by Vu Kim Chung
In 1997, equating health with height, some Vietnamese state officials claimed that by the year 2020 the average Vietnamese would stand 165 centimeters tall -- a full six centimeters more than in 1999.
Mesmerized by foreign media projections of their country as the next Asian "tiger economy" Vietnam's authorities believed that rapidly rising standards of living would also improve the average life expectancy of its citizens. However, with the Asian economic crisis banging at the doors, the bets are off. But experts point out that Vietnam's impressive public health achievements using its scarce resources means future generations could still be walking tall -- if not taller.
"Vietnam's past record on health and fertility improvements have been matched by few low-income countries," acknowledges a 1999 report for a health project funded by the World Bank, Asian Development Bank and the German and Vietnamese governments. Despite decades of war and turmoil, Vietnam's socialist planners have always shown a strong political commitment to health, allocating substantial resources to it. This means that while Vietnam remains one of the world's poorest countries, with a per capita income only slightly more than $200, its public health infrastructure can leave far richer neighbors green with envy.
Vietnam has 170 primary health clinics at the village level per million population, compared to 32 in Indonesia, 63 in China and 141 in Thailand. There is a hospital bed for every 389 Vietnamese, compared to 465 Chinese, 665 Thai and 1,743 Indonesians. Vietnam has more doctors per capita than all the Southeast Asian countries except Singpore.
In 1993, according to World Bank figures, nearly 97 percent of Vietnam's population of 76 million people had access to basic health services. Figures for life expectancy, infant mortality rates and literacy levels are all good. Since the late 1980s, however, doubts have arisen because an increasingly 'market friendly' government has favored greater involvement of the private sector in providing curative services and the sales of pharmaceuticals products. This will make it increasingly difficult for the majority of the Vietnamese, who in effect are peasants, to have access to good medical services.
"The Vietnamese government is still strongly committed to maintaining a strong public health network but there have been rapid changes in our society due to the transition to the market economy which are not yet fully understood," says Prof. Pham Huy Dung, Deputy Director of the Center for Social Sciences for Health of the Vietnamese Ministry of Health in Hanoi.
The dilemma appears to be that while political commitment remains, money is hard to find. The Health Ministry, for instance, has drawn up a long-term 'Strategy for Health for All by the Year 2000' and launched many national programs to address priority health issues and strengthen public health facilities. But, at $228 million, the money allocated for healthcare in 1998 was less in real terms than in 1997. Per capita health expenditure stood at $3.50 in 1997. Experts say the clearest symptom of recent decline in the Vietnamese health sector is the marked reduction in the use of health services.
According to the Ministry of Health, the number of outpatient consultations in state-run health centers has halved since the late 1980s -- from an annual rate of 2.1 visits per person in 1987 to 0.9 in 1993. Lack of funds to replace old medical equipment is cited as a reason. The changing face of the Vietnamese economy has also given rise to new public health problems -- such as those stemming from growing urban slums, environmental degradation and rapid but very unsafe industrialization.
In 1997, 402 workers died and 1,870 were injured in industrial accidents -- an 80 percent jump from the year before. A substantial threat to public health is the HIV/AIDS epidemic, spreading in tandem with increasing commercial sex activity and drug use, social evils that were rare until early 1997 when social attitudes suddenly began to change for some unknown reason, particularly in large urban centres. According to government estimates, about 100,000 Vietnamese were carrying the HIV virus at the end of 1998 and the number could increase to 350,000 people by the year 2000.
Rising costs of pharmaceutical products, a bulk of which are imported and hence affected by currency fluctuations, means that a larger number of citizens are now resorting to self-medication or traditional remedies -- not all of which are safe or effective.
"At one level the expansion of the private sector into health care can be seen as an example of markets addressing public health problems and improving efficiency. But it can also be seen as evidence of the need for more effective public health intervention," says the Hanoi-based Nguyen Hong Anh of Oxfam, a non-governmental organization.
Health experts say the lesson so far is that Vietnam cannot afford to be complacent as its main health problems are still poverty-linked, like in many other developing countries. Chronic malnutrition still affects more than half of all Vietnamese children between one and five years of age and in recent years there has been a resurgence of preventable diseases such as malaria and tuberculosis. But international agencies working in Vietnam remain upbeat about the country's ability to cope with these problems. Officials at the United Nations Development Program (UNDP) report that in the decade since 1986, when the economic reforms started, poverty levels in Vietnam have actually come down by over 35 percent, alongside improvements in life expectancy and adult literacy.
"There are lessons for all countries from Vietnam's experience of emphasizing growth, stability and equity," says a senior UNDP official in Hanoi.
According to most health experts in Vietnam, the twin agenda for the 21st century should be to improve the quality of public health services while controlling growing incidence of overpricing and fraud among private health providers.
With its long experience in fighting battles simultaneously on many fronts, they hope this will not be a tall order for Vietnam.