Quality of reproductive health services at commune health stations in Viet Nam: implications for national reproductive health care strategy

Abstract

This paper presents a qualitative study conducted in 2009 of provider and patient perceptions of primary level reproductive health services provided by commune health stations (CHSs), and the implications for Viet Nam's 2011–2020 National Strategy for Reproductive Health Care. In the three provinces of Thai Nguyen, Thua Thien Hue, and Vinh Long, we interviewed the heads of CHSs, held focus group discussions with midwives and women patients, and observed facilities. Half the 30 CHSs visited were in poor physical condition; the rest were newly renovated. However, the model of service delivery was largely unchanged from ten years before. Many appeared to fall short in meeting patient expectations in terms of modern medical equipment and technology, range of drug supplies, and levels of staff expertise. As a result, many women were turning to private doctors and public hospitals, at least in urban areas, or seeking medication from pharmacies. To make CHS clinics sustainable, promotion of access to reproductive health services should be undertaken concurrently with quality improvement. A responsive payment scheme must also be developed to generate revenues. Efforts should be made to reduce the unnecessary use of more costly services from private clinics and higher level public facilities.

Résumé

Cet article présente une étude qualitative réalisée en 2009 sur les perceptions chez les prestataires et les patients des services de santé génésique de niveau primaire assurés par les centres de santé communaux (CSC) et leurs conséquences pour la Stratégie nationale de soins de santé génésique 2011–2020 du Viet Nam. Dans les trois provinces de Thai Nguyen, Thua Thien Hue et Vinh Long, nous avons interrogé les chefs des CSC, organisé des discussions par groupe d'intérêt avec des sages–femmes et des patientes, et observé les installations. La moitié des 30 CSC visités étaient en mauvais état ; les autres venaient d'être rénovés. Néanmoins, lemodèle de prestation de services n'avait presque pas changé depuis dix ans. Beaucoup de CSC ne semblaient pas répondre aux attentes des patientes du point de vue de la modernité de l'équipement médical et de la technologie, du choix de médicaments disponibles et du niveau de compétence du personnel. Beaucoup de femmes s'adressaient donc à des médecins privés et des hôpitaux publics, au moins dans les zones urbaines, ou demandaient des médicaments dans les pharmacies. Pour que les CSC deviennent viables, la promotion de l'accès aux services de santé génésique doit être entreprise conjointement avec l'amélioration de la qualité. Un plan de paiement réactif doit aussi être mis au point pour créer des recettes. Il faut s'efforcer de réduire le recours inutile aux services coûteux de médecins et de centres privés ou d'installations publiques de niveau supérieur.

Resumen

En este artículo se presenta un estudio cualitativo realizado en 2009 de las percepciones del personal de salud y pacientes en cuanto a los servicios de salud reproductiva proporcionados en el primer nivel de atención por estaciones de salud comunitarias (CHS por sus siglas en inglés) y las implicaciones para la Estrategia Nacional de Servicios de Salud Reproductiva en Vietnam, del 2011 al 2020. En las tres provincias de Thai Nguyen, Thua Thien Hue y Vinh Long, entrevistamos la dirección de las CHS, realizamos discusiones en grupos focales con parteras profesionales y mujeres pacientes y observamos las unidades de salud. La mitad de las 30 CHS visitadas se encontraban en malas condiciones físicas; el resto había sido renovado recientemente. Sin embargo, hubo muy pocos cambios en el modelo de prestación de servicios creado diez años atrás. En muchas de las CHS hubo considerable insatisfacción por parte de las pacientes en cuanto al equipo médico moderno y la tecnología, la variedad de medicamentos y los niveles de conocimientos y experiencia del personal. Por consiguiente, muchas mujeres estaban acudiendo a médicos particulares y hospitales públicos, por lo menos en las zonas urbanas, o buscando medicamentos en las farmacias. Para lograr la sostenibilidad de las CHS, se debe promover el acceso a los servicios de salud reproductiva a la vez que se mejora la calidad. Además, se debe elaborar un esquema de pago receptivo para generar ingresos y se deben realizar esfuerzos por reducir el uso innecesario de servicios costosos proporcionados por médicos y clínicas particulares y unidades públicas de nivel superior.

