Second Health Human Resources Development Project (RRP VIE 40354)

JAPAN FUND FOR POVERTY REDUCTION GRANT

SECOND HEALTH HUMAN RESOURCES DEVELOPMENT PROJECT

I. INTRODUCTION 1. The proposed Second Health Human Resources Development Project will assist the Government of Viet Nam to achieve universal health coverage (UHC), including access to essential health care services. The project outcome is an increased supply of skilled health workforce. The project loan addresses the undersupply of health professionals by building new campuses for Hanoi Medical University (HMU) and the University of Medicine and Pharmacy at Ho Chi Minh City (UMP), increasing each university’s enrolment capacity. The Japan Fund for Poverty Reduction (JFPR) grant will address deficiencies in the responsiveness and quality of health graduates, and the existing health workforce, in meeting the needs of poor and vulnerable populations. In doing so, JFPR grant-supported outputs directly enhance the project’s pro-poor and inclusive characteristics.

II. THE GRANT A. Rationale 2. Sustainable inclusive growth and the health of the population are intricately linked. In Viet Nam, inequitable health outcomes and high out-of-pocket health expenditure associated with illness are a threat to inclusive growth. Inequitable health outcomes are entrenched, as evidenced by disparities on key health indicators depending on location. For example, in the impoverished Central Highlands, infant mortality was 24.8 per 1,000 live births in 2015, while the affluent South East region recorded infant mortality of 8.6 per 1,000 live births. Similar variations are found in reproductive health and maternal mortality outcomes.1 A concurrent challenge, morbidity and mortality associated with noncommunicable diseases (NCDs), comprised 73% of the national disease burden in 2015.2 Viet Nam’s aging population and exposure to risk factors linked to rapid urbanization are drivers of the NCD epidemic.3 Out-of-pocket health expenditure remains high, constituting 43% of total health expenditure in 2015.4 Patients bypass their local health care (LHC) facilities for higher-level hospitals, which contributes to elevated out-of-pocket payments.5 This is driven, in part, by patients’ perceptions that services and pharmaceuticals are of superior quality and effectiveness at these higher-level facilities (footnote 1). In 2014, 2.3% of households experienced catastrophic health spending.6 3. The goal of UHC aligns with addressing health inequity and attaining inclusive growth. The country’s shortfall in quality health workers is a key constraint to achieving UHC.7 An estimated additional 43,250 doctors, 249,416 nurses, and 22,199 pharmacists are required to

1 Government of Viet Nam, Ministry of Health (MOH). 2017. Joint Annual Health Review 2016: Towards Healthy

Aging in Vietnam. Hanoi. 2 Measured by disability adjusted life years. Institute for Health Metrics and Evaluation (accessed 26 April 2018). 3 T.V. Bui et al. 2016. National survey of risk factors for non-communicable disease in Vietnam: prevalence

estimates and an assessment of their validity. BMC Public Health. Volume Number 2016 16:498. 4 World Health Organization. Global Health Expenditure Database (accessed 10 May 2018). 5 LHC encompasses the network of commune health stations and district-level health facilities. 6 Health expenditure is considered catastrophic if a household’s financial contributions to health equal or exceed

40% of nonfood expenditures. 7 Government of Viet Nam, MOH. Decision No. 2992/QD-BYT (17 July 2015) approving the human resources

development plan in the universal health care system for 2015–2020.

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meet the 2030 targets for health workforce coverage.8 Workforce shortages are most evident in remote and mountainous areas. For example, the Central Highlands has 43 health workers per 10,000 people, while the Red River Delta region has 71 health workers per 10,000 people.9 The proportion of commune health stations (CHS) served by a doctor and a midwife or pediatric-obstetric assistant doctor is lowest in the Central Highlands and Northern Midlands and Mountains regions (footnote 1). CHS are the primary entry point for health care for low-income populations.10 A higher density of health workers is statistically associated with lower infant and child mortality and longer life expectancy.11 4. Skills deficiencies compound the effects of the health workforce shortage, particularly in LHC. A recent study of the LHC workforce found that doctors had inadequate knowledge of clinical guidelines (footnote 10). On average, medical doctors asked patients less than 50% of the required questions about their medical history and conducted less than 60% of the required physical examinations during diagnosis. Inadequate knowledge of case management protocols was also highlighted, with a significant share of medical doctors found to prescribe unnecessary and potentially harmful treatments. Health staff working in disadvantaged locations tended to have lower skills. Half of the medical doctors working in the poorest areas fell in the bottom two quintiles of the national ability scale. The capacity of assistant doctors, who are primarily located at CHS in remote areas, is less than 20% of the capacity of degree-qualified doctors.12 These deficiencies result in poor treatment quality, low service utilization, and worse health outcomes. Ministry of Health (MOH) programs to redress imbalances in the health workforce distribution and skill levels include rotating specialist staff from higher level to lower level facilities, deploying doctors to difficult areas, and granting preferential access to health education and professional training institutions (HEPTI) for students from disadvantaged regions.13 5. Insufficient supply of health professional graduates. While demand for admission to HEPTI is strong, inadequate infrastructure prevents universities from increasing enrolments to meet the health workforce targets. This is most evident in Viet Nam’s leading HEPTI, HMU and UMP. In 2017, only 7%–8% of applicants for undergraduate medicine at each university could be offered places. 14 Operating at capacity, HMU and UMP are unable to accommodate increased student numbers while maintaining teaching quality. 6. Graduates unresponsive to community’s health needs. The MOH issued competence standards for general medical practitioners in anticipation of the skills needed by

8 Sector Assessment (Summary): Health (accessible from the list of linked documents in Appendix 2 of the report

and recommendation of the President). 9 World Health Organization. 2016. Human Resources for Health Country Profiles: Viet Nam. Manila. 10 World Bank. 2016. Quality and Equity in Basic Health Care Services in Viet Nam: Findings from the 2015 Viet Nam

District and Commune Health Facility Survey. Washington, DC. 11 M.P. Nguyen, T. Mirzoev, and T.M. Le. 2016. Contribution of health workforce to health outcomes: empirical

evidence from Vietnam. Human Resources for Health. 14 (68). pp. 1–11. 12 Assistant doctors complete a four-year training program while medical doctors complete a six-year program. 13 Government of Viet Nam, MOH. Decision No. 585/QD-BYT (20 February 2013) approving the pilot project for

young doctors to work in mountainous, remote, border, island and disadvantaged areas; Hanoi; Government of Viet Nam, MOH. Decision No. 1544/QD-TTg (14 November 2007) approving the program on training health personnel for difficult and mountainous areas from provinces in the Northern, Central Coastal regions, the Mekong delta and Tay Nguyen. Hanoi; and Government of Viet Nam, MOH. Decision No. 1816/QD-BYT (25 May 2008) on the project for rotating healthcare workers from higher-level hospitals to support lower-level hospitals with the aim of improving quality of examination and treatment. Hanoi.

