An Assessment of the need for contraceptive introduction in Viet Nam : report of an assessment undertaken by Ministry of Health
Publication date: 1995
EXPANDING FAMILY PLANNING OPTIONS Rasesrch on the Infroducfion and Trcrnsfer of Technologies for Fertility Regulofion The Special Programme of Research, Development and Research Training in Human Reproduction was established by the World Health Organization in 1972 to coordinate, promote, conduct and evaluate international research in human reproduction. The Special Programme brings together administrators, policy- makers, scientists, clinicians and the community to identify priorities for research and for the strengthening, in developing countries, of research institutions. The current priorities of the Special Programme include research into new methods of fertility regulation for both women and men, the introduction of methods to family planning programmes, the long-term safety of already existing methods and other aspects of epidemiological research in reproductive health, social and behavioural aspects of reproductive health, and into methods of controlling the spread of sexually transmitted diseases which can cause infertility. The Special Programme also carries out activities to strengthen the research capabilities of developing countries to enable them to meet their own research needs and participate in the global effort in human reproduction research. Special Programme of Research, Development and Research Training in Human Reproduction World Health Organization 1211 Geneva 27 Switzerland Tel: 41-22-791 2111 Fax: 41-22-791 4171 EXPANDING FAMILY PLANNING OPTIONS MINISTRY OF HEALTH Do Trong Hieu Pham Thuy Nga Nguyen Kim Tong INSTITUTE OF SOCIOLOGY Doan Kim Thang UNFPA Andrew McNee UNDP/ UNFPA/WHO /World Bank Special Programme of Research, Development and Research Training in Human Reproduction wHo/HRPITTT 19s.3 Distr.: LIMITED AN ASSESSMENT OF THE NTED FOR CONTRACEPTTVE INTRODUCTION IN VIET NAIYI Report of an Assessment Undertaken by: NATIONAL COMMITTEE FOR POPULATION AND FAMILY PLANNING Vu Quy Nhan Nguyen Thi Thom WORLD HEALTH ORGANIZATION Ruth Simmons Peter Fajans Peter Hall VIETNAM WOMEN'S UNION Do Thi Thanh Nhan INTERNATIONAL COUNCIL ON MANAGEMENT OF POPULATION PROGRAMMES Kus Hardjanti World Health Organization Geneva 1995 © World Health Organization 1995. All rights are reserved by the World Health Organization (WHO). The document may not be reviewed, abstracted, quoted, reproduced or translated, in part or in whole, without the prior written per- mission of WHO. No part of this document may be stored in a retrieval system or transmitted in any form or by any means - electronic, mechanical or other - without the prior written permission of WHO. The views expressed in this document are either those of individual participants or represent a consensus view of the whole group. They do not necessarily represent the views and policies of the World Health Organization. The mention of specific companies or of certain manufacturers' products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters - 1 - - 2 - - 3 - Table of Contents List of Acronyms/Abbreviations 5 Foreword 7 Summary 9 Introduction 13 Objectives, Framework, and Methodology of the Stage I Assessment 15 Reproductive Health Indicators, the Family Planning Policy Context, and the Service Delivery System 19 Demographic Characteristics 19 Reproductive Health Indicators 19 Population Policy and the Family Planning Program Environment 21 The Family Planning Service Delivery System 25 Contraceptive Method Mix: Patterns of Use, Availability and Accessibility 27 Patterns of Contraceptive Use 27 Availability and Source of Supply of Fertility Regulation Methods in the Public Sector 29 Accessibility of Family Planning Services 30 Service Delivery Capability: Quality of Care, Programme Structure and Management 31 Quality of Care at the Policy Level 31 - 4 - Quality of Care at Service Delivery Points 32 Programme Structure and Management 35 The Social Context of Method Choice and User Perspectives 38 The Social Context of Method Choice 38 User Perspectives on Method Choice 39 Conclusions and Recommendations 42 Conclusions Related to the Three Central Questions 42 Recommendations for Research on Improved Utilization of Currently Provided Methods 45 Recommendations on Research Related to the Introduction of New Contraceptive Methods 49 Acknowledgements 51 References 52 - 5 - List of Acronyms/Abbreviations ADB Asian Development Bank AusAID Australian Agency for International Development AIDS Acquired Immune Deficiency Syndrome AVSC Association for Voluntary Surgical Contraception CCPFP Commune Committee for Population and Family Planning CHC Communal Health Centre CPR Contraceptive Prevalence Rate DHS Demographic and Health Survey DMPA Depot-Medroxy Progesterone Acetate ESCAP Economic and Social Commission of Asia and Pacific FP Family Planning GTZ Gesellschaft für Technische Zusammenarbeit HCMC Ho Chi Minh City HIV Human Immuno-deficiency Virus ICOMP International Council on Management of Population Programs IEC Information, Education, and Communication IMR Infant Mortality Rate IPAS International Projects Assistance Services IPMN Institute for the Protection of Mother and Newborn IUD Intra-Uterine Device KAP Knowledge, Attitudes, and Practice KfW Kreditanstalt für Wiederaufbau LAPRODEX Latex Product Export Company MCH Maternal and Child Health MERUFA Medical Rubber Factory MIS Management Information System MOH Ministry of Health NCPFP National Committee for Population and Family Planning NGO Non-Governmental Organization OC Oral Contraceptive PATH Program for Appropriate Technologies for Health PCPFP Provincial Committee for Population and Family Planning RTI Reproductive Tract Infection SIDA Swedish International Development Agency STD Sexually Transmitted Disease TBA Traditional Birth Attendant TFR Total Fertility Rate UNFPA United Nations Population Fund VINAFPA Viet Nam Family Planning Association VNWU Viet Nam Women's Union WHO World Health Organization - 6 - - 7 - Foreword The Government of Viet Nam is committed to improving the quality of care of family planning and reproductive health service delivery. As part of this effort, the Ministry of Health and the National Committee on Population and Family Planning (NCPFP) have acknowledged the importance of expanding the choice of contraceptive methods for Vietnamese women and men. This report, "An Assessment of the Need for Contraceptive Introduction in Viet Nam" is a very important tool in assisting government policy makers. It looks beyond the need for the introduction of new methods, to the broader issues of method mix in the context of quality of care. It reviews the characteristics of the service delivery system, the social context, as well as women and men's perspectives. The results and recommendations of this study are playing an important role in guiding and assisting the development of a policy on contraceptive introduction for Viet Nam. It is helping us develop strategies for national introduction based on careful assessment of the existing conditions and Vietnamese needs. In particular, we will be starting the introduction of the injectable contraceptive, depot medroxy- progesterone acetate (DMPA) utilizing a careful research approach which will include examination of user's and provider's perspectives on all methods of family planning including DMPA and on service delivery. It will help us identify adaptations in service delivery necessary to ensure that both DMPA and all other available methods are provided with increased quality of care. The participation of the Ministry of Health, NCPFP and the Viet Nam Women's Union at all levels in the assessment has allowed the findings and recommendations to be more readily accepted and implemented, while taking into account the needs of Vietnamese people. I would like to thank my colleagues in the Ministry of Health, NCPFP, the Vietnamese Women's Union and the Institute of Sociology for their hard work which made the process of this assessment and the resulting report such a useful activity. I would also like to thank WHO, UNFPA and International Council on Management of Population Programmes for their assistance and support of the assessment. Dr Tran Thi Trung Chien Vice Minister of Health - 8 - - 9 - Summary This report presents the findings from an assessment of family planning services designed to determine the need for the introduction of contraceptive methods in Viet Nam. This assessment represents the first step in a 3-stage strategy developed by the World Health Organization’s Task Force on the Introduction and Transfer of Technologies for Fertility Regulation. The strategy is based on the concept that the need for contraceptive introduction in a given country must be assessed within the context of 1) the current method mix in the programme, 2) the programme’s capacity to deliver services with appropriate quality of care and 3) the social and reproductive health context of method choice. This Stage I Assessment of the Need for Contraceptive Introduction in Viet Nam was carried out in October and November, 1994, as a cooperative endeavour between the Ministry of Health of Viet Nam, the National Committee for Population and Family Planning, the Vietnam’s Women’s Union, the Institute of Sociology, the International Council on Management of Population Programmes (ICOMP), and WHO. Viet Nam currently has a population of approximately 74 million people. Following periods of war and international isolation, the country is now experiencing rapid economic and social change. Despite relatively low living standards, the female literacy rate is very high (94%) and infant mortality lower than in many countries with stronger economic indicators. However maternal mortality remains fairly high. Viet Nam has a total fertility rate of approximately 3.5 and a contraceptive prevalence rate of about 50%. The Government has adopted a strong population policy which encourages couples to limit their childbearing to “one or at most two children”. Recent policy statements by the Ministry of Health, while still emphasizing the use of long-acting methods for family size limitation, indicate the government’s recognition of the importance of expanding contraceptive choices. The majority of family planning services are provided by the public sector at provincial and district hospitals and clinics and commune health centres (CHC). Services at CHC are frequently supported by mobile teams of providers from higher levels, and by a recently established system of community level motivators. Although officially intra- uterine devices (IUDs), oral contraceptives, condoms and male and female sterilization are all widely available, the method mix is dominated by the IUD (more than 60% of all methods) and traditional methods including the rhythm method and withdrawal. There are few users of oral contraceptives, and injectables are available only through the private sector. Unbalanced information for clients and strong provider biases contribute to the skewed method mix. High levels of unmet need for contraception are indicated by the fact that annually - 10 - more than one million women utilize the free menstrual regulation and abortion services provided by the government family planning programme. A variety of studies have indicated that the quality of care in family planning service delivery is weak, particularly with regard to providers’ counselling skills and the technical aspects of service delivery. Reproductive tract infections are considered to be a major health problem by both providers and women, although epidemiological data are scarce. Services for adolescents and youth are not readily available. In general, providers lack an appreciation of the importance of birthspacing and the health benefits of family planning, focusing instead on the programme’s demographic objectives. The principle recommendation that emerged from the assessment is that priority should be placed on the better and more appropriate utilization of fertility regulation methods currently provided in the public sector programme. Viet Nam’s public health system, while strong in many ways, still faces severe constraints. Thus, the widespread introduction of new contraceptive technologies may only serve to burden the system while not actually improving method choice or quality of care for women. Research on a number of service delivery issues related to improving the quality of care of existing methods was recommended. Topics requiring investigation include issues related to user perspectives on the different methods of fertility regulation, improved counselling and information, education, and communication (IEC) with the provision of balanced information, the development of appropriate IEC strategies targeted to women and men with specific reproductive health needs, and the development of alternative approaches to meet the needs of currently under served groups including adolescents and youth, and those living in remote or isolated areas. Service delivery research is also needed to develop new strategies to strengthen providers’ technical competence in areas such as the management of contraceptive side effects and the management of reproductive tract infections (RTI’s), as well as to test the feasibility of integrating RTI care with family planning services. Approaches to strengthening of non clinic-based service delivery are also in need of testing and evaluation. The team recommended that the introduction of any new methods to the public sector should proceed with care and in the context of introductory research in a few limited areas prior to widespread introduction. Given the Government’s interest in introducing DMPA, it was suggested that this be approached in a phased process that included acceptability studies, user perspective research, and service delivery research to address the managerial requirements and service delivery adaptations necessary to introduce the method more broadly in public sector settings. Such introductory research should focus on developing strategies for the strengthening of the quality of care of service delivery of all methods of fertility regulation, rather than focusing only on the introduction of DMPA. - 11 - - 12 - Introduction The introduction of new contraceptive technologies has long been seen as an important means of expanding contraceptive choice and thus increasing utilization. However, introductory efforts in the past have usually focused on a single method, emphasizing its technical characteristics and continuation rates, rather than potential users’ needs or service delivery capabilities. As a result, introduction