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MOLISA MOH MOET

NATIONAL REPORT ON THE BASELINE ASSESSMENT OF THE DISABILITY SUPPORT SYSTEM IN VIETNAM

Vietnam Assistance for the Handicapped

In partnership with Ministry of Labor, Invalids and Social Affairs

Ministry of Health, and Ministry of Education and Training

May, 2015

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This National Report on the Baseline Assessment of the Disability Support System in Vietnam is made possible by the generous support of the American people through the United States Agency for International Development (USAID). The contents are the responsibility of VNAH and do not necessarily reflect the views of USAID or the United States Government.

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Table of Contents LIST OF TABLES ............................................................................................................................... 6 LIST OF FIGURES ............................................................................................................................. 7 LIST OF ACRONYMS USED IN THE REPORT ................................................................................ 8 ACKNOWLEDGEMENTS ................................................................................................................. 10

EXECUTIVE SUMMARY ...................................................................................................................... 12 BACKGROUND AND PURPOSE OF THE SURVEY....................................................................... 12 SUMMARY OF FINDINGS ............................................................................................................... 12 POLICY ENVIRONMENT FOR PERSONS WITH DISABILITIES IN VIETNAM .............................. 12 DISABILITY SERVICE SYSTEM IN HEALTH, EDUCATION AND SOCIAL SERVICES SECTORS .......................................................................................................................................................... 14 NEEDS AND ACCESS TO SERVICES FOR PERSONS WITH DISABILITIES .............................. 19

PART I: INTRODUCTION AND METHODOLOGY OF THE BASELINE ASSESSMENT OF THE DISABILITY SUPPORT SYSTEM IN VIETNAM .................................................................................. 22

1. INTRODUCTION, OBJECTIVES AND SCOPE OF THE ASSESSMENT .................................. 22 1.1 BACKGROUND ................................................................................................................... 22 1.2 OBJECTIVES AND RESEARCH QUESTIONS .................................................................. 23

2. METHODOLOGY ......................................................................................................................... 24 2.1. OBJECTS AND SCOPE OF THE ASSESSMENT .............................................................. 24 2.2. FRAMEWORK OF THE ASSESSMENT ............................................................................. 25 2.3. SURVEY METHODOLOGIES, APPROACHES AND SAMPLING ...................................... 26 2.4. SURVEY TOOLS ................................................................................................................. 28 2.5. DATA COLLECTION PROCESS ........................................................................................ 29 2.6. LIMITATIONS OF THE SURVEY ........................................................................................ 30

PART II: FINDINGS OF THE BASELINE ASSESSMENT .................................................................. 31

3. ANALYSIS OF POLICIES TO SUPPORT PERSONS WITH DISABILITIES IN VIETNAM ....... 31 3.1. THE RELATIONSHIP BETWEEN VIETNAMESE DISABILITY POLICIES AND THE INTERNATIONAL LEGAL FRAMEWORK ....................................................................................... 31 3.2. DOMESTIC POLICY FRAMEWORK FOR SUPPORT OF PERSONS WITH DISABILITIES IN VIETNAM ..................................................................................................................................... 34 3.2.1. LEGISLATION REGULATING EDUCATION FOR CHILDREN WITH DISABILITIES .... 34 3.2.2. LEGISLATION REGULATING SOCIAL PROTECTION, LABOR AND EMPLOYMENT FOR DISABILITIES .......................................................................................................................... 35 3.2.3. LEGISLATION REGULATING HEALTH CARE AND REHABILITATION FOR PERSONS WITH DISABILITIES ......................................................................................................................... 36 3.3. CHALLENGES REGARDING THE POLICY FRAMEWORK .............................................. 36 3.3.1. KNOWLEDGE OF THE POLICIES AMONG RELEVANT STAFF .................................. 37 3.3.2. KNOWLEDGE OF THE POLICIES BY PERSONS WITH DISABILITIES ...................... 39 3.3.3. ASSESSMENT BY STAFF OF IMPLEMENTATION OF DISABILITY POLICIES .......... 41 3.4. DISABILITY DATA IN VIETNAM ......................................................................................... 44 3.4.1. LOCAL LEVEL COLLECTION AND USE OF STATISTICS ON PERSONS WITH DISABILITIES IN VIETNAM ............................................................................................................. 46 3.5. SUMMARY – ANALYSIS OF POLICIES TO SUPPORT PERSONS WITH DISABILITIES IN VIETNAM ..................................................................................................................................... 47

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4. SERVICE PROVISION SYSTEM ................................................................................................. 48 4.1. HEALTH SECTOR ............................................................................................................... 48 4.1.1. GOVERNANCE AND ADMINISTRATION ...................................................................... 48 4.1.2. EXISTING SERVICES .................................................................................................... 50 4.1.3. FINANCING AND HUMAN RESOURCES ...................................................................... 56 4.1.4. CROSS-SECTOR COORDINATION .............................................................................. 59 4.2. EDUCATION SECTOR ........................................................................................................ 60 4.2.1. GOVERNANCE AND ADMINISTRATION ...................................................................... 61 4.2.2. EXISTING SERVICES AND SUPPORT ......................................................................... 63 4.2.3. FINANCING AND HUMAN RESOURCES ...................................................................... 68 4.2.4. CROSS-SECTOR COORDINATION .............................................................................. 71 4.3. LABOR/SOCIAL SERVICES SECTOR ............................................................................... 72 4.3.1. GOVERNANCE AND ADMINISTRATION ...................................................................... 72 4.3.2. EXISTING SERVICES AND SUPPORT ......................................................................... 73 4.3.3. FINANCING AND HUMAN RESOURCES ...................................................................... 74 4.3.4. CROSS-SECTOR COORDINATION .............................................................................. 77 4.4. SERVICE PROVISION BY INTERNATIONAL AND LOCAL NGOS ................................... 81 4.5. SUMMARY: SERVICE PROVISION SYSTEM .................................................................... 85

5. NEEDS OF PERSONS WITH DISABILITIES AND ACCESS TO SERVICES ........................... 88 5.1. DEMOGRAPHICS OF THE SURVEYED PERSONS WITH DISABILITIES ....................... 88 5.2. OTHER CHARACTERISTICS OF PERSONS WITH DISABILITIES .................................. 91 5.3. INDEPENDENCE AND CARE FOR PERSONS WITH DISABILITIES ............................... 93 5.4. NEEDS VS. SUPPLY OF SOCIAL SERVICES FOR PERSONS WITH DISABILITIES ..... 97 5.4.1. NEEDS VS. SUPPLY IN THE HEALTH SECTOR .......................................................... 98 5.4.2. NEEDS VS. SUPPLY IN THE EDUCATION SECTOR ................................................. 100 5.4.3. NEEDS VS. SUPPLY IN THE SOCIAL AND EMPLOYMENT SECTOR ...................... 102 5.4.4. SATISFACTION WITH SERVICES RECEIVED ........................................................... 105 5.4.5. PARTICIPATION IN CULTURAL AND ENTERTAINMENT ACTIVITIES ..................... 107 5.5. CONCLUSIONS ................................................................................................................ 109

6. SOME EFFECTIVE MODELS OF COMPREHENSIVE DISABILITY SERVICE PROVISION .. 110 6.1. INTEGRATING CBR INTO PRIMARY HEALTH CARE .................................................... 110 6.2. CENTERS FOR INCLUSIVE EDUCATION DEVELOPMENT .......................................... 113 6.2.1. THE CENTER FOR INCLUSIVE EDUCATION SUPPORT (IEC) IN VINH LONG PROVINCE ..................................................................................................................................... 113 6.2.2. THE CENTER FOR INCLUSIVE EDUCATION SUPPORT IN DANANG CITY ........... 116 6.3. THUY AN CENTER FOR REHABILITATION FOR CHILDREN WITH DISABILITIES ..... 119

7. DISCUSSION AND CONCLUSIONS ......................................................................................... 120 7.1. POLICY .............................................................................................................................. 120 7.2. DATA ................................................................................................................................. 121 7.3. SERVICE PROVISION ...................................................................................................... 122 7.3.1. HEALTH ........................................................................................................................ 122 7.3.2. EDUCATION ................................................................................................................. 123 7.3.3. LABOR AND SOCIAL AFFAIRS ................................................................................... 124 7.4. ACCESS AND KNOWLEDGE OF PERSONS WITH DISABILITIES ................................ 125 7.4.1. SITUATION OF FAMILIES WITH A DISABLED MEMBER .......................................... 125

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7.4.2. KNOWLEDGE OF SERVICES BY PERSONS WITH DISABILITIES AND THEIR FAMILIES 126 7.4.3. ARE THE NEEDS OF PERSONS WITH DISABILITIES BEING MET? ........................ 126 7.5. COORDINATION ............................................................................................................... 127

8. RECOMMENDATIONS .............................................................................................................. 128 8.1. POLICY .............................................................................................................................. 128 8.2. DATA ................................................................................................................................. 128 8.3. SERVICE PROVISION ...................................................................................................... 129 8.4. ACCESS AND KNOWLEDGE OF PERSONS WITH DISABILITIES ................................ 129 8.5. COORDINATION ............................................................................................................... 130

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List of Tables Table 1. Survey Location 25 Table 2. Summary of Survey Methodology and Response Rate 26 Table 3. Comparison of CRPD and Vietnam Law/ National Action Plan (NAP), 2012-2020 32 Table 4. Legislation regulating education for children with disabilities 34 Table 5. Legislation regulating LISA sector 35 Table 6. Legislation regulating health and rehabilitation 36 Table 7. Levels of Social Protection Center staff knowledge of disability-related policies 38 Table 8. Levels of health staff knowledge of disability-related policies 38 Table 9. Levels of education staff knowledge of disability-related policies 38 Table 10. Difficulties in implementing disability determination and classification in compliance with the Disability Law 41 Table 11. Difficulties in implementation of vocational training and employment policies for persons with disabilities 42 Table 12. Difficulties in implementation of social protection policies 43 Table 13. Approximate prevalence figures in countries in south-east Asia region based on available data 46 Table 14. Rehabilitation services at district level (N=43) 51 Table 15. Rehabilitation services at commune level (N=37) 51 Table 16. Number of persons with disabilities receiving health 53 Table 17. Types of health and rehabilitation services for persons with disabilities 54 Table 18. Number of persons with disabilities serviced at rehabilitation hospitals, 2010-2011 55 Table 19. Achievements of CBR implementation (N=25) 56 Table 20. Frequency and methods of coordination between health and educational staff 60 Table 21. Frequency and methods of coordination between health and LISA staff 60 Table 22. Education services at provincial level 64 Table 23. Number of children with disabilities receiving educational support services 66 Table 24. Number of children with disabilities receiving education support at IEC/Special schools by type of impairment, 2010 and 2011 68 Table 25. Self-assessment by teachers of their technical skills 69 Table 26. Self-assessment by social protection center staff of their technical skills 75 Table 27. Survey of non-government sector response rate 81 Table 28. International NGOs and international organizations 81 Table 29. Local NGOs/Centers 81 Table 30. Number of persons with disabilities serviced by international NGOs 82 Table 31. Number of persons with disabilities serviced by local NGOs and Centers 82 Table 32. Number of persons with disabilities serviced by DPOs 83 Table 33. Activities to support persons with disabilities 84 Table 34. Interviews of persons with disabilities and family members 88 Table 35. Demographic information of surveyed persons with disabilities 89 Table 36. Information on disability status of respondents 90 Table 37. Economic status of persons with disabilities (PWD >=18 years old) 91 Table 38. Information on economic status of households with a person with a disability 92 Table 39. Care-givers for persons with disabilities in conducting activities of daily-life 94 Table 40. Estimated time per day spent by family members taking care of 94

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Table 41. Difficulties faced by family members in supporting people with a disability 95 Table 42. Causes of difficulties in meeting the needs of persons with disabilities 97 Table 43. Need for healthcare services and actual service provision 98 Table 44. Accessibility of healthcare services 100 Table 45. Need for educational services and actual service provision 101 Table 46. Accessibility to educational support establishments 102 Table 47. Need for social support services (LISA services) and actual service provision 103 Table 48. Accessibility to social support services 104 Table 49. How persons with disabilities find out about disability support establishments 105 Table 50. Income source used to pay service fees 107 Table 51. Accessibility of local facilities 109

List of Figures Figure 1. Structure of the survey team 30 Figure 2. Knowledge of health policies by persons with disabilities 39 Figure 3. Knowledge of education policies by persons with disabilities 40 Figure 4. Knowledge of social support policies by persons with disabilities 41 Figure 5. Number of general hospitals per province 50 Figure 6. Number of specialized hospitals per province (N=49) 50 Figure 7. Total specialized staff at rehabilitation hospitals (Number, %, Min-Max, Av.) 57 Figure 8. Comparison of respondents’ assessment of coordination between sectors 78 Figure 9. Mobility capacity of surveyed persons with disabilities 93 Figure 10. Ability of PWD to conduct daily activities 93 Figure 11. Satisfaction with services received 106 Figure 12. Payment for services 106 Figure 13. Level of difficulty in paying service fees 107 Figure 14. Frequency of persons with disabilities joining community activities 108 Figure 15. The structure and organization of the CBR project 111 Figure 16. Organizational structure of Vinh Long Inclusive Education Center 115 Figure 17. Organizational Structure of the Center for Inclusive Education Support, Danang 116

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List of Acronyms used in the Report ASEAN Association of Southeast Asian Nations BMF BIWAKO Millennium Framework on Disability CBM Christian Blind Mission CBR Community Based Rehabilitation CRPD The United Nations Convention on the Rights of Persons with Disabilities CWDs Children with Disabilities DIS Disability Information System DOET Department of Education and Training (Provincial level) DOH Department of Health (Provincial level) DOLISA Department of Labor, Invalids and Social Affairs (Provincial level) DPO Disabled People’s Organization FS Field Supervisor FW Field Worker GSO General Statistics Office GVN Government of Vietnam HMU Hanoi Medical University ICF International Classification of Functioning and Health ICT Information Communication & Technology IEC Inclusive Education Center INGO International Non-Government Organization IO International Organization KAP Knowledge Attitude Practice MCNV Medical Committee Netherlands-Vietnam MDG UN Millennium Development Goals MOET Ministry of Education and Training MOH Ministry of Health MOLISA Ministry of Labor, Invalids and Social Affairs NAP National Action Plan for Disability NCCD National Coordinating Council on Disability NGO Non-Government Organization PMU Project Management Unit PWD Persons with Disabilities UN United Nations UNFPA United Nations Population Fund UNICEF United Nations Children’s Fund USAID United States Agency for International Development

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VHLSS Vietnam Household Living Standards Survey VNAH Vietnam Assistance for the Handicapped VTC Vocational Training Center WHO World Health Organization

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Acknowledgements Vietnam Assistance for the Handicapped (VNAH) expresses thanks to all who involved in the survey. We particularly thank the team members from the three Ministries: Ministry of Labor, Invalids and Social Affairs (MOLISA), Ministry of Health (MOH) and Ministry of Education and Training (MOET) as well as the provincial and district level ministerial representatives and all service providers of the three sectors of health, education and social affairs. We thank the 1,203 persons with disabilities who participated in the survey. We would also like to thank all the contributors, editors and peer reviewers who made the sector and national reports possible. Finally, we would like to thank the management of VNAH and the United States Agency of International Development (USAID) for offering financial and technical support and guidance. List of Contributors National Report: Caitlin Wyndham, Independent Consultant on Inclusive Development Nguyen Thi Minh Thuy (data - quantitative analysis), Community - Based

Rehabilitation Department, Hanoi School of Public Health Core expert team:

Associate Professor Bui Xuan Mai - Dean of Social Work Department, University of Labor, Invalids and Social Affairs

Professor Nguyen Thi Hoang Yen - Vietnam National Institute of Educational Sciences.

Pham Dung - Medical Committee Netherlands Vietnam Maya Thomas - Technical Expertise during the research framework and

questionnaires development.

Survey groups: MOET:

Associate Professor and Doctor Le Van Tac, Director of Center for Research on Special Education – Vietnam Institute of Educational Sciences (Sector Report Writer)

Doctor Bui The Hop, Head of Language Development Education Department, Center for Research on Special Education – Vietnam Institute of Educational Sciences (Sector Report Writer)

Survey Team Members: Nguyen Duc Huu, Vice-Director, Department of Primary Education, Ministry of

Education and Training Nguyen Thi Quy Suu, Official, Department of Primary Education, Secretary of

Steering Committee on Inclusive Education for children with disabilities and disadvantaged children, Ministry of Education and Training.

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Ly Quoc Huy, Official, Department of Primary Education, Member of Steering Committee on Inclusive Education for children with disabilities and disadvantaged children, Ministry of Education and Training.

Nguyen Xuan Hai, Dean of Special Education Department, Hanoi University of Pedagogy

MOLISA:

Nguyen Bao Cuong, Deputy Director of Research Centre for Female Labor and Gender, Institute of Labor Science and Social Affairs (report writer)

Do Thi Thanh Huyen, Division for Social Security Policy, Institute of Labor Science and Social Affairs (report writer)

Survey Team Members: Dinh Thi Thuy, Vice Director NCCD office – Social Protection Department, MOLISA Nguyen Thanh Tam, NCCD office – Social Protection Department, MOLISA

MOH:

Tran Van Minh – Dean of Rehabilitation Department, Hanoi Medical University (report writer)

Survey Team Members: Le Tuan Dong – Head of Rehabilitation Unit, Bureau of Medical Administration,

Ministry of Health Nguyen Thi Dung, Rehabilitation Department, Hanoi Medical University Tran Thi Ha, Rehabilitation Department, Hanoi Medical University

Overall technical coordinator of the survey:

Nguyen Thi Thu Huong, Policy Team Leader of Vietnam Assistance for the Handicapped (VNAH)

Advisory Group:

Bui Van Toan – Country Director of VNAH Le Ha Van – Manager of USAID Programs for Vulnerable Populations Tran Quy Tuong, Deputy Head, Bureau of Medical Administration, Ministry of Health Nguyen Van Hoi, Vice Director, Social Protection Department, MOLISA

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EXECUTIVE SUMMARY Background and purpose of the survey In 2012, MOH, MOET and MOLISA, with technical and financial assistance from VNAH and USAID, conducted a national baseline survey of the disability support service system, focusing on the three key sectors of 1) health care, 2) social support/employment, and 3) education. The purpose of the survey was to provide a foundation for a national action plan/strategy to strengthen the existing disability service system, improve coordination between these three key sectors, and ensure quality services are provided to persons with disabilities. The survey included two elements:

Information on the national implementation of the disability service system, and A survey of a sample of persons with disabilities about their needs and their ability

to access disability support services in three selected provinces, one in each of northern, central, and southern Vietnam.

The survey included collection of both qualitative and quantitative data: Policy analysis; Questionnaires for service providers in three sectors in all 63 provinces of Vietnam Focus groups and interviews of key leaders and staff in the three sectors in three

provinces (Hanoi, Quang Tri and Vinh Long); Interviews of persons with disabilities and their family members in three provinces

(Hanoi, Quang Tri, Vinh Long); Questionnaires for non-government service providers.

Summary of findings The findings of the survey are extensive and are detailed in this report. This section reports a summary of the key findings, based on the original research questions. Policy environment for persons with disabilities in Vietnam Research questions: Are current policies appropriate and sufficient for the real needs of persons with disabilities? What are the challenges and difficulties in enforcing and implementing existing policies? Vietnam in 2012 has a relatively comprehensive policy environment for persons with disabilities. The Vietnamese Disability Law introduced in 2010 is very comprehensive, and aligned with the United Nations Convention on the Rights of Persons with disabilities (UNCRPD). In late 2014, Vietnam also ratified the UNCPRD, so all laws, policies and practices will be subject to review under this mechanism.

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In general, government officers and persons with disabilities themselves feel that most laws are appropriate, although officers at local level say they would like clearer, more detailed guidance on laws so to make implementation easier. The key difficulty with the policy environment is implementation of laws and policies. It seems that there is still some overlap or inconsistency in policies at the lower level (decrees, circulars, regulations) as these are created by individual Ministries with insufficient consultation with other Ministries. This causes confusion and difficulties at the local level in knowing how to implement the Disability Law. The survey of government staff in the three sectors and of persons with disabilities and their families indicated extremely low levels of knowledge and awareness about the relevant laws and policies. In particular, staff and persons with disabilities have very poor knowledge about the ‘rights-based’ policies; those policies on vocational training, independent living, employment, business development that are intended to improve the inclusion and independence of persons with disabilities. Thus, at least at the time of this survey, the reality on the ground for most persons with disabilities is still one of being treated as welfare recipients needing care and protection, with little to no access to other support services. Ensuring the effective implementation of this strong policy framework and improving the inclusion of persons with disabilities into the community will not be possible until there is much better knowledge and understanding of the relevant laws. Data collection and analysis is also a weakness in the current policy environment. While the Disability Law 2010 has a definition of disability, individual Ministries and non-government agencies, and different surveys, utilize different definitions and thus come up with different data about persons with disabilities. There is a need for an agreed, nationally applied definition of persons with disabilities and the different impairments. Once this is agreed a national disability information system should be developed (or applied nationally) to collect accurate, quality statistics that can be used for planning and decision making. Recommendations related to the policy environment for persons with disabilities

A greater coordination role for the National Coordinating Council on Disability (NCCD) in the development of laws and policies to ensure consistency with the overarching Disability Law and CPRD, as well as consistency and no overlap in decrees, circulars, regulations developed at Ministerial level. NCCD should be involved in all legislative development processes related to persons with disabilities.

Upgrade the capacity of NCCD to be able to provide appropriate legal and policy development advice to individual Ministries by recruiting legal experts or providing training for existing staff.

Conduct mass education campaigns targeting persons with disabilities, their families and the community in general regarding the approach and content of the Disability Law as well as Decree, Circulars guiding the implementation of the Disability Law.

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Conduct training and professional development for all staff (provincial, district and

commune level) in the three key Ministries about the Disability Law, and the supportive legislation and policies in their field. Focus such training on new, detailed policies such as the regulations on disability determination, and on policies that go beyond social protection.

Develop a consistent definition of disability for the purpose of data collection, and harmonize data collection processes and practices. Discussions to develop the definition should include at minimum, MOLISA, MOH, MOET, General Statistics Office (GSO) and representatives of persons with disabilities. It is recommended that an international approach such as the ICF is used, to enable comparison and collaboration with other countries.

Develop a system whereby local level authorities of DOLISA, DOET and DOH can collect data about persons with disabilities; their needs and access to services, and use this data for planning and staff training purposes. The newly implemented Disability Information System (DIS) could provide an appropriate platform.

Disability service system in health, education and social services sectors Research Questions: What are the strengths and weaknesses of the current support system in healthcare, social support and education in providing qualified services to persons with disabilities? How well does the current disability support system meet the needs of persons with disabilities? How do the sectors coordinate to provide comprehensive services to persons with disabilities? Financial resources for persons with disabilities Most service providers were unable to answer questions about financial resources for persons with disabilities, which seem to largely result from the fact that budget is provided by the central government for specific services and there are few specific line items for specific support for persons with disabilities. It seems that even social welfare payments are provided as one line item, not disaggregated by type of recipient (e.g.: war veterans, persons with disabilities, orphans, people living with HIV and so on). Most provinces estimated a very low amount of spending on persons with disabilities. In addition to this State budget, provinces try to mobilize additional resources from external sources (NGOs, local businesses, communities). However, this additional budget is highly variable and thus does not provide sustainable support for services. There is a need for more transparent budgeting processes, with itemized allocation for services specifically for persons with disabilities (e.g. inclusive education, social welfare payments, vocational training specifically for persons with disabilities). It is hoped that the new process of national action planning (under Prime Minister Decision 1019) will improve the provincial planning and budgeting processes; however, provinces will need technical assistance to implement this successfully.

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Strategic development of a quality disability service system The data collected from the survey on planning for development of support services for persons with disabilities showed that most sector departments lack strategic plans for disability support services. As the survey and interviews were conducted prior to the agreement of the National Action Plan for disability 2012-2020 (NAP), it is hoped that through the NAP dissemination process, each province and national ministry does now have an Action Plan. The NAP process provides a mechanism for better and more strategic planning, if it’s effectively disseminated to the local level and provincial level Ministries are provided support and assistance to develop their own plan. Facilities, training and working conditions The quality of facilities and equipment for services for persons with disabilities is a massive problem for effective service provision. Particularly at the provincial level and below, both buildings and equipment is poor quality, outdated and insufficient. Over 50% of the staff working in the three sectors indicated that additional and/or improved equipment and facilities are top of their list of needs in order to improve service quality. In addition, the working conditions and benefits for staff providing services for persons with disabilities pose a problem for quality service provision. All sectors reported that it is very difficult to attract staff because the cost norm for preferential policies is very low but the responsibility and difficulty of the work is very high. The qualifications and capacity of staff providing disability services is still very limited. Interestingly, despite these difficulties, most staffs who were surveyed indicated high levels of satisfaction with their working conditions, salary and training. Most staff also rated their own performance quite highly, indicating that they do have the skills to perform necessary tasks. Based on high levels of dissatisfaction about the services they provide from persons with disabilities and their family members, and the low level of training/qualifications of staff, it seems this confidence may be overrated. However, it seems clear that people working within the service system are very committed and want to provide good service. This should be capitalized upon by providing increased investment and training. Gaps in service provision This study shines light on the significant gaps in service provision in all three sectors. In particular, there are two significant problems: services are focused on ‘care and protect’ rather than rights and inclusion; and services are primarily available only for people with mobility impairments. On the first issue, the health, education and social services that are currently provided mainly focus on basic survival and does not cater for the higher level skills, education and social empowerment that is necessary for persons with disabilities to exercise their rights as full members of the community. If Vietnam is committed to the rights based approach, and to full integration of persons with disabilities into social and economic life, significant

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investment will need to be made in ‘higher level’ services such as secondary and higher education, vocational skills training, occupational therapy, comprehensive case management and referral, and so on. The second significant shortcoming of the existing service system is that even those basic level services are primarily only able to meet the needs of people with mobility impairments. Even with the limited information provided through this survey, it is clear that in all three sectors, there are very few services for people with sensory or intellectual impairments or mental health difficulties. The current system lacks the qualified staff, equipment and facilities, training opportunities and even basic knowledge about identification of people with intellectual or psychiatric impairments. Filling these gaps in service provision is essential, but will require high levels of investment. The non-government sector (INGOs, NGOs and DPOs) are very small players in terms of the number of people they reach and what they provide. However, they can provide models and target specific issues. There is some evidence that local NGOs and DPOs are reaching out to underserviced communities, such as people with hearing impairments, which should be continued and encouraged. Health services for persons with disabilities The primary responsibility of the health sector is rehabilitation for persons with disabilities. Despite a comprehensive network of hospital rehabilitation departments and a Community Based Rehabilitation (CBR) program, this task of rehabilitation is not meeting the needs of persons with disabilities. Rehabilitation services are too focused on Centers and hospitals, and rehabilitation largely consists of physiotherapy. There is a lack of specialized services for people with other impairments, such as speech and language therapy, occupational therapy, psycho-therapy, etc. This is reflected in the staff qualifications those who primarily have general rather than specific training. There is a need for expanded staff development in specialized rehabilitation skills other than just physical therapy. The CBR program is also failing to meet the needs of Vietnamese with disabilities. Based on the survey of departments of health as well as the persons with disabilities and their families, it seems that few people are currently reached through the program and the outcomes for those who do receive rehabilitation are relatively modest. There is a need for more investment in the CBR system: additional staff; increased training and equipment; expansion into all provinces in the country; and greater ability to provide a range of rehabilitation services. Education services for children with disabilities Vietnam has implemented a formal policy of inclusive education since 2005. However, the majority of provinces responding to the survey are only providing very limited educational services for children with disabilities. In particular, there is a lack of detection and early intervention.

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Limitations to the effective educational services for children with disabilities are similar to other sectors: lack of qualified staff; limited training opportunities; and inadequate infrastructure and equipment such as teaching materials. The Provincial Inclusive Education Centers (IECs)/special schools seem to be the one exception to the rule that most services are provided for people with mobility impairments. It is pleasing to see that these specialized service centers are focused on assisting children who face greater barriers to accessing regular schools, such as those with hearing impairments or intellectual disabilities. However, the figures may be misleading because they include responses from both IECs and special schools, such as schools specifically for hearing impaired children. The training and professional development for teachers in the MOET system seems to be relatively good. Over 70% of teachers reported having received some training in how to teach children with disabilities. While the total number of teachers with higher level degrees in special education is low, most teachers have received at least some instruction in inclusive educational techniques. Teachers however expressed strong desire for more training in how to best support and teach children with disabilities. This effort in teacher training should be continued to ensure more effective implementation of inclusive education policies and plans. Social Services This sector is very diverse with staff from Department of Labor, Invalids and Social Affairs (DOLISA) responsible for social protection, vocational training, employment, social work and a range of other services. In addition, the department has a wide range of disadvantaged people to assist. This makes providing quality services very difficult, particularly with the limited staff and lack of training and qualifications of these staff. A large number of commune and district level staff have only graduated from high school and have no specific training to support persons with disabilities. Training and upgrading the qualifications of DOLISA staff is essential. DOLISA at the provincial level seems far too focused on the ‘social protection’ part of their remit and does not seem concerned about rehabilitation, independent living, employment or skills development; services that could enable social and economic participation. Almost none of the DOLISA offices were able to provide information about vocational training, counseling, employment services, social work, and independent living services for persons with disabilities in their provinces. The Social Protection Centers at provincial level seem relatively well placed to provide basic care and medical support to persons with disabilities, with quite a large number of qualified doctors or nursing staff, and many staff having over 10 year experience working in centers. However, the role of these centers is supposed to be changing, to provide greater

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rehabilitation and independent living skills for persons with disabilities so that they can reintegrate into the community. Based on the results of this survey, centers are totally ill-prepared to take on this role, with no staff having qualifications in vocational training and very few equipped with social work qualifications. If the government is committed to changing the role of these centers, a substantial investment in either recruitment or training, as well as in physical infrastructure and equipment will be required. Coordination between the three sectors Coordination between the three key sectors, which is essential for comprehensive service provision to persons with disabilities, is currently quite poor. Coordination is limited and non-systematic, mainly only happening ‘as needs’ or on the request of persons with disabilities and their family members. Coordination at lower levels seems to be somewhat better – with schools collaborating with local health and DOLISA services to ensure appropriate classification and determination for example. The new ‘Social Work Centers” at provincial level and the Disability Information System software developed with USAID support could potentially provide a vehicle for better coordination of activities. It seems that staff in each sector aren’t really sure how to coordinate their activities, or don’t see it as their responsibility. The remit of these social work centers should be expanded beyond just being DOLISA focused, to provide a central focus for the comprehensive service provision for persons with disabilities, better referrals to necessary services and sharing of activities and information among the three sectors.

