Promoting migrant-sensitive heath policies and programs: Lesson learnt from Vietnam MA. Nguyen Van Tan Director General General Office on Population and Family Planning Ministry of Health, Vietnam
CONTENTS 1 Migration in Vietnam: Status and Characteristics 2 Migration Legislation and Policy 3 Challenges in Health Care Provision to Migrants 4 Standpoint and Solutions http://www.gopfp.gov.vn
MIGRATION IN VIETNAM: STATUS AND CHARACTERISTICS 1. INCREASING TREND IN DOMESTIC MIGRATION 100.0 90.0 80.0 4.6 6.8 5.7 70.0 60.0 2.5 50.0 40.0 30.0 20.0 10.0 0.0 1984-1989 1994-1999 2004-2009 2009-2014 Di Migration cư 2.5 4.6 6.8 5.7 Dân Population số 5+ 54.3 69.0 78.5 83.3 Quantity and Migrant Rates, 1999-2014 Source: Vietnam GSO, 2015 - A total number of domestic migrants (both intra-provincial and inter-provincial) increased from 4.6 million (1994-1999) to 6.8 million (2004 to 2009) and up to 5.7 million people (2009-2014); - Clear relationships are seen between migration and economic development. During the period 2004-2009 the economy saw a substantial level of development; during the period 2009-2014 the economy was faced with a lot of difficulties. 10.0 9.0 8.0 7.0 6.0 5.0 4.0 3.0 2.0 1.0 0.0 4.6 6.5 8.6 6.8 1984-1989 1994-1999 2004-2009 2009-2014
MIGRATION IN VIETNAM: STATUS AND CHARACTERISTICS 2. INCREASING RURAL-URBAN MIGRATION Like many other countries, most of the population in Vietnam live in rural areas. During the period 1999-2009 it was observed that there was a rapid increase in rural-urban migration (from 27,1% in 5 years prior to 1/4/1999 to 31,4% in 5 years prior to 1/4/2009). However, during the period of 2009-2014 the migration flow declined to 29%, but the urban-urban or urbanrural flows increased. This was because of the impact of the economic crisis in 2008, leading to urban-rural or urban-urban migration to search for employment opportunities. 40 35 30 25 20 15 10 5 37 33.8 31.4 28.8 29.0 30.1 27.1 26.2 26.4 12.1 9.7 8.4 1999 2009 2014 Rural Urban NT-NT rural NT-TT - TT-NT -Rural TT-TT Urban- Urban Rural- Source: Vietnam GSO, 2015
MIGRATION IN VIETNAM: STATUS AND CHARACTERISTICS 3. Rejuvenated migrants Intra district Intra provincial Intra country Non-migrants Male Female Source: Vietnam GSO, 2015 The average age and median age of migrants is always lower than non-migrants (Vietnam GSO, 2015).
MIGRATION IN VIETNAM: STATUS AND CHARACTERISTICS 4. Womanized trend among migrants 70.0 65.0 60.0 55.0 50.0 45.0 40.0 35.0 30.0 42.7 Rates of female migrants, 1999-2014 53.7 56.5 58.9 10.0 9.0 8.0 7.0 6.0 5.0 4.0 3.0 1984-1989 1994-1999 2004-2009 2009-2014 1989 1999 2009 2014 Source: Vietnam GSO, 2015 -The proportion of female migrants out of the total migrants increases faster than men, from 42.7% (1989) to 53.7% (1999), to 56.5% (2009) and to 58.9% (2014) of the total number of migrants. The largest group of migrants is the female migrants under 25 years old. (GSO & UNFPA, 2001), working in service sector, trade and industry. - In 2014, the number of migrants had declined but the proportion of female migrants tended to increase. 4.6 Rates of migrants, 1999-2014 6.5 8.6 6.8
MIGRATION IN VIETNAM: STATUS AND CHARACTERISTICS 5. Temporary migrants 60 50 46 49 47.7 40 37.8 31.1 34.0 30 20 12.1 11.8 11.9 10 8 4.1 6.3 0 Nam Nữ Chung Migrants are both male and female and mostly migrate in less than 6 months - Residence registration as KT4: 47.7% - Residence registration as KT43:34.0% In which migrants with residence registration are less than 6 months are mostly young and unmarried (64,9%) KT1 KT2 KT3 KT4 Source: Vietnam GSO, 2006 Trong đó: KT1: person whose residence registration is in the district level where he/she lives KT2: person whose residence registration is in another district in a province where he/she lives. KT3: person whose temporarily registers residence of more than 6 months KT4: person whose residence registration is less than 6 months
MIGRATION IN VIETNAM: STATUS AND CHARACTERISTICS 6. Migrants with low education, lack of technical expertise -Female migrant workers have not been trained professionally; only 10% are trained at secondary level, and the rest just graduated high school. -Mainly work in the private sector, or in the industrial zones 80.0 70.0 60.0 50.0 40.0 30.0 20.0 10.0 0.0 64.9 16.2 58.8 24.7 72.6 21.9 Source: Vietnam GSO, 2015 66.7 6.65.9 6.26.8 6.05.6 6.26.1 Di cư trong huyện Intra district Di Intra cư trong provincial tỉnh Di Inter cư provincial trong nước Di cư Migration Không Non có trình expertise độ CMKT Sơ Elem. cấp Cao College đẳng Đại University học trở and lên 15.8
