1. 1
UNIVERSITY VICTOR SEGALEN, BORDEAUX 2
INSTITUT OF PUBLIC HEALTH, EPIDEMIOLOGY & DEVELOPMENT
Public Health Master
Specialty: International health
Overview of the national Methadone Maintenance Treatment (MMT)
program in Vietnam: implementation process, key issues and
opportunities for scaling-up, from the perspective of four domains: Legal
framework, Stakeholder responsibilities, Financing and Technical factors
Internship Master Thesis from 04/11/2013 to 09/02/2013
Urban Care LLC
5, To Ngoc Van Street, Tay Ho District
Hanoi, Vietnam
With the technical support of FHI 360
7th
Floor, 18 Ly Thuong Kiet Street Hanoi, Vietnam
Publicly presented on 09/16/2013 in Bordeaux
By Géraldine CAZORLA, born on 04/20/1973
Supervisors: Pr. Peter Banys (FHI 360), Dr. Vincent Guérard (Urban Care)

2. 2
TABLE OF CONTENTS
LIST OF ACRONYMS....................................................................................................................................... 3
1. OVERVIEW OF THE SCIENTIFIC CONTEXT.............................................................................................. 4
2. HIV AND DRUG EPIDEMICS IN VIETNAM.................................................................................................. 4
3. STUDY RATIONALE, HYPOTHESIS AND SIGNIFICANCE ....................................................................... 5
3.1. Study rationale ........................................................................................................................................ 5
3.2. Hypothesis .............................................................................................................................................. 6
3.3. Significance............................................................................................................................................. 6
OBJECTIVES .................................................................................................................................................... 6
1. Main objective ............................................................................................................................................ 6
2. Specific objectives...................................................................................................................................... 6
METHODS......................................................................................................................................................... 6
1. Information & literature review ................................................................................................................... 7
2. Survey among key stakeholders................................................................................................................ 7
3. Survey among MMT clients and active IDUs............................................................................................. 8
ETHICAL CONSIDERATION............................................................................................................................ 9
RESULTS .......................................................................................................................................................... 9
Key findings.................................................................................................................................................. 10
1. Contradictory and Competing Responsibilities ........................................................................................ 10
2. Technical Factors: MMT Supply, Training Capacity and Human Resources .......................................... 14
3. Sustainable funding of Methadone Maintenance Treatment (MMT) ....................................................... 16
4. Legal Inconsistencies............................................................................................................................... 18
DISCUSSION .................................................................................................................................................. 19
RECOMMENDATIONS ................................................................................................................................... 21
REFERENCES ................................................................................................................................................ 25

3. 3
LIST OF ACRONYMS
AIDS Acquired Immune Deficiency Syndrome
ART Antiretroviral Therapy
CDC Center for Diseases Control
DOLISA Department of Labor, Invalids and Social Affairs
FSWs Female Sex Workers
GFATM The Global Fund to Fights AIDS, Tuberculosis and Malaria
HBsAg Hepatitis B surface Antigen
HCMC Ho Chi Minh City
HCV Hepatitis C Virus
HTC HIV Testing and Counseling
HIV Human Immunodeficiency Virus
HMU Hanoi Medical University
IBBS HIV/AIDS Integrated Biological and Behavioral Surveillance
IDUs Injecting Drug Users
MoH Ministry of Health
MoLISA Ministry of Labor, Invalids and Social Affairs
MoPS Ministry of Public Security
MARPs Most-At-Risk-Populations
MMT Methadone Maintenance Treatment
MSMs Men who have Sex with Men
NCADP National Committee on HIV/AIDS, Drugs and Prostitution Prevention and
Control
NIMH National Institute on Mental Health
NSEP Needle and Syringe Exchange Program
OST Opioid Substitution Therapy
PAC Provincial AIDS Committee
PEPFAR United States President’s Emergency Plan for AIDS Relief
PLHIV People Living with HIV
PWUD/ PWID People Who Use Drugs/ People Who Inject Drugs
UNAIDS Joint United Nations Program on HIV/AIDS
UNDP United Nations Development Program
UNODC United Nations Office on Drugs and Crime
USAID US Agency for International Development
VAAC Vietnam Administration for HIV/AIDS Control
WHO World Health Organization

4. 4
1. OVERVIEW OF THE SCIENTIFIC CONTEXT
At the end of 2011, 34 million [31.4 million–35.9 million] people were living with HIV worldwide with an
estimated HIV prevalence of 0.8% among those aged between 15 to 49. The burden of the epidemic varies
considerably throughout the world. The vast majority of infected people are found in low and middle-income
countries with 69% (23.5 million) living in Sub-Saharan Africa and about 15% (5 million) in living in the
regions of South, South-East and East Asia. About 1.0% of adults were living with HIV in Caribbean, Eastern
Europe and Central Asia in 2011 (1, 2).
Sharing needles and injection equipment is thought to be three times more likely to transmit HIV than sexual
intercourse. Globally, an estimated 14 million people aged 15-64 inject drugs with 1,6 million living with HIV
(3). According to the World Health Organization, on average, 10% of new HIV infections around the world
are caused by injection drug use (4), a figure that rises to 30% outside the Sub-Saharan Africa region. Forty
nine countries have found that injecting drug users (IDUs) had 22 times the rate of HIV infection as the
general population, with prevalence at least 50-fold higher in 11 countries than for the population as a whole
(2). The following regions rank as highest in terms of HIV prevalence among IDUs: the Russian Federation
(21%), the United States (15%) and China (10%). Together these three countries account for almost one half
(46%) of the global number of HIV positive IDUs (3).
Injecting drug use is also an important risk factor for transmission of tuberculosis (two to six-times higher
than compared to non injectors (5)) and other infectious diseases. Although existing data are far from
adequate, globally, an estimated 7.2 million injecting drug users might be infected with hepatitis C and 1.2
million with hepatitis B (3). Other research suggested that 6.4 million IDUs were anti-HBc positive, and 1.2
million were HBsAg positive (6). Compared with the general population, IDUs have an elevated risk of death
especially those who live in low-and middle-income country and are HIV positive (7). According to UNODC,
between 0.54 and 1.3% of deaths among adults can be attributed to illicit drug use (3).
In order to address drug-related harms, WHO strongly supports evidence-based methodologies such as
harm reduction and has defined a comprehensive package of interventions in the area of prevention,
treatment and care of HIV infection among people who inject drugs (4, 8). It includes:
However, in many low- and middle-income countries where the HIV epidemic is driven by injection use, a
limited progress in slowing the spread of HIV among IDUs has been observed.
2. HIV AND DRUG EPIDEMICS IN VIETNAM
In Vietnam, injection drug use is the main factor driving the country’s HIV epidemic. The HIV virus was first
recognized in Viet Nam in Ho Chi Minh City (HCMC) in 1990 and spread rapidly across the country. In
December 2012, the number of people living with HIV in Vietnam was estimated to be 250.000 [200,000-
330,000](9). People aged 20-39 years account for more than 80% of all reported cases (Ministry of Health
2012).Although HIV prevalence rate among adults aged 15 to 49 is relatively low (0.5% [0.4% - 0.6%], it is
much higher among three populations defined by high levels of HIV-transmission risk behaviors: IDUs, Men
who have Sex with Men and female sex workers.
Between 1994 and 2004, the number of opiate addicts tripled. Together the two biggest cities of HCMC and
Hanoi contributed more than a third (36%) of the total number of opiate users while accounting for only
10,7% of the total population of the country (Ministry of Labor, Invalids and Social Affairs
1
, MoLISA, 2004).
1
MoLISA is the Government body responsible for managing drug dependence treatment
 Needle and syringe programs (NSPs)
 Opioid substitution therapy (OST) and other evidence-based drug dependence treatments
 HIV testing and counseling (HTC)
 Antiretroviral therapy (ART)
 Prevention and treatment of sexually transmitted infections (STIs)
 Provision of condoms for people who inject drugs and their sexual partners
 Targeted information, education and communication (IEC) for people who inject drugs and their
sexual partners
 Prevention, vaccination, diagnosis and treatment for viral hepatitis
 Prevention, diagnosis and treatment of tuberculosis (TB)

