Continuing medical education in Vietnam - Wiley Online Library

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Continuing Medical Education in Vietnam: New Legislation and New Roles for Medical Schools

TON VAN DER VELDEN, MD, MPH; HUNG NGUYEN VAN, MD, PHD; HUY NGUYEN VU QUOC, MD, PHD, MIAC; HUU NGO VAN, MD, MPH; ROBERT B. BARON, MD, MS Driven by health care reform and the advent of the private sector in the late 1980s, and by commitments made to the Association of Southeast Asian Nations (ASEAN), Vietnam is faced with a need to increase the regulation and training of its health care professionals. Previously, a diploma from an accredited health professional school was sufficient to practice for a lifetime. Legislation has recently been passed that will institute a licensing system, will require continuing medical education (CME) to maintain the license, and will probably place a large burden on the health professional schools and training institutes to provide CME. Supported by international nongovernmental organizations and foreign universities, the medical universities in Vietnam are responding and are preparing for their new and expanded role. Key Words: Vietnam, continuing medical education, jurisprudence, education, medical, undergraduate, nursing, diploma programs, universities

Vietnam: A Rapidly Changing Environment Until recently it has been one of the world’s poorest countries, but Vietnam was granted World Trade Organization membership in January 2007, and by late 2009 the Vietnamese economy was among the fastest growing in the world.1 This success is widely attributed to the reforms under the Doi Moi policy introduced in 1986, which launched a move away from central planning and collectivist agriculture toward a market economy and private ownership.2 Health-sector reforms were an integral part of Doi Moi. They led to extensive changes in health care delivery, access, financing, and utilization.3,4 Among the changes was the legalization of the private medical sector starting in 1989,

Disclosures: The authors report none. Dr. van der Velden: Country Representative, Pathfinder International Vietnam; Dr. Nguyen Van: Senior Lecturer and Chair of the Department of Pharmacy, Hai Phong Medical University; Dr. Nguyen Vu Quoc: Associate Professor of Obstetrics and Gynecology, Hue College of Medicine and Pharmacy; Dr. Ngo Van: Program Manager, Pathfinder International Vietnam; Dr. Baron: Professor and Associate Dean for Graduate and Continuing Medical Education, University of California, San Francisco. Correspondence: Ton van der Velden, Pathfinder International Vietnam, 9 Galen Street, Suite 217, Watertown, MA 02472; e-mail: tvandervelden@ pathfind.org. © 2010 The Alliance for Continuing Medical Education, the Society for Academic Continuing Medical Education, and the Council on CME, Association for Hospital Medical Education. • Published online in Wiley InterScience ~www.interscience.wiley.com!. DOI: 10.10020chp.20068

leading to a public0private mix of care. As a result, health care is becoming increasingly driven by private, for-profit incentives and is now estimated to consume 70% of all health spending.5 The private sector has proliferated, with over 35,000 registered private practices now operating in Vietnam.6 The actual number of private practices may be much higher. A 2005 community-based study found that less than 20% of surveyed private providers had gone through the formal registration procedure required for opening a private practice.7 More than 96% of communes ~the grassroots level of the administrative system! throughout Vietnam have a private medical practitioner providing services, and it is estimated that the private sector provides up to 60% of outpatient services nationally.8 A community-based study showed that at least 11% of practitioners in the private sector surveyed were not trained health professionals.7 The same study found statistically significant lower-quality performance in the private sector compared to the public sector in such common tasks as identifying proper treatment for treating a child with acute respiratory infection, and in providing correct advice to the mother of a child with diarrhea without fever. This signals a need for more and closer regulation. The United States, United Kingdom, Canada, and Australia have had physician licensing and specialty accreditation for many years. In many European countries licensing of physicians did not start until the early 1990s and the process is still under development. Specific requirements and the implementing bodies vary greatly between countries.9,10

JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS, 30(2):144–148, 2010

Continuing Medical Education in Vietnam

In Southeast Asia, licensing and relicensing requirements are diverse. Some countries have stringent licensing and relicensing requirements. For example, Singapore has required continuing medical education ~CME! for renewal of its practice certificate for physicians since 2005.11 Objective structured clinical examinations ~OSCEs! will be incorporated into the Medical Licensing Examination in Korea in 2010.12 In contrast, Vietnam, Cambodia, and Laos do not yet require licensing for health professionals. Physicians, nurses, midwives, and other health care workers need only a diploma from an accredited school to practice for the rest of their life. In Vietnam this is about to change: In 2006 the Government of Vietnam committed to a mutual recognition of nurses’ licenses by June 2009 within ASEAN countries.13 This requires Vietnam to institute a licensing system. In 2006, there was no requirement to obtain CME for any health professional and national systems for CME were and are underdeveloped and underfunded.14 The public-sector budget allows for training of approximately 0.7% of the public-sector professional staff in any given year, but even this amount is often not completely utilized.15 National training centers are severely overloaded and lack sufficient numbers of qualified trainers and necessary facilities to support the training needs of an estimated 300 000 health care workers.14 Overall standards of training are considered poor, with few qualified staff, and little support for staff to participate in training.15 Constraints for CME in Vietnam’s emerging private health care sector are even more serious than those in the public sector. Given the Ministry of Health’s ~MOH! difficulties in reaching its own staff with in-service training, it cannot be expected that a publicly managed CME system for privatesector providers will be comprehensive enough to cover all needs or to alert health care providers about training activities. Additional capacity to provide continuing education for both public- and private-sector health professionals will be needed.

TABLE 1. University Training Institutions for Health Work Force by Region, 2009 23 Region

University

Northeast

Thay Nguyen Medical University

Northwest

None

Red River Delta

Hanoi Medical University Hai Phong Medical University Thai Binh Medical University Military Medical Academy

North Central Coast

Hue Medical and Pharmaceutical University

South Central Coast

Medical Faculty of Da Nang University

Central Highlands

Medical Faculty of Tay Nguyen University

Southeast

Ho Chi Minh City Medical and Pharmaceutical University Pham Ngoc Thach Medical University

Mekong Delta

Can Tho Medical and Pharmaceutical University

Vietnam has 10 medical universities providing undergraduate and postgraduate training for medical students and other health professional students. See TABLE 1 for allopathic medical schools. For medical doctors there are 2 curricula, a 6-year curriculum and a 4-year curriculum. See TABLE 2. In addition, Vietnam has 14 universities that provide 4-year bachelor of nursing degrees; 30 junior colleges in 30 provinces that provide 3-year training for nurses, midwives, medical technicians, and laboratory technicians; and 35 secondary medical schools in 35 provinces that train secondary and elementary medical workers in 2- and 3-year curricula.

Nguyen provinces, the MOH, and the Ministry of Education and Training, in collaboration with a number of international nongovernmental organizations ~NGOs! and donors, have been working for over a decade to improve the quality of medical education in Vietnam.16–18 One of these is Pathfinder International, an American NGO. International partners in Pathfinder’s project include The Center for Reproductive Health Research and Policy at the University of California, San Francisco ~UCSF!, and Jhpiego ~formerly the Johns Hopkins Program for International Education in Gynecology and Obstetrics!. In this project the 8 Vietnamese universities are assisted in improving their undergraduate curricula in reproductive health, in strengthening faculty classroom and clinical teaching skills, in increasing the number of affiliated hospitals to provide students with more clinical opportunities, in standardizing the way clinical teachers perform basic clinical skills, in adding clinical skills examinations to student assessment,18 and in introducing evidence-based-medicine and problem-based learning. In 2006, all deans and vice deans of the 8 universities ~the Working Group! discussed the need for CME in Vietnam and the role the universities could play in providing CME. One of the universities was supported in writing a position paper on behalf of all 8 universities to the MOH strongly advocating for obligatory CME. The universities already provide occasional training courses for public-sector medical doctors and other health professionals. These are typically conducted by different departments or under control of national programs. Although they are not considered CME, they could provide a basis for the development of CME in Vietnam.