LEGISLATION AND POLICY ON HEALTH CARE FOR MIGRANTS No law, ordinance that refers directly, spefifically to migrants. Most of the provisions of the law (Constitution, laws, ordinances,...) and the policy of the State on migration issues and migrants are expressed in general principles, applicable to all organizations and individuals in the country. There is no discrimination against migrants The freedom of movement and residence: are specified in the Constitution, the Law on civil status, household registration. The right to medical care and health protection: health policy, health care (law protecting people's health care, Health Insurance Law). The right to education, intellectual development: policies on education and training Employment rights of workers: policies on labour and jobs Right to residence and to legitimate property ownership: policies on construction, housing, and land use. Right to enjoyment of socioeconomic services: Policies on electricity, water, loans, poverty reduction
LEGISLATION AND POLICY ON HEALTH CARE FOR MIGRANTS RIGHTS TO FREEDOM OF MOVEMENT AND RESIDENCE The Constitution of Vietnam (2013) defines a number of articles on migration. Specifically, Article 23 stipulates: "Citizens have the right to freedom in movement and residence within the country, have the right to going abroad and returning home from abroad. The implementation of these rights prescribed by law: The provisions in the Constitution on education, labour and employment, health, health care, health insurance... applies to all subjects, regardless of the migrants. RIGHT TO HEALTH CARE AND HEALTH PROTECTION Law on protecting people's health care (1989): Identifying Vietnamese citizens to have the right to health protection. Health protection as the rights and obligations of citizens in general, irrespective of socio-economic characteristics, occupation or their relatives. The State to take care of people's health and to make this work in the plan of socio-economic development and the state budget. The law also defines the responsibilities of the Ministry of Health, People's Committee at all levels, individuals and employers in the protection of people's health care, regardless of the migrants. Health Insurance Law: Goals towards universal health insurance coverage, ensuring risk-sharing among the insured and without discrimination against migrants. The Law requires that children under 6 get free medical care
LEGISLATION AND POLICY ON HEALTH CARE FOR MIGRANTS LIMITATION IN POLICY ON HEALTH CARE FOR MIGRANTS No law nor ordinance that refers directly to migrants. No ministry ever assigned to be responsible for management of urban migration, therefor there has been shortage of an overall strategic planning and formulation of a comprehensive policies on migration, planning of industrial zones that limit the access to social services for migrants. Some policies guiding the implementation of laws and ordinances... issued strict regulations, required conditions and procedures to ensure the state management of the residence registration. Thus migrants can hardly benefit from social services in particular from health care and other social services in general (such as culture, education, labour, employment, etc...). When formulating social policies there is no keen attention to migrants. Budget allocation mechanism for social services is based on household register management, so migrants met with difficulty in access to social services.
CHALLENGES IN HEALTH CARE FOR MIGRANTS LIMITED KNOWLEDGE AND BEHAVIOURS IN HEALTH CARE AMONG MIGRANTS Migrants who have knowledge on STDs 86.0 84.0 82.0 81.8 81.7 84.1 83.3 82.8 82.1 81.5 81.5 82.6 82.2 82.0 83.4 80.0 15-29 30-44 45-59 Tổng Lậu Gonorrhea Giang Syphilis Mai Viêm Hepatitis gan B B Source: Vietnam GSO, 2006 - Migrants have better knowledge on STDs thanks to increasingly extended communications work. However, 1/3 of migrants have limited knowledge on the causes of STDs.