5. 5
At the same time, heroin supplanted opium as the most preferred drug particularly among urban young
users. This period also marked a shift in the mode of administration, from opium smoking to heroin injection
and this had important implications for the spread of infectious diseases including HIV, HBV and HCV (10,
11). Over the past decade, the use of methamphetamines has increased in Southeast and East Asia (12). In
Vietnam, ATS users account for 6.5% of all drug users (Ministry of Public Security, MoPS, 2011).
According to the Ministry of Public Security (MoPS, May 2012), there were 171,400 recorded drug users of
whom 85% use heroin (73% through intravenous injection). The number of IDUs is estimated at 217,000
(VAAC
2
, 2012) though many informants believe the actual number to be much larger because families often
support drug purchases in an effort to spare the drug user the consequences of being identified by Police.
National HIV prevalence estimates among IDUs ranges from 13.4% to 31.5% (13, 14) with some locales
having higher rates. Although other data source indicates a decrease in HIV prevalence among IDUs from
29.4% in 2002 to 18.4% in 2009 (15), in Vietnam IDUs remain the highest risk group for contracting HIV.
In this country, drug use is not only illegal, it is also officially (in Government policy) still considered as a
“social evil” (prostitution, addiction, theft). Historically, the response of the government to illicit drug use has
relied on repressive measures. Police crackdown have driven IDUs underground for fear of being arrested
and sent to ‘06’ centers where they receive detoxification, moral education and labor therapy (16-19). As of
May 2013, there were 121 rehabilitation centers in the country capable of housing approximately 70,000
drug users but with a 2013 steady-State estimated at 25-35,000. These compulsory drug rehabilitation
centers have received numerous UN and international criticisms (17, 20, 21)
A progression of HIV infection from circumscribed at-risk groups to the general population from the
interaction between injecting drug use and sex work prompted Vietnamese authorities to take vigorous harm
reduction, testing and treatment steps. In 2006, the Law on HIV/AIDS Prevention and Control clearly outlined
“the promotion of the use of condoms and sterile needles and syringes, treatment of opioid addiction by
substitution…to prevent HIV transmission” as one of the key prevention measures. (Article 2, Clause 15)
(14). The Vietnamese Ministry of Health started the Methadone Maintenance Treatment (MMT) program in
2008 with the launch of six pilot projects in HCMC and Hai Phong.
3. STUDY RATIONALE, HYPOTHESIS AND SIGNIFICANCE
3.1. Study rationale
The effectiveness of methadone maintenance therapy, widely documented in scientific literature as the gold
standard for treatment of heroin dependence (22-24) has also been demonstrated in the Vietnamese context
(13, 15, 25, 26). Furthermore, MMT has also proven to be a cost-effective intervention in Vietnam especially
when integrated with ART for HIV-positive drug users (27-29).
One of the national goals is to expand the national MMT program to 80,000 patients by 2015 (30), a target
identified as having the greatest impact on halting the HIV spread among IDUs (31). About 14,000 IDUs
were receiving methadone in 62 clinics implemented in 20 provinces by August 2013. Despite a strong will to
expand the MMT program ((13), four main issues seem to hinder its rapid scaling:
This situation is all the more worrying when seen within the context of a gradual reduction of international
funding from 2012. Now that Vietnam has attained middle income status, US support from USAID and CDC
is planned to gradually diminish substantially during the next 5 years and Vietnam must be prepared to bear
a greater part of the HIV/AIDs burden.
2
The Vietnam Administration of HIV/AIDS control is the General Department of Preventive Medicine and HIV/AIDS
Control within the Ministry of Health that coordinates and implements national HIV programs and activities
1- Legal framework: conflicts between public health vs. “social evils” ideology, law, decrees and
regulatory guidelines.
2- Regulatory responsibility: between the Ministry of Health (MoH), the Minisry of Labor, Invalids
and Social Affairs (MoLISA) and Ministry of Public Security (MoPS) for the implementation of
harm reduction and the management of drug users
3- Financing: Government commitments in wake of phased international withdrawal
4- Technical factors: including staffing pattern, training capacity, quality assurance and
methadone drug supply purchasing system

6. 6
The study conducted in Vietnam between April and August 2013, was intended to explore the context of
MMT implementation and categorize the most problematic issues encountered in scaling up. These
interacting issues were analyzed through a cross-sectional qualitative study. Semi-structured interviews with
key respondents involved in the development of MMT provided general information about implementation
and operating issues.
3.2. Hypothesis
 The working hypothesis is that competing and overlapping responsibilities between the three
ministries directly charged with HIV and illicit drug (Ministry of Health, Ministry of Public Security and
Ministry of Labor, Invalids and Social Affairs) will have proven to be more difficult and time-
consuming to address for the development of MMT than resources factors such as staffing, space
and equipment.
This study was conducted in the framework of a scientific cooperation between the firm Urban Care LLC
(Hanoi) and the French Institute of Public Health, Epidemiology and Development (ISPED), with the
technical support of the American NGO FHI 360. It produced respondent information on the implementation
and scaling-up of MMT in Vietnam, based on interviews with international donors and NGOs, institutional
actors and technical consultants. Practical data sources were provided through interviewing stakeholders
from one clinic in the late planning stage. The Bach Mai Hospital MMT Clinic and National Training Center
will be housed at the National Institute on Mental Health and will be affiliated with Hanoi Medical University.
This is the first hospital-based MMT clinic.
3.3. Significance
This study identified and categorized key issues for the scaling-up of methadone and surveyed solutions that
should be applied in order to overcome the most problematic of these issues. Based on the experience of
various stakeholders, lessons and recommendations were drawn for the development and rollout of future
clinics.
OBJECTIVES
1. Main objective
Describe and analyze the implementation of MMT in Vietnam from the perspective of four domains: 1) Legal
framework, 2) Stakeholder responsibilities, 3) financing and 4) technical factors with a view to supporting the
development of future MMT clinics.
2. Specific objectives
1. Assess the public health context of HIV prevention and IDUs’ care management in Vietnam and the
country’s gradual shift to harm reduction
2. Describe the MMT implementation and scaling-up program: players involved, resources needed
(human, financial, technical) and identify priority impediments to be addressed
3. Draw lessons and recommendations based on the stakeholders' experience, for the development of
future MMT clinics
METHODS
Study design: This Overview of the national Methadone Maintenance Treatment (MMT) program in Vietnam
was conducted from April to the end of August 2013.
This is a cross-sectional qualitative study aimed to formulate practical recommendations based on the
experience of various stakeholders, for the development and rollout of future clinics.
Semi-structured interviews have been developed uniquely for this study, however some items have been
taken from published or validated studies. In addition, focus group discussions of drug users were organized
to provide background information about prevailing drug abuse practices in Hanoi.
The respondents were recruited as an initial convenience sample and early informants were encouraged to
recommend additional informants from diverse sectors.

7. 7
1. Information & literature review
Search strategy and selection criteria: Between October 2012 and August 2013, a literature review was
conducted on the three following domains:
1) Global epidemiology of HIV/AIDs and harms related to injection drug use;
2) Harm reduction approach with a focus on MMT;
3) Vietnam specific epidemiology and legal framework.
Peer-reviewed database search: Peer-reviewed literature databases PubMed, Scopus and the Cochrane
Library were searched. To ensure the currency of data, articles published between 01/01/2008 and
08/25/2013 were selected. Data from more recent years were taken in preference to data from earlier years.
Unpublished reports were excluded. Terms included those relating to: HIV infection and prevention;
intravenous substance use, substance abuse, people who inject drug, harm reduction approach, substitution
treatment, methadone maintenance treatment, in the general context and in the Vietnamese context. The
search included MESH terms and text words to enhance retrieval of relevant studies.
Web-based grey literature: Web searches were also undertaken to obtain grey literature. Websites
identified as sources of information relating to HIV and injecting drug use were searched together with
websites of UN agencies, relevant non-governmental organizations and in-country data provided by the
Ministry of Health/ Vietnamese Administration of Drug Control. Websites were searched for key words by use
of their own search function or with Google advanced search.
2. Survey among key stakeholders
Study design: This qualitative survey was conducted in Hanoi between June and July 2013.
Study population and sampling: Twenty four persons involved in the field of harm reduction and in the
management of drug users at the national level were contacted to participate for interviews; 2 declined. In
total 22 key informants representing three stakeholders’ categories participated in interviews:
o International Stakeholders: 15/17 international stakeholders from international agencies, international
donors, non-Governmental organizations and international research institutes
o National and Local institutional Stakeholders: 5/5 national and local Vietnamese decision makers
from health and social sectors
o Local Non-institutional Stakeholders: 2/2 representatives from community-based organizations
Design
Components
Tools Purposes
1-Literature
review
 PubMed
 The Cochrane Library database
 Scopus
 Websites of the United Nations agencies,
including UNAIDS, WHO, UNODC, UNDP
 NGOs websites (FHI 360, PSI, CARE)
 VAAC/ Ministry of Health
 Background HIV and
addiction epidemiology
 Harm reduction &
MMT
 Vietnam specific
epidemiology
 Review of legal
framework
2-Survey
of stakeholders
Semi-structured interview guides were developed:
 For International & national stakeholders
(SSINAT) with a focus on MMT implementation
and scaling-up
 For local stakeholders from Bach Mai hospital
MMT Clinic, NIMH, HMU (SSILOC) with a focus
on the key issues during the implementation of a
new clinic. Additional questions on training
capacity were designed for NIMH & HMU
respondents
 Information and
lessons learned on
MMT from various
stakeholders
3-Survey of
drug users
Semi-structured interview guides were developed :
 for MMT patients (SSIMMT)
 for Active IDUs (SSIDU)
Background information about:
 MMT program entry,
barriers and legal risks