Recommendations related to the service system in three sectors: Change the budgeting processes at national and provincial level to allocate specific

funding for persons with disabilities. Currently, all three sectors report that they do not receive dedicated funding for persons with disabilities. In order to ensure adequate funding for services, specific, dedicated funding should be available for key services such as social protection, inclusive education, vocational training, employment services, and social work for persons with disabilities, CBR, detection and early intervention, and rehabilitation.

Improve coordination of policy implementation and service provision through more inclusive provincial planning processes. Each province should involve, at minimum, DOLISA, Department of Education and Training (DOET), Department of Health (DOH) and representatives of persons with disabilities in their annual planning process required under Prime Minister Decision 1019 (National Action Plan). The provincial plan should provide an overall framework for service provision that can then be translated into activity plans at each Ministry.

International donors and NGOs should make more effort to support the Vietnamese government’s attempts to increase services for people with sensory and intellectual impairments and mental health difficulties. Technical assistance and external resourcing will be necessary for Vietnam to develop appropriate services, with trained professionals.

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Increase investment in training specialized rehabilitation skills such as speech and language therapy, occupational therapy, psychiatry, etc.

Upgrade the professional skills of CBR workers, particularly in rehabilitation skills for those with sensory or intellectual impairments and mental health problems.

Extend the CBR program within existing provinces, and to cover all provinces.

Extend the services of the CBR program to ensure comprehensive rehabilitation, not just physical therapy. Improve the ability of community based CBR workers to refer persons with disabilities to necessary services such as education, vocational training, employment, specialized health services, etc.

Ensure every province has a Social Work Center, and pilot models of comprehensive service delivery through these facilities. Extend these Centers to include staff from DOH (CBR workers) and DOET (inclusive education staff), and provide information to all staff about the ‘case management’ approach piloted in Da Nang with USAID funding. Share the lessons of different approaches to case management and comprehensive service delivery with all provinces.

Needs and access to services for persons with disabilities Research questions: How diverse are the support needs of persons with disabilities and their families and what are the difficulties and obstacles for them to fully access necessary services? Are there any models of a comprehensive support system in Vietnam which seem feasible and viable for wide dissemination in Vietnam? The picture that emerges from the interviews with persons with disabilities and their family members is one where the vast majority of persons with disabilities are largely confined to their homes, poor and uneducated with their families struggling to provide them with the services they need and government providing only welfare payments to assist. Persons with disabilities and family members have very low levels of knowledge about and even less accessibility to most government services in all three sectors. For example, 80% of families have difficulties providing food, clothes and accommodation, 88% face difficulties in healthcare, 77% in rehabilitation, 70% of families face difficulties helping their disabled children access education and 79% of families struggle to assist their disabled members with activities of daily life. Cost is a major barrier, as is transport and accessibility of buildings. Even more concerning is that it seems despite high levels of poverty and disadvantage, persons with disabilities and their families don’t seem to feel that they need any services such as secondary or tertiary education, vocational training or employment that would help promote the greater inclusion and independence of disabled people. Overall, persons with disabilities in urban areas are better serviced than those in rural or peri-urban areas. Persons with disabilities indicate that they mainly access services at the

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local level, i.e. the commune level, however much of the disability service infrastructure such as hospitals and inclusive and special schools is based at provincial centers. This poses a significant problem for access since many persons with disabilities face difficulties in accessing transport and many families with a disabled member are very poor and cannot afford to regularly travel to central services. Knowledge of services by persons with disabilities and their families The knowledge about and access to health services is very poor. Other than commune health services, less than 50% of persons with disabilities knew about or had accessed any other kind of health service, including CBR, provincial and even district hospitals. The lack of knowledge about CBR services is particularly concerning considering it is the main way for the Ministry of Health to provide rehabilitation services to persons with disabilities particularly in rural areas. Persons with disabilities and their family members are also very unaware of educational services. Even at the commune level, people didn’t know about any inclusive schools indicating a lack of awareness of the inclusive education policy among persons with disabilities. There is a need for more outreach by schools and education sector to educate families about the options available for the education of their children. Knowledge about social/employment services other than social protection centers is also poor, although reassuringly quite a large percentage of persons with disabilities/family members did know about their local DPO, despite the fact that neither Vinh Long nor Quang Tri has provincial level DPOs. Are the needs of persons with disabilities being met? In terms of health, health insurance, diagnosis and basic health care are relatively well serviced for persons with disabilities. Unmet needs are in the areas of surgery, orthopedic and other assistive devices and equipment, hospital based rehabilitation and referrals to other levels for treatment. In the social/employment sector, the most common service provided by DOLISA is a monthly social protection payment, however less than 65% of the people surveyed who are in need of such support have received it. It was also striking in the survey of persons with disabilities and family members that expectations for social/employment services were very low. Only a very small number of people expressed that they needed vocational training services, employment assistance, social work, or so, and an even smaller number of these had been able to access such services. Unless these attitudes change and people demand services that can help them integrate and live independent lives, the service provision is unlikely to improve. In education, service provision was marginally better with 70% of those surveyed who had need for educational services having accessed services. However, knowledge about

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services provided in the education sector was still low. Even at the district/commune level, most (77%) persons with disabilities/caregivers seemed totally unaware of schools that could enroll persons with disabilities, non-government services or educational support services at higher levels (district or province level). Most of the persons with disabilities who were interviewed have not had to pay for the social support services they receive because they are in receipt of a benefit/health care card; however they were also not happy with the quality of service required. These interviews with persons with disabilities paint quite a poor picture of the access to and satisfaction with the service delivery system. This group at least has low awareness of their rights and the services they’re entitled to, low expectations of what services they should receive, and limited access to assistance from the government. Families seem to provide the basic care and welfare for the majority of persons with disabilities interviewed with very little external assistance, and facing great difficulties. The ability of the persons with disabilities to integrate into life and work is extremely limited – many do not even participate in family activities let alone integrate into society as full members. Recommendations related to the needs and access of persons with disabilities to services in three sectors:

Invest in education of persons with disabilities and family members about their rights to access all health, education and social services, and their right to live independently.

Upgrade the knowledge for persons with disabilities and family members about what services are available and how to access them. The most cost effective way to achieve this is through mass media and local information services such as loudspeakers. Consideration should be given to effective ways of reaching hearing impaired people – this may require additional research. Use the network of DPOs for awareness raising and providing information about available services.

More effort from sector staff to reach out to the community and provide accessible information about what services they provide – especially through DPOs, special schools, and NGOs and other agencies who have access to persons with disabilities (The Blind Association, Social Protection Centers, or so).

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Part I: Introduction and methodology of the Baseline Assessment of the Disability Support System in Vietnam

1. Introduction, objectives and scope of the assessment

1.1. Background According to the most recent and accurate data from the Vietnam National Census 2009, there are 6.7 million persons with disabilities (7.8% of the population) in Vietnam1. Persons with disabilities in Vietnam have long been considered by the State as a target group for community support and assistance. In 2010, the National Assembly of Vietnam officially enacted a National Law on Disability, effective from January 1st, 2011 – marking a significant advancement in the gradual improvement of the legal framework to ensure the rights of persons with disabilities. The introduction of the law has also stimulated additional mobilization of resources and participation of government, non-government organizations (NGOs), related stakeholders, persons with disabilities and their families in order to build a barrier free and rights based society to ensure the full inclusion of Vietnamese with disabilities. However, the legal framework is a necessary but not sufficient condition to ensure effective and sustainable efforts to include persons with disabilities. With the legal framework as foundation, there is a need for a comprehensive disability support service system which coordinates assistance by different sectors to respond to the diverse needs of persons with disabilities. Until now, there hasn’t been any formal research or assessment of the current disability service system, reports from workshops, and information collected from monitoring trips by projects supporting persons with disabilities indicate that there are a lot of shortcomings and challenges in service provision, particularly in terms of coordination between the key sectors of health, education and labor/social affairs. It seems that many disability support services are well delivered within one sector, however individual sector services are not comprehensive enough to meet the needs of persons with disabilities and there is insufficient coordination and cross-referral between sectors. Being aware of these issues, the Ministry of Health (MOH), Ministry of Education and Training (MOET), and Ministry of Labor, Invalids and Social Affairs (MOLISA), with technical and financial assistance from VNAH and USAID have conducted a national baseline survey of the disability support service system, focused on the three key sectors of 1) health care, 2) social support/employment, and 3) education. The results of the survey will provide a foundation for a national action plan/strategy to strengthen the existing disability service

1 The survey used the Washington short set group of questions, based on the International Classification of Functioning, Disability and Health of the World Health Organisation. The questions were asked of a sample of 10% of the population, randomly selected in all provinces of Vietnam. See section 4.3 for more information about prevalence of persons with disabilities in Vietnam.

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system, improve coordination between these three key sectors, and ensure quality services are provided to persons with disabilities. The baseline survey aims to provide quantitative data and qualitative information about the support system for persons with disabilities in the three sectors of 1) health, 2) social support/employment, and 3) education and training. This includes gaps and barriers to access for persons with disabilities and their families, to serve as a foundation to develop a strategy and support policy for persons with disabilities. The baseline survey includes two elements:

(a) Information on the national implementation of the disability service system, and (b) A survey of a sample of persons with disabilities about their needs and their ability to

access disability support services in three selected provinces, one in each of northern, central, and southern Vietnam.

1.2. Objectives and Research Questions

The objectives of the survey included:

(a) Analysis of current disability policies and laws to support persons with disabilities and comparative analysis with the international legal framework.

Research question: Are current policies appropriate and sufficient for the real needs of persons with disabilities? What are the challenges and difficulties in enforcing and implementing existing policies? (See section 3 of this report)

(b) Description of the situation of the current disability service system in the three

sectors of health care, education and social/employment. The assessment includes; the service system, resources, staff capacity, implementation of service delivery, service quality and products, accessibility to services for persons with disabilities, service delivery mechanism, multi-sector coordination of service delivery and challenges facing the sector. (See section 4 of this report)

Research questions: What are the strengths and weaknesses of the current support system in

healthcare, social support and education in providing qualified services to persons with disabilities?

How well does the current disability support system meet the needs of persons with disabilities? How do the sectors coordinate to provide comprehensive services to persons with disabilities?

(c) Analyze the needs and accessibility of persons with disabilities to necessary

services in the existing system. (See section 5 of this report)

Research question: How diverse are the support needs of persons with disabilities and their families and what are the difficulties and obstacles for them to fully accessing necessary services?

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(d) Analyze if any feasible and comprehensive disability support systems have been implemented in Vietnam. (See section 6 of this report)

Research question: Are there any models of a comprehensive support system in Vietnam which seem feasible and viable for wide dissemination in Vietnam? 2. Methodology The assessment included a very comprehensive survey nationwide of the existing government and non-government service provision system for persons with disabilities. Extensive surveys were carried out to collect quantitative information nationwide, and qualitative interviews of key informants, persons with disabilities and their family members was conducted in three provinces.

2.1. Objects and scope of the assessment The methodology for the four elements of the assessment was as follows:

(a) Analysis of current disability policies and laws: collection, desk review and

analysis of all relevant laws and policies that guide service provision for persons with disabilities. Preparation of a report on the policy analysis.

(b) Description of the situation of the current disability service system in three

sectors: included both quantitative and qualitative elements. A quantitative survey was conducted nationwide, through questionnaires to the following objects:

The disability service system in the three sectors of health, social/employment and education (public sector).

Technical staff in areas of rehabilitation, education and social support. Non-government organizations working to support persons with disabilities. Local authorities.

Qualitative information to support the survey data was collected through interviews and focus group discussions with technical staff and leadership of government departments and local authorities in each of the three sectors in four communes of two districts in each of three provinces/cities representing the three main regions of northern, central and southern Vietnam: Hanoi, Quang Tri and Vinh Long. Selecting three provinces aimed to facilitate the comparison of needs and services between the three regions.

(c) Analyze the needs and accessibility of persons with disabilities to necessary services: a survey of persons with disabilities and their families was carried out in the selected districts and communes.

(d) Analyze feasible and comprehensive disability support systems: models/practices for support of persons with disabilities were analyzed in the selected provinces and districts.

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Table 1. Survey Location

Province/City District/Town Commune/Ward Type

Ha Noi Cau Giay district

Nghia Do ward Urban

Trung Hoa ward

Thanh Oai district Kim Bai town Urban Dan Hoa commune Rural

Quang Tri Dong Ha city

Ward No. 1 Urban

Do Luong ward

Vinh Linh district Vinh O commune Rural Ho Xa town Urban

Vinh Long Vinh Long city

Tan Hoi commune Rural Ward No. 3 Urban

Tra On district Tra On town Urban Tra Con commune Rural

2.2. Framework of the assessment

Based on the objectives, the baseline assessment was conducted based on two themes:

Theme 1: Survey of the current situation of disability support system:

(a) Health sector (under MOH) including, but not limited to, rehabilitation, early detection and early intervention, disability prevention, health insurance for persons with disabilities, CBR, etc.

(b) Social/employment sector (under MOLISA) including, but not limited to, social work, social welfare, social services such as job training and creation, psychological counseling/advice, capacity building/life skills for persons with disabilities and families/care takers, CBR.

(c) Education and Training (under MOET) including, but not limited to, early detection and intervention, special and inclusive education services for persons with disabilities, etc.

Theme 2: Assess elements impacting coordination in providing comprehensive

support for persons with disabilities:

(a) Current laws and policies stipulating rights to access, benefit from disability services, regulations and guidelines on the management and organization of disability support system. This content was analyzed to identify: advantages, suitability, restrictions and obstacles in implementation.

(b) Needs of persons with disabilities and access conditions of support. Needs and accessibility of persons with disabilities were assessed in general, as well as specific needs based on population characteristics, geography, types of impairment, etc.

(c) Information sharing amongst sectors.

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(d) Technical support cooperation.

(e) Referrals between sectors.

(f) Role of authorities in ensuring and strengthening cross-sector cooperation in supporting persons with disabilities.

(g) Lessons about conditions, management know-how, organization of comprehensive support to persons with disabilities based on successful and feasible models for potential replication.

2.3. Survey methodologies, approaches and sampling

The survey used both qualitative and quantitative approaches. Quantitative data was collected to assess and describe the existing situation and more detailed qualitative interviews in the three selected provinces provided insight into the causes and nature of issues raised during the survey. Table 2 below summarizes the approaches and tools used to collect the information and data forming the basis of this report.

Table 2. Summary of Survey Methodology and Response Rate

Information Source/

Research Subjects

Tools and approaches used for data collection Response rate

Policy

Policy documents Qualitative: comparative analysis of the policies 47 policies/legal documents

Health System

Service Providers Quantitative: Questionnaires to Provincial Department of Health (form 5A)

57 responses (90% of total provinces) however 3 removed due to lack of data. 54 provinces analyzed (86%)

Quantitative: Questionnaires to Nursing and Rehabilitation Hospitals, and Rehabilitation Departments of Provincial General Hospitals (form 6A)

48 responses from Rehabilitation Department of Provincial General Hospitals (78% of total) and 30 forms from Rehabilitation Hospitals and Sanitariums (75% of total)

Qualitative: In-depth interview with director of the Provincial Rehabilitation Hospital in each of 3 provinces

3 interviews

Leadership and Rehabilitation Staff

Quantitative: Questionnaires to technical staff working in provincial rehabilitation hospitals. (Form 7A)

512 responses of 517 sent (99%)

Qualitative: In-depth interviews with key staff in 3 provinces. Provincial – Interview leader of provincial Department of Health in each of 2 provinces (Hanoi missing) District – Interview 1 technical staff member from the district level health department in each of 6 districts Commune – Interview 1 director of a commune

23 interviews

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health station in 2 communes of each of 6 districts (one town and one rural commune)

Focus group discussions

Focus Group Discussions with health staff in three provinces Province – 1 group of staff of rehabilitation hospital in each of 3 provinces District – 1 group of staff of district health center in each of 5 districts (Dong Ha district missing)

8 groups (7-15 people in each group)

Education System

Service Providers Quantitative: questionnaires to DOET at provincial level. (form 5B).

40 responses (63% of total provinces).

Quantitative: Questionnaire to special education school and inclusive education schools (form 6B)

56 responses from Inclusive Education Centers (IEC)/Special schools (70% of total 80 sent). 50 responses from Inclusive Education Schools/Establishments (94% of total 53 sent).

Qualitative: In-depth interview with Inclusive education centers, Inclusive education support center, early intervention center in Vinh Long and Quang Tri.

4 interviews

Technical staff Quantitative: Knowledge – Attitude – Practice (KAP) questionnaires to teachers (form 7B)

169 responses of 200 (84.5%)

Qualitative: In-depth interviews with key staff in 3 provinces. Provincial - Leader of provincial Department of Education and Training in each of 2 provinces (Hanoi missing) 1 technical staff member at provincial level in 2 provinces (Hanoi missing) District - 1 technical staff member at district level in 4 districts 6 interviews with representatives of special schools for children with disabilities, inclusive education schools in Vinh Long and Quang Tri.

14 interviews

Focus group discussions

Focus Group Discussions with staff in three provinces. At provincial level: Hanoi – representatives from the Research Center for Special Education of Hanoi University of Pedagogy Vinh Long – representatives of Inclusive Education Support Center for Children with Disabilities Quang Tri – representatives of Quang Tri special school for children with disabilities District - one group in each of 6 districts

9 focus groups (7-15 people in each group)

Social/Employment Sector Service providers Quantitative: questionnaires to DOLISA (form 5C) 48 provinces (89% of total)

Quantitative: questionnaire to social protection centers (form 6C)

114 centers responded of 150 total (76%)

Qualitative – interviews with leader of Social Protection Center in three provinces

3 interviews

Leadership and technical staff

Quantitative: KAP questionnaire to DOLISA staff (primarily in social protection centers) (form 7C)

116 of 116 (100%)

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Qualitative: Interview with leaders and technical staff. Provincial – Interviews with leader of DOLISA in three provinces Interviews with technical staff of DOLISA in three provinces District – Interview with leader of district level in 6 districts in three provinces Commune – Interviews with labor-social staff of 12 communes in three provinces

24 interviews

Focus group discussions

Focus Group Discussions with staff in three provinces Provincial – one group at each of three Social Protection Centers District – one group at each of 6 districts

9 groups (7-15 people in each group)

Non-Government Organizations (NGO) and Disabled Persons Organizations

NGOs Quantitative: E-questionnaire to local and international NGOs and DPOs

15 responses

Persons with disabilities and their families PWD, families and representatives

Quantitative: questionnaires to persons with disabilities/families (form 8AB)

1203 persons with disabilities or families interviewed (701 representatives and 502 persons with disabilities)

Qualitative: Focus Group Discussions 12 groups in 12 communes in 6 districts

Local authorities Leaders of People’s Committees

Interviews with senior members of People’s Committees in 2 provinces (not Hanoi), 11 districts/wards/towns of 3 provinces

11 interviews

2.4. Survey Tools

A range of different questionnaires were used for implementation of both the qualitative and quantitative surveys:

Qualitative: Questionnaire for group discussions with provincial technical staff (DOH, DOLISA and

DOET); Questionnaire for group discussions with staff at the commune and district levels (DOH,

DOLISA and DOET); Questionnaire for group discussions with staff at the social protection centers; Questionnaire for interviews with staff at the national level (ministry); Questionnaire for interview with provincial staff (DOH, DOLISA and DOET); Questionnaire for interview with district staff (DOH, DOLISA and DOET); Questionnaire for interview with commune staff (DOH, DOLISA and DOET); Questionnaire for interview with staff at the social protection centers.

Quantitative: Questionnaire for interview of persons with disabilities;

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Questionnaire for interview of persons with disabilities family members; Questionnaire for baseline survey in 63 provinces, sent to DOH, DOLISA and DOET,

and; Questionnaire for baseline survey of social protection centers.

2.5. Data collection process

The assessment was conducted in collaboration with MOET, MOH and MOLISA during 2012. An advisory committee was established with members from MOH Bureau of Medical Administration, MOLISA Department of Social Protection (SPD), MOET Steering Committee on Inclusive Education of Children with Disabilities and Disadvantaged Children, VNAH, and USAID. The Advisory committee provided guidance for the strategic objectives, scale of the assessment and the objects for the survey. Each of the three ministries formed a technical survey team for their respective sector assessment. These technical teams participated in designing survey tools, conducting the data collection and writing a report for their respective sector. The MOH technical survey team consisted of staff and lecturers from the Rehabilitation Department of Hanoi Medical University (HMU). The MOET technical survey team consisted of staff and researchers from the Vietnam Institute of Education Sciences. The MOLISA technical survey team consisted of staff from the Institute of Labor Science and Social Affairs. In addition, a team of three national independent consultants and one international consultant were contracted to provide technical assistance to the three ministerial survey teams, including designing survey tools, conducting data collection training, and providing comments and inputs for the sector reports. Data processing and analysis was done by the Department of Statistics and Epidemiology of the Hanoi School of Public Health.

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Figure 1. Structure of the survey team

2.6. Limitations of the survey The response rate to the questionnaire of service providers is relatively low; particularly the provincial departments in each sector, thus the data and information may not fully reflect the overall picture of the current situation of the country. In addition, many of the questionnaires which were returned had a lot of missing information, making the response rate on certain questions very low and reducing the reliability of the data. Information on the needs of persons with disabilities, accessibility to services, level of satisfaction, employment/job, and difficulties of persons with disabilities in their daily lives is not representative of the population of persons with disabilities as the sample size for the survey was not large enough, doesn’t represent all socioeconomic regions of Vietnam and was not randomly selected. Thus, the data should not be seen as a reflection of the situation of all persons with disabilities or all provinces, or used to indicate prevalence of disability in the general population. However, as the purpose of the survey was mainly to evaluate the disability service system and enable some comparison and analysis of the service system for persons with disabilities, the sample is sufficiently large, and represents the situation in three provinces. As those people selected are likely to be those who have some contact with the service system, their input is valuable. The scale and cross sector nature of this assessment meant that the actual data collection process took quite a long time, from April 2012 to the reports being completed in late 2013, and this final national report completed in April 2015. Thus, some of the information collected is out of date. For example, additional decrees and circulars guiding the implementation of the disability laws have been developed since the data on the policies was collected.

Health Survey Group

& 1 local

consultant

Social/Employment Survey Group

& 1 local consultant

Education Survey Group

& 1 local

consultant

Core expert team International consultant, 3 local consultants and 3

representatives from the Ministry/sector groups (each local consultant is assigned to each sector group)

Group of Advisors Representatives from

MOH, MOLISA, MOET, NCCD, USAID

Secretaries

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Part II: Findings of the Baseline Assessment 3. Analysis of policies to support persons with disabilities

in Vietnam The baseline assessment considered two aspects of policy analysis: i) the appropriateness of the existing policies on disability and to what extent the policies were in line with the international legal framework, and ii) the coverage and enforcement of the existing policies in Vietnam.

3.1. The relationship between Vietnamese disability policies and the international legal framework

Three international instruments are considered key enablers of policy and legislation support for persons with disabilities in the Asia Pacific region: the UN Convention on Rights of Persons with Disabilities (CRPD), the UNESCAP BIWAKO Millennium Framework (BMF) in the Asia-Pacific region, and the Millennium Development Goals (MDG). In Vietnam, the National Law on Disability agreed in 2010 and enacted in early 2011 is the highest legal document relevant for persons with disabilities. Implementation of the Disability Law is primarily achieved by the development and approval of the National Action Plan (NAP) for period 2012-2020 (GVN Decision 1019). In addition, in 2007 Vietnam signed the UN Convention on the Rights of Persons with disabilities (UNCRPD). Of the thirty basic articles of the UNCRPD, twenty five articles were applied in the National Law on Disability and the NAP. The harmonization of the National Law with the key principles of the CRPD indicates that the government of Vietnam is transitioning from a charity approach of ‘care and protection’ of persons with disabilities to the rights based approach enshrined in the UNCPRD and accepted internationally as best practice. However, this transition is still in process. For example, there is a key issue with the definition of person with a disability in the Vietnamese Disability Law, which takes a medical approach rather than the functioning and environmental barriers approach considered as international best practice, and enshrined in the UN Convention.

CRPD: “Persons with disabilities include those who have long-term physical, mental, intellectual or sensory impairments which in interaction with various barriers may hinder their full and effective participation in society on an equal basis with others”. Vietnam Disability Law: “Person with disabilities means a person who is impaired in one or more body parts or suffers functional decline manifested in the form of disability which causes difficulties to his/her work, daily life and study”.

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Table 3. Comparison of CRPD and Vietnam Law/ National Action Plan (NAP), 2012-2020

CRPD key articles Corresponding features in Vietnam Law

Corresponding features in NAP

Equality and non-discrimination Article 14 – Prohibited Acts Women with disabilities Children with disabilities Chapter 4-Education, Articles 27-31 Awareness raising Awareness raising on disability

and relevant issues Accessibility Article 39. Condominiums and public

works Article 40. Schedules for improvement of condominiums and public works

Construction accessibility Transportation accessibility ICT accessibility

Right to Life Situations of risk and humanitarian emergencies

Equal recognition before law

Article 4. Rights and obligations of persons with disabilities Article 7. Responsibilities of agencies, organizations and individuals

Access to justice Article 5. State policies towards persons with disabilities Article 7. Responsibilities of agencies, organizations and individuals

Legal assistance

Liberty and security Article 4. Rights and obligations of persons with disabilities

Freedom from torture or cruel, inhuman or degrading treatment or punishment

Article 14. Prohibited Acts

Freedom from exploitation, violence and abuse

Article 14. Prohibited Acts

Protecting the integrity Article 14. Prohibited Acts

Liberty of movement and nationality

Article 4. Rights and obligations of persons with disabilities

Living independently and being included in community

Article 4. Rights and obligations of persons with disabilities Article 25. Community-based functional rehabilitation

Personal mobility Article 41. Movement of persons with disabilities Article 42. Means of mass transit

Provision of assistive devices

Freedom of expression and opinion, and access to information

Article 13. Information, communication, education Article 43. Information technology and communication

Respect for privacy Respect for home and family

Article 8. Responsibilities of families

Education Article 27. Education for persons with disabilities Article 28. Modes of education applicable to persons with disabilities Article 29. Teachers, education administrators and education support personnel Article 30. Responsibilities of educational institutions Article 31. Integrative education development support centers

Education

Health Article 21. Primary healthcare at places of residence Article 22. Medical examination and treatment Article 23. Responsibilities of medical examination and treatment establishments

Early detection and intervention

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Habilitation and rehabilitation Article 24. Orthopedic and functional rehabilitation establishments Article 25. Community-based functional rehabilitation Article 26. Scientific research, training of experts and technicians, manufacture of equipment for persons with disabilities.

Early detection and intervention, orthopedics, rehabilitation and provision of assistive devices

Work and employment Article 32. Vocational training for persons with disabilities Article 33. Employment for persons with disabilities Article 34. Production and business establishments employing many persons with disabilities Article 35. Policies for recruitment of persons with disabilities

Vocational rehabilitation, vocational training and employment

Adequate standard of living and social protection

Article 44. Monthly social allowances and care-taking fund supports Article 45. Nurture of persons with disabilities in social-relief establishments Article 46. Funeral expenses Article 47. Establishments taking care of persons with disabilities Article 48. Responsibilities of establishments taking care of persons with disabilities

Participation in political and public life

Article 9. Organizations of persons with disabilities, organizations for persons with disabilities Article 11. Vietnamese Day of Persons with Disabilities

Participation in cultural life, recreation, leisure and sport

Article 36. Cultural, physical training, sport, entertainment and tourist activities for persons with disabilities Article 37. Organization of cultural, physical training, sport, entertainment and tourist activities of persons with disabilities Article 38. Responsibilities of cultural, physical training, sport, entertainment and tourist establishments.

Culture, tourism and sports assistance

Statistics and data collection

Article 50. Responsibilities of ministries, ministerial-level agencies and People’s Committees at all levels

Targets, definition of impact

International cooperation Article 12. International cooperation on persons with disabilities

National implementation and monitoring

Chapter 2. Disability Certification; Articles 15 -20 Article 6. Socialization of assistance activities for persons with disabilities Article 10. Funds for assistance of persons with disabilities Article 49. State management agencies in charge of affairs related to persons with disabilities Article 50. Responsibilities of ministries, ministerial-level agencies and People’s Committees at all levels Article 51. Application of law 2012 Decree on Stipulating in Detail and Guiding the Implementation of Some Articles of the Law on Persons with Disabilities

Human resource development, and monitoring and evaluation Targets Measures for implementation Budget Definition of impact Responsibilities of Ministries

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3.2. Domestic policy framework for support of persons with disabilities in Vietnam

The legal and policy framework for persons with disabilities in Vietnam is relatively comprehensive. As discussed, the Vietnam Law on Persons with Disabilities is the highest legal document providing the framework for all other laws, policies and action plans for persons with disabilities. This Law is translated into specific measures through decrees, circulars and directives at the Ministerial or inter-Ministerial level, based on their sector responsibility. The following tables summarize the policy framework for each of the three sectors: health, education and social/employment.

3.2.1. Legislation regulating education for children with disabilities

Table 4. Legislation regulating education for children with disabilities

Document Details

Decree 49/2010/ND-CP of the government, dated

1 July 2010 regulating tuition fee

exemption/reduction and support of learning cost

for school years of 2010-2011 to 2014-2015.