14 The UMP received 22,000 applications for the 1,600 available first year medicine places (source: UMP Department of Training). HMU received about 13,000 applications for 1,000 available places (source: HMU).

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future doctors to address the country’s evolving health needs.15 However, students do not have enough opportunities to develop competence in systems-based practice in rural and other disadvantaged communities, leaving graduates ill-equipped to work with poor and vulnerable populations.16 For example, fifth year medical students at HMU undertake practice placements in well-resourced urban health facilities. HEPTI have also been slow to operationalize these competence standards under their teaching programs. Assistance is needed to transition medical, and other health professional training programs, from a knowledge-based to competency-based curriculum. The introduction of faculty development programs to train medical educators in interactive teaching methods, clinical skills teaching, and supervision, including supervision for systems-based practice, is urgently required.17 7. Limited professional development opportunities in remote areas. The LHC workforce lacks opportunities to participate in ongoing professional development, including continuing medical education (CME).18 A 2015 study found that only 50% of doctors working in district hospitals received some form of training. Among CHS staff, the proportion participating in training in the previous 12 months was 58%–81%, depending on the province. Participation was lowest for traditional medicine doctors (49%) and pharmacists (51%) (footnote 10). Health workers in remote areas have limited access to professional development.19 Distance-learning technologies offer an opportunity to improve this access. HMU and UMP are licensed CME providers, but lack the experience and capacity to apply remote teaching technologies. 8. Development impact. The project will assist the government to achieve UHC, including access to essential health care services. The government’s commitment to UHC is confirmed in the National Action Plan for the Implementation of the 2030 Sustainable Development Agenda,20 which prioritizes ensuring an adequate supply of quality health workers, particularly at LHC level. The project’s outcome aligns with, and directly supports, this priority. The project loan will finance infrastructure for new campuses of HMU and UMP, ensuring the required physical capacity to increase graduate numbers. The JFPR grant will facilitate linkages between disadvantaged communities and these two HEPTI to (i) strengthen direct health service delivery to poor and vulnerable populations, (ii) produce cohorts of health professional graduates that are equipped to address health needs in disadvantaged communities, (iii) provide a pathway for students to work in disadvantaged communities when they graduate, and (iv) improve the skills of staff working in remote LHC facilities. JFPR financing is required because government regulations restrict the use of loan proceeds to finance soft activities.21 B. Outputs and Key Activities

15 Government of Viet Nam, MOH. Decision No. 1854/QD-BYT (18 May 2015) on competence standards for general

practitioners. Hanoi. 16 Systems-based practice is a competence standard of modern medical education that centers on students’

understanding of the broader context of patient care within the multiple layers of a health care system. 17 K. Foster and J. Morris. (draft). Doctors for the Future in Viet Nam. A Report for the World Health Organization.

Sydney. 18 CME refers to training undertaken by a health professional to licensing requirements. For example, a medical

practitioner must undertake 24 credits of CME every 2 years. 19 K. Takashima et al. 2017. A review of Vietnam’s healthcare reform through the Direction of Healthcare Activities

(DOHA). Environmental Health and Preventive Medicine. 22 (74). pp. 1–7. 20 Government of Viet Nam, Office of the Prime Minister. 2017. National Action Plan for the Implementation of the

2030 Sustainable Development Agenda. Hanoi. 21 Government of Viet Nam. Decree No. 16/2016/ND-CP (16 March 2016) on the management and utilization of

official development assistance and concessional loans of foreign donors. Hanoi.

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9. JFPR grant Outputs 1 and 2 align with Outputs 2 and 3 of the project loan.22 10. Output 1: Competency of graduates to respond to community health needs strengthened. The project grant will implement an innovative model that links HEPTI and LHC facilities to improve direct health service delivery to poor and vulnerable populations while facilitating “bottom–up” reforms to health professional training programs. Output 1 will pilot test a model of student practice placements in 35 rural and urban CHS servicing poor and vulnerable populations. Health facilities in pilot sites will be supplied with clinical and tele-mentoring equipment, including clinical equipment specific to health issues affecting women. 23 Seven hundred students will undertake practice placements at these CHS. In addition to enhancing service provision, the model will provide students with the understanding and experience of systems-based practice in disadvantaged settings, critical for developing competencies for future work in LHC (footnote 16). In parallel with the pilot test, Output 1 will (i) implement student-led assessments of health needs in disadvantaged communities and the behavioral, social, and environmental determinants of health inequality; (ii) review and update the curricula for four key degree programs, incorporating the findings of the community-level needs assessments, and benchmarked against international curricula and quality standards; and (iii) strengthen the capacity of female and male faculty members to deliver the revised curricula, including learning outcomes for systems-based practice. 11. Output 2: Quality of health workforce in disadvantaged communities enhanced. The project grant will enhance the quality of the health workforce in remote areas through a pilot project for the delivery of distance CME using mobile technologies. Output 2 will (i) equip health facilities in four remote districts to support the CME pilot project; (ii) develop 40 CME modules covering primary health care topics, including modules specific to the health needs of women;24 (iii) pilot test the distance delivery of CME for the health workforce in four districts and evaluate the efficacy of the approach; and (iv) apply evidence from the pilot test to inform replication by HEPTI and other registered CME providers. C. Cost Estimates and Financing Plan 12. The grant outputs are estimated to cost $3.1 million (Table 1). JFPR will provide grant cofinancing equivalent to $3.0 million.

