*population in 2020，GNI and life expectancy in 2019 are updated based on UN's data.
*Medical information is based on WHO's report of 2017 Mental Health Atlas-country profile.
Vietnam, a socialist country, is located at the eastern edge of the Indochinese Peninsula, and shares a border with China at the north, with Laos and Cambodia at the west side. It is a long and narrow territory shaped like the letter S, the total area is 331,689 square kilometers and about 9-times of Taiwan, with a population of over 97 million inhabitants. The population is densely inhabited in the Red River Delta area at the north and the Mekong River Deltaic region in the south. The major ethnic group, Vietnamese (known officially as Kinh), account for 87% of the nation's population, while there are another 53 ethnic minorities including 1.1% of Chinese. The GDP per capita in 2019 was approximately 2,590 US dollars.
The government's administrative system in Vietnam has the centralized (center) and decentralized (local) characteristics, and is organized into four levels-central, provincial, county, and township (commune). The central government is responsible for establishing national laws, policies and plans, allocating budgets to the provinces, and regulating their activities. It is organized in accordance with the overall governance structure for the work division, and the function and authority of the whole country is basically the same including the health system. Provincial governments are in charge of budget allocation and staff members' training and development.
The administrative districts are divided into 3 levels. For the First level, there are 5 municipalities and 58 provinces. The Second level is to cover the Counties, Provincial Cities, and the City Communes including a total of 707 units. As of 2020, Vietnam General Statistics Office (GSO) indicated that there are overall 10,614 Third level administrative units, with 8,297 Communes (Phường), 605 Townships (Thị Trấn) and 1,712 Wards (Phường).
Vietnam has a decentralized system where provinces, counties and communes are given autonomy to implement their own healthcare policies. The organizational structure of the hospital or healthcare system in Vietnam is divided into four groups.
l Central level – The Ministry of Health (MoH) is responsible for the healthcare in the government, and manages several institutions including hospitals, research institutions, and universities. Other Ministries also run their own network of hospitals.
l Provincial/Municipality City medical institutions affiliated to the Central Government – There are several hospitals and medicals centers. In addition, there also have medical colleges offering medicine, nursing, and pharmacy programs.
l District of County – In the district-level, there are health centers mostly to offer medical and preventive services.
l Commune – Commune health stations focus on primary healthcare services at a commune-level.
In 2016, there were totally 1,346 hospitals in Vietnam, which included 1,161 public hospitals and 185 private hospitals. The government health departments in the provinces and municipalities manage to nearly 80 percent of the public hospitals, while the Ministry of Health and other Ministries/Nation-owned enterprises operate the rest. The overall number of hospital beds increased from 209,485 in 2011 to 254,885 in 2016. The public sectors account for 240,700 beds, while the private sectors possess the remaining 14,185 beds. The government aimed to increase the share of private hospital beds to 20 percent of the total beds by 2020, through public-private partnerships.
Vietnam has gradually developed its healthcare; however, the large gap between urban and rural areas is still big, shortage and uneven distribution of medical resources and medical manpower still remain an issue so far.
II. Mental health policy and system
Vietnam has not issued a specific mental health law. The primary mental health policy at the national level has been the Mental Health Protection for Community and Children Project, a part of the National Target Programs on Health. In 1998, the government funded the project which was focused on schizophrenia and epilepsy with several objectives including early detection, management and treatment for people with these disorders. The fund had the provisions of continuing treatment on recurrence prevention, and rehabilitation and reduction of chronic disability.
For the time being, the primary related policy at the national level is that the government initiated the community-based National Mental Health Program (NMHP) in 2000. The main objective of the program was to provide mental health services at the community level through mobilizing community resources, and become a national project to treat schizophrenia and epilepsy in hospitals.
Later, the government formulated a five-year National Action Plan for 2006-2010, in which the mental health issue was included, and performed the mental health screening for the pregnant women and children. It was to focus on the schizophrenia in this period, however, the epilepsy and depression were included in the service items. NMHP executed a series of measures to meet the goals, including the educational communication, expansion of the mental health facility's network, and the training for the mental health workers and primary caregivers.
