Health systems around the world are working to tackle the challenge of ageing populations and a rising burden of noncommunicable diseases (NCDs) and chronic conditions. These changing demographic and epidemiological profiles are associated with increased needs for long-term care and social care services, in settings that are appropriate and convenient to those who require care.

Vietnam is no exception. The burden of disease in Vietnam is dominated by NCDs such as cancers, hypertension, and diabetes. Vietnam is also one of the most rapidly ageing countries in Asia. Yet, Vietnam’s health service delivery system remains geared toward the provision of and payment for curative care in tertiary and secondary care facilities. This system is increasingly incompatible with the burden of disease and the health needs of the Vietnamese population.

There is a critical need to shift towards more strategic service delivery models that can deliver the right care in the right settings, for those who need it. A new model of integrated care offers this opportunity. Integration of care refers to the coordination among primary health care (PHC) providers, hospitals, and community agencies to deliver care across the care continuum, working together to ensure that patients have access to appropriate medical care at sustainable cost and in patient-centered ways. Various models of integrated care have been implemented across the world: in Europe, pockets of the United States, and to varying degrees in other countries – most recently (and to an extensive scale) in China.

In 2009, China embarked on an ambitious process to reform its health service delivery strategy. The concept of "Person-Centered Integrated Care" (PCIC) was front and center of the reform initiative. The overarching aim of this strategy was to improve population health, raise the quality of care, and improve patient satisfaction at a price that is affordable to both citizens and government. PCIC involves shifting the balance of care across health care settings: from treatment to prevention and management, from hospital to ambulatory and home settings, from specialists to PHC practitioners, and from physical to virtual access and communication. PCIC also involves a series of arrangements in the financing, organization, and delivery of care.

Policymakers in Vietnam recognize the need to shift the country’s health service delivery system to one that is more responsive and appropriate to the needs of its population. Vietnam has laid out a vision for strengthening PHC and reorganizing the health system to ensure continuity of care and ease of access to appropriate care for the population.

Learning from China – whose health system was very similar to Vietnam’s, prior to its reforms – would greatly benefit Vietnam as it embarks on a process to achieve its vision. A knowledge exchange supported by the South-South Facility provided the opportunity for Vietnam officials to learn from China’s experience in integrated care reform, and to gain an understanding of the policies, institutional requirements, and implementation arrangements that have supported such reforms.

Vietnam is undergoing a rapid demographic and epidemiological shift. The percentage of the population age 65 and above in Vietnam is expected to increase by 2.5 times by 2050. Importantly, the ageing of Vietnam’s population is occurring at a much lower level of income than it did (or will) in other Asian countries such as Japan, the Republic of Korea, Thailand, and China. This raises questions about how the associated care needs will be addressed and financed. The NCD share of the disease burden grew rapidly from 51 percent in 1990 to 74 percent in 2017, and NCDs occupy seven spots in the top ten causes of Vietnam’s disease burden.

The health system in Vietnam is not yet ready to manage the changing health needs of its population. Vietnam has a fragmented health service delivery system with preventive and curative care provided in different facilities and paid for from different funding sources. The system is hospital-centric, with services that could be provided in an ambulatory care setting being delivered in a hospital setting instead. Vietnam’s rate of hospital admissions and average length of stay are higher than regional averages. In 2016, almost half of all outpatient visits took place in a hospital, and this share has been rising steadily over time, even as overuse of hospital care has long been recognized as a health system problem. This system is also inefficient and unsustainable from the financing perspective.

Increased knowledge of integrated care reforms in other countries would support Vietnam as it works towards reorganizing its health system to one that better facilitates continuity of care, shifts care out of hospitals into ambulatory and home settings and emphasizes prevention and management instead of treatment. Specifically, knowledge in the following areas would concretely support next steps in Vietnam:

- Health policy context and sequencing of integrated care reforms

- Institutional reforms, including organizational arrangements and governance

- Financing arrangements to incentivize coordination and integration across health providers

- Reforms to core services such as PHC and NCD management

- Tools and enablers, such as health information and information technology

China was identified as an appropriate knowledge provider due to its massive reform efforts on integrated care over the past ten years, similarities with Vietnam in its pre-reform health system, and shared cultural and political contexts.

