An overview of the CL/P situation in Vietnam

Vietnam is located in Southeast Asia with an estimated 97 million inhabitants (Worldometers, 2019). The total area is about 331,212 km² including numerous islands. There are 63 cities and provinces which can be grouped into three main regions: Northern, Central, and Southern Vietnam. Vietnam has focused on the development of advanced medical centres in Hanoi (Northern Vietnam), Hue (Central Vietnam), and Ho Chi Minh City (Southern Vietnam) (Pham, 2010).

Thua Thien-Hue Province is composed of one provincial city (Hue), two district-level towns, and six districts. In Hue, there are three large hospitals that treat patients with CL/P from the Thua Thien-Hue Province and neighbour cities in Central Vietnam: Hue Central Hospital, Hue University Hospital, and Hue Odonto-Stomatology Hospital.

Although Vietnam’s health care system was transformed from a fully public service system to a mixed public-private system in 1989, the public health care system still plays an important role in providing health services (Le et al., 2010). Currently, there is a lack of a healthcare workforce in Vietnam with the number of doctors being quite low (8 doctors/10,000 people) (Takashima et al., 2017).

Vietnam’s public health care system consists of four administrative levels:

national level, provincial level, district level, and commune level (Le et al., 2010). Accordingly, public medical institutions are classified into four levels:

national, provincial, district, and commune level. The primary public medical institution is commune health stations, about 11,000 health stations, which cover nearly all communes in Vietnam and are responsible for primary health care services. However, commune health stations have limited medicine and medical equipment, additionally, there are not many skilled doctors and nurses at these locations. Patients, therefore, might go to higher level medical institutions for examination and treatment (Sakano, 2015). Due to this, two to

three patients sharing a bed is becoming a common problem in many national and provincial hospitals (Takashima et al., 2017).

In 1992, health insurance was introduced (Le et al., 2010). About 86.9% of the Vietnamese population had health insurance in 2018 (Anh Xuan, 2018). The health insurance covers 80–100% of medical expenses depending on indivi-duals. Public medical institutions also run a referral system. The referral system affects the percentage that the health insurance covers, 40–70% of the expenses (EFY Việt Nam, 2014).

2.7.2. Management of CL/P in Vietnam

The prevalence of CL/P in Vietnam is unclear, and it is usually estimated from hospital registries. The estimated prevalence of CL/P in Vietnam is about 14.9 per 10,000 births (Nagato et al., 1998), or 14.1 per 10,000 births (Phan and Hoang, 2007). Agent Orange, which was used as a herbicide during the Viet-nam War, contained a synthetic dioxin compound—2,3,7,8-tetrachlorodibenzo-dioxin (TCDD). It allegedly attributed the increased risk of many congenital anomalies including CL/P in Vietnam (Clapp et al., 2014; Nagato et al., 1998).

However, there is no national registry for congenital anomalies, CL/P in parti-cular.

In spite of a high proportion of insurance coverage, patients as well as their families still depend on charitable cleft care mainly because of the high cost of care for local services, or their belief in the superiority of foreign doctors (Hoang and Nguyen, 2011; Lam et al., 2010; Yao et al., 2016). Many charity organizations come to Vietnam on a mission that brings smiles back to Vietnamese children, such as Operation Smile, Smile Train, Deutsche Cleft Kinderhilfe, Project Vietnam Foundation, and institutional teams. Specifically, in Hue, Operation Smile, Smile Train, Interplast, Chonbuk University operation team, and Global Care Korea have been collaborating with Hue Central Hospital, Hue University Hospital, and Hue Odonto-Stomatology Hospital to provide free surgery to patients with CL/P for many years.

Surgical treatment provided by charity teams usually lags behind the optimal window of timing compared to developed countries (Yao et al., 2016). Cleft individuals have had their first cleft repair at an average age of 3.2 years according to Yao et al. (2016), or 2.6 to 3.8 years according to Swanson et al.

(2017). Also, due to a limited timeframe within each mission, the team can usually perform the operation for one procedure of the surgery protocols, which can create a problem in the continuity of care for short-term medical missions (Hoang and Nguyen, 2011).

There are four barriers to surgical cleft treatment in Vietnam: patient charac-teristics, family education and socioeconomics, geographic location, and cleft treatment site features. Males are almost two times more likely than females to access surgical treatment before 18 months of age. Paternal education beyond secondary school is associated with timely surgery. Families living within 10

km from the nearest hospital are more likely to attain the surgery. Travel time, cost, and distance to the mission site are not associated with the timing of the treatment. Lastly, hearing about the cleft mission from family, friends, or social media channels are associated with timely treatment (Swanson et al., 2017).

2.7.3. Research on CL/P in Vietnam

A vast majority of research has focused on the comparison of surgical techni-ques or the evaluation of surgical outcomes (Nguyen TD and Thai, 2004;

Nguyen VT, 2013; Nguyen CT and Nguyen, 2007). Epidemiological studies on CL/P have been carried out in certain areas in Vietnam (Nguyen CU, 1999; Lam et al., 2010; Nguyen HL, 2006; Phan and Hoang, 2007). There are some studies about other aspects of CL/P, such as speech, and craniofacial morphology (Nguyen TTC, 2012; Vu et al., 2004; Huynh and Hoang, 2007).

In short, prior research in Vietnam has investigated one single aspect of the cleft treatment outcomes. No research has studied the multiple aspects of the treatment outcomes in patients with CL/P, especially, in Central Vietnam.