Health financing policies during the COVID-19 pandemic and implications for universal health care: a case study of 15 countries.

BACKGROUND: The COVID-19 pandemic was a health emergency requiring rapid fiscal resource mobilisation to support national responses. The use of effective health financing mechanisms and policies, or lack thereof, affected the impact of the pandemic on the population, particularly vulnerable groups and individuals. We provide an overview and illustrative examples of health financing policies adopted in 15 countries during the pandemic, develop a framework for resilient health financing, and use this pandemic to argue a case to move towards universal health coverage (UHC). METHODS: In this case study, we examined the national health financing policy responses of 15 countries, which were purposefully selected countries to represent all WHO regions and have a range of income levels, UHC index scores, and health system typologies. We did a systematic literature review of peer-reviewed articles, policy documents, technical reports, and publicly available data on policy measures undertaken in response to the pandemic and complemented the data obtained with 61 in-depth interviews with health systems and health financing experts. We did a thematic analysis of our data and organised key themes into a conceptual framework for resilient health financing. FINDINGS: Resilient health financing for health emergencies is characterised by two main phases: (1) absorb and recover, where health systems are required to absorb the initial and subsequent shocks brought about by the pandemic and restabilise from them; and (2) sustain, where health systems need to expand and maintain fiscal space for health to move towards UHC while building on resilient health financing structures that can better prepare health systems for future health emergencies. We observed that five key financing policies were implemented across the countries-namely, use of extra-budgetary funds for a swift initial response, repurposing of existing funds, efficient fund disbursement mechanisms to ensure rapid channelisation to the intended personnel and general population, mobilisation of the private sector to mitigate the gaps in public settings, and expansion of service coverage to enhance the protection of vulnerable groups. Accountability and monitoring are needed at every stage to ensure efficient and accountable movement and use of funds, which can be achieved through strong governance and coordination, information technology, and community engagement. INTERPRETATION: Our findings suggest that health systems need to leverage the COVID-19 pandemic as a window of opportunity to make health financing policies robust and need to politically commit to public financing mechanisms that work to prepare for future emergencies and as a lever for UHC. FUNDING: Bill & Melinda Gates Foundation.

Disparities in Gynecological Healthcare Service Utilization Among Ethnic Minority Women in Vietnam.

The study aimed to investigate differences in the prevalence of gynecological healthcare service utilization in 12 ethnic minority groups and associated socio-demographic correlates with gynecological healthcare service utilization in Vietnam. Based on the national survey on healthcare utilization among 6912 people in 12 ethnic minorities, 900 women aged 21-49 years were included in the final analysis. Prevalence of gynecological healthcare service utilization in 12 ethnic minority groups was measured, based on the question "Have you ever used any gynecological healthcare services?" Socio-demographic characteristics including region, ethnicity, age, marital status, literacy level, education level, languages spoken, occupation, religion, household economy status, using contraception, and distance to the nearest healthcare facility were examined. The association between gynecological healthcare service utilization and socio-demographic characteristics was assessed by using logistic regression. The results showed that the prevalence of gynecological healthcare service utilization was 62.0% (95% CI: 58.7-65.2%), which ranged from 36.5 (Mnong) to 87.7% (Bru Van Kieu). Bru Van Kieu women had significantly higher odds of gynecological healthcare service utilization (OR = 9.42, 95% CI = 3.71-23.91), compared to those in Khmer ethnicity. Besides, Ba Na, Cham Ninh Thuan, and Dao women also had significantly higher odds of gynecological healthcare service utilization (Ba Na: OR = 5.73, 95% CI = 2.15-15.26; Cham Ninh Thuan: OR = 4.24, 95% CI = 1.79-10.06; Dao: OR = 3.43, 95% CI = 1.49-7.90), compared to those in Khmer ethnicity. Getting married, being older, being not poor, and using contraception had significantly higher odds of using gynecological healthcare services. Health education specialists and healthcare workers should be aware of these issues so that they can provide appropriate gynecological healthcare services and ensure high coverage of routine gynecological exams in ethnic minority women in reproductive age.

Cost-effectiveness of clinical breast examination screening programme among HER2-positive breast cancer patients: a modelling study.