Children, pupils and students with disabilities having

financial difficulty will be exempted or reduced tuition fee

(Point 3, Article 4) and supported the costs of learning

(Point 2, Article 6).

Decree 61/2006/ND-CP of the government, July

2006 on policies for teachers, managers working

for the special schools, and in the areas with

difficult socio-economic conditions.

Teachers and managers working at schools or classes with

children with disabilities will receive an allowance of 70%

current salary (Point 2, Article 5).

Inter-Circular 06/2007/TTLT-BGDDT-BNV-BTC of

MOET/MOHA/MOF, dated 14 July 2006 guiding

implementation of Decree 61/2006/ND-CP dated

20 June 2006 by the Government.

Guiding the implementation of policies for teachers,

managers working at special schools, and in areas with

difficult socio-economic conditions.

Decision 23/2006/QD-BGD&DT of MOET, dated

22 May 2006 on inclusive education for persons

with disabilities.

Specific regulations on organization and activities of

inclusive education; teachers, and support staff; persons

with disabilities in inclusive education establishments;

facilities; equipment and teaching aids for inclusive

education.

Correspondence 9890/BGD&DT-GDTH of MOET

dated 17 September 2007 guiding the content

and methodology of teaching disadvantaged

children.

The training content is primarily based on the common

education program and curriculum, and adjusted to the

ability and learning conditions of students.

Students with disabilities will have individual learning plan

and their progress will be reviewed annually.

Correspondence 9547/BGDDT–GDTH of MOET

dated 13 October 2008 guiding application for

inclusive education by students with disabilities.

Besides the application documents required for all students,

students with disabilities need to have individual education

plan (personal information and monitoring progress of

students).

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3.2.2. Legislation regulating social protection, labor and employment for disabilities

Table 5. Legislation regulating social/employment sector

Document Details

Decree 136/2013/ND-CP of the government, dated 21 October 2013 on social support policies.

Regulating social support policies, in particular emergency social support at community, nursing in community, nursing and care in social protection centers and social centers.

Circular 23/TC/TCT of Ministry of Finance (MOF), 26/4/1996 guiding tax exemption procedure by enterprises specifically for employees with disabilities.

Regulating all types of tax that enterprises for persons with disabilities are entitled to be exempted including sales tax, income tax, land tax, tax on the use of agricultural land.

Vocational Training Law (Law No. 76/2006/QH) approved by the National Assembly on 29 November 2006 and took effect on 01 June 2007.

Article 7 – Chapter I – General Provision, point 4: Regulating those who are entitled to vocational training for job placement and self-employment (including persons with disabilities). Chapter V – regulating rights and responsibilities of enterprises in vocational training activities: Point 2 – Article 55: Enterprises can organize vocational training for their employees; and are entitled to preferential policies when providing vocational training programs or employing persons with disabilities. Chapter VII – regulating vocational training for persons with disabilities, including Articles 68, 69, 70, 71 and 72:

- Article 68: Objective of vocational training for persons with disabilities.

- Article 69: Regulations for vocational training establishments for persons with disabilities

- Article 70: Policies for vocational training establishments for persons with disabilities.

- Article 71: Policies for persons with disabilities enrolled in vocational training.

- Article 72: Policies for teachers involved in vocational training for persons with disabilities.

Decree 139/2006/ND-CP of the Government dated 20 November 2006 guiding the implementation of the Education Law and the Labor Code

- Article 22 – point 3: Vocational training centers for war invalids, persons with disabilities, persons of ethnic minorities and the unemployed are entitled to tax reduction and exemption.

- Article 24 – policies for people involved in vocational training including scholarship, school fee support, tuition fee exemption and reduction under Article 33 of Decree 75/2006/ND-CP of the Government dated 2 August 2006 regulating in details and guiding implementation of some articles on vocational training for persons with disabilities within the Education Law.

Circulars/Decrees/Decisions in the process of development Circular of MOH on Community Based Rehabilitation

36

3.2.3. Legislation regulating health care and rehabilitation for persons with disabilities

Table 6. Legislation regulating health and rehabilitation

Document Details

Decree 136/2013/ND-CP, dated 21 October 2013.

Regulating social support policies for social protection objects. Article 9. Provision of health insurance for persons with moderate and severe disabilities.

Inter-Ministerial Circular 37/2012/TTLT-BLDTBXH-BYT-BTC-BGDDT, dated 28 December 2012 by MOLISA, MOH, MOET and MOF.

Regulating disability classification and determination by the Communal Disability Classification Council.

Inter-Ministerial Circular 34/2012/TTLT-BYT-BLĐTBXH, dated 28 December 2012 by MOLISA and MOH.

Regulating disability classification and examination by the Provincial Health Examination Council.

Circular 14/2014/TT-BYT by MOH dated 14 April 2014

Regulating the referral mechanism between health care facilities.

The objective by 2015 for the National Targeted Program on Health

100% patients with disabilities enrolled in rehabilitation programs and disability prevention programs

Directive 03/2007/CT-BYT by MOH on strengthening rehabilitation activities.

- Promote information, education and communication on the role of rehabilitation in health protection, care and improvement, particularly disability prevention, disability detection and intervention.

- Develop a nationwide rehabilitation system from commune, district, provincial to central levels.

- Provide facilities and equipment for rehabilitation departments and rehabilitation departments, renovate or build new rehabilitation departments, focusing on developing rehabilitation techniques.

- Sustain and develop the CBR program, improve and standardize the CBR training program for use on national scale.

3.3. Challenges regarding the policy framework

Despite the comprehensive legal and policy framework outlined above, and some efforts by government, NGOs and civil society to educate the public and government officials about the contents and implementation, there are still significant challenges in these laws and policies actually having an impact on the lives of persons with disabilities. The results of the surveys and in depth interviews with local authorities, sector departments and persons with disabilities and their families conducted as part of the VNAH survey highlighted several short-comings:

The level of support stipulated in the policies often does not meet the needs of persons

with disabilities. In particular, many policies are developed such that only a small number of people are entitled to assistance compared to a very high number of people in need of support. For example, the eligibility criteria for monthly social protection payments only include people with severe disabilities and without family or other caretakers. However, in

37

reality many people with minor or moderate impairments but without jobs or income also need monthly allowances.

The social protection monthly allowance is very low (below the poverty line) and not responsive to changes in the market and the society. The total budget for social protection is also very low, so that many people who qualify for assistance nevertheless do not receive it due to budget shortfalls.

The overall framework is provided by the Disability Law, then circulars, decrees and guidelines for implementation are developed by each sector Ministry. This can mean overlapping and even contradictory policies.

As indicated in the survey, the understanding and effective enforcement of policies is challenging for many government staff and officers, especially at lower levels of administration (district and commune level).

There is a lack of communication and training on enforcement of policies leading to highly inconsistent implementation in different provinces and even within provinces in different districts and communes. At commune level, most officers and staff did not know anything about relevant disability policies.

The administrative procedure to identify eligible recipients is complicated without clear guidelines making it difficult for local government staff to implement policies.

The majority of persons with disabilities and their families do not have a good understanding of their rights and responsibilities as stipulated in the law and relevant policies. Thus, they do not seek out relevant information about their rights or demand the services they are entitled to.

There is insufficient coordination and cooperation amongst different agencies and sectors in health care and providing opportunities for persons with disabilities to participate in society.

3.3.1. Knowledge of the policies among relevant staff The survey of health, education and social protection center staff included questions to self-assess the knowledge of relevant policies for persons with disabilities, including domestic laws such as the Disability Law as well as international instruments such as the United Nations Convention on the Rights of Persons with disabilities. Responses were assessed in three categories; ‘Don’t know’ means having never heard of the policy, ‘knowing partially’ means the staff have heard about the policies, can name some contents of the document, or discuss what the document is about in general, and ‘knowing fully’ means that staff can explain the essential contents of the document. The results from the survey for staff from the three sectors are as follows:

38

Knowledge of relevant policy among social/employment staff

Table 7. Levels of Social Protection Center staff knowledge of disability-related policies

No. Policies Level of knowledge (N= 116) Don’t know Know partially Know fully

1 Disability Law 10 (9%) 81 (70%) 25 (22%) 2 Law on Healthcare 61 (53%) 45 (39%) 10 (9%) 3 Law on Education 49 (42%) 55 (47%) 12 (10%) 4 Health Insurance policies 7 (6%) 81 (70%) 28 (24%) 5 Decree 67/2007/ND-CP, Decree 13/2010/ND-

CP on Social Protection 11 (10%) 78 (67%) 27 (23%)

6 Other disability-related social protection policies 9 (8%) 81 (70%) 26 (22%) 7 The UN Convention on the Rights of Persons

with Disabilities 27 (23%) 77 (66%) 12 (10%)

8 The UN Convention on the Rights of the Child 29 (25%) 76 (66%) 11 (10%) Knowledge of relevant policy among health staff

Table 8. Levels of health staff knowledge of disability-related policies No. Policies Level of knowledge (N = 512)

Don’t know Know partially Know fully 1 Disability Law 80 (16%) 344 (67%) 88 (17%) 2 Law on Healthcare 41 (8%) 325 (64%) 146 (29%) 3 Health insurance policies 37 (7%) 258 (50%) 217 (42%) 4 United Nation Convention on the rights of

persons with disabilities 130 (25%) 290 (57%) 92 (18%) 5 United Nation Convention on the rights of the

child 86 (17%) 321 (63%) 105 (21%) 6 Policies on medical fee reduction and

exemption, rehabilitation for persons with disabilities 66 (13%) 262 (51%) 184 (36%)

Knowledge of relevant policy among education staff

Table 9. Levels of education staff knowledge of disability-related policies

No. Policies Levels of knowledge (N=169) Don’t know Know partially Know fully

1 Disability Law 24 (14%) 110 (65%) 35 (21%) 2 Law on Education 7 (4%) 92 (54%) 70 (41%) 3 Law on Child Protection, Care and Education 7 (4%) 92 (54%) 70 (41%) 4 The UN Convention on the Rights of persons

with disabilities 30 (18%) 105 (62%) 34 (20%)

5 The UN Convention on the Rights of the Child 21 (12%) 94 (56%) 54 (32%) 6 Policies on tuition fee reduction and exemption

for CWDs 22 (13%) 90 (53%) 57 (34%)

7 Policies on allowance for teachers working with CWDs 51 (30%) 85 (50%) 33 (20%)

It is perhaps unsurprising that the staffs are most knowledgeable about the policies relevant to their own sector; however even in their specific sectors the level of understanding of the relevant policies is relatively poor. Only just over 20% of Social Protection Center staff have a full understanding of the relevant social protection laws, 40% of education staff fully understand the education laws and 28% of health staff fully know the law on healthcare for persons with disabilities, even by their own admission.

39

The low level of knowledge about the Disability Law, the overall framework guiding all disability activities, is also concerning; only 20% of education staff, 17% of health staff and 21% of social protection center staff have a thorough understanding of this Law. Clearly there is significant work to be done in educating staff working with persons with disabilities in the relevant legal and policy framework within which they work. This alone could significantly improve the implementation of preferential and supporting policies and thus improve the lives of persons with disabilities.

3.3.2. Knowledge of the policies by persons with disabilities In order to ensure effective implementation of policies and services for persons with disabilities it is essential that the intended beneficiaries know about the laws and policies and their entitlements so they can request the necessary services. To determine the level of knowledge of persons with disabilities, during the survey people were asked if they knew about specific relevant policies. The results are shown in the figures below.

Figure 2. Knowledge of health policies by persons with disabilities

The survey findings indicate that most persons with disabilities have a relatively good knowledge about health insurance policies and their rights to have health insurance, however the percentage of people knowing about exemption of medical fees is relatively low, and those who know about orthopedics and rehabilitation is very low at only 8% fully understanding this policy. Hanoi has the lowest percentage of persons with disabilities who did not know and the highest percentage of those who had good knowledge on all three mentioned health policies. Persons with disabilities in Vinh Long have the least knowledge about these three support policies.

345

569

199

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536

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97

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400

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Reduction andexemption of medical

check-up andtreatment fees

Orthopedics andrehabilitation

Health insurance

No

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Don’t know

Partially know

Fully know

40

Knowledge of education policies

Figure 3. Knowledge of education policies by persons with disabilities

It is clear from these results that the majority of persons with disabilities and their family members did not know about the exemptions, assistance and other educational support they are entitled to (59% - 78%). In particular, persons with disabilities do not know that they are entitled to fee exemptions for vocational training (78% don’t know this policy). In general, the rate of persons with disabilities that has knowledge of educational support policy was lower than that of health support policy. Again, persons with disabilities in Hanoi had slightly better knowledge of the relevant policies than people in Quang Tri or Vinh Long. Knowledge of social/employment support policies Similar to educational policies, knowledge of persons with disabilities and their families on social support policies was quite limited. The majority of people did not know most of the policies other than the monthly welfare payment.

709

931 909 870

399

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41

Figure 4. Knowledge of social support policies by persons with disabilities

People in the rural province of Vinh Long seem particularly uninformed about the support they are entitled to, with 70% of people not knowing about any policy other than the monthly pension, and 40% even not knowing that. In particular, those policy areas intended to increase the integration and independence of persons with disabilities such as support for vocational training, employment, business development and public transport are the least understood areas of policy. This is concerning.

3.3.3. Assessment by staff of implementation of disability policies Given that it seems the primary issue for improving the lives of persons with disabilities through policy is implementation rather than a particular weakness in the policy framework, it is useful to consider what relevant staff think are the main difficulties in implementation and how they might be overcome. The survey of social/employment staff (primarily people working in social protection centers) included questions to enable the staff to express their opinion on difficulties they face in implementing particular policies. The results are below. (Unfortunately these questions were not asked of health or education sector staff) Social/employment staff assessment of implementing disability determination and classification Table 10. Difficulties in implementing disability determination and classification in compliance

with the Disability Law

Content of policy Quantity (N=116) Not difficult Difficult

Disability determination (6 types of disabilities regulated by Disability Law) 11 (10%) 105 (91%)

Disability classification (severity of impairment; persons with minor disabilities, persons with moderate disabilities and persons with severe disabilities)

13 (11%) 103 (89%)

616

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828 773 792

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As shown in Table 10, about 90% of social/employment staff indicates that it is difficult to implement disability determination and classification. The reasons given are as follows2: Lack of specific criteria for and detailed guidance on disability determination and

classification (72%); Lack of cooperation between health, social/employment, etc. in implementing disability

determination and classification (68%); Lack of facilities (67%); Lack of qualified staff (59%); Too many persons with disabilities are in need of disability determination and

classification for local authorities to meet their needs; No/Lack of funding sources (43%); Unable to establish councils on disability classification at communal/ward level as

required by the Law (38%); Lack of councils/establishments/organizations implementing disability

determination/classification (36%). Note that the guidance policies for disability determination were still under development when this survey was conducted. Social/employment staff assessment of implementing vocational training and employment policies

Table 11. Difficulties in implementation of vocational training and employment policies for

persons with disabilities

Policies on vocational training and employment Quantity (N=116)

Not difficult Difficult Free job counseling and vocational training for persons with disabilities 49 (42%) 67 (58%) Vocational training establishments need to meet the requirements to provide vocational training for persons with disabilities.

18 (16%) 98 (85%)

Free job counseling for persons with disabilities 51 (44%) 65 (56%) Provision of loan with low interest rate, guidance on production techniques, technology transfer, support in consumption of products for self-employed persons with disabilities/families.

16 (14%) 100 (86%)

Preferential policies for enterprises hiring persons with disabilities (for enterprises employing 30% or more of their labor force as persons with disability)

18 (16%) 98 (85%)

According to the results in Table 11, most social protection center staffs think they face difficulties in the implementation of policies on vocational training and employment for persons with disabilities. The reasons given include:

2 Note: staffs were given a list of options to choose from, as well as space to write in a different reason.

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Limited vocational training establishments with sufficient facilities to provide vocational training for persons with disabilities (74%);

Limited enterprises employing persons with disabilities due to difficulties in arranging work for them (72%);

Business development projects of persons with disabilities are not realistic so it is difficult for them to access loans with low interest rate (64%);

Banks do not want to let persons with disabilities borrow as they view them as high-risk clients (64%);

Persons with disabilities face difficulties in transport and access to vocational training establishments (63%);

Persons with disabilities have limited learning ability (52%);

Few vocational training establishments admit persons with disabilities into their vocational training programs (52%);

There are no clear and specific regulations of the tasks and roles of each related sector/agency in provision of disability support services (50%);

Limited capacity of social/employment staff, counselors/teachers (31%). Social/employment staff assessment of implementing social protection policies

Table 12. Difficulties in implementation of social protection policies

Social protection policies Quantity (N=116)

Not difficult Difficult Monthly support allowance 87 (75%) 29 (25%) Monthly cost of care in social protection establishment 80 (69%) 36 (31%) Providing care in social protection establishments 77 (66%) 39 (34%) Funeral cost in the community 77 (66%) 39 (34%) Psychological and legal counseling 52 (45%) 64 (55%) Vocational training 43 (37%) 73 (63%) Employment creation, business support 42 (36%) 74 (64%)

Staff of social protection centers indicated that direct support policies such as monthly welfare allowances, care in social protection establishments, and covering the costs of funerals are generally not difficult to implement. However, most of the informants state that they have difficulties in implementing the policies on psychological or legal counseling, or vocational training, employment and business creation. The reasons given for their difficulties in implementation of these polices include:

The criteria for classification of beneficiaries is unclear and not specific enough (51%);

Limited social protection establishments (52%);

Limited number of beneficiaries admitted to social protection establishments (27%);

Lack of multi-sector cooperation (76%);

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Limited staff capacity (44%).

3.4. Disability data in Vietnam Collection of data on the prevalence of persons with disabilities is challenging in any country, and even more so in developing countries. Defining and identifying persons with disabilities in countries with underdeveloped health and education systems and lack of early identification of children with disabilities poses large challenges to collecting accurate data. In Vietnam, various Ministries collect their own information about persons with disabilities, including Ministry of Labor – Invalids and Social Affairs (MOLISA), Ministry of Health (MOH) and Ministry of Education and Training (MOET). However, the data is incomplete and not comparable as the Ministries use different definitions of disability. In recent times there have been two national surveys of persons with disabilities conducted with the involvement of the General Statistics Office (GSO) and using the internationally recognized ‘functioning’ approach embodied in the World Health Organization’s International Classification of Functioning, Disability and Health (ICF) (http://www.who.int/classifications/icf/en/). The functioning approach differs from other ways of distinguishing disability in that it considers not what capacity or limb has been lost or damaged, but rather asks the respondent about their ability to do certain tasks, such as to see, hear, to walk up stairs, etc. Thus it is a measure of the challenges faced by the individual in their particular environment, rather than trying to be an objective measure of a medical problem. At the UN meeting in New York City in 2001, a group was formed to develop survey items that would utilize the ICF functioning approach to measure disability prevalence, but could be broadly and easily applied across different country situations. This group, the Washington Group, developed a set of six questions based on the ICF and known as the ‘Washington Group short-set questions’. These are the questions used by the GSO for the national surveys of disability prevalence. The Washington group short set was included in the 2006 Household Living Standards Survey (VHLSS) as a pilot to test the short set questions in Vietnam. The second survey was part of the 2009 Census. The Washington Group short set questions were included in the comprehensive sample census which is conducted with a representative sample of 10% of the population, randomly selected across all provinces. The results of the two surveys are very different, despite using the same questions. See below for more detailed information about these two surveys. Vietnam Household Living Standards Survey (VHLSS) 2006, General Statistics Office, Hanoi

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The 2006 Vietnam Household Living Standards Survey (VHLSS), conducted by the General Statistics Office (GSO) of Vietnam with technical support from the World Bank covered 9,189 households and 39,071 individuals, representative of rural and urban areas and eight geographic regions. This was the first survey to specifically use the Washington group short set questions and was considered a pilot test of the approach. While all six functional areas were included in the survey, following the Washington Group recommendation, the report defines a ‘person with a disability’ as a person with at least ‘some difficulty’ in at least one of the four main ICF domains (hearing, seeing, walking or climbing stairs, remembering or concentrating).3 Using this definition, this survey finds a prevalence of 15.7% of people over 5 years old. This is similar to rates in many other countries that rely on a similar approach, for example, 12.2% for the United Kingdom, 14.5% for Brazil, 18.5% for Canada, and 19.4% for the United States. According to these data, persons with seeing difficulties comprised the highest number, followed by those with difficulties in walking. Note: this is the only study done in Vietnam to find an urban prevalence of disability higher than the rural prevalence. The 2009 Census (see below) finds an urban prevalence of 6.3% and rural of 8.3%. Note: For a useful interpretation of the VHLSS 2006 survey and a consideration of the links between disability and poverty see Mont, Daniel & Nguyen Viet Cuong, 2011, Disability and Poverty in Vietnam, The World Bank Economic Review, Vol. 25, No. 2, pp. 323–359. UNFPA, December 2011, Persons with disabilities in Vietnam. Key Findings from the 2009 Vietnam Population and Housing Census, Hanoi. The second key national survey of persons with disabilities was included in the official GSO Population and Housing Census of 2009. The census involves a questionnaire interview with every household in the country – the head of household answers on behalf of all members of the household. A sample of 10% of all households, randomly selected from every province is asked a more comprehensive list of questions and the disability status questions were asked of this sample. This survey also used the Washington Group short form questions to identify difficulties in functioning in six areas; hearing, seeing, walking or climbing stairs, remembering or concentrating, self-care and communicating. Same as the VHLSS, a person with a disability is defined as a person with at least ‘some difficulty’ in at least one of the four main ICF domains (hearing, seeing, walking or climbing stairs, remembering or concentrating). A person with

3 Note that most of the data analysis uses only 4 of the 6 domains as there is very little difference in the prevalence rates from using 4 domains or 6 domains of the ICF.

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severe disability is defined as a person who ‘cannot do at all’ in at least one of the four domains. Using these definitions, the census found a prevalence of persons with disabilities at 7.8% of people over 5 years old (9.2% of people over 15 years old), and people with serious disabilities at 0.48% of people over 5 years old. For persons with disabilities, around 53.8% are girls and women, and approximately 75% live in rural areas. The highest prevalence is among older people with 43.3% of people aged 60 years or older reporting disabilities and only 4.7% children between 5-18 years. People reported difficulties in all four domains were with the highest prevalence, followed by those who face difficulties in seeing. People reporting difficulties in walking, hearing, cognition or multiple domains have similar prevalence rates. Note that neither of these surveys measure disability prevalence in children under 5 years old, because the functioning approach is less appropriate for very young children. This means that there are no comprehensive, accurate statistics for young children with disabilities in Vietnam. MOLISA now accepts these census figures as the most accurate data available and tend to use the figure of 7.8% as the official prevalence rate of persons with disabilities in Vietnam. Vietnam seems to have taken the lead in the Association of Southeast Asian Nations (ASEAN) region in using broader, functional classifications and definitions based on the ICF in prevalence surveys (see Table 13 below). Most other countries in the region have far lower prevalence figures that are likely to underestimate the true numbers of persons with disabilities in the country.

Table 13. Approximate prevalence figures in countries in south-east Asia region based on

available data

Country Prevalence Source Bangladesh NA Bhutan 3.4% Population and Housing census of Bhutan (PHBC), 2005

DPR Korea 3.4% North Korea’s Federation for the Protection of the Disabled, quoted in “Disabled in North Korea” (2007)

India 2.1% (2001) Census of India reports Indonesia 2 to 3% (2007) Mont ( 2007) Maldives 4.7% (2009) Human Rights Commission of Maldives (2010) Myanmar 2.35% Union of Myanmar (2009) Nepal 1.63% (2001) UNICEF. Situation Analysis of Disability in Nepal, 2001 Sri Lanka 1.6% (2001) Sri Lanka Census of Population and Housing 2001 Thailand 1.6% The National Statistical Office of Thailand’. Disability survey, 2007 Timor Leste 4.6% (2010)

3.4.1. Local level collection and use of statistics on persons with disabilities in Vietnam

There is no consistency in the data collection and use in different Ministries and agencies, and at different levels of government. Ministries seem to do their own ‘surveys’ at every level.

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Each level of authority and each Ministry will tell you exactly how many persons with disabilities are in their province/district/commune, and what kind of impairments these people have, and each will be completely different. For example, during the in-depth interviews for this baseline survey, the Provincial People’s Committee in Quang Tri province claimed that 37,292 or 60% of the population of the province has a disability, while the commune health station in Ward 1 of Dong Ha city, Quang Tri claimed that there were 183 persons with disabilities out of 19,337 people, or less than 1% of the population. Clearly these figures cannot both be correct. There is a need for a national definition of disability and harmonization of the collection and storage of disability statistics. The Inter Ministerial-Circular 37 by MOLISA, MOET and MOH provides guidance for local officials on disability classification, and a survey on disability prevalence has been planned after the circular was enacted but due to limited funding for the survey, the survey has not been completed and may take some time.

3.5. Summary – analysis of policies to support persons with disabilities in Vietnam

The purpose of the policy analysis was twofold; to determine how appropriate the policy framework was and if it was in line with international instruments, and secondly to assess the coverage and enforcement of policy for persons with disabilities in Vietnam. From the analysis above it can be seen that the policy framework, after some years of development, is fairly comprehensive, covering most of the issues relevant to persons with disabilities. The Disability Law provides an overall framework that is largely in line with the UN Convention on the Rights of Persons with disabilities, and attempts to take a right based approach. Supporting laws, decrees and guidelines, in particular the National Action Plan 2012-2020 attempt to put this Law into practice and facilitate understanding and enforcement at the local level. Unfortunately, no one at the local level understands this legal framework; an essential precursor to its effective implementation. Persons with disabilities, their family members and staff of the relevant government agencies have extremely poor levels of understanding of the relevant policies. In particular, staff and persons with disabilities have very poor knowledge about the ‘rights-based’ policies; those policies on vocational training, independent living, employment, business development, that are intended to improve the inclusion and independence of persons with disabilities. Thus, at least at the time of this survey, the reality on the ground for most persons with disabilities is still one of being treated as welfare recipients needing care and protection, with little to no access to other support services. Ensuring the effective implementation of this strong policy framework and improving the inclusion of persons with disabilities into the community will not be possible until there is much better knowledge and understanding of the relevant laws. Vietnam is leading the region in the collection of disability statistics at the national level, implementing the internationally accepted ICF approach. However, there is a lot of work to be

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done to standardize the collection of disability statistics in different Ministries and at different levels. There is a need for a standard definition of disability and a common approach to collection and use of statistics about persons with disabilities. Currently, the statistics held by Ministries and Provincial Peoples’ Committees should be considered ‘service statistics’; numbers of people receiving services at the local level rather than actual numbers of persons with disabilities living in that area.

4. Service provision system

The system of service provision in these three key sectors was analyzed based on the WHO recommended approach for analyzing a service system. The four key areas are:

(a) Governance/Administration

(b) Existing services and support

(c) Financing and human resources

(d) Cross-sector coordination.

This section of the report considers each of the three sectors; health, education and social services in turn according to these four categories.

4.1. Health sector For the health sector, a range of informants were surveyed and interviewed, including surveys to the provincial departments of health in each province, provincial hospitals and rehabilitation centers, health colleges and Universities and staff of hospitals. In addition, in depth interviews and focus groups were held with directors of provincial rehabilitation hospitals and provincial health departments as well as district and commune level technical staff working in the department of health or commune health stations. The qualitative and quantitative information was analyzed using the WHO approach as follows.

4.1.1. Governance and administration Planning and monitoring of policies From the in-depth interviews of Ministry of Health staff at different levels it is clear that there is very low awareness of the legal and policy environment governing their work. Staffs at junior level at the provincial level seem to have better knowledge than managers, but even these staffs don’t have a comprehensive knowledge. None of the commune health staffs who were interviewed were aware of any support policies for persons with disabilities, other than one commune in Hanoi knowing about health insurance and one commune in Hanoi which had received information about the Disability Law from the local DPO. It is also clear that there is little upward communication about necessary policy or support for persons with disabilities – from rehabilitation hospitals and district level staff back up to provincial level department of health.

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The management of information about persons with disabilities and rehabilitation activities at provincial level is still quite unsophisticated, with only thirteen (of a total of 40 provinces responding to this question) using electronic data systems, and seven reporting that they have no information management system at all. The information that is collected is used to share with other relevant departments in the health and other sectors, but is rarely used for planning of necessary services and activities for persons with disabilities. No rehabilitation department that responded to the survey has detailed information about the types of reports that they have provided to MOH over the three years 2009-2011, only 24 of the 48 hospitals have statistical data on the number of persons with disabilities receiving rehabilitation services at their departments, of which only three record the disability statistics by the six types of impairment as defined in the Disability Law. The provincial departments at rehabilitation hospitals have limited written plans for their activities, three of 48 departments do not have any type of plan, 45 of the 48 responding departments have an annual work plan (accounting for 94%) and 16 of the 48 departments have a plan for the next 3-5 years (33%). Most of these annual plans focus on targets for medical diagnosis and treatment, very few annual plans consider issues such as training and development of the work force, new technology, community-based rehabilitation (CBR) or communication. The few departments that have 3-5 year plans do include consideration of these issues; human resource development targets (44% of plans for the next 3-5 years), CBR (22%), professional/infrastructure development targets (17%). This is despite the existence of a national CBR policy and plan. At the DOH at province level, the planning situation is little better. Only 17 of the total of 54 provinces have a provincial rehabilitation plan. Of these, 12 provinces have annual plans, 7 provinces have 3-5 year plans and 7 provinces have a 10-15 year plan (some provinces selected more than one option). Monitoring of implementation of health policies is done primarily through the formal reporting system. Provincial DOH reports to the Ministry of Health at national level. Most provinces (69%) report annually, with 6 provinces reporting bi-annually. In Vinh Long and Quang Tri, Provincial Health Department staff reported they take monthly monitoring trips to district and commune level to monitor CBR implementation and/or health policy implementation. Al lower levels, health centers/departments and hospitals report to provincial DOH. The majority (65%) of the Provincial DOH report that they receive reports every six months, with the remainder receiving the reports quarterly (one province: Quang Tri, receives these reports only annually). Health stations report to district management offices. Most of the provincial DOH surveyed was not able to provide information on how often this reporting happens, however those 16 provinces who did respond indicate it is monthly, with a few provinces indicating a quarterly reporting schedule. All the rehabilitation hospitals responding to the survey have annual work-plans, 76% have 3–5-year plans, 41% have plans for longer than 5 years and 41% of rehabilitation hospitals have

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long-term strategies. Most of the hospitals (96%) provide annual reports in addition to quarterly reports (93%) and 6-monthly reports. Most also provide monthly reports (86%). Primarily these reports are sent to the provincial Department of Health and MOH, although five hospitals admitted they file the reports at the hospital only. Only half the hospitals consider their reports as the foundation for their planning processes. Financing health and rehabilitation services for persons with disabilities The number of provinces providing detailed information about their budgets and expenditure for health and rehabilitation was very limited. However, the trends seem to be clear. Most of budget for health and rehabilitation is allocated by the Provincial government with supplemental funding from the central government. The contribution by international organizations is small, but growing, and the budget mobilized locally is also increasing over the period 2009-2011.