Key Words:

• reproductive health services
• health policy and programmes
• quality of care
• primary health care
• Viet Nam

The social and economic reforms introduced in Viet Nam in 1986 have shifted the country from a centrally-planned to a market-oriented economy. Health sector reforms, begun in 1989, legalised private health services, allowed commercial supply of pharmaceuticals, and introduced fee-for-service in public hospitals.¹ To improve reproductive health in the country as part of development initiatives, the Ministry of Health promulgated a National Strategy for Reproductive Health Care (2001–2010).² The Strategy called for universal access to low-cost, community-based, quality reproductive health services in order to promote equity of access between regions and population groups. While maternal and child health remained a priority, attention was also to be given to the needs of men, adolescents and older people. At the same time, national standards and guidelines for reproductive health services³ were developed for the provision of maternity services, family planning, safe abortion, and adolescent services.

Compared to other developing countries with similar GDP per capita, Viet Nam has made impressive improvements in population and reproductive health, particularly maternal and child health. The maternal mortality ratio has decreased dramatically from 120 per 100,000 live births in 1990 to 75 per 100,000 live births in 2008, and approximately 93% of women receive delivery care from skilled attendants.⁴⁵ However, wide disparities persist in outcomes and coverage between the regions and income groups. For example, while 96% of urban pregnant women received at least one antenatal care visit by a trained provider, the figure was 84% in rural areas.⁶

As a contribution to the evaluation of the first national strategy, we conducted a qualitative study of the challenges faced by local CHSs in three provinces of Viet Nam and the extent to which they had achieved universal access to community-based primary reproductive health care in the context of an increasingly commercialised health market. Specifically, we explored provider and patient perceptions of primary level reproductive health services, provided by CHSs, and the implications for Viet Nam's next ten-year reproductive health strategy.

Public reproductive health services in Viet Nam

The health system of Viet Nam consists of the national level (Ministry of Health and national referral hospitals); provincial level (Provincial Department of Health and provincial hospitals); district level (district health centres and district hospitals); and commune level (CHSs). Reproductive health services are available at health facilities at all four levels. In addition, each province has a Provincial Centre for Reproductive Health Care, established as a technical agency affiliated with the Department of Health to assist in the implementation of reproductive health programmes.

The CHSs provide basic reproductive health care and family planning services. They are required to meet numerical government targets on primary health care use indicators, including for reproductive health. Almost every CHS (93.3%) is staffed by at least one midwife,⁵ who acts as the focal point for antenatal check-ups and vaccination, delivery, gynaecological examinations and treatment, and family planning services: intrauterine devices, oral and injectable contraceptives, condoms, and first trimester surgical abortion. Some CHSs that are close to a hospital are, however, restricted from providing delivery and abortion services.⁷ Local CHS services remain fully or partially subsidised by the state. However, CHSs that provide specialised services or services higher in quality than mandated by the government, are informally charging fees for such services (e.g. ultrasound scans).⁷

Under the national population programme, CHSs are responsible for registering and managing all pregnant women in the commune, and conducting monthly antenatal clinics. There are also three-day, semi-annual reproductive health campaigns, based at the CHS, with the assistance of doctors or midwives from the district hospital or Provincial Centre for Reproductive Health Care, which offer clinical examination for early detection and treatment of reproductive tract infections (RTIs) and sexually transmitted infections. Women are invited to attend these free services. In addition, family planning outreach workers, who have basic training in reproductive health education and services, conduct regular outreach activities, providing information and contraceptives (e.g. condoms, pills), and referring couples to the CHS for reproductive health services.