PURPOSE: For many low- and middle-income countries (LMICs), breast cancer (BC) screening based on mammography is not a viable option. Clinical breast examination (CBE) may represent a pragmatic and cost-effective alternative. This paper examines the cost-effectiveness of CBE screening programme among a patient group for whom its cost-effectiveness is likely to be least evident (HER2-positive patients) and discuss the wider implications for BC screening in LMICs. METHODS: A Markov model was used to examine clinical and economic outcomes over a life-time horizon from the patient, public payer, and healthcare sector perspective. HER2-positive patients entered the model at either disease-free survival or metastatic BC state. The downstaging effect of CBE determined the starting probabilities in the no-screening and screening scenarios. The model used a monthly cycle length, with half-cycle correction. Costs and outcomes were discounted at 1.5% annually. RESULTS: Compared with no-screening, the cost-effectiveness ratio (ICER) per quality-adjusted life-year gained for the CBE screening programme was $1801, $2381, and $4179 from three mentioned perspectives, respectively. The finding of cost-effectiveness remained robust to a range of sensitivity analyses. The parameters to which ICERs are most sensitive are average age of cohorts, reduction in proportion of metastatic patients at diagnosis, cost of CBE, and BC detection rate of the programme. CONCLUSION: For HER2-positive patients and compared with no-screening, CBE screening programme in Vietnam is cost-effective from all investigated perspectives. CBE is a 'good value' intervention and should be considered for implementation throughout Vietnam as well as in LMICs where mammography is not feasible.

Cost of Delivering Tetanus Toxoid and Tetanus-Diphtheria Vaccination in Vietnam and the Budget Impact of Proposed Changes to the Schedule.

INTRODUCTION: In 2017, aligned with global World Health Organization tetanus guidelines, Vietnam prepared evidence to support a recommendation to introduce the tetanus-diphtheria (Td) vaccine into routine immunization. This study aimed to provide evidence on the costs and budgetary impact of the potential replacement of the tetanus-toxoid (TT) vaccine with the Td vaccine, considering different possible delivery strategies. METHOD: We used an activity-based ingredients costing approach to estimate the 2017 program costs of providing TT vaccination to girls aged 15-16 years and conducting Td campaigns in outbreak areas. We performed a budget impact analysis for 2018-2025 using the cost per dose estimates based on the current delivery of these vaccines. We assumed complete cessation of TT vaccination of girls aged 15-16 years and a transition period where Td outbreak control campaigns would still occur. Td vaccine was assumed to be provided to children aged 7 years using either facility- or school-based delivery or combined facility- and school-based delivery. RESULTS: The delivery cost per dose for current TT vaccination for girls aged 15-16 years was US$1.49 for school-based delivery, US$1.76 for facility-based delivery, and US$3.86 for delivery via outreach. Td vaccination through campaigns was estimated to cost US$3.56/dose. During 2018-2025, replacing the TT vaccine for girls aged 15-16 years with the Td vaccine for children aged 7 years is estimated to save US$4.61 million in immunization delivery costs if a school-based delivery strategy is used or US$1.04 million if facility-based delivery is used. CONCLUSION: Compared to the current plan, delivery of Td routine vaccination via a school-based strategy was the most cost saving. These results were used in late 2019 to support the delivery of Td vaccination using a school-based delivery strategy for children aged 7 years in 30 Northern provinces in Vietnam.

Key Factors Influencing Use of Immunization Cost Evidence in Country Planning and Budgeting Processes: Experiences From Indonesia, Tanzania, and Vietnam.

In many low- and middle-income countries, planning cycles and policy decisions are not always informed by cost evidence, even where relevant and recent cost evidence is available. The Immunization Costing Action Network (ICAN) project was a research and learning community designed to strengthen country capacity to generate immunization cost evidence and to understand and improve the evidence-to-policy linkages for the evidence. We identified key factors that increase the likelihood that health policy makers will use evidence for policy making or planning, which shaped the development of a 6-step evidence to policy and practice (EPP) facilitated process. ICAN used the EPP process in Indonesia, Tanzania, and Vietnam from 2016-2019. The experience resulted in several insights regarding country priorities related to cost evidence and factors that determine uptake. Cost evidence is more likely to be used if it answers a specific policy question prioritized by the immunization program, while the use case is less clear and urgent for routine planning and program management. Nonhealth ministries and subnational stakeholders can provide important perspectives to inform the research and its usability. The use case for evidence should be revisited periodically as divergences from formal planning cycles are common and new policy windows open. Ensuring evidence is available at the right time is critical, even if this requires a sacrifice between rigor and speed. Engaging a small group of stakeholders, rather than an individual, to champion the research may be more effective, and the research has greater legitimacy if it is produced by multidisciplinary country teams. Evidence and messages should be tailored for and packaged targeting different audiences. Going forward, continued support is necessary to bridge the divide between those who generate cost evidence and those who translate evidence for policy and planning decisions.

