The Assessment Social Impacts Report
MINISTRY OF HEALTH
Central North Health
Support Project
The Social Impact Assessment Report
October.2009
Table of Contents
Chapter 1: INTRODUCTION 1
1.1. The project background 1
1.2. The objectives and contents of the report of the social impact Assessment 6
Chapter 2: SOCIAL IMPACT ASSESSMENT FRAMEWORK 10
2.1 Legal and Policy Framework 10
2.2 Determining stakeholders in social assessment and coordination 14
2.3 Social impact Assessment framework 15
Chapter 3: THE SOCIO-ECONOMIC SITUATION OF THE PROJECT AREA 16
3.1. The Socio-economic situation of the project area 16
3.2. Healthcare situation 24
3.3.Diseases burden 26
3.4. Accessibility and utility by local people of health services 29
Chapter 4: THE IMPACTS OF THE PROJECT TO ETHNIC MINORITY 34
4.1. Identify the level of positive impacts of the project to the poor, near poor and ethnic minority people 34
4.2. Socio- Economic condition of some Ethnic minorities in the Project areas 41
4.3. Identify the level of negative impacts of the project’s activities to the living and healthcare to the poor, near poor and ethnic minority people. 47
4.4. Propose the solution to minimize or avoid the negative impacts of the project to the vulnerability targets. 48
4.5. Constraints that limit ethnic minority people to access public health care services 48
Chapter 5: THE RESETTLEMENT 51
5.1. The planning and reclaiming land for constructing the PHCs 51
5.2. How the project have been affected on cultures, religions and beliefs 56
5.3 Procedure of issuing the land use certificate 56
5.4. The project impacts to the living and production of the households 57
5.4 Results of consultation of affected households 59
Chapter 6: THE CONSULTATION OF THE STAKEHOLDERS OF PLANNING THE SOCIAL IMPACT ASSESSMENT 61
6.1. Ideas and viewpoints of the stakeholders during preparing the project workplan 61
6.2. Proposing the workplan of social impact evaluation during the project implementation in the local 64
CONCLUSION 67
The Assessment Social Impacts Report
List of Tables
Table 1.1- List of 30 District Preventive Health Centers for project investment 4
Table 3.1. Some features on natural and socio-economic situation of six provinces of the Project 16
Table 3.2. Monthly income per capita by sources of income quintile 17
Table 3.3. Socio-economic situation of district selected of project Thanh Hoa province 18
Table 3.4. Socio-economic situation of district selected of project Nghe An province 19
Table 3.5. Socio-economic situation of district selected of project Ha Tinh province 20
Table 3.6. Socio-economic situation of district selected of project Quang Binh province 21
Table 3.7. Socio-economic situation of district selected of project Quang Tri province 22
Table 3.8. Socio-economic situation of district selected of project Thua Thien Hue province 23
Table 3.9. Percentage of illness or injuies in year 2006 by province 24
Table 3.10. Malnutrition in weight by age among children under 5 years (%) in Central North and 6 provinces 2007 25
Table 3.11. Mortality pattern in the six selected provinces 25
Table 3.12. Percentage of illness or injuies in year 2006 by urban rural, region, income quintile, sex, age group and ethnic 27
Table 3.13. Rate (%) Sick cases not treatment during 4 weeks before survey 29
Table 3.14. Percentage of in-patient treatment in year 2006 by type of health facilities, region, sex, age group 30
Table 3.15. Distribution of rounds of medical consultation and treatment during 4 weeks before the survey (%) 31
Table 3.16. Use of public hospitals in 6 project provinces 32
Table 4.1. Percentage of people having treatment in the last 12 months in year 2006 by urban rural, region, income quintile and sex 34
Table 4.2. Percentage of out-patient treatment in year 2006 by type of health facilities, urban rural, region, sex, age group and ethnic 35
Table 4.3. Percentage of in-patient treatment in year 2006 by type of health facilities, urban rural, region, sex, age group and ethnic 36
Table 4.4. Percentage of people having treatment in the last 12 months in year 2006 by age group and ethnic 37
Table 4.5. Percentage of poor, near poor and ethnic minority of districts prioritised for project investment 38
Table 5.1 List of the PHCs prepared the document of land certificate 55
Table 5.2 The households and people affected by the project 57
The Assessment Social Impacts Report
ACRONYMS
EG / Ethnic groupFS / Food Safety
GH / General Hospital
HC / Health Center
HD / Health Department
HI / Health Insurance
HMIS / Health Management Information System
HS / Health services
HW / Health worker
MoH / Ministry of Health