Health sector reforms have led to the reduction in government subsidies for CHS facilities, equipment and human resources development. In 2005, for example, only 2.3% of the state health budget was allocated to the CHSs,⁵ compared to 5% in the early 1990's.⁸ At the same time, the growth of private practice, and the weakening of the gate-keeping, referral functions of lower-level health facilities has led to a shift away from usage of CHSs. Increasingly, people are seeking care at private clinics or bypassing their local CHS for higher-level health facilities, and they are willing to pay higher fees for what they perceive to be better quality of care and enhanced technology. In addition, self-treatment with medicine purchased from pharmacies is widespread.¹⁹

From the provider perspective, problems with provision of reproductive health services through the CHS system reflect the gap between the national strategy and local implementation. This includes a lack of physicians, with only 65% of CHSs nationwide having a doctor,⁵ poor in-service training for staff, deteriorating infrastructure, weak information systems, inadequate financing mechanisms for universal coverage, and failing procurement systems for supplies.¹⁰ In addition, analysis of national statistics showed substantial differentials in utilisation of CHSs, a significant problem for the primary health care network.¹¹ The proportion of CHSs that meet national standards is low in many provinces.¹²

Private providers

Private health care services in Viet Nam are comprised of private hospitals and private clinics, principally located in major cities, and practitioners in rural areas who are not licensed and not considered as part of the formal health system.¹³¹⁴ By 2008, the country had 74 non-public hospitals with 5,600 beds (accounting for just over 3% of the total number of hospital beds nationally), just over 30,000 registered private clinics, and over 21,600 registered private pharmacies.⁵

As part of the private sector, reproductive health services are provided by the clinics of private doctors or other practitioners such as midwives and assistant doctors. Private doctors' clinics are mostly located in urban or township districts, operated by specialist obstetricians or gynaecologists who simultaneously work in a public hospital or are retired. In terms of levels of expertise and medical technology, these clinics are perceived to offer more than what is available through the CHSs, though in practice they mostly focus on antenatal care and gynaecological check-ups.¹⁵ Traditional birth attendants also provide home-based delivery services in rural settings, without a licence, but their services have become less popular in recent years.¹⁶ Lastly, local pharmacies sell drugs, including antibiotics and birth control methods such as condoms and the pill, without prescription.

Methods

This paper reports part of a baseline assessment carried out in 2009 for a project that aims to strengthen the CHS reproductive health network in three provinces: Thai Nguyen, Thua Thien Hue and Vinh Long. Thai Nguyen is located in the northern mountainous and midland areas of Viet Nam, Thua Thien Hue in the central region with urban, semi-urban, rural and mountainous areas, and Vinh Long in the rural Mekong delta region in the south. All three provinces had a population of just over a million people, with GDP ranging from US$860–1000 per person per year. Thai Nguyen had 180 CHSs with an average of 4.7 health staff each.¹⁷ Thua Thien Hue had 152 CHSs,¹⁸ and Vinh Long had 107 CHSs.¹⁹ More than 90% of CHSs in the three provinces were staffed by a doctor, and all had at least one midwife.²⁰

According to national living standards surveys²¹ the percentage of the population using CHS services increased between 2004 and 2006 (Thai Nguyen from 36.5% to 41.3%; Thua Thien Hue from 20.8% to 43.9%, and Vinh Long from 33.2% to 39.6%). However, statistics from the provincial departments of health^22–24 indicated that 70% of CHSs in Vinh Long, 56% in Thai Nguyen and 51% in Thua Thien Hue were housed in old and inadequate buildings with crumbling infrastructure. Compliance with infection control procedures was described as weak, with only 20% of CHSs in Thai Nguyen and 33.9% in Thua Thien Hue reported as meeting government infection prevention procedures.²²²³ (A corresponding figure for Vinh Long was not available.)

Data were obtained from a field study in 15 purposively selected districts in the three provinces, representing urban, rural and mountainous regions (6 in Thai Nguyen, 5 in Thua Thien Hue, and 4 in Vinh Long). In these districts, we observed 30 CHS clinics, interviewed 30 CHS heads, and held 30 focus group discussions with women patients and 15 focus group discussions with midwives. Patients were women who had attended CHS reproductive health services within the last six months. They were recruited from the community to avoid any possible courtesy bias arising from their relationship with CHS service providers.¹¹²⁵

Key topics covered in both interviews and focus group discussions with providers were their perceptions of service quality (e.g. the physical environment of the CHS clinic, its facilities and equipment and level of staff expertise) as compared to alternative providers, and difficulties faced by the CHS in provision of reproductive health care. We asked women also about their perceptions of service quality, satisfaction with services provided, and their preferences when attending reproductive health services. All interviews and focus groups were digitally recorded and transcribed verbatim. Data collection was completed between June and July 2009. Each woman was given 100,000 VND (US$5) for her participation.

