiveness of the Eat Less Salt (ELS) intervention with a view to scaling up to a regional or national level	Adults aged 25–64 yr	Screening (non-random)	Baseline: n = 509
				Follow-up after 1yr	Follow-Up: n = 511
	Therapeutic randomised trial
13.	Nguyen MH, 2012	To investigate and examine the effects of Tai Chi on physical fitness, perceived health, blood pressure, and preventing falls among the elderly	Community-dwelling elderly 60–79 yr	Patients recruited, randomly divided to intervention & control groups	Intervention: n = 39 Control: n = 34
14.	Nguyen HL, 2017	To report the results of a cluster-randomised feasibility trial at three months follow-up conducted in Hung Yen province, designed to evaluate the feasibility and acceptability of two community-based interventions to improve hypertension control: a ‘storytelling’ intervention, ‘We Talk about Our Hypertension,’ and a didactic intervention	Adults ≥50yr living in 4 communes	Cluster randomisation Screening for all adults invited	n = 331
			hypertensive patients	Follow-up after 3mo	Storytelling: n = 79 Didactic: n = 80
Ministry of Health (MoH) intervention
15.	Nguyen QN, 2011	To summarise our approaches on how to implement a programme on hypertension management in rural commune in Vietnam, and to involve all related partners, and finding potential factors which could influence local people’s adherence	Community-based study Adults ≥25yr in one commune	Random	n = 1,180
			hypertensive patients	Follow-up after 17mo	n = 469
16.	Nguyen QN, 2012	To evaluate the impact of healthy lifestyle promotion campaign on CVD risk factors in the general population in the context of a community-based programme on hypertension management	Quasi-experimental study Adults ≥25yr in two communes	Random in each commune (baseline vs. 3yr follow-up)	Intervention: n = 1,131 vs. n = 1,185 Reference: n = 1,162 vs. n = 1,190
17.	Lim, 2014	To examine cases of innovation and identify critical success factors in NCD management in ASEAN	Review	NA	NA
Ability of population
	Cross-sectional
18.	Duong, 2003	To determine the risks associated with hypertension in Vietnamese communities around Ho Chi Minh City	Adults living in one city	Non-random screening	n = 357
19.	Son, 2012	To characterise the prevalence and distribution of hypertension, together with awareness, treatment and control in the general adult population (25 years and over) in Vietnam, with a view to providing a better evidence base for health planning.	Adults ≥25yr nationally	Multistage stratified cluster	n = 9,823
20.	Boas, 2012	To study the prevalence of undiagnosed hypertension and the treatment of those diagnosed with hypertension	Adults aged ≥35yr in 6 communes	Randomised cluster	n = 1,621
21.	Ha DA, 2013	To describe the prevalence, awareness, treatment, and control of hypertension, and to examine factors associated with these among the adult population residing in Thai Nguyen province, a mountainous northern region of Vietnam	Adults ≥25yr in one province	Multistage stratified cluster	n = 2,348
22.	Ha NT, 2014	To measure quality of life among hypertensive people in a rural community in Vietnam, and its association with socio-demographic characteristics and factors related to treatment	hypertensive patients >50yr managed in one CHS	Random	n = 275
23.	Do HTP, 2015	To present the national prevalence of pre-hypertension and hypertension and their determinants, as well as levels of awareness, treatment, and control, based on a large nationally representative sample of Vietnamese adults examined in 2005	Adults 25–64 yr nationally	Multistage stratified cluster	n = 17,199
24.	Nguyen TPL, 2015	To evaluate differences in health-state utilities related to characteristics of these patients to identify potential predictors using the Short-form 36 version 2TM (SF-36v2) questionnaire to collect data on health-related quality of life (HRQoL)	hypertensive patients <80yr	Non-random clinic recruitment	n = 691
	Modelling
25.	Nguyen QN, 2012	To estimate the time trends in blood pressure, body mass index (BMI), and smoking status in adults Vietnamese population over a nine-year period and highlight the differences between men and women as well as the differences between urban and rural areas	Adults 25-74 yr nationally	5 cross-sectional surveys (2 included in review)	n = 23,563
	Qualitative
26.	Veith, 2016	To identify the critical barriers facing patients with hypertension when trying to access care	hypertensive patients Physicians	Non-random clinic recruitment	Patients: n = 89 Physicians: n = 3
	Cohort
27.	Nguyen TPL, 2017	To (i) assess the level of adherence of hypertensive patients visiting CHSs in a rural area in Vietnam; (ii) examine the relationship between level of adherence and cardiovascular risk among hypertensive patients; and (iii) get a better understanding of adherence and factors influencing adherence among these patients	Adults aged 35–64 yr in 4 communes	Random	n = 3,779
			hypertensive patients	Follow-up for 1yr	Survey: n = 315 In-depth interviews: n = 18