NCR / North Central Region
NHS / National Health Survey
GoV / Government of Viet Nam
PC / People’s Committee
PH / Preventive Health
PHC / Preventive Health Center
PMU / Project management Unit
PPMU / Provincial Project Management Unit
SC1 / Specialist Class I
TM / Traditional medicine
WB / World Bank
The Assessment Social Impacts Report
Chapter 1: INTRODUCTION
1.1. The project background
1.1.1. Introduction
The Central North Health Support project is designed to follow the government’s regional approach to health system development by targeting the northern region of the central coastal area, referred to as Central North region. The region, with a population of 10.7 million, is the second poorest among the eight regions of Vietnam; 25% and 30% of the population is classified as poor and near poor respectively (2006). Average per capita income in the Central North is 317,000 VND (2004) compared to the national average of 445,000 VND (2004). The inhabitants of the region (approx. 85% of them) live in rural areas and make their living from self-employed agriculture and fish farming; the share of self employment is 79.5% in the total employment structure according to 2004 data. Overall, the health status of the region is poor. Average Infant Mortality Rate is 22 (ranging from 15 to 36) compared to the national average of 16, and Maternal Mortality Rate is 200 compared to the national average of 75. The leading causes of morbidity are associated with respiratory conditions and diseases of the digestive system.
With its regional focus and design, the Central North region project is fully aligned with the government’s strategy to strengthen the health systems in disadvantaged regions by relying on three pillars: (a) reducing demand-side barriers to health services for the economically vulnerable population, (b) improving the quality of pro-poor health services, and (c) reducing the shortage of competent health care professionals in underserved areas. The project will reduce demand barriers by increasing affordability of health insurance to the near poor population by providing significant subsidies towards health insurance premiums, above what is currently offered by the government. This will be complemented by a strong Information and Education Campaign, social marketing, and a number of incentive mechanisms to increase enrollment of the target population in the health insurance scheme. In order to improve the quality of pro-poor health services, the project will invest in district hospitals and DPHCs in the most disadvantaged districts, thereby making basic health care available at a lower cost and closer to the communities. Most of the investment will go into equipping hospitals with most basic medical equipment and refurbishing the DPHCs. This will be combined with a Results Based Financing pilot to test some innovative mechanisms to promote better performance, accountability and client-orientation of health services. The project will address the human resource constraint in the Central North region by training specialists that are in short supply and creating stronger local medical training institutions for more sustainable results.
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1.1.2 Legal justification
On April 14th, 2009, the Prime Minister released document 551/TTG-QHQT giving approval for the World Bank supported “Central North Region Health Support Project”.
For a long time, WB has been assisting the health system with various major Projects in Vietnam. Such as, National Health Support Project, HIV/AIDS Prevention Project, Mekong Health Support Project, Regional Blood Transfusion Center, Northern Uplands Health Support Project etc. Assisting socio-economically disadvantaged regions, supporting health care facilities utilized by the poor, near-poor and etchnic minorities, and reducing poverty through human development efforst is the top priority of WB.
WB has been assisting various countries in developing their health system. This has given the WB a significant experience in designing projects in a way that can maximize the impact for the poor and prevent any possible negative impact on marginalized societies.
1.1.3. Objectives of the project
The project development objective is to strengthen district level curative and preventive health services and improve their accessibility for the economically vulnerable population.
Intermediate objectives are:
- Increasing health insurance coverage among the near poor population;
- Upgrading capacities of district hospitals and DPHCs;
- Improving supply and quality of health care personnel.
