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United Nations Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health Mr. Anand Grover

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Date: 05 December 2011
Event: United Nations Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health, Country Visit to Viet Nam, 25 November to 5 December 2011
Venue: UNDP Rose Conference
Speaker: Mr. Anand Grover, United Nations Special Rapporteur

Members of the press,

Ladies and gentlemen,

Allow me to begin by warmly thanking the Government for inviting me to Viet Nam and for facilitating a rich and interesting programme of meetings and visits. During my visit, I have met with Government officials, as well as representatives of international organizations and civil society. I have also visited health centres, rehabilitation centres and a prison. Throughout my visit, I have been met with warm hospitality and courtesy. There has been a candid and frank exchange of views and senior Government officials have been forthcoming in their views on sensitive issues. I take this opportunity to thank all those who have given me the benefit of their time and experience. I would also like to thank the United Nations Resident Coordinator’s Office for their tireless efforts in ensuring the smooth running of this mission. I am also grateful to the Ministry of Foreign Affairs for all their efforts in organizing and facilitating my mission.

You will find in this room a short document that explains my UN responsibilities as Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health (for short the right to health). In brief, I am an independent expert who reports to, and advises, the UN Human Rights Council and UN General Assembly on the realization of the right to health. Although appointed by the Human Rights Council, I am not employed by United Nations and the position I hold is honorary. As an independent expert, I exercise my professional judgement.

Today, I would like to confine myself to discussing some of my preliminary observations, which will be explored in more detail in the final report to be presented in due course to the Human Rights Council in June 2012.

The objective of my mission was to understand, in the spirit of co-operation and dialogue, how Viet Nam has implemented and endeavours to implement the right to health. The focus of the mission was on three major issues that I find of particular importance in Vietnam: health systems and financing, access to medicines, and HIV/AIDS prevention and treatment, focusing on vulnerable groups.

I would first like to commend the Government of Viet Nam for its substantial poverty reduction efforts that have led to the improvement of the lives of millions of people over the last two decades. The Government’s strong commitment to improving the lives of the poor is demonstrated by the fact that Viet Nam has exceeded the Millennium Development Goal (MDG) of cutting in half the proportion of people whose income is less than one dollar a day. Viet Nam’s economic growth has been more equitably distributed than that of many of its neighbours in the region and throughout the rest of the world.

I would also like to note Viet Nam’s commendable work in the last two decades to improve the health system as a whole, and its commitment to ensure access to healthcare for all. A functioning health system is the basis for the exercise of the right to health, and data indicates that admirable advances have been made amongst many key health areas, including child and maternal health.

The Government of Viet Nam is laudably committed to providing health care for all. For example, there is a National Assembly resolution to ensure that the growth rate of public spending on health consistently exceeds the total growth rate of government spending. As Viet Nam transitions to a socialist-oriented market economy and the Government seeks to generate resources for the health sector, it faces a number of challenges. Government’s strategies toward this end include the issuing of government bonds and encouraging foreign and domestic private investment, including through public-private partnerships, in the health sector. At the same time, due to Viet Nam’s decentralization of its health system and health financing mechanisms, provincial and district level health facilities have been granted greater management autonomy, amongst other things, to generate revenue. This will likely result in increased costs of goods and services, further limiting access for the poor and near poor. The above, together with the high rates of inflation, not only exacerbates the situation but also threatens the availability and economic accessibility of health goods and services for those who cannot afford to pay, thus preventing the full realization of the right to health.

In order to ensure adequate public funding for health services at the provincial, district and local levels, I encourage the government to consider alternative revenue-generating mechanisms, such as progressive taxation. I have been told that the Government is considering increasing the excise tax on tobacco products and a step increase in the social insurance contribution from 4.5 to 6 per cent, part of which will be directed toward public health expenditures. Both measures would be welcome developments.

As I said, Viet Nam’s commitment to addressing the health care needs of the poor and other vulnerable groups is admirable. The Government has instituted a number of initiatives to address these concerns, such as the national health insurance law and the health care fund for the poor. Both programs, however, face significant challenges in meeting their stated goals. Health insurance only covers basic health services, the quality of which has to be substantially upgraded. This requires patients to pay costly user fees for additional services. Even though national health insurance provides full health insurance coverage for the poor and fifty percent coverage for the near poor, as well as direct reimbursement for health facilities, out-of-pocket expenditures account for the majority of total health expenditures, and more than 30 per cent of individuals live in households that experience catastrophic out-of-pocket payments. However, the poor and near poor, especially those in rural and mountainous areas and predominantly populated by ethnic minorities, are burdened by additional expenditures on food, travel and accommodation in order to access basic health services. In fact, these expenditures often cost more than the health services sought. Moreover, informal payments to health providers, or “envelope payments”, increases out-of-pocket expenditures for all users of the health system, and impedes access to health care services for the poor and the near poor.

I have been informed that the Government is considering an increase in the level of reimbursement for basic health services for the near poor from 50 to 70 percent along with subsidies for travel and food expenses for the poor. While this is welcome, there is a need for much more support for the poor and near poor.