4.1.2. Existing services The health sector in Vietnam has a comprehensive network of general health facilities. Most provinces have a general hospital, with an average of two per province and a maximum of five general hospitals in one province. In addition, approximately 80% of provinces have a traditional medicine hospital. Some provinces also have specialized hospitals, such as maternity and children’s hospitals (approximately 40% of provinces), mental hospital (50%), tuberculosis and pulmonary hospital (20%), eye hospital (25%) and cardiovascular hospital (5%).

Figure 5. Number of general hospitals per province

Figure 6. Number of specialized hospitals per province (N=49)

8 (16.40%)

23(47.00%) 9 (18.30%)

9 (18.30%)

1 -2 general hospitals 3 - 4 general hospitals 5 - 6 general hospitals More than 6 general hospitals

3 (6.10%)

24 (48.90%) 14 (28.50%)

8 (16.50%)

No specialized hospital 1 -2 types of specialized hospitals 3 - 4 types of specialized hospitals 5 - 6 types of specialized hospitals

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However, the health network is mostly at the provincial level, and the health facilities are much less available at district and commune levels, while around 80% of persons with disabilities live in rural areas. On average, there are two health centers or district hospitals in each district of the province. However, there is high variation among the provinces, from 0.8 - 5.9 health centers/district. At the commune level, 50 provinces reported 8,531 commune level health stations. Four different health establishments provide rehabilitation services at provincial level: rehabilitation departments at general and specialized hospitals; nursing and rehabilitation hospitals; centers for nursing and rehabilitation; and centers for health care and rehabilitation. Most provinces have physical therapy - rehabilitation departments in the general hospital (93%), followed by nursing - rehabilitation hospitals (70%), centers for nursing and rehabilitation, and centers for health care and rehabilitation have similar proportion of 19% and 16%. Over 50% of provinces have one or two specialized facilities providing physical therapy/rehabilitation services. Fifteen provinces have 3-4 physical therapy/rehabilitation services (35%) and five provinces have five different facilities (12%). It is worth noting that the majority of the rehabilitation network (98%) is in the public system.

Table 14. Rehabilitation services at district level (N=43)

Type of provider Number of

provinces with services (%)

Total Mean of

providers/province (Min-Max)

Public (MOH) 42 (98%) 339 7.9 (0-16) Private 1 (2%) 1 0.2 (0-1) Others (not MOH) 2 (5%) 4 0.1 (0-2) Total 42 (98%) 344 8 (0-16)

Table 15. Rehabilitation services at commune level (N=37)

Type of provider Number of

provinces with services (%)

Total Mean of

providers/province (Min-Max)

Public (MOH) 6 (16%) 338 9.1 (0-91) Private 1 (3%) 6 0.2 (0-6) Others (not MOH) 1 (3%) 1 0.03 (0-1) Total 6 (16%) 345 9.3 (0-92)

In terms of training facilities, there are 8 medical universities, 1 military health university and 3 medical colleges. Provision of health services for persons with disabilities Over the 3 years 2009-2011, on average each rehabilitation department at provincial level receives 50-100 persons with physical impairments per month and 3-13 persons with other impairments. This indicates that the support services at rehabilitation department have yet to meet the diverse demand of persons with disabilities and/or that people with impairments

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other than physical impairments have little information about or little confidence in the services provided by the rehabilitation department. This is possibly not surprising as the survey also indicates that the main services provided in the rehabilitation sector are basic physiotherapy, and there are virtually no services for speech or language impairments, behavioral difficulties or visual impairments. Staffs report that they are primarily trained and confident to provide basic physiotherapy services rather than rehabilitation services to people/children with other kinds of impairments. However, even for people with mobility impairments, the services are not comprehensive and do not meet the needs. For example, only between 2-6% of provinces responded that they are able to fit prosthetic devices and only 8-12% is able to fit various orthotic devices. Respondents indicated that provision of orthopedic services, speech therapy, disability screening for children with disabilities, community based rehabilitation and orthopedic surgery are the highest priority needs that are currently not provided in the system. Very few provincial health departments were able to provide detailed accurate data about the number of people receiving rehabilitation services in 2011 (less than 50% of provinces completed the reports). In addition, for those who did provide information there is very high variation in the numbers indicated. It is likely that this is as a result of differences in data collection and storage procedures, rather than large variations in service provision; however it’s not possible to draw conclusions from the data provided. It is clear that the ability of provincial health departments to collect and report data about their service provision needs improvement. The trend however seems clear: health and rehabilitation services are primarily provided for people with physical disabilities, and the level of quality of service provision is questionable due to the lack of appropriately trained staff.

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Table 16. Number of persons with disabilities receiving health and rehabilitation services in 2011

Items No. of

provinces reporting

No. provinces providing data (%) Mean (Min-Max/Total)

Persons with disabilities

0-18 years 36 18 (50%) 3,642 (43 - 23,132/65,549)

Over 18 years 36 15 (42%) 10,387 (119 – 85,563/155,803)

Persons with physical impairments

0-18 years 35 17 (49%) 1,730 (22 -15,451/29,409)

Over 18 years 33 14 (42%) 4,180 (119 - 33,840/58,521)

Persons with visual impairments

0-18 years 35 12 (34%) 657 (4 – 5,641/7,880)

Over 18 years 33 10 (30%) 3,862 (4 – 33,840/38,621)

Persons with hearing and speaking impairments

0-18 years 34 13 (38%) 578 (4 - 3,526/7,509)

Over 18 years 32 9 (28%) 3.322 (24 - 18,119/29,895)

Persons with mental health difficulties

0-18 years 33 12 (36%) 402 (1 – 2,630/4,821)

Over 18 years 33 11 (33%) 1,493 (12 – 7,171/16,424)

Persons with intellectual impairments

0-18 years 33 14 (42%) 321 (7 - 1,172/4,493)

Over 18 years 33 12 (36%) 1,220 (1 – 6,743/14,644)

Although the data is not good quality, the trend in which particular services are provided seems quite clear, with the majority of provinces focused on physiotherapy, and very limited provision of speech and language services, hydrotherapy, assistance in forming DPOs, screening and early detection, advice on employment, or advice about health insurance. The number of provinces providing different specialized services has not changed significantly between 2009-2011, indicating a lack of service development in the sector. Provincial health departments indicated that there are a number of services that are necessary for persons with disabilities but they are not yet able to provide. Thirty seven provinces responded, indicating the most necessary are: physical therapy, language therapy, heat therapy (49% provinces); screening and early detection, disability classification, early intervention, prevention (46%); provision of assistive devices, replacement devices (43%); and orthopedic surgery for persons with disabilities (41%).

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Table 17. Types of health and rehabilitation services for persons with disabilities provided by the health sector 2009–2011

Types of health support services (N=54) 2009 2010 2011

Screening, early disability detection 27 (50%) 27 (50%) 24 (44%) Diagnosis and disability classification 32 (59%) 34 (63%) 31 (57%) Rehabilitation for persons with disabilities 36 (67%) 37 (69%) 38 (70%) Early intervention for children 22 (41%) 26 (48%) 26 (48%)

Orthopedic surgery 23 (43%) 25 (46%) 26 (48%)

Provision of assistive devices for persons with disabilities 34 (63%) 33 (61%) 31 (57%)

Physiotherapy 38 (70%) 39 (72%) 39 (72%) Electrotherapy 31 (57%) 33 (61%) 31 (57%) Hydrotherapy 18 (33%) 19 (35%) 19 (35%)

Occupational therapy 32 (59%) 33 (61%) 34 (63%) Heat therapy 24 (44%) 25 (46%) 24 (44%) Language therapy 19 (35%) 19 (35%) 20 (37%) Provision of training for family members of persons with disabilities 24 (44%) 25 (46%) 25 (46%)

Rehabilitation counseling for PWD and their families 32 (59%) 33 (61%) 33 (61%)

Enrolment of children with disabilities in school 24 (44%) 26 (48%) 27 (50%) Employment counseling for persons with disabilities 22 (41%) 24 (44%) 24 (44%)

Support in establishment of organizations, self-help groups of persons with disabilities 13 (24%) 13 (24%) 14 (26%)

Health insurance support for persons with disabilities 21 (39%) 23 (43%) 23 (43%) Disability prevention 26 (48%) 26 (48%) 26 (48%)

Others 6 (11%) 6 (11%) 6 (11%) Service provision at rehabilitation hospitals Very few of the surveyed rehabilitation hospitals were able to provide data about how many persons with disabilities they had treated in 2010-2011. Only 11 of 29 hospitals responded (37%). It is clear that even at these specialized rehabilitation hospitals, it is primarily people with mobility impairments who are receiving services. Very few hospitals are able to provide specialized services for other impairments, and the number has not changed significantly from 2010 to 2011. In addition, these numbers are very small compared to the total number of persons with disabilities – even when the low number of hospitals providing data is taken into account. Even for people requiring physical rehabilitation, the ability of these rehabilitation hospitals to provide appropriate treatment and services is limited. None of the hospitals surveyed indicated that they could treat all 50 diseases regulated by MOH in Decision 23/2005/QD-BYT dated 30 August 2005. Approximately 60% of the hospitals could treat 36 diseases, primarily through physiotherapy and rehabilitation techniques for people with mobility impairments (rehabilitation for patients with stroke, physiotherapy and rehabilitation for people with nervous system injuries, etc.). About one third of rehabilitation hospitals provide

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physiotherapy and rehabilitation techniques for patients with lung, heart diseases, and patients needing a prosthesis. Most of the rehabilitation hospitals are also unable to fit and supply the prosthetic, orthotic and other assistive devices as regulated by the Ministry of Health. For each device (such as crutches, prosthetic and orthotic devices, breathing assistance devices, splints, walking frames etc.), only around 35-40% of hospitals answered that they could supply it. Fit and supply of prosthetic devices is particularly limited.

Table 18. Number of persons with disabilities serviced at rehabilitation hospitals, 2010-2011

Impairment

2010 2011

No. of hospitals providing

services (n)

Mean No. of patients

(Min-Max) Total

No. of hospitals providing

services (n)

Mean No. of patients (Min-

Max) Total

Mobility 11 (37) 496

(19-974) 5454 11 (37) 706

(30-2216) 7769

Intellectual 10 (33) 52

(0-197) 522 10 (33) 99

(0-436) 986

Hearing 5 (17) 42

(0-160) 210 5 (17) 86

(0-380) 430

Speaking 6 (20) 66

(0-362) 397 6 (20) 149

(0-848) 891

Visual 6 (20) 122

(0-475) 733 6 (20) 180

(0-728) 1079

Autism 6 (20) 15

(0-53) 90 7 (23) 19

(0-70) 135

Epilepsy 4 (13) 8

(0-27) 32 6 (20) 8

(0-42) 49

Leprosy 5 (17) 3.4

(0-15) 17 6 (20) 3

(0-13) 19

Community Based Rehabilitation (CBR) The investigation from 54 provincial health departments shows that in the last five years, community based rehabilitation has been implemented in 34 provinces/cities (63% of provinces responding to survey). Of these, 17 provinces report that 100% of their districts have carried out community based rehabilitation (236 of a total 353 districts, 65%). At the time of the survey however (2012), only 138 districts are still implementing CBR (59%). Eleven of 22 provinces report that 100% of their districts are still implementing community based rehabilitation programs. At the commune level, in the 34 provinces providing data, 2,942 of 5,707 total communes have implemented CBR (52%). Thirteen out of 33 provinces report that all their communes implemented community based rehabilitation in the past, with only seven (Quang Tri, Tuyen Quang, Lang Son, Ben Tre, Tien Giang, Bac Ninh, Kon Tum) reporting that 100% of communes are still implementing the program (equating to a total of 2,204 communes). The information about the achievements of the CBR program was quite limited, despite the fact that 23 provinces claim good cooperation between the different levels in implementation and monitoring of the CBR program. The results of the CBR program are reported as follows:

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Table 19. Achievements of CBR implementation (N=25)

Items Number of provinces with data

Mean (Min - Max)

% Ratio (%) of people with improved functioning capacity 17 (68%) 53 (7-80) Ratio (%) of people participating in their household activities

16 (64%) 37 (9-79)

Ratio (%) of people participating in community activities

17 (68%) 24 (2-56)

These results seem quite disappointing, with an average of only 50% of persons with disabilities recovering improved functioning, and less than a quarter gaining improved participation in their communities. The lowest figures provided by some provinces are even more concerning: 7% of persons with disabilities receiving CBR gaining improved functioning and 2% participating in the community. Thus, although the coverage of CBR is relatively broad (but decreasing), the effectiveness of CBR as a strategy to rehabilitate persons with disabilities and help them integrate into the lives of their communities is clearly limited.

4.1.3. Financing and human resources The responses sent back from the provincial DOH offices unfortunately do not include good data about the number and qualifications of staff working in rehabilitation sector. However, from the surveys of provincial hospitals, and staff working in Department of Health, it is clear that the number of specialized staff working in rehabilitation sections of provincial health facilities is quite low, with the majority of staff being nurses, physiotherapists and doctors. In particular, there is a serious lack of qualified speech therapists and occupational therapists. The survey indicates that there is quite a lot of short term training in CBR at the commune level (training for CBR collaborators), however very few staff are attending college or degree level specialized training. Rehabilitation departments at provincial general hospitals The rehabilitation departments at provincial hospitals have limited trained staff to assist persons with disabilities. Of the 48 departments that responded to the survey, only 25 have between 1 and 5 doctors working in the rehabilitation department, with an average of 2 doctors. In addition, 43 departments have an average of 5 technical staff (mostly physical therapists) and 31 departments have an average of 5.4 nursing staffs or physicians at post-secondary level. Less than 50% of rehabilitation departments have staff with undergraduate degrees. However, 98% of the rehabilitation departments who responded to the survey has staff with a rehabilitation specialization (average of 6 staff per department). Approximately two thirds of rehabilitation departments also include staff with a specialization other than rehabilitation (such as nursing) and on average there are 7.1 staffs with another specialization in each department. The majority of these staff with a rehabilitation specialization has only a 3 year or 4 year undergraduate level qualification (accounting for 89% and 70% respectively).

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Over half of the rehabilitation departments have yet to meet the MOH requirements that rehabilitation departments at provincial levels need to have doctors with post-graduate degrees. This is a concern of provincial health departments and they recommend more staff training, additional specialized staff, and in particular more training and resources for CBR collaborators (working directly with persons with disabilities and their families) as necessary for better service provision for persons with disabilities. Specialized rehabilitation hospitals At the specialized rehabilitation hospitals and sanatoriums, the picture is somewhat better. On average there are 19 management staff (Deputy Director/Division and above) and 46 specialized staff in each hospital. More than 60% of the total staff at management level has over ten years of experience in rehabilitation, and over 90% of the total rehabilitation hospitals have management level staff with over ten years of experience in rehabilitation. All the rehabilitation hospitals responding to the survey (75% of the total number of rehabilitation hospitals in the country) have management staff with postgraduate qualifications, and almost 50% of the total staff at management level has postgraduate qualifications. Ninety three percent of rehabilitation hospitals have university doctors/physicians who have more than 10 years of rehabilitation experience, 76% have staff with 5–10 years of experience in rehabilitation. Two thirds of hospitals have staff with university level qualifications, but with less than 5 years of rehabilitation experience.

Figure 7. Total specialized staff at rehabilitation hospitals (Number, %, Min-Max, Av.)

Figure 7 indicates that all the 29 rehabilitation hospitals responding to the survey have specialized staff. There are a total of 1,367 staff, or an average of 46 in each of the 29 rehabilitation hospitals. The percentage of doctors/physicians with university level qualifications accounts for 20%, 60% are physician/nursing staff with post-secondary qualifications, and 21% are technicians (primarily physiotherapists). Most of these specialized staff have qualifications in and are working in general rehabilitation and physical therapy. Only 30% of the hospitals have staff with qualifications in language therapy and a third have

19.50%

59.60%

20.90% Doctor/Physician at university level (266;19.5%; 1-22; 9)

Nursing staff/Physician at post-secondary level (814; 59.6%; 1-79; 28)

Technician (285; 20.9%; 1-32; 10)

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occupational therapists. Very few hospitals have staff with knowledge of psychological therapy or social work. The responses to the survey of health facilities and of provincial Department of Health indicate that there is significant concern about inadequate and lack of equipment and infrastructure (space and buildings) for rehabilitation services as well as inadequate funding. DOH management indicated they often have to wait for private or non-government organization projects and funding in order to undertake rehabilitation activities. In-depth interviews with health staff at provincial and district level and working in rehabilitation hospitals also indicated concerns about financial and human resources. The most common reason for limitations in implementation of policies mentioned by health staff was the low number and limited skills and knowledge of staff. Other reasons were the limited number of specialized staff, lack of knowledge and expertise on disability rehabilitation, poor infrastructure, limited budget, lack of concern from higher level authorities about rehabilitation issues and poor coordination with other sectors. Capacity building and training at rehabilitation hospitals has been significant however. Between 2009 and 2011, each rehabilitation hospital sent an average of 13 staff to attend long-term training courses (equivalent to approximately a quarter of total staff). During these three years, all the rehabilitation hospitals sent staff to training programs on speech and language therapy, 73% had staff participating in general practitioner courses at university level, 53% rehabilitation hospitals sent staff to physical therapy courses and 47% sent staff to postgraduate rehabilitation courses. Finance The Ministry of Health can only estimate the budget spent on persons with disabilities as it is not itemized but is included in budget for mainstream service provision, e.g.: for surgery, rehabilitation, nutrition, etc. Provincial level staff advised that there is insufficient specific budget for purchase of necessary equipment for rehabilitation, training of staff providing health and rehabilitation for persons with disabilities, and for rehabilitation activities, including CBR. There is no specific budget for rehabilitation (including CBR) or disability at district or commune level. Rehabilitation hospitals report that the majority of their budget comes from the State budget, with a smaller percentage coming from international organizations, local fundraising, and other sources (patient charges, etc.). Interestingly, none of the rehabilitation hospitals answer that budget comes from persons with disabilities and their families – this is despite people reporting that they do pay for some services. It seems likely that the hospitals have indicated these fee-for-service activities as ‘other’ rather than considering them funds from persons with disabilities and families. Facilities and equipment

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The survey responses from rehabilitation hospitals make it clear that the infrastructure, facilities and equipment at the hospitals is insufficient. The MOH Circular 10/1999/TT-BYT specifies fifteen specific rehabilitation equipment that all rehabilitation hospitals should have. However, 47% of the hospitals responding to the survey has fewer than six of these 15 and only 7% have more than twelve.

4.1.4. Cross-sector coordination Provincial DOH reported very poor cross-sector coordination. A third of the provinces report absolutely no coordination with other sectors or organizations. Twenty eight provinces (52%) report cooperation with the education sector, and thirty four (63%) indicate cooperation with the social/employment services sector. Eleven provinces (20%) have cooperation with other sectors and organizations such as the Vietnam Red Cross and the Women’s Union. This finding is backed up by the survey of Ministry of Health staff who report limited coordination with both the education sector concerning education for children with disabilities, and DOLISA primarily regarding rehabilitation, detection, diagnosis and early intervention for children with disabilities, and vocational training and employment. This collaboration is not frequent or institutionalized and is usually only done on the request of person with disability or their family. Particularly worrying is that 109 health staff responded that there was no coordination between health and educational staff in any activities (21%) and 168 people thought that there was no cooperation between health and social/employment staff on any activity (33%). The rehabilitation hospitals also indicate limited cross-sector coordination. Most rehabilitation hospitals report regular coordination with their local People’s Committee and with other hospitals (18 out of 22 rehabilitation hospitals). However, only around 50% of rehabilitation hospitals have coordinated with the social/employment sector, and around 40% have cooperated with the education sector. The in-depth interviews with health staff also highlighted difficulties with multi-sector coordination. Most of the higher level (provincial, district level) respondents felt that there was limited coordination, and that which did happen was primarily in response to external projects such as campaigns by the Red Cross, or a project of an international NGO. However, based on the in-depth interviews with commune health center staff it is clear that they do coordinate with the other sectors, including with schools to help children enroll in both special and inclusive schools, with the Women’s Union and Farmers Union to assist families with a disabled person to get loans, and with the Vietnam Red Cross to help persons with disabilities get assistive devices such as wheelchairs. This is somewhat encouraging, although even these staff indicated more could be done in terms of effective coordination. Specialized rehabilitation staff at provincial and district level Rehabilitation Hospitals also seem to regularly coordinate with both education and social/employment sector, in areas such as early intervention, assisting children to attend school, disability assessment and

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classification, provision of assistive devices, development of curriculum for children with intellectual and developmental delays (cooperation with the Vietnam Institute of Educational Science) and, development of professional training courses for collaborators working in the community (provided by the Child Protection Foundation and DOLISA). Provincial DOH reported that the cooperation and coordination between sectors needs to be improved to ensure better service delivery. See also tables below comparing the cooperation between sectors

Table 20. Frequency and methods of coordination between health and educational staff

No. Content (N=403) Quantity Percent % Frequency of coordination

1 Once a year 50 13 2 Every 6 months 41 10 3 Every 3 months 9 2 4 Monthly 21 5 5 At their request (up to the needs of a child with

disability) 282 70

Methods of coordination 1 Telephone 98 24 2 Meeting and discussing in person 197 49 3 Cooperation to implement intervention 130 32 4 Information and knowledge sharing 164 41 5 Monitoring and evaluation 137 34 6 Others 8 2

Table 21. Frequency and methods of coordination between health and social/employment staff

No. Content (N=344) Quantity Percentage Frequency of coordination 1 Once a year 46 14 2 Every 6 months 38 11 3 Every 3 months 9 3 4 Monthly 18 5

5 At their request (up to the needs of the person with a disability) 233 68

Methods of coordination

1 Telephone 79 23 2 Meeting and discussing in person 139 41 3 Cooperation to implement intervention 103 30 4 Information and knowledge sharing 138 40 5 Monitoring and evaluation 130 38 6 Others 8 2

4.2. Education sector

For the education sector, quantitative surveys were sent to the provincial departments of education, special education schools and inclusive education schools as well as teacher training universities and colleges, and teachers working in both special and inclusive schools. Interviews and focus groups were held with teachers, management of Inclusive Education Support Centers and research institutes, leaders of provincial departments of education and technical staff at provincial and district level departments of education.

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However, only 40 Provincial Department of Education and Training (63% of total) sent back the surveys. In addition, many of the survey forms that were returned were incomplete and with inadequate information. This means the data regarding educational support services for children with disabilities is not very reliable.

4.2.1. Governance and administration Planning and monitoring of policy implementation Only sixteen Provincial DOET responded to the question about strategic planning, of which eleven have annual action plans (57.9%), eight have 3-5 year plan (44.4%), five have 5-10 year plans (27.8%), and only two have 10-15 year plans (11.1%). Within the education sector, the disability information management system includes regular reports and periodic reports on education for children with disabilities. Data consists of lists of students, number and rate of persons with disabilities accessing education and individual profiles of children with disabilities. However, most of the information is collected only for internal use within MOET, and is very difficult to access. Of the 37 provincial Departments of Education and Training that responded to the survey, the majority reported that they make a provincial summary of local level reports and it is filed electronically (27 provinces, 73%), 29 provinces indicated they store information in general record books (78%) and 17 (46%) provinces do not have records at the provincial level, but request to local levels (district level section of education and training and other education agencies) when they need information on education for children with disabilities. It is noted that 5% of the provinces reported that they did not file information and data on education of persons with disabilities. The provinces reported that this data is primarily collected and used for the purpose of reporting to MOET and the Provincial People’s Committees (33/37 provinces, 89%). Although 22 provinces (62%) also use this information to produce plans for children with disabilities and 20 (54%) use it for the basis of DOET plans for the development of education for children with disabilities. In addition, 21 provinces (57%) reported they share this information with other sectors. Monitoring of lower level implementation of inclusive education Monitoring by provincial level of district level Of the twenty nine provincial departments of education and training which are implementing inclusive education, twenty six provided information in the survey about their monitoring of district level inclusive education implementation. Ten provinces report annual monitoring of districts (38.5%), 12 conduct semi-annual monitoring (46.2%), four provinces carry out quarterly monitoring (15.4%), and just two provincial departments of education and training implement monthly monitoring of their districts (7.7%). Monitoring indicators: Only 22 provincial DOET provided information about the monitoring indicators used to monitor district education departments. Indicators include: results and

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quality of inclusive education (100% or 22 provinces); statistics, management of children with disabilities in district (14 provinces, 63.6%); professional support for teachers who teach inclusive education (7 provinces, 31.8%). Monitoring by district education department of schools Of the 29 provincial DOET implementing inclusive education, 23 provided information on how often the district level monitors schools’ implementation of inclusive education. Most districts conduct monitoring bi-annually (43.5% of provinces), quarterly monitoring is done by 30% of provinces, and annual monitoring by 22% of provinces. Only 3 provinces conduct monthly monitoring of schools by the district (13%). Monitoring indicators: Eighteen provincial DOET provided information about the indicators used for district monitoring of schools’ implementation of inclusive education. The primary indicator is about the results and quality of inclusive education (14 out of 18 provincial DOET, 78%); professional support for teachers who teach inclusive education (8 provincial DOET, 44%); statistics and management of children with disabilities in district (7 provinces, 39%); management of children with disabilities in schools (6 provinces, 33%). Monitoring by schools of individual families of children with disabilities Twenty one of the 29 provincial DOET provided information. Most indicated they undertake monitoring on a quarterly basis (8/21 provinces, 38%), monthly monitoring is conducted by 7 provinces (33%), and semi-annual monitoring by four provinces (19%). Only three provinces indicate annual monitoring (14%). Monitoring indicators: Only 14 provincial DOET reported about the indicators used for monitoring: support of children with disabilities at home (9 out of 14 provinces, 64%); support children in inclusive education (8 provinces, 57%); monitoring and management of children with disabilities (5 provinces, 36%). Reporting on Inclusive Education to higher levels Province reporting to Ministry of Education and Training Only twenty seven of the total forty provinces responded to questions concerning their reporting to higher levels. Of these, the majority report to MOET annually (67%) or six monthly (30%). Only one province makes a quarterly report to MOET. These reports are primarily focused on general statistics about the number of children with disabilities and the numbers of children with disabilities attending school and their results in education. A very small number of provinces report issues such as infrastructure, numbers of teachers in inclusive education, etc. District education departments reporting to provincial level Twenty seven provincial DOET offices reported on how often they receive reports from the district level. Approximately half receive reports from districts every six months, with the remainder receiving them annually. Four provinces report that they receive quarterly reports from their districts, and two receive monthly reports.

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Education establishments reporting to management Only 19 of the Provincial level DOET were able to provide information on the frequency of reporting by education establishments to management level. The majority (9 provinces) indicate that education establishments report six monthly, four provinces indicate schools report monthly, two provinces report quarterly and three annually. Difficulties and suggestions for improvement A large number of provinces indicated that a major difficulty in the provision of inclusive education was a lack of infrastructure and tools for teaching children with disabilities, as well as a lack of space for special education. Provincial education departments indicate that there are some policy difficulties in implementing inclusive education. Fifteen of the 32 provinces indicated that the lack of preferential policies for teachers providing inclusive education is a problem. Four provinces also indicated that the inclusive education policies are not appropriate, and another four indicated that the lack of preferential policies for children with disabilities is a difficulty. In addition, finance and budget for inclusive education is a barrier to effective implementation, with 23 of 32 provincial DOET (72%) indicating that the lack of a separate budget specifically for inclusive education is a problem. A number of provinces also indicated that the budget from the central government was insufficient and much of the funding came from local sources. Suggestions for improvement Thirty three provincial DOET made recommendations to improve the quality of education support for children with disabilities in provinces. Over 60% of recommendations focused on the need for better professional support, allowances and policies for inclusive education teachers (23/33 provinces). In addition, additional finance for inclusive education activities was recommended by 10 provinces; improved infrastructure and facilities for inclusive education by eight provinces; and the strengthening of inter-sector cooperation by seven provinces. Other recommendations include: strengthening leadership at higher levels, establishment of inclusive education centers for children with disabilities in every province, capacity development for specialized staff and the finalization of policies and mechanisms related to education for children with disabilities.

4.2.2. Existing services and support Provincial level service provision The number of provinces providing education services for children with disabilities has increased over the past three years, however not significantly and there are still large gaps in service provision. Of the 40 provinces responding to the survey, 37 responded to the question about provision of inclusive education of which 29 have provided inclusive education projects/programs over the past five years. According to the survey of provincial education departments, the most commonly provided service is support for inclusive education (20 of 40 provinces providing) and the least commonly provided are psychological counseling (11 of 40 provinces) and provision of assistive devices (11/40). These figures are however quite low,

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considering that only around 50% of the respondents provide these services and the respondents represent only 63% of total provinces in the country. In particular, it is concerning that only 20 provinces feel they are providing support for inclusive education, despite all provinces delivering inclusive education to children with disabilities. The number of provinces providing screening, disability identification and needs assessment is also very concerning (14/40 provinces).