Thematic analyses were undertaken with textual data. Data analysis began with coding texts based on some pre-defined themes surrounding reproductive health service delivery and utilization plus those that emerged during coding. We used observation and staff evidence to triangulate patient views. For this article, we focus on three overlapping themes that emerged most frequently: (i) CHS clinic facilities and reproductive health service availability; (ii) patient and provider perspectives on clinical effectiveness and service responsiveness; and (iii) the shift away from CHS services. Data analyses were assisted by the Atlas.ti qualitative software.

Findings

CHS facilities and reproductive health service availability

The field study found that among the 30 CHSs, half had deteriorating or severely deteriorating infrastructure, and half had been rebuilt or renovated within the past five years with funding from local government or external sources (e.g. donor agencies) after many years of neglect and decay. The deteriorating CHSs often lacked basic facilities to ensure the safe delivery of services, inadequate space, poor sanitation and even lack of running water. There was often only one room for reproductive health services. For example, Tan Thanh CHS clinic in Phu Binh district, Thai Nguyen province, was an example of a deteriorating clinic in a mountainous district of the province, written up in our notes as follows:

“The CHS building is very old and small, severely downgraded. The rain spills over the roof. There is one open bathroom and toilet outside the building, inconvenient for patients to use. There is only one room to accommodate all kinds of patients, including women in labour. The patient beds are very old, some even nearly broken. One woman in a focus group recounted her experience when giving birth there: ‘I thought the beds for the mothers were clean, but in fact they were not. There was even no mosquito net, so that my baby got mosquito bites. Two patients had to share one bed as some beds were nearly broken. The toilet was very dirty. I did not dare use it. The bathroom was outside the building, with grass growing inside. There was only one ring well to supply water, but not so clean. I had to have my clothes taken home to be washed….’”

In contrast, a newly built CHS was typically comprised of a two-storey building with space for reproductive health services often located on the first floor, provided in four separate rooms: a pregnancy examination room (phong kham thai), a gynaecological check-up room (phong kham phu khoa), a labour and delivery room (phong de), and a family planning room (phong ke hoach hoa gia dinh). Most newly built CHSs had a waiting area with a reception desk for first contact with patients. The toilet was inside the building and convenient for patients to use.

Interviews with staff showed that most CHSs focused on traditional reproductive health services funded by subsidies from the national population programme (antenatal care, gynaecological check-ups, and delivery). These services were cited by women as most commonly used as well, though levels of use varied greatly depending on the capacity of the CHSs, their location (urban vs. rural), women patients' incomes, and availability of locally accessible private clinics. Some important primary level services were missing or not provided on a regular basis, such as screening for cervical and breast cancer, menopause care and fertility care. Sexual education for adolescents and reproductive health care for men and those beyond reproductive age were mostly neglected and very few or no patients were found to be seeking these services at the CHSs. Only a few CHSs were able to supplement basic services with some laboratory tests, such as wet mount to detect common infectious agents, blood tests, and urine testing. Hence, the rest of this paper focuses on perceptions of antenatal, gynaecological and delivery services.

Perspectives on clinical effectiveness

Rightly or wrongly, almost all the focus group discussions with women associated the free services provided by the local CHS with poor quality, which they defined as low availability and quality of drug supplies, inadequate equipment, and limited expertise. They believed that CHS doctors had a low level of expertise and were there because they were not qualified to work in a hospital:

“Competent doctors do not have to work at the CHS level.”

Women also considered that subsidised drugs (e.g. antibiotics prescribed for common RTIs under the national guidelines) were ineffective, so they did not use them.

