BARRIERS TO IMPLEMENT THE NATIONAL GUIDELINES ON NEWBORN CARE IN A RURAL MOUNTAINOUS PROVINCE OF VIETNAM
Le Minh Thi1*, Bui Thi Thu Ha1, Dinh Thi Phuong Hoa1
ABSTRACT
Reducing the disparity in neonatal health among regions to ensure every mother and her newborn receive the health care they need is a priority in Vietnam. This study was conducted to assess the barriers in implementing the National guidelines on newborn care in a rural mountainous province of Vietnam. Qualitative methods were applied with 28 in-depth interviews and 4 focus group discussions in DakNong province. The results showed that
there exist many barriers in implementing the national guideline in newborn care services.
There is a big gap between health policy development and policy implementation. The Vietnam government had approved a good strategy and guidelines. Efforts now need to focus on implementing the national guideline and improving quality of care.
Keywords: Neonatal health, barriers, implement health policy, Vietnam
1 Hanoi school of Public Health
* Corresponding author: Le Minh Thi, Hanoi school of Public Health, 138 Giang Vo, Ba Dinh, Hanoi, Vietnam. Email: [email protected]
BACKGROUND
Vietnam has experienced rapid economic growth and social development during the last 30 years and is now classifi ed as a lower middle-income country. Poverty has been reduced (from 37% in 1998 to 3.3% in 2011) while social inequity has grown1.
Vietnam has also been successful in increasing life expectancy at birth and reducing the under-fi ve-year mortality rate (U5MR) and the maternal mortality ratio (MMR). According to Vietnamese Minitry of Health (MOH), MMR in Vietnam has declined from 223/100,000 live births in 1990 to an estimated 69/100,000 live births in 2009. The UNICEF study for Multiple Indicator Cluster Surveys in Vietnam showed in 2014 that the neonatal mortality rate (NMR) was 12 per 1,000 live births, the infant mortality rate (IMR) was 17 per 1,000 live births and U5MR was approximately 20 per 1,000 live births. The rates decreased about 23% for IMR indicators, in comparison to the data from 2000 (see Table 1). However, the NMR (i.e. death within the fi rst 28 days of life) has not declined at the same rate and is estimated to be 17,000 neonatal deaths annually2,3,4.
Despite signifi cant improvements in health care for mothers and newborns in Vietnam over the past decade, quality of health care for mothers and neonates remains poor in most disadvantaged areas of Vietnam1. The NMR differed substantially across provinces.
Currently, NMR in Vietnam is estimated to account for more than half of the total number of deaths of children under fi ve years and more than three-quarters of the total number of infant deaths4. Furthermore, NMR among ethnic minority groups in remote and mountainous regions is still two to three times higher than
the rate among the Kinh majority in urban areas. The ethnic minority population in Vietnam constitutes 14% of the nation’s total population1.
The offi cial causes of neonatal mortality are not directly reported to the MOH maternal health system. However, according to the most recent national study by MOH regarding the cause of death in neonates, potential causes are prematurity and low birth weight (38%), asphyxia (25%), sepsis (16%) and congenital malformations (9%). Almost 60% of neonatal deaths occurred within the fi rst 24 hours after delivery5. The recently completed Neonatal Knowledge Into Practice project (NeoKIP) in QuangNinh province showed that NMR within the study area was 16 per 1,000 live births, similar to the MOH data. The study also indicated that the leading causes of death were prematurity and low birth weight (38%), intrapartum-related neonatal deaths (33%), infections (13%) and congenital malformations (7%)6.
Reducing the disparity in neonatal health across regions to ensure every mother and her newborn receive the health care they need is a priority in many government documents. Vietnam MOH had developed and approved the national guideline in reproductive health services and newborn services (NGRHS) since 2009. This NGRHS is the leading document that sets the neonatal services implementation for all level of health facilities (commune, district, provincial and national level). The NGRHS has been applied to both government and private health facilities since 2010 at district and commune levels. The Chapter 3 focused on guidelines for newborn care services with 40 topics covering most of newborn problems. This study was
conducted to 1) describe the NGRHS and related regulation on newborn care in Vietnam, and 2) to assess the barriers to implement the national guidelines on newborn care in a rural mountainous province of Vietnam.
