HEALTH CARE DEMAND AND HEALTH SERVICES DELIVERY IN RURAL AREAS Rural areas in Vietnam encompass 9,068 communes, which are the lowest territorial and administrative units in the country where 60.7 million people (67.67% of total population) reside1-3. Despite a remarkable development in the past decades, these areas are still economically and socially disadvantaged.
A rural inhabitant’s income per capita GDP is low: 1,124 USD/year, i.e. about half of the nationwide 2,109 USD/year and far less than that of the urban one4. Moreover, poor and ethnic minorities live mostly in rural areas. While the poverty rate for households nationwide is 4.5-5%, the poverty rate in rural areas is about 8.2%5.
Vietnam’s health system is organized into central, provincial, district and commune levels. Almost all hospitals and clinics belong to the fi rst three levels and are located in cities or
towns. The nearest commune district hospitals are usually small and the number of their beds account for only 36% of total hospital beds. At the commune level, health stations (CHSs) are only state-owned health facilities. The ratios of medical doctors, nurses and midwives per 10,000 inhabitants in rural areas are apparently very low at 1.3, 2.3 and 1.9, respectively.
Whereas those numbers in urban areas are much higher at 17.5, 25.5 and 5.56.
Such distributions of medical facilities and staff are evidently unfavorable for rural dwellers whose opportunities to access to full and qualifi ed health services are very limited, namely because: (i) The hospitals are located tens to hundreds of kilometers far away from their homes and are often overcrowded. The CHS’s capacitis are very limited due to lack of medical equipment and highly qualifi ed medical workers (only 76% of CHSs have doctors). Therefore, these CHSs can provide
TRADITIONAL MEDICINE:
MORE EFFECTIVE SERVICES IN RURAL AREAS
Nguyen Phuong Mai1, Le Minh Thi2*
1 Ministry of Health
2 Hanoi School of Public Health
* Corresponding author: Le Minh Thi, Hanoi school of Public health, 138 Giang Vo, Hanoi, Vietnam.
only preliminary and simple medical services as fi rst aid, temporary or emergency treatment for simple cases and midwife services. In cases beyond capacity, patients are subject to being transferred to the district or higher level hospitals. (ii) Due to fi nancial constraints, most rural inhabitants fi nd it burdensome to go to these hospitals, as the transportation and communication infrastructure is still poor.
These issues are one of the main reasons of inequity between rural and urban people in accessing quality health services7,8.
PROMOTE MORE EFFECTIVE
TRADITIONAL MEDICINE SERVICES FOR RURAL DWELLERS
Being deeply rooted in Vietnamese communities, encouraged by a consistent policy for development alongside modern medicine, traditional medicine is very popular and highly respected in Vietnam. However, its delivery of services differs between rural and urban areas.
In urban areas, traditional medicine comprises only a small part of total health services. There are only 60 traditional medicine hospitals out of 1,180 hospitals. The number of beds and doctors in traditional medicine hospitals respectively account only for 3.76% and 4.6%
compared to total hospital beds and total doctors of the system.
By contrary, in rural areas, on-site health services rely only on CHSs and non-state traditional medicine units that are run by herbalists. Traditional medicine non-state units are available almost in every commune and 75% of CHSs take part in traditional medicine activities. The statistics of traditional medicine activities, especially on traditional medicine doctors, herbalists and non-state
traditional medicine units are limited and not systematically updated. There are an estimated 3,000 traditional medicine doctors, compared to total of 68,466 doctors currently working in the health system and more than 10,000 herbalists practicing in 10,470 non-state traditional medicine units. A total of 9,028 CHSs are working now without traditional medicine doctors and herbalists. Based on facts that herbalists are practicing in almost 9,068 communes and only 75% CHSs have modern medicine doctors, we can estimate the ratio of herbalists to modern medicine doctors in communes is high, it must be greater than 1, while the ratio of traditional medicine physicians (traditional medicine doctors and herbalists) to modern medicine doctors in the country is very low, about 0.26,9,10. For rural people, going to CHSs or local herbalists for health care are their fi rst choices. Moreover, many ethnic minorities living far away in high mountains cannot even reach CHSs, so their only opportunities for health services are in the hands of local herbalists.
For rural dwellers, traditional medicine is appropriate in treating recognizable common ailments and chronic diseases in geriatrics, gynecology and pediatrics. The commune herbalists can be fairly confi dent and effective in treating such illnesses. At the same time, traditional medicine is closely linked to preventive medicine in terms of its measures taken for disease prevention. More specifi cally, it focuses on disease resistance and comprehensive treatment rather than only on biomedical causes of disease. Likely a number of lost and unknown precious medications are preserved by anonymous herbalists or inhabitants. However, traditional medicine is less effective in treating acute
diseases, emergency cases, fast and widespread infections and surgery.
The quality of herbalist services are often associated with their prestige and acknowledged by the people. In fact, many herbalists have in- depth knowledge of the materials from plants, animals, insects, minerals and their curative powers. Their heirlooms, specialized methods of treatment and remedies have shown to be effective for certain cases over time. Unfortunately, currently rural traditional medicine units usually are poorly equipped with modern diagnostic and treatment facilities, so the quality of services are often unstable and depend too much on an herbalist’s experiences while there not enough standardization for their training and practicing.
A number of medicines used by herbalists have not been tested scientifi cally to prove their effectiveness. Since many of these drugs are produced in small scale and are unrefi ned for short-term use, they are inconvenient to test.