Table 1: Cost Estimates ($ million)

Item Amounta Share of Total (%)

A. Base Costb 1. Competency of graduates to respond to community

health needs strengthened 2.35 75.8 2. Quality of health workforce in disadvantaged

communities enhanced 0.51 16.5 Subtotal (A) 2.86 92.3 B. Contingenciesc 0.24 7.7 Total (A+B) 3.10 100.0 Administrative Budget Support 0.09

a Includes taxes and duties of $0.2 million to be financed from the Japan Fund for Poverty Reduction.

22 The design and monitoring framework is in Supplementary Document 1. 23 For example, gynecology examination instrument sets. 24 For example, sexual and reproductive health and rights, including maternal health, family planning, sexually

transmitted infections and HIV/AIDS, and gender-based violence.

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b In mid-2018 prices. c Maximum of 10% of the total cost. Source: Asian Development Bank.

13. The financing plan is in Table 2. The executing and implementing agencies will provide in-kind counterpart support in the form of counterpart staff, office space, student placement accommodation, office supplies, secretarial assistance, domestic transportation, and other in-kind contributions. The JFPR grant will finance (i) local travel costs for students, trainees, and trainers participating in the two pilot initiatives; and (ii) international and domestic airfares for consultants.

Table 2: Financing Plan

Source Amount ($ million) Share of Total (%)

Japan Fund for Poverty Reductiona 3.0 96.8 Government 0.1 3.2

Total 3.1 100.0 a Administered by the Asian Development Bank. Source: Asian Development Bank estimates.

D. Implementation Arrangements 14. The MOH is the executing agency for the project, which will be supported by a project coordinating unit (PCU). The HMU and UMP are the implementing agencies for the JFPR grant. Separate advance accounts will be established at HMU and UMP. Procurement will follow the Procurement Regulations for ADB Borrowers (2017, as amended from time to time). The implementation period for grant-financed activities is April 2019–March 2023. The closing date is 30 September 2023. The implementation arrangements are described in detail in the project administration manual.25 15. Individual project implementation units (PIUs) comprising university-appointed staff will be established at HMU and UMP. PIUs will be supported by a project coordination specialist (full-time) and a finance specialist (full-time). Each PIU will engage a firm to supply technical experts (international and national) to support activity implementation. A procurement and contract management specialist located within the PCU at the MOH will provide support to procurement-related activities under the grant.

Table 3: Implementation Arrangements

Aspects Arrangements

Implementation period April 2019–March 2023

Estimated completion date 31 March 2023

Management

(i) Oversight body Project Steering Committee Health minister (chair) Ministry of Education, MOH Department of Planning and Finance, presidents of HMU and UMP (members)

(ii) Executing agency MOH

(iii) Key implementing agencies UMP and HMU

(iv) Implementation unit 1. HMU project implementation unit, 4 staff 2. UMP project implementation unit, 4 staff

25 Project Administration Manual (accessible from the list of linked documents in Appendix 2 of the report and

recommendation of the President).

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Aspects Arrangements

Procurement OCB national advertisement

4 contracts $0.72 milliona

RFQ 8 contracts $0.32 milliona

Consulting services QCBS 30 person-months $0.24 million

ICS 200 person-months $0.52 million

Retroactive financing and/or advance contracting

Advance actions include finalizing terms of reference for all individual consultants and consulting firms; advertising requests for expressions of interest, invitation for bids, and requests for quotations; and initiating proposal and/or bid evaluations.

Disbursement The grant proceeds will be disbursed following ADB’s Loan Disbursement Handbook (2017, as amended from time to time) and detailed arrangements agreed between the government and ADB.

ADB = Asian Development Bank, HMU = Hanoi Medical University, MOH = Ministry of Health, OCB = open competitive bidding, QCBS = quality- and cost-based selection, ICS = individual consultant selection, UMP = University of Medicine and Pharmacy at Ho Chi Minh City. a Excludes contingencies. Source: Asian Development Bank.

III. DUE DILIGENCE A. Technical 16. The project design incorporates a series of innovative approaches to address health workforce constraints in achieving UHC’s promise of access to essential health care for the whole population. By institutionalizing linkages between poor and vulnerable communities and HEPTI, the project provides the mechanism to improve health service delivery in these settings while facilitating bottom–up reforms to health professional training programs that strengthen graduates’ responsiveness to the needs of poor and vulnerable populations. 17. Community-level assessments of health needs in poor and vulnerable communities, and the determinants of health inequality, will generate key inputs for the revision of curricula frameworks and learning outcomes of health professional degree programs. This includes the learning outcomes for student practice placements in these poor and vulnerable communities. Service quality during practice placements will be maintained through a student–clinical supervisor ratio of 5:1. Clinical equipment provided to LHC facilities will be technically appropriate to the setting, the users’ capacity, and the priority health issues of the community. Communication campaigns, conducted as part of the student’s health promotion activities, will raise community awareness of the enhanced services being provided through their LHC facilities. 18. Lack of access to CME for health professionals in remote areas is a key constraint to health workforce quality. To address this, an innovative model for the delivery of distance CME will be pilot tested. Mirroring the bottom-up approach applied to curriculum reform, CME module development will draw on the findings of the community-level needs assessments. Equipment to enable distance CME will be supplied to pilot sites, with a focus on readily available technologies and user-friendly interfaces. Evaluation of the pilot test will inform replication of the approach by HEPTI and other registered CME providers. B. Economic and Other Impacts, Financial Viability, and Sustainability 19. The project’s net present value is projected at $2.2 billion over a 35-year period. The