METHODS
A qualitative study design based on primary and secondary data collection was used to address the research objectives. Three types of research methods were used in this study including key informant interviews, focus group discussions, and document review. For the document review, a total of 10 national policy documents, 39 studies (in English and Vietnamese), and some secondary data (annual
reports within 3 years of CHC, district and provincial hospital) were collected.
The study site was chosen based on neonatal health indicators and vulnerable and underserved populations. DakNong province, one of the poorest of the fi ve provinces in the Tay Nguyen (Central Highlands) region, was chosen as the study site. In 2012, DakNong had about 550,000 inhabitants, and 90% of the population was considered poor according to the national standard (average income per capita lower than 400,000VND or about 19USD per month)8. The residents of the province includemore than 40 ethnic groups, with the majority of the Kinh group (accounting for about 60% of the population)8. Most of the ethnic minority groups have their own language and culture, which can differ greatly from each other. In the Central Highlands, the availability and accessibility of quality services remain
limited for many ethnic minorities. Dak Nong is divided into 8 districts with a wide variety of geographical traits, from large fi elds and lakes in the South to high mountainous areas in the North. The province borders Cambodia to the West (Figure 1).
The country research team selected a district and a commune with the assistance of the organiser at the provincial health department from the developed list of health facilities in DakNong province (2 provincial hospitals and MCH center, 8 district hospitals and 8 district MCH centers). Selection was based on the following criteria: a remote rural district having the highest neonatal health indicators and the willingness of the district’s health managers to participate in study development as well as in the fullscale study. DakGlong district and DakR’Mang commune were also selected as the study sites.
A total 28 key informants conducted indept interviews (2 key informants at the national level and 26 key informants at DakNong province) and four focus group discussions were conducted with four different women’s ethnic groups (Mong, Thai, Kinh and Mnong).
Figure 1. Study area – DakNong province, Vietnam.
The following table indicated the detail of key informants who involved in indepth interviews (IDI) and focus group discussions (FGDs).
Table 1. Key informants involved in indepth interviews and FGDs
Level Location Type of key informant Sample
size National level Hanoi
Key informants at national level - 1 leader of MCH department in MOH - 1 representative of MCH from UNICEF
2
Provincial
level DakNong
Policy makers at provincial level - 1 vice-director of Provincial health department
- 1 manager at Provincial Reproductive Health Centre
2
Senior health service professional at provincial level
- 1 offi cial in Medical Professional Division, Provincial health department
- 3 offi cers at Provincial Reproductive Health Centres
- 2 health care providers in OBGYN department at Provincial Hospital - 2 health care providers in paediatrics department at Provincial Hospital
8
District level DakGlong
District health service managers - Vice director of district hospital - Head of OBGYN department - Head of paediatrics department - 1 midwife in OBGYN department - MCH manager of District Preventive Medicine Centre
- 1 offi cer responsible for maternal and child health at district MCH centre
- 1 midwife in MCH department
7
Community level
DakR’Mang Community level representatives
- 1 head of commune people’s committee 1
DakR’Mang CHCs
Frontline health workers at primary and referral levels - 1 head of commune health centre
- 1 midwife at commune health centre - 1 village midwife
- 3 village health workers
- 2 village women union representatives 8
Total number of key informant interviews: 28
Community level (FGD)
H’mong group (9 persons) 1
M’nong group (6 persons) 1
Thai group (9 persons) 1
Kinh group (4 persons) 1
Total of FGDs (28 participants) 4
For IDI, potential informants were asked to make appointments for the interview during the weekly fi eld trip. Each interview lasted approximately one hours. Besides, health managers of provincial hospital, district
hospital and CHCs also answered the self- assessment regarding services implemented in their institution among 40 services that were indicated in the NGRHS.