1.1.4- Direct project beneficiaries
The project beneficiaries will include the following three groups:
(i). Local people: especially the near poor and the ethnic minority people are the most important and beneficiaries of the project. While the project provides direct demand-side subsidies to the near poor, it also benefits the poor and ethnic minorities by making affordable and improved health services available at the local level, close to their communities. .
(ii). Health care service provision network: District hospitals will receive medical equipment and District Preventive Health Centers will receive new buildings (technical and administration blocks) and medical equipment. Health care personnel will benefit from improved working conditions as a result of infrastructure investment. They will also receive training.
(iii). Administration agencies: District Health Offices and district branches of Vietnam Social Security Administration will receive training and support for institutional capacity building. They will also benefit from improved working conditions and as well as from the innovative pilots for improving the efficiency of managing the health system.
1.1.5. The project components
The project has four components including:
Component 1: Providing health insurance to the near-poor people
1. This component aims to expand access to health insurance for near poor households in the Central North region and to improve the system’s capacity to manage health insurance. It will do so by (i) subsidizing health insurance for the near poor, (ii) conducting a social marketing and Information and Education Campaign, and (iii) strengthening institutional capacities for the administration of health insurance. Specifically, this component will finance the bulk of the out-of-pocket price faced by near poor households with the objective of increasing the take-up of health insurance among this group. In addition, it will entirely sub-contract the social marketing component to a qualified local TA firm that will provide technical assistance on social marketing techniques to the Health Information and Education Centers (HIEC) and Vietnam Social Security Office (VSS). The project will also provide limited support to VSS with additional administrative operating costs resulting from expected increased enrollment of the near poor. This will start as a pilot incentive scheme whereby the VSS will receive a fixed per-capita amount (2% of the premium) for each additional near poor enrolled in the scheme. Finally, a Joint Working Group on Health Financing will be established in order to foster national level engagement with key stakeholders on health reform issues, facilitate dialogue and knowledge exchange between the project provinces and the center, and support capacity-building.
Component 2: Assistance to strengthen the district-level health service
The objectives of this component are to: (a) improve the capacity of district hospitals to provide basic curative health services to the population, and (b) strengthen the capacity of District Preventive Health Centers to carry out basic public health functions. The component will achieve its objectives through investing in upgrading medical equipment in the district hospitals, building and equipping District Preventive Health Centers where they do not have adequate functional space, and piloting performance-based financing mechanisms to incentivize health care providers to perform better and more efficiently.
Sub-component 2.1 – Upgrading capacities of district hospitals The Government of Vietnam is paying significant attention to district level health facilities because they are physically most accessible and also pro-poor. In 2008 the government launched a large scale investment of the funds generated from the sale of State bonds into district hospitals. This amount (approximately seven thousand billion VND) has been already distributed among the districts. However the funding is not sufficient to address all equipment needs and to cover all districts. The government funding was used mostly for civil works. In addition to these resources, some district hospitals have received funding from international donors. For example KfW has invested in 18 district hospitals in Thanh Hoa and Nghe An provinces.
Sub-component 2.2 – Upgrading capacities of District Preventive Health Centers The objective of this sub-component is to strengthen preventive health services in districts and thereby scale up delivery of basic public health services to the population. The project will achieve this by providing 30 districts with new facilities for DPHCs, equipment and training. The project will also implement a performance-based financing pilot to improve the effectiveness of DPHCs.
It was decided that the project will only support construction of technical and administrative blocks of District Preventive Health Centers with a size of 500-600 square meters. These are the two essential functional blocks in district preventive centers. It is expected that the local governments will finance building of supporting blocks, such as stores, gardens, garages, etc. It is estimated that the construction of one administrative and technical block will cost approximately $200,000. The project will provide equipment based on the MOH’s standard list of essential equipment for District Preventive Health Centers, the current stock of equipment, and the capacity of each District Preventive Health Center. After being separated from the hospital, no preventive center has had its own vehicle, making it extremely difficult for it to perform epid-surveillance, sanitary control and other functions. The project will provide one off-road vehicle to each district preventive health center under its ambit. It is estimated that about $200,000 will be required to provide the necessary set of medical equipment to each preventive health center.