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Strengthening government primary reproductive healthcare services through social franchising in rural Viet Nam

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Nguyen Thi Bich Hang's presentation at the International Conference on Family Planning, 2013 on: …

Nguyen Thi Bich Hang's presentation at the International Conference on Family Planning, 2013 on:

Strengthening government primary reproductive healthcare services through social franchising in rural Viet Nam: the “tinh chi em” (Sisterhood) model

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  • -Emphasis hard to reach groups: rural; isolated; ethnic minority etc – CHS is a key point of care for these groups but often bypassed for higher level-While CPR is increasing in most regions CPR is atually gradually decreasing in RED RIVER DELTA and NORTHERN MIDLANDS AND MOUNTAINS REGION
  • There are more than 11,000 Commune health stations in Viet Nam, forming a nation-wide communal primary health care system
  • Commune Health Stations (CHS) form the basic unit of the health system, delivering primary care at the local level including SRH and FP services. Coverage is high; in rural areas, 94% of communes have their own CHS and services at the CHS remain fully or partially subsidized. However, development of CHS infrastructure and medical expertise fell behind those in the private sector leading to perceived poor quality of services at CHSs amongst the public. This, combined with low levels of awareness of SRH services, led to declines in utilization of CHSs.CHS staff are poorly monitored and lack equipment to ensure they meet the policy guidelines on quality. The under-ultilisation of SRH services at the CHS level and over-reliance on hospitals reduce the capacity of the health system, and highlight a need for improvements in services at the local level to reduce the burden on provincial and central public hospitals. Uỷ ban Dânsố, GiađìnhvàTrẻem [Việt Nam], và ORC Macro. 2003. Điềutranhânkhẩuvà y tếtạiViệt Nam 2002. Calverton, Maryland, USA: Uỷ ban Dânsố, GiađìnhvàTrẻemvà ORC Macro
  • WHY SF at the public sector? Standardization of services and service provision procedures based on national standards; structured monitoring and evaluation of service quality and performance of the network; more effective awareness raising and demand generation using a unique, culturally appropriate brand name (sisterhood, with the marketing slogan of “Empathy, Privacy and Devotion in SRH care” to re-position” a not very positive image of CHS in the mind of many rural communities.
  • Emphasizethe importance of partnership, success in getting govt buy-in and investment in scale up over the phases.We have successfully advocated with the DOH in the project provinces to leverage funding and in-kind contributions to replicate ‘tinh chi em’ in nearly 100 (88) CHS in Da Nang and Khanh Hoa, Thai Nguyen, ThuaThien Hue, and Vinh Long provinces to date, with intentions/commitments for even more replication by 2015’
  • illustrates AP and EU combined phase II data The total number of client visits in phase II increased 453% in 2012 compared to 2010, of which 178% increase in FP and 393% increase in SRH client visits). Highly effective for reaching poorer women. A project evaluation from phase II showed that women in the poorest communes were 1.6 more likely to access the services than the women in the less poor communes of TCE. In addition ethnic minority 1.2 x more likely to access services than Kinh. Illustrates that GSF plays an important role in enabling vulnerable segments of the population to access SRH and FP services at the commune level.
  • Both qualitative and quantitative studies conducted to assess provider and client perceptions of the SF CHSProviders exhibited increased internalisation of key messages such as service quality and client focussed care.Providers also reported more positive attitudes to communicating with clients about CHS services (quote)Satisfaction – women also more likely to report that they would recommend services to others following implementation of the GSF model; high likelihood to return; and expressed increased perceptions of service quality (including staff expertise and attitudes, clinic environment and equipment). Clients reported an increased willingness to pay
  • Transcript