8. 8
The primary respondents were recruited using a convenience sample based on an initial list of contacts
prepared in cooperation with FHI 360 and Urban Care. One or two persons were contacted in each
organization. If identified contacts were not available, other persons were identified within the organization as
alternatives. Secondary respondents were identified in conversations with primary respondents
Data collection: semi-directive interviews were carried-out face-to-face or by Skype. Two semi-structured
exploratory interview guides were used: one for the International and National Stakeholders within the
general framework of the MMT scaling-up program; one for the Local Stakeholders involved in the
implementation process of the new Bach Mai Hospital MMT Clinic. Each interview was carried-out in a
confidential space and took about 45-60 minutes. If the respondent did not speak English, the interview was
held in Vietnamese with the support of an EN-speaking staff from Urban Care.
Data management and analysis: To enable a more open dialogue and given the sensitive nature of the
subject, none of the interviews were audio-recorded. The interviewer took notes during the meeting and
synopses of each interview were added after the meeting. For confidentiality reason, a unique random 4-digit
number was assigned to each interviewee’s data. None of the resultant anonymized interview data was
linkable to the name or role of the respondent—except by the principal investigator.
The data was analyzed and summarized according to the four domains of discourse. For that purpose, a
specific Microsoft Excel grid was created to score or quote from the results collated from the semi-structured
interviews guides. Consensus (or non consensus) on key issues were noted. For each study question, the
most common and repeated answer was summarized. Participants' similar examples and phrases were
grouped for each theme. New and important identified themes were added during the data analysis. Different
points of views and discrepant ideas were also noted and explored
Design limitation: The study has several limitations. The respondents were not representative for all
stakeholders involved in the field of harm reduction and management of drug users in Vietnam. For example,
the Ministry of Public Security and their narcotics control division was not queried. Findings from this study’s
urban perspective may not be transferable to other, particularly rural settings. This study is based on
stakeholders’ perceptions and response bias is likely. In order to reduce institutional biases, key informants
were selected from a range of relevant statutory agencies, including international and local stakeholders,
institutional and non-Governmental organizations. The aim was to present a variety of opinions and
perspectives, based on respondents’ particular insights.
3. Survey among MMT clients and active IDUs
Study design: In June 2013, 5 MMT clients and 9 active IDUs not registered in any MMT program were
surveyed through semi-structured interviews and focus group discussions. This survey aimed to get
additional background information on community drug abuse practices and on entry processes for MMT
programs, including barriers and perceived legal risks.
Study populations and sampling:
 MMT clients in Hanoi: Our source population was composed of a sample of 4 male and 1 female
former IDUs, aged more than 18 years, registered in a MMT program for more than 6 months and
willing to participate in the study (convenience sample) in order to share their experience. The focus
was put on their experience as MMT patients and the steps they had to go through to enroll.
 Active IDUs not registered in any MMT program in Hanoi: our source population comprised a
sample 9 active male IDUs, aged more than 18 years, not registered in MMT program and willing to
take part in the study (convenience sample).
Data collection: Two specific semi-structured exploratory interview guides were designed: one for MMT
patients, one for active IDUs. Some sections of these interviews guides were adapted from international
reference documents. Respondents were contacted and informed about the survey through the intermediary
of a self-help group. The investigator met the MMT patients and active IDUs exclusively face-to-face.
Five semi-structured interviews were conducted with MMT patients. Two focus-group discussions were
conducted with active IDUs. All the meetings were held in Vietnamese language with the support of an
English-speaking translator. The interviews took about 60 to 90 minutes. Interviews were conducted within
the premises of the self-help group, a place where respondents could feel comfortable and private.
Respondents were given an incentive of 100,000VND (US$5) for transport costs.
Data management & analysis: To protect confidentiality, a random 4-digit number was assigned to each
interviewee’s data. Themes and sub-themes were recorded in a specific grid (Microsoft Excel form) derived
from the semi-structured interview guides.

9. 9
ETHICAL CONSIDERATION
The research protocol and the informed consent forms were submitted to the Hanoi School of Public Health
in May 2013 and were approved in June 12
th
, 2013. In compliance with the ethical, legal and regulatory
requirements for research on human subjects, all participants were informed beforehand about the purpose
of the study, their right to withdraw at any time and that their individual data would be kept anonymous. Each
participant was asked to sign a written informed consent prior to the interview. Participation in this study was
anonymous and entirely voluntary. No personal identifier was stored with data. All study-related data were
organized under random codes and were stored securely at the Urban Care LLC office. Identifiers and coded
data were encrypted and stored separately. Only the Principal Investigator had the means to link respondent
to data. All participant information, study data-collection forms and reports were stored in a locked area. Data
stored in the principal investigator’s computer were encrypted and password-protected. Daily backups were
made on an external hard-drive.
RESULTS
The context of MMT implementation in Vietnam:
 Most informants mentioned the HIV epidemic as the main reason why Vietnam decided to adopt
harm reduction, including methadone maintenance treatment (MMT)
 The evidence-based effectiveness of MMT to reduce drugs injection and HIV transmission was
highlighted by the majority of respondents especially when compared to other drug treatment
approaches that are still used in Vietnam, such as detoxification in the community or in compulsory
‘06’ Centers. Most informants mentioned the lack of effectiveness of prior approaches along with
international human rights criticisms as an additional reason to justify the implementation of MMT.
 Despite the well-documented failure of the “06” system, about one quarter of respondents argued
that the implementation of a national MMT program did not happen overnight and involved political
battles at the highest level. Half of informants emphasized that donors’ pressure (including financial
support) was strong and played a positive role to convince the policy makers to move on.
 About one third identified different economic reasons that influenced the decision to implement MMT.
Towards MMT scale-up:
 Interviewees emphasized the remarkable changes undertaken by Vietnam over the past decade
towards a more progressive approach to drug use. A majority of them were supportive of the rapid
scale-up of MMT and believed that Vietnamese society at large has evolved and was more
accepting of harm reduction.
 Several stakeholders from the Government health sector and international organizations pointed out
the positive achievements of this program:
“The methadone program in Vietnam is among the most successful in the world in terms of
adherence to treatment, low dropout, lack of overdoses and stopping heroin use. Although there
is about 15% of the population of people on methadone who are still using heroin after 6 months,
that’s among the lowest in the world” (a respondent from an international agency).
Benefits for MMT Patients
Among the 5 MMT patients who were interviewed: one has been treated for 6 months, three for 10 to 15
months, one for 4 years. Cited MMT benefits included:
 Improved relationship with the relatives and income opportunities (5/5). “I don’t need to chase
after money all the time” (3 MMT patients).
 Reduced or stopped use of injection drugs (3/5). “I regret all the years when I was addicted to
drugs. Now I feel free” (a MMT patient).
 Improved health status “My life is better, my health has stabilized. I gained 10 kilos in one year”
(a MMT patient).
All considered that the benefits outweighed the constraints such as the need to go to the clinic everyday
(4/5), the side effects (3/5), the loss of pleasure (2/5). All would recommend MMT to an IDU friend: “All
IDUs want to get rid of drugs. The life of an IDU is like a circle, you can't ever get out. The drug controls
you. Without methadone I would not have been able to get rid of the drug” (a MMT patient).

