Transforming Commune Health: Vietnam’s Urgent Push for Stronger Primary Care

Vietnam's Commune Health System faces declining utilization, severe medicine and equipment shortages, staff gaps and fragmented governance despite decades of strong policy commitments to primary health care. Strengthening financing, procurement, workforce incentives and person-centred care is essential for rebuilding trust and ensuring equitable, high-quality services nationwide.

Vietnam’s ambition to reform its health system comes at a crucial moment, and this WHO review, developed with research support from the Health Strategy and Policy Institute (HSPI), the Hanoi University of Public Health Ethics Council, and independent consultants, reveals both impressive achievements and deeply rooted vulnerabilities within the Commune Health System (CHS). Against the backdrop of administrative restructuring and a political mandate to provide free health care by 2035, the review positions the CHS as indispensable to meeting the country’s changing health needs. Despite high life expectancy, strong vaccination performance, and near-universal health insurance coverage, the system faces mounting pressure from rising noncommunicable diseases, rapid ageing, and a steady shift of patients toward provincial and central hospitals rather than commune-level care.

Uneven Service Access and Declining Trust

While nearly every commune has a functioning health centre and most employ physicians, the picture on the ground is far from uniform. Utilization of CHCs has steadily declined, with only around 18% of outpatient visits occurring at commune-level facilities by 2020. Many Vietnamese increasingly bypass their local centres, perceiving them as under-equipped or lacking the medicines and diagnostics needed for quality care. WHO’s structured survey found CHCs stocked an average of just 14 out of 36 essential medicines, and none met even 80% of the recommended list. Equipment shortages were equally stark: broken ultrasound machines, unused diagnostic devices, and missing consumables forced physicians to limit care to common minor ailments. These gaps reinforce the public’s perception that higher-level hospitals or private clinics offer superior services, further reducing CHC utilisation.

Procurement Bottlenecks and Broken Supply Chains

The shortages documented in the report stem from rigid and risk-averse procurement systems. Centralized bidding rules require prices to be based on previous years’ data, ignoring inflation or market disruptions, often resulting in failed bids and inadequate supply. CHCs are hesitant to use direct procurement, even when legally permissible, due to fear of violating regulations. Moreover, medicine planning is frequently anchored to last year’s consumption patterns rather than clinical need; if a drug was scarce last year, procurement rules ensure it remains scarce. In parallel, informal norms push physicians to keep prescription costs low, prompting patients to travel to district hospitals for better-stocked pharmacies. This dynamic reduces communal demand, which in turn reduces future supply planning, perpetuating shortages year after year.

Human Resources: High Expectations, Low Incentives

Although staffing numbers appear strong nationwide, rural and remote provinces struggle to recruit and retain qualified physicians. Young doctors prefer urban postings with better professional development opportunities and higher supplementary income. Commune-level workers, by contrast, often hold lower professional titles, receive lower pay, and have limited access to continuing medical education. The review highlights striking differences across provinces: where district health centres actively rotate staff, offer training, and provide clinical supervision, service quality and staff morale are significantly higher. However, such support is uneven, and existing incentive schemes, recruitment subsidies, allowances, or training support have had limited effect in overcoming systemic disincentives associated with communal postings.

Fragmented Care and Financial Imbalances

Despite longstanding policy support for family medicine, CHCs largely deliver reactive, episodic care rather than person-centred, continuous services. The absence of a nationwide electronic health record exacerbates fragmentation, as patients discharged from hospitals rarely return to CHCs for follow-up. This leads to duplicated tests, rising costs, poor chronic disease management, and inefficient use of clinical resources. Financially, the imbalance is stark: although health insurance covers more than 94% of the population, only about 2% of total SHI spending reaches commune-level facilities. Hospitals, driven by fee-for-service incentives, dominate resource flows and patient volumes. CHCs, lacking revenue-generating capacity, struggle to maintain staff, equipment, or public health programmes, especially in mountainous provinces where autonomy policies expect them to self-finance much of their operations.

Governance Gaps and the Road Ahead

Frequent restructuring over the past two decades has left governance of grassroots health care fragmented and inconsistent. Some district centres provide robust support and supervision, while others rarely engage with CHCs. Reporting remains largely manual and output-focused, with little emphasis on outcomes or patient experience, and no dedicated agency exists to advocate for or monitor the CHS. The report concludes that Vietnam’s policy vision aligns strongly with global best practice, but implementation remains hampered by structural inefficiencies, unclear responsibilities, inadequate financing, and fragmented oversight. Strengthening the CHS, through updated service packages, streamlined procurement, improved workforce incentives, enhanced financing, and a dedicated governance entity, will be essential if Vietnam is to build a more equitable, integrated, and person-centred health system capable of meeting the needs of its rapidly changing population.