NCDs, non-communicable diseases; CVDs, cardiovascular diseases; CHSs, commune health stations; HC, health care.

NA: Not applicable; NS: Not specified.

Table 3. Characteristics of included grey literature documents.

No.	First author, Year	Title	Publisher
	Joint Annual Health Review (JAHR): Vietnam Ministry of Health (MoH) & Health Partnership Group
1.	2007	JAHR 2007	Vietnam MoH & Health Partnership Group
2.	2008	JAHR 2008: Health financing in Viet Nam	Vietnam MoH & Health Partnership Group
3.	2009	JAHR 2009: Human Resources for Health in Vietnam	Vietnam MoH & Health Partnership Group
4.	2010	JAHR 2010: Vietnam’s health system on the threshold of the five-year plan 2011–2015	Vietnam MoH & Health Partnership Group
5.	2011	JAHR 2011: Strengthening management capacity and reforming health financing to implement the five-year health sector plan 2011–2015	Vietnam MoH & Health Partnership Group
6.	2012	JAHR 2012: Improving quality of medical services	Vietnam MoH & Health Partnership Group
7.	2013	JAHR 2013: Towards universal health coverage	Vietnam MoH & Health Partnership Group
8.	2014	JAHR 2014: Strengthening prevention and control of non-communicable diseases	Vietnam MoH & Health Partnership Group
9.	2015	JAHR 2015: Strengthening primary health care at the grassroots towards universal health coverage	Vietnam MoH & Health Partnership Group
	More official documents
10.	Harper C, 2011	Vietnam noncommunicable disease prevention and control program 2002–2010: Implementation review	World Health Organization (WHO)
11.	2012	One Plan 2012–2016 between the government of the Socialist Republic of Viet Nam and the United Nations in Viet Nam
12.	2014	Guidelines for diagnosis, treatment, prevention of hypertension: 1^st Vietnam Congress of Hypertension	Vietnamese Society of Hypertension & Vietnam Heart Association, 2014
13.	2016	Five-year Plan: For people’s health protection, care and promotion in the period 2016–2020	Vietnam MoH
14.	2016	Independent Review of the One Plan (2012–2016) between the Government of the Socialist Republic of Viet Nam and the United Nations in Viet Nam	SIPU
15.	2016	National survey on the risk factors of non-communicable diseases (STEPS) Viet Nam, 2015	Vietnam MoH & WHO
	Doctoral dissertation
16.	Hoang VM, 2006	Epidemiology of cardiovascular disease in rural Vietnam	Umea University: Sweden
17.	Nguyen QN, 2012	Understanding and Managing Cardiovascular Disease Risk Factors in Vietnam: Integrating Clinical and Public Health Perspectives	Umea University: Sweden
18.	Son PT, 2013	Hypertension in Vietnam: From community-based studies to a national target programme	Umea University: Sweden
19.	Duong DB, 2015	Understanding the service availability for non-communicable diseases prevention and control at public primary care centres in Northern Vietnam	Harvard Medical School: USA
20.	Nguyen TPL, 2016	Health economics of screening for hypertension in Vietnam	University of Groningen: The Netherlands

Figure 4. Timeline for included studies and records by publication year, framework and type (n = 46) Population; ability of population. System; accessibility of system. MoH; Ministry of Health.

