Overall picture of Japan’s development cooperation for health in Vietnam
To our knowledge, this is the first study that identified an overall picture of Japanese development cooperation for health in Vietnam for both ODA and non-ODA public funded projects. This is also the first study to assess Japanese health cooperation using the WHO’s framework of six building blocks. A total of 68 projects were funded by the Ministry of Foreign Affairs and four other ministries; and implemented by a wide range of entities including governmental agencies, medical institutions, academia, for-profit businesses, and civil society organizations. These entities mobilized their technical expertise, with a heavy focus on heath service delivery, in cooperation with Vietnamese counterparts from central, provincial, and local levels. This involvement of diverse resources supported the aim of Japanese polices that have endeavored to utilize Japan’s non-ODA public financial resources and various other resources in development cooperation .
The projects in our study sample addressed a wide range of health issues across all six building blocks of the Vietnamese health system. In the categorical analysis of the main six building blocks, health service delivery accounted for the focus of more than 60% of the projects, followed by health information system. This trend is similar to a previous study that reported service delivery and health information systems to be the most common interventions in five African countries . In contrast, the recategorized building blocks showed a clear change in terms of the increased proportions of the other building blocks. This reveals that the target of Japanese funded projects was not necessarily concentrated in the area of health service delivery block. Through the recategorization, it became clear that one-quarter of the projects were devoted to health workforce. Similar to our research results, health service delivery and health workforce were included among the three major approaches to strengthen the health system of eight countries including Vietnam in a study analyzing Germany’s bilateral cooperation with these eight countries ; however, the funding resources of this study included only ODA. Unlike Germany, whose most prioritized focus area was leadership and governance, only three ODA projects in our study focused on leadership and governance as well as health financing. These blocks play a significant function in advancing UHC . Since leadership and responsible stewardship are essential in directing an efficient health system at a national level, further cooperation in this area should be fostered.
Strong cooperation with the central hospitals
This study observed health cooperation with the central hospitals to be a major characteristic of Japan’s development cooperation for health in Vietnam. Almost half of the projects involved Vietnam’s central hospitals; specifically, two central hospitals in large cities were involved in 25 projects. The budget distribution was also the largest at the central level.
The concentration of projects in central hospitals can be considered a result of the historical background of Japan’s ODA with Vietnam. After resuming Japan’s ODA in 1992, JICA implemented various projects targeting central hospitals that served as regional medical service hubs in the northern, central, and southern regions of Vietnam. Several projects were conducted by both the grant aid scheme for infrastructure development of hospitals and the technical cooperation scheme for improving the quality of medical services and hospital management, and developing human resources . It is likely that the long-term partnership of Japan with these central hospitals through ODA resulted in their being considered as co-implementing institutions when starting a new project. Accordingly, various projects have been launched with these central hospitals by utilizing ODA schemes such as the public-private partnership (PPP) scheme of JICA as well as the relatively new non-ODA schemes of MHLW and METI for promoting Japan’s medical skills and technology internationally. Clinical research projects have also been launched as a new area of collaboration between Japanese institutes and Vietnamese central hospitals using MHLW funds.
The close cooperation with these central hospitals can be utilized by Japanese funded projects to proceed to the next stage of cooperation, aimed at addressing the major challenges in health service delivery in Vietnam. A plan of Vietnamese Ministry of Health for people’s health protection, care, and promotion between 2016 and 2020 aimed to reduce the overcrowding of patients, particularly at the central hospitals, which has been a long-term challenge in Vietnam[29, 30]. Several measures were proposed in this five-year plan, such as increasing the number of health facilities at all levels, developing a satellite hospital network, and enhancing technical transfer between medical institutions across health administration levels by rotating human resources for health. However, this study found that only a few Japanese funded projects worked to improve medical services at provincial or local levels by linking the central and provincial level health systems. For example, an MHLW project collaborated with a Vietnamese central hospital and a medical educational institute for implementation of Vietnam’s policy on the ground by strengthening a rotation training system for newly graduated physicians working at provincial hospitals. Additionally, a JICA project that aligned with Vietnam’s health policy, called the “Direction Office for Healthcare Activities (DOHA),” worked to strengthen the referral system between medical facilities at different health administration levels in mountainous areas, and promoted clinical skill guidance and supervision activities among these medical facilities.