=> Migrants are mainly youth, unmarried young people, those who are of limited education therefore they become more vulnerable to infection. It is more important to note that more and more young migrants are young women. 103.0 98.0 93.0 CHALLENGES IN HEALTH CARE FOR MIGRANTS 1. LIMITED KNOWLEDGE AND BEHAVIOURS IN HEALTH CARE AMONG MIGRANTS Migrants who have knowledge on HIV/AIDS 97.1 97.9 97.6 96.3 95.6 96.0 96.6 93.6 91.9 96.9 96.8 88.0 15-29 30-44 45-59 Tổng Lậu Gonorrhea Giang Syphilis Mai Viêm Hepatitis gan B B Source: Vietnam GSO, 2006 - Migrants who have high level of knowledge on HIV/AIDS. The main sources of information are through TV (96.5%), Radio (68.5%) and press (61.1%). - However, their knowledge on the causes of infection is low (63.1%), lower than non-migrants (64.9%).
80 60 40 20 0 43.8 CHALLENGES IN HEALTH CARE FOR MIGRANTS 1. LIMITED KNOWLEDGE AND BEHAVIOURS IN HEALTH CARE AMONG MIGRANTS 48 65.5 15-29 30-44 45-59 Di cư Migrants Smoking and Drinking 50 63.8 61.8 60.2 40 Non migrants Không di cư Source: Vietnam GSO, 2006 - Smoking is common in Vietnam. There is an increase in smoking among male migrants, in the age group 30-44, from 65.5% (before migration) to 70.1% (after migration). The main reasons are such as boredom, work pressure, depression. - Migrants tend to have less drinking than non-migrants, but drinking is still common among male migrants => Bad habits (smoking, drinking) damage health and cause various diseases 30 20 10 0 23.5 19.7 16.2 19.2 11.8 6.4 Uống Daily hàng drin ngày king Vài A few lần trong times es tuần a Migrants Di cư Một Once lần a trong week tuần 15 12.1 Một Once lần trong a tháng month Non migrants Không di cư 42.4 32.4 Uống khi liên hoan Drinking in party
CHALLENGES IN HEALTH CARE FOR MIGRANTS 2. LIMITED LIVING CONDITIONS OF MIGRANTS Migrants have better housing than non migrants, 59.7% of migrants live in solid house or semi permanent house compared to 42.9% of non migrants. The main reason is that migrants moving to the urban areas enjoy better housing in cities. Migrants often rent housing (55%) compared to non-migrants (8.3%) (Vietnam GSO, 2006). => Because of their lodging the access to health information is a particular challenge. Sexual and reproductive health education to young migrants is particularly difficult 70.0 60.0 50.0 40.0 30.0 20.0 10.0 0.0 25.3 59.7 Di cư Migrants 47.0 42.9 2.9 6.3 1.7 3.7 Source: Vietnam GSO, 2015 Không di cư Non migrants Kiên Solid cố Bán Semi kiên solid cố Thiếu No solid kiên cố Đơn Rudimentary sơ
2. LIMITED LIVING CONDITIONS OF MIGRANTS The rate of migrants living in less than 4m2/person to 10m2 (the lowest standard) is higher than non-migrants. Highly concentrated lodging by migrants in more economically developed areas, mostly economic zones the demand for housing for rent is high when the supply is limited or the cost is high. => Housing condition is inconvenient - living in small area, lacking facilities, poor hygienic conditions. That affects badly the health status of migrants 90.0 80.0 70.0 60.0 50.0 40.0 30.0 20.0 10.0 0.0 CHALLENGES IN HEALTH CARE FOR MIGRANTS 69.2 18.0 3.6 8.7 0.6 Di cư Migrants Source: Vietnam GSO, 2015 2.3 11.3 Không di cư Non migrants 85.3 Dưới <4m2 4 m² 4-dưới 4-6 m2 6 m² 6 đến 6-10 dưới m2 10 m² Trên >10m2 m²
CHALLENGES IN HEALTH CARE FOR MIGRANTS 3. Employment opportunities of migrants Migrants having low education level: low skill labor workforce, 46.4% of migrants do simple jobs (Vietnam GSO, 2006). Migrants mostly work in private sector: private firms (18%); privately owned trade business (49%). Their wages are normally low, no labor contract signed with employers therefore they are not covered by social insurance or health insurance schemes. Private sector 18% Joint venturei 19% => Access to social services, health care service is difficult because they are not covered by health insurance policy, the health care cost is high when the need for savings to support their families are high. Source: Vietnam GSO, 2006 Unidenti fied 1% Public sector 13% Small private business 49%