Medical Education Innovation in Vietnam

New Legislation on CME

Eight of the universities, in Hanoi, Hue, Ho Chi Minh City, Can Tho, Thai Nguyen, Hai Phong, Thai Binh, and Tay

Recognizing the need for a licensing system and other policy reform in the health care sector, in November 2009 the

Current Preservice Training Capacity

JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS—30(2), 2010 DOI: 10.1002/chp

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van der Velden et al. TABLE 2. Description of the 6- and 4-Year Medical School Curricula There are 2 medical curricula in Vietnam—a 6-y and a 4-y. Generally, for the 6-y program, students enter medical school directly after high school graduation, at approximately 18 y old. High school graduates have to pass the national entrance examination for enrollment. National entrance examination passing grades for students from remote and mountainous areas, where a severe health care worker shortage exists, are lower. In addition, students from remote and mountainous areas ~all from ethnic minorities! can be nominated by their Provincial People Committee, and enter medical education without entrance exams.24 The first 2 y of study include biology, histology, anatomy, physiology, biochemistry, and foreign languages ~either English, French, or Russian!. The third year of study includes pharmacology, pathology, parasitology, microbiology, public health, biostatistics, and forensic medicine. During this year also students start acquiring clinical experience. Year 4 includes internal medicine, surgery, pediatrics, and obstetrics and gynecology. They also do 8–10 wk of rotations in these subjects. In year 5 clinical disciplines such as infectious disease, tuberculosis, radiology, anesthesia, otolaryngology, ophthalmology, psychiatry, dermatology, and traditional medicine are covered. Internships of 2– 4 wk in these subjects are included. The sixth year is almost entirely used for internships and clinical lectures. Internships include a minimum of 10 mo of rotations including 8–10-wk rotations each in internal medicine, gynecology and obstetrics, general surgery, and pediatrics. The internship program is largely a hospital-based experience covering a spectrum of medical problems. Students have to take final exams for these 4 subjects. Both knowledge and skills are tested. For the 4-y program, students are recruited from assistant doctors who already have at least 3 y of clinical working experience. They are admitted upon passing an entrance examination. Those enrolled in the 4-y curriculum study the same topics as those in the 6-y curriculum, but devote less time to each topic. Internships take place during years 3 and 4.

National Assembly of Vietnam passed the Law on Examination and Treatment ~LET! that calls for 1-time revocable licenses to be issued to health care providers ~physicians, nurses, midwives, and assistant doctors among them! by 2016, when the LET will take effect.19 The LET includes a provision that those who do not have the required CME for 2 years will have their license revoked. The LET does not specify the detailed requirements for number of hours or types of CME or when required CME begins, nor does it specify which institutes will be accredited CME providers. These provisions await the detailed guidelines and decrees by the MOH that are currently being drafted. In anticipation of the new law, and coincident with university advocacy efforts, the Department of Science and Training in the MOH in May 2008 issued Circular 7, which recommends CME ~at 20 h per year!.20 It provides for blanket accreditation to all universities, medical colleges, and secondary medical schools ~nurse, midwife, and assistant doctor training institutes! as CME providers. It is likely that these institutes will be accredited CME providers under the LET. This will put a huge burden on these schools, which will therefore need to strengthen their capacity in providing CME. University Responses to New Legislation Strengthening CME capacity will require each university to develop specific policies and the administrative structures to support these policies. In addition, faculty and administrative staff will need to develop new skills and adapt to changes in workload. In early December 2008, Pathfinder International and faculty and staff from UCSF facilitated a roundtable discussion with the Working Group on key priorities in medical edu146

cation reform, including CME. The seminar was an open forum through which leaders of the 8 medical schools could share experiences about the current status and reform efforts, and discuss, among other things, the role of medical education institutions in providing CME. At the seminar, all 8 universities concluded they needed to prepare the infrastructure and facilities as well as local policies and administrative structures to respond to an expanded role in providing CME. After 6 months, a follow-up workshop with the same partners was organized. The workshop discussed the current status of CME in Vietnam and more detailed descriptions of how CME might be organized in medical schools. Topics such as defining practice gaps and needs assessment, principles of adult learning and learning strategies, outcomes measurement, conflict of interest, and how to establish a CME department were discussed. Most notably, 2 universities reported that they had started the formation of CME centers, both placed administratively directly under the dean of the medical school. Both CME centers had initiated CME training activities. Hai Phong Medical University is a large university in the northeast part of the country. Although it had already provided a significant volume of continuing education, these short training courses were previously coordinated by different departments, under different leadership, without standard criteria for design, provision, follow-up, and evaluation of training. In anticipation of the increasing demand, the university recognized the need for a specialized administrative structure to organize, standardize, and coordinate the CME. Therefore, a CME center was established, directly reporting to the dean board of Hai Phong Medical University. This center is expected to play a key role in coordinating and implementing all CME activities at the university. To date the center has coordinated 2 distance-learning CME


Continuing Medical Education in Vietnam TABLE 3. Distribution of Allopathic Health Work Force 16 Urban Central Staff Category Doctor Assistant doctor Nurse Midwife Total

No. 10 627

Rural Province

% 20

No. 21 678

District % 40

No. 14 657

Commune % 27

No. 6 957

Total % 13

No.