Since the Japanese funded projects majorly concentrate on the central hospitals, a greater number of projects funded by Japan should leverage the strengths of this cooperation with the central hospitals. Doing so will allow the central hospitals to efficiently and simultaneously transfer advanced and cutting-edge technical skills to provincial level health facilities. For example, Vietnam’s Satellite Hospital Project prioritized several specialties such as oncology, traumatology, and cardiology, and has actively promoted the transfer of its advanced medical and surgical skills from the central to provincial hospitals . Carrying out projects that align with core Vietnamese priorities and policies jointly with central hospitals could further enhance Vietnam’s sense of ownership and contribute toward a sustainable health system. These efforts would allow more patients to receive quality medical and healthcare services locally, which, in turn, would reduce the workload of central hospitals.
Addressing health disparity by improving Primary Health Care through further cooperation
In order to reduce heath disparities between the urban and rural populations, effective provision of appropriate healthcare services at the community level in the rural areas of Vietnam is a key challenge [29, 31]. Major efforts have been made by the Vietnamese Ministry of Health’s initiatives to improve Primary Health Care (PHC) such that healthcare services are accessible to all people who need it [32, 33]. Quality and accessible primary healthcare is essential for achieving UHC [34, 35]. However, this study’s analysis revealed that only 10% of the projects were conducted at the local level, and these projects were mainly ODA projects. For example, the Embassy of Japan in Vietnam allocated their Grant Assistance for Grassroots Human Security Projects for the expansion of five commune health centers in the rural areas of Vietnam. A survey project was also initiated for a need assessment in local areas of rapid diagnosis test kits for hepatitis B virus invented by a Japanese company under the JICA’s PPP scheme. Such rapid, affordable, and easy diagnosis tools can be beneficial for securing the health of newborn babies, especially in remote and local areas.
Moreover, various innovative approaches should be proactively initiated so that those providing clinical technical support to health personnel in Vietnamese health facilities can benefit from the improvement of medical services at the local level. Through PPP, several projects at the central hospitals promoted both technical skills transfer of medical services and utilization of Japanese medical devices for efficient medical services. For example, a clinical tele-consultation system between a group of physicians from Vietnam and Japan was developed to improve child cancer diagnosis skills in Vietnam. This kind of telemedicine could be applied to the development of remote clinical consultation systems for rural or hard-to-reach areas in Vietnam.
Simultaneously, community-based health promotion as well as elderly care and support are also imperative to respond to the increasing prevalence of noncommunicable diseases and the needs of an aging society . Vietnam is the one of the most rapidly aging countries in Asia [36, 37]. Thus, the role of Vietnam’s local communities in healthcare is critical as they can take on responsibility for providing comprehensive and easily accessible care and support to the elderly in their communities [38, 39]. In July 2019, the Japanese and Vietnamese governments signed a Memorandum of Cooperation in the field of healthcare . This memorandum emphasized the promotion of a Japanese policy called the Asia Health and Wellbeing Initiative that aims to foster development of long-term care for elderly people through the PPP approach and human resource exchange programs. The Asia Health and Wellbeing Initiative, which is led by the Japanese government, should be taken as an opportunity to boost Japan’s development cooperation for community based long-term care and support for the elderly in Vietnam .
Ensuring efficient and effective overall development cooperation for health
Despite the fact that Japan devotes a large portion of its public funds to bolster the health scenario in Vietnam, only a small number of projects included in our study reported outcomes with objective indicators. Outcome indicators were likely to be reported if the project period was longer than four years. Instead, only output indicators were reported by projects that culminated within three years where a majority of them were implemented for only one year. A sufficient project period, therefore, is needed to allow for measurement and evaluation, which should focus on the outcomes of cooperation that primarily aims to improve the health of the people . In addition, it is desirable to establish an independent body of external experts for technical guidance on monitoring and evaluation across schemes.
