The findings of this study confirm Vietnam’s impressive progress in reducing child deaths; the mean IMR and U5MR decreased by more than 40% in 1997–2006. The findings also suggest that the distribution of RMNCH and nutrition outcomes and intervention coverage among different population groups is inequitable. Despite some progress, inequalities in health outcomes persisted between 1997 and 2006; the CI for IMR and U5MR became slightly more inequitable. Inequalities in coverage of health interventions decreased between 1997 and 2006, which due to time lags of effects of certain interventions, such as immunization, on health outcomes may result in reduced inequalities in infant and U5MR in subsequent surveys. Increasing inequalities in health outcomes despite decreasing inequalities in health service coverage may also suggest that other factors related to Vietnam’s rapid socioeconomic development, for example transportation and living environments, may drive inequalities in health outcomes.
Generally we found larger inequalities by living standards compared to inequalities by education of mother, ethnicity, region, urban versus rural residence, and sex of child. An implication of this finding is that government policies aimed at reducing inequalities - such as free health insurance cards for the poor, ethnic minorities and children under six - may benefit from a complimentary policy instrument that also increases income, such as conditional cash transfers. This policy instrument provides a cash payment to households conditional upon carrying out actions such as attending growth monitoring sessions, receiving immunizations and getting regular health check-ups .
Inequalities in child nutrition were larger for underweight and stunting, which signal long-term nutritional deficiencies, compared to wasting, which is usually a result of a sudden, short-term reduction in nutritional intake. Given that we only had data on these three outcomes for 2000, we were not able to study trends over time.
The determinants of birth weight are multi-factorial, but it is well known that malnutrition of the mother plays an important role, not just during pregnancy but in her whole life leading up to pregnancy. There was a large decrease in inequalities in low birth weight over time (the CI in 2006 was less than half of what it was in 1997), which suggests that the nutritional status of pregnant women in the poorer quintiles of the population is catching up with that of those in the richer quintiles, but it is not clear from this analysis why that may be the case.
Our study found that inequalities were greater for interventions that require more than one service contact, such as DPT immunization, which needs to be taken in three doses to be fully effective, and antenatal care, which should ideally be provided at least four times during pregnancy, or at least three times as recommended by the Ministry of Health of Vietnam . This suggests that inequalities can be reduced by strengthening outreach by frontline workers such as community health workers and village health workers, particularly in rural and remote areas, to facilitate antenatal care visits for pregnant women, follow-up visits for mothers who have recently delivered, and health check-ups and growth monitoring sessions for children. It also suggests that addressing financial and other access barriers needs to complement targeted investments in the health system. Such demand-side barriers include distance to health facilities, transportation network, opportunity costs for the patients and care-takers, and cultural factors .
Inequalities were also larger for interventions that require support from the health system, such as skilled birth attendance, compared to interventions that can be delivered with less support from the health system through campaigns, such as certain immunizations and Vitamin A supplementations. A similar pattern was found by a World Bank study of inequalities in health in 56 countries , the Countdown to 2015 equity analyses [22, 28, 49] and a study of equity in MNCH in Thailand . This suggests that policies aiming to reduce inequalities should invest in health system strengthening, particularly in areas that are disproportionately inhabited by the poor and other vulnerable groups, such as ethnic minorities. Current investment in Vietnam favors urban areas and higher levels of the health system, such as tertiary hospitals, at the expense of investments in primary care .
The two indicators related to breastfeeding displayed a pro-poor distribution of inequalities. Further study is required to shed light on the reasons behind this result, but possible reasons may include changing social norms and behaviors among the growing number of more affluent households, cultural beliefs, lack of means by the poor to seek alternative nutrition intake sources for their infants should they wish to do so (even if not desirable from a health point of view), and marketing of infant formula - often next to schools - in affluent urban areas of Vietnam.