CHALLENGES IN HEALTH CARE FOR MIGRANTS 4. RESIDENCE REGISTRATION SYSTEM A BARRIER TO HEALTH CARE TO MIGRANTS Most of migrants (male and female) are temporary, less than 6 months ( registered as KT4 account for 47.7%, KT3 34%). Migrants change their migration destinations very often because of the instability in their jobs => Difficult for migrants to access to health care service as well as in health care provision to migrants; The health education and health care to migrants is limited because of the access issue Charter of Health Insurance (Ordinance 63/29005/NĐ-CP May 16, 2005) stipulates that the person who has health insurance selects the health clinic for PHC assigned to the area where he/she has residence registration. => Temporary migrant, worker without labor contract who have health care needs can not be
STANPOINT AND SOLUTIONS Quan điểm Considering migration as a law, indispensable elements and driving forces of socio-economic development. Integrating migration into the programs and activities. Creating stable conditions for migrants and improving their access to health services, sexual health care / RH / FP. Considering the household registration as social management tool to protect residence right, but not a tool to address the health care policy
STANPOINT AND SOLUTIONS SOME SOLUTIONS Government Stipulates children under 6 years old registered under KT3 category (temporarily migrated less than 6 months) be given free health insurance card by the authorities where they are registered. If they do not have health insurance card yet their parents can use birth certificate or birth notification to access free health care for the children. Revised Health Insurance Law (2004): The revised law stipulates compulsory participation in the health insurance scheme (policy requesting less premium, government subsidization to some groups of people). This is a solution to move forward to universal health insurance coverage. Liberalizing utilization of health clinics where patients can use health insurance card to allow maximum conditions in access to health care services. From Jan 2016 patients in different communes can access health clinics in other communes or those at district level. From Jan 2021 this policy will apply to all provinces in the country. Increase the benefits to health insurance beneficiaries: The benefits will increase in line with a roadmap that has been worked out.
STANPOINT AND SOLUTIONS IMPLEMENTATION OF SOLUTIONS Ministry of Health Implementing health care programs: TB prevention and treatment, HIV/AIDS control program, S/RH program to be implemented for immigrants. Provision of free drug to mental health patients, TB patients: Provision of free drugs regardless of migrant status or not. In health care and treatment: there will be no discrimination against migrants
STANPOINT AND SOLUTIONS IMPLEMENTATION OF SOLUTIONS General Office for Population and Family Planning, Ministry of Health: Intensify communications (through radio, population collaborators) to reach migrants in living quarters, industrial zones (focusing on households, male and female migrants) on policy, directions and knowledge on population/srh/fp. Model on information and RH service provision to migrants in Hanoi, HCMC: face to face communications, IEC material provision, building communication corners (materials, contraceptive supplies) in the lodging houses with the owner s participation If we do not well provide health services to migrants, especially young female migrants there will be more unwanted pregnancies, HIV infection cases and STDs. They may pread out to the community
STANPOINT AND SOLUTIONS IMPLEMENTATION OF SOLUTIONS General Office for Population and Family Planning Project Ameliorate the population/rh - FP status for adolescents during the period 2016-2020 with the following objectives: Decrease 50% of female adolescents and youth who have unwanted pregnancies by 2020; Increase the youth friendly S/RH-FP service points to 75% by 2020; Sensitize to have 50% of parents who have their children at adolescent ages to support, guide, assist their children in gaining knowledge and in assessing S/RH-FP services. If we do not well provide health services to migrants, especially young female migrants there will be more unwanted pregnancies, HIV infection cases and STDs. They may pread out to the community
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