In this study, numerous projects by Japanese resources were identified that were implemented simultaneously to improve the health sector of Vietnam. However, this study was unable to capture the synergetic effects produced by potential collaboration or harmonization between these projects. Prior to this study, aside from the data on ODA, there were no comprehensive data on Japan's overall health cooperation projects for a recipient country. In this regard, it would be ideal for the Japanese government to set a country-specific mechanism for strategic coordination across the ministries for development cooperation for health. Such a step will not only aid the efficiency of Japan but also promote coordination among other donors and partners in Vietnam [43, 44], or any other country. In fact, taking the current study as an opportunity, the Embassy of Japan in Vietnam has begun to release a list of Japanese health cooperation projects in Vietnam , by utilizing the project information gathered in this study.
Strengths and limitations of this study
Continuous improvement of objective assessment with internationally common frameworks is required for development cooperation for health. In particular, Japan’s cooperation approach is diversifying; therefore, it would be helpful to examine whether the cooperation is relevant to the recipient country’s health policy and efforts. There are only a very limited number of studies on Japan’s development assistance for health, and these studies have assessed ODA funding at a global level . However, the current study is the first to reveal Japan’s unique approach for development cooperation for health at the recipient country level by mobilizing both Japan’s ODA and non-ODA public budget.
The six building blocks framework that was utilized in our study refers to the essential functions of health systems. Inter-dependence between blocks is the nature of a well-functioning health system [9, 11]. This may imply that defining the characteristics of each project with only a single block is unrealistic. Since utilizing this framework simply in analysis has a limitation [24, 25], interaction with other blocks should be considered in understanding the extent to which projects address each of the building blocks. We countered this issue in our study through additional analysis using the recategorized six building blocks, which reflected a more comprehensive understanding of the focus areas of each project. This approach also had a limitation in that we equally redistributed the health administration levels and building blocks as we did not have the relevant information to determine the proportionate variation in the characteristics of these projects according to health administration level and building blocks. In order to elaborate on how projects addressed each building block in their multiple approaches rather than in terms of equal proportions, in-depth interviews with each project implementing organization will be required.
In terms of capturing the overall Japanese resources in development cooperation for health, there were some limitations of this study. First, we had no systematic way of identifying other possible Japanese interventions except for the major Japanese independent administrative agencies in the fields of health and development. Thus, this study did not cover other potential health projects, especially research projects using public funds that worked in collaboration with Vietnamese institutes. Second, the target projects were collected majorly based on publicly available information. However, our independent access to the different characteristics of each agency's website may have biased the collected data. Third, several Japanese funded projects have strived together with Vietnamese counterparts on health focus areas such as infectious diseases and maternal and child health. These specific health focus areas can be captured by using the Organisation for Economic Co-operation and Development methodology , which our study did not employ. However, based on the data of the current study, a future study can assess the distribution of Japanese projects by health administration level based on the framework of "capacity building,” “infrastructure,” “medical equipment,” and “research and development” to lend insight into the characteristics of Japan’s contribution for development cooperation for health. Last, the results of this study cannot be generalized to Japan's overall development cooperation for health, since this was a cross-sectional study focusing on Japan’s cooperation initiatives with only one country.
The analytic approach adopted in this study needs to be developed further to capture a more realistic proportion of each area that the projects worked for. Despite its limitations, the WHO’s six building blocks framework can be utilized with such an arrangement to try capturing efforts on health system strengthening. Although the assessment framework for health system strengthening needs improvement, this study was the first to assess Japan’s development cooperation for health in a specific recipient country, by including projects funded by both ODA and non-ODA financial resources. In the future, longitudinal studies on Japan’s health cooperation with Vietnam are expected. Further external reviews on Japan’s development cooperation for health in other recipient countries are also necessary for formulating effective cooperation strategies. An assessment of the mobilization of other Japanese resources from the private sector and private philanthropy is also needed in a future study, considering that these resources are expected to drive health cooperation in the global health architecture .
Lastly, donor countries should examine international cooperation to strengthen the health system of the target country as some top ODA donor countries do [25, 42, 49]. Objective and systematical reviews of health cooperation based on internationally common assessment frameworks such as the one used in the current study should be promoted. Consequently, the review results should be reflected in the development of recommendations on the cooperation strategy. Based on the current study’s review, priority setting should be strategized and the synergetic effects of various projects employing Japanese resources should be increased to realize efficient and effective development cooperation for health.