Do health preferences differ among Asian populations? A comparison of EQ-5D-5L discrete choice experiments data from 11 Asian studies.

INTRODUCTION: Many countries have established their own EQ-5D value sets proceeding on the basis that health preferences differ among countries/populations. So far, published studies focused on comparing value set using TTO data. This study aims to compare the health preferences among 11 Asian populations using the DCE data collected in their EQ-5D-5L valuation studies. METHODS: In the EQ-VT protocol, 196 pairs of EQ-5D-5L health states were valued by a general population sample using DCE method for all studies. DCE data were obtained from the study PI. To understand how the health preferences are different/similar with each other, the following analyses were done: (1) the statistical difference between the coefficients; (2) the relative importance of the five EQ-5D dimensions; (3) the relative importance of the response levels. RESULTS: The number of statistically differed coefficients between two studies ranged from 2 to 16 (mean: 9.3), out of 20 main effects coefficients. For the relative importance, there is not a universal preference pattern that fits all studies, but with some common characteristics, e.g. mobility is considered the most important; the relative importance of levels are approximately 20% for level 2, 30% for level 3, 70% for level 4 for all studies. DISCUSSION: Following a standardized study protocol, there are still considerable differences in the modeling and relative importance results in the EQ-5D-5L DCE data among 11 Asian studies. These findings advocate the use of local value set for calculating health state utility.

Costs of breast cancer treatment incurred by women in Vietnam.

BACKGROUND: There is a paucity of research on the cost of breast cancer (BC) treatment from the patient's perspective in Vietnam. METHODS: Individual-level data about out-of-pocket (OOP) expenditures on use of services were collected from women treated for BC (n = 202) using an online survey and a face-to-face interview at two tertiary hospitals in 2019. Total expenditures on diagnosis and initial BC treatment were presented in terms of the mean, standard deviation, and range for each type of service use. A generalised linear model (GLM) was used to assess the relationship between total cost and socio-demographic characteristics. RESULTS: 19.3% of respondents had stage 0/I BC, 68.8% had stage II, 9.4% had stage III, none had stage IV. The most expensive OOP elements were targeted therapy with mean cost equal to 649.5 million VND ($28,025) and chemotherapy at 36.5 million VND ($1575). Mean total OOP cost related to diagnosis and initial BC treatment (excluding targeted therapy cost) was 61.8 million VND ($2667). The mean OOP costs among patients with stage II and III BC were, respectively, 66 and 148% higher than stage 0/I. CONCLUSIONS: BC patients in Vietnam incur significant OOP costs. The cost of BC treatment was driven by the use of therapies and presentation stage at diagnosis. It is likely that OOP costs of BC patients would be reduced by earlier detection through raised awareness and screening programmes and by providing a higher insurance reimbursement rate for targeted therapy.

Cost Analysis of Community-Based Smoking Cessation Services in Vietnam: A Cluster-Randomized Trial.

The study aimed to estimate the cost for developing and implementing 2 smoking cessation service delivery models that were evaluated in a 2-arm cluster randomized trial in Commune Health Centers (CHCs) in Vietnam. In the first model (4As) CHC providers were trained to ask about tobacco use, advise smokers to quit, assess readiness to quit, and assist with brief counseling. The second model included the 4As plus a referral to Village Health Workers (VHWs) who were trained to provide multisession home-based counseling (4As + R). An activity-based ingredients (ABC-I) costing approach with a healthcare provider perspective was applied to collect the costs for each intervention model. Opportunity costs were excluded. Costs during preparation and implementation phase were estimated. Sensitivity analysis of the cost per smoker with the included intervention' activities were conducted. The cost per facility-based counseling session ranged from USD 9 to USD 11. Cost per home-based counseling session at 4As + R model was USD 4. The non-delivery cost attributed to supportive activities (eg, Monitoring, Logistic, Research, General training) was USD 107 per counseling session. Cost per smoker ranged from USD 6 to USD 451. The study analyzed and compared cost of implementing and scaling community-based smoking cessation service models in Vietnam.

Outpatient satisfaction with primary health care services in Vietnam: Multilevel analysis results from The Vietnam Health Facilities Assessment 2015.