Table 22. Education services at provincial level

Types of services No of provinces providing

service (N=40) 2009 2010 2011

Screening, early disability detection 12 14 14 Capacity and needs assessment for CWD 13 15 14 Early educational intervention 11 11 12 Rehabilitation (physical, sensory, recognition and language development) 11 11 12

Provision of special education 12 12 13 Inclusive education 20 23 22 Provision of assistive devices for children with disabilities 9 10 11 Organization of social/community activities with participation of children with disabilities 13 15 14

Psychological counseling 11 12 11 Career orientation and vocational training 12 14 14 Others 4 5 5

The survey form also asked about the provision of inclusive education at lower levels (district and commune) and the data seems inconsistent with the provincial level answers. There is clearly a problem with reporting and recording information about service provision at different levels. In this report we provide the information as given in the survey; however the specific numbers are potentially not reliable. Provision of inclusive education at district level Thirty of the forty provinces that responded to the survey provided data about inclusive education at district level. In total, these provinces include 311 districts of which 300 districts are implementing inclusive education. On average, the proportion of districts in each province providing inclusive education is 97% with 27 of the 30 provinces reporting that 100% of their districts are implementing inclusive education. However, in the other provinces the number of districts providing inclusive education is as low as 31%. Provision of inclusive education at commune level Twenty eight provinces provided data on communes, with a total 4,377 communes of which 3,976 are providing inclusive education. On average, the proportion of communes providing inclusive education in each province is 97.06%, however the range is from 30.8% to 100%. Eighteen of twenty eight provinces report that 100% of their communes are implementing inclusive education. At the school level, responses by educational staff indicate that they are indeed providing inclusive education services to children, either with or without assistance from the DOET. When asked to list their daily work activities, most educational staff answered formal teaching (75%), soft skills and self-care skills training for children with disability (CWD) (30%), teaching

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communication skills (28%) and caring for CWD in their daily activities (10%). One fifth of educational staff participated in the educational support process for CWD (including need assessment, developing individual educational plan, one-on-one teaching, performance appraisal etc.). In addition, teaching staff are involved in early intervention (9%), extra-curricular activities (9%) and counseling for parents of CWD (6%). It seems that there is a gap between the daily activities of staff and their qualifications or training. As discussed below, staff have largely not received training in how to teach communication skills, interpersonal skills, soft skills and self-care skills for children with disabilities, even though they are frequently required to do this. Unfortunately the data provided by Provincial Department of Education and Training regarding the number of children attending school and those not attending school is not very reliable. However, the general trend is clear, more children with disabilities are attending school at lower levels (kindergarten and primary school) and the numbers become less as the level of school increases. In addition, the data collection and reporting at provincial level also becomes worse. All 26 provinces that returned the survey were able to provide the number of children attending school, and 22 were able to provide the numbers not attending school. However at high school level only 16 provinces could provide data on CWD in school and only 9 on the children not in school. As can be seen in Table 23 below, very few provinces were able to provide statistics about the number of children with disabilities who had received educational services in the period 2009-2011. Statistics about provision of special and inclusive education were the best recorded and reported service. Very few provinces were able to provide information about psychological assistance, vocational training, screening and early detection and rehabilitation for children with disabilities.

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Table 23. Number of children with disabilities receiving educational support services by type of service 2009-2011

Support Services No. of

provinces reporting

Average No. CWD / province (Min-Max)

Total CWD receiving service

Screening, early disability detection 2009 5 858

(15 – 3,897) 4,288

2010 6 837 (25 – 3,908) 5,023

2011 7 1,816 (39 – 5,900) 12,713

Capacity and need assessment of CWD 2009 7 1,523

(15 – 4.041) 10,661

2010 8 1,330 (25 – 3.908) 10,641

2011 8 1,544 (39 – 3,988) 12,354

Early educational intervention 2009 7 636 (1 – 3,897) 4,454

2010 7 646 (1 – 3,908) 4,521

2011 7 682 (1 – 3.988) 4,776

Rehabilitation (physical, sensory, recognition and language development, etc.)

2009 5 210 (10 – 789) 1,049

2010 5 243 (15 – 922) 1,213

2011 7 215 (27 – 1,076) 1,503

Provision of special education 2009 8 289 (14 – 1,804) 2,314

2010 9 297 (20 – 2,098) 2,675

2011 11 262 (4 – 2,259) 2,882

Support in inclusive education 2009 11 1,413 (9 – 4,006) 15,545

2010 12 1,279 (14 – 3,881) 15,348

2011 14 1,215 (15 – 3,889) 17,005

Provision of assistive devices for children with disabilities 2009 6 172

(3 – 672) 1,029

2010 6 193 (2 – 827) 1,157

2011 9 340 (3 – 1,643) 3,061

Organization of social/community activities with participation of children with disabilities

2009 7 386 (1 – 1,987) 2,700

2010 8 377 (1 – 2,132) 3,016

2011 9 396 (1 – 2,378) 3,560

Psychological counseling 2009 4 192 (15 – 690) 766

2010 4 239 (17 – 868) 955

2011 4 293 (17 – 988) 1,171

Career orientation and vocational training 2009 5 218

(2 – 871) 1,092

2010 5 234 (5 – 883) 1,170

2011 6 259 (10 – 897) 1,551

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As an indication of whether these statistics are meeting the needs of children with disabilities, the highest average number of children receiving services is 1,800 children/province and the services included mainly screening and early detection. Each province on average has 11 districts (698 districts/63 provinces) and each district has about 17 communes (11,161 commune/63 provinces), therefore approximately 10 children with disabilities have been screened during 2011 in each commune. According to the General Statistics Office, children 0-14 years old account for 25% of the population and each commune has an average of 8,000 people. UNICEF estimates that the percentage of children with disabilities in Vietnam is 3%, meaning approximately 60 children with disabilities per commune. Based on the statistics above this would mean that only one sixth of the total children with disabilities have received disability screening – the most commonly provided service. The conclusion to be drawn is that either the provision of educational services for children with disabilities is not meeting demand or the statistical data is not adequate. Given that the number of responses is very low, the data is incomplete, and we can conclude that at least the recording of information about children with disabilities within DOET is inadequate. However, it seems also likely that many children with disabilities are not receiving the educational services they require. This conclusion is also supported by the survey of families of children with disabilities as part of this study. The interviews with families finds that a very small number had accessed any kind of educational services for their children: 11% at commune and district level inclusive education schools, 8% at special schools, 5% from the inclusive education centers at provincial level and less than 4% at charity educational centers. It seems there is significant work to do in terms of meeting the educational needs of children with disabilities. Inclusive Education Centers (IEC)/Special Schools The survey was sent out to 80 IEC/Special schools and 56 returned the form. Of these, two establishments have a research function, one is involved in both research and teaching, and the other 53 establishments specialize in teaching children with disabilities. Provision of specific education services at IEC/Special schools for 2010, 2011 is provided in the table below. Of the 56 schools, however only 39 were able to report on the children they serve by type of impairment. These IECs/Special schools are providing a range of services for children with disabilities. The majority of centers are providing teaching services (special education) and the majority (over 90%) also organize extra-curricular activities. Around 70% of the Centers provide rehabilitation services such as language development, two thirds are providing assistive devices, and two thirds are providing vocational counseling. Activities such as early education intervention, psychological consultation and inclusive education are implemented by 40%-50% of establishments.

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Table 24. Number of children with disabilities receiving education support at IEC/Special schools by type of impairment, 2010 and 2011

Impairment

(n=56) No. of Centers

responding Total PWD Total

teachers PWD/

Teacher

Intellectual impairment 2010 37 (66%) 1516 494 3.1

2011 39 (70%) 1755 523 3.4

Hearing impairment 2010 35 (63%) 1523 479 3.2

2011 37 (66%) 1603 515 3.1

Mobility impairment 2010 24 (43%) 313 287 1.1

2011 25 (45%) 342 300 1.1

Autism 2010 23 (42%) 199 324 0.6

2011 26 (46%) 247 359 0.7

Speaking impairment 2010 14 (25%) 483 147 3.2

2011 19 (34%) 568 210 2.7

Visual impairment 2010 14 (25%) 579 219 2.6

2011 14 (25%) 624 219 2.9

Learning difficulties 2010 10 (18%) 64 122 0.5

2011 12 (21%) 89 165 0.5

Behavioral disorders 2010 8 (14%) 49 114 0.4

2011 8 (14%) 56 114 0.5

Emotional disorders 2010 4 (7%) 24 54 0.4

2011 4 (7%) 26 54 0.5

Other 2010 18 (32%) 119 241 0.5

2011 20 (36%) 216 275 0.8

4.2.3. Financing and human resources Finance The data collected from provincial level DOET about the financing of education for children with disabilities was highly unreliable and cannot be included in this report. Very few provinces were able to or willing to report their financial expenditure on inclusive and special education. The provinces did report that most of the budget comes from the provincial level, with additional funds raised at the district or local level and from charity organizations. Inclusive education centers and special schools report that the vast majority of their funding comes from the State budget, however a significant amount (10%) comes from fees/contributions by persons with disabilities and their families. A very small amount of funding comes from international organizations or locally raised funds. Around 70% of this

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budget is spent on staff salaries and infrastructure, with insignificant amounts going to equipment, training or supporting activities for persons with disabilities and their families. Human resources The results of surveying 169 teachers working in the education service system (both special and inclusive education) in the three target provinces showed that 90% have completed undergraduate or graduate education but only 60% of informants have completed training on educational support for CWDs. Of these, 73% have received training in teaching methodology for children with different impairments (hearing impairment, visual impairment, mobility impairment, intellectual impairment, autism), 33% have been trained in teaching and management skills for inclusive education, and 24% have received training in disability early detection and early intervention. Only 6.7% of the surveyed teachers that were trained in general teaching methodology also had a degree in special education. Although this data is not necessarily representative of the situation in all provinces, it does indicate a relatively low level of qualification among those teachers working with children with disabilities. Despite this, teachers self-assessed their level of skill in providing education for children with disabilities as relatively good. As can be seen in the Table 25 below, the majority state that they are confident in conducting the thirteen steps necessary for the provision of inclusive education support for CWD.

Table 25. Self-assessment by teachers of their technical skills

No. Technical skill Self-assessment (N=169)

Cannot do Can do but not confident

Can do with confidence

1 Assessing the capacity and needs of CWD 10 (6%) 26 (15%) 133 (79%) 2 Early intervention for CWD 29 (17%) 18 (11%) 122 (72%) 3 Development and implementation of individual

education plans for CWD 7 (4%) 15 (9%) 147 (87%)

4 Modification of training curriculum for CWD 7 (4%) 16 (10%) 146 (86%) 5 Assessing the progress of CWD 4 (2%) 4 (2%) 161 (95%) 6 Communication with CWD 7 (4%) 1 (0.6%) 161 (95%) 7 Soft skill training for CWD 24 (14%) 30 (18%) 115 (68%) 8 Cooperating with and supporting inclusive

education teachers at other schools in the community

46 (27%) 12 (7%) 111 (66%)

9 Counseling for families of CWD 6 (4%) 15 (9%) 148 (88%) 10 Mobilizing resources for development of inclusive

education 45 (27%) 19 (11%) 105 (62%)

11 Designing and delivering effective lessons 14 (8%) 17 (10%) 138 (82%) 12 Organization of learning activities for CWD 8 (5%) 14 (8%) 147 (87%) 13 Organization of extracurricular activities to promote

participation of CWD 12 (7%) 14 (8%) 143 (85%)

The majority of people working in Inclusive Education Centers/Special schools have teaching qualifications, however only 31% have qualifications in special education, although 86% of the establishments responding to the survey have at least one staff member with professional training in special education. Over 40% of these staff in IECs has less than 5 year experience working with children with disabilities, and only 30% have over 10 year experience. Over 50% informants stated that they have sufficient work facilities and equipment including infrastructure, equipment, materials and access to internet, and levels of job satisfaction were

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quite high; 85% are satisfied with working conditions, 82% are satisfied with the quality of service they provide and over 80% are satisfied with their professional training opportunities. Staff are least satisfied with their salary and allowances, with only 65% expressing satisfaction and 137 staff (81%) recommending that staff involved in early intervention and inclusive education, nursing staff working overtime, and school health care staff should receive preferential treatment such as increased salary/allowances, reduction in the number of pupils in one class, rewards for good performance. The survey and interview results indicate that equipment and materials for both teachers and students were lacking and poor quality. Only around 50% of staff indicated that they had sufficient technical facilities, materials, access to online information and teaching aids. Assistive devices for persons with disabilities including wheelchairs, hearing aids, supportive software, Braille, glasses, and mobility canes for the blind are usually provided by the children or families themselves or charity organizations. This is even the case in special schools. Only 13 of 56 IEC Centers/Special schools had computers for students, eight of 56 have Braille printers, seven have wheelchairs and six have hearing aids/pictures/tools for hearing impaired students. Provincial DOET recognized the difficulties with finance and human resources, with 17 provincial DOET (53%) indicating that lack of teachers, and managers for inclusive education and 15 (47%) indicating that lack of training for teachers was a barrier for the effective implementation of inclusive education. Teacher training The survey also analyzed the situation of training for teachers of children with disabilities. Two Universities and three colleges with special education departments were interviewed: Department of Special Education, Hanoi University of Pedagogy; Department of Special Education, National College of Pedagogy; Department of Special Education, National College of Pedagogy Nha Trang; Department of Special Education, Ho Chi Minh City University of Pedagogy; and the Department of Special Education, National College of Pedagogy Ho Chi Minh City. Training of teachers for the implementation of inclusive education is done at all Universities and teacher training colleges through a general module on teaching children with disabilities. The University of Pedagogy in Ho Chi Minh city and Hanoi are the only universities equipped to provide specific technical training in teaching children with hearing impairment, intellectual impairments and visual impairments. These Universities primarily provide degree level courses and some short in-service certificate training. The Hanoi University of Pedagogy has recently introduced master level training in Special Education. There is very little research in special/inclusive education being undertaken at any of these Universities and Colleges. A large number of surveyed staff of DOET (78%) indicated that they need further training in “understanding the psychological features and personal characteristics of CWD, methods used for taking care of, communicating with/educating CWD (formal education, soft-skill training, behavior management, support methods)”. This shows that although most staff found

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confident in conducting education support activities for children with disabilities (as shown in Table 25 above), they need further training in this issue. 14% of staff would like to learn more about disability laws and policies, and less than 5% expressed a need to learn more about the tools and tests used for assessment, communication skills with parents of children with disabilities, early detection and early intervention. In Inclusive Education Centers/Special schools, approx. 50% of the total staff has attended professional development within the three years before the survey, the largest percentage of them were teachers (595 teachers of a total of 818 teachers in 50 IECs). These establishments also lack documents and resources to support teachers. Of the 56 establishments responding to the survey, 19 have general resources on early intervention for children with disabilities (34%), 12 have general books on special education for children with intellectual disabilities (21%), six have materials regarding teaching methodologies for children with different impairments (11%), and only five have documentation supporting teaching for children with hearing impairments (9%).

4.2.4. Cross-sector coordination There is some coordination between the education sector and both the social and health sectors in providing services to persons with disabilities. Thirty one of the provincial DOET offices surveyed answered the questions about coordination with other sectors, and 29 indicated that they do collaborate, primarily with Department of Health, and secondly with the social/employment sector. The survey of 75 special education schools/centers indicated that some coordinate with the social sector in order to ensure children with disabilities receive the monthly government allowance and to transfer older children to vocational training centers. The coordination between health and education sectors in early detection and early intervention was also not as close as expected. The survey results of 75 education establishments showed that the main areas of coordination between health and education are 1) diagnosis and assessment of persons with disabilities, (2) early intervention in education, and 3) practice of special skills. About 61% of educational staff think they have partial cooperation with health staff. Over one fifth of educational staff thinks their cooperation with health staff is not good, meaning not close or no cooperation at all in the nine identified areas. The survey of provincial level DOET also indicates high dissatisfaction with coordination of education sector with other sectors. Seventeen of the 32 provincial DOET mention that the inter-sector cooperation is not permanent, consistent, and efficient (53%) and four suggest that the total lack of inter-sector cooperation is a difficulty. The main activities for collaboration with other sectors are in providing inclusive education and development of support plans for children for special and inclusive education. The areas with the poorest collaboration include: CBR, early detection and intervention, career orientation and business development, psychological counseling, legal assistance, referrals and development of DPOs.

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Collaboration most often takes the form of meetings and exchange (25/31 provinces); followed by joint interventions and collaboration (19 provinces). Seventeen provinces conduct joint monitoring activities, and 14 provinces cooperate through telephone consultations. Provincial DOET indicated that the lack of clear policy guidelines, roles and responsibilities was a barrier to more effective coordination, also lack of funding for coordination. In order to improve coordination, provinces recommended greater attention to policies, documents and leadership from higher levels as well as attention to strengthening the system of inclusive education and enhancing the budget. At the Inclusive Education Center level, there is significant collaboration with social/employment (45 of 47 Centers responding to the survey), and some with DOH (40/47) as well as collaboration with local authorities and local socio-political organizations (Women’s Union, Youth Union, etc) (40 centers). This collaboration with social/employment sector is primarily for the purpose of mobilizing resources (71% of 40 centers), as well as referrals (67%), support with integration (62%) and vocational education and training (56%). Collaboration with the health sector is focused on early intervention (70%) and detection (68%) as well as supporting integration (65%), diagnosis and assessment (63%) and rehabilitation (63%). See Figure 8 comparing the cooperation between sectors.

4.3. Labor/social services sector The labor/social services sector includes all those services provided by the Ministry of Labor, Invalids and Social Affairs. Quantitative surveys were sent to provincial DOLISA officers, DOLISA staff at social protection centers and colleges and universities training staff in social work. Qualitative interviews and focus groups were held with leaders and technical staff at provincial level DOLISA and technical staff at district and commune level.

4.3.1. Governance and administration According to the returned questionnaires from 48 of 63 provinces (76%), the management and monitoring systems within DOLISA are relatively well established but are mainly focused on those persons with disabilities receiving social protection payments and/or living in social protection centers. Monitoring of the implementation of policies is done through reports (profile of individual persons with disabilities as well as summary reports) as well as visits to social protection centers, and to persons with disabilities and their families on a bi-annual basis. Monitoring includes checking of disability classification, on time payment of allowances, provision of basic services in centers. It is not focused on evaluation of quality of life or improvements in the situation of persons with disabilities. Monitoring of different levels is not widespread. Less than 50% of the 48 provincial DOLISA offices reported that they undertake regular (monthly, bi-annual or annual) monitoring of

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district level, district to commune level or commune to households with a disabled member. The monitoring reports that are done are used to report to higher levels, but also to develop support plans for persons with disabilities (40 of 43 provinces responding) and for development of policies (31 of 43 provinces). Most of the provinces who answered the survey indicated they have a one year plan for activities (54%), 27% of responding provinces have a 3-5 year plan, 22% have a 5-10 year plan. 20% of the provinces either did not respond to the question or do not have a plan for supporting persons with disabilities.

4.3.2. Existing services and support MOLISA is the lead agency for providing services to persons with disabilities and for implementation of the Disability Law and as such the service network in the social/employment sector is quite comprehensive. According to statistics provided by the Social Protection Department (SPD) of MOLISA, there were 420 social protection establishments in 2010 with total of 8012 staff providing residential care for more than 40,000 people, including the elderly, children, persons with disabilities, people with HIV/AIDS, and other vulnerable groups. The results from the current baseline survey of 48 provinces (of 63 provinces) indicate a total of: 168 social protection centers (including both public and private centers) with an average of 3.7 per province. The data provided through the survey of DOLISA offices about vocational training, orthopedic, day care, counseling, employment, social work, independent living centers and other facilities was very inaccurate, with only 16 provinces reporting about vocational training centers, and less than ten provinces providing data about the other range of institutions. These social/employment services are primarily within the public system, however there are also significant numbers of centers and facilities operated by charity organizations, mass organizations and the private sector. Only 41 of the 48 provinces responding to the survey provided data about the number of persons with disabilities they serve, indicating a total of 780,150 people, and only less than 20 of these provinces were able to provide a breakdown by type of impairment. This is clearly very low as the Census indicates that 7.5% of the population over 5 years old is living with an impairment of some kind. It is concerning that provincial DOLISA offices are unable to provide accurate statistics about the number of persons with disabilities they are providing services to. It seems that DOLISA may not have accurate breakdown of the types of people receiving services such as care in social protection centers, monthly allowances (i.e. whether they are elderly, orphans, people with HIV). This survey was conducted in 2012, about data from 2011, so hopefully this problem has now been rectified and DOLISA now has better data collection and storage.

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DOLISA offices indicated that there are various problems with service provision for persons with disabilities. In particular, lack of resources, equipment and infrastructure seems to be a major problem, as well as a lack of appropriately trained and qualified staff. Within the social protection centers there is seen to be a lack of appropriate infrastructure and equipment for persons with disabilities, as well as limited budget. In addition, the lack of full time staff qualified in rehabilitation and psychology is seen as a major problem in these Centers. In order to improve social support for persons with disabilities, particularly to support them to live in the community, DOLISA staff recommend additional budget for community based care, as well as vocational training and employment for persons with disabilities and increased promotion of the Disability Law and related policies.

4.3.3. Financing and human resources Provincial DOLISA The survey of provincial DOLISA offices was returned by 48 provinces (89% of total provinces). The survey indicates that the human resources committed to working with persons with disabilities are relatively well qualified at the provincial level, with qualified staff decreasing at district and commune level. At provincial level none of staff have only primary school level education, and most staffs have at least college level education while at commune level, the majority of staff working with persons with disabilities has only primary or secondary level education. Staffs working for DOLISA have qualifications in a range of different fields, with the majority having qualifications in economics. A significant number of provinces have staff with qualifications in social work, education, law and sociology. The predominance of economics qualifications is at every level, from commune to provincial level. DOLISA offices were asked to provide information about the number of staff sent for training from 2009-11, however very few provinces responded. It seems that the majority of staff who are participating in training are only joining short courses of less than three months. Very few staff have participated in degree level, or even 6-month courses in these three years, however as the response rate is very low this information may not be reliable. Social Protection Centers The staff of Social Protection Centers that responded to the survey indicated difficulties in terms of funding, infrastructure and equipment, and human resources at the centers. The Centers have very experienced staff, the majority (50%) has worked in the social/employment sector for 10 years or more and over 50% have been working with children with disabilities for 10 years or more. The majority of the staff working in social protection centers has an undergraduate degree, but very few have specific qualifications in disability or social work or have had training in these fields. Only 19% of the staff who responded to the survey has degrees in social work. The majority of staff responding to the survey has medical qualifications (50% of the 116 respondents) and only 15.5% of the informants have degrees in psychology, teaching/pedagogy or special education. Of particular interest, no respondents

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have qualifications or have accessed professional training in providing vocational training. This is despite the explicit role of Social Protection Centers to provide vocational training and employment counseling for their residents (as stipulated by the regulations of the Ministry of Labor, Invalids and Social Affairs (MOLISA) and Ministry of Home Affairs on the tasks and powers of a social protection center (Circular No. 32/2009/TTLT-BLDTBXH-BNV). The survey indicates that 52% of social/employment staff have been trained to assist persons with disabilities; 85% in care for persons with disabilities, children with disabilities and the elderly, 27% in social work with individual, family and employment for persons with disabilities, 10% in special education, 10% in sign language and 10% in law and legislation related to persons with disabilities and elderly people. Another 5% have been involved in other training courses such as methods of inclusive teaching for children with disabilities, physical therapy, determination of types of disabilities, etc. When asked about their daily work related to persons with disabilities, 72% indicated that their work activities are related to healthcare, medical check-up/treatment and rehabilitation, 12% related to teaching children with disabilities, 12% administrative tasks, 11% cooking and care and 16% other assignments (management of the objectives in the centers, monitoring and evaluation, etc.). Virtually no staff of the Social Protection Centers mentioned tasks related to vocational training and employment for persons with disabilities. This indicates that the qualifications and training of these social protection center staff is quite appropriate to their current tasks. However, their current tasks, and their qualification and experience are not appropriate for the most recent roles and responsibilities of Social Protection Centers as laid out by the Ministry in 2009 (Circular No. 32/2009/TTLT-BLDTBXH-BNV). In particular, the Centers are still focused on basic care and protection of persons with disabilities and the elderly, not on inclusion, vocational training or employment assistance. The survey asked staff to assess their own skills in specific areas seen as essential for working with persons with disabilities. The results for the 116 respondents are as follows:

Table 26. Self-assessment by social protection center staff of their technical skills

No. Technical skills Self-assessment

Cannot do Can do but not confident

Can do with confidence

1 Assessing the capacity and needs of PWD 37 (32%) 8 (7%) 71 (61%)

2 Early intervention for PWD 36 (31%) 7 (6%) 73 (63%)

3 Development and implementation of support plans for PWD 54 (47%) 5 (4%) 57 (49%)

4 Modification of support programs for PWD 53 (46%) 9 (8%) 54 (47%)

5 Assessing the progress of PWD 37 (32%) 4 (3%) 75 (65%) 6 Communication with PWD 27 (23%) 1 (0.9%) 88 (76%) 7 Soft skill training for PWD 67 (58%) 4 (3%) 45 (39%) 8 Consultation and counseling PWD and their families 64 (55%) 5 (4%) 47 (41%) 9 Career orientation for PWD 51 (44%) 4 (3%) 61 (53%) 10 Filing PWD profiles 37 (32%) 1 (0.9%) 78 (67%)

11 Mobilization of resources for disability support 69 (60%) 4 (3%) 43 (37%)

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At first glance it seems concerning that over 20% of respondents answer that they cannot even communicate with persons with disabilities and 32% cannot file profiles of persons with disabilities. However, it is important to remember that Social Protection Centers provide care for a wide range of people, including the elderly and orphans, so it may be that these staffs do not work with persons with disabilities. However, the level of self-assessed skill in certain areas does seem concerning, given the specific mandate of Social Protection Centers to provide not only care, but also to assist persons with disabilities to integrate into society. For example, only 61% of respondents are confident in assessing the needs and capacities of persons with disabilities, 49% are confident in developing support plans, only 52% of respondents express confidence in providing career orientation and only 39% feel confident to provide soft skill training.

Management indicated that it is difficult to recruit qualified staff, particularly in the public system, as the pay is low and the level of work and responsibility is very high. In addition, staffs have to provide care and services for a wide range of different people in the same center, from the elderly and people affected with HIV, to people with various kinds of impairments, including intellectual impairments and psychiatric problems making the work very challenging. However, the Center staff themselves indicate quite high levels of satisfaction with the facilities; nearly 80% state that there are sufficient work facilities and equipment at the Centers, including infrastructure, equipment, materials and access to internet. This means that the Center staffs are more satisfied with the work facilities at their workplace than education or health staff. Despite this, of the 72 staff that provided recommendations for improving the service for persons with disabilities, 92% recommended to improve infrastructure and 79% to provide more equipment and medicines. The surveyed staffs also indicated high levels of satisfaction with their working conditions; 99% are satisfied with the quality of the services they provide, 94% with their working conditions, and 84% with their professional training opportunities. In common with education staff, the lowest satisfaction is with salary (65%) and allowances (60%). However, of the 75 staff that made recommendations about capacity building for staff, 96% proposed more training in caring and rehabilitation for persons with disabilities. In addition, 89 people recommended that technical staff should receive more preferential treatment such as salary/allowance increase. Other recommendations from staff included:

- Disability-related policies need to be more clear, specific and detailed (including standards/criteria);

- Improved regulations of the missions and roles of each sector/agency/organization in provision of disability support services;

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- Regulation of the structure of multi-sector cooperation in implementing disability support activities;

- Establishment of centers for provision of support services for persons with disabilities (such as social protection center, counseling services center, social work center in separate education school, vocational training school, etc.);

- Development of professional social work;

- Increase in State investment in public construction, infrastructure, accessible transportation, etc.

- Capacity building for staff working on disability support. Finances for social/employment services The majority of the funding for social and employment activities is provided by the state budget; however there is no separate budget line specifically for disability. Significant budget for DOLISA activities is also provided by provincial budgets, with smaller amounts coming from international organizations and local sources of funding. The majority of the funding allocated to provinces is for social protection allowances, and the second biggest expenditure is for health care. Very little budget, in very few provinces, is allocated for services such as psychological counseling, legal advice, vocational training or employment support, staff training, support for DPOs, or even equipment for persons with disabilities. The interviews with staff from DOLISA indicated that budget provided by government for supporting people in Social Protection Centers is very low and insufficient to provide nutritious meals and recruit sufficient qualified staff. The Centers also lack appropriate equipment and assistive devices for persons with disabilities, particularly children with disabilities. Centers are thus in the position of trying to raise funding locally from charity and private sector organizations, which means the funding is unstable year on year.

4.3.4. Cross-sector coordination Inter-agency coordination seems relatively well developed between the labor/social sector and health and education (as well as with other relevant agencies). As MOLISA is the lead agency for persons with disabilities and their range of services is extremely broad this is perhaps not surprising. However, it seems that the staffs of Social Protection Centers assessed their collaboration with health staff and education staff far more highly than the reverse. For example 18% of social protection center staff stated that the cooperation with the health sector is good, while only 0.4% of health staff responded that their cooperation with social/employment staff is good. It is possible that the health staff were responding on their collaboration with other DOLISA staff, not social protection center staff, or that the questions were interpreted differently by the different sectors. The respondents from social protection centers claim that they collaborate with health staff monthly and another 31% collaborate on a needs basis (at

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the request or need of the person with a disability). While over 65% of health staff indicated that they only collaborate with social/employment staff on the request/need of persons with disabilities. The majority of staff of social protection centers also rated their collaboration with the education sector as good (70% rate collaboration as partial or good). The respondents indicate they collaborate monthly or on a needs basis, primarily through meetings or working together on interventions. If this is an indication that staff are working with teachers and Department of Education staff to ensure access to school for children in social protection centers, then this is a very promising finding. Unfortunately there is insufficient detail in the survey to know if this is in fact the case. The interviews and the survey responses indicate that much of the coordination between sectors is still mainly on request and is not institutionalized. The main activities where there is a coordinated approach are related to social protection allowances, health insurance and health care cards and disability awareness raising. There is insufficient cross-referral of persons with disabilities for comprehensive service provision, and insufficient regular information sharing between agencies. Also see below for assessment of coordination between different sectors

Figure 8. Comparison of respondents’ assessment of coordination between sectors

N = 512

0%10%20%30%40%50%60%70%80%90%

100%

Cooperation of health staff with education sector

Good

Not good

79

N = 169

N = 512

0%10%20%30%40%50%60%70%80%90%

100%

Collaboration of education staff with health sector

Good

Not good

0%10%20%30%40%50%60%70%80%90%

100%

Cooperation of health staff with LISA sector

Good

Not good

80

N = 116

N = 169

0%10%20%30%40%50%60%70%80%90%

100%

Cooperation of SP center staff with health sector

Good

Not good

0%10%20%30%40%50%60%70%80%90%

100%

Cooperation of education staff with LISA sector

Good

Not good

81

N = 116

4.4. Service provision by international and local NGOs

To understand the extent and nature of service provision by the non-government sector, those international and local NGOs involved in service provision for persons with disabilities were surveyed.