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economic internal rate of return is forecast at 19.2%, exceeding the threshold for social sector projects.26 Economic benefits derive from (i) direct labor productivity gains from the entry of additional medical professionals into the labor force and (ii) indirect labor productivity gains from a reduction in illness and premature death resulting from an increase in the number of health professionals per capita. Each university will finance operation and maintenance of their new campuses through revenue generated from tuition, external training, and hospital services. Tuition revenue will increase from 2025 because of higher enrolments and tuition fees.27 The resulting increase in the net operating cash flow of the two universities is projected to cover operation and maintenance. JFPR grant-financed activities—equipping LHC facilities in disadvantaged areas, enhancing service delivery through student rotations, and increasing access to CME for remote health staff—contribute to the project’s economic benefits through improved health outcomes and an associated reduction in health-related socioeconomic disadvantage among poor and vulnerable populations. C. Governance 20. The pre-mitigation financial management risk of the project is high. Financial and procurement risks for the grant component are moderate. A financial management assessment of the executing and implementing agencies found that the key issues relate to unclear accounting guidelines for the project investment and a lack of internal controls through a fully integrated system within the executing agency. The MOH, HMU, and UMP have experience in managing and implementing official development assistance-funded projects, including projects financed by ADB, and they have adequate capacity to implement the grant. 21. The technical capacity of HMU and UMP to implement the project’s pilot initiatives and execute the teaching program reforms will be supplemented by international and national consultants. The project includes fiduciary risk mitigation and accountability mechanisms to ensure compliance with ADB regulations and policies. It will establish a PCU at the MOH and PIUs at HMU and UMP. The project will provide training on ADB procedures for project financial management, procurement, accounting, and auditing as well as safeguards monitoring and reporting requirements. ADB’s Anticorruption Policy (1998, as amended to date) was explained to and discussed with the government and the MOH. The specific policy requirements and supplementary measures are described in the project administration manual (footnote 26). D. Poverty and Social Impacts 22. The project will have immediate benefits for poor and vulnerable women, men, and children living in disadvantaged communes targeted by the project. The 35 communes located in six rural and urban districts will participate in the student placement pilot project. The target districts are listed in Supplementary Document 6. Target districts were selected using (i) poverty rates, (ii) locations where each university has an existing relationship, and (iii) student safety. Pilot communes in each district will be selected during project implementation in consultation with district authorities and in parallel with the community-level needs assessments. The primary criteria to be applied for commune selection are (i) poverty rates, (ii) communes that have a functioning CHS building, and (iii) student safety. Residents of these communes, estimated to be more than 683,000 people, will benefit from strengthened LHC service delivery

26 Economic and Financial Analysis (accessible from the list of linked documents in Appendix 2 of the report and

recommendation of the President). 27 Under the government’s policy on university autonomy, HMU and UMP will set their own tuition fees from 2025.

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resulting from student placements and improved equipment—particularly members of the poorest households for whom CHS are the primary entry point for health care (footnote 10). Communities in four remote districts will benefit from the enhanced skills of 1,020 health professionals (60% female) who have access to CME through distance learning. Estimates of population size in target districts, poverty rate in target districts, and national poverty rates are in Supplementary Document 7. 23. In the long term, the project will have positive impacts on health outcomes in disadvantaged communities through the supply of a quality health workforce that is responsive to the health needs of poor and vulnerable populations. The project’s poverty and social impacts are elaborated in the Summary Poverty Reduction and Social Strategy.28 24. The project is categorized effective gender mainstreaming. A gender action plan was prepared with strategies to address gender equality, including (i) LHC facilities supplied with equipment for health conditions affecting women, (ii) equitable participation of female and male students in the student placement program, (iii) gender considerations integrated in the revised curricula, (iv) at least 10% of CME modules specific to health issues directly affecting women, and (v) proportional participation of female health staff in project-sponsored CME. 29 E. Participatory Approach 25. Beneficiary-centered programming underlies the project preparation and implementation approach. National consultations to identify activities and investment requirements for strengthening LHC services, conducted under ADB technical assistance to the MOH, have informed the project design.30 Drawing on the technical assistance project’s outcomes, each university has consulted with health authorities on community health needs in target areas and the design of the project’s pilot initiatives. Stakeholder consultations on CHS equipment requirements were conducted, ensuring equipment supplied by the project will be relevant to the priority health issues of communities, including health issues affecting women. 26. The input of primary beneficiaries—the poor and vulnerable—during project implementation, will be facilitated through community-level needs assessments. Assessment findings will inform the content of revised degree program curricula, the structure and learning outcomes of student practice placements, and the content of CME modules for health professionals in remote areas. Evaluation activities will involve community members as the beneficiaries of enhanced LHC services. Health professionals in target sites will also participate in the evaluation of student practice placements and distance delivery of CME. Indicators in the design and monitoring framework include targets to measure the reach of each pilot program. F. Development Coordination 27. A strategic partnership between ADB and the Japan International Cooperation Agency (JICA) identifies the promotion of UHC for vulnerable populations as an area for operational

28 Summary Poverty Reduction and Social Strategy (accessible from the list of linked documents in Appendix 2 of the

report and recommendation of the President). 29 Gender Action Plan (accessible from the list of linked documents in Appendix 2 of the report and recommendation

of the President). 30 ADB. Viet Nam: Support to Strengthening Local Health Care Program.

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collaboration.31 ADB maintains regular dialogue with JICA representatives in Viet Nam on health sector collaboration, including support for developing health human resources toward UHC. In designing the project, the project team explored complementarities with current JICA support for strengthening the clinical training of newly graduated nurses.32 ADB met with the Embassy of Japan in Viet Nam during project preparation to provide briefings on the project and the JFPR grant-financed activities.33 28. Under the lead of the MOH, ADB and other key development partners working on health human resources coordinate to ensure system-wide impacts from individual investments. The JFPR grant-financed activities have been designed with reference to the following development partner projects: (i) the World Bank-financed Health Professionals Education and Training for Health System Reforms Project, cofinanced by the European Union, which supports curriculum reform for the medical, dentistry, and nursing programs in a number of HEPTI, including HMU and UMP;34 (ii) the Partnership for Health Advancement in Viet Nam’s IMPACT MED Alliance-financed technical assistance to curriculum development for undergraduate medical programs under HEPTI and support for reform of postgraduate medical training;35 and (iii) the World Health Organization-financed technical assistance to the MOH and HEPTI in areas pertaining to health workforce development and management. G. Safeguards 29. Outputs financed by the JFPR grant will have (i) minimal or no adverse environmental impacts, (ii) no involuntary resettlement impacts, and (iii) no impacts on indigenous peoples. 30. In compliance with ADB’s Safeguard Policy Statement (2009), the project’s safeguard categories are B for environment, B for involuntary resettlement, and C for indigenous peoples.36 The categorization is based on the impacts of the project loan financed output that will construct the second campuses of HMU and UMP. H. Risks and Mitigating Measures 31. Risks and mitigating measures are summarized in Table 4 and detailed in the risk assessment and risk management plan.37 The integrated benefits and impacts of the project are expected to outweigh the costs.

Table 4: Summary of Risks and Mitigating Measures Risks Description Mitigating Measures

Public financing management

Weak capacity to plan, budget, and manage state investments in a sustainable manner linked to performance measurement system.