The FGDs were conducted in DakR’mang commune health centre in November 2014.
Each focus group consisted of 4-9 participants and lasted approximately 40-60 minutes. Policy makers, health managers, and health workers were interviewed in their offi ces. All other women who had delivered within one year in the community were listed and invited by local health providers to come to the commune health centre. A member of the qualitative research trained team led the discussion, while another member assisted with note taking and organisation of the FGD. Only one FGD with H’Mong group was conducted with the help of a translator due to the reason that all H’Mong women can not speak Kinh language.
Annual reports of CHCs, district and provincial hospitals within 3 years colleted during the fi eld visits were read, and related data were extracted according to the themes derived from the research objectives. The annual reports provided in details the information on human resources, equipments and services provided by each institution. Regarding qualitative data, all FGDs and interviews were identifi ed with a code, then transcribed verbatim in the local language. A copy of all the data was created and kept safety. Content analysis using themes (from the framework of Walt and Gilson's policy triangle on content, context, and actors in health policy processes underpinned the analysis)7 was applied. The computer programme “NVIVO 8” and Mindmap Mind Manager 7 were used to support the analysis. The qualitative data analysis was implemented in two stages. In
the fi rst stage, two independent researchers coded the two transcriptions manually and independently to compare and constrast the code list. After that, the code list was revised and two researchers together defi ned all codes and codes’ defi nition. The codes were devided into three groups according to the frameworks including content of the regulation (know/not know, available/not available, train/not train regulation), actors (developer/implementer/
users, develop, who train/ not train, implement/
not implement, monitor and evaluation/
not), context (including 2 sub-theme: service delivery context (human resource-quality/
quantity, equipments, drug -full/lack/not used, fi nancial/budget support) and social cultural and community context (traditional customs toward newborn care, accessibility such as weather, road diffi culty, cultural belief and practices, and language). In the second stage, all transcriptions were coded by one researcher using Nvivo 8 software. After that, the code transcription was checked by the second researcher. The information was triangulated with the information in the fi eld notebook such as availability of guidelines in the hospitals, or triangulated with the secondary data reports such as training materials, self administration answer sheets, report on monitoring and evaluation. The initial report of data analysis then was copied to Mind Manager Pro 7 software to map all the data’s results. The mapping was used to write full report/ articles.
This study was approved by the Research Ethics Committee at the Hanoi School of Public Health.
All participants were given verbal and detailed, written information about the nature and purpose of the research prior to participating in the study. Some informed consents were signed by two witnesses instead of the participants due
to illiteracy of the participant (mainly H’mong women at the community level). Participants were made aware of their right to decline to answer questions, and their answers were kept anonymously.
RESULTS
Neonatal health services guidelines
Availability of guidelines at different levels of the health system
From observations and interviews at the study site, it was determined that the NGRHS is available at all health facilities from the provincial hospitals to the commune health stations. The research team had asked the key informants to show the national guidelines, and all health workers could show the availability of the national guidelines. The guidelines are also available at the provincial health department, provincial centre of reproductive health care (RHC), and district preventive health centre because this guideline is used for monitoring and evaluation health information statistics, and other purposes (training, research).
“We received the re-printed version of the national guideline from the provincial health department in 2011. The guideline was reprinted using provincial budget. All health facilities received the guideline” (interview with a health manager at the provincial RHC centre).
Training on how to use the guideline
In 2010 the training manual for NGRHS was completed. The MOH had issued the dispatch 585/2009 on implementation of the national target program for 2009. The training program for the NGRHS was one activity of the national target program. Representatives of DakNong Provincial health department
(PHD), the provincal centre of RHC, and the provincial hospital were sent to the training program conducted by MOH in DaNang province. The training course lasted 2 weeks. These members took on the responsibility of provincial training of trainers (TOT) in DakNong province (interview health workers at provincial health department and provincial reproductive health centre).
By the end of 2011, health workers from district hospital pediatric and Obstetrics and Gyneacology (OBGYN) departments as well as midwives and doctors at CHCs were sent to the provincial centre of RHC for training concerning NGRHS.