Agricultural worker at a communal health clinic for reproductive health treatment near Hanoi, 2005

“In our commune, some women threw away the drugs offered during the reproductive health campaign. They thought that because these drugs were free the quality must be low.” (Patient focus group, Thai Nguyen)

“My neighbour and I experienced different symptoms of RTIs, but we were given the same drugs after attending a check-up at the CHS. I thought the drugs might not be appropriate and did not trust them.” (Woman patient, Thua Thien Hue)

Such perceptions may or may not be correct, since the same antibiotic may well serve for two different RTIs, and the fact that a drug is free does not make it ineffective. However, the syndromic approach to RTI treatment used at the CHSs stipulated only one kind of antibiotic. Consistent with patients' comments, CHS heads indicated that low state subsidies led to serious constraints, including a shortage of diagnostic and therapeutic capacity and inadequate supplies of medical equipment and drugs for routine care. This, they said, was true even when the CHS informally charged small fees for medical consumables (e.g. gloves, antiseptic). Coupled with the lack of basic laboratory testing in most CHSs, physicians' ability to make accurate diagnoses and give appropriate treatment was limited.

“Drug subsidies are limited to 10,000 VND (US$0.50) for each prescription, including only vaginal hygienic liquid and common antibiotics, not sufficient for treating severe infections. Patients often complain about this.” (CHS head, Thai Nguyen)

In addition, midwives working in CHSs with crumbling infrastructure and lack of hygiene facilities reported unwillingness to provide clinical services where there was a high risk of infection:

“The clinic facilities are in a very poor condition, so I do not dare to do IUD insertions because I am afraid that the woman may get an infection. I have to refer them to a hospital.” (Midwife, Thua Thien Hue)

Service responsiveness

Most focus group discussions with women were critical of CHS services, while a minority praised them. Criticisms described included inconvenient opening hours, long waiting times, and lack of privacy and confidentiality, especially when they wanted advice on sensitive issues like sexual health.

“The CHS is only open during the daytime but it often opens very late and is not always staffed. Once I went there at 2 pm, but it was still closed with no staff present.” (Women patient, Vinh Long)

“The CHS does not have a private room where women can come for counselling on sensitive issues. I had to wait until there was nobody else in the examination room to consult the staff-person on duty. While waiting, I felt very embarrassed as I could be seen by people outside, even from the street.” (Women patient, Vinh Long)

The semi-annual reproductive health campaign also appeared to be problematic. Women said they only used this screening service in response to a CHS invitation or when the service was provided by staff from a higher level health facility. They complained about there being no schedule for appointments, long waiting times, uncomfortable waiting areas and poor sanitation facilities, and expressed concern about quality of treatment:

“The CHS building is very small with a narrow corridor where patients can stay while waiting for services. During the reproductive health campaign, we had to stand outside, whether sun or rain, which was very frustrating for women who were pregnant and mothers with children. The toilet was overcrowded, with inadequate running water even for washing the hands. There was no changing room.” (Patient focus group, Hue)

The screening services – essentially for RTIs – did not meet women's expectations; they considered the clinical examination too short or not properly performed. Some women expressed concerns about poor infection control practices. They were also dissatisfied with the limited choice of subsidised drugs, compared to the wider range of drugs prescribed at private clinics:

“I do not want to attend free services during the campaigns any more. In the previous campaign… the examination was not thorough. They detected my infection, but gave me cheap brand-name drugs that were ineffective. I'd be better off going to the private doctor who often prescribes appropriate drugs that I can easily buy from a pharmacy.” (Women patient, Thai Nguyen)

“We attended a gynaecological check-up… after receiving an invitation letter. It was very crowded. The equipment did not look good. The sterilisation time was too short to have equipment ready for the next patient. There were five or six check-ups in one hour using one set of equipment, which may cause cross infection.” (Patient focus group, Vinh Long)

As the CHSs are required to provide check-ups for hundreds of women in only a few days, the above complaints are unsurprising.