Social Health Insurance (SHI) in Vietnam was established in 1992, and is now regarded as the main method of public financing fundraising for health care. The government uses its tax revenues to subsidize vulnerable groups such as the poor, the ethnic minority, children under 6, and the elderly above 80. The health insurance coverage, as of June 2019, was about 90.5% of the population. The government planned to reach the coverage rate of 95% by 2025.
The World Health Organization (WHO) drew up the guideline for the mental health in primary care, and thereafter, the therapy of mental health in Vietnam has made a great improvement since then.
III. Human resource
According to WHO information in 2017, there were 286 psychiatrists in Vietnam. i.e., 1.01 psychiatrists per 100,000 people. Reportedly, there were 0.9 medical doctors (not specialized in psychiatry), 2.1 nurses, 0.06 psychologists, and 0.15 social workers out of 100,000 population, and no occupational therapists so far. Therefore, it still is in severe shortage as the mental health is concerned.
There are currently about 20 universities and schools of health science in Vietnam, which are distributed throughout the country and are offering medical training programs. Two programs for generalist training exist in Vietnam, i.e., a 6-year program and a 4-year program. The 4-year program was established by the Ministry of Health in response to the shortage of community physicians.
Students in both programs are admitted based on their examination scores, it will be a direct recruitment without examination, or by signing a contract with the internship facility where the student agrees to practice in following graduation. Students admitted to the 6-year programs are high school graduates who have passed the National Entrance Examination. Students admitted to the 4-year programs are usually assistant doctors who have passed the medical university’s in-house examination. Each medical university requires its individual curriculum on the framework curricula. The framework curricula for both 6- and 4-year programs have two stages of training. The first stage is general education, while the second stage is professional education. At the completion of their medical training, students must pass their university's in-house graduation examination. No national examination or independent accreditation examinations are necessary in Vietnam.
Psychiatrists are trained in three medical universities in Vietnam, including Ho Chi Minh Medical University, Hanoi Medical University and Hue Medical University. In 1958, a Department of Pedagogical Psychology was set up at the Hanoi National University of Education, and in 1965 it became the Faculty of Psychology and Pedagogy, specialized for the training of bachelor degree students (four years), MAs (two years) and PhDs (four years). Now, there have four more Faculties of Psychology, including the University of Social Sciences and Humanities (an affiliate of Vietnam National University, Hanoi), the Ho Chi Minh University of Pedagogy, the Political Institute of the Vietnam People’s Army, and the Civilized College of Vietnam Renmin University. In addition, there are departments of psychology in all educational universities, colleges and schools throughout the country. Psychological courses are also taught at specific universities in such fields as politics, military, public security, administration, law, economics, trade, culture, arts, and the media.
There are two training systems for psychiatrists. The first is mainly clinical training, including primary and secondary level with two years for each. There are two-year training in general psychiatry for nurses at all levels. Some of psychiatric hospital has short-term training for mental nurses, while there is no psychiatric training in colleges. For clinical psychologist in specialized hospitals require more training courses. At present, there is only general rehabilitation therapists in Vietnam. There is no formal psychological rehabilitation training, but only has short-term training or self-study.
IV. Mental health system and promotion
The Mental health facilities in Vietnam
Central-level institutions：There include the two National Psychiatric Hospitals I & II and the National Institute of Mental Health.
Provincial -level institutions：In 2014, there were 36 provincial psychiatric hospitals, 24 departments of mental health in provincial centers for disease protection or centers for preventive medicine, and 25 departments of mental health in provincial general hospitals.
Commune-level institutions：Mental health care at district and commune levels is integrated into general health care facilities, namely district general hospitals, and district health centers, and commune health stations at commune-level.
The capacity of mental health facilities in North Vietnam, there are 49 provincial facilities out of 31 provinces and indicated that the total number of inpatient beds was 4,525. The average ratio of inpatient beds per 100,000 populations was 10.7, but some poor socio-economic regions had the inadequate distribution. Three provinces had no inpatients beds, the patients with severe illness had to be referred to the nearby provincial or central government's facilities. There is no information about the community residential facilities, and the statistics of facilities/beds which reserved for children and adolescents is also insufficient.