Patient satisfaction has implications for resource distribution across primary, secondary, and tertiary care, as well as accessibility of quality services and equity of service delivery. This study assessed outpatient satisfaction with health services and explored the determinants at the individual and contextual levels in Vietnam. Data on 4372 outpatients were extracted from the Vietnam Health Facility Assessment survey 2015. Three levels of logistic regression were applied to examine the association between outpatient satisfaction and three types of explanatory variables. Outpatients satisfied with their community health center or district hospital accounted for relatively high proportions (85% and 73%, respectively). Patients' age, occupation, and individual characteristics were significant predictors of patient satisfaction, whereas provincial level factors were not significantly associated with the dependent variable. When individual-level characteristics were controlled, outpatients who had a longer waiting time for health services were less likely to report being satisfied. Interventions for improving outpatient satisfaction should pay attention to simplifying the health procedure at health facilities to reduce patients' waiting time and increase their examining time.

Financial toxicity due to breast cancer treatment in low- and middle-income countries: evidence from Vietnam.

BACKGROUND: This study examined the financial toxicity faced by breast cancer (BC) patients in Vietnam and the factors associated with the risk and degree of that toxicity. METHODS: A total of 309 BC patients/survivors completed an online survey (n=209) or a face-to-face interview (n=100) at two tertiary hospitals. Descriptive statistics and χ2 tests were used to identify and analyse the forms and degree of financial toxicity faced by BC patients/survivors. A Cragg hurdle model assessed variation in risk and the degree of financial toxicity due to treatment. RESULTS: 41% of respondents faced financial toxicity due to BC treatment costs. The mean amount of money that exceeded BC patients/survivors' ability to pay was 153 million Vietnamese Dong (VND) ($6602) and ranged from 2.42 million VND to 1358 million VND ($104-58,413). A diagnosis at stage II or III of BC was associated with 16.0 and 18.0 million VND (~$690-777) more in the degree of financial toxicity compared with patients who were diagnosed at stage 0/I, respectively. Being retired or married or having full (100%) health insurance was associated with a decrease in the degree of financial toxicity. CONCLUSIONS: A significant proportion of Vietnamese BC patients/survivors face serious financial toxicity due to BC treatment costs. There is a need to consider the introduction of measures that would attenuate this hardship and promote uptake of screening for the reduction in financial toxicity as well as the health gains it may achieve through earlier detection of cancer.

The Utilization of Maternal Healthcare Services Among Ethnic Minority Populations in Vietnam.

BACKGROUND: Previous studies have observed lower utilization of maternal healthcare services by ethnic minority groups in Vietnam compared with the majority Kinh community. This study sought to assess the utilization of maternal healthcare service-associated factors within 12 ethnic minority groups. METHOD: The cross-sectional study enrolled 996 women from 12 ethnic minority groups in Vietnam in 2019. Women had pregnancy outcomes in the last 5 years. The two variables for maternal healthcare utilization were [1] a minimum of four antenatal contacts and [2] health facility-based delivery. We examined the association of individual characteristics of maternal healthcare services using multilevel modeling. Odds ratios (ORs) and 95% confidence intervals (CIs) were reported. RESULTS: This nationally representative study found that 34.1% of women from ethnic minority backgrounds had four or more antenatal contacts during pregnancy, ranging from 8.3% in Mong community to 80.2% in Cham An Giang. Most of the women (94.4%) delivered at health facilities. Factors independently correlated with having fewer than four antenatal contacts included being illiterate, early marriage, unemployment, religious affiliation, household economy, and distance to the nearest health facility. Factors significantly associated with home delivery were living in the most disadvantaged areas and having fewer than four antenatal contacts. CONCLUSION: Substantial inequity exists in antenatal coverage both within ethnic minority groups and between socio-economic groups. The low coverage of having at least four antenatal contacts and its' correlates with facility-based delivery suggests that the government should focus efforts on increasing the number of antenatal contacts for ethnic minority women.

Effectiveness of clinical breast examination as a 'stand-alone' screening modality: an overview of systematic reviews.