The groups in a few communes made positive comments on CHS services: short travel distance, friendly reception, respectful staff and low price. They also reported that the presence of an experienced doctor or well-known midwife, cleanliness of clinic facilities, display of new medical equipment, and provision of diagnostic tests (e.g., wet mount to detect RTIs, urine or blood tests) increased their confidence in service quality. A few women also appreciated CHS health workers' thoroughness in taking patient histories, conducting clinical examinations, and communicating with patients, which they believed could not be obtained in a crowded hospital:

“We are very pleased with services here. If we have a severe illness that is beyond the CHS's abilities, the doctor will refer us to a hospital after giving a thorough examination and consultation. The CHS is close and convenient for a visit. The doctor is caring and enthusiastic and often spends time with us.” (Patient focus group, Hue)

The shift away from CHS services

Due to perceptions of low service quality and dissatisfaction with CHS services, many women reported shifting to hospitals or private clinics for basic reproductive health care, willingness to pay fees in order to get enhanced technology, better equipment, a higher level of expertise, and more flexible drug prescriptions. Many others opted to ask a local pharmacy or drug vendor when experiencing RTI symptoms. Better-off women preferred to attend antenatal check-ups with a specialist doctor in a hospital or private clinic, even though the fee was 10 times more expensive – 20,000 VND or US$1 vs. 2,000 VND or US$0.10 – because they could use the ultrasound service. Women particularly preferred private antenatal care from the same physicians who offered reproductive health services in a public hospital where they chose to deliver their babies:

“We prefer the private doctor who is currently working in the hospital, as we can get the doctor's support when admitted to the hospital to deliver the baby.” (Patient focus group, Vinh Long)

Most women reported having their most recent delivery in a public hospital. This is because the two-child population policy has made couples more cautious about delivery outcomes, and they would choose hospital-based delivery if they were not confident in the CHS providers' expertise and if life-saving emergency care was not readily available.

Consistent with patients' views, low use of CHS reproductive health services was often reported by staff in urban and township areas located near hospitals, independent of whether the CHSs met national standards for clinic infrastructure, facilities, equipment, and staffing levels. Under-utilisation of services was evident in many CHSs we visited, even those that were newly built. The rooms for reproductive health services were often locked or dusty.

“Our CHS comprises a new two-storey building. But our commune is very close to the district hospital, so fewer women go to the CHS compared to other communes. The CHS would need a specialist obstetrician or gynaecologist and additional medical equipment in order to attract more patients.” (CHS head, Thua Thien Hue)

Situation for poor and rural women

In contrast, interviews and discussions with both patients and staff indicated that despite criticisms of the quality of care within the CHS system, poor women and those who live in remote or rural areas continued to rely on their local CHS for basic reproductive health care. This is partly because they could not afford service fees charged by private doctors and hospital clinics and partly because going to a hospital involved extensive travel time and associated expenses. For example, women in a mountainous area of Thai Nguyen province reported paying 50,000 VND (US$2.50) for delivery at their local CHS while it cost at least 200,000 VND (US$10) in the district hospital, excluding travel expenses. Because neither obstetricians nor gynaecologists were accessible in rural and remote communes, women would only seek care in a hospital when referred by the local CHS.

Discussion

As far as we are aware, this is the first qualitative study of patient and provider perceptions of the quality of CHS reproductive health services in Viet Nam. We found that many of the CHSs appeared to be falling short in meeting patients' expectations and maintaining their trust in CHS services, which have been weakened by crumbling facilities, long waiting times, short consultations during campaigns, and limited drug availability. CHS clinic staff too pointed to poor infection control and too limited funds to improve the situation, even when they charged informal fees.

These perceptions of CHS services were largely influenced by women's experience with alternative services providers (i.e. private physicians, hospitals and pharmacies). With the transition from state monopoly to pluralistic provision of reproductive health services, the CHS system is being challenged by growing expectations in the population for better quality of care, for example for antenatal and delivery care, which they could get from private physicians working independently or in public hospitals, and for treatment of RTIs direct from pharmacies. In this changing scenario, there has been a shift towards greater use of higher level reproductive health services, both because they have more to offer, e.g. ultrasound scans,²⁶ and due to the lack of referral functions at the CHS level.

The shift by women away from CHSs to more expensive services clearly makes it more difficult to achieve universal access to community-based primary reproductive health care, which was the main goal of the 2001–2010 National Strategy. Our findings raise questions about whether a critical assessment is needed of: i) the current model of providing primary reproductive health care services through the CHS system and ii) the quality of semi-annual CHS-based, free gynaecological check-up campaigns, based on meeting quantitative targets.