The PHD also used the local fi nancial budget to re-print the national guidelines. According to the interviews, health workers
agreed that they gained knowledge on 3rd stage active management, breastfeeding counseling, eye and cord care, and Apgar rating through hands-on training and practice with real patients. As a result, health workers applied these services quite well (see detailed services in the table 2 and table 3).
Implementation of the NGRHS in DakNong province
The implementation of the NGRHS in DakNong province is not complete. Not all of the services at DakNong health facilities are being implemented according to the new guidelines.
The following services are implemented well (according to the self-assessment and interview with health managers at different levels). The defi nition of well implementation of services is based on criteria of correct and suffi cient steps according to the NGRHS. The blank table indicates that the services have not implemented in the health facilities.
The following areas of the guidelines are not implemented in the province (Table 3).
Some services have been implemented well completed, especially basic services such as counselling, advocate breastfeeding, normal care for both mothers and babies. Certain
No. Service Province District CHC Village
midwife 1 Umbilical care for neonate
x (cover umbilical
cord)
x (cover umbilical
cord)
x (cover umbilical
cord) 2 Normal care of mother and newborn in
the fi rst day after birth x x x x
3 Communication and provision of empathetic support to the relatives and family of the sick baby
x x x
4 Safe transfer of the newborn x x
5 Counsel on breastfeeding x x x x
6 Principles for using antibiotics for
treatment in neonates x x
7 Co-operation between obstetric and
paediatric specialties in newborn care x x
8 Care of premature and low birth-weight newborn
x (above 30 weeks
only) 9 Technique of phototherapy to treat
jaundice x
10 Essential drugs for newborn care at
different levels of health care system x x x
11 Neonatal sepsis x
12 Eye infections x x x
13 Omphalitis x
14 Newborn resuscitation immediately after birth
x (with ambu
bag)
x (with ambu bag)
x (manual / without ambu
bag) x (manual / without ambu
bag)
15 Hypothermia in the newborn x
16 Respiratory distress in the newborn x 17 Continuous positive airway pressure x
18 Milk choke emergency x
19 Intravenous nutrition in newborn baby x 20 Technique of nasogastric tube insertion
for the newborn x
Table 2. Newborn care services implemented in the province
regular neonatal services are also done well such as breast-feeding initiation within one hour after delivery (with normal deliveries), newborn examinations, and safe referral of sick newborns to the higher levels. However, there are many services which are not implemented according to the national guidelines, even though the health workers have been trained in care practices such as Kangaroo care, neonatal sepsis, care of premature and low birth-weight newborn. For example, the main reason not to apply Kangaroo care (skin to skin contact between mother and child) is health workers
practice in the ways that they are familiar with the old daily practices such as separate mother and newborn after birth and lack of monitoring and evaluation.
It illustrated managerial problems in monitoring and evaluation.
Challenges to implementation
Challenges in guideline implementation at the national level
According to a health manager at MOH, the issuance of the related documents has shown evidence that leadership and policies set by the government and MOH for newborn care have provided an adequate and timely response to the need for improving neonatal health alongside the nation’s socioeconomic development. However, it is challenging to translate these policies into practice.
Several reasons at the national level were listed following in-depth interviews with policy makers at MOH including (1) the number of MOH focal persons is insuffi cient to cover all newborn care activities, (2) inadequate coordination between the preventive health sub-sector and the treatment sub-sector, (3) there is no focal person for neonatal health at the Health Service Administration in the Ministry of Health, causing diffi culties in conducting supportive supervision at provincial hospitals and (4) the technical group at the national level for neonatal health was established but is not currently active.