Ahead of a study visit to Fuzhou, in China’s Fujian Province, the World Bank Health team in Vietnam facilitated a discussion with a Vietnam Government delegation in Hanoi on November 8, 2018. The objective of this discussion was to introduce key concepts related to PCIC to members of the delegation and discuss the relevance of integrated care in the Vietnam context. This enabled the delegation to go on the study visit to China with foundational knowledge on PCIC, to be better able to absorb the breadth and depth of information that Chinese counterparts would be sharing.

The Vietnam Government delegation participated in a knowledge exchange / study visit on person-centered integrated care (PCIC) in Fuzhou, China, from November 12-14, 2018. The visit was planned to coincide with an international workshop on "Building Value-based Quality Service Delivery Systems", hosted by the National Health Commission of the People’s Republic of China. This brought together international experts from US-based health networks, non-profit organizations, think tanks, and academia, all of which added to the learning experience.

The knowledge exchange event included information sharing sessions by health officials from China on PCIC reforms at the national level, as well as in a range of provinces (Fujian, Anhui, Shaanxi, Zhejiang). The second day of the event included field trips to health facilities, including a tertiary hospital, and an urban health center, a county hospital, a rural health center, and a village health post. This was followed by "deep dive" sessions for in-depth discussions on core elements of PCIC, such as governance and organizational models, service and functional integration, financing, quality of care, and health information systems.

On November 16, 2018, a post-trip debriefing session in Hanoi provided an opportunity for the Vietnamese delegation to reflect on the knowledge gained and lessons learned. The delegation also shared their thoughts on how Vietnam could take its integrated care reform efforts forward.

Key lessons and takeaways for the Vietnamese delegation included:

- An understanding of the importance of clear policy direction on integrated care. A coherent national strategy on integrated care is a critical next step for Vietnam. Part of this would be to document the status of integration of care in Vietnam, highlighting potential entry points and crucial policy gaps.

- An appreciation for the large-scale effort of integrated care reform, and the various elements that need to be in place for the reform to be widespread and sustainable. A key takeaway was that successful implementation requires national-level ownership and leadership.

- An understanding of the importance of consultation and negotiation with key stakeholders, ranging from policymakers at the macro level, to health facility managers at the "meso" (organizational) level, to health practitioners at the micro level.

- Innovative ideas for entry points and pilots. Brainstorming by the Vietnamese delegation suggested that it could be a good idea to start PCIC-related reforms in a small way by prioritizing selected NCDs and piloting NCD management at the local level, possibly in selected provinces. This would be a proof of concept, before expanding NCD management at the local level on a broader scale.

Vietnamese delegation:

- Deputy Director, Department of Organization and Manpower, Ministry of Health (MOH) Vietnam

- Expert, Department of Planning and Finance, MOH Vietnam

- Expert, Department of Health Insurance, MOH Vietnam

- Expert, General Department of Preventive Medicine, MOH Vietnam

- Senior Expert, Medical Services Administration, MOH Vietnam

- Expert, Health Insurance Implementation Department, Vietnam Social Security (VSS)

- Expert, Northern Center for Medical Review and Tertiary Care Payment, VSS

- Participation by various representatives from the Health Policy and Strategy Institute, Vietnam

Chinese counterparts:

- Deputy Director General, Development Center for Medical Science and Technology, National Health Commission

- Director, Division of Supervision, Health Reform Department, National Health Commission

- Deputy Director, Center for Health Policy Research, Anhui Medical University

- Deputy Director, China National Health Development Research Center

- Director, Shanghai Health Development Research Center

- Deputy Director, National Finance Division, Ministry of Finance, China

- Director, Department of International Cooperation, National Development and Reform Commission, China

The knowledge exchange with China was financed through the World Bank South-South Facility and additional contributions from World Bank programs in Vietnam and China. Pre and post-trip briefings and small group meetings between the World Bank Vietnam health team and the Vietnamese delegation also allowed for opportunities to engage in meaningful dialogue on how integrated care could be relevant to and applied in Vietnam.

The World Bank health team in Vietnam has been in discussion with key counterparts about conducting an assessment of integrated care. This would document the status of integration of care in Vietnam and highlight potential entry points and crucial policy gaps. Together with Vietnam’s Health Strategy and Policy Institute, the World Bank team is developing an assessment framework and research protocol for this purpose. The work is ongoing at the time of writing and is expected to be completed by early 2020.