strategies have often overburdened services that were not adequately prepared for the use of the new technology. This has at times resulted in impairment of the quality of services and even the failure of the introduction of the method. More recently, experience with the introduction of new technologies has suggested that it is critically important to take a broader perspective, addressing the new method being introduced in the context of both the existing capabilities of the service delivery system and the needs and perspectives of family planning users. This report presents the findings from an assessment of family planning services designed to determine the need for the introduction of contraceptive methods in Viet Nam. The undertaking represents the first step in a 3-stage strategy developed by the World Health Organization’s Task Force on the Introduction and Transfer of Technologies for Fertility Regulation. The strategy is grounded in the concept that the need for contraceptive introduction in a given country must be assessed within the context of: 1) the current method mix in the programme, 2) the programme’s capacity to deliver services with appropriate quality of care and 3) the social and reproductive health context of method choice. This is Stage I of the strategy which is used to identify the need to introduce or reintroduce a method or methods of fertility regulation. A subsequent research phase (Stage II) follows where appropriate. A set of policy dialogues utilizing the results from this research and the initial assessment for planning and implementing programmes constitute the final step in the process (Stage III). The concept for the three-stage strategy is detailed in a recent WHO publication (Spicehandler and Simmons, 1994). The Stage I Needs Assessment for Viet Nam began with preliminary discussions between government officials and representatives of WHO and ICOMP. Prior to the assessment, two comprehensive reviews of the available literature were conducted to identify important issues for consideration in the assessment (Young and Simmons, 1994; Hardjanti, 1994). The actual field work was carried out in October and November, 1994 as a cooperative endeavour between the Ministry of Health of Viet Nam, the National Committee for Population and Family Planning, the Vietnam’s Women’s Union, the Institute of Sociology, the International Council on Management of Population Programmes (ICOMP), and WHO. - 14 - Recommendations for both programmatic action and potential Stage II research projects are presented in this assessment. These recommendations were based on an analysis of information obtained during field visits and policy briefs, as well as on a review of reports and studies on family planning and reproductive health in Viet Nam. A draft report was prepared by the team during the last week of the assessment, which was then distributed among Ministry and NCPFP policy-makers and programme managers for review and comment. In February of 1995, the draft report was presented at a two day workshop in Hanoi. This workshop was attended by over eighty individuals including Ministry of Health and NCPFP officials, provincial level program managers and providers from the two organizations, members of NGOs active in reproductive health, researchers from a number of universities and research institutes, and representatives of international organizations and bilateral donors assisting in the field of family planning and reproductive health in Viet Nam. Following initial presentations of the findings and recommendations, small group and plenary discussions were held. After contribution of many valuable comments and much discussion, consensus concerning the recommendations of the assessment was reached. These recommendations are presented in the report that follows. - 15 - Objectives, Framework and Methodology of the Stage I Assessment A key component of the new WHO strategy for contraceptive introduction involves a shift in attention from a focus on a single method to an examination of the mix of methods available within a given setting. In the past, “introductory trials” which examined the continuation and discontinuation rates of a single, new contraceptive method were conducted in order to make comparisons between users in different countries. These projects also provided opportunities for professionals, researchers and policy- makers to gain experience with new technology. In some recent introductory efforts, research designs have begun to include studies which explore both method acceptability and the service delivery implications of adding new methods to family planning programmes. The WHO strategy is based on the principle that introductory research and decisions about the use of new technology should be preceded by a comprehensive evaluation of a country's current method mix, its service delivery capabilities, and user perspectives and needs. Particular emphasis is also placed on the policy environment and the socio-cultural context of method introduction. This approach has been adopted to assure that introductory efforts arise out of the real needs of countries for new methods, and are considered only in those settings where provider, logistics, and management competency exist to introduce new methods with appropriate levels of quality of care. The assessment begins with a general overview of findings from demographic surveys and studies on reproductive health. A discussion of the policy and programmatic context of family planning is then presented. Subsequently, four key areas - the policy environment, method mix; the service delivery system including the quality of care, and users’ perspectives are reviewed. This provides a context for answering three basic questions on contraceptive introduction. @ Is there a need to reintroduce or better utilize contraceptive methods currently provided in the family planning program? @ Is there a need to remove any existing methods? @ Is there a need to introduce new contraceptive methods? Answers to these questions were derived from this assessment of Viet Nam’s method-mix. The essential components of the overall introduction strategy and the Stage I assessment are elaborated upon below. Method mix oriented: The method mix approach used in the needs assessment is based on a fundamental shift from an exclusive focus on the introduction of new contraceptive methods to a more general examination of existing technology. There are many family planning programmes where methods which meet identified needs of users - 16 - are physically available within the service delivery system, but where proper introduction has never occurred. This often leads to inappropriate or under utilization of methods. In other cases, methods which have been legally approved for use in a country are not found at service delivery sites due to problems of logistics, lack of resources, or strong biases among managers and/or providers. Hence, it is important to incorporate the concept of reintroduction into the Stage I Assessment and subsequent recommendations aimed at improving overall method-mix. Finally, it is also necessary to consider which methods, if any, may no longer be appropriate given advances in technology, or research which questions the safety of a previously accepted formulation. Examples include high dose oral contraceptives or outdated IUDs. In examining the broader contraceptive method mix of a country, the Stage I Assessment should ascertain whether a programme provides methods that should be withdrawn from a service delivery system, in addition to addressing questions of contraceptive introduction or reintroduction. Strong Emphasis on the Perspectives of Women and Users: Current patterns of use of fertility regulating methods reflect the demand or need for contraception and provide evidence of unwanted pregnancy and fertility. Yet, a simple examination of contraceptive use patterns does not allow for a sufficient understanding of the realities of clients’ decisions. It is essential to discern users' attitudes towards and experience with particular methods, and to place these within a broader social context of decision-making. Understanding users’ experiences within the service delivery system is equally crucial, as these can strongly affect decisions on contraceptive use. Such an examination of user perspectives, achieved through individual discussions and a review of the available research on users’ and non-users’ contraceptive knowledge, practices, beliefs and needs, is an important component of the Stage I Assessment. Additional valuable information is obtained through dialogues with women's groups about their experiences with and perspectives on contraceptive technology. Driven by Management and Service Delivery Capabilities: It is unusual to find an emphasis placed on service delivery capabilities in most contraceptive introduction activities. In previous efforts, implementors have assumed that the service delivery system would be capable of offering the new technology or that the system could be improved where necessary. If the addition of new technology is to truly expand choice, it is not adequate to focus only on training, IEC materials and guaranteeing supplies of the newly introduced method. There must be some certainty that the service delivery system has the necessary human and physical resources, and a commitment to establishing the support systems necessary for introducing a new method with a high level of quality. However, many public sector programmes are severely constrained in their resource base, which limits the availability of competent and technically skilled personnel, administrative and technical supervision, necessary infrastructure, and adequate logistics and supply systems. It is increasingly recognized - 17 - that the introduction of new contraceptive methods adds burdens and complexities to the service delivery, training, and administrative or operational systems, and may act to reduce rather than improve quality of care. Thus, an analysis of service delivery capacity is an integral part of an assessment aimed at recommending future activities for method mix expansion. Focused on Quality of Care: The focus on overall method mix, which is central to this new approach to contraceptive introduction, derives from a concern for quality of care in family planning services. The six elements of quality of care in family planning programmes identified by Bruce (1990) are: 1) choice of methods; 2) information given to clients; 3) technical competence; 4) interpersonal relations; 5) mechanisms to encourage continuity; and 6) appropriate constellation of services. The first element, which involves increasing meaningful rather than theoretical contraceptive options available to women and couples, is the central objective of contraceptive introduction efforts. Methods should be available to "serve significant subgroups as defined by age, gender, contraceptive intention, lactation status, health profile and - where cost of method is a factor - income groups" (Bruce, 1990). For example, appropriate choice of methods must be available for women and men who wish to space births, those who wish to limit their fertility, those who cannot tolerate hormonal contraceptives or are breast-feeding, and so forth. The technical capabilities of providers and their interpersonal and communication skills clearly influence the quality of care that their clients receive, as does the availability of services to meet the broader reproductive health needs of clients. These various dimensions of quality are all necessary if choice is to be meaningful. Thus, examining the existing quality of care in the provision of current methods can help to anticipate the impact of introducing a new method or methods on the resulting method mix and overall quality of care within a programme. The Stage I assessment presents information on each of the quality of care indicators as revealed in discussions with clients and direct observation of family planning services and as depicted in previous reports and studies. Participatory and Country Owned: Viet Nam has a moderately high contraceptive prevalence rate, a total fertility rate (TFR) of approximately 3.5, and a method mix that is skewed towards the IUD. Indicators of under served or unmet need include high levels of reproductive tract infections (RTIs) which preclude use of the IUD for many women who desire to do so, and high levels of legal menstrual regulation (MR) and abortion. Concern about these indicators and the strong interest on the part of the Ministry of Health and the National Committee for Population and Family Planning (NCPFP) in expanding method choice made Viet Nam an appropriate candidate country for a Stage I Assessment. The Director for MCH-FP of the Ministry of Health (MOH), as well as the Director of the Centre for Population Studies and Information (CPSI) of the NCPFP participated in all stages of this assessment. In each of the study sites, the assessment was undertaken in collaboration with - 18 - officials from the provincial, district and local health and PCPFP authorities. This assessment is based on information from field visits to sites in three provinces and the capital city of Hanoi, and an analysis of recently published data and research reports. During field visits, interviews were conducted with key provincial and district level MOH and PCPFP staff. Representatives of the Viet Nam Women's Union were interviewed in two provincial capitals, in Hanoi and during some of the visits to communes. A total of 8 districts were visited, including 12 commune health centres and 2 inter- communal polyclinics. Approximately 100 interviews with individuals or groups of users or non-users were conducted. Analysis of the available literature on family planning in Viet Nam included the 1988 Viet Nam Demographic and Health Survey (VNDHS), the 1989 Census, the 1993 Demographic Dynamics Change and Family Planning Survey, the 1993 UNFPA KAP survey, as well as recent reports from researchers and donor agencies. Citations of these are provided in the text and the bibliography1. The sites for field visits were chosen to provide some representation of regional variation in socioeconomic development and programme effort. The province of Yen Bai in the North of Viet Nam, Hue 1 Following completion of the assessment workshop and finalization of this report, the results of the 1994 Viet Nam Intercensal Demographic Survey (ICDS) were published (Statistical Publishing House, Hanoi, May 1995). The results of this survey provide estimates for the TFR, CPR and other reproductive health indicators which are somewhat different than those of previous