Assessment of availability, readiness, and challenges for scaling-up hypertension management services at primary healthcare facilities, Central Highland region, Vietnam, 2020

Cardiovascular disease (CVD) was the leading non-communicable disease (NCD) in Vietnam, accounting for 31% (approximately 170,000 cases) of all deaths in 2016, an increase from 25.1% in 2011 [1‐4]. The primary CVD risk factor, hypertension (HTN), became prevalent with 18.4% of population between 2002–2015, pooled from three national surveys [5]. However, it is estimated that 30% of people aged 18 to 69 have never had their blood pressure measured by a health care professional and only 14% of patients with hypertension are being managed at health facilities [6]. Additionally, only 12% to 30% of people diagnosed with hypertension have been registered for treatment, and the proportion of treatment adherence was less than 70% [6].

Primary health care centers, namely commune health stations (CHSs), are the first level of care in the Vietnamese health care system, providing both preventive and treatment services [4]. A CHS usually serves 5,000–20,000 people depending on its catchment area [7]. The CHSs could provide effective management and treatment services, but in a national survey of risk factors of NCDs in 2015, they managed approximately 19% of patients with hypertension [8, 9].

The Vietnamese Government has set a national goal of 95% of CHSs implementing hypertension management programs by 2025, but only 12% of all CHSs in Vietnam implemented the hypertension management model in 2018 [10, 11]. For the Central Highland region, one of the most disadvantaged areas in Vietnam, this goal will be difficult to reach. The prevalence of hypertension here was approximately 20% in 2021, in which 11% of patients were managed at CHSs [12‐15].

Better understanding of the capacity in hypertension management service provision of CHSs in the Central Highland region will provide baseline evidence for strategic health system planning. We assessed the availability and readiness of hypertension management services at CHSs in the Central Highland region and identified challenges to facilitate evidence-based planning.

This study quantified the availability and readiness of hypertension management services at primary health care centers in Vietnam’s Central Highland region. Our study provided the first comprehensive exploration of the current situation of hypertension management programs in this region, as well as identifying the challenges in implementing the program at communal level.

The results provide essential information for developing the strategic plan to strengthen the regional health system. The National guideline recommends staff quantity and composition based on the size of the population and geographical characteristic of the catchment area. According to the guideline, each CHS should have 5 to 10 health staff and at least one medical doctor working full-time or part-time by 2020. However, the results suggest that CHS in the Central Highland region are still understaffed, and many have not been adequately trained. There were slight differences between availability indices (65%) and readiness indices (62%) of hypertension management services in the region. This means approximately two-thirds of the CHSs in the region had the capacity to provide hypertension services in 2020, with urban CHSs somewhat better equipped than rural CHSs. However, meeting the target of having fully functional hypertension services in 95% of CHSs by 2025 remains challenging. We identified three primary areas for improvement, including staff capacity and ambiguity in national hypertension treatment guidelines, insufficient essential medicines supply mechanism, and low priority and funding limitations for the hypertension program.

Compared with results of studies from other regions, the availability of hypertension services in the Central Highland region was lower. A study from Northern Vietnam reported 88% of CHSs had hypertension services available [13, 14], while a study in Ho Chi Minh City (the largest city in Southern Vietnam) showed that 100% of CHSs had hypertension services available [18]. As for service readiness, there were no large-scale studies in Vietnam. Results from single provinces reported both lower (51%) and higher (82%) [15] levels of hypertension service readiness compared to our results (63%). Compared with the results of from other countries, the regional service readiness was both lower and higher than that in other countries. A study from Uganda demonstrated a higher level of service readiness for hypertension management (86%), but with weaknesses in capacity of health staffs and lack of functional equipment [19]. While another study from Ethiopia reported lower levels of service readiness for Hypertension management at primary health care units (29%), influenced by insufficient equipment for screening and diagnostic, insufficient essential medicines, and lack of basic training and guideline for non-communicable diseases [20]. However, results should be interpreted with caution as the discrepancies between studies could be due to study location, sample size or instruments used.