Table 27. Survey of non-government sector response rate

Type of organization No. sent No. returned Response

rate International NGOs/ International organizations (IO)

21 11 (one IO)

52%

Local NGO/ Center 18 10 55% DPO 15 5 33%

General information about respondent organizations

Table 28. International NGOs and international organizations

Note that most of the very large INGOs and UNICEF only spend a very small percentage of their total budget and staff for persons with disabilities (less than 25%) so these numbers could be somewhat misleading.

Table 29. Local NGOs/Centers

0%10%20%30%40%50%60%70%80%90%

100%

Cooperation of SP center staff with education sector

Good

Not good

Characteristic Min/Max Average Age (N=9) 9 / 37 20 Annual budget (N=8) $300,000 / $18 mil 6,899,407 No. of staff (N=9) 6 / 208 54

Characteristic Min/Max Average Age (N=9) 1yr / 18yrs 8yrs Annual budget (N=6) $13,658 / $800,000 $284,776 No of staff (N=9) 7 / 92 30

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Organizations of Persons with disabilities (DPO) One mass organization (the Vietnam Blind Association) has been operating for 43 years, however the other DPOs responding to the survey have been established for 10-12 years. Only two DPOs responded to the question about annual budget; one has a budget of $1,000 and one of $9,600. The budget for the Blind Association would be significantly higher, but unfortunately they didn’t answer the question. Most of the DPOs do not have staff. The Blind Association has large numbers of staff from National to commune level, with 33 staff at Head office in Hanoi. Number of persons with disabilities assisted by non-government organizations

Table 30. Number of persons with disabilities serviced by international NGOs

Type of Impairment INGOs (N=4)

2009 2010 2011 Total Mobility impairment 18,768 17,644 18,368 54,780 Hearing and speaking impairment 1,040 702 737 2,479 Visual impairment 5,075 5,028 4,920 15,023 Intellectual impairment 1,022 702 678 2,402

Mental health problem 250 250 311 811 Others 58 58

Note: one INGO reported information by the type of assistance provided since 2008 (e.g.: glasses, wheelchair, physiotherapy) rather than type of impairment. Another INGO reported assisting 422 persons with disabilities in 2009 and 247 in 2011, but don’t have the breakdown by type of impairment. It is surprising, and concerning that most of the INGOs were unable or unwilling to provide the answer to this question about the number of people they have assisted over the past three years. People with mobility impairments make up the majority of people serviced by international NGOs, with quite a large number of vision impaired also receiving services from INGOs. The vast majority of the people with physical disabilities assisted, over 17,000 people per year, have been serviced by one INGO: Netherlands Leprosy Relief. Services provided by local NGOs Local NGOs and centers work in twenty one provinces throughout the country, although primarily in the major cities and delta areas.

Table 31. Number of persons with disabilities serviced by local NGOs and Centers

Type of Impairment Local NGOs (N=4)

2009 2010 2011 Total Mobility impairment 477 3,132 4,758 8,367 Hearing and speaking impairment 42 51 69 162 Visual impairment 100 200 305 605 Intellectual impairment 368 503 646 1,517 Mental health problem N/A N/A N/A 0

Others (specify if possible) 40 25 56 121

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In addition, Center for Research and Education for People with Hearing Impairment (CED) reported that they have provided the following services for people with hearing impairment: no. of beneficiaries in 2011:

• Advice/Counseling: 717 times people attend. • Training sign language: 193 people. • Training and regular activities of the Club of people with hearing impairment: 1,781

times people attend/benefit. • Training/workshops: 1,498 times people attend/benefit.

The majority of people assisted by local NGOs and Centers are also those with mobility impairments; however it is interesting to see that local NGOs seem to be providing services to people with intellectual and sensory disabilities as well, potentially they are filling the gap left by the lack of service provision by government or INGOs. Services provided by DPOs DPOs, virtually by definition operate in one province only (or if registered at the district level, in one district). The exception is the Vietnam Blind Association which operates in 47 provinces covering 2,000 communes.

Table 32. Number of persons with disabilities serviced by DPOs

Type of impairment DPOs (N=4)

2009 2010 2011 Total

Mobility impairment 155 200 160 515

Hearing and speaking impairment 11 11 11 33

Visual impairment 50,003 57,003 60,003 167,009

Intellectual impairment 5 4 7 16

Mental health problem 0

Others (specify if possible) 3 3 3 9

DPOs have very small budgets, no staff and have limited activities. While this is now changing, in 2012 when this survey was conducted most DPOs were self-help and friendship groups for their members. So it’s not surprising that the number of people serviced by these four DPOs is small. The Blind Association is an exception, with a budget from the central government, a very long history and established staff and programs, they provide assistance (micro loans, vocational training, mobility support) to a very large number of visually impaired people every year (50,000 in 2009, 57,000 in 2010 and 60,000 in 2011).

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Table 33. Activities to support persons with disabilities

Activity No. of NGO

No. of DPO

No. of INGO

Assess the need and capacity of PWD 9 2 8

Early intervention 6 2 5 General health care services 4 4 Medical/surgical interventions 3 1 7 Medical institute based rehabilitation 4 1 3 Rehabilitation therapy (physical, sensory development, recognition and language) 5 6

Special education 6 2 4 Promoting inclusive education 7 2 6 Providing assistive devices 7 3 8 Organizing social/community/sports activities with participation of PWD 2 5 8

Emotional and Psychological Counseling 9 2 2 Self-help groups/DPOs 7 3 7 Family training 6 1 6 Parent associations 7 2

Vocational Training 6 3 10 Counseling and support for job placement 7 3 6 Microcredit/ revolving fund 1 1 5 Advocacy 8 4 8 Awareness raising 9 5 11 CBR 7 2 6

Legal aid 1 1 1 Mainstreaming disability into development 2 Independent living 1 Life skills for children with disabilities 1 Climate change 1

Challenges and successes of non-government actors The non-government organizations were also asked about the challenges they faced in providing services to persons with disabilities, and their successes in servicing persons with disabilities. All three groups (INGOs, NGOs and DPOs) identified that increased acceptance, support from and collaboration with government has been a significant recent success. The three groups also felt that there was increased community support and recognition for local NGOs and DPOs to play a role in providing services and assistance for persons with disabilities. In the areas where NGOs and INGOs are operating, there was felt to have been improved access to rehabilitation, education, sports and cultural activities and livelihoods for persons with disabilities and their families. It’s not clear however how widespread this improved access is. In terms of challenges, DPOs and NGOs identified a lack of funding, accessibility and infrastructure as major challenges. They also mentioned that low awareness and the expectation of charity rather than rights among persons with disabilities and their families was

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a barrier to greater inclusion. The INGOs mentioned lack of inter-sector coordination as a problem, as well as difficulties with the capacity of government partners, capacity among persons with disabilities themselves and difficulties in accessibility, transport and infrastructure. NGOs and INGOs recommended more and better training for local officials to ensure stronger implementation of disability laws, and the introduction of regulations for penalties for violations of disability legislation. These agencies also suggested better disability information, both in terms of identification and classification, and for the establishment of a national database of persons with disabilities to ensure effective service delivery according to needs. DPOs suggestions focused on the need for more funds, training and capacity building for DPOs, which was also supported by INGOs. NGOs and DPOs recommended better mainstreaming of services for persons with disabilities into regular health and education services. Finally, INGOs and DPOs expressed the need for expansion of services, particularly in rural and mountainous areas to ensure all persons with disabilities have access. Multi-sector coordination Non-government organizations and DPOs feel that there is now more commitment from government to multi-sector coordination, particularly from the social/employment sector at central and local level. Because of collaboration, services for persons with disabilities have become more coherent and comprehensive; it is now possible to carry out large-scale activities, for example, eye screening, and leprosy control. To some extent, non-government collaboration with government has improved access for persons with disabilities to necessary services, and has helped with capacity building of service providers and mobilizing resources. However, there are still challenges in effective collaboration. Some partners still lack commitment to multi-sector coordination and there is still very low awareness about the rights and needs of persons with disabilities at the local level. Many government agencies still have a charity approach, and cumbersome bureaucratic procedures hinder effective collaboration and effective service provision. Human resources, particularly at the local level, require greater training in disability rights, as well as in the specific skills and knowledge for delivering quality services. Effective coordination will require greater commitment from government and for leadership from government.

4.5. Summary: Service Provision System While each sector provides different services and is affected by different policy environment, the quantitative surveys and qualitative interviews elicited some key issues in service provision that seem to affect all the sectors. Financial resources for persons with disabilities Most of the provinces were unable to provide answers to the questions about budget sources and finance allocated for disability services. In the interviews with managers of sector

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departments and service providers, it became clear that provinces don’t have a specific budget allocation for disability programs; rather they could only estimate the percentage of the total budget for healthcare, education or social protection that was spent on persons with disabilities. The logbooks and financial reports do not have specific budget lines for disability, therefore the data on financial resources or expenditure was very poor. Most provinces estimated a very low amount of spending on persons with disabilities as there are no regular activities or specific programs for persons with disabilities. The budget allocated for the disability service system mainly comes from the state budget allocated based on annual budget planning by provinces, which doesn’t include specific line items for disability activities. In addition to this State budget, provinces try to mobilize additional resources from external sources (NGOs, local businesses, communities, etc.). However, this additional budget mobilized from community and organizations is highly variable. In the focus groups and in the interviews, respondents were most concerned about insufficient budget for implementation of policies, investment in human resource development and purchase of facilities. These were seen as the main challenges negatively impacting on the quality of services and the coverage of policies. Strategic development of a quality disability service system The data collected from the survey on planning for development of support services for persons with disabilities showed that most sector departments lack strategic plans for disability support services. Some provinces have a 3-5 year work plan, however this is largely the result of NGO funded and supported activities in those provinces. As the survey and interviews were conducted prior to the agreement of the National Action Plan for disability 2012-2020 (NAP), it is hoped that through the NAP dissemination process, each province and national ministry does now have an Action Plan. The NAP process provides a mechanism for better and more strategic planning, if it’s effectively disseminated to the local level and provincial level Ministries are provided support and assistance to develop their own plan. Facilities, training and working conditions In general, the survey results collected in the three sectors showed that the facilities and equipment for services for persons with disabilities were poor quality, outdated and insufficient. Infrastructure for persons with disabilities, including rooms for providing services, is very limited and creates difficulties in quality service provision. Most agencies do not have specific technical rooms for special interventions. Over 50% of the staff working in the three sectors indicated that additional and/or improved equipment and facilities are top of their list of needs in order to improve service quality. In addition, the working conditions and benefits for staff providing services for persons with disabilities are very difficult. All sectors reported that it is very difficult to attract staff to provide services for persons with disabilities because the cost norm for preferential policies is very low but the responsibility and difficulty of the work is very high. The qualifications and capacity of

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staff providing disability services is still very limited. Interestingly, despite these difficulties, most staffs who were surveyed indicated high levels of satisfaction with their working conditions, salary and training. In addition, staff self-assess that they feel relatively confident in providing services for persons with disabilities. Around 60% of the surveyed educational staff indicated that they are confident in conducting thirteen steps to provide inclusive education support for children with disabilities. Figures are similar for health and social services staff, although there is less confidence in more advanced activities such as providing counseling for persons with disabilities and families, providing soft skills training for disabled people or early detection of delayed development for children with disabilities. The qualifications and training of most of the provincial and district level staff are quite low, and lower than the ministerial standards specify. Training is improving, with more opportunities for staff to attend specialized training in teaching children with disabilities, or specific health interventions for different kinds of impairments. The vast majority of staffs seems aware of their knowledge and skill limitations, and indicated a desire for more professional and technical training in how to provide services to persons with disabilities. Gaps in service provision The services provided in all three sectors are extremely limited and do not meet the needs of persons with disabilities. Overall there are two main limitations of service delivery: services are focused on ‘care and protect’ rather than rights and inclusion; and services are primarily available only for people with mobility impairments. On the first issue, the health, education and social services that are currently provided mainly focus on basic health care, center based care for persons with disabilities who do not have families to support them, small allowances for families to provide care, and primary level education. While this likely means that most persons with disabilities do receive basic food, shelter and literacy, this existing service system will never deliver the higher level skills, education and social empowerment that is necessary for persons with disabilities to exercise their rights as full members of the community. If Vietnam is committed to the rights based approach, and to full integration of persons with disabilities into social and economic life, significant investment will need to be made in ‘higher level’ services such as secondary and higher education, vocational skills training, occupational therapy, comprehensive case management and referral, etc. The second significant shortcoming of the existing service system is that even those basic level services are primarily only able to meet the needs of people with mobility impairments. Even with the limited information provided through this survey, it is clear that in all three sectors, there are very few services for people with sensory or intellectual impairments or mental health difficulties. The current system is not at all equipped to provide comprehensive rehabilitation services for people with these impairments. There is a severe lack of qualified staff with appropriate qualifications, for example speech and language therapists, psychiatrists and psychologists, occupational therapists, and special educators. In addition, there are limited facilities, equipment and resources committed to assisting these people. For

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people with sensory, intellectual and mental health impairments even receiving basic care, literacy and social services is very difficult and providing services that will enable their social and economic integration will require a massive investment of time, training and resources. Services provided by non-government actors INGOs, NGOs and DPOs are very small players in terms of the number of people they reach and what they provide. However, they can provide models and target specific issues. Some evidences that local NGOs and DPOs are meeting needs that aren’t met in the government system, this should be encouraged.

5. Needs of persons with disabilities and access to services A key issue to be examined through the baseline assessment was to determine to what extent existing services were able to meet the needs of persons with disabilities. This question was researched through a questionnaire and interviews with persons with disabilities and their families.

5.1. Demographics of the surveyed persons with disabilities The baseline assessment survey team interviewed 1,202 people; 502 persons with disabilities and 700 family members answering the interview on behalf of children and persons with disabilities who were unable to answer on their own.

Table 34. Interviews of persons with disabilities and family members

regarding needs and service provision

Total interviewees Urban Rural Hanoi 403 70% 30% Quang Tri 397 57% 43% Vinh Long 402 33% 67% Total 1,202 55% 45%

The lists for selection of persons with disabilities to interview were put together based on data from the Provincial People’s Committee and DOLISA. Thus, it is not a random sample, but likely primarily those people who are receiving social protection allowances or other form of government assistance. In addition, the 1,202 sample is only drawn from three provinces, although both rural and urban areas of these provinces. Thus the data below cannot be considered representative of the general population of persons with disabilities. For the purposes of this survey however, the selected persons with disabilities are likely to have received some form of government assistance, thus can report their experiences and difficulties and are an appropriate group to survey for this purpose. Thus, the demographic information below is provided primarily as background for a better understanding of which persons with disabilities responded regarding their needs and experiences of services in Vietnam.

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This data should not be used as representative of the total population of persons with disabilities in Vietnam.

Table 35. Demographic information of surveyed persons with disabilities

No. Information Ha Noi (N=403)

Quang Tri (N=397)

Vinh Long (N=402)

Total (N=1,202)

Age***

1 0-5 years old 8 (2%) 19 (5%) 17 (4%) 44 (4%) 2 6-18 years old 56 (14%) 92 (23%) 169 (42%) 317 (26%) 3 19-30 years old 65 (16%) 87 (22%) 74 (18%) 226 (19%) 4 31-59 years old 178 (44%) 142 (36%) 113 (28%) 433 (36%) 5 60 years old and above 96 (24%) 57 (14%) 29 (7%) 182 (15%) 6 Mean + SD (Min-Max)*** 43.1 + 21.5

(1-99) 35.1 + 21.8

(1-99) 26.2 + 18.9

(1-92) 34.8 + 21.9

(1-99) Total 403 397 402 1,202 Gender***

1 Male 207 (51%) 256 (65%) 226 (56%) 689 (57%) 2 Female 196 (49%) 141 (36%) 176 (44%) 513 (43%) Ethnicity***

1 Kinh majority 403 (100%) 368 (93%) 381 (95%) 1152 (96%) 2 Others 0 (0%) 29 (7%) 21 (5%) 50 (4%) Education level ***

1 Cannot read or write 120 (30%) 132 (33%) 146 (36%) 398 (33%) 2 Kindergarten 41 (10%) 15 (4%) 15 (4%) 71 (6%) 3 Primary school 86 (21%) 102 (26%) 178 (44%) 366 (31%) 4 Secondary school 82 (20%) 108 (27%) 46 (11%) 236 (20%) 5 High school 74 (18%) 40 (10%) 17 (4%) 131 (11%) Marital status (for PWD 18 years and above)*** N = 344 N = 293 N = 221 N = 858

1 Single 167 (49%) 128 (44%) 145 (66%) 440 (51%) 2 Married 158 (46%) 152 (52%) 59 (27%) 369 (43%) 4 De facto partner 8 (2%) 3 (1%) 7 (3%) 18 (2%) 3 Divorced/ Separated 1 (0.3%) 1 (0.3%) 0 (0%) 2 (0.2%) 5 Widowed 10 (3%) 9 (3%) 10 (5%) 29 (3%) Post-secondary qualifications (for 18 years and above) N = 344 N = 293 N = 221 N = 858

1 No information 154 (45%) 149 (51%) 180 (81%) 483 (52%) 2 Information available*** 190 (53%) 144 (49%) 41 (19%) 375 (48%) 3 Elementary/Intermediate 27 (14%) 22 (15%) 3 (7%) 52 (14%) 4 College/ University 17 (9%) 7 (5%) 2 (5%) 26 (7%) 5 Postgraduate 2 (1%) 0 (0%) 0 (0%) 2 (0.5%) 6 Others 7 (4%) 32 (22%) 4 (10%) 43 (12%) 7 Do not attend any courses 137 (72%) 83 (58%) 32 (78%) 252 (67%)

* p<0.05 ** p<0.01 *** p<0.001 From this data it is clear that most of the persons with disabilities surveyed have very low educational levels and have had limited access to post-secondary training.

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The gender and age information of the surveyed sample indicate the skewing of the sample. For comparison, the 2009 Census which interviewed 10% of the population regarding their disability status indicates that disability is more prevalent among females than males and that disability is primarily a problem of the elderly. The census finds that 4 per cent of persons with disabilities are children aged 5 to under 16 years; 283,733 or 5% of the disabled population are children and adolescents aged 5 to 18 years; 3,314,700 or 55% of the disabled population are elderly aged 60 years or older. It seems that the sample interviewed for this report is slightly younger and more male than the overall population of persons with disabilities.

Table 36. Information on disability status of respondents

No. Disability information Ha Noi (N=404)

Quang Tri (N=397)

Vinh Long (N=402)

Total (N=1,202)

Type of impairment (note, some respondents have more than one impairment) 1 Mobility ** 170 (42%) 215 (54%) 191 (48%) 576 (48%) 2 Intellectual *** 92 (23%) 126 (32%) 174 (43%) 392 (33%) 3 Mental health *** 118 (29%) 57 (14%) 43 (11%) 218 (18%) 4 Hearing and speaking ** 51 (13%) 87 (22%) 64 (16%) 202 (17%) 5 Visual disability ** 48 (12%) 60 (15%) 28 (7%) 136 (11%) 6 Other 3 (0.7%) 11 (3%) 17 (4%) 31 (3%) Total 482 556 517 1,555 Duration of disability*** 1 Less than 5 years 19 (5%) 48 (12%) 18 (9%) 85 (7%) 2 From 5 to less than 10 years 52 (13%) 65 (16%) 93 (23%) 210 (18%) 3 From 10 to less than 20 years 84 (21%) 112 (28%) 146 (36%) 342 (28%) 4 20 years and above 248 (62%) 172 (43%) 145 (36%) 565 (47%) Cause of impairment*** 1 Congenital 212 (53%) 213 (54%) 215 (54%) 640 (53%) 2 Disease 111 (28%) 65 (16%) 147 (37%) 323 (27%) 3 Daily-life accident 11 (3%) 34 (9%) 12 (3%) 57 (5%) 4 Labor accident 14 (4%) 23 (6%) 6 (2%) 43 (4%) 5 Traffic accident 10 (3%) 21 (5%) 5 (1%) 36 (3%) 6 War 39 (10%) 36 (9%) 11 (3%) 86 (7%) 7 Other 6 (2%) 5 (1%) 6 (2%) 17 (1%) Total 403 397 402 1,202

* p<0.05 ** p<0.01 *** p<0.001

The sample surveyed for this report is dominated by people with mobility impairments (48%) then intellectual disabilities (33%), mental health difficulties (17%) and only 17% hearing and speaking impairments and 11% visual disability. In this survey people with multiple impairments have been listed according to all their impairments, thus the total is higher than the number of people interviewed. These ratios are somewhat different to the overall disabled population. The 2009 Census found that vision impairment is the most common impairment when a functioning approach is used, followed by hearing, mobility and cognitive impairments. The census found very high rates of people with multiple impairments (e.g. mobility and seeing difficulties) especially

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among older people. As people with multiple impairments have been listed under their individual impairments it’s not possible to determine the rate of multiple impairments in this sample.

5.2. Other characteristics of persons with disabilities

Table 37. Economic status of persons with disabilities (PWD >=18 years old)

No. Employment and income of

PWDs Ha Noi (N=404)

Quang Tri (N=397)

Vinh Long (N=402)

Total (N=1,202)

Current job n=344 n=293 n=221 n=858 1 Unemployed 268 (78%) 181 (62%) 175 (79%) 624 (73%) 2 Employed* 76 (22%) 112 (38%) 46 (21%) 234 (27%) 3 Farmer 7 (2%) 23 (8%) 0 (0%) 30 (4%) 4 Worker 2 (0.6%) 3 (1%) 2 (0.9%) 7 (0.8%) 5 Government staff 3 (0.9%) 1 (0.3%) 2 (0.9%) 6 (0.7%) 6 Freelance (small) trader 11 (3%) 14 (5%) 12 (5%) 37 (4%) 7 Self-employed 53 (15%) 71 (24%) 30 (14%) 154 (18%) PWD current income (for PWD who are currently employed)*** N=76 N=112 N=46 N=234

1 No income 9 (12%) 12 (11%) 19 (41%) 40 (17%) 2 Have income** 67 (88%) 100 (89%) 27 (59%) 194 (83%) 3 100,000 – 1 million VND 31 (46%) 69 (69%) 22 (82%) 123 (68%) 4 >1 mil – 3 mil VND 32 (48%) 26 (26%) 5 (19%) 41 (23%) 5 >3 mil – 5 mil VND 2 (3%) 2 (2%) 0 (0%) 8 (3%) 6 >5 mil – 7 mil VND 0 (0%) 2 (2%) 0 (0%) 9 (4%) 7 Above 7 million VND 2 (3%) 1 (1%) 0 (0%) 3 (1%) 8 Average income per month

(Min-Max) 1.460.000 + 1.590.000 (100.000-

10.000.000)

1.140.000 + 1.500.000 (100.000-

10.000.000)

690.000 + 370.000

(100.000-2.000.000)

1.190.000 + 1.450.000 (100.000-

10.000.000) PWD current source of income (more than one option possible) N=344 N=293 N=221 N=858

1 Employment *** 67 99 28 194 2 Pension, social allowance *** 251 145 84 480 3 Saving interest* 5 0 7 12 4 Support from family, relatives 255 204 162 621

The vast majority of the samples do have some income, mostly from a welfare allowance. For those who are employed, 20% do not receive an income (this likely means they are working for family businesses). Those who do earn income from employment, almost 70% earn less than 1 million VND per month and 90% earn less than 3 million a month. The poverty line is under 400,000 VND per month per household in rural areas and under 500,000 in urban areas4, however with the additional costs of impairment such as medication, transport, it is likely that the majority of persons with disabilities earning less than 1 million per month are facing significant poverty and finding it difficult to meet their daily needs. Persons with

4 Decree No. 9/2011/QD-TTG of Prime Minister on poverty line for the poor household and for the close to poor household applied in the period of 2011 – 2015

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disabilities in Vinh Long report a lower percentage of people with income (only 59%) and even these people have significantly lower incomes than those in Ha Noi or Quang Tri. The survey indicates that persons with disabilities are highly dependent on income from government welfare and from family and relatives. Income from employment is reported by only a small number of people as their primary source of income. (This also supports the contention that the sample is made up primarily of people receiving government pensions.) The survey also asked respondents about their household economic status. Results are shown below.

Table 38. Information on economic status of households with a person with a disability

No. Economic status of PWD

household Ha Noi (N=404)

Quang Tri (N=397)

Vinh Long (N=402)

Total (N=1,202)

Economic activity of PWD and their families ***

1 Self-employed, free-lance (small) trader 171 (42%) 257 (65%) 272 (68%) 700 (58%)

2 Worker 14 (4%) 5 (1%) 7 (2%) 26 (2%) 3 Government staff 68 (17%) 22 (6%) 25 (6%) 115 (10%) 4 Farmer 127 (32%) 94 (24%) 89 (22%) 310 (26%) 5 Others (retired, unemployed) 23 (6%) 19 (5%) 9 (2%) 51 (4%) Total 403 397 402 1,202

Self-evaluation of living standard of families ***

1 Rich 1 (0.3%) 4 (1%) 6 (2%) 11 (1%) 2 Average 40 (10%) 18 (5%) 18 (5%) 76 (6%) 3 Very close to poverty-line 261 (65%) 200 (50%) 153 (38%) 614 (51%) 4 Poor 95 (24%) 157 (40%) 173 (43%) 425 (35%) 5 Very poor 6 (2%) 18 (5%) 52 (13%) 76 (6%)

Current income source of PWD families (more than one option possible)

1 Employment*** 246 345 340 931 2 Pension, social benefit*** 275 177 78 530 3 Saving interest* 12 2 7 21 4 Support from family, relatives*** 159 72 71 302 5 Other 16 15 0 31

TOTAL 708 611 496 1815 Thus the majority of the families with a disabled member are involved in small trading or are self-employed, earning a low income from employment and government pensions. Quite a large number of the families in Hanoi are also receiving support from other family members, although the numbers receiving such assistance in other provinces is low. Two fifths of respondents evaluate the living standard of their families to be poor or very poor compared with other families. There is a difference in this percentage between the three provinces, with Ha Noi having the lowest percentage (25%) and Vinh Long the highest (56%).

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5.3. Independence and care for persons with disabilities Figures 9 and 10 show the ability of persons with disabilities to move around their house and independently carry out activities of daily life. Findings show that 55% of surveyed persons with disabilities can move around their house and 46% can conduct activities of daily life on their own. An additional 29% can move around their house with assistance and 17% are totally dependent on others when they need to move around their house. Approximately 33% of persons with disabilities can conduct daily life activities with assistance from others and 20% are totally dependent on others in conducting activities of daily life.

Figure 9. Mobility capacity of surveyed persons with disabilities

Figure 10. Ability of PWD to conduct daily activities

0%10%20%30%40%50%60%70%80%90%

100%

Hanoi Quang Tri Vinh Long Total

155 (38.50%) 191 (48.10%) 211 (52.50%) 557 (46.30%)

190 (47.20%) 104 (26.20%) 108 (26.90%) 402 (33.40%)

58 (14.40%) 102 (25.70%) 83 (20.70%) 243 (20.30%)

Can do Can do with assistance Cannot do

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Hanoi Quang Tri Vinh Long Total

213 (52.90%) 207 (52.10%)

241 (60%) 661 (55%)

140 (34.70%) 104 (26.20%) 98 (24.40%)

342 (28.50%)

50 (12.40%)

86 (21.70%)

63 (15.70%) 199 (16.60%)

Can move around the house easily Can move with assistance

Can not move without assistance

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The following table indicates that family members are primarily providing the assistance with mobility and activities of daily life required by persons with disabilities.

Table 39. Care-givers for persons with disabilities in conducting activities of daily-life

Care-givers Ha Noi (N=248)

Quang Tri (N=206)

Vinh Long (N=191)

Total (N=645)

Parents** 135 (59%) 124 (54%) 128 (67%) 388 (60%)

Spouses/Children*** 72 (32%) 72 (32%) 14 (7%) 160 (25%)

Siblings** 65 (29%) 33 (14%) 31 (16%) 127 (20%)

Grandparents 20 (9%) 20 (9%) 23 (12%) 63 (10%)

Relatives** 25 (11%) 11 (5%) 8 (4%) 42 (7%)

Neighbors** 2 (0.9%) 11 (5%) 4 (2%) 18 (3%)

Others (teachers, babysitters, etc.) 4 (2%) 12 (5%) 0 (0%) 12 (2%)

Note: Only for those PWD who require assistance

Table 40. Estimated time per day spent by family members taking care of

persons with disabilities

Time spent Ha Noi (N=248)

Quang Tri (N=206)

Vinh Long (N=191)

Total (N=645)

Day and night 43 (17%) 73 (22%) 73 (27%) 208 (23%)

The whole day 9 (4%) 10 (3%) 26 (10%) 49 (5%)

4-5 hours/day 10 (4%) 44 (14%) 36 (13%) 94 (10%)

2-3 hours/day 7 (3%) 15 (5%) 21 (8%) 46 (5%)

Not fixed, upon request of PWD 156 (63%) 185 (57%) 112 (42%) 523 (57%)

The survey indicates that care is primarily provided upon the request of the person with a disability (57%), however a relatively high percentage of persons with disabilities surveyed require care twenty-four hours a day. This percentage is highest in Vinh Long (27%) and only 17% in Hanoi, with 22% of people surveyed in Quang Tri requiring full time care.