A major diffi culty in analysing the fi nancial needs of newborn care is that there is no specifi c budget for neonatal health care. The budget for newborn care is combined with the MCH budget. Thus, it is not possible to have Table 3. Newborn care services not implemented
(according self assessment of health managers)
No. Service Provincial District CHC Village
midwife 1
Care of premature and low birth-weight newborn (under 30 weeks) 2
Kangaroo care (skin to skin contact between newborn and mother)
(trained, not applied)
(trained, not applied)
(not applied)
(trained, not applied)
3 Newborn malformation requiring early intervention
4 Fluid and electrolyte disorders 5 Indirect hyperbilirubinemia
jaundice
x (rare cases)
6 Pneumonia
(not confi dent for severe cases) 7 Bleeding in the newborn
8
Infants born from mothers infected with Hepatitis B, tuberculosis, gonorrhea, syphilis, or HIV
9 Neonatal convulsion 10 Umbilical venous catheterization 11 Blood transfusion
12 Exchange blood transfusion in the neonates
13
Others: Arterial puncture for drawing blood
Heel stick puncture Endotracheal intubation Tube thoracostomy Lumbar puncture Neonatal hypoglycemia
specifi c data on the total budget needed for activities related to improvements in neonatal health and survival. However, estimates have shown that funding for newborn care activities (including international funding) only meets about 45% of the actual demand (fi gures from MOH 2011/2012)9.
“Neonatal health is now main target for MCH program. However, the budget for neonatal has not met the demand. In the short term strategy, we will focus on training and simple intervention on essential newborn care. In the meantime, we need to call for further international support” (Interview with MOH) Another fi nancial barrier to interventions on newborn care is that inappropriate cost norms (the cost norm was set too low compared to the real cost in practice) and cumbersome administrative procedures, making it diffi cult to implement activities9.
Challenges in implementation of NGRHC in DakNong province
Lack of training in new techniques
Only the theory behind advanced techniques such as newborn resuscitation and newborn sepsis diagnosis and treatment is covered in training due to the lack of newborn models, available patients, and equipment. In practice, health workers at the district and commune levels are not confi dent in applying these skills (interview with health workers at district and CHC). Every year representatives from all health facilities are sent to the Provincial Centre of RHC to receive training in the updated the NGRHS within four-day course. Experts on the subject matter are sometimes invited from pediatric hospitals in Ho Chi Minh city to offer further training.
“The training in the province is in theory only.
It is hard to understand without a model. We have to invite experts from Ho Chi Minh City to our hospital to train our doctors, especially the complicated techniques” (Interview health manager at provincial hospital).
Lack of training in updated techniques at the district level and monitoring after training According to an informant, not all health workers receive the annual NGRHS training.
Due to a lack of human resources, district hospitals fi nd it diffi cult to send doctors or other health workers to attend the training. For example, there is only one general practitioner who graduated from medical school in the OBGYN department at the district hospital. If she was sent to the training, there would be no one capable of handling her workload at the district hospital.
“Our department has only one doctor, I could not attend the training” (Interview health worker at district hospital).
Monitoring and evaluation after training is considered to be weak in DakNong province.
Many simple services are trained but not implemented due to lack of monitoring and evaluation.
“We are familiar with old practices and we have not applied the new services. No one reminds or monitors us” (Interview health workers in the CHC)
Lack of human resources in neonatal health care and limited skills of health workers
DakNong is a remote province, and the hospital can only recruit doctors who specialize in general medicine. Consequently, health workers at the provincial hospitals are not confi dent in treating premature newborns.
“We are not very confi dent in newborn diseases,
especially the early premature newborns. For those cases, we refer to Ho Chi Minh city”
(Interview health worker at provincial hospital) At the district level, human resources for health care are severely inadequate. A lack of doctors specializing in pediatric medicine at the district hospital is a barrier to implementation of the guidelines. Neonatal cases diagnosed with any problems at the distric level must be referred to the provincial level.
“We do not treat any neonatal disease in this hospital. All cases are referred.”(Interview health worker at district hospital).
Lack of medical equipment and drugs
Lack of medical equipment and drugs was considered a main reason for how poorly the NGRHS was implemented in DakNong province.
The lack of medical equipment and drugs for newborns prevented treatment opportunities for the baby at local health facilities, even if the health workers had been trained.
“We can take care of some premature babies.