It is clear that the advent of a health care market with basic reproductive health services available from a range of health facilities has given many women, especially those in urbanised areas, a range of alternatives, similar to what has happened in parts of China and Cambodia, which have also undergone health sector reforms.²⁷²⁸ However, the pluralistic nature of service provision is also driving the unnecessary use of higher cost, higher level facilities and more expensive health professionals for routine reproductive health care, which could and we believe should continue to be managed at the CHS level. The opportunity costs involved result in decreased access overall, especially for the poor, who cannot afford higher fees and who therefore often seek self-treatment options from a pharmacy. This often results in late treatment, over-use or misuse of drugs, potentially dangerous side effects, and wasteful expenditure, especially given the poorly regulated drug market in Viet Nam.⁸²⁹ Under these circumstances, charging affordable fees for higher quality services may better serve the needs of those who do not have the resources to pay for higher-end hospitals or private doctors.

However, CHS services remain the central option in rural and remote areas, where hospitals and private doctors are not accessible locally. Yet, many CHSs in these areas have been left to function in deteriorating facilities, without adequate infection control or safe and hygienic management of care. As poor women are the most vulnerable group in terms of adverse reproductive health outcomes and continue to rely on CHSs for subsidised reproductive health care, improving CHS service quality to protect the poor and ensure equity of access to that care is desperately needed.

The CHS model of service delivery has largely remained unchanged, despite competition from alternative services. The cost of free services for all is not sustainable, and where continued, has resulted in lower quality care.²⁹ Our data support previous findings in 2009⁷ that subsidised services are no longer valued as free but instead are perceived to be of low quality. Under-utilised clinic facilities, even in some newly built CHSs, further demonstrates that supply-side investment in primary level infrastructure – unless it is responsive to community expectations and comprehensively improves service quality – is unlikely to be effective.

Policy implications and conclusions

We believe that the CHS system should continue to be the backbone of the state health system in Viet Nam. As CHS clinics are present in every commune, the CHS system is currently better placed than private clinics and hospitals to ensure the delivery of primary health care, including reproductive health care, to the bulk of the country's population, especially the poor. We, therefore, support the strengthening of the CHS system to provide universal access to primary reproductive health services and consider this as the most feasible and cost-effective option in the next ten-year (2011–2020) National Strategy for Reproductive Health Care.

First, the CHS system needs to be made responsive to local needs. In areas with accessible alternative health services, largely urban, reducing and rationalising CHS reproductive health services is needed. CHSs that have to function in the shadow of hospital facilities need to be protected by referral guidelines and clear differentiation of services rendered. Services that are not used by local residents should be folded into the hospital structure. On the other hand, investments should target areas where the CHS is the only source of locally available primary reproductive health care, such as remote or mountainous areas. Moreover, those CHSs that are unable to ensure the safe or hygienic management of patients need to be immediately upgraded, and patients need to be informed of these improvements in order to regain their confidence.

Second, promoting access to CHS reproductive health services should be undertaken concurrently with quality improvement. With the reduction in state subsidies, a responsive payment scheme must be developed at the CHS level, generating revenues for the sustainable provision of quality services. Improving quality together with application of affordable and/or sliding scale service fees based on income, which are less costly than those from private doctors or hospitals, is a viable option. Experiments with the government social franchise business model,³⁰ which increases service utilisation and patient perceptions of quality through branding and social marketing programmes, quality improvement, formalisation of user fees and staff incentive schemes have been successful in some CHS system trials in Viet Nam.³¹³² Revenues generated by user fees can be used to improve and sustain service quality. Both the poor who need subsidies and those who are better off will benefit from higher quality services offered at their local CHS as a result of such initiatives.

Thirdly, raising providers' awareness of community expectations regarding CHS reproductive health services is required to support service utilisation. This can be done via a patient feedback system to record concerns. At the same time, efforts should be made to educate the population as to what constitutes good quality of care, so that they can avoid using costly services in the private sector and/or attend higher level public facilities for primary level services unnecessarily.

Acknowledgements

This study is part of the Vietnam Evidence for Health Policy Project, funded by the Atlantic Philanthropies. Data collection was administered through Marie Stopes International Viet Nam. The authors would like to thank the project team and the provincial Departments of Health in the three provinces for their institutional support for data collection.