Project to build capacity of MOH and PIUs of HMU and UMP; and establish measures to monitor progress and performance.

31 JICA. 2017. Signing of Memorandum of Understanding with the Asian Development Bank: Strengthening a

partnership in the health sector in Asia and Pacific Island countries with graying societies. News release. Yokohama.

32 JICA. 2016. Strengthening Clinical Training System of newly-graduated nurses. 33 Supplementary Document 3: Specific Coordination Details with the Local Embassy of Japan and Japan

International Cooperation Agency. 34 World Bank. 2014. Health Professionals Education and Training for Health System Reforms. 35 The Partnership for Health Advancement in Vietnam. IMPACT MED Alliance. 36 ADB. Safeguard Categories. 37 Risk Assessment and Risk Management Plan (accessible from the list of linked documents in Appendix 2 of the

report and recommendation of the President).

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Unreliable reports caused by errors and limited staff capability in ADB financial reporting requirements.

MOH to hire three finance specialists to assist the implementing agencies; train staff on project accounting and reporting requirements of ADB and MOH.

Procurement -

Weak capacity of implementing agencies to prepare and manage financial information, procurement documents, and related project activities to comply with ADB guidelines and reporting requirements.

MOH to recruit (i) project management and procurement specialists to assist the PCU and implementing agencies to update procurement plan, prepare master bidding documents, review and evaluate bids, and manage contracts; (ii) three finance specialists to assist the PCU and implementing agencies; and (iii) project implementation consultants to provide support to PIUs of HMU and UMP.

ADB to provide orientation on ADB Procurement Policy (2017, as amended from time to time); and support preparation of procurement manual, including standard bidding documents.

Project implementation

Lack of coordination between provincial health departments and HMU and UMP

ADB and PIUs ensure regular consultation and involvement in project implementation to gain ownership

Lack of operation and maintenance resources for sustainability after project completion

Prepare an operation and maintenance plan with commitments from the universities and provinces to cover recurrent and maintenance costs to ensure sustainability of investments.

ADB = Asian Development Bank, H = high, HMU = Hanoi Medical University, MOH = Ministry of Health, M = moderate, PCU = project coordinating unit, PIU = project implementation unit, UMP = University of Medicine and Pharmacy at Ho Chi Minh City. Source: Asian Development Bank.

IV. ASSURANCE 32. The government and the MOH have assured ADB that implementation of the JFPR grant shall conform to all applicable ADB policies, including those concerning anticorruption measures, safeguards, gender, procurement, consulting services, and disbursement as described in detail in the project administration manual and the grant agreement. Supplementary Documents 1. Design and Monitoring Framework for Project Grant Outputs to be Financed by the

JFPR Grant 2. Japanese Visibility 3. Specific Coordination Details with the Local Embassy of Japan and Japan International

Cooperation Agency 4. Detailed Cost Estimates by Output 5. Administrative Budget Support Details 6. Project Locations 7. Estimates for population size and percentage of poor households in target districts. 8. List of equipment for commune health stations and universities

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ANNEX 1: DESIGN AND MONITORING FRAMEWORK FOR PROJECT GRANT OUTPUTS TO BE FINANCED BY JAPAN FUND FOR POVERTY REDUCTION38

Impact the Project is aligned with: UHC, including access to essential health care services, achieved (Target 3.7: National Action Plan for the Implementation of the 2030 Sustainable Development Agenda)a

Results Chain Performance Indicators with Targets and Baselines

Data Sources and Reporting

Risks

Outcome Supply of skilled health workforce

a. Annual intake of undergraduate programs increased by 1,100 students per year at HMU and 1,100 students per year at UMP by 2027 (baseline 2018: HMU = 1,600; UMP = 1,600)

a. b. 80% of students from targeted

degree programsb at HMU and UMP that participated in pilot practicums met learning outcomes for CHS practice placements by June 2023 (baseline 2018: HMU = 0%, UMP = 0%) c. 1,020 LHC staff, 60% of whom are

women,c have received distance CME by June 2023 (baseline 2018: HMU = 0, UMP = 0)

a–c. HMU and UMP project progress reports, and annual reports

Shift in political leadership to weaken support for health human resources development

Outputs 1. Competency of

graduates to respond to community health needs strengthened (Output 1 aligns with Output 2 in the project loan DMF).

1a. 35 CHS are equipped to serve as student placement sites, including with equipment for health conditions affecting women,d by December 2021 (baseline 2018: 0) 1b. One health professional education program at HMU and three health professional education programs at UMP have revised curriculum,e including gender specific content by January 2022 (baseline 2018: HMU = 0, UMP = 0) 1c. 400 HMU students (at least 50% female) and 300 UMP students (at least 50% female), participated in practice placements in CHS under the revised curriculum by March 2023 (baseline 2018: HMU = 0, UMP

1a-e. Project progress reports

Shortage of counterpart funds in approved budgets result in implementation delays

38 Captures outputs and activities that are only supported by the grant.

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Results Chain Performance Indicators with Targets and Baselines

Data Sources and Reporting

Risks

= 0) 1d. 240 traineesf from HMU and UMP teaching staff (at least 60% female) trained on modern teaching methods by March 2023 (baseline 2018: HMU = 0, UMP = 0) 1e. Community members in 35 disadvantaged rural and urban communes receive health services from HMU or UMP students by January 2022 (baseline 2018: HMU = 0, UMP = 0)

2. Quality of health workforce in disadvantaged communities enhanced (Output 2 aligns with Output 3 in the project loan DMF).

