Current status of policies and conditions to ensure the operation of school health in Vietnam
Nguyen Thi Hong Diem1 ,2*, Nguyen Thanh Van3, Nguyen Huy Nga2 ABSTRACT
Background: Good healthcare and education for students promotes improvement of the quality of the country future human resource. School health has received the attention of the Party and the Government as reflected in laws, resolutions and decisions facilitating the legal framework in the implementation. However, there are still many difficulties and challenges in the implementation.
This paper reviewed existing policies and guidelines on school health in Vietnam and assessed the implementation of school health activities, difficulties and challenges in the implementation.
Methods: Descriptive study design combining desk review, qualitative and quantitative methods were applied. In-depth interviews and focus group discussions with leaders of health sectors, education sectors, home affairs and social insurance sectors at commune, district and provincial levels; school administrators, school health staffs at all levels of education from kindergarten, primary school, secondary school and high school had been implemented in 5 provinces of 5 regions of Vietnam.
Results: The policy documents on school health in Vietnam have been issued quite comprehensively, which were the legal basis for localities to perform well. However, there were still many difficulties and challenges due to gaps in regulations on conditions to ensure the operation of school health.
Survey results in 05 provinces in 2017 with 5.540 schools at all levels showed that 89.9% of schools had school health staffs; 56.5% of the schools had school-based health staffs and the rest was contracted. The rate of non-medical school staff was 37.5%. The benefits and regimes of school health staffs were facing many difficulties. The training was implemented annually;
however, the training quality was not enough. The budget for investment in school health activities was still limited that not meet the demand.
Conclusions: The legal documents were adequate to facilitate the implementation of school health activities. However, there were still many difficulties and challenges in some localities and schools in the implementation. Therefore, it is necessary to promulgate more practical policies. The coordination between the health and education sectors was still not close and lacked consistency and synchronization.
Keywords: policy, school health, Vietnam.
Author
1 General Department of Preventive Medicine, Ministry of Health
2 Quang Trung University, Quy Nhon city, Binh Dinh province
3 Hanoi University of Public Health, Hanoi Email: nthdiem@qtu.edu.vn
I. INTRODUCTION
Children under 15 years accounts for one third of Vietnam’s population. Good healthcare and education for children promotes improvement of the quality of the country’s future human resource. In Vietnam, several laws, policies and decrees enacted by the government and relevant authorities of education and health sectors that set a strong base for favourable conditions to organize and implement school health programs and services.
Over the past years, school health in Vietnam has been gradually organized systematically and effectively. School health programs and services have significantly contributed to improving and enhancing the health of school children and students. Common diseases have been decreased in schools with no epidemics occurring; learning and health care conditions have been enhanced significantly. However, there were some provinces and schools facing difficulties and challenges. School children and students are in a period of continuous development with incompleteness in physical, mental and behaviour aspects. Thus, they face various health risks from the environment, and changes in socio-economic conditions. This leads to a wide range of diseases emerging in schools such as refractive errors, spinal
deformity, overweight, obesity, mental disorder, accidents and injuries or school violence, etc. These diseases, if not detected and treated in time, will affect the physical and mental development of students. Many studies pointed out that one of the causes of the above problems is the difficulties in resources, management, conditions to ensure the implementation of school health activities, as well as the lack of comprehensive, practical and feasible school health policies 1, 2. Vietnam has no recent reviews or studies that consider the overall analysis of the current situation of policy documents and conditions to ensure the operation of school health. This study has the following objectives:
1. Reviewing existing policy documents on school health including regulations on content of school health activities and conditions to ensure their implementation.
2. Evaluation of the operation of school health in 5 provinces to find out the causes and policy gaps.
II. METHODOLOGY 2.1. Study design
Descriptive study design combining desk review, qualitative and quantitative methods was applied.
2.2. Study time
Desk study: review and update policy documents until 2022. Field research: using research data from September - October 2017.
2.3. Study areas
The fieldwork research was conducted in 4 provinces and 1 city, which represent 5 regions of the country: (1) Northern region: Quang Ninh; (2) North Central region: Thanh Hoa;
(3) Highland region: Lam Dong; (4) Southeast region: Ho Chi Minh City; (5) Southwest region: Tien Giang.
In each province, 2 districts were selected as representatives for urban and rural areas. In each district, 4 schools from 4 levels (pre- school, primary, secondary and high school levels). 8 schools were selected in each province. Altogether, there were 40 schools surveyed in the study.