10. 10
 However, without being opposed to the use of methadone, other stakeholders expressed
reservations on the publicity given to this treatment.
“The harm reduction approach is pushed by the central level but I’m not sure that there is a
widespread acceptance. We have to be very careful with the message about MMT. There is a risk
to presenting methadone as a magic bullet … We should ask what will come after that. What else
will be available?” (a respondent from an international agency)
“Even if the MoH achieves its goal to treat 80,000 IDUs with MMT by 2015, over half of the total
number of IDUs won’t have access to this treatment. They will need to receive another kind of
support such as detoxification, counseling, education and vocational trainings” (a respondent
from the public social sector).
 A large majority of respondents agreed that the biggest problem was the lack of availability of this
evidence-based drug treatment.
Key findings
When asked about the main reason(s) for blockages and delays in MMT scale-up:
1- Almost all respondents (19/22) identified conflicting objectives and responsibilities between
ministries charged with HIV and illicit drug (Ministry of Health, Ministry of Public Security and Ministry
of Labor, Invalids and Social Affairs) as a key obstacle. Of them, about 60% cited this reason as the
most problematic issue.
2- More than two-thirds (15/22) regarded the lack of MMT supply, training capacity and human-
resources factors as very problematic. Out of them, about a quarter ranked these technical aspects
as the number one impediment.
3- 41% (9/22) mentioned financial aspects and more specifically difficulties to sustain the stand-alone
model. Of them, 18% considered that funding was the biggest barrier.
4- More than one quarter (6/22) considered that discrepancies in the legal framework had a negative
impact on MMT scale-up. Of them, 14% ranked this as the biggest issue
1. Contradictory and Competing Responsibilities
A majority of respondents identified competing responsibilities between the three ministerial agencies in
charge of the management of IDUs as the key issue for MMT scale-up. Two thirds of respondents specified
that conflicts between law enforcement and health sector were nurtured by negative perceptions of drug
users and differing understandings of drug addiction.
 Stereotypes and prejudices against drug users are still deeply rooted in the culture according to the
majority of respondents.
“The main issue is the way society views IDUs as ‘social evils’. This is not only the society, it is
also the Government’s view and it has an impact on the society” (a respondent from an
international agency).
“You still have this approach to lock them up. Stigma around drug use is very high” (a respondent
from a research institute).
Stigma from an IDUs’ Perspective
 “The main difficulty is stigma. Even when you get rid of the drug, people don't believe you” (an IDU).
 “I need people to give me a job but nobody trusts me, not even my family” (an IDU).
 “It's hard for IDUs to make a living. It's a vicious circle: they need money to buy drug but they can't find
any job as nobody trust them. Then they commit small crimes and are sent to 06. When they go back
to the community, people look down on them. They even feel worse and use drug again, they can't
help doing drug" (a MMT patient)
Finding 1.1. Ideology and Criminalization:
Vietnamese culture remains strongly rooted in social evils thinking about addiction

11. 11
 A large majority of respondents linked stigmatizing attitudes towards IDUs to differing perceptions of
drug addiction.
“MoPS and MoLISA still think that addiction is a curable disease. They are really concerned about
relapse” (a respondent from the public health sector).
 However, a few informants disagreed with these views:
“The Government has organized a big conference to disseminate Decree # 96. The chairmen and
vice chairmen of the 63 provinces, people from MoPS and from MoLISA were invited. During this
meeting, it was repeated that drug addiction is a chronic disease” (a respondent from the public
health sector).
“The Government and MoLISA have changed their point of view on addiction treatment … Before;
addiction in Vietnam was considered as a social evil, a vice, now we understand that drug
addiction is a brain disorder” (a respondent from the public social sector).
 When asked if those divergent points of views could be attributed to a lack of information, one third
of respondents had no opinion on this question; about 40% agreed that a lot of investment and
efforts were made to train Police and MoLISA on harm reduction which has helped.
 However, most of respondents also acknowledged that trainings did not necessarily target the right
audience, namely the direct implementers.
“Police and MoLISA are sensitized to harm reduction at the high level, at the managerial level, but
not at the grass-roots level” (a respondent from an INGO)
 Accordingly, about one third of respondents considered that at local level, Police and DoLISA should
be further trained.
 The implementation of MMT has been included in the Renovation Plan for ‘06’ Centers. This plan
also includes the provision of services that appear to be lacking in the current MMT program,
according to several respondents:
“Apart from medication, nothing else is offered to clients … MoLISA can play a role in providing
psychosocial support, vocational trainings, income generation activities” (a respondent from an
international agency).
“There are more and more drug users using ATS [Amphetamine-Type-Stimulants] in Vietnam.
There is no medicine for ATS. Only education works” (a respondent from the public social sector).
 However, several informants expressed reservations about having a ministry taking the lead on
psychosocial activities:
“In Western and Northern countries, these [psychosocial] aspects are usually managed by NGOs
and private actors rather than by State actors” (a respondent from a research institute).
The need to empower civil society through contracting with community-based support groups to
provide services was mentioned.
 Moreover, several stakeholders expressed concerns about the lack of cooperation between MoH
and MoLISA ministries:
“We know nothing about this plan. We have not received any document, we are not invited to the
meetings; we are not asked to be involved in the drafting process” (a respondent from the public
health sector).
“The plan of MoH and the plan of MoLISA are developing in parallel … Both MMT and
psychosocial approaches are components of treatment but they are in the hands of two different
ministries. This contradiction should be further clarified and it has not been done at the highest
level of the Government” (a respondent from an international agency).
Finding 1.2. Training at Local Level:
Harm reduction trainings have targeted the leadership rather than the grass-root levels
Finding 1.3. Inter-Ministry Competition for Management of Addicts:
MoH and MoLISA have few collaboration and have developed separate plans for
treatment of heroin addiction.

12. 12
 A number of doubts also emerged regarding the capacity of a ministry with no expertise on MMT to
run such program.
“The Government thinks that we need to set up MMT services outside the mental health system
but drug abuse is a mental health issue and MoLISA don’t have the background, the knowledge”
(a respondent from the public health sector).
 About one quarter reported that competing responsibilities between ministries was reflected at the
grass-roots level through imposing more bureaucracy:
“The implementation of MMT programs is very complicated in terms of procedures” (a
respondent from an INGO)
“Even though Decree # 96 simplifies the procedure … a circular [n°12] was needed to provide
clear guidance on the implementation process. It took 6 months to have it issued [on April
2013]. It has delayed the opening of new clinics” (a respondent from the public health sector).
 The lack of coordination between ministries also caused confusion regarding who is doing what at
implementation levels according to the majority of informants. However, one respondent from the
public health sector found the cooperation between MoH, MoLISA and MoPS fully satisfactory, at
least in Hanoi.
 Interestingly, several respondents identified the role played by provincial authorities
3
in MMT
implementation as a good way to counterbalance ministerial squabbling and reduce contradictions.
“Before Decree # 96
4
, we needed a consensus from many stakeholders. The implementation of
MMT depended very much on the commitment of local governors. Without enough commitment,
MMT could not expand rapidly” (a respondent from the public health sector)
 More specifically, the People’s Committee was described as the cornerstone of MMT scale-up:
“Wherever there is a committed People’s Committee, MMT expands rapidly” (a respondent from
an INGO).
 However, the level of commitment varied considerably from province to province.
“We assumed that People Committees are taking a strong role whereas they haven’t always,
they have left if to the ministries, to the Police or DoLISA. (…) Hanoi is a very good example of
where the PCs have been very weak in supporting the expansion of methadone” (a respondent
from an international agency)
 There was a consensus among respondents that in the provinces where local Governments did not
provide strong leadership to implement MMT, conflicts occurred between Police and health sector.
“In some provinces, local governors and Police were not supportive of MMT. Even though
they had a high number of IDUs, they did not want to expand MMT” (GOV_2889)
 The vast majority of informants mentioned the fear of being identified by Police as the main reason
that could prevent IDUs for seeking methadone:
3
Vietnamese provinces are controlled by a People's Council, elected by the inhabitants. The People's Council appoints a
People's Committee, which acts as the executive arm of the provincial Government
4
The Decree # 96 regulating Substitution Treatment of Opioid Addiction was adopted in November 2012.
Finding 1.4. Lack of Ministry Harmonization:
MoH, MoLISA and MoPS have competing objectives, lack of coordination, large
bureaucracies and blurred MMT implementation responsibilities.
Finding 1.6: Fear of compulsory detention:
IDUs are afraid to apply for MMT because of arrest and detention risks.
Finding 1.5. Local Peoples’ Committees:
Local support, including partial financing, is essential for initial implementation.