2a. Four district health facilities in remote areas are equipped to pilot distance CME delivery for LHC staff by Q3 2020 (baseline 2018: 0) 2b. 40 CME e-learning modules for primary health, including 10% of the modules focused on health issues affecting women,g developed by HMU and UMP by March 2023 (baseline 2018: HMU = 0, UMP = 0)

2a.-b. Project progress and capacity building reports

Key Activities with Milestones 1. Competency of graduates to respond to community health needs strengthened 1.1 Commence community-based diagnostics assessments by Q3 2019. 1.2 Complete implementation arrangements and equipment provision for student placements in rural health

facilities by Q1 2020. 1.3 Commence student placements by Q2 2020. 1.4 Complete benchmark review of international curriculum at UMP by Q2 2020. 1.5 Commence IEC campaigns as part of student placement program by Q3 2020. 1.6 Complete faculty consultation and curriculum design workshops for at least one-degree program at

HMU and one-degree program at UMP by Q1 2021.c 1.7 Issue revised curriculum for at least one-degree program at HMU and one-degree program at UMP by

Q2 2021. 1.8 Complete training workshops for faculty on teaching methods and technologies by Q4 2022. 2. Quality of health workforce in disadvantaged communities enhanced 2.1 Commence CME module development by Q3 2019. 2.2 Supply equipment for distance CME technology to pilot sites by Q3 2020. 2.3 Commence pilot of CME delivery in remote sites by Q1 2021. 2.4 Evaluate pilot of distance CME delivery by Q2 2022. 2.5 Commence dialogue with HEPTI on model replication by Q3 2022.

Project Management Activities Establish project management units at each university (Q2 2019) Engage individual consultants to support delivery of project outputs (Q3 2019) Recruit project implementation firms (Q4 2019)

Inputs Japan Fund for Poverty Reduction: $3.0 million (grant) Government: $0.1 million

Assumptions for Partner Financing Not applicable

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ADB = Asian Development Bank, CHS = commune health station, CME = continuing medical education, DMF = design and monitoring framework, HMU = Ha Noi Medical University, IEC = information, education and communication, JFPR = Japan Fund for Poverty Reduction, HEPTI = health education and professional training institutions, LHC = local health care, NA = not applicable, UHC = universal health coverage, UMP = University of Medicine and Pharmacy at Ho Chi Minh City. a Government of Viet Nam, Office of the Prime Minister. 2017. National Action Plan for the Implementation

of the 2030 Sustainable Development Agenda. Hanoi. b Target programs for pilot placements are (i) fifth year and third year undergraduate medicine students at

HMU, and (ii) fourth year public health and sixth year general preventive medicine students at UMP. c Reference points for gender targets (i) 69.6% of staff in CHS nationwide are female (2015 data) and (ii)

proportion of students who are female is 57.2% at HMU and 63.7% at UMP (2017 data). d For example, gynecology examination instrument set. e HMU will review curriculum for the undergraduate medical program. UMP will review curriculum for the

undergraduate public health, traditional medicine, and pharmacy degree programs. f One faculty member may participate in more than one training. f For example, sexual and reproductive health and rights, including maternal health, family planning,

sexually transmitted infections and HIV/AIDS, and gender-based violence. Source: Asian Development Bank.

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ANNEX 2: JAPANESE VISIBILITY

1. The project will draw on the experience and learning of Japan as a global leader in efforts to progress universal health coverage commitments under the Sustainable Development Goals. The project will utilize, whenever feasible, specialists from Japan for international consulting inputs. Both the Ha Noi Medical University and the University of Medicine and Pharmacy at Ho Chi Minh City have existing cooperation programs with a number of universities, training institutes, and research centers in Japan (Table 1). These, or other Japanese institutions, may be drawn on as a source of expertise in areas not limited to (i) design of epidemiological studies (community-level needs assessments), (ii) curriculum revision and learning outcomes for community-based practice placements, and (iii) application of information technology for e-learning systems. 2. Strategies for Japanese visibility contained in the Japan Fund for Poverty Reduction (JFPR) guidelines will be closely adhered to, including (i) acknowledgement that the activities are supported through funding from the Government of Japan, including in press releases and write-ups; (ii) use of the JFPR and Japan Official Development Assistance logos on all equipment, materials, publications, at workshops and consultation meetings; (iii) maximizing coverage of the grant project in media, with explicit acknowledgement of Japan as the source of funding; and (iv) invitation of officials from the Embassy of Japan to milestone events. 3. The Asian Development Bank will continue to meet with representatives of the Japan International Cooperation Agency (JICA) to review the complementarities of this JFPR grant financed activity and JICA’s ongoing program of support to the Viet Nam health sector, particularly in the area of health workforce development. This includes exploring opportunities to utilize JICA volunteers and experts in the fields of health and community development.

Table 1: Japanese universities, training institutes, and research centers collaborating with HMU and UMP

HMU UMP

Ritsumeikan University Tsukuba University and Tsukuba Hospital

Ritsumeikan Asia Pacific University International University of Health and Welfare

Shimane University Chiba University Kyoto University, Department of Medicine Kyoto University Osaka City University, Department of Medicine Hiroshima University Kagoshima University, Graduate School of Medical and Dental Science

Fukushima University

Jumonji University Yamanashi University Fujita Health University Takasaki University Kobe University, Graduate School of Health Sciences

Osaka University

International University of Health and Welfare Tokyo University of Medicine and Dentistry Teikyo University Heisei Medical School Kyoto Institute of Technology Kansai University

HMU = Ha Noi Medical University, UMP = University of Medicine and Pharmacy at Ho Chi Minh City.

Source: Asian Development Bank.

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ANNEX 3: SPECIFIC COORDINATION DETAILS WITH THE LOCAL EMBASSY OF JAPAN AND JAPAN INTERNATIONAL COOPERATION AGENCY

1. Embassy of Japan in Viet Nam (EOJ). A meeting with the EOJ was held on 15 March 2018. Officials met were Mr. Ryusuke Momoi (First Secretary), Ms. Ai Chuman (Second Secretary), and Ms. Masae Otsuka (Second Secretary, Economic Section). The Asian Development Bank (ADB) officer briefed EOJ representatives on the Second Health Human Resources Development Project and the proposed Japan Fund for Poverty Reduction (JFPR) grant financed activities. Strategies for ensuring Japanese visibility were discussed, including opportunities to utilize Japanese consultants under the project. Both Ha Noi Medical University and University of Medicine and Pharmacy at Ho Chi Minh City have existing relationships with academic institutions in Japan. EOJ representatives requested ADB to meet with Japan International Cooperation Agency (JICA) to explore complementarities under JICA’s ongoing program of support to the Viet Nam health sector. In subsequent correspondence, the EOJ requested updates on project progress via email. 2. Japan International Cooperation Agency. A meeting with JICA was held on 21 June 2018. Officials met were Ms. Nozomi Iwama (Senior Representative), Ms. Yutori Sadamoto (Representative), Ms. Kyoko Takashima (Senior Project Formulation Advisor), and Ms. Chu Xuan Hoa (Senior Program Officer). The ADB team introduced the proposed project, including activities to be financed under the JFPR grant. The representatives from JICA provided an overview of current health sector operations in Viet Nam. The synergies between these JICA projects and the proposed project were also discussed. Representatives of JICA confirmed the importance of the grant activities in linking the loan outputs to communities. They expressed interest to remain informed on the outcomes of the pilot models for student practice placements and distance delivery of continuing medical education for remote health staff.