In tandem with the assessment and as further follow up, the delegation is keen to organize further knowledge sharing sessions to bring the lessons from China and other countries to a wider audience in Vietnam. This could take the form of workshops, small group meetings, and/or site visits.

Put together, this could facilitate the development of a roadmap towards a coherent national strategy on integrated care in Vietnam, with buy-in from relevant stakeholders, and to be implemented in Vietnam in the medium to long-term.

Over the course of three learning days, the delegation learned the core concepts of integrated care, gathered valuable information on the context and process of China’s PCIC reform effort, and learned the "nuts and bolts" of integrated care (and saw it in practice).

Five main points of learning are detailed below. The relevance to Vietnam and key questions and ideas that were provoked are outlined as well.

1. PCIC-related reforms within broader health sector reform

PCIC-related reforms in China were launched in 2009, as part of an overarching health sector reform which included various phases, with the goal of achieving Universal Health Coverage by 2020. Broadly, the phases are as follows:

- The first phase of the reform (2009-2011) targeted five priorities: 1) establishing the basic medical insurance system; 2) establishing a national essential medicine system; 3) strengthening health services at primary care level; 4) ensuring equal access to basic public health services; and 5) piloting public hospital reform.

- The second phase began in 2012 when the central government issued the 12th Five-Year Plan for Health Reform; this phase ended in 2015. The second phase of the reform is anchored in three interdependent areas: 1) expediting the establishment of universal health insurance coverage system; 2) strengthening and improve the essential medicines system and primary care system; and 3) promoting public hospital reforms. This phase focused its most attention on public hospital reforms.

- China's health reform entered its third phase when the Chinese government announced the 13th Five-Year Plan for Health Reform (2016-2020). The Plan pushed subnational governments at all levels (provincial, municipality prefecture, county, township, village, etc) to step up efforts to build five systems: 1) tiered service delivery system, 2) modern hospital management system, 3) universal health insurance coverage system, 4) pharmaceutical supply system, and 5) comprehensive regulation system.

Presentations from various provinces – Fujian, Anhui, Shaanxi, and Zhejiang – highlighted how each province has been implementing key reforms, in line with the national directives, and ongoing challenges that continue to need to be addressed through further reform efforts.

A key learning point for the Vietnamese delegation was that integrated care reforms need to be conceived and contextualized within the broader health system reform. Successful implementation requires national-level ownership and leadership. The delegation recognized that PCIC concepts were not entirely new to Vietnam – many ongoing reforms (e.g. referrals, improvement of quality of care at the PHC level) are integral parts of PCIC, but they have not been brought together in a cohesive way in Vietnam’s health sector discourse yet. Developing a coherent national strategy on integrated care would be a critical next step for Vietnam.

2. Organizational arrangements and governance

PCIC-related reforms in China have introduced a tiered service delivery system. This model of care depends on a service delivery system in which the first point of contact is at the PHC level, effective two-way referral, clearly defined responsibilities of providers at different levels, and shared clinical and management protocols across various care settings. In general, across the Chinese provinces, there are two main features of this tiered service delivery system:

- Integration via medical alliances. All tertiary hospitals in China (>2000 facilities) have joined medical alliances. There are various forms of medical alliances e.g. closely integrated medical groups, specialist alliances, looser "collaborations" across facilities etc. Shaanxi province gave an example of a medical alliance led by a teaching hospital, which focuses on providing training to member facilities. Zhejiang, on the other hand, highlighted the wide reach of its medical alliances (526 in total). Closely integrated medical alliances operate as a single entity and provide continuous service to people in their catchment area. Many of them have a combined management structure, and shared procurement and data services. Zhejiang province emphasized the importance of medical supervision, which they see as the most critical element of the medical alliance, as it facilitates regulation of service provision and quality of care. Closely integrated medical alliances also have shared finances, which will be elaborated on below.

- Contract-based service delivery by family doctors. Service contracts for a pre-determined package of services (predominantly PHC services) are signed with family doctors. The population living in each designated catchment area then registers with that family doctor in order to receive these services. The intent is for family doctors at the PHC level to act as the first point of contact for the population.