surveys. The text of this report reflects the information that was available at the time of its preparation. However, none of the conclusions of this report are altered by these additional data. in the central region, and Binh Thuan in the northern part of the South were chosen for field visits. Exposure to the field, especially to the more remote rural areas was limited. This report is not intended to provide an exhaustive description and analysis of family planning in Viet Nam. No effort was made to cover all or even a representative number of individuals and institutions in the field. However, given the extensive availability of research reports and related documents, the number of contacts made in the field, and the extensive experience of key members in the assessment team with family planning in Viet Nam, the team was in a position to examine the central questions that guide a Stage I Assessment. - 19 - - 20 - Reproductive Health Indicators, the Family Planning Policy Context and the Service Delivery System Demographic Characteristics Recent information on the demographic situation in Viet Nam is based on the 1988 Viet Nam Demographic and Health Survey (VNDHS), the 1989 Census, and the Demographic Dynamics Change and Family Planning Survey conducted in 1993 with a sample size of 250,000 households (as quoted in Vu Quy Nhân, 1994). According to the 1993 survey, Viet Nam was estimated to have a population of 70.6 million, a total fertility rate (TFR) of 3.5, and a crude death rate of about 7. According to the 1989 Census, the infant mortality rate (IMR) was 45 per 1000 live births, while under five mortality was relatively high at 100 per 1000 live births (as reported in Johansson et al., 1993). Table 1: Population Characteristics Characteristics 1989 1993 Population (millions) 64.4 70.6 Crude Birth Rate 31.3 30.4 Total Fertility Rate 3.8 3.5 Crude Death Rate 8.0 7.1 Population Density (per sq. km) 195 214 Urban Population (%) 20 Female Literacy (%) 94 Reproductive Health Indicators Maternal mortality: In 1990 the Ministry of Health reported an estimated Maternal Mortality Rate (MMR) of 107 per 100,000 births. The Institute for the Protection of Mother and Newborn (IPMN) reports an MMR of 576 per 100,000 deliveries in a survey of hospitals. Leading causes of maternal mortality are infection, anaemia, postpartum or post-abortion haemorrhage, and toxaemia (World Bank, 1993). Ninety percent of maternal deaths are thought to be preventable by ante natal care, screening for risk factors and referrals to higher levels of care (IPMN, 1985). Access to prenatal and birthing care: Prenatal care is under-utilized and weak. A 1993 KAP study found that 62% of rural women had seen a doctor during their last pregnancy, and less than one quarter of illiterate women had attended even one prenatal visit. Much of the prenatal care delivered is limited in scope. Fewer than one-third of pregnant women are immunized - 20 - against tetanus. Sixty to seventy percent of pregnant women are estimated to be anaemic, but iron pills are typically not provided during ante natal care (Tran Thi Trung Chien, 1994). Lack of equipment and essential drugs are major constraints in weak ante natal care (Johansson et al., 1993). While the MOH reports that the large majority of deliveries occur in health facilities under supervision from a trained health provider, a Swedish International Development Agency (SIDA) survey showed that half of all births had been delivered at home, 60% of which were attended by a health professional (Johansson, 1993; World Bank, 1993). Birthing care is considered to be weak (Truong Viet Dung et al., 1994). The average length of breast-feeding is 14.5 months (VNDHS, 1988). Sexually transmitted diseases/Reproductive tract infections (STDs/RTIs): Reliable STD data are scarce in Viet Nam. Evidence from 1978 indicates regional variation in gynaecological infections ranging from 40 to 70% (Banister, 1985). No current, large scale epidemiological data on STDs in Viet Nam exist, several studies are, however, planned or underway and interviews with clinical staff conducted by SIDA indicate increasing numbers of women being treated for STDs (Johansson et al., 1993). High rates of gynaecological infection were frequently mentioned in the assessment team's interviews with provincial health authorities, by district level providers, and members of mass organizations. For example, when asked what is the most important health problem in the community, members of local mass organizations said spontaneously "gynaecological diseases. People want treatment but can't afford it." The National Institute of Venereology and Dermatology estimates that 20-40% of the rural population has a reproductive tract infection; the urban rate is cited as half the rural rate (as cited by Whittaker, 1994). Understanding of RTIs including their aetiology, diagnosis, and treatment was limited, even among relatively senior physicians interviewed by the assessment team. By November 11, 1994 a total of 1941 HIV-positive cases and 48 AIDS related deaths had been reported according to the National Committee on AIDS. Nearly 78% were drug-related and 12.5% of HIV positive cases were women. HIV testing for drug users, prostitutes, people getting married and gay men is mandatory. The commercial sex industry exists throughout Viet Nam but is reported to be primarily urban and more predominant in the South. Little detailed information about the industry is available. Adolescents: The VNDHS and other surveys find a relatively high age at marriage of 23.5 for women. However, adolescent sexual activity and pregnancy appear to be on the rise in Viet Nam. The Ministry of Health claims that there were at least 300,000 pregnancies to women under age 20 in 1992. A recent KAP survey revealed that 19.4% of women under age 20 were using the IUD, while no one of this age was using the oral contraceptive pill. This method mix is unusual considering that the pill is one of the most popular methods among young people in other countries, while non-parous and young women are - 21 - rarely prescribed the IUD in other parts of the world (NCPFP, 1993b). Menstrual regulation and induced abortion: Menstrual regulation and abortion are legal in Viet Nam. It is estimated that more than 1 million women use abortion or menstrual regulation annually, however, only 3- 4% of women actually report the use of these procedures (Allman, 1991). Menstrual regulation and abortions are rising rapidly, and there is evidence of repeat abortions (Do Trong Hieu et al., 1993a). The IPMN reports that over 1,242,000 menstrual regulation and abortion procedures were performed in Viet Nam in 1992, while over 1,437,000 were performed in 1993. A substantial proportion of women use pregnancy termination as a substitute for contraception. In one study, slightly over 38% of women seeking pregnancy termination had not used a modern or traditional method of family planning since their last menstruation (Do Trong Hieu et al., 1993a). Many providers consider abortion to be a good method of contraception. A lack of access to contraception for unmarried women may contribute to high rates of menstrual regulation. For example, the MOH MCH/FP Centre in the province of Hue states that nearly half of all menstrual regulations provided are for young and unmarried women. Menstrual regulations appear to be performed very early in pregnancy. Providers report that women frequently come for a menstrual regulation only three or four days after their missed period. Most providers state that they perform menstrual regulations using a suction syringe and plastic cannula one to two weeks after a woman's missed period. If more than two weeks have passed, they perform a surgical dilatation and curettage (D&C). Providers report chronic shortages of equipment for providing menstrual regulations. Population Policy and the Family Planning Program Environment The government of Viet Nam has an explicit policy to regulate and control population growth. In the North, government encouragement of family planning began in the 1960s; since reunification in 1975 the government has expressed increasing concern for population growth and has expanded family planning service delivery throughout the country. Several governmental decrees supporting these efforts have been issued over the years. For the first time in the history of the programme, the Communist Party of Viet Nam passed a resolution on population and family planning in 1993, which was followed by a "Planning Strategy to the Year 2000" issued by the National Council for Population and Family Planning (NCPFP, 1993a). The newly articulated policy established replacement level fertility as a target, indicating that, "Each family should have one to two children so that by the year 2015 the average number of children for each family is only two" (NCPFP, 1993a). Key guidelines state: · Population and family planning should be the focal point in the concrete programme of activities of the Party, Government and mass organizations at all levels; · A sufficient budget for population and FP programmes must be adequately ensured; - 22 - · Population and FP committees from central to grass-root levels must be upgraded; · Population and FP systems must reach the grass-root level of communes and wards; · IEC activities should be promoted; · Timely and adequate provision of contraceptives must be ensured; · Material and spiritual incentives should be applied for couples who practice FP well; · Administrative measures should be imposed on party members and state employees who do not practice FP. (Source: Vu Quy Nhân, 1994) The subsequently issued strategy document from NCPFP re-affirms the principle of voluntarism and the right to access to free contraceptives and services (NCPFP, 1993c). The principle of voluntarism in family planning had been established earlier in the 1989 Health Law. Family planning policy and method choice: In earlier years national policy focused almost exclusively on the use of IUDs. Targets were set for new acceptors of this method and field workers only received “credit” for new IUD users. Recently policy-makers have expressed interest in expanding the method mix. However, family planning motivators and providers typically receive “credit” for new acceptors of the IUD and sterilization, but not for new users of other methods. Nationally, new acceptors of sterilization are given bonuses and incentives, as are new acceptors of the IUD in some provinces according to local initiative. In contrast, those choosing the pill, condoms, or other methods are given no such benefits. The National Committee for Population and Family Planning announced in their 1993 strategy statement that "special emphasis will be laid on the increased use rate of modern, highly effective, and long-acting methods" (NCPFP 1993). This emphasis was confirmed in some of our discussions with provincial and district health authorities. For example, we were told that there is a policy to appeal to women to use the IUD "because it will stay longer and has no serious side- effects." Some officials interviewed spoke of the importance of allowing free choice, while others emphasized the need to guide women of low education to long-term, effective methods. The recruitment of community-based NCPFP staff, coupled with the recent decision to decentralize distribution of oral contraceptives can be expected to lead towards a shift to greater emphasis on condoms and pills. National drug policy with regard to contraceptives: The Government of Viet Nam has a long-standing commitment to stimulate local production of contraceptive products. The 1993 NCPFP strategy document reaffirms the commitment to local production, but also establishes that the importation of contraceptive devices will be duty-free. Viet Nam manufactured IUDs modelled after the Czech "Dana" between 1984 and 1988. However, production was discontinued in light of increased awareness of the greater efficacy of copper bearing IUDs. UNFPA began the importation of TCu 380A IUDs in the early 1990s (UNFPA, 1994). Multiload IUDs have been purchased from Organon with government funds. Condoms are produced in two local factories, MERUFA and LAPRODEX, - 23 - which have a combined production capacity of 160 million condoms per year. Oral contraceptives are predominantly provided by UNFPA. Current research on new methods of family planning and national plans for contraceptive introduction: There is interest among senior health officials in Viet Nam in broadening choice and promoting a wide range of contraceptives including supporting the introduction of new methods. Particular interest and emphasis has been placed on the introduction of DMPA and Norplantâ, and the government has requested that several donors, including UNFPA, procure these contraceptives. A small number of Norplantâ implants are available at a limited number of MOH sites, where they have been utilized in small studies or introduction efforts. Findings from these introductory effort of Norplantâ have not yet been published. The MOH plans as of January 1995 are to introduce Norplantâ in the context of introductory research at the School of Medicine at the University of Hanoi and in Ho Chi Minh City with technical assistance from agencies experienced with such introductory research. A small number of injectables are also available at a limited number of MOH sites. The once-a-month injectable, Cyclofem, has been provided within the context of a small study comparing DMPA and Cyclofem. Interest also exists in introducing mifepristone in limited settings. Two small studies of mifepristone are currently being undertaken. Between January 1989 and October 1992 over 31,000 women were sterilized using quinacrine hydrochloride pellets in a field trial conducted by the Ministry of Health (Do Trong Hieu et al., 1993b). A retrospective study of women receiving the method was presented at a workshop in January 1995 (MOH and FHI, 1995). Further broad scale introduction of quinicrine sterilization in Viet Nam has been deferred pending further clarification of the safety and efficacy of the procedure. The role of donor agencies with regard to method choice: Until recently, UNFPA was the only major donor providing support to the Vietnamese family planning programme. UNFPA's support to the MCH/FP and IEC sectors during the fourth funding cycle (1992-1995) has been national in scope for certain activities and targeted to 7 priority provinces for other activities. National level activities include the supply of contraceptives - oral contraceptives (low-dose Rigevidon) and IUDs (TCu 380A). Activities focused in the 7 priority provinces include supply