CHAPTER 7
Decentralization and Government Stewardship
In any health system two key issues are: what should government do, and what roles should different ministries and different levels of government play? Vietnam is no exception. And like many other countries, Vietnam seems likely to end up reassessing many of the assignments of responsibilities in the years to come. As is apparent from the previous chapters, the health sector has been swept along on a number of economywide reforms over the years, including the introduction of a private sector, decentralization, and greater autonomy for public service delivery organizations. It has also promulgated some path-breaking reforms of its own, most notably the introduction of fees and drug sales in public facilities, and health insurance. Yet the Ministry of Health and the health departments of provincial governments still see themselves essentially as the financier and operator of the supply side of the health system, despite the fact that much of the supply side is not public, that much of the public sector enjoys considerable autonomy, and that providers are increasingly drawing their revenues from insurance reimbursements and out-ofpocket spending rather than supply-side subsidies. Furthermore, the central government has been slow to respond to the decentralization of power to the province. The Health Ministry acts as if the health sector is simply administratively deconcentrated as before, and can be expected to follow central directives. To some degree, the behaviors of local government mirror this behavior of the central government. Local health officials still look to MOH as their guardian and “clan� leader, although by law they are answerable to local political 143