%

53 919

100

302

1

7 985

17

14 759

31

24 842

52

47 888

100

7 933

13

27 631

44

17 063

27

10 413

17

63 040

100

734

3

5 200

23

7 047

31

9 739

42

22 720

100

19 596

10%

62 494

33%

53 526

29%

51 951

28%

187 567

100

activities, 1 on HIV0AIDS palliative care and 1 on methadone maintenance therapy. Given the distribution of health care workers in remote areas ~see TABLE 3!, the high cost of travel and lodging, and the reluctance of health workers to leave their part-time private practices, we believe distance learning has great potential to become an important element in a larger CME strategy for universities, as it has in many countries. Studies have proven that Web-based CME can change provider behaviors.21,22 As the CME center and the upcoming legislation will have significant impact on the professional lives of the university faculty, it was felt that a comprehensive orientation for them would be needed to establish the CME center. Two workshops on Circular 7, the Law, the resulting CME requirements, and the role of the new CME center were organized at Hai Phong Medical University. Representatives of the dean board, the Training Department, and key faculty members participated, and agreed upon how to coordinate and implement activities related to CME. The Hue College of Medicine and Pharmacy is the largest training institution for medical professionals in central Vietnam. Recognizing the increasing demand for CME, Hue College of Medicine and Pharmacy established a CME center in January 2009 and encouraged all faculty to become involved in teaching CME. To date, 2 distance-learning CME activities on HIV0AIDS topics and 1 videoconference for practice improvements in family medicine have been completed. A fourth CME activity consisted of training in endoscopy, using a skills workshop with models and on patients. The Hue College of Medicine and Pharmacy intends to expand its CME training to other areas and include the use of other approaches, such as short didactic courses and scientific conferences. Conclusion Driven by health care reform, the advent of the private sector, and commitments made to the international community, Vietnam is currently faced with a need to increase regulation and training of its health care professionals. In Novem-

Lessons for Practice • Vietnam is instituting a licensing system for health professionals. • Continuing medical education (CME) will be required to maintain licensure. • The medical universities in Vietnam are responding to prepare for their new and expanded role as providers of high-quality CME.

ber 2009, legislation was passed that will require as-yetunknown amounts and types of CME. This is likely to place a large burden on the health professional schools and training institutes. References 1. WorldBank. Taking Stock, An Update on Vietnam’s Recent Economic Developments, Washington DC: WorldBank; 2009. http:00site resources.worldbank.org0INTVIETNAM0Resources0TakingStock December2009.pdf. Accessed February 8, 2010. 2. Boothroyd P, Xuam Nam P, eds. Socioeconomic Renovation in Viet Nam: The Origin, Evolution and Impact of Doi Moi. Ottawa, Canada: International Development Research Center; 2000. 3. Glewwe P. An overview of economic growth and household welfare in Vietnam in the 1990s. In: Glewwe P, Agrawal N, Dollar D, eds. Economic Growth, Poverty, and Household Welfare in Vietnam. Washington, DC: World Bank; 2004:1–27. 4. Witter S. “Doi moi” and health: the effect of economic reforms on the health system in Vietnam. Int J Health Plann Manage. 1996;11~2!: 159–172. 5. Sepehri A, Chernomas R, Akram-Lodhi AH. If they get sick, they are in trouble: health care restructuring, user charges and equity in Vietnam. In J Health Serv. 2003;33~1!:137–161. 6. Ministry of Health. Implementation of the 10 Year Socio-Economic Plan 2001–2010 and Development of the 10 Year Socio-Economic Plan 2011–2020. Hanoi: Ministry of Health; 30 July 2009. Report No. 7140BC-BYT.


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