China’s medical alliances and contracted family doctors are very different from Vietnam’s service delivery network, which at present is not vertically integrated. While it appears to be working in China, the delegation agreed that its applicability in Vietnam would need to be studied further. In particular, key outstanding questions include:

- How well-defined are the roles and responsibilities of each provider?

- Is the alliance imposed or do providers have a choice to join?

- What is the motivation for each member to keep the alliance going?

- Who makes a final decision on clinical care if professional opinions differ

- Is the model sustainable?

Establishing vertically-integrated networks would represent a sea change in Vietnam’s health service delivery model. The above questions would need to be discussed among key stakeholders in Vietnam to build a consensus on how to reorganize the service delivery network and agree on what it would take to implement such a reform, and who could implement it.

3. Financing

A defining feature of the PCIC reforms was the introduction of shared financing – or capitated global budget – across members of the medical alliance. Typically, funds are managed by a lead agency (usually the largest hospital within the alliance). Funds are then distributed to participating members by the lead hospital, based on the chosen payment method (e.g. case-based payment or fee-for-service for inpatient care), and also based on funds availability and performance assessment. The alliance manages within their allocated amount and assumes risk for surpluses or deficits. If there is surplus, the alliance keeps the balance. Typically, the majority of surpluses are given to the county hospital, of which half is retained by the hospital and half is used for further integration efforts. A small share is given to the village level, and slightly more to the township. If costs exceed revenue, the alliance bears the cost collectively, with lead or larger facilities typically bearing a larger portion of the loss.

In the context of Vietnam’s existing health financing and provider payment system, more work would need to be done to understand the potential roles of the state budget for health versus social health insurance in a population-based payment system for integrated care, and the incentives it would create (i.e. how to avoid under-provision of certain services and over-provision of others). Stakeholders in Vietnam would also need to be consulted on a potential financial risk-sharing system such as in China’s medical alliances.

4. Primary health care and chronic disease management

PCIC reforms have supported the strengthening of PHC service delivery, and vice versa, in several ways. First, the use of two-way referrals and the establishment of care protocols have facilitated and given confidence to both higher level (tertiary and secondary care) and PHC professionals to "hand off" their patients to a different facility, for follow-up care. The pervasive use of information technology (IT) has also facilitated referrals (see below for more information). Second, a strengthened PHC system is better able to manage NCDs and chronic conditions. For example, Fujian province has piloted Type 2 diabetes integrated management in municipalities, while Anhui province has recruited veteran nurses to do NCD management in urban settings. This has been well-received by residents; these nurses serve as "connectors" between PHC and higher-level facilities.

That said, trust and confidence by the community of PHC services can be further improved. This is an ongoing challenge in China, Vietnam, and elsewhere. International experts stressed the importance of continuous training for staff, quality improvement, the use of appropriate incentives, and the need for care at the PHC level to be respectful and of good quality. Only then can practitioners instill confidence in the population they serve.

5. Health information and use of information technology

The use of IT and sharing of health information was a highlight in the study tourt. The Vietnamese delegation witnessed the use of telemedicine in remote consultations at various facilities during the site visit on Nov 13. The picture (attached) shows a team of health professionals engaging with a team it has partnered with, in a different location. Patient scans and data are available to both teams, who can review the information during the remote consultation, while discussing the case.

Chinese government officials also explained that the medical alliance service level agreement defines what services should be provided by each provider and what they will help each other with through referrals and telemedicine. Shaanxi province, for example, has an agreement within its oncology medical alliance for remote consultations across different levels of facilities, and tracks the same quality indicators across facilities too. Telemedicine is especially useful in the context of specialty care for which there are few doctors, as well as to provide support to remote areas.

The Vietnamese delegation was very impressed with the use of health information technology in China, where even the smallest facilities e.g. at the township level could connect to higher level facilities. The site visit showed how this saves time for the patient and is also reassuring for providers at the local level. However, the knowledge exchange also reminded participants that there are many ways to strengthen local level care which are NOT very high tech – and these can (and should) be used to ensure proper care coordination, team-based care, and population health management in the PHC setting.

From China:

• Provincial Health Commissions from Fujian, Anhui, and Zhejiang provinces
• National Health Commission, People’s Republic of China
• Ministry of Finance, People’s Republic of China
• National Development and Reform Commission, People’s Republic of China