13. 13
“In some places the drug users … have been required to enroll first with the Police as drug users
and only then would they be allowed to enroll in methadone … Across the country, some drug
users managed to escape registration for many years, and it’s of course quite threatening to have
to go to the Police to register” (a respondent from an international agency).
“There is a serious risk for them of being arrested if they disclose their addiction” (a respondent
from a research institute).
“People are afraid to be sent to 06 if they apply for MMT, especially in Hanoi” (a respondent from
a local NGO).
 Most of respondents stressed that the arrest quota were a major barrier for patients enrollment.
 Another frequently, not to say systematically cited barrier was the complexity to enroll in MMT,
especially in areas where demand significantly exceeds supply.
“The registration mechanism was very complicated. It used to include many steps and
stakeholders” (a respondent from international donors).
“Many users don’t have certificates of residence which is a major barrier to MMT access” (a
respondent from a research institute).
 About two thirds of respondents agreed that this cumbersome registration process along with the
scarcity of methadone supply left room for corruption. Several informants suggested that this
situation may have resulted in an under-representation of socio-economically vulnerable IDUs in
MMT.
 Nevertheless, a few informants stressed that this strict selection process certainly helped reassuring
and convincing the policy-makers:
“In the pilot phase, we needed to have very compliant patients in order to demonstrate the
effectiveness of MMT” (a respondent from international donors).
 More than one third of informants urged to simplify the selection process and leave this responsibility
to the health sector alone. Other respondents recalled that Decree # 96 marked a decisive step in
this direction:
“Overall, Decree # 96 is good. The question is: how to put it in practice? How to ensure that the
criteria of selection and the selection process described in the decree are fully applied and
respected?” (a respondent from an INGO).
Reasons that could prevent IDUs for applying to MMT from an IDU’s Perspective (1/2)
 “It's difficult to disclose addiction. You can be put on the list and sent ‘06’” (an IDU).
 “There are 2 categories of people in MMT: 1) those who really want to get rid of drugs, 2) those who
want to register to be protected by the program and avoid being arrested by the Police. The ‘06’
system still needs to have people in the centers. There are 2 competing systems between MMT and
‘06’. It slows the process and makes the target of having more IDUs treated with MMT impossible to
reach” (a MMT patient).
Reasons that could prevent IDUs for applying to MMT from an IDU’s Perspective (2/2)
Of the 14 IDUs and MMT patients who were interviewed in Hanoi, 13 considered that the entry process
was far too complicated and was likely to discourage IDUs to apply.
 "You need to have the stamps from many agencies: health station, Police, People’s Committee... Then
the application file is submitted to local authorities then it goes to district level ... It's very difficult to get the
stamp from the Police” (an IDU)
 “Too many people are involved in the process of selection. It makes everything complicated and slow. At
the policy level everything looks good but at the implementation level it really depends on the goodwill of
people, especially Police” (a MMT patient)
Finding 1.7. MMT Enrollment Complexity
The selection mechanism for MMT has too many steps and too many stakeholders.

14. 14
2. Technical Factors: MMT Supply, Training Capacity and Human Resources
 More than half of respondents expressed serious concerns regarding the lack of methadone supply.
A few among them considered that developing local production could help address this issue, a
suggestion in line with the MoH’s objectives to cover 80% of the needs with locally produced
methadone by 2015. However this aim seems far from being achieved. To date, all the methadone
used in Vietnam is still imported. Several options are presently being discussed to overcome this
difficulty:
“Vietnam will try to produce methadone step by step. A first step could be to import the raw
materials (powder) then manufacture finished product in Vietnam. We have identified 5 local
factories that are able to do it. We sent our proposition to the Government in July. If it is
approved, it could make methadone cheaper. Malaysia does that and in this country it contributed
to reducing the cost” (a respondent from the public health sector).
However, most of informants doubted that domestic production would be a cost-saving option:
 Concerns were expressed regarding the lack of committed funding for methadone drug purchases
against the backdrop of tight negotiations between international donors and Government. On the one
hand, donors have set purchase limits on methadone to encourage Vietnam to sustain MMT as a
program within the national budget; on the other hand, the Government is delaying making such
commitments partially to test donor resolve and partially to press for continuing donor commitment
because of the manifestly large unmet needs.
 The MMT procurement and supply management was another source of concern. In Vietnam, this
responsibility is predominantly ensured by PEPFAR through the Supply Chain Management System
(SCMS). One of SCMS’ duties is to support the Government to develop sustainable narcotics supply
chain management so as to meet the requirement of MMT scale up. However, more than half of
respondents working at MMT operational level were highly critical.
“MMT procurement is a disaster, the PEPFAR system is an aberration. Over the past 10 years,
PEPFAR has handled everything in terms of procurement [including ARV]. As a result, there is no
national supply chain system and the fact that PEPFAR manages everything does not foster
Vietnamese authorities’ involvement. It’s a vicious circle” (a respondent from a research institute)
Without being opposed to these criticisms, one informant from international donors stressed that
SCMS could not be held solely responsible for this situation.
“SCMS is trying to work more efficiently and transfer capacities to Vietnam [but] we need a clear
sense of ownership from the Government of Vietnam” (a respondent from international donors).
However, one respondent from the health sector estimated that “the country had the full capacity to
manage the MMT program without SCMS support”
SCMS was reached but did not respond to our request for an interview.
 The availability of trained staff was seen as another major source of concern by respondents. At the
pilot phase of MMT program, the trainings were mostly, not to say exclusively, ensured by
international experts. They are now provided both by international experts and national staffs from
VAAC and PAC. There is a training unit within the MoH health AIDS division which is strongly
supported by the donors, by FHI predominantly. Despite the efforts invested in training, about 40% of
respondents considered that the national capacity remained insufficient.
 In order to build this expertise in anticipation of a gradual donors’ withdrawal, the Government has
recently assigned leadership and training authority to the National Institute of Mental Health (NIMH)
affiliated with the Hanoi Medical University (HMU). At regional level, two more psychiatrist hospitals
and one medical university (HCMC) are expected to complete the supply of training.
Finding 2.1: Methadone Drug Supply:
Negotiations between Government of Vietnam and international donors over methadone
drug purchases are a proxy for clarifying the level of future international financial support
Finding 2.2: National Training Capacity:
INGOs provide almost all MMT trainings. Mental health has been assigned national
responsibility but has not developed a master training plan to date.

15. 15
The majority found it surprising that NIHM and HMU were entrusted with the responsibility of
becoming the National training center on MMT. Very few respondents considered that NIMH/HMU
had the requisite expertise to assume this responsibility. Questions also arose regarding their human
resources capacity in a context of increasing demand for training. In this context, concerns emerged
regarding the quantity and quality of training when donors pull out.
 The lack of training capacity is reflected at grass-roots level on the difficulty to recruit qualified staff
for MMT program.
“Today, there is no addictionist in this country. People were trained to rapidly provide patients
with minimum care and that’s it” (a respondent from a research institute).
 Staffing patterns and salary: The staffing structure of MMT stand-alone clinic currently comprises 11
to 15 staffs including: 2 physicians, 1-2 nurses, 1 lab technician, 2-3 pharmacists/ dispensers, 2
counselors, 1-2 administrative staff, 2-3 other staffs (cleaners, guards).
Decree # 96 limits staff members responsible for MMT technical aspects and for providing treatment
to the following categories: medical doctors having completed training on OST granted by a training
institution designated by the MoH; and staff who work full time at a MMT clinic
 According to several respondents, finding such qualified staff is a challenge in some provinces as
there is currently no curriculum on drug addiction treatment for medical students. It is also difficult to
motivate people: “they have to work every day of the week; they have to deal with difficult and
instable patients” (a respondent from the public health sector).
 Among MMT staffs, some are Government staff; some are project staff, the ratio depending on the
donor. For instance, staffing costs are shared on a 63/37 basis in FHI-supported MMT clinics.
Salaries supported by donors are higher than Governmental salaries. On average, personnel costs
represent 40% of total MMT clinic expenditures. More than half of informants expressed concerns
about potential staff shortage when donors reduce contributions or withdraw. With a view to MMT
scale up, maintaining the current staffing structure was considered unrealistic.
 A consensus emerged on the need to identify solutions to reduce staff costs. The idea of pooling
resources through integrating MMT into other health services was seen by the majority of
respondents as a good way of lowering the costs and improving treatment efficiency. It was also
perceived as a way to motivate the staff. The same recommendation applied to infrastructures with
the possibility to share certain services (administrative room, pharmacy, etc.) if MMT was integrated.
 Quality Assurance: Quality control was not mentioned as a top priority issue by respondents. Several
reasons were given. According to one respondent from an international agency as “we are running
short of time; the focus is put on the implementation rather than on quality control”. Several
informants stressed that MMT was not that difficult to manage:
“Methadone is remarkably safe and easy, it’s actually much easier than HIV treatment … I think
that the strong guidelines and the quite well established expertise we now have in methadone
clinics will be the basis for a reasonable quality program as long as they [the MMT clinics] are
used as teaching and trainings sites” (INT_3563).
Finding 2.3 Staffing Capacity:
Counseling is not a recognized profession in Vietnam. Addiction treatment is not in post
graduate curricula.
Finding 2.4: Donors Supplements for Salary:
Donors’ plan for financial withdrawal threatens staff sustainability.
Finding 2.5. Staff Inefficiency:
Redundancies need to be eliminated.
Finding 2.6: Quality Control vs. Expansion:
Rapid expansion to reach more heroin users is more important than quality control