    • 1. Strengthening government primary reproductive healthcare services through social franchising in rural Viet Nam: the “tinh chi em” (Sisterhood) model Presenter: Nguyen Thi Bich Hang, Country Representative, Marie Stopes International in Viet Nam Authors: Nguyen H Thang1, Nguyen Thi Quy Linh1, Dinh Thi Nhuan1, Erik Munroe2, Thoai D Ngo2 1 Marie Stopes International in Viet Nam, 2 Marie Stopes International Strengthening government primary reproductive healthcare services through social franchising: The “tinh chi em” ( Sisterhood ) model in rural of Vietnam SLIDE 1
    • 2. Content  Country context: Vietnam  Government Social Franchise (GSF) Model  Effectiveness  Conclusions  Lessons learnt & implications Strengthening government primary reproductive healthcare services through social franchising in rural Viet Nam: the “tinh chi em” (Sisterhood) model SLIDE 2
    • 3. Viet Nam  Population: 90 million people, 50% < 25 years old  Women of reproductive age: 55.6%~25 million; approx 1.8 million women deliver a baby each year  CPR: modern methods account for 67.5%  Abortion rate: 2.5 abortions/woman per lifetime*; 30% among women < 20 years of age Sources: Viet Nam Health Plan 2011-2015; DHS, 2010; Viet Nam JAHR, 2010 * http://www.guttmacher.org/pubs/journals/25s3099.html Strengthening government primary reproductive healthcare services through social franchising in rural Viet Nam: the “tinh chi em” (Sisterhood) model SLIDE 3
    • 4. Vietnam health system: key issues  Health Insurance Coverage: 68%  Private sector providing 60% outpatient visits; out-of pocket accounts for 52% of total health expenditure  Underutilization of local (commune) level care and overburdening of higher level services (district and provincial)  Disparities in health between regions and population groups: • MMR in rural areas (145) remains high compared to national (79) with gaps between regions remaining the same despite overall decreasing MMR • CPR gradually decreasing in rural/remote areas (Red River delta, Northern Midlands, Mountains Region) • Unmet need for modern contraceptives: 29,4% for married women; 50,4% for unmarried women (UNFPA 2012) Source: Vietnam JAHR 2012 Strengthening government primary reproductive healthcare services through social franchising in rural Viet Nam: the “tinh chi em” (Sisterhood) model SLIDE 4
    • 5. SRH service delivery system in Viet Nam National/central Gyn/Obs hospitals Provincial general or Gyn/Obs hospitals Provincial centre for reproductive healthcare District health centre/ hospital Commune people‟s committee Commune Health Station (CHS) Village health workers Population collaborators Strengthening government primary reproductive healthcare services through social franchising in rural Viet Nam: the “tinh chi em” (Sisterhood) model SLIDE 5
    • 6. Commune Health Stations (CHS)  Key point of primary care for rural/remote communities  Limited investment - perceived poor quality of services  Under-utilization of SRH services  Low level of awareness of SRH/FP services  Need for service improvement – Training: client focused – Adequate medical supplies – Adequate medical equipments Strengthening government primary reproductive healthcare services through social franchising in rural Viet Nam: the “tinh chi em” (Sisterhood) model SLIDE 6
    • 7. Government Social Franchise (GSF) Model Franchisor: Franchisees: Department of Health Commune Health Stations Technical Support: MSI Viet Nam Strengthening government primary reproductive healthcare services through social franchising in rural Viet Nam: the “tinh chi em” (Sisterhood) model SLIDE 7
    • 8. Implementation: 1. Mapping/recruitment of CHS 2. Needs assessment 3. Brand and guideline development 4. Training of provincial master trainers & service providers 5. Branding of CHS 6. Certification of participating CHS 7. Brand promotion/Demand generation strategy development 8. Pre-launch/launching of GSF 9. Brand communication/demand generation activities 10. Continuous Quality assurance, monitoring and improvement support Strengthening government primary reproductive healthcare services through social franchising in rural Viet Nam: the “tinh chi em” (Sisterhood) model SLIDE 8
    • 9. Phases and scale-up Phase Provinces Donor Funded DOH Funded Scale Up Total GSF Established Phase I Pilot Khanh Hoa Da Nang 38 38 76 Thai Nguyen 130 Hue Vinh Long 59 189 Ca Mau Dak Lak Yen Bai NA NA 2007-2009 Phase II 2010-2012 Phase III 2013-2015 90 (Planned) Strengthening government primary reproductive healthcare services through social franchising in rural Viet Nam: the “tinh chi em” (Sisterhood) model SLIDE 9
    • 10. Service utilisation Franchise membership associated with increased utilisation:  453% increase in total use, 393% increase in SRH use, 178% increase in FP use  Women in poor communes were 1.6x more likely to access the TCE services than in less poor communes. Ethnic Minority were 1.2x more likely than Kinh. Strengthening government primary reproductive healthcare services through social franchising in rural Viet Nam: the “tinh chi em” (Sisterhood) model SLIDE 10
    • 11. Service quality improvement Strengthening government primary reproductive healthcare services through social franchising in rural Viet Nam: the “tinh chi em” (Sisterhood) model SLIDE 11
    • 12. Provider and client satisfaction  Providers reported feeling “more confident in our abilities to provide accurate diagnoses and treatment and thus confident when promoting our services to clients”  Client‟s reported increased perceptions of service quality: -95% reported that health workers seemed knowledgeable -100% reported staff were friendly  Client satisfaction and likeliness to return to CHS high (>80%)  Increased willingness to pay extra service fees for what clients perceived as higher quality services Strengthening government primary reproductive healthcare services through social franchising in rural Viet Nam: the “tinh chi em” (Sisterhood) model SLIDE 12
    • 13. Sustainability  “The „tinh chi em‟ model has developed solutions to improving the quality of services in the context of the country becoming a Middle Income Country” (MOH representative)  Core provincial training networks are established to ensure retraining/supervision systems remain in place post project phase out.  Gained commitment of local authorities to budget allocation towards the expansion of the model Strengthening government primary reproductive healthcare services through social franchising in rural Viet Nam: the “tinh chi em” (Sisterhood) model SLIDE 13
    • 14. Conclusions  Harnessing existing public health system infrastructure to increase SRH service delivery is highly effective  Model improves quality and utilization of services, especially amongst vulnerable and hard to reach groups, which reduces the burden on provincial and central hospitals  Lower income segments are able to access affordable high quality RHFP services locally  Clients willing to pay for high quality services at affordable prices Strengthening government primary reproductive healthcare services through social franchising in rural Viet Nam: the “tinh chi em” (Sisterhood) model SLIDE 14
    • 15. Lessons learnt & implications  Project monitoring and evaluation play an important role  Strong collaboration and local ownership amongst partners is key to success and sustainability  Potential for successful replication by local health authorities & other donors due to its integration into existing health system  Need for evaluation on the effectiveness of GSF in improving health outcomes and the cost-effectiveness of the model Strengthening government primary reproductive healthcare services through social franchising in rural Viet Nam: the “tinh chi em” (Sisterhood) model SLIDE 15
    • 16. Thank you! To find out more about how we are addressing unmet need by reaching the most underserved, please visit www.mariestopes.org Strengthening government primary reproductive healthcare services through social franchising in rural Viet Nam: the “tinh chi em” (Sisterhood) model SLIDE 16