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ANNEX 4: DETAILED COST ESTIMATES BY OUTPUT ($ MILLION)

ADB GOV

Item Total Cost Output 1 Output 2 (Output 1&2)

A. Investment Costs

Surveys, Workshops and Training 0.42 0.41 0.01 - Equipment 1.04 0.83 0.21 -

Pilot models 0.54 0.40 0.14 Consultants 0.76 0.63 0.13

Subtotal (A) 2.76 2.27 0.49 -

B. Recurrent Costs

1. Salaries and operating costs 0.10 0.00 0.00 0.10 Subtotal (B) 0.10 0.00 0.00 0.10 Total Base Cost 2.86 2.27 0.49 0.10

C. Contingencies 0.24 0.20 0.04 0.00

D. Financial Charges During Implementation

Total Project Cost (A+B+C+D) 3.10 2.47 0.53 0.10

% Total Project Cost 100% 79% 17% 3%

ADB = Asian Development Bank, GOV = Government of Viet Nam. Note: Numbers may not sum precisely because of rounding. Includes taxes and duties of $0.2 million to be financed from the Japan Fund for Poverty Reduction. Source: ADB estimates.

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ANNEX 5: ADMINISTRATIVE BUDGET SUPPORT DETAILS 1. Administrative budget support. The project’s focus on piloting of several innovative models across multiple locations requires extra resources for coordination, technical monitoring, and evaluation. The administrative budget will support (i) coordination support to ensure the poverty reduction and social development outcomes of the Japan Fund for Poverty Reduction (JFPR) remain at the center of project activities, (ii) high quality monitoring, including technical monitoring of pilot initiatives, and (iii) dissemination of outcomes to development partners through coordination forums. JFPR visibility will be enhanced through the administrative budget support. 2. The administrative budget is detailed in Table 1. The budget will fund (i) a national staff consultant as JFPR coordinator, (ii) national staff consultant travel and per diem, and (iii) stakeholder meetings and consultations for monitoring and evaluation missions.

Table 1: Cost Estimate of Administrative Budget Support Expenditure Category Quantity Unit Cost Total

Staff consultant (national) Remuneration

18-person months

$3,500

$63,000

Staff consultant (national) Travel

24 trips

$250

$6,000

Staff consultant (national) Per diem

100 days

$80

$8,000

Stakeholder meetings and consultations for monitoring and evaluation (2 per target district)

16 meetings

$350

$5,600

Contingency $7,400 Total $90,000

Source: ADB estimates.

3. Terms of Reference - JFPR Coordinator (national). The staff consultant will be responsible for (i) coordinating with each project management unit on the implementation of JFPR activities; (ii) technical monitoring of pilot implementation and evaluation; (iii) liaison with ADB and support to project review missions; (iv) ensuring donor visibility; and (v) communicating project results. 4. The consultant will have (i) qualifications in public health or a related field; (ii) 10 years experience in social development programming, with demonstrated understanding of approaches to poverty reduction and gender mainstreaming; and (iii) demonstrated experience translating pilot initiatives into policy and programming action.

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ANNEX 6: PROJECT LOCATIONS Output 1: Student placement pilot

Hanoi Medical University Thanh Hoa Province Thuong Xuan District

Quan Son District Lang Chanh District

Ha Nam Province Kim Bang District University of Medicine and Pharmacy at Ho Chi Minh City

Ho Chi Minh City Cu Chi District Long An Province Duc Hue District

Output 2: CME for remote health staff

Hanoi Medical University Thanh Hoa Province Thuong Xuan District

Quan Son District University of Medicine and Pharmacy at Ho Chi Minh City

Gia Lai Province Chu Pah District Tra Vinh Province Cau Ngang District

Source: Asian Development Bank.

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ANNEX 7: ESTIMATES FOR POPULATION AND POVERTY

Table 1: Population and Poverty Estimates in Target Districts

Province District Population % Poor HH Number of Communes/Towns

Thanh Hoa Province

Thuong Xuan 90,126 d f 20.9 d f 16 communes/1 town Quan Son 37,343 d g 34.42 d n 12 communes/1 town

Lang Chanh 48,803 b h 23.7 e o 10 communes/1 town Ha Nam Province Kim Bang 134,200 b i 3.28 e p 16 communes/ 2 towns Ho Chi Minh City Cu Chi District 105,278 d j 6.11 d j 20 commune/1 town Long An Province Duc Hue District 68,238 c k 11.5 d q 10 Commune/1 town Gia Lai Chu Pah District 65,451 b l 15.41 e r 13 commune/2 towns Tra Vinh Cau Ngang District 136,244 a m 8.41 e s 13 commune/2 towns a 2005 b 2008

c 2013

d 2016

e 2017 f Source: http://thuongxuan.thanhhoa.gov.vn/portal/pages/print.aspx?p=4451 g http://huyenquanson.vn/gioi-thieu/dieu-kien-tu-nhien/8 h http://prpp.molisa.gov.vn/ (accessed 31 August 2018) i http://hanam.gov.vn/Pages/UBND-huyen-Kim-Bang638715135.aspx j http://hanam.gov.vn/Pages/toan-tinh-phan-dau-giam-them-015-ho-ngheo-trong-nam-2018.aspx k http://eng.longan.gov.vn/ l http://www.gialai.gov.vn/gioi-thieu-chinh-quyen/ubnd-huyen-chupah.56.aspx m http://www.travinh.gov.vn/wps/portal/caungang/ n http://thuongxuan.thanhhoa.gov.vn/portal/pages/print.aspx?p=4451 o https://thanhhoaedu.vn/index.php?option=com_content&view=category&id=34&Itemid=129 p http://baothanhhoa.vn/portal/pages/galkfa/new-article.aspx

j Steering Committee Poverty Reduction Program, Ho Chi Minh City People’s Committee. 2016

q http://la34.com.vn/tin-tuc/thoi-su-long-an/nam-2017-long-an-ty-le-ho-ngheo-giam-0-46/ rhttp://baogialai.com.vn/channel/1624/201803/chu-pah-phan-dau-giam-634-ho-ngheo-vao-cuoi-nam-

2018-5575539/index.htm shttp://tapchinganhang.com.vn/von-tin-dung-chinh-sach-gop-phan-giam-ngheo-tai-tra-vinh.htm Source: ADB estimates.