16. 16
 Decree # 96 was referred to as a good reference document to ensure quality control. However,
several respondents considered that:
“Circulars are needed to clearly define respective responsibilities” (a respondent from an
international agency)
“Detailed standards should be developed [and that] an independent organization should be
responsible for assessing the quality of MMT services” (a respondent from international donors).
 According to a few informants, one of the best ways to ensure quality control was to build up a strong
team of technical assistance providers with local mentors in each province.
 Some informants from international organizations deplored the lack of appropriate monitoring and
evaluation tools and insisted on the necessity to improve the current monitoring and evaluation
system. However, a respondent from the public health sector pointed out that the data collection and
reporting systems were being improved.
3. Sustainable funding of Methadone Maintenance Treatment (MMT)
Closely linked with what was discussed earlier in this report regarding methadone supply, training capacity
and staffing salary, concerns about financing MMT program were identified as the third main impediment to
MMT scale-up. More than 40% of respondents questioned the financial sustainability of the program in a
context of gradual reduction of international funding. Among them, almost 20% considered that funding was
the most problematic obstacle.
 The majority stressed that now that Vietnam has reached middle-income country status, it was time
for the State to substantially invest in MMT. Although the State was supposed to fund most of the
program during the scale-up phase (2013-2015) this scenario does not appear to be likely. This
issue is all the more delicate that many uncertainties remain regarding donors’ funding in the coming
years:
“The donors are often giving schizophrenic messages to Vietnam: they announce that they will
reduce their contribution then finally they don't. Today we don't know what will happen” (a
respondent from an international agency)
“We don’t know what our level of funding is going to be … the timeline might be longer (a
respondent from international donors)
 According to a respondent from an INGO, international donors have actually committed to covering
up to 60% of costs during the MMT scale-up phase.
“Donors will provide technical assistance and medication; the remaining 40% which includes staff,
infrastructure maintenance, tests, etc. will be paid by the Government”.
 In order to further increase the State’s financial contribution without burdening the overall bill, more
than one third of respondents suggested reallocating part of “06” Centers budget to MMT program.
 To reduce dependence on donors, several respondents recommended targeting local authorities:
“There is too much expectation of the national Government to support this [MMT] when in fact it’s
the local Governments who will benefit most from this” (a respondent from an international
agency) as “they are the ones that can provide money to sustain this program” (a respondent
from international donors).
 Advocacy activities were mentioned as a good way to help them understand how cost-effective and
beneficial to the whole community methadone was.
Finding 3.1. State Investment:
State’s investment remains insufficient and long-term sustainability after donor withdrawal
is not secure.
Finding 3.2. Importance of Local Data:
Local authorities need local MMT outcome data to justify expenditures.

17. 17
 Although not all respondents spontaneously referred to funding when asked about the key issues for
MMT development, the vast majority of them criticized the original design of MMT clinics.
“The American agencies [PEPFAR] recommended stand-alone clinics, we recommended
integrated clinics. But there are not that many integrated services. There’s a couple in Hanoi that
are fully integrated into other district health services and that works in reducing the infrastructure
and the staffing cost. If you build a stand-alone clinic, there is quite substantial infrastructure cost
and on-going higher staffing cost” (a respondent from an international agency).
The majority of respondents insisted on the necessity to make this model cheaper especially now
that “Decree # 96 [article 31] requires that each district with 250 registered drug addicts implement
MMT” (a respondent from the public health sector).
 Numerous ideas surfaced to expand MMT at a lower cost, including a substantial increase in the
number of patients enrolled or the development of satellite dispensary models for stable patients.
 Several respondents agreed that it was crucial to develop services closer to people in order to keep
patients in treatment.
“In the long run, there is a risk that patients get tired of coming to the clinic every day. We see
that dropout rates are increasing (…) Mobile teams should be developed outside the clinics to
provide treatment to stable patients. It would help them have a social life, a job” (a respondent
from a research institute).
 A few respondents recommended implementing long-acting opioid substitution [such as LAAM]
which is cost-effective and/or “community or family-based DOTS as it has been already experienced
with ARV and TB treatments. It was also suggested that MMT clinics deliver methadone all day and
not only 2 or 3 hour a day as it’s the case today due to heavy paperwork.
 A broad consensus emerged on the need to integrate MMT into other health services especially in
remote areas. A broad range of health-care structures were identified by the respondents.HIV
services, district health services and mental health hospitals were cited as potential structures, with
the aim to reduce not only staff costs but also general infrastructure costs.
 A pilot co-pay model opened was introduced in June 2011 in Hai Phong. Treatment costs are
partially shared by drug users and Government. About three-quarters of participants saw this model
as an interesting way to sustain MMT and favor patient compliance provided that the costs remain
affordable. 13 out of 14 interviewed IDUs and MMT patients said they would agree to pay. However,
a few respondents expressed serious reservations about this model:
“Wherever the co-pay system has been implemented, for instance in China, it has not worked
well. This option should be used for short term only if it helps scale up access to MMT. But it
should not be considered as a long term answer to a chronic disease” (a respondent from a
research institute).
 Several respondents stressed that the private sector could play a pivotal role in MMT scale-up
“Transition for MMT is not a transition from donors support to MoH; the real critical step is
privatizing based on standards … This would help create a career path for people: Their
employment options would not be only in the public sector, they could make a career in the
private sector in addiction counseling, MMT and services around ATS use” (a respondent from
international donors).
Finding 3.3. Stand-Alone Model:
Stand-alone clinics of 250 patients are not cost-effective.
Finding 3.4. Integration of MMT:
The future of MMT is to become fully integrated within the local health care system.
Finding 3.5. Co-Pay Model:
In the future, patient co-pay and private-pay will replace some lost donor funding

18. 18
4. Legal Inconsistencies
 Participants generally acknowledged the progress made by Vietnam towards a science-based public
health approach. The legal framework has evolved accordingly.
“There is a greater harmonization between the HIV law and the Law on drugs. The law on administrative
violations has been amended and drug users should be entitled to due process” (a respondent from an
international agency).
“In the Renovation Plan for ‘06’ Centers it is said that no new compulsory treatment center should be
built. The current ‘06’ system should be partly converted into community-based drug treatment” (a
respondent from an INGO).
“Now the law considers that IDUs are not criminals but patients who should be treated with
compassion” (a respondent from the public health sector).
 Most of respondents claimed that the legal environment was no longer an obstacle and was actually
more supportive of people who use drugs than in many other countries.
 However more than one quarter considered that inconsistencies between legislations were an
obstacle to MMT expansion.
“Having different legal frameworks is clearly problematic. The amended law on Administrative
Violations still States that people who relapse can be sent to ‘06’ Centers. It’s not consistent with
the fact that drug dependence is a disease; it’s not consistent with HIV prevention” (a respondent
from an international agency)/
“Even though there is an improvement with the introduction of the “due process”, the court
procedures are still under definition (…) we expect that the definitions in the [future] decrees will
moderate the law” (a respondent from an international agency).
According to several interviewees, these discrepancies were likely to cause either conflicting
responses at the grass-roots level or a justification to do nothing.
 Article 21.2 of Decree # 96 calls for MMT termination for patients who test positive in two drug
toxicology screens after the first 12 months in care. A few stakeholders presented this article as a
“necessary evil” in a Decree which also contains many positive things.
 Almost all respondents strongly criticized this article. If strictly enforced, the consequences of this
article would be dramatic for the patients according to several stakeholders:
“This article is a big mistake. The objective of MMT program is to reintegrate people into society
and avoid that they transmit HIV, hepatitis and commit crimes. Evidence shows that even those
who continue injecting take less risk when they are treated. It would be a major step back to
exclude them from the program. Doing so, they would go back to high drug using and risky
behavior. Our efforts would be reduced to nothing” (a respondent from a research institute).
 Several respondents stressed that it could lead to a highly imbalanced power relationship between
patients and care giver:
“IDUs will have no other choice but to fake the urine tests if they want to stay in the program.
There is a risk of creating a feeling of mutual mistrust between patients and staff [and that] some
medical staffs use this information to blackmail patients” (a respondent from a local NGO).
 However very few respondents believed that this regulation has strictly been followed in the reality.
Finding 4.1. Enabling legal environment:
Systematic revision of laws, decrees, circulars and guidelines is underway, but compulsory
‘06’ center will continue to be protected
Finding 4.2. Relapse Remains A Criminal Offence:
Decree # 96/ article 21.2 (Nov 2012) terminates MMT for 2 relapses after 1 year.