BACKGROUND: There is uncertainty about the effectiveness of clinical breast examination (CBE) and conflicting recommendations regarding its usefulness as a screening tool for breast cancer. This paper provides an overview of systematic reviews that assessed the effectiveness of CBE as a 'stand-alone' screening modality for breast cancer compared to no screening and focused on its value in low- and middle-income countries (LMICs). METHODS: We searched MEDLINE, EMBASE, Scopus, Web of Science, and the Cochrane Database of Systematic Reviews for systematic reviews reporting the effectiveness of CBE published prior to October 29, 2019. The main outcomes assessed were mortality and down staging. The AMSTAR 2 checklist was used to assess the methodological quality of the reviews including risk of bias. RESULTS: Eleven systematic reviews published between 1993 and 2019 were identified. There was no direct evidence that CBE reduced breast cancer mortality. Indirect evidence suggested that a well-performed CBE achieved the same effect as mammography regarding mortality despite its apparently lower sensitivity (40-69% for CBE vs 77-95% for mammography). Greater sensitivity was recorded among younger and Asian women. Moreover, CBE contributed between 17 and 47% of the shift from advanced to early stage cancer. CONCLUSIONS: CBE merits attention from health system and service planners in LMICs where a national screening programme based on mammography would be prohibitively expensive. In particular, it is likely that considerable value would be gained from conducting implementation scientific research in countries with large numbers of Asian women and/or where younger women are at higher risk. REGISTRATION: PROSPERO, registration number CRD42019126798 .

Overweight and obesity among Vietnamese school-aged children: National prevalence estimates based on the World Health Organization and International Obesity Task Force definition.

BACKGROUND: Overweight and obesity is a severe global health issue in both developed and developing nations. This study aims to estimate the national prevalence of overweight and obesity among school-aged children in Vietnam. METHOD: We conducted a national cross-sectional study on 2788 children aged from 11-14 years old from September to November 2018. We applied the WHO 2007 and IOTF criteria to estimate the prevalence of overweight and obesity among participants. Poison regression analysis with cluster sampling adjustment was employed to assess associated factors with obesity and overweight. Metadata on sociodemographic characteristics, physical measurements, and lifestyle behaviors were also extracted to investigate these factors in association with overweight and obesity prevalence. RESULTS: The prevalences of overweight and obesity in Vietnamese children were 17.4% and 8.6%, respectively by WHO Z-score criteria, and 17.1% and 5.4%, according to the IOTF reference. Using WHO Z-score yielded a higher prevalence of obesity than the IOTF and CDC criteria of all ages and both sexes. The proportions of overweight and obesity were substantially higher among boys than girls across ages. Parental BMI was shown to be a significant factor associated with overweight/obesity status in both girls and boys. Only for boys, age (PR = 0.83, 95% CI 0.76-0.90) and belonging to ethnic minorities (PR = 0.43, 95% CI 0.24-0.76) were significant risk factors for overweight/obesity. CONCLUSION: Our findings indicate a high prevalence of childhood overweight and obesity in Vietnam, especially in boys.

A qualitative assessment of factors influencing implementation and sustainability of evidence-based tobacco use treatment in Vietnam health centers.

BACKGROUND: Effective strategies are needed to increase implementation and sustainability of evidence-based tobacco dependence treatment (TDT) in public health systems in low- and middle-income countries (LMICs). Our two-arm cluster randomized controlled trial (VQuit) found that a multicomponent implementation strategy was effective in increasing provider adherence to TDT guidelines in commune health center (CHCs) in Vietnam. In this paper, we present findings from a post-implementation qualitative assessment of factors influencing effective implementation and program sustainability. METHODS: We conducted semi-structured qualitative interviews (n = 52) with 13 CHC medical directors (i.e., physicians), 25 CHC health care providers (e.g., nurses), and 14 village health workers (VHWs) in 13 study sites. Interviews were transcribed and translated into English. Two qualitative researchers used both deductive (guided by the Consolidated Framework for Implementation Research) and inductive approaches to analysis. RESULTS: Facilitators of effective implementing of TDT included training and point-of-service tools (e.g., desktop chart with prompts for offering brief counseling) that increased knowledge and self-efficacy, patient demand for TDT, and a referral system, available in arm 2, which reduced the provider burden by shifting more intensive cessation counseling to a trained VHW. The primary challenges to sustainability were competing priorities that are driven by the Ministry of Health and may result in fewer resources for TDT compared with other health programs. However, providers and VHWs suggested several options for adapting the intervention and implementation strategies to address challenges and increasing engagement of local government committees and other sectors to sustain gains. CONCLUSION: Our findings offer insights into how a multicomponent implementation strategy influenced changes in the delivery of evidence-based TDT. In addition, the results illustrate the dynamic interplay between barriers and facilitators for sustaining TDT at the policy and community/practice level, particularly in the context of centralized public health systems like Vietnam's. Sustaining gains in practice improvement and clinical outcomes will require strategies that include ongoing engagement with policymakers and other stakeholders at the national and local level, and planning for adaptations and subsequent resource allocations in order to meet the World Health Organization's goals promoting access to effective treatment for all tobacco users. TRIAL REGISTRATION: NCT02564653 , registered September 2015.