2.4. Research subjects
Existing policy documents on school health;
documents, decisions, reports on school health in the last 10 years of the province and local schools were included in the study.
The leaders of relevant authorities of health, education, internal affairs, and insurance and agencies directly managing school health activities at provincial and district levels, leaders of commune People's Committees, heads of commune health stations; members of the school management boards and school health workers of study provinces participated in the survey.
2.5. Data collection
To review current policy documents at national
level on school health, in the past 10 years to analyze regulations on content of school health and conditions to ensure their implementation.
In-depth interviews with leaders and officials of relevant sectors at all levels. In-depth interview contents were results of implementing school health activities in localities; difficulties and barriers in the policy documents, and recommendations.
To collect existing reports on school health in Vietnam in recent years.
2.6. Data synthesis and analysis
The existing policy, reports on school health in Vietnam in recent years were collected and analysed. All interviews and group discussions were recorded or written in minutes to ensure all information was accurately recorded without loss or distortion of information. The information was then coded and analysed with approach of quantitative method. Available data was presented by number and percentage.
2.7. Ethical considerations
The study was implemented after officially approved by the Ethics Committee of Hanoi Medical University under Decision No. 04.18/
HDDDDHHYHN. The study received the agreement of General Department of Preventive Medicine, Ministry of Health (MOH).
III. RESULTS
1. Reviewing the existing policy documents on school health including regulations on content of school health activities and conditions to ensure their implementation 1.1. Policy documents related school health
Among this group of documents, Directive No. 23/2006/CT-TTg dated 12/7/2006 of the Prime Minister on the improvement of school- based healthcare shall be first mentioned;
and following is Decision No. 401/2009/QĐ- TTg dated 27/3/2009 of the Prime Minister on approval of disease prevention program at education facilities in the national education system 3, 4.
In addition to the main documents mentioned above, over the years, the Government also issued many guiding documents specialized in prevention of HIV/AIDS, dengue, A/H5N1 flu, expanded program on immunization, prevention of malnutrition, overweight and obesity, accident and injury prevention, prevention of harmful effects of tobacco, food hygiene and safety, dental care etc. These healthcare programs were clearly stated the responsibilities for implementation by schools and educational institutions, which is one of the contents of school health activities.
The most important inter-ministerial document currently valid and the most comprehensive document on school health activities is the Joint Circular No. 13/TTLYT-BYT-BGDĐT dated May 12, 2016 on school health regulations 5. The contents of school health were mentioned in this circular, specifically as follows:
Article 4. Requirements for classrooms, student desks, chalkboards, lighting systems and toys in schools
Article 5. Requirements for water supply and drainage and environmental hygiene in schools
Article 6. Requirements for food safety
Article 7. Execution of school health policies and development of social relationships between schools and community
Article 8. Requirements for school’s first aid rooms and medical staff
Article 9. Organization of school health management, students’ health protection and care activities
Article 10. Health education
Article 11. School health reporting and assessment
The policy documents have also determined that the content of school health was quite complete, actually approaching the general trend of the times according to the model of
"Health-Promoting School".
1.2. Regulations on conditions to ensure the operration of school health
Regulations on organization of school health network
Since 2000, the MOH and the Ministry of Education and Training (MET) have issued many regulations on organizing the school health network. Now, the Joint Circular No.
13/2016 of MET and MOH promulgating regulations on school health work was the most comprehensive 5. Accordingly, school health system is jointly managed by education and health sectors. The connection of the two sectors clearly indicated that it is the responsibility of the People's Committees at all levels, through the School Health Steering Committee (SHSC). SHSCs at all levels have the annual task of approving the school health activity plans in their area and mobilizing resources
to upgrade facilities, improve the study and health care conditions in schools, directing the stakeholders to coordinate and participate in implementing school health activities in the area. From preschool to high school, in each school, a Student Health Care Committee was established and is responsible for advising the school administrators to make annual plans and organize the implementation of school health activities. It also directs the supervision of the implementation of school health activities.
Regulations on school health staffs
School health workers are responsible for advising and organizing the implementation of school health activities. At schools at all levels, from pre-schools to public high schools, there are positions of school-based medical staff in the group of job positions associated with administrative work. In Circular No.
16/2017 of MET, based on the workload and characteristics of the works done by these staffs, the recruitment method as civil servant, contract labour or hiring will be selected and one staff can be in charge of different tasks at the same time 6.