However the lack of drugs such as Surfactant prevent us from keeping the premature babies in the hospital” (Interview health worker at the provincial hospital).
The basic equipment for newborn care at the district hospital is limited and inadequated compared to the National standards requirements, and this also prevents the services from implementation.
“As for equipment we have only one professional ultrasound Doppler, two deliveries kits and two perineal suture kits. That's all!
Tools are inadequate, heat lamps for babies are also not available in this hospital” (Interview health worker at district hospital).
Cultural customs of the ethnic women
Almost mothers who delivered at the health facilities follow the intructions and counselling of health workers. However, the implementation of NGRHS faced challenges in ethnic minority group who delivered at home or after they were discharged from the health facility. Some of cultural customs can be considered good such as drinking warm water, having nutrionous food.
On the other hand, some certain traditional postnatal practices among ethnic groups act as barriers to full implementation of the service guidelines, such as women taking the colostrum away or feeding the newborn with honey. As a result, many people do not follow the instructions of health workers advices after the mother has delivered, especially those women who are cared for by their mothers or mothers-in-law.
“Ethnic minority people had their own cultural practices. Although we had instructed breastfeeding, they sometimes feed the newborns with honey. According to their explanation, honey is good for babies’ digestions. The practices are more common especially after the women and their babies are discharged from the health facilities” (Interview health worker at district hospital).
“My mother in law said that honey is good for both mothers and babies and it helps the baby better digestion” (FGDs among Thai group) Home delivery is common among Hmong and Mnong group while Thai and Kinh ethnic groups are more likely to deliver babies at health facilities. Home delivery without skilled birth attendants may prevent emergency aid management for both mother and newborn in case the complication happens.
“Our custom is home delivery; only husband and mother in law attend the birth. Many women in the community also deliver at home.
If there is any problem, we will call the village health worker” (FGDs among Hmong group) Language barrier
There are many ethnic minority communities living in DakNong province, while the majority of health workers belong to the Kinh ethnic majority. Language barrier was identifi ed during in-depth interviews and FGDs session as one of the signifi cant challenges faced by both health workers and clients in their attempts to communicate. Almost all ethnic minority women can speak Vietnamese. However, there are some H’mong and Ma ethnic minority women who are unable to speak Vietnamese to communicate with health workers.
“Different language prevents us from communicating with women. When the client talks, we cannot understand and vice versa.
This always happens with H’mong clients”
(Interview health worker at district).
“Only male Hmong can attend school, so they can speak Kinh language. Not many Hmong women can communicate with health workers due to illiteracy. If we visit communal health center, our husbands will translate for us. I hesitate to go to the hospital by myself and if I visit hospital, I have to ask my husbands for translation on delivery issue” (FGD Hmong women group)
Village ethnic midwives are not allowed to perform some services at home
The language barrier is also considered as a barrier to access to health services for some ethnic minority women. Therefore, the health care services performed by trained ethnic minority midwives were an effort to bridge
the gap between the health system and the ethnic minority community. In the study site, although no deliveries occurred at the CHC, the village ethnic minority midwife attended 22 home deliveries in 2013. Some services were not covered at home (such as 3rd stage active management, monitoring of the labor chart, vitamin K1 injections) because village health workers are not allowed to inject any types of drugs at home (according to the Decision 385/2001/ MOH).
Traditional postnatal care prevents maternal and newborn care
Delivery at home is one of the traditional practices of minority women of the H’mong, M’nong, Ma, and Ede ethnic groups. For the H’mong, the only person who can attend the delivery is the woman’s husband and sometimes her mother-in-law. Home delivered babies do not receive vitamin K1 injections or vaccinations within 24 hours.
Difficulties with weather and roads/
transportation in remote areas
The H’mong people also live in one of the province’s most remote villages (40-100km away from the nearest commune health stations). Home delivery is common practice among Hmong community. Diffi culties with the weather during the rainy season and poor roads prevent women from accessing health facilities. Almost all home delivery cases in DakR’Mang in 2014 occurred among the H’mong ethnic group. If the newborn was ill, it was diffi cult to refer the baby to the CHC due to lack of money and diffi culties with weather and transportation.