Figure 5. Overview of key results on access to hypertension care at primary health care in Vietnam based on the framework on people-centred access to health care. HBP, high blood pressure; DHs, district hospitals; PHC, primary health care; CHS, commune health station.

Table 4. Availability of selected essential hypertension (oral) medication based on health insurance drug formulary and two studies that investigated capacity of commune health centres.

Selected essential HTN medicines	Health Insurance Drug Formulary, 2011		Health Insurance Drug Formulary, 2014	Commune Level Document, 2017	Mendis, 2012 (n = 15)	Van Minh, 2014 (n = 18)
	District Level	Commune Level	When different from previous edition	When different from Health Insurance Drug Formulary
Diuretics
Thiazide
Hydrochlorothiazide, %	+	+			40.0	100.0
Indapamide	+	−
Loop
Frusemide^a, %	+	+			86.7	61.1
Potassium sparing
Spironolactone^a	+	+				0.0
Adrenoceptor antagonists
β-blockers^b
Atenolol^c, %	+	+			93.3	16.7
Acebutolol, Bisoprolol, Carvedilol, Metoprolol, Nebivolol	+	−
Labetalol	+	−	+ Commune Level
Propranolol^c	+	+
α1-selective blocker
Doxazosin	+	−
Centrally acting α2-agonist
Clonidine	+	+		−
Methyldopa	+	+
Centrally acting I1-selective imidazoline receptor agonist
Moxonidine, Rilmenidine	+	−
Calcium-channel blockers
Dihydropyridine
Amlodipine, Nifedipine, %	+	+			86.7	66.7
Cilnidipine, Felodipine, Lacidipine, Lercanidipine, Nicardipine	+	−
Phenylalkylamine
Verapamil^d	+	+
Benzothiazepine
Diltiazem^c	+	−
Targeting renin-angiotensin system
Angiotensin-converting enzyme (ACE) inhibitors
Enalapril, Captopril, %	+	+		+	60.0	61.1
Perindopril	+	+		−
Benazepril Hydrocloride, Imidapril, Lisinopril, Quinapril, Ramipril	+	−
Angiotensin II receptor antagonist
Losartan	+	−	+ Commune Level
Candesartan, Irbesartan, Telmisartan, Valsartan	+	−
Direct Arterial Vasodilators
Hydralazine	+	−	- District Level
Combined medication
Thiazide diuretic with beta-blocker
Hydroclorothiazide + Bisoprolol	+	−
Thiazide diuretic with ACE inhibitor
Indapamide + Perindopril	+	+		−
Thiazide diuretic with angiotensin II receptor antagonist
Hydroclorothiazide + Losartan	+	−	+ Commune Level	−
Hydroclorothiazide + one of (Irbesartan, Telmisartan, Valsartan)	+	−
ACE inhibitor with calcium-channel blocker
Perindopril + Amlodipine	+	−
Other
Isosorbide dinitrate^c, %	+	+			60.0	0.0
Statin, lipid-lowering medication
Atorvastatin	+	−	+ Commune Level	+
Fenofibrat^d	+	+
Simvastatin^d, %	+	−	+ Commune Level	+	46.7	0.0
Acetylsalicylic acid (Aspirin), %	+	+			100.0	55.6

(+), available; (−), not available

Commune-level document, Vietnamese official document with list of medications that should be available at commune health stations.

Italic, medication investigated by empirical studies.

NA, medication is not reported in the study, although according to Health Insurance Drug Formulary it can be available at commune and district levels.

^a Medicines are listed with diuretic drugs and not hypertension drugs.

^b According to 2014 Joint Annual Health Report, beta blocker is not reimbursed at commune level, because it should be provided by the National Hypertension Program.

^c Medicines are listed with antianginal drugs and not hypertension drugs.

^d Medicines are listed with Lipid-lowering agents.

Hoang TP, Tran TMO. 2016. Strategic Purchasing for Universal Health Coverage: social Health Insurance Fund in Vietnam [Internet]. Vietnam: Health Strategy and Policy Institute. Available from: http://resyst.lshtm.ac.uk/resources/strategic-purchasing-universal-health-coverage-social-health-insurance-fund-vietnam

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