Phase 2 of a health systems strengthening (HSS) grant worth $36.2 milllion in incremental funding for Viet Nam will scale up activities and address key bottlenecks. The principal recipient (PR) for Grant VTN-011-G10-S is the Ministry of Health.
Viet Nam's significant progress in controlling HIV, TB and malaria has been mitigated by the major constraints faced by the country’s health system in terms of equitable access to quality services for people living in remote rural areas where health needs are greatest.
These constraints have been linked to the shortage of essential equipment at the rural facility level, inadequate training of health workers and a shortage of doctors.
The funding under Phase 2 will allow for the recruitment, training and staffing of district health centres and community health stations with trained doctors. These facilities will also be equipped to provide TB smear testing; DOTS therapy; HIV prevention and testing; malaria testing and treatment; and maternal, neonatal and child health (MNCH) services.
The programme will continue to support the training of assistant doctors towards full qualifications, leading to an increase in the ratio of doctors per 10,000 population from 6.2 to 7.0 at the end of the implementation period.
Phase 2 will continue the training programmes for 2,880 village health workers begun in Phase 1. Phase 2 will also include new training – short-term training courses on HIV, TB, malaria; MNCH clinical updates; and health management training – for health workers and private practitioners.
The Grants Approval Committee said that the World Bank, the Asian Development Bank, and the GAVI Alliance are investing in comparable activities elsewhere in Viet Nam to ensure there is neither gapping nor overlap across the health system. Other measures to harmonise and optimise donor coordination are also envisioned.
The GAC believes that the HSS grant has the potential to improve health outcomes in the three diseases and in MNCH services. The grant targets key affected populations (people who inject drugs, men who have sex with men, and transgendered persons) in 15 provinces with high HIV prevalence, accounting for 3,200 new HIV cases and malaria incidence 1.6 times higher than national rate, with some provinces exceeding five times the national rate. The grant focuses on the poorest districts and communes in remote mountainous areas, which have an acute shortage of adequately trained health workers and essential health equipment.
When the request for continued funding was submitted, the Secretariat reduced or eliminated some budget lines that it concluded were inflated or unwarranted. In the process, the Secretariat identified savings of $1.7 million in the training budget alone. These and other savings allowed the GAC to approve an addition to the budget of $2.1 million to provide essential medical equipment to 100 commune health stations and district health centres.
The GAC recommended that more be done in Phase 2 to strengthen procurement and supply chain management, quantification and forecasting, and knowledge transfer. The GAC said that in Phase 2 the PR should work with the disease-specific programmes to enhance key outcomes – by, for example, focusing training of health workers to effectively address needs of key affected populations, linking private providers in the training, working on stigma elimination at community level and increasing uptake of antiretroviral therapy among TB/HIV co-infected patients.
However, GFO understands from one sub-recipient in Viet Nam that the level of coordination between those working with HSS and within the three diseases has been unsatisfactory thus far. There have not been demonstrable clear, concrete links established with the three disease programmes, the SR explained. As an example, there have been few broad lines drawn between HSS and facilitation at the dispensary level of anti-retroviral treatment or methadone maintenance treatment for injected drug users. TB notification is another area where the level of coordination has been lower than anticipated, the SR added.
One critical area where the HSS grant must work harder to demonstrate impact is in clearly defining the interaction between the health system and key populations; this can include not only collaboration between health facilities and advocacy or outreach groups but also communications or outreach efforts around the implementation of health insurance plans for key populations.
The SR suggested that improved mapping by the Ministry of Health of health facilities that have received significant international support as well as investment by central or local government would go a long way towards linking HSS work with other disease-specific programming in Viet Nam.
Information for this article was taken from Board Decision GF-B30-EDP3 and from GF-B30-ER2, the Report of Secretariat Funding Recommendations. These documents are not available on the Global Fund website. See also separate GFO article on the Global Fund’s decision to stop funding HIV treatment services in Viet Nam’s compulsory drug treatment centres.