19. 19
DISCUSSION
 The main finding of this study was in Domain 2 that conflicting objectives and overlapping
responsibilities between three responsible ministries (Ministry of Health, Ministry of Public
Security and Ministry of Labor, Invalids and Social Affairs) constituted the greatest barrier to
MMT scale-up. The main contradictions are between harm reduction policy initiatives and law
enforcement, a finding consistent with studies previously conducted in Vietnam (16, 18, 32-35),
China (34) and Cambodia (36).
 These impediments are not specific to low and middle-income countries. Many industrialized
countries have encountered similar difficulties. In France, under the Law relating to the trafficking
and use of drugs (Dec. 1970), policies towards drug users have been predominantly repressive. “It
needed the threat of AIDS and the disastrous situation for heroin users from the 1980s to the mid
1990s, for France to agree to try out a harm reduction strategy, officially limited to infection risks”
(37). In Russia, where HIV epidemic among drug users is among the fastest growing in the world,
substitution therapy is still forbidden by law.
 Although Vietnam has gradually moved from punitive control measures to evidence-based actions,
incompatible ideologies of drug addiction continue to collide among Government sectors, which has
been observed in other studies (32, 36). Article 21.2 of Decree # 96, which calls for treatment
termination for relapse occurring after the first 12 months, is a perfect example of competing views of
addiction. In this case, an initial treatment is considered a sign of a medical illness, but a relapse is
considered a sign of an anti-social decision. Drug use remains an administrative violation that can
lead to extra-judicial compulsory rehabilitation without due process, similar to systems observed in
other Asian countries such as China, Cambodia or Lao (38-41). A final judicial review will be added
in 2014, in part as a response to international human right criticisms.
 Few respondents believed that drug detention centers could be a suitable treatment or deterrent
against heroin (42); a large majority reiterated international criticisms regarding their lack of
effectiveness and human rights violations (21, 43). However, in spite of the Joint Statement issued in
March 2012 by twelve UN agencies that calls for the closure of these centers (44), 238,000 people
are currently detained in over 1,000 centers in East and South-East Asia (45, 46).
 Nonetheless, things seem to be moving towards greater respect of human rights. Vietnam may
gradually transform the majority of compulsory centers into voluntary treatment facilities as Malaysia
has done (41). Moreover, in a statement released on July 31
st
, 2013, the Global Fund announced
that the US$85 million grant signed in May 2013 with Vietnam includes a condition that requires the
government to identify an independent international organization to monitor compulsory drug
detention centers (47). According to this statement the GF has also been “closely working with its
Vietnamese counterparts to ensure a sensible timeframe to close the centers”.
 In spite of substantial efforts to raise awareness about harm reduction benefits, too little attention
was paid to the grass-roots level, especially to the local Police (33, 35). A similar observation was
made in Cambodia (36). Consequently, despite a strong demand for MMT, a significant number of
drug users may be reluctant to apply, fearing detection and registration by Police with subsequent
detention for years (14, 32, 35). Cumbersome entry processes, especially in areas where demand
outstrips supply, and Police’s involvement in selecting MMT patients (48), were considered as a
major obstacle, leaving ample room for corruption.
 Lack of cooperation between ministries (14, 18) is a basic barrier to MMT scale-up in an area where
“coordination is a critical ingredient for successful drug policy responses. (…) Poor coordination may
increase fragmentation, reduce accountability, increase the time and cost of responding, reduce
public respect for policies and lead to internal conflict between government sectors and service
providers” (49).
 This lack of coordination along with competition between MoH and MoLISA for the management of
drug users has resulted in blurred responsibilities and a lack of transparency. A top-down policy-
making process, mainly controlled by central State institutions (14, 18), has not favored the
involvement of provinces. This is a missed opportunity because local authorities were perceived as
likely to counterbalance ministerial delays and mobilize financial resources for MMT whenever they
were strongly convinced of the benefits of methadone for their community.

20. 20
 The next most problematic issues described by respondents were closely interwoven and
related to technical factors and financial sustainability. Vietnam, like other low and middle-
income countries, is faced with a twofold problem: 1) a heavy reliance on international funding
whose continuity is precarious in the current economic climate (40); 2) and a lack of domestic
resources “to quickly implement and scale-up treatment for opioid dependence” (50) particularly in
light of a manifest resistance by Government to reallocate financial resources from MoLISA’s
compulsory centers to the Ministry of Health for MMT clinics.
 Although Vietnam formally supports MMT, this “is not translated into adequate and sustainable
funding to ensure access to and good coverage of opioid substitution therapy” (51). Although
Vietnam’s economic growth rate remains high (estimated at around 5.3% in 2013), it is lower than
past years due to the effects of the global financial crisis (52). To what extent a worsening of global
economics affect future State investment in MMT is hard to predict. However, this scenario causes
great concerns especially considering the lack of committed funding for methadone drug purchases.
In the meantime, no new clinics have opened between October 2012 and June 2013.
 Stand-alone clinics were seen as financially not viable unless they serve more than 250 patients per
clinic. A repeated opinion was the necessity to integrate MMT into other health settings such as HIV
or mental health services (27, 29) and district health facilities. Integration was presented as a priority
option for improving treatment efficiency, particularly for the patients infected with HIV (50, 53),
overcoming geographical barriers and lowering the costs. However, integrating MMT raises
questions. If not done properly, there could be a risk of reducing drug addiction to a biomedical issue
only addressed with pharmaceuticals. In reality, drug addiction treatment is far more complex and
requires a comprehensive package of interventions (40) including: stimulant relapse prevention,
psychosocial support, job opportunities…What would happen to these services (viewed as partly
lacking in the current stand-alone model) in case of integration, remains uncertain.
 The co-pay model, where costs are partially shared by patients and State, was regarded as an
additional way to sustain the program and increase patient capacity. Interestingly, IDUs expressed
willingness to pay for MMT, provided that costs remain affordable, which is consistent with a
previous study (54). Different possible reasons can be considered. Firstly, medical services are
rarely free of charge in Vietnam, including within the public health system. Secondly, registering in
MMT can be seen by IDUs as a way to avoid detention making them more willing to pay for
treatment. Under such circumstances, one may question the real motives behind applying to MMT.
 To respond to the large latent demand for MMT services in terms of both quality and quantity, a
massive investment in human resources recruitment, training and development is required.
Otherwise, the quality in MMT clinics may suffer as it did in China during its program scale-up (55).
In some clinics, over 60% of staffs’ salaries are paid or supplemented by donors. The reduction of
funding directly threatens staff retention and, secondarily, the quality of care.
 National training capacity is far from optimal (32) according to the majority of informants, which
makes it difficult to generate skilled staff. So far, trainings on MMT have been mostly provided by
international organizations. In order to build a sustainable national training system, the Government
has assigned leadership and training authority to the National Institute of Mental Health (NIMH)
affiliated with the Hanoi Medical University (HMU). However, the majority of informants believe that
NIMH/HMU lacked both staff numbers and requisite expertise to fulfill their eventual training,
mentoring and supervision responsibilities.
 Staff development remains one of the biggest challenges to MMT scale-up. It can also be seen as an
opportunity for the country to better respond to other health and social issues and develop
employment opportunities for medical students and students in behavioral sciences. Indeed,
addiction treatment is not in post graduate curricula, and counseling is not yet a recognized
profession in Vietnam. Filling these gaps through the development of university curricula would
benefit addiction prevention and psychosocial treatment in a country where methamphetamine use is
increasing (12) and where nearly half of men older than 15 years smoke (56).
 Finally, development of private sector MMT clinics would also help create a career path for
experienced staff whose employment options would not remain restricted to the public sector.