“In the rainy season, people take hours to get here, they usually walk or sometime go by
motorbike, they do not have any other means, nothing. /.../ There is a woman. I remember a few months ago. She was seven months pregnant and suffered from abdominal pain, but her place was too far away, and it was very diffi cult to go there so she ended up delivering on the way to the CHCs” (Interview with a health worker at the CHCs).
Inaccessible health services because people cannot afford the indirect service cost
According to health insurance law, health insurance covers 95% of healthcare costs for ethnic minorities and the poor. These two groups can receive a small amount of money for public transportation and food (in case of referral). Although the local people have health insurance cards, those who are poor often are reluctant to access health facilities due to lack of money for indirect costs such as cost of food, transportation, extra drugs, and for relatives who take care of the women.
“If a H’mong woman has access to a health facility to give birth, some family member such as her husband, mother, mother in law, and even her aunt accompany her. After delivery, at least two of the relatives stay to take care of her.
Some poor families cannot afford the costs for the relatives during the period at the hospital”
(Interview health workers at district hospital).
“Eventhough we have health insurance; however, we do not have enough money to spend for other expenses such as food, transportation and costs for the care takers” (FGD the Mnong group).
DISCUSSION
The catchment areas in this study were selected for largely practical reasons and the sample size in this qualitative study is small. Therefore, the study is not intended to be generalizable and any inferences made from the fi ndings must
be treated with caution. However, the study provides rich information on a smale scale exploration of these issues.
Although the National guideline on neonatal health care has been implemented since 2009, after 5 years, they have not been fully implemented due to lack of infrastructure, equipment and human resources. However, some simple basic services were not implemented because health workers are familiar with old practices that they have done for many years even though they were traing with new technique such as Kangaroo care.
The policy addressed two aspects of policy implementation - the administration in the national level and the implementation in a rural mountainous province. Both aspects were implemented diffi cultly in the context of Vietnam. At the national level, the major barrier which appears to have infl uenced implementation is lack of fi nancial budget, lack of expertise and lack of equipment.
Our findings indicate that despite some awareness of best practices, staff are unable to implement these practices in settings with shortages of human resource and managerial problems (monitoring and evaluation). At the provincial level, our fi ndings show poor quantity and quality of care for the newborn.
Poor service delivery is in part, due to human resource shortage, lack of equipment and drugs at the commune and district levels. The lack of human resources also causes the health workers not attend the national guideline training. As a result, staff is unable to implement even the simplest services such as Kangaroo care.
Our study offers important insights showing how systems and structures fail to ensure an
‘enabling environment’ for quality care for the newborn.The research suggests that the basic medical equipment should be equipped in the province and routine monitoring and evaluation should be done strictly to implement the regulation successfully.
Besides, our study also presents the number of challenges that poor ethnic people who are living in the remote province of Vietnam have barriers in accessing to the health services such as home delivery customs, language barriers, indirect costs and road/climate diffi culties. This suggests that culture issue has not developed in the health system especially in the remote areas.
Research suggests that addressing the social cultural factors of women and their newborn accessing services could be potentially useful ways to improve services.
CONCLUSION AND RECOMMENDATION There are many barriers in implementing the
national guidelines in newborn care services.
There is a big gap between health policy development and policy implementation. The Vietnam government had approved a good strategy and guidelines, efforts now need to be focused on implementing the national guidelines and improving quality of care. While investing in demand side programmes like the social supports, improve infrastructure and road for the people who are living in rural remote area, it is a prerequisite to ensure the supply side of services delivering good quality care.
CONFLICT OF INTEREST AND FUNDING The project was funded through a Liverpool school of Tropical and Medicine grant to the Hanoi School of Public Health through its Neonatal health program. This paper was a part of an international research project funded by MRC-UK under sub-contract grant number SC1407128TMHSPH on Improving neonatal health in China and Vietnam (MRC).
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