Promoting more effective traditional medicine services means to encourage their strengths and limit their weaknesses, as mentioned above.
For this we recommend:
Promoting traditional medicine activities The support from government and professional associations is an indispensable factor to promote traditional medicine roles in communes. Based on “Government action plan for development of traditional medicine in Vietnam to 2020”11, the support could be in many forms such as investment, partnership, fi nancial incentives and in-kind support.
Our idea is to promote investment in both CHSs and commune non-state traditional medicine units. On one hand, the government could upgrade the equipment and improve the human
resources at CHSs. On the other hand, private investment at commune traditional medicine units should be incentivized by tax reduction and lower land hiring.
Workforce training is also an important subject of investment. The qualifi cations of health staff at commune levels are not high. At the same time, herbalists are on-the-job trained by traditional way based on experiences, specifi c remedies and heirloom methods. Traditional medicine services in communes would be signifi cantly improved if the capacity of traditional medicine staff is strengthened. Therefore, the training of traditional medicine doctors must be upgraded not only at the Vietnam Academy of Traditional Medicine, but also in traditional medicine facilities of modern medicine universities and traditional medicine secondary schools. We recommend also to improve herbalist practices by offering them continuous training courses on basic medical knowledge and experience- exchanging seminars between modern and traditional healers, as well as encouraging young herbalists to enroll in traditional medicine academic programs. In addition, training local people and ethnic minorities as traditional medicine health workers should be a priority. Furthermore, both working and retired traditional medicine doctors should be encouraged to get involved in commune non- state traditional medicine units.
The collaboration between CHSs and commune non-state traditional medicine units as well as between public health workers and private herbalists could be also important. Modern medical technology and equipment are placed to assist traditional medicine in the analysis, diagnosis and detection of diseases as well as in preparing traditional drugs. A number
of rich and cheap traditional pharmaceutical resources and drugs are used for the preparation and supply of modern medicines and many traditional medicine skills such as acupuncture, therapeutic spas and cupping are supplementing modern medical care and vice versa.
Ensuring the quality and safety of traditional medicine services
Vietnam needs to strengthen and complete a system of standards and regulations for traditional medicine activities. Such a system must be upgraded enough to ensure quality and safety by integrating traditional medicine activities into the national health system. This system should be designed to preserve and prevent damage of traditional medicine specifi c characteristics like tradition, nature, popularity and locality.
Reducing the fi nancial burden for rural people
The prices of herbal medicine should be decreased by improving the cultivation and processing of medicinal herbs, innovating service delivery methods, rationalizing territorial distribution of traditional medicine units and encouraging charitable services.
Reducing the fi nancial burden can be made not only by reasonable prices, but also by expanding health insurance for rural people.
CONCLUSIONS
Promoting more effective traditional medicine services in rural areas is necessary and appropriate for a developing country like Vietnam where those services are still quite close and affordable to local people, giving them more options for on-site health services, contributing to healthcare improvement in communes. The appropriate management and investment in traditional medicine will enhance its further development towards the demand of rural people.
CONFLICTS OF INTEREST
The author declared no potential confl icts of interest with respect to the research, authorship, and/or publication of this article.
The views expressed in this commentary are fully the responsibility of the authors and do not necessarily refl ect the views of the organizations they work for.
REFERENCES
1. Vietnam General Sta s cs Offi ce. Sta s cs Yearbooks 2013 Hanoi: General Sta s cs Offi ce (Vietnam); 2013.
2. Vietnam General Sta s cs Offi ce. Sta s cs Yearbooks 2014 Hanoi: General Sta s cs Offi ce (Vietnam); 2014.
3. Total Popula on of Vietnam. h p://data.world- bank.org/indicator/SP.POP.TOTL; 2014. Accessed 10/Feb/2015.
4. GDP per capita (current US$). h p://data.world- bank.org/indicator/NY.GDP.PCAP.CD; 2014. Ac- cessed 10/Feb/2015.
5. Vietnam Government offi ce. Evalua on report on implementa on the Na onal target programs:
Vietnam Government offi ce,;2015.
6. Vietnam Ministry of Health. Health Sta s cs Yearbooks 2013 Hanoi: General Sta s cs Offi ce (Vietnam); 2013.
7. Tran TK, C. T. Nguyen, H. D. Nguyen, B. Eriksson, G. Bondjers, K. Go val, H. Ascher, and M. Pet- zold,. Urban-rural dispari es in antenatal care u liza on: a study of two cohorts of pregnant women in Vietnam BMC Health Services Research 2011;11:120.
8. Tuan T, V. T. Dung, I. Neu, and M. J. Dibley,.
Compara ve quality of private and public health services in rural Vietnam Health Policy Plan 2005;20(5):319-27.
9. Vietnam Ministry of Health HPG. Joint Annual Health Review (JAHR) 2009: Human resources for health, JAHR, 2009: Vietnam Ministry of Health;2009.
10. Vietnam Ministry of Health HPG. Joint Annual Health Review (JAHR) 2013: Toward to Universal Health Coverage. Available at h p://jahr.org.vn/
downloads/JAHR2013/JAHR2013_Final_EN.pdf:
Vietnam Ministry of Health;2013.
11. Vietnam Prime Minister. Decision No. 2166/QĐ- TTG Promulga on of the Government ac on plan for development of tradi onal medicine in Vietnam to 2020. In: offi ce VPM, ed2010.