21. 21
RECOMMENDATIONS
5
The NCADP, which represents the Government, was established in 2000 and tasked with coordination of programs for the prevention and control of HIV and drug use. It is chaired
by one Deputy Prime Minister and consists of 18 members from Government agencies, some socio-political & professional organizations, and centrally run Government agencies.
Domain 1- Competing responsibilities
Recommendations Target Implementer Suggested
funding
Recommendation 1.A: Raise awareness on the benefits of MMT
 1.A.1 Pursue advocacy efforts
Raise awareness in Vietnamese society of the benefits of MMT, through:
- Mass-media campaigns
- The testimony of MMT patients and their relatives, which could have an impact on
the mentalities given the importance of the family in Vietnamese society.
 1.A.2 Promote MMT at local level
Raise local decision makers’ awareness of the benefits of MMT  Seminars should be
organized by the Central Government to build a shared knowledge among participants.
Target street Police and DoLISA social workers through:
- training sessions on drug addiction with a focus on the reduction of drug-related
crimes in communities.
- study tours and police-to-police dialogues, so as to move from an ideological
resistance to harm reduction to health centered-approaches (57).
Vietnamese
society /
households +
community of
drug users
Provincial
People’s
Committees &
Health Centers
Street Police
and DoLISA
social workers
Ministry of Health &
Provincial Health
Departments
through mass-media
National Committee
on HIV/AIDS, Drugs
and Prostitution
Prevention and
Control (NCADP)
5
+
MoH + international
organizations
(UNAIDS, USAID…)
State (central &
local budgets) +
tax cigarettes,
alcohol
State (central &
local budgets)
State through
MoPS &
MoLISA budgets
+ donors
Recommendation 1.B: Close drug detention centers & provide voluntary-based treatment
 1.B.1 Continue to demonstrate the effectiveness of evidence-based treatment through additional
evaluations of MMT programs in Vietnam and cost-effectiveness studies
 1.B.2 Increase access to voluntary evidence-based treatment as per the Joint Statement of twelve
UN entities (44). The example of Malaysia where drug treatment centers are gradually
transformed into “cure and care” services (41) could be used as a benchmark for Vietnam.
 1.B.3 Ensure that MoLISA provide voluntary-based treatment in the framework of its Renovation
Plan for ‘06’ Centers and commit to cooperate with MoH for the development of MMT
programs.
Government,
MoPS,
MoLISA
Drug users
Drug users
Research institutes +
FHI 360/Urban Care
MoH & MoLISA
MoH + Intl.
donors
MoLISA, MoH +
Intl. donors +
health insurance
MoH & MoLISA

22. 22
 1.B.4 Offer alternative to detention for IDUs involved in criminal activity, through developing
partnerships between the health care system and the criminal justice system, as per the
Program on Drug Dependence Treatment and Care jointly launched in 2009 by WHO &
UNODC (58).
As an example, for many years in Italy, drug users who have been arrested can request a
full or semi-residential therapeutic program at Villa Maraini (Red-Cross program) in the “In-
House Detainees Community” (59).
Prosecuted
drug users
MoH & MOLISA
under the
supervision of
NCADP and UN
agencies
Ministry of Justice
with the support of
UNODC & WHO
State + UN
agencies
Recommendation 1.C: Strengthen the cooperation between ministries and define their
respective responsibilities regarding drug users
 1.C.1 Strengthen the NCADP from central level to local governments. The role of the NCADP is
critical in bringing the three ministries together in a coordination group.
 1.C.2 Harmonize the responsibilities of each ministry, both at national and implementation levels.
The example of Malaysia could help in providing guidance to define complimentary
responsibilities between ministries.
MoH, MoPS &
MoLISA
NCADP supported
by UN agencies and
international
organizations UN agencies +
intl. donors
Recommendation 1.D: Simplify the entry process
 1.D.1 Improve access to MMT program through ensuring that the selection of patients fully
belongs to the health sector as per Article 23Decree # 96.
Drug users NCADP + MoH
Domain 2- Technical Factors : MMT Supply, Training Capacity and Human Resources Target Implementer Funding
Recommendation 2.A: Set up a sustainable national MMT supply chain system
 2.A.1 Encourage the government to commit funding for methadone drug purchases through
providing technical assistance to the MoH to develop:
- a roadmap for MMT supply needs in the coming years
- a national MMT supply chain management, with a centralized procurement unit, in order
to keep price stability.
Government SCMS Donors
Recommendation 2.B: Build the capacities of National Training Center and develop university
curricula on drug addiction and counseling
 2.B.1 Support NIMH/ HMU in developing a master training plan and build the clinical experience
of their staffs through on-site trainings. Having their own MMT clinic at the Bach Mai
Hospital may help strengthen their capacities.
NIMH/ HMU MoH/VAAC,
FHI 360, SAMHSA
MoH, PEPFAR

23. 23
 2.B.2 Build a technical resource pool with local mentors in each province to train the trainers who
would later be responsible for providing ongoing training at local level as successfully
experienced in China (55).
 2.B.3 Develop curricula on drug addiction management for medical students and students in
behavioral sciences, which is theoretically planned for 2014. In 2013, the ANRS in
cooperation with the University of Paris XI will organize a program on drug addiction in
Haiphong, validated by a diploma.
Students
MoH/VAAC, HMU,
FHI 360,
SAMHSA ,ANRS
+ ANRS
Recommendation 2.C: Improve efficiency of human resources
 2.C.1 Determine staff needed in MMT, based on the result of the analysis conducted in 2013 by
VAAC & FHI
 2.C.2 Pool human resources through integrating MMT into other health services (MT). However,
prior to integration, staff should be extensively trained in order to address drug addiction
comprehensively.
 2.C.3 Develop MMT in the private health sector in order to create a career path for qualified staffs
MMT Clinics,
HIV services,
district health
services,
psychiatrist
hospitals…
MoH/VAAC +
People’s Committees
+ Provincial Health
Departments
State (central &
local budget)
Private sector
Recommendation 2.D: Keep enhancing the MMT legal framework and improve the monitoring
and evaluation system
 2.D.1 Support MOH in developing a roadmap for MMT implementation (including planning &
budgeting)
 2.D.2 Build the capacity of provincial health services on MMT development as they are
responsible for granting, renewing and revoking the licenses of a treatment facility (Decree
# 96, clause 2)
 2.D.3 Implement an electronic client management system. This quality system should be tested
first as a pilot in well performing MMT clinics before being standardized.
MoH/VAAC
Provincial
health services
MMT Clinics &
services
USAID/FHI360,
Global Fund
VAAC + intl.
organizations
State + intl.
donors
Domain 3- Sustainable Funding of MMT Target Implementer Funding
Recommendation 3.A : Increase State investment
 3.A.1 Demonstrate the cost-effectiveness of methadone (see 1.A.2, 1.B.1) and develop a national
MMT supply chain management (see 2.A.1)
 3.A.2 Reallocate part of “06” Centers budget to MMT
People’s
Committees
Research institutes,
Urban Care/ FHI,
SCMS
Intl. donors
State (through
MoLISA budget)

24. 24
Recommendation 3.B: Develop various MMT delivery models
 3.B.1 Involve more than 250 patients in MMT Clinics, through:
- developing satellite dispensary model for stable patients
- extending hours of operation for methadone dispensing
- implementing long-acting OST & family-based DOTS.
 3.B.2 Integrate MMT into other health services (3.C.2)..
 3.B.3 Increase the capacity of self-help groups and community-based organizations (CBOs) to
deliver services (MT). For instance in India, Nepal and Maldives, local NGOs provide
psychosocial services to patients, including peer-based counseling, outreach and follow-up
(60).
Drug
users/MMT
patients
See 3.C.2
Self-help
groups, CBOs
Provincial Health
Dpts with VAAC and
INGOs support
INGOs (CARE,
PSI…) & local NGOs
(SCDI)
State + intl.
donors
Intl. donors
Recommendation 3.C: Develop fee-for-service models
 3.C.1 Develop co-pay clinics where costs are partially shared by drug users and Government and
remain affordable for MMT patients. Services should remain free-of-charge for the most
socioeconomically vulnerable patients, as per Decree # 96, Art.23.2
 3.C.2 Provide MMT in the private sector for patients who can afford it (see also 2.C.3)
Drug users/
MMT patients
Provincial Health
Dpts
State + patients
Patients
Domain 4- Legal Inconsistencies Target Implementer Funding
Recommendation 4.A.:Harmonize the legal framework
 4.A.1 Pursue advocacy efforts towards a science-based public health approach to drug addiction.
See also recommendations 1.A & 1 B.
 4.A.2 Continue to review the legal framework in order to reduce contradictions, between HIV law
and drug laws.
Policy makers,
MoPS, MoH &
MoLISA
NCADP + UNODC
with the support of
lawyers
UNODC
Recommendation 4.B.:Remove article 21.2 of Decree #96
 4.B.1. Lower the threshold of MMT program to make services more accessible and acceptable to
patients:
- Cancel urine testing
- Simplify admission and functioning process (see also 1.D and 3.B.1)
Low-threshold programs implemented in Asia and in other countries (60, 61) could be used
as a source of inspiration for Vietnam
Drug users/
MMT patients
MoH with the support
of international
organizations

25. 25
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