Vietnam Climate Change and Health Vulnerability and Adaptation Assessment, 2018.

BACKGROUND: The Global Climate Risk Index 2020 ranked Vietnam as the sixth country in the world most affected by climate variability and extreme weather events over the period 1999-2018. Sea level rise and extreme weather events are projected to be more severe in coming decades, which, without additional action, will increase the number of people at risk of climate-sensitive diseases, challenging the health system. This article summaries the results of a health vulnerability and adaptation (V&A) assessment conducted in Vietnam as evidences for development of the National Climate Change Health Adaptation Plan to 2030. METHODS: The assessment followed the first 4 steps outlined in the World Health Organization's Guidelines in conducting "Vulnerability and Adaptation Assessments." A framework and list of indicators were developed for semi-quantitative assessment for the period 2013 to 2017. Three sets of indicators were selected to assess the level of (1) exposure to climate change and extreme weather events, (2) health sensitivity, and (3) adaptation capacity. The indicators were rated and analyzed using a scoring system from 1 to 5. RESULTS: The results showed that climate-sensitive diseases were common, including dengue fever, diarrheal, influenza, etc, with large burdens of disease that are projected to increase. From 2013 to 2017, the level of "exposure" to climate change-related hazards of the health sector was "high" to "very high," with an average score from 3.5 to 4.4 (out of 5.0). For "health sensitivity," the scores decreased from 3.8 in 2013 to 3.5 in 2017, making the overall rating as "high." For "adaptive capacity," the scores were from 4.0 to 4.1, which meant adaptive capacity was "very low." The overall V&A rating in 2013 was "very high risk" (score 4.1) and "high risk" with scores of 3.8 in 2014 and 3.7 in 2015 to 2017. CONCLUSIONS: Adaptation actions of the health sector are urgently needed to reduce the vulnerability to climate change in coming decades. Eight adaptation solutions, among recommendations of V&A assessment, were adopted in the National Health Climate Change Adaptation Plan.

Review of Public Financing for Water, Sanitation, and Hygiene Sectors in Vietnam.

BACKGROUND: Vietnam declared its national roadmap towards Sustainable Development Goals number 6 by 2030. However, specific supporting programmes and financial means to proceed with the roadmap have not been passed on. Evidence on the financing for water, sanitation, and hygiene (WASH) being allocated or spent has not been well documented in Vietnam. This study aimed to obtain an overview and assessed the public funding across the WASH sector of Vietnam in 3 fiscal years 2016, 2017, and 2018. METHODS: A cross-sectional study was conducted for information about the public financing for WASH at both national and sub-national levels. An activity-based costing approach was applied to determine WASH-related public expenditure. Fourteen focus group discussions with key stakeholders were used to identify the WASH activities and to access financial reports of these relevant institutions. TrackFin methodology was used to assemble the public financing for WASH in Vietnam. RESULTS: The public expenditure of WASH declined by about 30.7% over the 3 fiscal years, from US $2016 million in 2016 to US $1397 million in 2018. Meanwhile, this expenditure allocated to the poor or mountainous areas increased by 3 folds. The highest proportion of WASH public funding was invested in sanitation through large network systems (59.07% of the total public expenditure), whereas the lowest was in hygiene promotion and handwashing facilities. The domestic budget was still the main source of public financing for WASH services, with 2 largest shares coming from government revenues (47.24%) and repayable loans (20.49%). CONCLUSION: The main source of financing for WASH was from the government, yet its public expenditure has been decreased. A refined roadmap with specific steps for a sustainable WASH financing system in Vietnam, particularly to leverage government and private sector resources, is required to ensure no one is left behind.

Meta-analysis of average costs of HIV testing and counselling and voluntary medical male circumcision across thirteen countries.