of essential medical equipment and family planning drugs; strengthening the logistics and management information system; training of health workers in MCH/FP clinical, management and IEC skills; and training non-health workers in counselling, IEC and motivation activities, and the development of IEC materials. In addition to the provision of oral contraceptives (OCs) and the TCu 380A, UNFPA is also providing support for the local manufacture of condoms, with particular emphasis on improving quality. Locally manufactured condoms are provided to the family planning programme throughout the country. In addition UNFPA, has plans to support the Government in the introduction of a number of new methods or new formulations of - 24 - existing contraceptives into the programme. These include another brand of a low dose pill (Marvelon), a progestogen-only pill, the injectable contraceptive DMPA and Norplantâ. With the resumption of bilateral aid and the commencement of activities of the World Bank and Asian Development Bank, there has been a large increase in the number of donors currently providing or planning to provide assistance to the Government in the MCH/FP sector. The main activities of other donors are summarized below: · Gesellschaft für Technische Zusammenarbeit (GTZ) plans to implement a Family Health Project over 12-15 years in 5 provinces. Total cost is expected to be in the vicinity of US$ 15-17 million. The first phase of the project will be implemented in 2 to 4 districts in each province over 3 years and will cost approximately US$ 3 million. The main focus will be on training and IEC, with a particular emphasis on adolescents and groups at high risk for STDs. The project includes an operational research component on reproductive health, HIV, social aspects of service use, sexual behaviour, as well as studies on the acceptability of new methods and client satisfaction. · Kreditanstalt für Wiederaufbau (KfW) is currently planning its assistance in the form of contraceptive supply and basic drugs. · The World Bank is developing a project to begin operations in 5 provinces with a possible expansion at a later date. The total project is expected to cost approximately US$ 90 million with co-financing from the Asian Development Bank (ADB) and KfW. The project would focus on supply of contraceptives, drugs, medical equipment, civil works and strengthening of management and IEC. The project includes some operations research. · The Australian Agency for International Development (AusAID) has designed a four year AU$ 8-9 million project in three provinces in the south. The project focuses on policy level activities, quality of care, training in counselling, provision of contraceptives, social marketing of condoms, scholarships to study in Australia, and provision of equipment and kits for TBAs. It also includes a KAP study and studies on the economic and financial costs of quality of care, the development of an innovative health promotion programme and the analysis of community self- financing. · The Reproductive Health Program (Pathfinder, AVSC, IPAS and Buffet) is implementing a four year project in four provinces which will include the supply of basic equipment, the introduction of a self-evaluation process for clinics and a comprehensive reproductive services training course. In addition to traditional target groups, the Program will focus on adolescents and cultural minority groups. The Program is planning to introduce DMPA and Norplantâ on an experimental basis in Hanoi and HCMC. The Family Planning Service Delivery System - 25 - Public sector: The Vietnamese Family Planning Programme is a multi-sectoral effort with contributions from several ministries and mass organizations. The two key ministries involved are the Ministry of Health (MOH) and the National Committee for Population and Family Planning (NCPFP). The NCPFP has responsibility for coordination between various ministries involved in population activities, for advising the government on policy and programme development, and for the organization of community level promotion and distribution of condoms through a network of community-based staff and motivators (from November 1994 onwards, distribution of OCs is included in this programme as well). The NCPFP also provides budgetary support for family planning activities. At the provincial and district levels, the organization of the NCPFP is closely linked to local People's Committees. The MOH is responsible for contraceptive service delivery through its extensive network of health facilities at communal, inter-communal, district and provincial levels. A commune level health centre (CHC) typically covering a population between 7,000 and 12,000, is intended to be staffed by at least one assistant doctor, one midwife, one primary level pharmacist, and one assistant doctor for traditional medicine. Actual size of the staff varies somewhat with the population size of the commune. In the near future, medical graduates may be assigned to CHCs for a compulsory period of rural duty upon completion of their medical training. The CHC is responsible for the distribution of pills and condoms, and since 1993, for IUD insertion and menstrual regulation where physical conditions and staff training permit. IUD insertions are also provided by mobile teams organized by the district health office. These teams consist of specially trained doctors or midwives who travel to commune health centres either by motor vehicle or by bicycle to provide services such as IUD insertions, especially when these cannot be handled by CHC staff. Some mobile units also provide vasectomy and tubal ligation. More extensive family planning service provision including vasectomy and tubal ligation is available at the district and provincial levels. The community-based programme consists of the NCPFP staff and part- time motivators, many of whom are recruited from mass organizations such as the Viet Nam Women's Union and from retired health sector staff. Part- time motivators receive brief family planning training. They are expected to conduct regular visits to provide health education and family planning motivation to a varying number of households (anywhere from 10-100). Motivators receive US$ 1.50 per month, and in some communities they also receive in-kind contributions. By the end of 1994, two-thirds of all communes had a full-time NCPFP staff member in place for community-based outreach and supervision of part-time motivators. Future plans call for a worker to be placed in the remaining communes by the end of 1995. These workers receive a monthly salary of US$ 8.00. The Ministry of Education and Training is involved in population education, and several mass organizations including the Viet Nam Women's Union and the Fatherland Front carry out IEC activities. The Viet Nam Women’s Union is the most active mass - 26 - organization in promoting IEC among women while the Youth Union has been motivating young people to use family planning since 1988 (Le Thi Nham Tuyet, 1994; NCPFP, 1992). Since 1984, population and family life education have been taught in pre- schools and schools for children up to age 18. The mass media, including radio, TV and newspapers have devoted entire programmes or pages to population education. One survey indicated that while many people do not actually own a radio or television, the majority listen to the radio or watch TV on a daily basis (Goodkind and Hoc, 1993). Private sector: Contraceptives, including injectables, are increasingly available through private sector pharmacies. The doi moi policy (economic liberalization) has encouraged the movement of private organizations into the field of family planning. Since 1988, private medical practices and pharmacists have been allowed to provide family planning. Nearly one-third of oral contraceptive users and 17% of condom users acquire methods through commercial channels according to the 1988 VNDHS. Today, approximately 15,000 pharmacies which serve between 5 and 15% of the population in Viet Nam supply pills and condoms; (UNFPA, 1994). While private practitioners could potentially play an important role in expanding contraceptive and service delivery options, information available to private providers about various methods and brands is limited, and providers' technical knowledge of methods is often incorrect. Within the last few years, the Viet Nam Family Planning Association (VINAFPA), an NGO IPPF affiliate has made advances in providing services. VINAFPA has clinics in a number of cities including Hanoi, Ho Chi Minh City and Hue, and is expanding service delivery sites. IUDs, pills, condoms and injectables are available through VINAFPA, and there are plans to offer implants in the near future. Contraceptive Method Mix: Patterns of Use, Availability and Accessibility Patterns of Contraceptive Use Contraceptive prevalence rates: Viet Nam has a moderately high level of contraceptive use with variations in patterns of use by region and socioeconomic status. There is substantial evidence of unwanted fertility as well as a high unmet need for contraception. The TFR of Viet Nam had declined to 3.7 in 1992 from the earlier 5.1 estimate for 1979 provided by the Census. Although Viet Nam's contraceptive prevalence rate is similar to that of other Asian countries at comparative stages in their development, little or no increase in contraceptive prevalence has occurred over the past few years. The VNDHS conducted in 1988 reported a contraceptive prevalence rate (CPR) of 53.2%, and the Demographic Dynamic Change and Family Planning Survey of 1993 documented a rate of 49.4% (Vu Quy Nhân, 1994). - 7 - Table 3: Contraceptive Prevalence and Total Fertility Rate by Region Region CPR (1993) TFR (1992) Northern Uplands 48.56 4.47 Red River Delta 65.96 2.90 North Central 48.53 4.32 Central Highlands 27.42 4.32 Central Coast 44.36 4.03 Southeast 55.62 2.99 Mekong River Delta 47.65 3.20 Viet Nam 49.4 3.73 (Source: Vu Quy Nhân, 1994) Regional variation is clearly apparent in Table 3, prepared from the 1993 DDCFP Survey. The Red River Delta has the highest contraceptive prevalence rate (66%), with the Central Highlands the lowest (27%). Contraceptive prevalence is higher in urban than in rural areas, and varies by education (VNDHS, 1988). Regional variation also exists in method use. For example, we were told that in the province of Hue, sterilization rates are high in mountainous regions while use of family planning is low among people who make their homes on boats. Unwanted fertility and unmet need for contraception: As indicated earlier, the frequency of menstrual regulation and induced abortion in Viet Nam provides evidence of a high level of unwanted fertility. Based on the 1988 VNDHS data, the unmet need for contraception, defined as women of reproductive age not using a method and not wanting any more children was 41% (World Bank, 1993). This figure underestimates total unmet need for contraception since it does not include spacing needs, which were not measured by the VNDHS. Patterns of method use: Data from the 1988 VNDHS and the 1993 DCDFP confirm the widely noted pattern of use of a limited number of methods in Viet Nam as well as the dominant emphasis on the IUD. Almost two-thirds of contraceptive prevalence is accounted for by the IUD. Moreover, in spite of a 1988 government decree to diversify the method mix, there has been little change in the pattern of method use between 1988 and 1993. Only minor change can be seen in the increase of oral contraceptives and "other" methods, as well as a decrease in the reported use of withdrawal. The dominant role of the IUD has remained static. Table 4: Contraceptive Method Mix According to the VNDHS and the 1993 Demographic Dynamics Change and Family Planning Survey by Percentage of Users - 7 - Contraceptive Method 1988 DHS 1993 DDCFP IUD 62.30 62.45 Oral pill 0.77 3.51 Injectables 0.00 0.38 Implants 0.00 0.02 Female Sterilization 5.20 5.64 Male Sterilization 0.58 0.36 Rhythm 15.21 15.83 Withdrawal 13.18 6.85 Condoms 2.18 2.68 Others 0.62 2.28 Source: Vu Quy Nhân, 1994 Programme emphasis: To date the programme has placed primary emphasis on promoting and providing long term, effective methods to limit fertility. Focus was originally directed to the IUD with more recent emphasis being placed on promoting female sterilization. Relatively less emphasis has been given to promoting contraception for the purpose of birth spacing or to addressing men as potential family planning users. Adolescents and unmarried women have not been targeted for service delivery or IEC activities. Availability and Source of Supply of Fertility Regulation Methods in the Public Sector Four methods of contraception, the IUD, sterilization, pills and condoms, as well as menstrual regulation and induced abortion are provided in the public sector family planning programme in Viet Nam. A very small number of service delivery points also provide injectables and Norplantâ. The major source of systematic information on the availability and accessibility of contraceptives is the 1990 ESCAP study on Accessibility of Contraceptives (Cuong and Thieu, 1991). Theoretically, commune health centres have the potential for providing an extensive range of contraceptive services; this potential, however, has not yet been realized. The 1990 Survey of the Accessibility of Contraceptives found that only 49% of women lived in areas where the commune health centre provided family planning (Cuong and Thieu, 1991). Commune health centres dispense condoms and re- supply pills, but a pill prescription requires medical examinations that can typically be carried out only at a higher level facility. A policy decision instituted in November 1994 has liberalized the provision of oral contraceptives, allowing distribution through health workers using a check list. Thus, in the future, a physical examination will no longer be required for the initiation of oral contraceptives. CHC staff also assist district level mobile teams in IUD insertion. According to the ESCAP survey, two- - 29 - thirds of IUD insertions occur at commune health centres. However, since mobile units come to commune health centres only once or at most twice per month, and often less frequently, availability of IUD services at the commune level is limited. Approximately 40% of the condoms, and 10% of pills used were obtained at the commune health centre (Cuong and Thieu, 1991). The inter-communal health centre (polyclinic) is authorized to perform sterilizations, IUD insertions and removals, menstrual regulation, induced abortion, and to distribute condoms and pills. However, these services are not always available as many sites do not