Regarding the qualifications of shool health staff, the Joint Circular No. 13/2016/
TTLT-BYT-BGDĐT dated May 12, 2016 stipulated that school health staffs must have a professional qualification from a mid-level physician or higher. However, in Circular 30/2020/TT-BYT dated December 31, 2020 stated that people who are fully qualified to practice medical examination and treatment in accordance with the law, it is not necessary to have an intermediate medical degree5,7. Thus,
the regulations on qualifications of school health staff are currently not consistent among documents.
Regulations on funding for school health activities
Funding for school health activities includes the following sources: (1) annual school health care funding source according to the decentralization of authorities; (2) student health insurance source as defined current regulations; (3) sponsorship from local and international organizations and individuals as defined current regulations; (4) other lawful revenue sources (if any) 5.
Regulations on inter-sectoral coordination Decision No. 401/2009/QD-TTg dated March 27, 2009 of the Prime Minister on strengthening prevention and control of school diseases and Joint Circular No. 13/2016 regulations on school health stated clearly the responsibilities of the People's Committees at all levels, the local sectors to the educational institutions in the school health management system 4, 5. Therefore, the existing policy documents in Vietnam had sufficient provisions to ensure resources for implementing school health activities from the organizational system, human resources and funding sources.
2. Current situation of organizing the implementation of school health policies at schools at all levels and difficulties and obstacles in the implementation process in 5 research provinces
2.1. On the school health organization and management system, the inter-sectoral
coordination
All 5 research provinces have established SHSCs from provincial to commune level with the prescribed component. These SHSCs have the general tasks as defined in the Joint Circular No. 13/2016 of MOH and MET 5.
In fact, in some localities, especially in SHSCs at district and commune levels, they were inefficient. A Vice Chairman of Town People's Committee told that "Our town has 13 schools, 4 preschools, 5 elementary schools, 2 junior high schools and 02 high schools but we do not have a SHSC, no one reminded about this issue". A leader of Department of Education
and Training said that "In the province, there is a SHSC, but members of this Committee are not working regularly, health and education sectors were main members. Many meetings did not have sufficient attendants".
Through in-depth interviews, all confirmed that the attention of the Party and local authorities was one of the most important factors making the effective school health activities. The better coordination of health and education sectors with proactively develops plans and implements, reports, the more effectively SHSC works.
2.2. Current situation of school health workers
Table 1. Number of school health workers in 5 surveyed provinces
Province Number of
schools
Number of school health workers
Number of school health workers with payroll
n % n %
Quang Ninh 641 632 98.5 535 84.2
Thanh Hoa 2,092 1,543 73.8 860 55.7
Lam Dong 700 700 100 321 45.6
Ho Chi Minh City 1,530 1.530 100 547 35.8
Tien Giang 577 577 100 552 95.7
Total 5,540 4,982 89.9 2,815 56.5
89.9% of study schools had school health workers. The lowest percentage was in Thanh Hoa where 73.8% of schools had no school health staff, 3 provinces (Lam Dong, Tien Giang and Ho Chi Minh City) reported that
100% schools had school health staff. Among schools having health staff, only 56.5% of which had permanent health staff, the rest had contracted staff.
Table 2. Number of school health workers by school level in 5 surveyed provinces School level Number of schools Number of school
having health workers
Number of school having no health workers
n % n %
Preschool 1,964 1,826 93.0 138 7.0
Primary school 1,837 1,662 90.5 175 9.5
Secondary school 1,338 1,163 86.9 175 13.1
High school 401 331 82.5 70 17.5
Total 5,540 4,982 89.9 558 10.1
The percentage of school health staff at the pre- school level was the highest, accounting for
92.9%. The lowest percentage was 82.5% at high school level.
Table 3. Qualifications of school health staff in 5 surveyed provinces
Province
Number of school health workers
With medical background Without medical background General physician
or above (n) % Other % N %
Quang Ninh 632 341 54.0 137 21.7 154 24.3
Thanh Hoa 1,543 272 17.6 246 16.0 1,025 66.4
Lam Dong 700 311 44.4 161 23.0 228 32.6
Ho Chi Minh 1,530 533 34.8 872 57.0 125 8.2
Tien Giang 577 118 20.6 122 21.0 337 58.4
Total 4,982 1,575 31.6 1,538 30.9 1,869 37.5 Table 3 showed that school health staff with
medical qualifications accountted for 62.5%;
31.6% of them had the qualification of general physician or above. The percentage of school medical staff without medical expertise in the 5 provinces was 37.5%.