Table 2: National Poverty Estimates (2016) Area Poverty Ratea

Whole Country 5.8% Urban 2.0% Rural 7.5%

Notes: a Measured using the government poverty line Source: Government Statistics Office. 2017. Statistical Yearbook of Viet Nam 2016. Ha Noi.

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ANNEX 8: LOCATION MAP

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ANNEX 9: List of equipment for commune health stations and universities

Table 1: Equipment for commune health stations

NAME OF EQUIPMENT (IN VIETNAMESE LANGUAGE)

NAME OF EQUIPMENT (ENGLISH LANGUAGE)

UNIT QUANTITY

I THIẾT BỊ PHỤC VỤ SINH VIÊN (Xã) EQUIPMENT FOR LIVING STUDENT ROOM AT CHS

1 Giường ngủ cho sinh viên 2 tầng Single Bed (2 layer) Piece 3

2 Tủ lạnh Refrigerator Piece 1

3 Tủ quần áo Wardrobe Piece 2

II THIẾT BỊ Y TẾ PHỤC VỤ KHÁM BỆNH Ở CƠ SƠ (xã)

EQUIPMENT FOR CHS

4 Máy vi tính để bàn Personal Computer Set 1

5 Máy in laser Laser printer Piece 1

6 Đèn soi đáy mắt Ophthalmoscope Set 1

7 Đèn khám đeo trán Clear Lamp Set 1

8 Tủ sấy dụng cụ Drying Oven Piece 1

9 Máy lọc nước Water Purification Piece 1

10 Bộ dụng cụ khám mắt Eye Exam. Set Set 1

11 Bộ dụng cụ khám RHM Dental Exam. Instrument Set Set 2

12 Bộ dụng cụ khám Tai mũi họng ENT Exam. Instrument Set Set 2

13 Bộ dụng cụ khám sản Gynecology Exam. Instrument Set Set 2

14 Đèn khám bệnh (đèn gù) Exam. Lampe Piece 1

15 Xe đẩy dụng cụ (xe tiêm 2 tầng) Stainless steel inox cart Piece 2

16 Máy xét nghiệm nước tiểu 10 thông số Urine Analyzer 10 parameter Piece 1

17 Máy xét nghiệm đường huyết Blood glucose meter Piece 2

18 Dụng cụ đo lưu lượng đỉnh Peak Flow Measuring Equipment Set 2

19 Bộ đo Huyết áp + ống nghe Blood Pressure meter with Stethoscope

Set 2

20 Máy khí dung Nebulizer Piece 2

21 Cân sức khỏe có thước đo chiều cao Health meter with height measurement

Piece 1

22 Bộ dụng cụ lấy và bảo quản mẫu xét nghiệm

Sample transport box Set 1

23 Tủ lạnh bảo quản mẫu Refrigerator for Samples Piece 1

24 Bộ dụng cụ tiểu phẫu Minor Surgery Set Set 2

25 Máy Doppler tim thai Fetal Doppler Piece 1

26 Máy đo bão hòa oxy kẹp ngón tay - SpO2 SpO2 meter Piece 1

27 Bóp bóng người lớn/trẻ em Ambu Ball Squeezed Adult/Pediatric

Piece 2

28 Máy hấp tiệt trùng để bàn Tabletop Sterilizer Piece 1

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III THIẾT BỊ HỘI NGHỊ TRUYỀN HÌNH CHO TRẠM Y TẾ XÃ

VIDEO CONFERENCING EQUIPMENT FOR CHS

4 Bộ Camera bao gồm bộ điều khiển, micro đa hướng

Camera with control unit and Multidirectional Microphone

Set 1

5 Phần mềm VPN (Visual Privat Network) Software Visual Privat Network Set 1

6 Ti vi 60 inch TV set 60 inch Piece 1

Table 2: Equipment for HMU and UMP

NAME OF EQUIPMENT (IN VIETNAMESE LANGUAGE)

NAME OF EQUIPMENT (ENGLISH LANGUAGE)

UNIT

QUANTITY

I THIẾT BỊ HỖ TRỢ SINH VIÊN THỰC TẬP/ TẠO RA CME (CHƯƠNG TRÌNH ĐÀO TẠO Y KHOA LIÊN TỤC)

AUDIO VISUAL EQUIPMENT TO SUPPORT STUDENT PLACEMENTS/ CREATING CME

1 Thiét Bị Audiovisual set Set 1

II THIẾT BỊ HỖ TRỢ CUNG CẤP DỊCH VỤ ĐÀO TẠO Y KHOA LIÊN TỤC

EQUIPMENT TO SUPPORT CME DELIVERY

1 Máy chủ Server Set 1

2 Tablet Tablet Set 150

III THIẾT BỊ VĂN PHÒNG CHO BAN QUẢN LÝ DỰ ÁN

OFFICE EQUIPMENT FOR PROẸCT IMPLEMENTING UNIT

1 Bộ bàn ghế phòng họp 12 ghế Meeting Room Furniture, 12 seats

Set 1

2 Bộ bàn ghế phụ trách dự án Furniture for Project Manager Set 1

3 Bộ bàn ghế làm việc của nhân viên Furniture for Staff Set 5

4 Tủ tài liệu Document Bookcase Piece 4

5 Máy điều hoà nhiệt độ Air conditioner Piece 2

6 Máy Photocopy Photocopy Machine Piece 1

7 Máy tính để bàn Desktop Computer Piece 1

8 Máy tính xách tay Laptop Computer Piece 4

9 Máy ảnh Photo Camera Piece 1

10 Máy in laser Laser Printer Piece 2

11 Máy Scanner Scanner Piece 1

12 Ti vi 60 inch TV 60 inch Piece 1

13 Máy chiếu đa năng Projector Piece 1