actually have a family planning unit. According to the ESCAP survey, only about half of the women interviewed lived near a polyclinic with family planning services. District hospitals have obstetrics and gynaecology surgical facilities and are therefore qualified to perform sterilizations. Half the female sterilizations in rural Viet Nam are performed at district hospitals; the remaining tubal ligations are performed at provincial or central hospitals. All district hospitals insert IUDs, although stock-outs occasionally occur. One- third of all IUDs were inserted at district hospitals and one-third of pills and condoms were distributed there. Most but not all district hospitals have supplies of pills and condoms, but supplies were sometimes low (Cuong and Thieu, 1991). Problems of condom shortages at service delivery sites have recently arisen because of shifts in responsibility for condom distribution from the MOH to the NCPFP. According to the VNDHS, vasectomies are performed at either provincial or central hospitals; however, members of the assessment team observed vasectomy services at a commune on the outskirts of Hanoi which were provided by a mobile team. Accessibility of Family Planning Services Time and distance: Most people live within a short walking distance of a commune health centre, but as noted above only half of these provide family planning services. At others, the range of services is limited. Women desiring an IUD may have to wait weeks or even months before a mobile team with trained staff arrives at the CHC to provide services. Long waiting periods for other services regularly provided at the facilities do not appear to be a major problem. District facilities are also relatively close to the majority of the population. Half of the respondents of the ESCAP sample (1991) live within 7.5 kilometres of the nearest district hospital and only 10% live further away than 20 kilometres. Transport by bicycle is widely used by both men and women. However, regional variations in terrain, transportation and roads are important. People in mountainous, riverine or otherwise remote areas, where adequate transportation and well maintained roads do not exist, may experience difficulty in reaching a district or higher level health care facility. Access to services in the south is more difficult than in the north. Costs: Family planning services are free of charge to users wherever they choose to seek care within the private sector. Nonetheless, cost can be a barrier to services. Providers reported to us that many women who wish to use the IUD have recurrent reproductive tract infections for which - 30 - they must pay for treatment after free initial medication. Several women interviewed during field visits by the assessment team indicated they could not afford treatment for their recurrent infections and therefore could not use the IUD. In another example, a woman claimed that she could not afford sterilization because it requires time for recovery and special care. In her calculations, the financial incentives paid to sterilization acceptors would not outweigh the overall costs of undergoing the procedure. Overall, contraceptive services in Viet Nam appear to be more readily available and accessible to people than they actually are. While the number and location of clinics is generally adequate, necessary equipment and supplies may not be available. Furthermore, although midwives or doctors are present at the commune level, they may have not been trained in provision of contraceptives. A broad range of contraceptive services are often available only at higher levels. The NCPFP policy to recruit a full-time family planning staff member (each supervising a group of 15 part-time motivators) for each commune, as well as the recent policy decision to allow distribution of oral contraceptives at the community level, contribute to expanding service availability. However, although these staff will provide information and counselling, they will only provide OCs and condoms. Service Delivery Capability: Quality of Care, Programme Structure, and Management Quality of Care at the Policy Level Government officials in Viet Nam have repeatedly expressed commitment to voluntarism and individual free choice in the utilization of contraception. However, it is also clear that other policy measures, such as acceptor targets for sterilization and IUDs, establish pressures on health and community-based personnel that could jeopardize the complete implementation of voluntarism and free choice at the level of service delivery. National level policy-makers argue that these targets are solely intended to facilitate a rational allocation of resources, and that the pressure on individual providers is created through local misinterpretation of national policy. Incentives for acceptors of some methods and disincentives for those not complying with government norms relating to the two-child family policy also have the potential for limiting voluntarism. Participation of senior policy makers in the International Conference on Population and Development in Cairo has heightened attention to the reproductive health objectives of family planning. Such objectives include a broader focus on quality of care rather than the earlier focus on demographic objectives. However, broad-based attention to reproductive health as a major goal in family planning has not yet been realized. The programme continues to be strongly oriented towards the recruitment of new users and neglects emphasis on the health benefits of limiting family size and of spacing. This bias often emerged in conversations with programme - 32 - managers and providers. In fact, many providers appear not to understand the health benefits of contraceptive use for women and infants, nor to recognize the health benefits gained from the use of specific methods. This lack of understanding was clearly illustrated in the statement by a provincial level official who explained that family planning services for minority groups in the province were not a priority because infant mortality rates among these populations were high. Earlier emphasis on IUDs has recently been replaced with broader policy support for the provision of multiple contraceptive options. Evidence of such commitment can be seen in policy statements about the importance of male methods and support for expanded training in the no-scalpel vasectomy method. The recent change in the restrictive prescribing regulations for oral contraceptives also reflects this policy commitment to expand choice. Interest in and support for the introduction of new methods arises out of this same commitment. As stated earlier, their is great interest in introducing DMPA and Norplant®, and procurement of supplies has been requested from various international and bilateral organizations. However, policy contradictions regarding choice remain. In spite of interest in method diversification, policy preference for the utilization of long-acting methods continues to be strong. This can be seen in the NCPFP strategy document (1993) which stipulates that "special emphasis will be laid on the increased use rate of modern, highly effective and long-lasting methods." Providers and motivators receive incentives for new female sterilization acceptors, but not for motivating new pill and condom users. Similarly, a subtle method bias is apparent in the pamphlets which the Viet Nam Women's Union produced on contraceptive methods. Leaflets for every contraceptive method exist, but information on hormonal contraceptives is presented very briefly. Extensive plans for future training and retraining of personnel at all levels in both technical skills and counselling is an example of policy-makers' commitment to strengthening quality of care by improving technical competence and information provision. Quality of Care at Service Delivery Points Choice and information giving: Although there is official emphasis on free choice, there are many barriers to the provision of a broad range of contraceptive options at the point of service delivery. Constraints on the availability and accessibility of contraceptives have already been discussed in the earlier section of this report. Additional barriers are discussed here. The contradiction between voluntarism in family planning and local pressures to complete targets and to show results is evident at the level of programme implementation. For example, team members witnessed intense pressure on women immediately postpartum to accept sterilization. Concern about informed choice also arises where programme managers discuss increases in sterilization cases in remote mountain areas where mobile teams serve illiterate populations who speak non-Vietnamese languages. The concept of counselling actual or potential users is not well established in Viet Nam, and is rarely practised at - 33 - the level of programme implementation. The predominant approach is for either community-based motivators or health centre staff to suggest a method to the user. For example, interviews with community-based motivators revealed that they emphasize sterilization or the IUD, and only if the potential user shows disinterest in these methods are pills and condoms mentioned. Even if a full range of methods is mentioned by the motivator, he/she is likely to conclude with the statement "but the IUD is best." A study on the IUD (Do Trong Hieu, 1993d) showed that typically new acceptors of IUDs reported being informed of pills and condoms in addition to the IUD, but not of sterilization. To the extent that users choose among family planning methods, their decision rarely represents well informed choice. Potential users are likely to be given information only about the positive aspects of methods such as the IUD. Moreover, health personnel or motivators contribute toward the many biases, fears, or misconceptions which users have about methods. Provider bias against oral contraceptives has been documented in a recent study (Phan Thuc Anh et al, 1993), and by an earlier study of the knowledge and attitudes of family planning workers (Vu Quy Nhân, 1989). Beyond specific method bias, provider bias is readily apparent in providers' stereotypical views of rural people and their needs. "Rural people want simple things", or "uneducated or rural women will not remember to take the pill" are standard beliefs. Such stereotypes present obstacles to the development of educational programs, and discourage user choice. One encounters a range of opinions in the field, including the one that it is not up to the woman to choose. The following quote from a community-based motivator represents one end of a continuum of perspectives: "The decision about the method is up to the doctor and the mid-wife." Health workers are also biased against the pill because pill distribution requires regular supplies and is perceived to involve more effort than other methods. They are also hesitant to provide oral contraceptives because they lack the ability to address side-effects. The fact that information for users is extremely limited or non-existent has been documented in evaluations and study reports about family planning in Viet Nam (Jain et al., 1993) and was observed by the team. For example, members witnessed a complete absence of counselling or information provision prior to a vasectomy procedure. Clients have little opportunity to look at methods. As one provincial manager put it, "seeing once is as valuable as listening 100 times." Community- based motivators are not accustomed to showing methods to perspective users. Moreover, motivators and health personnel are inexperienced in counteracting misinformation of clients. For example, they do not explain that vasectomy failures have several potential causes, one of them being the lack of use of another method which is required for a period of time after the operation. Team members witnessed a lack of balance in information giving by providers. The providers explained the disadvantages of oral contraceptives, yet in discussing the IUD, providers only mentioned the advantages. IEC materials for distribution to clients at the community health centres were often found to be limited or unavailable. However, the NCPFP is in - 34 - the process of distributing to households booklets with information on a broad range of contraceptives. It is important to note that both IEC materials and training manuals for providers give unequal weight to various methods. Extensive discussion is given to the IUD and sterilization, with less emphasis given to oral contraceptives or condoms. Technical competence: A recently conducted evaluation of quality of care in family planning service delivery in provinces receiving UNFPA support reports that most providers (assistant doctors and midwives) had received three or more weeks of training in family planning techniques, but little or none in counselling (UNFPA, 1993). Technical knowledge of oral contraceptives was variable. Some providers did not know the difference between the high dose Ovidon and low dose Rigevidon pills, and reported randomly providing one or the other brand. Pill users were told to rest after one year's continuous use, a practice which is also reflected in some of the IEC materials produced by some PCPFPs (Phan Thuc Anh et al., 1993). Another study on quality of care found that screening for contraindications was not done and blood pressure and weight were not systematically measured (Jain et al., 1993). According to the UNFPA evaluation, pelvic examination and follow-up were well performed for IUD acceptors, but diagnosis of infection and treatment procedures were weak. Attention to asepsis was also inadequate; many providers do not wash hands between clients, nor do they use gloves during pelvic examinations (Jain et al., 1993). Another study on the IUD suggested weaknesses in technical aspects of IUD service delivery (Do Trong Hieu, 1993d), and a small study of four commune health centres found the technical competence of IUD insertions adequate in three settings but weak in the fourth centre (Truong Viet Dung et al., 1994). Interviews by the assessment team with providers and managers as well as field observations confirmed many of the weaknesses in the technical dimensions of care discussed above. In several instances, we were told that community women prefer to seek care at the district level because they lack confidence in commune-level providers. Interviews also revealed that providers do not always know that the lifetime of the TCu 380A has been extended (now approved for 10 years by the US Food and Drug Administration), and consequently remove IUDs too early, sometimes after only three years (The