The qualitative results provided context for better understanding and interpretation of our availability and readiness assessment. Most CHSs in our study were reported to experience a lack of trained health staff and low availability of essential medicines and commodities. This was similar with findings from other studies in which the shortage of hypertension services was mainly caused by a lack of basic medicines, national guidelines, and trained health staff [2, 7, 8, 21, 22]. The low level of availability and readiness of trained staff at CHSs has been explained by the lack of training and the high turnover rate due to restructuring of the health system in recent years [23].

Well prepared and standardized guidelines for diagnosis and treatment of hypertension could play a key role in offering consistent hypertension management services [2]. However, IDI respondents noted multiple guidelines with conflicting guidance, which confused health professionals. The inconsistencies included differences in hypertension diagnostic procedures (threshold, and steps of diagnosis) and management practices at CHSs [5].

Insufficient essential medicines readiness hindered providing hypertension service at CHSs. These medicines are provided through a universal insurance scheme and are out of the control of the local health system [5]. Lack of sufficient essential medicines may reduce patient visits at CHSs and overload health facilities at higher levels.

The lack of financial support led to ineffective implementation of hypertension activities, such as training, and behavioral change communication and education. Much of the government’s support for preventive healthcare, more than 60% in 2011 of the national health budgets, was focused on infectious disease [2]. Despite 20 years of Vietnam’s NCD prevention and control strategy, there remains a lack of financial support at the national level. Lack of training also resulted from limited financial support, and insufficient training makes it difficult for providers to implement guidelines, especially at the commune level [2].

Our study has several strengths. We used a mixed methods approach with qualitative data to complement and enhance the interpretation of the quantitative data to comprehensively answer our research questions. We also piloted our questionnaires and had clear quality assurance for the data collection process to assure the accuracy of the data. However, there were limitations in our study. Firstly, the WHO-SARA tool could not capture other aspects of access to health services such as geographical, economic, or quality aspect of the services. Secondly, self-reported questionnaires were used to assess availability, which may have led to both systematic and random errors. Readiness was validated /observed during video-visits rather than in-person visits, and this could have been a source of data collection bias. Thirdly, due to resource constraints, we could not select all CHSs for qualitative interviews. However, by selecting two centers (one high and one low performance) from each of the four provinces, we diversified our sample and were still able achieved data saturation. Lastly, this study only focused on the Central Highland region. Therefore, the results may not be generalizable to the rest of Vietnam, particularly to large metropolitan areas with more advanced socioeconomic status.

In conclusion, the overall availability and readiness of hypertension management services at CHSs in Central Highland were low, reflecting the low capacity of the primary healthcare facilities. To strengthen the hypertension program in the Central Highland region and to meet the goal of 95% of CHSs providing effective hypertension programs by 2025, the health authorities could increase financial support, ensure adequate types of basic medicines, and issue clear guidelines for the prevention, management, and treatment of hypertension for the CHSs. Public health actions should include: (1) Develop policy on capacity building for local health professionals and human resources retention to maintain a proper workforce at the grassroots level for essential NCD services; (2) The Ministry of Health (MoH) should streamline standardized guidelines on hypertension management at CHSs and provide training on the guideline to all CHSs for consistency; (3) More financial support is needed for the NCD program, not only from the MoH budget line but also from the Provincial Government budget; (4) Improve the essential medicine procurement process by allowing long-term essential medicine procurement instead of quarterly/biannual/annual procurement. The Provincial Department of Health, who oversees conducting competitive bidding to buy essential medicines, then redistributes the medicines to CHSs, should have a long-term plan for procurement to secure a stable supply of essential medicines for their jurisdictions. At the higher level, the MoH and Ministry of Social Welfare need to agree on the list of essential medicines provided through universal insurance scheme to meet the need for hypertension treatment.