Ladies and Gentlemen,

Access to affordable to safe and quality medicines is a fundamental component of the right to health framework. Expenditures on medicines account for the majority of health care costs in Viet Nam. Medicines are purchased using reference prices based on the high reference cost of drugs resulting in prices of medicines being higher than in some developed countries. This is an unsuitable practice for a country in which medicine prices are already out-of-reach for a large percentage of the population. Moreover, as part of the decentralization in health decision-making and management, there has been a general shift towards placing procurement responsibilities with facilities and individual programmes. In doing so, it has unnecessarily forfeited its bargaining power as a bulk purchaser, leading to higher prices and varying cost of drugs throughout the country.

I have been told that the Vietnamese Government is interested in promoting the growth of its domestic generic pharmaceutical industry to ensure the availability of low-cost medicines through increased competition. While this is a welcome development, I believe there are numerous complex challenges to develop such local industries, which need to be identified and addressed.

Moreover, Viet Nam is currently in negotiations towards the adoption of the Trans-Pacific Partnership Agreement (TPPA) with a view to facilitating an increase in exports for Viet Nam. During the TPPA negotiations, there is a risk that TRIPS-plus provisions will be agreed to that will prevent the Government from using of TRIPS flexibilities. This may well delay the introduction of generic medicines, including locally produced, thereby result in further increases in the price of medicines, as evidenced by the experience of other countries.

As a middle-income country, Viet Nam will face a reduction in international donor funding for HIV/AIDS and other health interventions. International funding accounts for approximately 70 per cent of all HIV/AIDS related funding in Viet Nam, including nearly all antiretroviral treatment programs. The resultant funding shortfalls will dramatically affect access to treatment services for people living with HIV/AIDS.

According to official statistics, HIV prevalence in Viet Nam is 0.3 percent for the general population and 0.43 percent for people aged 15 to 49. Though sero-prevalence may be stabilizing in some at risk groups in some areas it is increasing in others such as men who have sex with men and the absolute numbers are quite high. Official statistics show the total reported cumulative cases are 193,000, but estimates put the actual number closer to 250,000. The lack of transparent, validated data and under-reporting is a systemic concern resulting in unreliable data. These problems are compounded by stigmatization of vulnerable groups. As has been recently reported by the Commission on AIDS in Asia, key at risk populations, including female sex workers, injecting drug users, and men who have sex with men, are fuelling the epidemic on the continent. This is also the case in Viet Nam.

Stigmatization and discrimination against people living with HIV/AIDS, injecting drug users, female sex workers and men who have sex with men contributes to the spread of the epidemic amongst these populations and into the general population. Stigmatization and discrimination severely hinder prevention efforts and are in fact exacerbated by laws relating drug use and commercial sex work. In addition, it is regretful that the detention of these groups in rehabilitation centres (05 and 06 centres) and compulsory treatment of injecting drug users and female sex workers perpetuates stigmatization and discrimination.

The rehabilitation centres are ineffective in reducing drug use and sex work, which is their stated objective. They are not cost effective either, as indicated in my meetings with government officials. Compulsory detention in the rehabilitation centres raises concerns about due process for the detainees, as they have no right to know the case against them and challenge it at a hearing before the decision is made. Moreover, there is no guarantee of prompt access to a court in order to challenge the legality of their determination as an injecting drug user or as a female sex worker after the decision is made. Treatment provided to injecting drug users in rehabilitation centres is not evidence-based and is ineffective, as demonstrated by high relapse rates. As the treatment is obligatory in the majority of cases, the detainees are denied the right to be free from non-consensual treatment as well as the right to informed consent in all medically related decisions. The centres are also counterproductive for the Government’s HIV/AIDS efforts. I believe that the current approach to rehabilitation centres violates the right to health.

Fortunately, the Government has implemented a number of pilot methadone treatment programs, which are less costly and more effective in reducing drug use and facilitating the reintegration of injecting drug users back into the community. I was pleased to learn that the draft administrative reform law that is currently pending in the National Assembly would expand key due process protections for injecting drug users and discontinue detention of sex workers in rehabilitation centres. These changes are welcome and will have significant positive health impacts, especially with respect to HIV/AIDS. There is also a perspective within the Government that favours the closure of the rehabilitation centres. I wholeheartedly support the closure of the rehabilitation centres. It is essential to ensure that the considerable resources now invested in these centres are used instead to expand alternative treatments for injecting drug users, including methadone treatment and community-based vocational training.

I would like to conclude by stressing that participation of affected populations in health decision-making is an essential component of the right to health. Effective monitoring and evaluation rests on the ability of the government to incorporate the input of affected populations into all planning and implementation decisions. I would encourage the Government to empower affected populations, including people living with HIV, injecting drug users, female sex workers, and men who have sex with men, so they may actively participate in the formulation and implementation of all decisions affecting their health.

Dear members of the press,

I am very grateful to the Government of Viet Nam for inviting me to visit, enabling me to deepen my understanding of the right to health-related issues. The Government’s invitation – and much of what I have learnt during my visit – confirms how seriously it is taking the issues related to the enjoyment of the right to health. I would like to use this opportunity to encourage the Government to extend a standing invitation to all special procedures mandate holders, to afford other special rapporteurs and independent experts the same opportunity I have had.

As mentioned earlier, these are my preliminary findings. I will develop them further in my report to the Human Rights Council. Thank you for your kind attention.

I now welcome your questions.