Objective: Explore facility-level average costs per client of HIV testing and counselling (HTC) and voluntary medical male circumcision (VMMC) services in 13 countries.Methods: Through a literature search we identified studies that reported facility-level costs of HTC or VMMC programmes. We requested the primary data from authors and standardised the disparate data sources to make them comparable. We then conducted descriptive statistics and a meta-analysis to assess the cost variation among facilities. All costs were converted to 2017 US dollars ($).Results: We gathered data from 14 studies across 13 countries and 772 facilities (552 HTC, 220 VMMC). The weighted average unit cost per client served was $15 (95% CI 12, 18) for HTC and $59 (95% CI 45, 74) for VMMC. On average, 38% of the mean unit cost for HTC corresponded to recurrent costs, 56% to personnel costs, and 6% to capital costs. For VMMC, 41% of the average unit cost corresponded to recurrent costs, 55% to personnel costs, and 4% to capital costs. We observed unit cost variation within and between countries, and lower costs in higher scale categories in all interventions.

Feasibility assessment of invigorating grassrooTs primary healthcare for prevention and management of cardiometabolic diseases in resource-limited settings in China, Kenya, Nepal, Vietnam (the FAITH study): rationale and design.

BACKGROUND: Cardiometabolic diseases are the leading cause of death and disability in many low- and middle-income countries. As the already severe burden from these conditions continues to increase in low- and middle-income countries, cardiometabolic diseases introduce new and salient public health challenges to primary health care systems. In this mixed-method study, we aim to assess the capacity of grassroots primary health care facilities to deliver essential services for the prevention and control of cardiometabolic diseases. Built on this information, our goal is to propose evidence-based recommendations to promote a stronger primary health care system in resource-limited settings. METHODS: The study will be conducted in resource-limited settings in China, Kenya, Nepal, and Vietnam using a mixed-method approach that incorporates a literature review, surveys, and in-depth interviews. The literature, statistics, and document review will extract secondary data on the burden of cardiometabolic diseases in each country, the existing policies and interventions related to strengthening primary health care services, and improving care related to non-communicable disease prevention and control. We will also conduct primary data collection. In each country, ten grassroots primary health care facilities across representative urban-rural regions will be selected. Health care professionals and patients recruited from these facilities will be invited to participate in the facility assessment questionnaire and patients' survey. Stakeholders - including patients, health care professionals, policymakers at the local, regional, and national levels, and local authorities - will be invited to participate in in-depth interviews. A standard protocol will be designed to allow for adaption and localization in data collection instruments and procedures within each country. DISCUSSION: With a special focus on the capacity of primary health care facilities in resource-limited settings in low- and middle-income countries, this study has the potential to add new evidence for policymakers and academia by identifying the most common and significant barriers primary health care services face in managing and preventing cardiometabolic diseases. With these findings, we will generate evidence-based recommendations on potential strategies that are feasible for resource-limited settings in combating the increasing challenges of cardiometabolic diseases.

The cost of implementing Vietnam's national plan of action for nutrition for 2017-2020.

BACKGROUND: There is an urgent need to carry out a costing exercise of the National Plan of Action for Nutrition (NPAN) 2017-2020 since the costing of nutrition-sensitive interventions was not entirely integrated and proved difficult to track the different sectors' contributions to the nutrition program. OBJECTIVE: To estimate the required budget for the activities of the NPAN in 2017-2020. METHODS: A standard ingredients approach activity-based costing was employed from the provider perspective. RESULTS: The budget amount required for the NPAN activities in 2017, 2018, 2019 and 2020 would be US$ million 269.0; 310.5; 350.2 and 378.1, respectively. State budgets (especially from Ministry of Health) would be the main funding source for the NPAN. The budget required for implementing nutrition-sensitive interventions would be the largest share (more than 90%) while less than 10% are required for nutrition-specific interventions. The four interventions requiring the largest budget proportion (in 2020) included 1) Micronutrient supplementation (28.3%); 2) Breastfeeding & complementary feeding (21.9%); 3) Treatment of severe acute malnutrition (15.6%); and 4) Disease prevention and management (13.4%). CONCLUSIONS: Based on the data from Vietnam National Health account and the data on GDP of Vietnam, the total required budget for the Vietnam NPAN 2017 (USD millions 5,082) as shares of the State budget for health, total State (Government) budget, and GDP would be 5.29%, 0.49% and 0.14%, respectively. From the estimation, Vietnam represents the nutrition strategy which prioritized on nutrition-sensitive actions, similar to most of the SUN Movement member countries.