2.3. The capacity of school health staff
A summary of the opinions from the managers and self-assessments of 40 school health workers showed that school health staff with medical background can complete their responsibilities. Every year, the health sector
and education sector at the provincial or district levels coordinated to organise training and knowledge updating for school health staff so that they can basically perform their tasks. For school health staff without medical background (about 30 – 60%), school health activities were implemented in a limited manner. Several tasks were not implemented despite the annual trainings were still being organised. The main reason of this issue was that these schools just had school teachers, accountant, or treasurer, who were assigned to take additional part-time job of school health workers. This position was
frequently changed among school staff so that they did not spend enough time on the school health tasks or were not proactive at work.
2.4. The benefits and incentives for school health workers
Permanent school health staffs with medical background had salaries and preferential allowances as prescribed 8. However, according to in-depth interview results, the income of school health staffs remained very low in comparison with that of teaching staff.
For contracted school health workers, there were still arguments on whether the pay rate should be in line with the salary rankings applied in the education or health sector, or it should be a rate mutually agreed by both the employers and the employees. In Ho Chi Minh City, 450,000VNĐ per month was allowance for school health workers with intermediate medical degree or higher (about 35% of total school health workers) from July 2015. These were policies to attract and support workers and civil servants working in health facilities in the field of preventive medicine9.
2.5. The budget of school health activities With regard to funding sources and expenditures for school health activities, schools shall apply the Circular 14/2007 of the Ministry of Finance (MOF) guiding the implementation of school health activities, which stipulates the funds for school health activities from non- business budget, health insurance and other legal sources; the Joint Circular No. 41/2014 of MOH and MOF guiding the implementation of health insurance; the Joint Circular No. 14/2014 guiding medical examination and treatment
contracts with health insurance at medical facilities and schools10, 11, 12. Accordingly, the budget for school health activities was spent on: (1) salary and allowances for full-time school health workers, (2) regular operational expenses on school medical services such as screenings, first aid and emergency, training for capacity improvement, (3) expenses on medicines, medical equipment; and (4) other auxiliary expenses for school health activities.
Our survey found that most of the surveyed schools mainly used the budget from the school health insurance revenues to cover all school health activities. For example, Tien Giang Department of Education and Training and Tien Giang provincial Social Insurance were issued guideline on “setting primary healthcare fund from the health insurance as the only funding source" 13. It was clear that funding for school- based healthcare activities must be allocated from different sources as defined in the Joint Circular No. 14/2014 above. Relying on the school insurance revenue as the only funding source for school healthcare was inappropriate and insufficient. Most of the provinces found that the funds for the school health activities were insufficient, failed to meet the demand, and lacked consistent guiding from relevant authorities of education, health, finance and social insurance sectors.
IV. DISCUSSION
Over the years, the government’s policy documents, directives and resolutions had shown consistency and concern for the students' health care and protection. These policies were derived from the perspective “for the future
of the Vietnamese young generation” of the Party, as reflected in the Law on Protection of People's Health, the Law on Children, the Law on Education, the Law on Health Insurance, Law on Medical examination and treatment and legal documents, health and education sector regulations 14, 15, 16, 17, 18.
The current legal documents, directives and decisions of the Government on school health content were quite complete, and had been supplemented and perfected over time, in line with the economic development conditions of the country. It was responded to WHO's recommendations for health promotion schools, which shows the Party and State's interest in health care activities for pupils, students.
The ineffective implementation of school health content in the locality as mentioned above was due to many gaps in the conditions to ensure the operation such as lack of human resources, lack of funding, lack of equipment and lack the inter-sector coordination.
The results showed that the attention of the Party and local authorities was one of the most important factors making the effective school health activities. The role of connection among stakeholders of school health activities effectiveness was mentioned in S. Tomokawa’s research in Thailand 19.
A well-organized system will determine the quality of professional and technical activities.
In the 1980s of the 20th century, the health sector in Vietnam paid much attention to the development of the network of school health facilities throughout the country. The Department of Preventive Medicine was the
focal point at the central level and regional Institutes in the North, the Central and the South forming the Department of School Health. At the provincial level, the focal point was the Preventive Hygiene Station which included school health department. At the district level, there was a district hygiene and preventive health team, and at commune level, staff at health stations were assigned to do this task.
With the subsidy, the activities of school health basically covered the localities and achieved a lot of outstanding results. The education sector also had school health staff to work at the schools. Therefore, the healthcare for student was carried out quite smoothly 2.