Central and provincial psychiatric hospitals are the key organizations in providing inpatient services for the mentally ill patients. There is limited social care for severe psychiatric patients. National and provincial social affairs authorities provide a minimum life requirements, while large social protective institutions have almost no other services.
The supply and pricing of psychotropic medicines are regulated by the Vietnamese government, and all mental health clinics have psychoactive medications, including antipsychotics, antidepressants, mood stabilizers, anti-anxiety medicines, anti-epileptics, etc. Psychiatric hospitals usually hold enough pharmaceutical drugs, and 51%-80% of primary health care facilities have at least one type of psychotropic medicament.
Psychiatric diagnosis, psychotropic medication prescription, and inpatient mental health care may only be done at provincial and central levels, especially in the specialist hospitals. There are 11,000 commune health stations and 600 district hospitals, which have made a remarkable contribution to Vietnam's achievements in general health care, these facilities however have very limited capacity to respond effectively to the needs of the growing number of patients with mental illness.
This may be attributed to several factors as listed below.
(1). Lack of mental health law
(2). Insufficient political commitment
(3). Insufficient skills and knowledge of health workers at district and commune facilities
(4). Lack of necessary drugs and equipment at health facilities
(5) Inappropriate health insurance reimbursement policies
(6). Lack of linkages and integration between preventive and curative care
(7). Fragmentation in health service that prevents comprehensive and continuous care
There are currently no strategies concerning health promotion or disease prevention, and no community or primary care policies that address health issues. However, the government had brought in mental health issues in the five-year National Action Plan for 2006-2010.
V. Major issues, challenge, and opportunities.
Vietnam's healthcare is facing the main challenges, including overcrowding, shortage of medical staff, and outdated equipment in surgical operation and intensive care units. The professionals in psychiatric hospitals in Vietnam are similar to the early development of psychiatric medicine in Taiwan, which most of them are based on general physicians and nursing staff. The others in the psychiatric medical teams, such as occupational therapists, clinical psychologists, social workers, etc., are to cultivate in the near future.
The major issues in Vietnam include
(1). Mental Health legislation
(2). Develop medicine, psychological and occupational therapy.
(3). Enhance professional training for mental health manpower, and to construct mental health training system for nurses, psychologists, occupational therapists.
(4). Increase national investment to improve the quantity and quality of mental health system.
In 2014, Vietnam’s Psychiatric Association conducted a study to identify the 10 most common mental illnesses which affect the country mostly. The three most well-known issues were alcohol abuse, depression, and anxiety. However, further research should be needed to address these conclusions and to evaluate their causes. See the following table.
Source: Taiwanese Journal of Psychiatry (Taipei) Vol. 31 No. 4 2017 P.296
Mental disorders are sometimes imbued with shame and disgrace in the country, which can prevent individuals from speaking openly about their distress. For example, bác sĩ tâm thần is Vietnamese for psychiatrist; however, it is directly translated into English as "doctors who treat madness". These references are embedded with cultural stigma, implying those who seek psychological assistance are treating their obscenity behaviors.
A joint study between UNICEF, UNRISD, and MOLISA of Vietnam, in 2015, they surveyed the rural area of Dien Bien Province in northwest Vietnam and discovered 140, out of 333 attempted suicides, were 19 years or younger, and 16 out of the 73 committed suicides were children. Alarmingly, the survey found that suicidal tendencies were the pressing issue among Vietnamese youths in the province of Dien Bien. It's a problem that was never given much attention before. However, the surge in suicidal cases is a newly recognized concern, and more research is required to address the factors that cause adolescent distress in Vietnam.
VI. Potential exchange issues
Based on frequent bilateral interactions and cooperations over the past years, the potential future exchange issues with Vietnam can be in the community psychiatric rehabilitation, adolescent and children's psychological treatment, suicide prevention, and the promotion of multi-functional psychiatric team. Further assistance in developing in mental health professional training system shall include psychiatric education, medication development and its industry, psychotherapy and occupational therapy research, and so on.
We expect to promote more joint training for mental health staff in psychiatric treatment, and to meet the requirements with better response and communication.