Population Council, 1994). Moreover, criteria for decisions about which type of IUD to use are not well established and often inappropriate. Physical facilities and equipment are variable but tend to be poor at lower level service facilities. The UNFPA evaluation found inappropriate medical instruments or instruments of poor quality. Sterilization equipment was typically available, but gloves were not, and the majority of commune health centres had no running water (Jain et al., 1993). Examination tables in commune health centres are often rusty and very old. Interpersonal relations: The UNFPA evaluation reports a satisfactory quality of interpersonal relations. Users of services were treated in a respectful manner, and greeting styles were particularly friendly when providers and clients knew each other from - 35 - previous service encounters. Variations in the degree of support to patients during IUD insertions or check-ups as well as attention to privacy were observed. Mechanisms to assure continuity: Health facilities maintain records on clients, and users are expected to return regularly for follow-up. In practice, return visits tend to be crisis- oriented rather than for routine check- ups. Follow-up and continuity of care are facilitated by the existence of community-based family planning motivators. However, since community-based family planning workers represent mass organizations which are held accountable for fulfilling targets, these mechanisms may serve more to attain demographic rather than reproductive health objectives (Jain et al., 1993). Appropriate constellation of services: Quality of care for all women implies not only the appropriate provision of a single service but attention to related health needs. Family planning is part of reproductive health care; thus one of the important questions to examine is whether other reproductive health care needs are attended to. Reproductive health services outside of family planning and basic ante-natal and delivery care are not available to most women in Viet Nam. Pap smears and breast exams are not routinely provided. Care for reproductive tract infections is minimal and often technically inappropriate. Providers' capability to diagnose RTIs/STDs is weak. Laboratory facilities are not available at the CHC level and providers appear to have little knowledge of syndromic approaches to the diagnosis and treatment of RTIs. Appropriate drugs are reported to be frequently unavailable and little counselling concerning the importance of partner referral in cases of suspected STDs is provided to clients. Many women are not permitted to use the IUD because of their reproductive tract infections. Although initial treatment is provided free of charge at the health centre, repeated treatments are only provided for a fee, which women may not be able to afford. During field visits, the assessment team talked to a woman with an infection who bought medicines once but could not afford to buy an additional treatment or seek care from the private sector. Another woman with an IUD who was experiencing symptoms of an infection was afraid to go to the health centre for care because she feared her IUD would be removed. The common but mistaken belief of providers that IUDs must be removed in the presence of vaginitis constitutes a barrier to their use. Programme Structure and Management Previous sections of this report have noted that the family planning situation in Viet Nam is characterized by moderately high levels of demand for contraceptives, as well as by considerable evidence of unmet need and unwanted pregnancy. Considerable weakness in the quality of contraceptive care has been observed, and the availability and accessibility of methods are constrained. In this section of the report, we identify characteristics of programme structure and management that shape these conditions of service delivery. Political Commitment: The family planning programme in Viet Nam is - 36 - supported by strong political commitment from the leadership within the Party and the Government. This commitment is predominantly focused on the objective of attaining replacement level fertility and slowing population growth. The importance of viewing family planning as one element within a broader reproductive health strategy is not yet widely appreciated. The limited emphasis on birth spacing and on the health benefits of contraceptive use within the programme are indicative of this lacking reproductive health perspective. So is the lack of attention to the need for treatment of RTIs, especially in connection with IUD use. Interagency coordination: The multi- sectoral nature of the programme’s organization is a source of strength but also produces a need for inter-agency coordination, especially between the MOH and NCPFP. This need for closely coordinated service delivery and management strategies among various agencies will continue to grow as the community-based approach to education and service delivery is further developed. This is of immediate importance, as the distribution of oral contraceptives is de-medicalized and shifts to the community level. The move in service delivery strategy towards greater emphasis of community-based approaches reflects a keen understanding of the potential demand that has remained unserved. However, the organizational culture and accountability system of mass organizations involved in community- based activities may not lend themselves readily to the development of user-oriented educational approaches. Provincial autonomy: The considerable degree of provincial autonomy in Viet Nam which is conducive to programme innovation at the local level, may at the same time constrain the development of uniform directions for policy implementation. For example, as new methods of contraception are brought into Viet Nam, the MOH and NCPFP may have limited control over their utilization at provincial levels, in spite of the growing commitment to a cautious, research- based approach to method diversification. Weakness in the resource base: The network of commune health centres suffer from a weak resource base. Funding and resources remain threatened in the wake of economic reform and uncertain commitment of central funds for the support of CHCs. Salaries for staff are low and funding in the past has come largely from the commune, not from central sources. Indications are that increased salary support from the central government will be established 1995. However, inadequate funding for salaries is not the only source of weakness. The physical infrastructure of commune health centres exists but is not well maintained. Staff training, qualifications, and morale are also inadequate, and as mentioned earlier, many commune health centres do not have staff qualified to deliver family planning services. As community- based approaches are further developed, the need for medical and counselling back-up at the level of the community health centre will be essential. District mobile teams may be inadequate to fill the gap, particularly for assistance with management of contraceptive side-effects. - 37 - Management Support Systems: Logistic systems, management information systems and supervision are essential components of an effective reproductive health care system. Although the logistics system does not necessarily conform to standards of modern management, it has succeeded in assuring a fairly reliable level of contraceptive supplies to various service delivery points. Record keeping, however, is characterized by a misplaced and inappropriate emphasis on new acceptors; a reorientation to a coverage-based management information system would be beneficial. The assessment team also saw evidence of emphasis on long-acting methods in some local record keeping systems. Some registers had columns for sterilization and IUDs but not for pills or condoms, showing once again the lack of balance in method provision. Supervision is focused on target fulfilment rather than on problem- solving approaches while technical supervision, especially at lower levels, is weak. - 38 - The Social Context of Method Choice and User Perspectives The Social Context of Method Choice Discussion of family planning in Viet Nam has not extensively focused on the relationship between social and economic conditions and the practice of contraceptive use or method choice. Economic reform and related social change, however, are likely to have very significant implications for both demand and supply of services. Economic progress: Economic growth has brought considerable improvements to many households and individuals in Viet Nam. Exposure to mass media is beginning to be wide- spread; housing, sanitation, and water supply have improved. These are likely to affect the demand for children, as well as the demand for services. However, not all social groups have benefited from these advances and many remain extremely poor. While some people told us that life is much easier for them now, others indicated that "things are getting better for some people but not for me." As a result the public sector will be confronted with a more highly differentiated set of needs and demands than in the past. The private sector and social marketing programmes can assume greater importance for some people, but by no means for all. The perceived and actual indirect costs of contraceptive use may continue to be high, even though contraceptive methods are free of charge. This is especially true for methods such as sterilization. Decreasing family size desires: Desired family size is decreasing in Viet Nam but is still higher than what is consistent with the government's demographic policies and objectives. Most people still want more than two children. According to the VNDHS, 40% of women with two living children wanted more children, and 24% of those with 3 children wanted more (VNDHS, 1988). Many people expressed a desire for 4-5 children in our conversations, and son preference continues to be strong. Sons are important to satisfy ancestral duties; for certain groups, sons as well as daughters provide economic benefits. This was clearly expressed in fishing communities. While some people expressed a clear sense that too many children are a burden, that the costs of raising children is increasing, and that the need to invest in their future implies financial responsibilities which require limiting family size, there are also many other people who do not expect to conform to the government's policy of the two child family. Regional/rural-urban variations in demand for fertility limitation: The demand for children varies by region and rural-urban setting. Urban areas as well as the Red River and Mekong Delta have lower birth rates than mountainous areas and more remote rural areas. Women in the north are more likely to accept a small family, in part because the family planning programme began earlier in this part of the country. - 39 - Women's status and gender imbalance in family planning responsibilities: Women's status in Viet Nam, although improved in comparison with the past, still remains lower than that of men. There is a strong cultural expectation that women should bear the burden of contraceptive use; and when they desire to do so, should consult with their husbands or other family members especially their mothers-in- law. A study of urban women using the TCu 380A, for example, showed that most had discussed the decision with their husband and received their consent prior to insertion (Pham Bich San, 1993). The same study showed that the majority of the IUD users had received support from their mothers-in- law. There is some indication that women's autonomy regarding contraceptive decision-making may be increasing. For example, members of a local mass organization pointed out that there has been much improvement in women's position and that, "if a woman likes family planning and the rest of her family doesn't agree, she decides for herself." However, a number of women readily talked about the difficulties of getting men to become involved in family planning. Peer influence: The importance of peers or other social influences on contraceptive use and method choice were repeatedly mentioned in discussions with providers, programme managers and users. For example, we were told that, "country people like to use the most popular method", which given the history of family planning in Viet Nam is the IUD. Interviews with users confirmed strong patterns of social influence through discussions of specific methods with friends, neighbours and family members. Strong peer influence was also noted in interviews with vasectomy acceptors who reported that their conversations with friends had been instrumental in their choice of vasectomy. User Perspectives on Method Choice User perspectives on method choice have not been a major focus of research in Viet Nam. Even less is known about how method choice and contraceptive use more generally have affected women's lives and their relationships with their partners. The few existing studies have been focused on specific methods, rather than on the method mix, and have directed attention to women and not to men. Moreover, studies providing evidence on the user perspective tend to be quantitative in orientation, missing the rich contextual data and insight that can be derived from more qualitatively oriented work. Nonetheless there is sufficient evidence from various surveys and from our interviews to arrive at some very general conclusions. It is clear that women believe that they must be in particularly good health to initiate any type of modern contraceptive use. They perceive contraception as having negative impacts on health and thus one must be strong and in good physical condition before using a modern contraceptive method. Oral contraceptives: A variety of sources, as well as discussions in the field revealed that most providers believe that rural women cannot remember to take oral contraceptives. However, evidence from a study of users and non-users of oral contraceptives suggests that these - 40 - views represent bias rather than fact. Only 15% of users, and about one-third of non-pill users or former pill users agreed with the statement that the pill is inconvenient to take for most women (Phan Thuc Anh et al., 1993). These findings were also supported by conversations conducted with women during the field visits of the assessment team. A very important finding from the oral pill study is that half of the women who discontinued did so because of side- effects, supporting once again the urgent need to develop counselling skills and appropriate back-up from family planning staff and motivators. Programme managers