When Vietnam shifted to a market economy, the network of school health staff also changed and a number of officials left the state to work in private business. The network of school health staff separated due to the lack of funds for salary payment and other activities. Despite many difficulties, the health sector in the past few years has tried to strengthen the preventive medicine system which included the school health activities. Up to now, the number of school health staff has increased both in quality and quantity 2.
For the education sector, school health activity still faced difficulties due to the shortcoming in school health network arrangement. With over 42,000 schools and 26 million students, the education sector had no common medical system.
Results of the study in 5 provinces showed that only 89.9% of the schools had school health staffs. Among these, only 62.5% were medical background. Among the part-time staff, most of
them were teachers; the rest were accountants, treasurers etc. This result was higher than the data collected nationwide in 2017 from the General Department of Preventive Medicine, which showed that the percentage of schools having staff monitoring school health activities was 85.1%. However, the percentage of staff with medical background was 71.7% which was higher than the study results 1. It showed that the high percentage of schools having no health staff with medical background in the payroll. It greatly affected the quality and effectiveness of school health activities.
The results also showed that the availability of school health staff at preschool level was prioritised wih 92.9% of preschools having health staff. This figure decreased when going to higher education levels with only 82.5% at high school level. The percentage of schools with school-based health workers on the payroll was only 56.5%. The recruitment of qualified school health workers was difficult, the payroll for this staff was also limited, especially since 2015, under the direction of the Government Office on temporarily hiring full-time health officials, localities also stopped recruiting this contingent and school health activities faced more difficulties in the implementation process 20. Currently, the regulation of the qualifications of school medical staff between documents was not consistent, leading to difficulties in recruitment.
The quality of work substantially depended on the qualification, capacity and implementation ability of the in-charge staff. In general, training programs on school health were very limited and inconsistent, as well as less frequently updated 2.
Commune-level health staffs and schools were mainly trained through short courses organized by the health and education sectors. However, the research results showed that the content of the short-term training courses mainly focused on theoretical guidance, with limited practical content, the effectiveness in capacity building was not high. It showed that the demand for the training on capacity building was always essential and needed to be reformed.
Regarding the benefits and regimes of school health staff, the results showed that the salary, incentives and allowance regime for school health staff were not commensurate with huge load of work and other concurrent works. It made them did not stick to the work. It affected the quality of student healthcare.
The funds for support school health activities in each school mainly deducted from health insurance revenue. Meanwhile, according to regulations, the budget for school health activities was supposed to be set from the state budget, health insurance and other legal sources. The coordination between the health sector - education still faced many difficulties.
Schools had a Student Health Care Committee.
At the People's Committees at all levels, there was a SCSH. However, the tasks and operating conditions of these Committees were not clear, leading to the inefficiency of the Committees.
Thus, besides the difficulty in quantity and quality of school health workers, the difficulties in financial sources, lack of coordination inter-sectors were interested issues that need to be solved. The effectiveness of chool health programs strongly depended on the
qualification, passion and enthusiasm of school health workers, the interest and investment of the governments, the authorities and the school management boards.
Limitations
There were few studies on school health policy analysis in Vietnam, so it is difficult in getting reference sources. This is a qualitative study, so the information was obtained from the available data sources and reflected the participant's subjective opinion.
V. CONCLUSIONS
The Government of Vietnam had shown strong commitment to school health by promulgating the laws on people's health protection, children protection, and the education law, law on medical examination and treatment. Other relevant policies and guiding documents endorsed by relevant national authorities of education and health sectors also aimed at promoting school health. The policy documents on school health in Vietnam had been issued quite comprehensively, which were the legal basis for localities to perform well. However, there were still many difficulties and challenges due to gaps in regulations on conditions to ensure the operation of school health.
In 5 surveyed provinces with 5,540 schools at all levels, 89.9% of schools had school health workers; and 56.5% of them were permanent staff, the rest were contracted. The school health workers who did not have medical qualifications accountted for 37.5%.
School health workers with medical qualifications performed better than those
without medical expertise. The benefits and working conditions of school health workers were not seen favourable as they were expected to be. Though training was carry out annually, the training quality was not effective. The budget for school health was limited and failed to meet the demand. The inter-sectoral coordination, especially between the primary health care level and schools, was still not close.
Acknowledgement
This research was funded by Australian NGO Cooperation Program (ANCP) via The Fred Hollows Foundation. The information and opinions contained in the research do not necessarily reflect views or policies of either ANCP or The Fred Hollows Foundation.
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