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Table 41. Difficulties faced by family members in supporting people with a disability

No. Level of difficulty Ha Noi (N=403)

Quang Tri (N=397)

Vinh Long (N=402)

Total (N=1,202)

Supporting in food, clothes, accommodation, material support to PWD 1 Not difficult 78 (19%) 67 (17%) 91 (23%) 236 (20%) 2 Difficult 139 (35%) 146 (37%) 112 (28%) 397 (33%) 3 Very difficult 186 (46%) 184 (46%) 199 (50%) 569 (47%) Diagnosis and medical treatment, healthcare support 1 Not difficult 41 (10%) 37 (9%) 61 (15%) 139 (12%) 2 Difficult 138 (34%) 103 (26%) 96 (24%) 337 (28%) 3 Very difficult 224 (56%) 257 (65%) 245 (61%) 726 (60%) Orthopedics, rehabilitation 1 Not difficult 119 (30%) 75 (19%) 90 (22%) 284 (24%) 2 Difficult 131 (33%) 51 (13%) 43 (11%) 225 (19%) 3 Very difficult 153 (38%) 271 (68%) 269 (67%) 693 (58%) Activities of daily-life 1 Not difficult 78 (19%) 82 (21%) 103 (26%) 263 (22%) 2 Difficult 143 (36%) 145 (37%) 116 (29%) 404 (34%) 3 Very difficult 182 (45%) 170 (43%) 183 (46%) 535 (45%) Spiritual encouragement 1 Not difficult 95 (24%) 88 (22%) 112 (28%) 295 (25%) 2 Difficult 171 (42%) 127 (32%) 95 (24%) 393 (33%) 3 Very difficult 137 (34%) 182 (46%) 195 (49%) 514 (43%) Psychological counseling 1 Not difficult 90 (22%) 70 (18%) 96 (24%) 256 (21%) 2 Difficult 164 (41%) 123 (31%) 76 (19%) 363 (30%) 3 Very difficult 149 (37%) 204 (51%) 230 (57%) 583 (49%) Legal assistance 1 Not difficult 155 (39%) 41 (10%) 78 (19%) 274 (23%) 2 Difficult 138 (34%) 97 (24%) 73 (18%) 308 (26%) 3 Very difficult 110 (27%) 259 (65%) 251 (62%) 620 (52%) PWD from 6 to 18 years old N=59 N=62 N=169 N=317 School education 1 Not difficult 12 (21%) 11 (12%) 36 (21%) 59 (19%) 2 Difficult 12 (21%) 13 (14%) 18 (11%) 43 (14%) 3 Very difficult 32 (57%) 68 (74%) 115 (68%) 215 (68%) PWD >18 years old N=344 N=293 N=221 N=858 Post-secondary, undergraduate and graduate education 1 Not difficult 195 (57%) 85 (29%) 37 (17%) 317 (37%) 2 Difficult 51 (15%) 47 (16%) 19 (9%) 117 (14%) 3 Very difficult 98 (29%) 161 (55%) 165 (75%) 424 (50%) Vocational training 1 Not difficult 177 (52%) 71 (24%) 34 (15%) 282 (33%) 2 Difficult 61 (18%) 51 (17%) 22 (10%) 134 16%) 3 Very difficult 106 (31%) 171 (58%) 165 (75%) 442 (52%) Employment 1 Not difficult 156 (45%) 52 (18%) 33 (15%) 241 (28%) 2 Difficult 61 (18%) 62 (21%) 20 (9%) 143 (17%)

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3 Very difficult 127 (37%) 179 (61%) 168 (76%) 474 (55%) Access to information technology and communications 1 Not difficult 169 (49%) 59 (20%) 42 (19%) 270 (32%) 2 Difficult 82 (24%) 86 (29%) 25 (11%) 193 (23%) 3 Very difficult 93 (27%) 148 (51%) 154 (70%) 395 (46%) Access to public transportation and buildings 1 Not difficult 135 (39%) 54 (18%) 41 (19%) 230 (27%) 2 Difficult 97 (28%) 86 (29%) 30 (14%) 213 (25%) 3 Very difficult 112 (33%) 153 (52%) 150 (68%) 415 (48%) Cultural, sports and tourism activities 1 Not difficult 148 (43%) 42 (14%) 37 (17%) 227 (27%) 2 Difficult 93 (27%) 81 (28%) 27 (12%) 201 (23%) 3 Very difficult 103 (3%) 170 (58%) 157 (71%) 430 (50%)

It is perhaps not surprising that a majority of family members face difficulties in providing legal assistance or psychological counseling for persons with disabilities, however it is concerning that such a high number of family members express difficulties in meeting the basic needs of persons with disabilities such as food, clothes and accommodation (80% find difficult or very difficult), healthcare (88%), rehabilitation (77%) and activities of daily life (79%). Families in Hanoi are facing least difficulties in these areas, with Vinh Long expressing most difficulties. Nearly 70% of families answered that they find it very difficult to meet the study needs of disabled children of school age (6-18 years old). This percentage is lowest in Ha Noi and highest in Quang Tri. Approximately 50% of family members responded that they find it very difficult to meet persons with disabilities needs for vocational training, employment and accessibility. This is particularly the case in Vinh Long province (over 70%). It may appear from this survey that families face fewer difficulties in helping persons with disabilities with access to information technology (IT) and communications than access to buildings. However, it is important to remember that the majority of the samples are people with mobility impairments, and the number of people with sensory impairments is quite low. If the number of hearing and vision impaired were higher, it could be that access to IT and communications would show greater difficulties. The survey also asked family members for the primary reasons they faced difficulties in meeting these needs of persons with disabilities. Family members have many difficulties in meeting their disabled family member’s needs, however the main challenge is a lack of financial resources – i.e. the cost of services is too high for families. Also important however was a lack of knowledge, skills and information about the relevant services. This issue could potentially be easily addressed, while family poverty is more challenging.

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Table 42. Causes of difficulties in meeting the needs of persons with disabilities

Causes Ha Noi (N=403)

Quang Tri (N=397)

Vinh Long (N=402)

Total (N=1202)

Lack of time 94 (23%) 183 (46%) 160 (40%) 437 (36%) Lack of financial resources 276 (69%) 308 (78%) 333 (83%) 917 (76%) Lack of care giver 126 (31%) 137 (35%) 110 (27%) 373 (31%) Lack of knowledge and skills 229 (57%) 288 (73%) 184 (46%) 701 (58%) Lack of information about support policies and services 84 (21%) 275 (69%) 188 (47%) 547 (46%) Other (poor health, old age etc.) 5 (1%) 2 (0.5%) 8 (2%) 15 (1%) Total 814 1,193 983 2,990

Note: more than one answer possible

5.4. Needs vs. supply of social services for persons with disabilities

In general the survey indicates that there is a very wide gap between the needs of persons with disabilities and the supply of services, in all three key sectors. Access to necessary services in all the sectors studied is better in Hanoi than in Vinh Long or Quang Tri, which is perhaps unsurprising as Hanoi has both more services and better transport options. Persons with disabilities in rural areas face particular difficulties accessing the education, health and social services they require. The most commonly provided services are basic needs support: monthly subsistence allowances from the government, medical diagnosis and treatment, health insurance and basic education. More specialized services and services that go beyond basic survival to enable independence and inclusion are less available. In addition, the majority of persons with disabilities interviewed in this assessment had physical impairments, and it is reasonable to assume that people with visual or communication impairments, intellectual disabilities and mental health problems fare even worse in getting access to the specialized services they require. Another interesting finding of the survey was how few persons with disabilities and family members felt that persons with disabilities actually needed access to services, particularly services that would enhance their independence. For example, in Vinh Long province, only 6% of respondents said that persons with disabilities need access to public transport and buildings and sport, cultural and tourism activities and only 18% said persons with disabilities need support for vocational training. Even for some basic services such as education, the number of parents said their children have a need for education is only just over 50%. It is possible that parents whose children were already accessing education answered that they didn’t need access, but a more concerning interpretation is that parents don’t believe their disabled children are able to be educated. The survey thus indicates that there is a need for awareness raising of persons with disabilities and their family members about their rights to access all health, education and social services and to live independently. One barrier to accessing services seems to be the cost. Over half of those interviewed responded that they faced difficulties in paying for necessary services. Even in Hanoi where

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services are more available, cost is a barrier for persons with disabilities to get the required assistance. Cost is particularly prohibitive for women with disabilities, possibly partially explaining their reduced access to services (see below for more details). When asked about their support needs, persons with disabilities and family members suggested:

- 34% stated that disability policies need to be strengthened; - 32% persons with disabilities and families need support for medical checkup and

treatment, provision of health insurance; - 28% need a monthly social allowance; - 25% propose that monthly social allowance needs to be increased; - 15% state that they need to be counseled on disability policies, and knowledge and

skills to provide support to persons with disabilities, and; - 11% propose that vocational training and job creation should be improved.

5.4.1. Needs vs. supply in the health sector Based on the survey of persons with disabilities, the needs for health care and rehabilitation are very high. Seventy percent of those persons with disabilities interviewed indicated that they needed regular health care and rehabilitation, and the majority would prefer such care to be provided in the community as it is more convenient. In general, the gap between needs and supply of health services was quite wide, with the exception of health insurance which has expanded rapidly so the majority of people requiring insurance do have access. Access to all kinds of health services is slightly better for men than for women, although this is not a representative survey so it is not possible to say whether this is broadly the case.

Table 43. Need for healthcare services and actual service provision

No. PWD need for healthcare and rehabilitation services vs. services received

Ha Noi (N=403)

Quang Tri (N=397)

Vinh Long (N=402)

Total (N=1202)

Disability diagnosis and assessment

1 Need 317 (79%) 370 (93%) 223 (56%) 910 (76%)

2 Received services (% of those in need) 257 (81%) 248 (67%) 98 (44%) 603 (66%)

Medical treatment

1 Need 336 (83%) 338 (85%) 215 (54%) 889 (74%)

2 Received services (% of PWD in need) 274 (82%) 241 (71%) 113 (53%) 628 (71%)

Orthopedic surgery

1 Need 115 (29%) 156 (39%) 67 (17%) 338 (28%)

2 Received services (% of those in need) 51 (44%) 33 (21%) 23 (34%) 107 (32%)

Rehabilitation in hospital

1 Need 123 (31%) 154 (39%) 65 (16%) 342 (29%)

2 Received services (% of those in need) 55 (45%) 38 (25%) 18 (28%) 111 (33%)

Guidance on community-based rehabilitation (CBR)

1 Need 116 (29%) 188 (47%) 83 (21%) 387 (32%)

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2 Received services (% of those in need) 40 (35%) 50 (27%) 31 (37%) 121 (31%)

Assistive devices

1 Need 83 (21%) 168 (42%) 62 (15%) 313 (26%)

2 Received services (% of those in need) 28 (34%) 36 (21%) 22 (36%) 86 (28%)

Orthopedic equipment

1 Need 64 (16%) 99 (25%) 20 (5%) 183 (15%)

2 Received services (% of those in need) 27 (42%) 10 (10%) 4 (20%) 41 (22%)

Rehabilitation devices

1 Need 79 (20%) 125 (32%) 36 (9%) 240 (20%)

2 Received services (% of those in need) 22 (28%) 16 (13%) 4 (11%) 42 (18%)

Referral to higher levels for diagnosis and rehabilitation

1 Need 136 (34%) 29 (11%) 104 (26%) 511 (43%)

2 Received services (% of those in need) 44 (32%) 29 (11%) 19 (18%) 92 (18%)

Support for rehabilitation fees

1 Need 184 (46%) 290 (73%) 118 (29%) 592 (49%)

2 Received services (% of those in need) 69 (38%) 44 (15%) 28 (24%) 141 (24%)

Health insurance

1 Need 366 (91%) 383 (97%) 266 (66%) 1015 (84%)

2 Received services (% of those in need) 285 (78%) 278 (73%) 205 (77%) 768 (76%)

Knowledge and access to services Persons with disabilities (and family members) were asked about their knowledge of and access to services. Surprisingly low numbers of persons with disabilities were aware of local healthcare services. In particular, almost 80% of persons with disabilities said they were unaware of the Community Based Rehabilitation program. This is a concerning finding in provinces which do have a CBR program. Vinh Long has a CBR program supported by Handicap International in 107 communes; Quang Tri has had a CBR program in the two research locations of Vinh Linh and Dong Ha town since 1993. Hanoi CBR finished in 2009, but was active until then. The lack of knowledge about services is higher in the rural provinces of Quang Tri and highest in Vinh Long province. People in Hanoi seem to both know more about available services as well as have better access, which is possibly not surprising. This survey indicates that most persons with disabilities are accessing health care services at the lowest level; commune health care stations. Very few have accessed specialist services at the provincial level, either a hospital or rehabilitation hospital. This is likely due to difficulties in transport, and the cost of attending a provincial hospital (transport, accommodation and service fees). Very few persons with disabilities have used private healthcare facilities, which is likely due to the perceived high cost of private services.

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Table 44. Accessibility of healthcare services

No. Levels of accessibility Ha Noi (N=403)

Quang Tri (N=397)

Vinh Long (N=402)

Total (N=1,202)

Rehabilitation Department of provincial hospitals

1 Don’t know 176 (44%) 270 (68%) 282 (70%) 728 (61%)

2 Know about the service 56 (14%) 36 (9%) 57 (14%) 149 (12%)

3 Have accessed services at the establishment 171 (42%) 91 (23%) 63 (16%) 325 (27%)

Rehabilitation hospitals

1 Don’t know 224 (56%) 339 (85%) 328 (82%) 891 (74%)

2 Know about the service 70 (17%) 35 (9%) 43 (11%) 148 (12%)

3 Have accessed services at the establishment 109 (27%) 23 (6%) 31 (8%) 163 (14%)

District hospitals

1 Don’t know 69 (17%) 125 (32%) 222 (55%) 416 (35%)

2 Know about the service 31 (8%) 59 (15%) 58 (14%) 148 (12%)

3 Have accessed services at the establishment 303 (75%) 213 (54%) 122 (30%) 638 (53%)

Communal healthcare stations

1 Don’t know 23 (6%) 41 (10%) 142 (35%) 206 (17%)

2 Know about the service 13 (3%) 51 (13%) 54 (13%) 118 (10%)

3 Have accessed services at the establishment 367 (91%) 305 (77%) 206 (51%) 878 (73.0%)

Community-based rehabilitation program

1 Don’t know 289 (72%) 321 (81%) 329 (82%) 939 (78%)

2 Know about the service 66 (16%) 36 (9%) 43 (11%) 145 (12%)

3 Have accessed services 48 (12%) 40 (10%) 30 (8%) 118 (10%)

Private clinics

1 Don’t know 307 (76%) 367 (92%) 311 (77%) 985 (82%)

2 Know about the service 58 (14%) 8 (2%) 41 (10%) 107 (9%)

3 Have accessed services at the establishment 38 (9%) 22 (6%) 50 (12%) 110 (9%)

5.4.2. Needs vs. supply in the education sector There is a significant gap between the number of children with disabilities requiring education and those who are able to access it, and this gap widens as the level of education increases. With over 30% of the persons with disabilities surveyed indicating they can’t read or write, and another 30% having only studied to primary school level (see table 45 below), access to schooling is a crucial need for persons with disabilities. Despite this, only around 50% of persons with disabilities/caregivers indicated that education and vocational training was a significant need for them. For those who did feel education was a need, relatively low numbers have received educational services (around 70% of those in

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need). The provision of vocational training services is even lower at only tiny numbers of persons with disabilities (19 people of the surveyed 1,202).

Table 45. Need for educational services and actual service provision

No. Need for educational support services vs. services received

Ha Noi (N=403)

Quang Trị (N=397)

Vinh Long (N=402)

Total (N=1202)

Early intervention (children with disabilities under 6 years old) N=8 19 17 44

1 Need 5 (63%) 15 (79%) 6 (35%) 26 (59%)

2 Received services (% of those in need) 5 (100%) 3 (20%) 4 (67%) 12 (46%)

School education (children with disabilities from 6-18 years) N=56 92 169 317

1 Need 36 (64%) 52 (57%) 91 (54%) 179 (57%)

2 Received services (% of those in need) 21 (58%) 30 (58%) 80 (88%) 131 (73%)

Vocational training (persons with disabilities from 15-30 years) N=85 115 967 297

1 Need 32 (38%) 41 (36%) 18 (19%) 91 (31%)

2 Received services (% of those in need) 10 (31%) 7 (17%) 2 (11%) 19 (21%)

PWD family members N=64 111 186 361

Counseling for working with children with disabilities

1 Need 28 (44%) 79 (71%) 39 (21%) 146 (40%)

2 Received services (% of those in need) 7 (25%) 15 (19%) 25 (64%) 47 (32%)

Skills in communication with children with disabilities

1 Need 28 (44%) 75 (68%) 45 (24%) 146 (40%)

2 Received services (% of those in need) 5 (18%) 14 (18%) 27 (69%) 46 (32%)

Support for establishment of parents’ association

1 Need 25 (39%) 65 (59%) 24 (13%) 114 (32%)

2 Received services (% of those in need) 2 (7%) 21 (27%) 3 (8%) 26 (18%)

The survey indicates very low awareness about educational services. Table 46 below indicates that even at the district/commune level, most (77%) persons with disabilities/caregivers seemed totally unaware of schools that could enroll persons with disabilities (theoretically all schools should enroll children with disabilities through the government’s inclusive education program). People were also unaware of non-government/charity educational establishments, and educational support services at provincial level. In terms of educational services, it is surprising that Hanoi doesn’t show better knowledge and access. In this particular sector, Vinh Long indicates the highest level of access and knowledge to services although it is still very low.

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Table 46. Accessibility to educational support establishments

No. Level of accessibility Ha Noi (N=403)

Quang Tri (N=397)

Vinh Long (N=402)

Total (N=1,202)

Provincial schools for children with disabilities

1 Don’t know 331 (82%) 316 (80%) 293 (73%) 940 (78%)

2 Know about the service 56 (14%) 46 (12%) 70 (17%) 172 (14%)

3 Have accessed services at the establishment 16 (4%) 35 (9%) 39 (10%) 90 (8%)

Provincial centers for inclusive education support and development

1 Don’t know 339 (84%) 370 (93%) 300 (75%) 1009 (84%)

2 Know about the service 47 (12%) 21 (5%) 64 (16%) 132 (11%)

3 Have accessed services at the establishment 17 (4%) 6 (2%) 38 (10%) 61 (5%)

District/commune schools enrolling children with disabilities

1 Don’t know 288 (72%) 347 (87%) 294 (73%) 929 (77%)

2 Know about the service 60 (15%) 31 (8%) 49 (12%) 140 (12%)

3 Have accessed services at the establishment 55 (14%) 19 (5%) 59 (15%) 133 (11%)

Charity centers for vocational training for children with disabilities

1 Don’t know 337 (84%) 362 (91%) 327 (81%) 1026 (85%)

2 Know about the service 41 (10%) 29 (7%) 62 (15%) 132 (11%)

3 Have accessed services at the establishment 25 (6%) 6 (2%) 13 (3%) 44 (4%)

The results of interviews also indicate that equipment and learning materials specifically for children with disabilities are largely not available at either inclusive or special schools. Children with mobility difficulties often don’t have access to classrooms or toilets and there are few learning or play facilities adapted for children with vision or hearing impairments.

5.4.3. Needs vs. supply in the social and employment sector The interviews of persons with disabilities indicated that the majority of persons with disabilities want a monthly payment to assist them to cover their daily living expenses. Only a small number of persons with disabilities who are not currently living in social protection centers expressed the desire for center-based care, on the whole they are happy with the support they receive from their families. Those people who were already living in centers expressed that they needed to stay living in the centers (probably because centers primarily provide care for those people who don’t have families to care for them). In general, most of the social services needs of persons with disabilities remain unmet. The most commonly received service is monthly social protection payments, as was also found in the survey of service providers. The demand of persons with disabilities for vocational training and employment services is very poorly met by the supply. Only around 20% of persons with disabilities interviewed who

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needed training were able to access vocational training services. The main reason provided was that vocational training centers were inaccessible (too far away from their homes) and expensive so persons with disabilities couldn’t attend the training. In addition, many persons with disabilities were concerned that they would not be able to find a job after the training, so the investment in training was not worthwhile. Only 13% of those interviewed had accessed employment assistance. In the social/employment portfolio, again persons with disabilities/ caregivers have very poor awareness of the services available to them. Even social protection centers, a mainstream service provided in every province and most districts, are not well known about by persons with disabilities (76% don’t know). Knowledge is best about local People’s Committees and then DPOs, with 17% of people having accessed DPOs and another 17% having heard about them. Knowledge about social work centers, vocational training centers and job placement centers is very low, and very few persons with disabilities have ever accessed services at these centers.

Table 47. Need for social support services and actual service provision

No. Need for social support services vs. services received

Ha Noi (N=403)

Quang Tri (N=397)

Vinh Long (N=402)

Total (N=1202)

Care/accommodation in social protection establishments

1 Need 76 (19%) 117 (30%) 29 (7%) 222 (19%)

2 Received services (% of those in need) 21 (28%) 14 (12%) 2 (7%) 37 (17%)

Monthly social allowance

1 Need 348 (86.%) 365 (92%) 251 (62%) 964 (80%)

2 Received services (% of those in need) 241 (69.%) 202 (55%) 174 (69%) 617 (64%)

Persons with disabilities 18 years and above N=344 293 221 858

Support for vocational/professional training

1 Need 38 (11%) 76 (26%) 36 (16%) 150 (18%)

2 Received services (% of those in need) 6 (16%) 12 (16%) 9 (25%) 27 (18%)

Employment

1 Need 59 (17%) 106 (36%) 47 (21%) 212 (25%)

2 Received services (% of those in need) 7 (12%) 15 (14%) 6 (13%) 28 (13%)

Support for business development

1 Need 71 (21%) 136 (46%) 33 (15%) 240 (28%)

2 Received services (% of those in need) 15 (21%) 34 (25%) 4 (12%) 53 (22%)

Access to information technology and communications

1 Need 65 (19%) 90 (31%) 9 (4%) 164 (19%)

2 Received services (% of those in need) 12 (19%) 28 (31%) 1 (11%) 41 (25%)

Access to public transportation and buildings

1 Need 128 (37%) 100 (34%) 14 (6%) 242 (28%)

2 Received services (% of those in need) 60 (47%) 26 (26%) 8 (57%) 94 (39%)

Support for participation in cultural, sport, tourism and leisure activities

1 Need 88 (26%) 121 (41%) 14 (6%) 223 (26%)

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2 Received services (% of those in need) 25 (28%) 40 (33%) 6 (43%) 71 (32%)

Support for establishment of clubs, self- help groups of PWD

1 Need 88 (26%) 158 (54%) 27 (12%) 273 (32%)

2 Received services (% of those in need) 22 (25%) 46 (29%) 11 (41%) 79 (29%)

Again, living in the urban center of Hanoi seems to convey little advantage in terms of knowledge about or access to social protection and employment services, other than DPOs. This is likely because Hanoi has a well-established and active provincial level DPO which has done extensive outreach to persons with disabilities in the city. There is no provincial level DPO in Vinh Long or Quang Tri.

Table 48. Accessibility to social support services

No. Level of accessibility Ha Noi (N=403)

Quang Tri (N=397)

Vinh Long (N=402)

Total (N=1,202)

Social protection centers

1 Don’t know 277 (69%) 324 (82%) 311 (77%) 912 (76%) 2 Know about the service 103 (26%) 39 (10%) 66 (16%) 208 (17%)

3 Already access services at the establishment 23 (6%) 34 (9%) 25 (6%) 82 (7%)

Social protection establishments admitting children with disabilities

1 Don’t know 328 (81%) 357 (90%) 277 (69%) 962 (80%) 2 Know about the service 50 (12%) 26 (7%) 60 (15%) 136 (11%)

3 Already access services at the establishment 25 (6%) 14 (4%) 65 (16%) 104 (9%)

Vocational training centers for persons with disabilities

1 Don’t know 324 (80%) 347 (87%) 324 (81%) 995 (83%) 2 Know about the service 63 (16%) 35 (9%) 59 (15%) 157 (13%)

3 Already access services at the establishment 16 (4%) 15 (4%) 19 (5%) 50 (4%)

Vocational training and employment promotion centers

1 Don’t know 342 (85%) 366 (92.2%) 334 (83%) 1042 (87%) 2 Know about the service 49 (12%) 18 (4.5%) 53 (13%) 120 (10%)

3 Already access services at the establishment 12 (3%) 13 (3.3%) 15 (4%) 40 (3%)

Social work service centers

1 Don’t know 364 (90%) 387 (98%) 366 (91%) 1117 (93%) 2 Know about the service 31 (8%) 9 (2%) 29 (7%) 69 (6%)

3 Already access services at the establishment 8 (2%) 1 (0.3%) 7 (2%) 16 (1%)

DPOs

1 Don’t know 192 (48%) 281 (71%) 326 (81%) 799 (67%) 2 Know about the service 110 (27%) 50 (13%) 40 (10%) 200 (17%)

3 Already access services at the establishment 101 (25%) 66 (17%) 36 (9%) 203 (17%)

Communal people’s committee

1 Don’t know 37 (9%) 92 (23%) 185 (46%) 314 (26%)

2 Know about the service 29 (7%) 92 (23%) 47 (12%) 168 (14%)

3 Already access services at the establishment 337 (84%) 213 (54%) 170 (42%) 720 (60%)

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The survey asked persons with disabilities how they found out information about available services. Mass media seems to be the primary channel currently (70%), followed by talking to local authorities (49%) and other people in the community (45%) and the commune loudspeakers (42% note that more than one option was available). Very few persons with disabilities are using the internet to find out information about services, possibly reflecting a lack of easy Internet access. However as the interviews were conducted in 2012 this situation may have improved. It also seems that the sector staffs (social/employment staff, teachers, health workers) are not effective sources of information about the services they provide, neither mass organizations such as the Women’s Union, Youth Union. It isn’t clear whether this is because the staffs do not try to reach out and provide information, or if their strategies are not effective.

Table 49. How persons with disabilities find out about disability support establishments

Information channel Ha Noi (N=403)

Quang Tri (N=397)

Vinh Long (N=402)

Total (N=1,202)

Mass media (TV, radio) 334 (83%) 257 (65%) 252 (63%) 843 (70%)

Local authority 203 (50%) 218 (55%) 164 (41%) 585 (49%)

People at the community 251 (62%) 190 (48%) 99 (25%) 540 (45%)

Commune/ward loud speakers 258 (64.%) 124 (31%) 127 (32%) 509 (42%)

Labor - social staff 281 (70%) 69 (17%) 49 (12%) 399 (33%)

Health workers 76 (19%) 202 (51%) 120 (30%) 398 (33%)

Staff of mass organizations 89 (22%) 50 (13%) 36 (9%) 175 (15%)

Meetings, training, workshops 40 (10%) 121 (31%) 13 (3%) 174 (15%)

Newspapers, magazines 70 (17%) 57 (14%) 32 (8%) 159 (13%)

Other PWD 28 (7%) 76 (19%) 48 (12%) 152 (13%)

Schools, teachers 23 (6%) 24 (6%) 70 (17%) 117 (10%)

Internet 26 (6%) 16 (4%) 5 (1%) 47 4%)

5.4.4. Satisfaction with services received

In order to assess the satisfaction level for the services received, the research team asked persons with disabilities to classify in five levels: totally disappointed, a bit satisfied, satisfied, quite satisfied, very satisfied. In the chart below this has been rationalized into three levels: Not satisfied, satisfied (a bit satisfied, satisfied) and very satisfied (quite satisfied and very satisfied). Figure 11 shows that most persons with disabilities and their families (55%) are not satisfied with the services received. Quang Trị has the lowest percentage of persons with disabilities and their families who are satisfied and very satisfied compared to Ha Noi and Vinh Long (p<0,01). Unfortunately, only one question was asked about any service received, not broken down by the particular type of service or the sector, making it difficult to act on this information.

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Figure 11. Satisfaction with services received

Figure 12. Payment for services

Figure 12 indicates that over half of people surveyed have not had to pay for support services they received. Only 43% of persons with disabilities and their families have to pay for services received. Ha Noi has the highest percentage of people having to pay for services (56%) while Vinh Long has the lowest percentage (34%).

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Hanoi

Quang Tri

Vinh Long

Total

191 (52.20%)

224 (59.40%)

159 (51.60%)

574 (54.60%)

158 (43.20%)

191 (36.90%)

129 (41.90%)

426 (40.50%)

17 (4.60%)

14 (3.70%)

20 (6.50%)

51 (4.90%)

Not satisfied Satisfied Very satisfied

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Hanoi Quang Tri Vinh Long Total

208 (56.80%)

141 (37.40%) 105 (34.10%) 454 (43.20%)

144 (39.30%)

142 (37.70%) 128 (41.60%)

414 (39.40%)

14 (3.80%)

94 (24.90%) 75 (24.40%) 183 (17.40%)

Don't have to pay as poor householdDon't have to pay as beneficiary of social support policyHave to pay

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For those persons with disabilities who did have to pay for services, the majority have used funds from their families or relatives to pay, however quite a large number have also used their own income. Around 16% have had to borrow to pay for services, and this rate is highest in Quang Tri and Vinh Long.

Table 50. Income source used to pay service fees

Income source (More than one answer possible)

Hà Nội (N=208)

Quảng Trị (N=141)

Vĩnh Long (N=105)

Total (N=454)

Family support 195 (94%) 106 (75%) 84 (80%) 385 (85%) Personal income 50 (24%) 61 (43%) 15 (14%) 126 (28%) Relatives’ support 78 (38%) 24 (17%) 11 (11%) 113 (25%) Loan 7 (3%) 42 (30%) 23 (22%) 72 (16%) Saving interests 12 (6%) 0 0 12 (3%) Others (social allowance) 1 (0.5%) 0 0 1 (0.2%)

Total 348 233 133 709

For those persons with disabilities who did have to pay for services, the vast majority (more than 90%) faced difficulties in paying these bills. People in Vinh Long in particular faced difficulties paying for services.