reported to the assessment team that women fear long term health effects such as cancer or that the pill will, "ruin their health." Concerns about effects on future fertility were also reported to be frequent. IUDs: The IUD has been used for many years in the Vietnamese Family Planning Programme and is widely accepted. In fact, there is almost a “culture” of IUD use, where this method is supported by networks of peers and family members who have used IUDs, and is considered by many to be the only acceptable option among modern methods. As described earlier, some women are extremely fearful of the diagnosis of an RTI because it is likely to result in the removal of their IUD. At the same time, it has also been reported that rumours about the IUD are widespread at the village level, resulting in fear of the IUD (Nguyen Huyen Chau, 1988). Le Thi Nham Tuyet et al. (1994) report that while some women experienced greater control over their lives as a result of IUD use, others described it as a "mixed blessing, even a heavy burden; something which is 'eating the mind'". According to the same study, there were many rumours about poor quality and bad side-effects of the IUD. In contrast, a recent study of urban IUD users found that although half of the women had experienced some side- effects, only a small percentage of them were anxious about them (Pham Bich San, 1993). Tubal ligation: Spousal disapproval and fear of disruption in bodily functions (menstruation and sex drive) were cited as important reasons for not seeking sterilization among women interviewed at the time of an abortion (Do Trong Hieu et al., 1993c). The low demand for sterilization is also considered a function of traditional beliefs that the procedure constitutes major surgery. A study of tubectomy users in two urban and one rural area indicates that most women made the decision by themselves to have a tubal ligation, and most chose tubectomy because of its simplicity, safety and convenience (Institute of Sociology, 1994). Condoms: As in many other parts of the world, condom use is associated with promiscuity in Viet Nam. However, evidence from a recent KAP study revealed that the condom is now the second most popular modern contraceptive method in Viet Nam (NCPFP, 1993b). The only study focusing on the use of condoms for family planning which was available to the assessment team compares various brands but does not investigate overall acceptability and patterns of beliefs about condoms (Do Trong Hieu et al., 1993c). There appears to be evidence of high condom acceptability in special - 41 - project areas which focus on pills and condoms. Providers and project managers reported that condoms and OCs were popular with government workers and other educated urban couples. Vasectomy: Fear of and prejudice against vasectomy appear to be widespread in Viet Nam. Health concerns were expressed in the VNDHS about vasectomy (as well as about other methods). Vasectomy is often equated with castration in the minds of many people. In discussions with members of various mass organizations at the commune level, team members were told that men were not interested in vasectomy because they must remain strong and healthy to support their families. Thus women accept family planning to avoid compromising their husbands' health. However, in communities with vasectomy acceptors, there appears to be a ripple effect whereby a satisfied initial acceptor results in additional vasectomy users. Detailed or extensive studies about men or women's perspectives on vasectomy do not exist. A small study of two communes reports the commonly held belief that vasectomy affects the male sex drive or that men become "half-witted" (Tran Thi Hoai, 1994). Traditional methods: Given the high prevalence of traditional methods, very little appears to be known about people's attitudes and beliefs about these methods of contraception. Many KAP surveys focus exclusively on modern methods. A series of KAP surveys conducted by the NCPFP and the Institute of Sociology found that 34% of couples had used rhythm or withdrawal at some point in their reproductive lives and that 26% were currently using these methods. Surprisingly, the use of traditional methods was considerably higher in urban than in rural areas. In two provinces where respondents were asked to name the most ineffective methods, 58% named rhythm and withdrawal (NCPFP and NCSS, 1993). - 42 - Conclusions and Recommendations This report has presented findings from an assessment of the need for contraceptive introduction in Viet Nam, undertaken as a collaborative effort between the MOH, NCPFP, and WHO; with support from several other institutions. The objective of this assessment was to make policy recommendations about the three central guiding questions of Stage I Assessments and to identify relevant areas for introductory research that would broaden contraceptive options within a context of quality of care. The three guiding questions are: 1) Is there a need to reintroduce or appropriately introduce existing methods? 2) Is there need to remove any currently available method?, and 3) Is there need to introduce new contraceptive technology? Conclusions Related to the Three Central Questions This assessment has confirmed the widely noted pattern of extensive use of and satisfaction with the IUD in Viet Nam, but also finds evidence of growing interest in sterilization, pills and condoms. There is strong policy commitment to broadening method choice, and a variety of operational measures are currently undertaken to put this commitment into practice. Donor interest in expanding contraceptive choice is also strong. However, major imbalances in the method mix remain, and a variety of service delivery constraints inhibit broader method choice. Such constraints exist with regard to: 1) several dimensions of quality of care, 2) institutional weaknesses of service delivery at the commune level, and 3) to weaknesses in key aspects of the management support system. 1. Priority should be placed on better and more appropriate utilization of fertility regulation methods currently provided within the public sector programme. Given the constraints within the public sector programme, priority should be placed on policy and research related to the utilization of methods currently provided within the family planning programme in Viet Nam. Several of these methods are under- utilized and/or provided with inadequate quality of care. Oral contraceptives and male methods are available but not widely accepted. These methods suffer from extensive provider bias and inaccurate information regarding such issues as the need for a period of "rest" from OC use. Widespread misinformation among women and men concerning the potential health effects of these methods also exists. Female sterilization remains limited. Menstrual regulation and abortion are widely utilized, but require technical review to encourage a shift in technique from sharp curettage to vacuum aspiration throughout the first 12 weeks post-last menstrual period (LMP). While there is much experience with both the TCu 380A and the Multiload 375 within the public sector - 43 - programme, technical weakness exists in maintenance of infection control, knowledge of the replacement lifetimes, selection criteria for IUD use, and practices regarding removal for women with vaginitis. There is strong evidence that under- utilization or inappropriate utilization results not from a lack of potential demand for these methods but from constraints within the service delivery system and in its outreach and media components. The question of how good counselling and greater technical expertise can be introduced into the public sector family planning programme in Viet Nam is more urgent than the addition of any new contraceptive hardware. Research can make an important contribution towards the development of policy designed to strengthen the delivery and utilization of such methods as condoms, sterilization and the oral pills which are currently under-utilized. Research can also lead to improved understanding of how traditional or natural methods of family methods can be most effectively used by those who prefer them. 2. There is no need for removal of currently existing methods from the public sector family planning programme provided that high dose oral contraceptives are not re-supplied. All methods currently provided in the public sector meet recognized safety standards. The assessment team notes the discontinuation of the introduction of quinacrine sterilization as well as the organization of a study designed to assess the quality of care and safety issues associated with the quinacrine introductory effort. Issues pertaining to quinacrine have been discussed in the international literature (Do Trong Hieu et al., 1993b; Carignan et al., 1994; Pies et al., 1994). The fact that during field visits assessment team members were approached by community motivators expressing concerns about bleeding problems in women with quinacrine sterilization suggests that follow-up of all women with such sterilizations must be assured. The high dose oral contraceptive, Ovidon, was found to be available in some service delivery sites, but the assessment team was informed that there will be no further re-supply of this pill formulation. Given the availability of low dose pills, distribution of high dose formulations should be discontinued. 3. Introduction of fertility regulation technology currently not available or not widely available within the public sector should be approached with great caution. We recommend caution with regard to the introduction of new fertility regulation technology into Vietnam’s public sector family planning programme. New technology broadens choice only if accompanied by appropriate quality of care standards. Given current programme weakness in counselling and technical dimensions of care, the introduction of new technology should await the development of greater capability to assure quality of care within the programme or be undertaken in connection with carefully phased introductory research. DMPA: If appropriately introduced, an injectable contraceptive like Depo- - 44 - Provera has the potential to meet identified needs for a reversible, highly effective, relatively long-acting method. Depo-Provera is of particular interest to women who are breast-feeding. This is of special importance in light of the need for the family planning programme to place greater programmatic emphasis on child- spacing. However, unless consistent availability and quality of care, including informed consent and counselling, can be assured, the addition of this method would not increase contraceptive choice or improve women's options. For example, without adequate counselling about changes in bleeding patterns, DMPA use is likely to prove unacceptable to Vietnamese women, and may even produce increased demand for unnecessary menstrual regulations. We recommend the introduction of Depo-Provera in a limited number of public sector settings in Viet Nam within a context of introductory research. DMPA should not be provided outside of such research settings until introductory research has been completed and a policy review has occurred about its utilization in a broader range of settings. Introductory research should consist of three components: 1) a modified introductory trial to study continuation rates and reasons for discontinuation, and more generally to provide opportunities for health professionals to gain greater familiarity with this method; 2) acceptability studies; and 3) service delivery research in areas taking part in the introductory trial. These should be undertaken as coordinated research activities. In addition, initial service delivery research should be conducted in areas where DMPA was formerly provided as part of the DMPA/Cyclofem clinical trials. Findings from this introductory research should form the basis for further policy decisions about expanded service delivery. Progestogen-only pills: Progestogen- only pills provide suitable protection for breast-feeding women and should be made more widely available within the programme. Training will be essential to assure the appropriate differentiation between progestogen-only pills and combined oral contraceptives. However, it is recommended that wider introduction of this oral contraceptive be evaluated in connection with other introductory research in order to establish whether it is appropriately prescribed and utilized by programme providers at various levels. Norplantâ: Norplantâ is an effective, long-acting, progestogen-only method with a proven safety record. The introduction of Norplantâ @would add another long-acting method to the three currently available (IUD, tubal ligation and vasectomy). Norplantâ requires unique technical, counselling and follow-up services that distinguish it from other methods. Not only must a high level of technical quality of care be assured in insertion and removal, but appropriate counselling and freedom of choice, removal on demand as well as five-year removal tracking must be assured. These requirements constitute considerable additions to the burden of service delivery within a public sector programme. Given the weaknesses in quality of care in the public sector family planning programme in Viet Nam identified in this assessment, the dominant view within the team was not to recommend Norplantâ introduction at the present time. An alternative position was to - 45 - introduce Norplantâ in a limited number of urban settings. There was consensus that in case of such limited introduction, the same type of introductory research process described for DMPA should be associated with Norplantâ introduction. Recommendations For Research on Improved Utilization of Currently Provided Methods It is recommended that the WHO Task Force on Research on the Introduction and Transfer of Technologies for Fertility Regulation as well as other donors support research endeavours in Viet Nam which are consistent with the priorities identified by this assessment. A variety of research strategies will be required to study how currently under- utilized or poorly utilized methods can be more widely or more appropriately introduced into public sector delivery settings in Viet Nam. Research should be undertaken to monitor and understand: 1) user perspectives on contraceptive methods and users' attitudes towards and experience with the institutions of service delivery; 2) the service delivery environment with a focus on how the management of services, client-provider interactions, and larger operational factors influence the method mix and the quality of care with which methods are provided; and 3) contraceptive prevalence, method mix and fertility preferences. Key questions to be addressed are: · What measures can be undertaken to increase emphasis on the health benefits of contraceptive use for women and infants? Can infant and child health care settings and immunization activities be better utilized to promote this objective? · How can attention to the contraceptive needs of specific population subgroups be increased and greater attention paid to the need for spacing as well as limiting of childbirth? · What IEC or related strategies can be utilized by the public sector programme to increase the knowledge and technical competence of private providers? · What are innovative media or other strategies for increasing the role of men in family planning? Can credible sources of information or testimonials be developed by using mass media and satisfied acceptors as motivators? · How can services for young women and adolescents be made available? Will such services decrease the incidence of menstrual regulation and abortion among these groups? · What service delivery strategies are needed to serve people in low- prevalence areas such as the central highlands? · What motivates high interest in traditional methods of family planning in Viet Nam? · How can community-based outreach be organized to assure balanced approaches to information giving (including discussion of potential side-effects and method disadvantages) and user-need rather than target-oriented approaches to the education and - 46 - recruitment of actual and potential users? · Can a checklist for oral contraceptive for community-based workers improve the accessibility of, and quality of care in service delivery, of OCs? · What is the most appropriate division of responsibilities and tasks between district level mobile teams and commune health centre staff? · How can the technical competence of commune level providers in counselling and IUD insertion be improved so that women become more confident in services at this level and less frequently resort to care at higher levels? · What contribution can comprehensive, balanced and method mix- focused training in technical skills and counselling make in assuring better utilization of methods currently provided by the public sector programme? · What has been the effect of incentives on overall and method- specific contraceptive prevalence? Should incentives be continued? What effect would the elimination of method-specific targets have on field workers' efforts? · How can providers' capabilities be strengthened to diagnose and treat RTIs/STDs and to integrate RTI/STD control with family planning services? Can syndromic approaches to diagnosis and management be widely introduced at the primary level of health care? How will this affect IUD prevalence and continuation rates? · Can the practice of performing menstrual regulations less than two weeks after a missed period be reduced so as to increase the probability that a woman undergoing the procedure is indeed pregnant? What is the cost effectiveness of using an inexpensive pregnancy tests as the basis for induced abortion? · What are appropriate mechanisms for implementing a population- based MIS system which allows providers at each level from the community motivator on up to assess overall contraceptive prevalence and current use by each method? What lessons can Viet Nam learn from the experience of using a simple management information system in the public sector community-based programme in Bangladesh? Both qualitative and quantitative research methods are necessary for the research suggested below. Given the greater emphasis on quantitative studies in the past, we strongly recommend that emphasis be given to qualitative approaches. The following specific recommendations for research are suggested: Demonstration projects using experimental designs: There is a need to explore how currently under-utilized methods, such as oral contraceptives, vasectomy, tubal ligation and condoms can be more broadly introduced while at the same time assuring that the quality of care for the IUD and traditional methods is improved. There have been many previous studies and excellent recommendations made for strengthening the family planning - 47 - programme in Viet Nam. The challenge at this point is to translate this knowledge into specific programme strategies and activities. To this end, demonstration projects provide a vehicle to test new programmatic alternatives. As we indicated above, such research involves answering a set of questions related to the service delivery aspects of method provision both in a technical and a managerial sense. Such research also requires better understanding of user perspectives as well as ongoing monitoring of contraceptive prevalence and analysis of contraceptive use dynamics. We recommend that such research be undertaken as demonstration projects utilizing experimental designs. Such research might be undertaken in two experimental and two comparison districts. Demonstration projects should use a process of diagnostic assessments, interventions and evaluation with the objective of broadening the method mix, assuring quality of care both in its counselling and technical sense and in achieving coordination between community-based and clinic services and education. It is suggested that demonstration projects use "organization development" approaches, whereby research is undertaken as a way to accomplish organizational improvement with the help of outside "change agents" or "catalysts". Organization development is a well establish tradition of research- based learning and improvement widely discussed in the literature on organization sciences (See for example, French and Bell, 1978). Working in close collaboration with programme staff, researchers diagnose organizational problems, identify possible interventions and evaluate their effectiveness. Such approaches have been successfully implemented in the family planning programme in Bangladesh (Phillips et al., 1984) and are currently underway in Brazil in an effort to "reintroduce" under-utilized methods within the public sector programme (CEMICAMP, 1994). Organization development projects operate within the existing institutional and resource constraints of the public sector MCH and FP programmes. Operational changes are tested for the purpose of establishing their contribution towards broadening contraceptive options and identifying how such changes could be more widely implemented within the national family planning programme. The proposed demonstration project (or projects) should have research, intervention, and information dissemination components. Research should consists of: 1) diagnostic studies to guide activities including baseline assessments where necessary; 2) studies documenting the experience of specific interventions undertaken; and 3) overall evaluation of project impacts. Research undertaken within the demonstration project(s) would be expected to include some of the issues and approaches which are discussed below as separate research activities. User perspective research: We recommend a series of studies on user perspectives related to contraceptive choice and experience with service delivery systems. Recommended areas for research include: user attitudes about contraceptive methods, perceptions of health and other concerns relevant to method use, and - 48 - experience with community-based motivators, as well as service providers and in health care facilities. Special emphasis should be given to user attitudes towards male methods and to research exploring attitudes of young people. Studies of client-provider interactions and quality of care: Documentation and analysis of client- provider interactions should be undertaken to improve understanding of the existing conditions of service delivery. Studies should focus on indicators pertaining to the quantitative as well as to the qualitative dimensions of the interactions. They should be conducted both with clinic and community-based staff. Research on client-provider exchanges under routine conditions of service delivery can identify training needs and opportunities for introducing a broader focus on method choice. Such observational studies can also be a helpful tool in evaluating change in service delivery and quality of care over time. Studies on IEC strategies: An important area of work concerns research on how educational and informational materials can best present a balanced approach to method choice and how they can best be disseminated within and beyond the clinic setting. This should include research on the true role of the media. One specific area which will require research is how to effectively incorporate information on the need to protect against RTIs/STDs in addition to pregnancy. Research on IEC should also include attention to the question of how the appropriate types of educational materials can reduce provider bias against under-utilized methods. Service delivery research: Research should be undertaken on the organizational, management and policy context within which services are provided to assess how these could be utilized to support broader method choice and quality of care. For example, projects might assess how a simple coverage or prevalence-based management information system could be developed, and what kind of provider or motivator incentives can be instituted to encourage a balanced approach to method choice. It is important to document the constraints on the ability of the system to deliver currently available methods and identify factors which could be modified to assure broader method choice and quality of care. Contraceptive prevalence surveys and the analysis of contraceptive use dynamics: Monitoring of national level contraceptive prevalence and method mix at regular intervals, measurement of fertility preferences, and the analysis of contraceptive use dynamics will be essential. Recommendations on Research Related to the Introduction of New Contraceptive Methods While many of the research strategies listed above are also relevant for the introduction of new methods, research on the introduction of new methods should consist of the following three components: 1) a modified introductory trial; 2) acceptability studies; and 3) service delivery research. As noted before, these research components - 49 - should be undertaken through closely coordinated activities. Modified introductory trials: As indicated in the previous section of this report, introduction of new methods such as DMPA should proceed through a carefully phased process of introductory research and policy development. In the initial phase, the new method should be introduced in a small number of settings which have demonstrated records of better than average quality of service. Introduction of DMPA should, within the framework of a modified introductory trial, be focused on reasons for method acceptance, the study of continuation rates and reasons for discontinuation. Standard introductory trial protocols should be modified to examine not only the new method, but all methods being provided, to assure that it is integrated into routine service delivery. This approach will make it possible to evaluate the contribution of the new method within a context where quality of care and balanced approaches to all methods are assured. Acceptability studies: Qualitative acceptability studies which analyze user perspectives on and experience with the new method, as well as with the service delivery system, should accompany the introductory trial. Focus group studies, in-depth interviews and other such approaches would be appropriate. Service delivery research: Service delivery research associated with the introduction of a new method must address two central questions: 1) What are the managerial requirements and organizational adaptations necessary to assure quality of care in the addition of the new method to contraceptive service delivery in the settings where introductory trials are conducted?; and 2) What are the managerial or service delivery requirements and adaptations necessary if the new method were introduced into the broader public sector context of family planning in Viet Nam? Policy review and further research: After completion of the three components of introductory research, findings should be evaluated by policy makers to identify where within the public sector the method can be made available in a next stage of introduction. This phase of broadened availability of the new method should once again be associated with research, although service delivery studies might be sufficient at this stage. New methods should not be made available outside of the introductory research process until the conclusion of research and subsequent policy dialogue about the future role and place of the method within the family planning programme. Donor coordination in regard to this issue is essential. With specific regard to Norplantâ, prior to conducting any introductory trials, service delivery research should be conducted in the province of Nam Ha investigating the experience of both providers and users who participated in earlier informal Norplantâ introduction activities. - 51 - Acknowledgements The Assessment of the Need for Contraceptive Introduction in Viet Nam was undertaken by the Ministry of Health and the National Committee for Population and Family Planning (NCPFP) of the Government of Viet Nam, with financial and technical support from the UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Reproduction. The success of this assessment was dependent on the support and participation of numerous individuals and institutions. The research team would like to thank Professor Mai Ky, Minister of the NCPFP and Dr. Tran Thi Trung Chien, Vice Minister of Health for their encouragement and support. The team would also like to thank the many staff members of the Ministry of Health, the Committee for Population and Family Planning and the Vietnamese Women’s Union at the national, provincial, district and commune levels who gave their time for discussions with team members. The study also benefited greatly from the active participation of the UNFPA Viet Nam office, including the Country Representative Ms Linda Demers, Ms. Nguyen Thi Mai Huong and Mr. Andrew McNee (who served as a team member). We would like to acknowledge the University of Michigan for support provided to Dr Ruth Simmons and Dr Peter Fajans, faculty members of the Department of Population Planning and International Health, as well as Ms. Anne Young who assisted in editing the report for publication. 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