Figure 13. Level of difficulty in paying service fees

5.4.5. Participation in cultural and entertainment activities In order to determine whether and how persons with disabilities are participating in normal family, cultural and social activities, they were asked about how often they participate in specific activities. The answers indicate that while persons with disabilities are well integrated into family life and participate in family activities in the home, they very rarely join social activities outside the home, or even to visit relatives in other locations. The results suggest

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Hanoi Quang Tri Vinh Long Total

12 (5.80%) 3 (2.10%) 9 (8.60%) 24 (5.30%)

52 (25%) 30 (21.30%)

20 (19.10%) 102 (22.50%)

99 (47.60%) 67 (47.50%)

21 (20%)

187 (41.20%)

45 (21.60%) 41 (29.10%)

55 (52.40%)

141 (31.10%)

Not difficult at all, affordable A little difficult Difficult Very difficult

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that persons with disabilities rarely leave their homes and are highly dependent on their immediate family for social contact and entertainment.

Figure 14. Frequency of persons with disabilities joining community activities

One reason for this reluctance of persons with disabilities to leave their homes and participate in community activities could be the level of accessibility to public facilities. Table 51 shows

0

200

400

Nev

er/R

arel

y

Som

etim

es

Freq

uent

ly/V

ery

freq

uent

ly

Frequency of joining family activities

Hà Nội (n=403)

Quảng Trị (n=397)

Vĩnh Long (n=402)

050

100150200250

Nev

er/R

arel

y

Som

etim

es

Freq

uent

ly/V

ery

freq

uent

ly

Frequency of visiting relatives & neighbors

Hà Nội

Quảng Trị

Vĩnh Long

050

100150200250300350

Nev

er/R

arel

y

Som

etim

es

Freq

uent

ly/V

ery

freq

uent

ly

Frequency of joining community festivals, sports, cultural events

Hà Nội

Quảng Trị

Vĩnh Long

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the results of a question to persons with disabilities about whether they could access key public buildings.

Table 51. Accessibility of local facilities

Facility Hanoi

(N=403) Quang Tri (N=397)

Vinh Long (N=402)

Total (N=1,202)

Government buildings 174 (43%) 141 (36%) 87 (22%) 402 (33%)

Train and bus stations 96 (24%) 109 (28%) 66 (16%) 271 (23%)

Healthcare centers 238 (59%) 197 (50%) 162 (40%) 597 (50%)

Markets, shopping centers 147 (37%) 164 (41%) 136 (34%) 447 (37%)

Counseling and consultation centers 45 (11%) 47 (12%) 30 (8%) 122 (10%)

Educational and vocational training

institutions 82 (20%) 94 (24%) 108 (27%) 284 (24%)

Cultural, tourism and sports facilities 91 (23%) 84 (21%) 57 (14%) 232 (19%)

Public transportation facilities 94 (23%) 97 (24%) 49 (12%) 240 (20%)

Table 51 shows that the percentage of persons with disabilities who can access health care centers was highest (50%), however the fact that just over 50% of people couldn’t access their local healthcare center should be a concern. Other public facilities including public transport stations are very inaccessible to persons with disabilities. Hanoi has the highest percentage of persons with disabilities who are able to access health care establishments and cultural venues. Despite over ten years of implementation of the Code and Standards for Accessible Construction, it seems that access to public buildings is still a major barrier to the true independence and integration of persons with disabilities.

5.5. Conclusions The picture that emerges from the interviews with persons with disabilities and their families members is one where the vast majority of persons with disabilities are largely confined to their homes, poor and uneducated with their families struggling to provide them with the services they need and government providing only welfare payments to assist. Persons with disabilities and family members have very low levels of knowledge about and even less accessibility to most government services in all three sectors. Cost is a major barrier, as is transport and accessibility of buildings. Even more concerning is that it seems despite high levels of poverty and disadvantage, persons with disabilities and their families don’t seem to feel that they need any services such as secondary or tertiary education, vocational training or employment that would help promote the greater inclusion and independence of disabled people.

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6. Some effective models of comprehensive disability service provision

6.1. Integrating CBR into Primary Health Care

Christian Blind Mission (CBM), an international development organization supporting disability and inclusive development initiatives, commenced work in Vietnam in 1982. In collaboration with the Hue Provincial Department of Health (DOH) and Hue Eye Hospital, CBM started a community based rehabilitation (CBR) project in 4 districts - Phu Vang, Phu Loc, Huong Thuy and Hue city - focusing on assisting people who were incurably blind and those needing medical referral, in partnership with the district outreach program from Hue Eye Hospital. In 2005, the CBR project management was moved to the Peace Village, a National Rehabilitation Centre in Hue under Hue DOH. A 3 year CBR project was initially planned and completed between 2006 and 2009, during which time the project focus expanded to include persons with other categories of impairment, within the framework of the World Health Organization’s CBR Matrix, and the National CBR Program of the Ministry of Health in Vietnam. During the second phase (2010-2012), the CBR project expanded to two new districts of Phong Dien and Quang Dien. The project aimed to integrate CBR activities within the existing structure and systems of the District Health Centers, using the personnel of the health system. Towards this end, the project’s overall objective was “to contribute towards Article 1 of National Action Plan to Support Persons With Disabilities issued by the Prime Minister 2005 – 2010”, according to which, “the State encourages and creates favorable conditions for disabled persons to exercise on an equal basis their political, economic, cultural and social rights and develop their abilities to stabilize their life, integrate themselves into the community and take part in social activities”. The main activities were training and building capacity of field level staff (Field Supervisors and Field Workers) to enable them to address the needs of persons with disabilities at the community level; other activities included workshops for stakeholders, referrals, access to health insurance and other schemes of the government, community awareness, vocational training and income generation through a revolving fund. In the 4 older districts, the Field Supervisors (FS) and Field Workers (FW) have been with the CBR project between 8 to 10 years, and are full time workers. For these FS and for some FW, CBM provided an additional honorarium. In the 2 new districts, the FS and FW are part-time (working 4 hours a day on CBR), and are paid by the Hue DOH, with CBM contributing an incentive. All of them are village health volunteers, unlike the staff of the older districts.

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Figure 15. The structure and organization of the CBR project

Each field worker handles an average of six clients, and supervises between two to six village level workers – the hamlet nurses. The main tasks of the FW are identification of persons with disabilities, planning for rehabilitation, referrals to hospitals, home visits for follow up, family training, assistance in getting and making assistive devices, enrolment of children with disabilities in schools, identifying clients for loans, providing information on possible jobs, some local resource mobilization, and some awareness raising in the community. The hamlet nurses assist the FWs with identification of clients, and do the follow up after the FWs have worked with clients for about 2 months in the community. The Peace Village Project Management Unit (PMU) supports the field staff with training and technical support, apart from being a referral centers for clients. The Hue DOH provides some finances, and there are occasional field visits from the senior staff. Annual reports are submitted to the Hue DOH from Peace Village. Project outcomes A mid-term review conducted in 2011 showed that the CBR project was able to ensure better coverage through community and home based services involving families. The review used a methodology of appreciate inquiry thus the outcomes are primarily qualitative impressions. However, those interviewed indicated that the situation of persons with disabilities had improved in terms of improved mobility, self-help skills, and increased income due to loans. Families’ knowledge about disability had increased and they were able to carry out simple rehabilitation tasks and develop simple assistive devices at home, under the guidance of the FW.

DOH

FS HUE

3 FW

10 VOLUNTEERS

FS PHU LOC

4 FW

11 VOLUNTEERS

FS HUONG THUY

2 FW

11 VOLUNTEERS

FS PHU VANG

3 FW

12 VOLUNTEERS

FS PHONG DIEN

5 FW

37 VOLUNTEERS

FS QUANG DIEN

3 FW

19 VOLUNTEERS

PEACE VILLAGE PMU

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In the 6 districts, about 70% of the identified persons with disabilities had been assisted. The majority of persons with disabilities received physiotherapy, followed by referral assistance and provision of assistive devices. Although the CBR Matrix was used as the framework for planning of activities, project interventions had focused on, and been more successful in, health related rehabilitation interventions and less so in areas of education, livelihoods, social or empowerment domains. The review found that the majority of FS and FW were competent, motivated and well accepted by the clients and families who acknowledge the improvements due to the efforts of the field staff. Stakeholder capacity and awareness about needs and rights of persons with disabilities were also found to have increased. According to the review findings, a good rehabilitation service network had been built from the commune level upwards to the provincial level. The availability of trained CBR staff at the community level had contributed to reducing the duration of hospital stays (and consequent expenses) for older persons who are disabled due to stroke for example. Community awareness and cooperation had also increased, and there was evidence of community support in terms of loans to persons with disabilities from local people and organizations; and support from local authorities towards allowances for some persons with disabilities like those with cerebral palsy. Lessons learned Multi-sector coordination at the commune level has been a challenge; and involvement of some sections within the health system at province, district and commune levels has not been to the expected level. Since this project is supposed to be integrated into the existing structure and system of the provincial health department, concerted efforts are needed to improve the involvement of significant stakeholders in the health departments at all levels as the sustainability of the project depends largely on them. The project has also recognized the limitations in attempting a comprehensive CBR project that includes all the domains of the WHO CBR Matrix, when the local partner belongs to the health sector. With the challenges of multi-sector collaboration, the project now focuses on activities to achieve limited goals that are within the control of the health sector. In all four original districts, the field staff report low salaries and allowances, and lack of insurance as a major challenge. Some field workers face the challenge of distances to travel, very large communes to service, and difficult transport conditions during heavy rains. In the new districts, lack of time is a challenge, since the field staffs are part-time and have other responsibilities to fulfill. The original districts have produced better outcomes because the staff work full-time, and are paid an additional amount by CBM, but this is not sustainable in the long term. The system practiced in the new districts is more likely to achieve the aim of integration of CBR

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activities into the health structure and service delivery system as all staffs are village health volunteers, although impact may be limited because the staffs are part-time. Sustainability In the current phase of the project, efforts are underway to further integrate activities into the existing health system as in the new districts. This way, the project is expected be sustainable, although with a lower level of impact because the field staff are multipurpose, and CBR is just one activity for them. However the principle of ‘something better than nothing’ will still bring benefits to persons with disabilities who otherwise would not have access to such services in the community. The project is also focusing mainly on health related CBR activities, and carrying out referrals to related sectors for other CBR issues, in the interests of sustainability.

6.2. Centers for Inclusive Education Development For the effective implementation of inclusive education in Vietnam, it was agreed to establish Centers for Inclusive Education Development that would be able to provide technical assistance for schools as they transitioned to providing inclusive education; providing education for children with disabilities in the same classrooms as non-disabled children. Centers for Inclusive Education Support have been piloted over the past ten years in the provinces of Cao Bang, Vinh Long, Tien Giang, Dac Lac, Phu Yen, Phu Tho, Bac Kan. The Center in Vinh Long can be seen as a particularly successful model and is profiled below.

6.2.1. The Center for Inclusive Education Support (IEC) in Vinh Long Province

Following the Decision No. 2305/QD-UBND on 8 November 2007, the Inclusive Education Center (IEC) was established at the School for Education of Children with Disabilities of Vinh Long Province. This IEC is administered by the Vinh Long Department of Education and Training (DOET), and has the following functions:

- Consult with the DOET to provide guidance to district, town, related agencies and organizations, and parents’ associations about care, early detection and intervention, education and vocational training for persons with disabilities.

- Training and human resources development for education managers, teachers and staff working on education, rehabilitation, vocational training for persons with disabilities.

- Develop special skills for children with disabilities in the Center and transfer the approaches and techniques to teachers, staff and parents in the localities.

- Participate in coordination of education for children with disabilities.

- Implement programs for vocational training and orientation, and employment support for youth with disabilities.

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- Cooperate with organizations, individuals inside and outside of the country for education, vocational training and orientation for children and youth with disabilities.

Specific tasks and responsibilities of the IEC include: a) Counseling:

- Consult with DOET on the direction for development of education for children with disabilities in the province;

- Respond to questions related to the need for care, education and capacity development of children with disabilities;

- Help families and communities understand the characteristics of child development, approaches for the care and education for children with disabilities in order for them to be included in the community.

b) Training and human resource development:

- Train education managers, teachers (of pre-schools, primary schools, secondary schools and high schools), members of mass-organizations, family members of children with disabilities, community support members, and volunteers in knowledge and skills of early intervention, care and education for children with disabilities in order to meet their development needs;

- Train collaborators and health staff on rehabilitation, use of rehabilitation equipment and how to make and use rehabilitation equipment/devices from local materials;

- Provide guidance to parents on how to take care of children with disabilities, education and rehabilitation for persons with disabilities in the family;

- Identify the capacity and needs of children with disabilities for education, early intervention and community support;

- Provide equipment and devices necessary for children to access education (Braille equipment, hearing aids, wheelchairs).

c) Participation in early intervention and inclusive education activities:

- Develop guidelines and procedures for management of inclusive education;

- Mobilize children with disabilities to attend school;

- Coordinate with community technical groups and centers to monitor, evaluate and resolve difficulties related to education for children with disabilities;

- Select appropriate primary schools to implement inclusive education;

d) Vocational training:

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- Identify the capacities and needs for employment of youth with disabilities and their families.

- Conduct surveys, classify and find jobs that are suitable for youth with disabilities, organize on-the-job training programs.

- Mobilize and coordinate with labor/social affairs, social organizations and enterprises to provide vocational training and job orientation for youth with disabilities.

- Act as focal point for national and international organizations and individuals that want to contribute to the development of children with disabilities.

- Train knowledge and skills in inclusive education for other localities.

Figure 16. Organizational structure of Vinh Long Inclusive Education Center

After five years, the IEC for Children with Disabilities in Vinh Long province has made a significant contribution towards the education of children with disabilities (CWD) in the province. Vinh Long has developed a plan for education of CWD, and the Center has provided technical support for pre-schools and primary schools in the province. The rate of persons with disabilities accessing education in Vinh Long is now 19%, much higher than that of Hanoi (4%) and Quang Tri (3%). The model of Center for Inclusive Education Support was included in Article 31 of the National Law on Disabilities enacted on 1 January 2011. The law is a legal framework to govern all services for persons with disabilities in Vietnam. However, the operation, development and replication of the IEC model still faces some challenges. Firstly, development of human resources for IECs takes significant investment of time and resources. The operation of the center needs strong and close coordination with

Management

Board

Counselling and

Technical Council

Administration

Early Intervention and

Education Division

Special Skill Practices and Health Care

Division

Vocational Training and Orientation

Division

Division of Social Work

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the inclusive education system, and sufficient budget to ensure they can conduct all activities. The experience of Vinh Long indicated that it takes at least five years, with significant investment (in Vinh Long from Norwegian Organization, the Vietnam Institution of Education Sciences, and from other technical organizations) to develop a pool of skilled staff with the capacity to implement the functions and tasks of the center.

6.2.2. The Center for Inclusive Education Support in Da Nang city The Center was established in March 2011 under Decision No. 528/QD-SGDDT of the Director of Department of Education and Training of Da Nang on 3rd March 2011. The center is monitored and managed by the Nguyen Dinh Chieu Special School. The Center has 1 Director (also cum Vice-Rector in charge of technical aspects of the school) and three staff. The teachers are responsible for both teaching classes and the operations of the center.

Figure 17. Organizational Structure of the Center for Inclusive Education Support, Da Nang

Functions and Tasks of the Center:

- Coordinate with the health sector to do disability screening, assessment and classification for children;

- Organize early intervention for children with disabilities and their families before primary education age, counseling for parents of CWD on health, education and vocational training services;

- Support inclusive education and semi-inclusive education for CWD in all schools;

- Vocational training and orientation for CWD;

- Provide advice to DOET and People’s Committee on special education for persons with disabilities;

- Mobilize resources for educational services for persons with disabilities;

- Collect, record and develop manuals on education for persons with disabilities.

Director

Early Intervention

Division

Assess- ment

Division

Observation Division

Rehabilitation Division

Sensory Regulation

Division

Life skills Division

Informationcounseling

and support Division

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The clients of the center include:

- Children with all types of impairments: hearing, visual, autism, intellectual, mobility impairments from 0 to 18 years old;

- Parents of children with disabilities;

- Teachers of primary schools and pre-schools who are teaching children with disabilities.

Services and approaches to deliver services Services delivered by the center:

- Assess, screen disability: using the criteria of PEP-3 (The PEP–3 is a revision of the popular instrument that has been used for more than 20 years to assess the skills and behaviors of children with autism and communicative disabilities who function between the ages of 6 months to 7 years);

- Provide guidance to parents of children with disabilities on the skills to identify, care for and educate children with disabilities, advice on school choice and appropriate inclusive education programs;

- Early intervention for children with disabilities at the center and at home;

Support for Inclusive Education:

- Support children with disabilities to study in inclusive schools

- Training for parents of children with disabilities on approaches to educate children

- Training for teachers involved in teaching children with disabilities on developing individual learning plan.

Vocational Training and Orientation:

- Provide counseling on vocational training for persons with disabilities at vocational training centers;

- Conduct vocational training that is relevant to the capacity of children with disabilities: music, making flowers, tailors, etc.

- Collect, record and develop manuals for teachers and parents on disability identification and education for children with disabilities.

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Figure 18. Service Provision Approach

The Center’s achievements so far (in 2011) include:

- Assessment and intervention plans for 18 children with autism in special schools, assessment of 10 children with autism at the primary inclusive education schools and assessment of 60 students at special education schools.

- Conduct training programs for hearing impaired, visually impaired and intellectually impaired children in centers and home-based intervention for three children with disabilities (with the funding support from an International NGO, FIDA International from Finland).

- Support individual education for 19 children with disabilities at inclusive education schools.

- Conduct awareness-raising training for parents of children with hearing and visual impairments studying in inclusive education in Hiep Duc, Thang Binh, Quang Nam districts.

- Conduct training for parents of children with autism in Da Nang City on education approaches for children with autism.

- Provide 80 counseling sessions for parents of children with disabilities on identifying, caring and educating CWD, choosing schools and appropriate education programs.

- Conduct training for 210 primary school teachers and 180 pre-school teachers in inclusive education and developing individual education plans for children with disabilities.

- Conduct need assessment, capacity assessment and support 26 children with disabilities studying at 8 primary schools in Da Nang city.

Needs Assessment of Clients

Consulting and Counselling for

Clients

Introduction and Referral

Health

Agencies for

review, screening

and Rehabilita

tion

Vocational Training Centres

Education establish

ments

Providing appropriate

services

Screening and

assessment

Intervention (at the

centre or at home)

Support to inclusive education (Support

and training for teachers and parents)

Vocational Training

and orientation

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- Conduct vocational training for 20 visually impaired children in music, flower making, incense making, and tailoring, introduce 3 visually impaired students to jobs.

- Provide advice and support for persons with disabilities at vocational training centers.

- Provide materials, textbooks for teachers, parents, and communities on early detection, care and education for persons with disabilities.

Although the IEC in Da Nang has not been operating for very long, these early results are very positive, and there seems to be an increase in the number of children attending inclusive schools, and improvement in the awareness of the community about inclusive education and the rights and abilities of children to attend school and vocational training.

6.3. Thuy An Center for Rehabilitation for Children with Disabilities The Thuy An Center for Rehabilitation for Children with Disabilities (Social Protection Center) was established in Thuy An commune, Ba Vi district of Ha Noi on 26 July 1976. The Center has 78 staff caring for 200 children with disabilities. The total area of the Center is 37,400 m2 of which 5,000 m2 is leisure area. The area is surrounded with a garden and trees to provide a nice environment for rehabilitation. The main functions of the Center are:

- Health check-up, treatment and rehabilitation for children with disabilities and disabled war veterans;

- Care for non-disabled children in difficult circumstances (orphans, children with HIV);

- Organize educational activities and vocational training for children with special needs;

- Organize production and fitting of orthopedic devices for persons with disabilities;

- Organize health check-up and treatment for persons with disabilities;

- Participate in the training and conduct refresher training for Government social affairs staff;

- Coordinate with local health agencies on disease prevention and disability prevention;

- Cooperate with international and national organizations to carry out other tasks and duties as set by the Government.

The children resident in the center have different types of impairments, including mobility, vision, hearing and intellectual impairments. Results of operations:

- Health check-up and treatment for more than 15,000 cases over the past 36 years.

- Rehabilitation for 2,255 CWDs of whom 1,765 were resident in the Center.

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- Surgery provided 505 times for 426 children with disabilities. 688 children with disabilities were provided with orthopedic devices.

- Most children treated have progressed, such as learning to walk and do other daily activities.

- The rate of children with disabilities progressing to higher grades at school is 95-100% and 45-50% with good results. Many have passed university entrance exams and 22 have studied at university or colleges and 1 is studying a master program overseas.

- Five persons with disabilities have gone overseas to work.

The government has recognized the achievements of the Center and in 2011 it was awarded the Independence Medal that recognizes outstanding contribution and achievement of an individual or organization towards development in all areas. The comprehensiveness of the services The rehabilitation center of Thuy An provides a comprehensive rehabilitation model. Persons and children with disabilities participate in all activities of rehabilitation and other services when they come to the center assisting with both physical and mental development. The services include orthopedic surgery, physical therapy, vocational training (sewing, knitting, incense production, office skills), special education, early intervention, counseling and introduction to jobs. These help persons with disabilities to be integrated in the community and to have stable lives. The close combination of rehabilitation and vocational education has been applied over 36 years at the center. This was also the first center to apply comprehensive rehabilitation in Vietnam as suggested by an international rehabilitation model.

7. Discussion and Conclusions

7.1. Policy The two main issues considered in this review of the policy framework were the appropriateness of the policy environment and how it aligns with international arrangements, and secondly how well the policies are implemented and enforced. In terms of appropriateness, the Vietnamese Disability Law is very comprehensive, and aligned with the UN Convention on the Rights of Persons with disabilities. Vietnam has also now signed and ratified the UNCPRD, so all laws, policies and practices will be subject to review under this mechanism. In general, government officers and persons with disabilities themselves feel that most laws are appropriate, although officers at local level say they would like clearer, more detailed guidance on laws to make implementation easier.

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Implementation of laws and policies is a significant problem for effective service delivery for persons with disabilities. There are significant weaknesses in the knowledge and understanding of government staff about the relevant laws and policies. It seems that there is still some overlap or inconsistency in policies at the lower level (decrees, circulars, regulations) as these are created by individual Ministries with insufficient consultation with other Ministries. This causes confusion and difficulties at the local level in knowing how to implement the Disability Law. The survey of government staff in the three sectors, and of persons with disabilities and their families indicated extremely low levels of knowledge and awareness about the laws and policies affecting persons with disabilities. The lack of knowledge among government staff means that it is impossible to properly implement policies, and the lack of knowledge of persons with disabilities and their families means they do not demand the services and assistance they are entitled to. Although this survey was conducted some years ago now, it’s likely that this lack of knowledge continues, particularly in rural areas where most people live. There is an urgent need for mass education and awareness raising about the Disability Law and all supporting policies for government staff, persons with disabilities and their families, and the community in general. There is a particular need for training of government staff in the more detailed policies and policies that go beyond basic social protection. For example, the new regulations on determination of disability need focus and appropriate training. In addition, policies that aim to assist people with impairments other than mobility, and issues related to greater independence, rather than just social protection, such as entitlements to vocational training subsidies etc. seem to be particularly poorly understood and implemented.

7.2. Data There is a need for more consistency in data collection and use, which will require the adoption of a common definition for a person with a disability and a common approach to detecting each type of impairment which all sectors can use. A comprehensive, coordinated approach to persons with disabilities will never be possible unless different Ministries use the same definition for data collection purposes. The ICF, as an international accepted approach which has been tested in Vietnam, is likely the most appropriate way for Vietnam to conduct disability data collection. It is recommended that this approach is applied to all Ministries. Individual Ministries at the local level also collect statistics on the number of persons with disabilities accessing their services. Unfortunately however, the consistency and quality of this data collection is very poor. Efforts need to be made to collect accurate information about who is accessing government services, and to disaggregate this by, at minimum, gender, ethnic status, type of impairment (using the approved categories in the Disability Law) and age. This data is essential for the monitoring of service provision and for planning

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for future needs and all three key ministries responsible for persons with disabilities need to invest in this. From the limited data that is available from the local level it is clear that people with mobility impairments are over-represented, pointing to a problem with the detection of people with other impairments. Ministerial statistics and provincial and district level statistics always indicate that mobility impairments are the most common disability. However, the 2009 census, which is the most representative and accurate survey done in Vietnam, found that multiple and vision impairments were most common when the ICF functioning approach is used. This highlights the importance of agreed definitions and approaches to identifying persons with disabilities. It seems that people with sensory and intellectual impairments are being under-detected and thus under-serviced, and it seems likely that many of the people classified as having mobility impairments may have multiple difficulties in functioning which are being ignored in service provision.

7.3. Service Provision In general, service provision is uncoordinated and insufficient to meet the needs of persons with disabilities. The overall approach seems to be on social protection and welfare rather than services that will enable persons with disabilities to live a full, independent life. The only policy and service that is relatively well implemented is the monthly social protection payment, and even then many people who need it are missing out due to inadequate classification or identification, and budget shortfalls. Social protection and basic health care and education should be seen as the minimum service. Vietnam will never achieve the ambitions of the Disability Law or the CPRD without services that go beyond basic survival to enable rehabilitation, skills development and economic and social participation. The study has also found that all sectors are too focused on mobility impairments, sometimes to the complete exclusion of any services for people with other types of impairments. In particular, people with intellectual disabilities or mental health problems are underserviced in all three sectors. This is possibly not surprising for a country of Vietnam’s income level and development, however as Vietnam has had such success in poverty reduction it is clear that they are able to integrate those facing most disadvantage into economic development. The same ‘growth with equity’ approach should also be taken in the disability sector and greater consideration given to sensory and intellectual impairments and mental health problems.

7.3.1. Health The primary responsibility for the health sector is rehabilitation for persons with disabilities. Despite a comprehensive network of hospital rehabilitation departments, and a Community Based Rehabilitation program this task of rehabilitation is not meeting the needs of persons with disabilities. Rehabilitation services are too focused on Centers and hospitals, and rehabilitation largely consists of physiotherapy. There is a lack of specialized services for

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people with other impairments, such as speech and language therapy, occupational therapy, psycho-therapy, etc. This is reflected in the staff qualifications who primarily have general rather than specific training. There is a need for expanded staff development in specialized rehabilitation skills other than just physical therapy. The CBR program is also failing to meet the needs of Vietnamese with disabilities. This approach, which provides outreach to the homes of persons with disabilities who largely live in rural areas, is far more effective and cost effective in low-budget settings such as Vietnam. However, it seems that few people are currently reached through the program, with most persons with disabilities interviewed in this survey completely unaware of the scheme. According to the data provided by DOH in provinces, the CBR program has contracted since 2010, with fewer districts reporting 100% coverage. There is a need for more investment in the CBR system: additional staff, increased training and equipment, expansion into all provinces in the country and greater ability to provide a range of therapy and referral beyond basic physical therapy. The infrastructure and equipment for rehabilitation at both specialized and general hospitals is insufficient to meet the needs of persons with disabilities, and is a serious concern for both staff and management within this sector. Again, the equipment that is available is primarily for rehabilitation of people with physical impairments.

7.3.2. Education Vietnam has implemented a formal policy of inclusive education since 2005. However, it seems that the actual implementation of the policies and plans is still very limited and inconsistent. The majority of provinces responding to the survey are only providing very limited educational services for children with disabilities. In particular, there is a lack of detection and early intervention. Limitations to the effective educational services for children with disabilities are similar to other sectors: lack of qualified staff, training opportunities, infrastructure and equipment such as teaching materials. In particular, staff and management are concerned about the lack of preferential salary/bonus policies for teachers providing inclusive education. The Provincial IECs/special schools seem to be the one exception to the rule that most services are provided for people with mobility impairments. It is pleasing to see that these specialized service centers are focused on assisting children who face greater barriers to accessing regular schools, such as those with hearing impairments or intellectual disabilities. However, the figures are also distorted somewhat because they include responses from both IECs and special schools, such as schools specifically for hearing impaired children. The training and professional development for teachers in the MOET system seems to be relatively good. Over 70% of teachers reported that they have received some training on

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how to teach children with disabilities. While the total number of teachers with higher level degrees in special education is low, most teachers have received at least some instruction in inclusive educational techniques. Teachers however expressed strong desire for more training in how to best support and teach children with disabilities. This effort in teacher training should be continued to ensure the more effective implementation of inclusive education policies and plans.

7.3.3. Labor and social affairs The social/employment sector as the lead agency for persons with disabilities also has possibly the widest responsibility for different services, from social protection in centers through welfare payments, vocational training and employment. Based on the survey responses, however it seems that DOLISA is failing to manage this wide range of services. The provincial DOLISA offices were unable to provide even basic data about the persons with disabilities they serve. It seems that they cannot disaggregate the different categories of people living in social protection centers and receiving welfare payments (e.g. disaggregate persons with disabilities from orphans, widows, people living with HIV, etc). From the data provided, it is difficult to know whether the social/employment sector is meeting the needs of persons with disabilities, but from the responses to interviews by persons with disabilities and their families it seems that services are inadequate and poor quality. DOLISA at the provincial level seems far too focused on the ‘social protection’ part of their remit and does not seem concerned about rehabilitation, independent living or services that can assist persons with disabilities to re-integrate into the community, access work, family life, etc. For example, virtually none of the DOLISA offices were able to provide information about vocational training, counseling, employment services, social work, independent living services in their province. The Social Protection Centers at provincial level seem relatively well placed to provide basic care and medical support to persons with disabilities, with quite a large number of qualified doctors or nursing staff, and many staff having over 10 year experience working in centers. However, the role of these centers is supposed to be changing, to provide greater rehabilitation and independent living skills for persons with disabilities so that they can reintegrate into the community. Based on the results of this survey, centers are totally ill-prepared to take on this role, with no staff having qualifications in vocational training and very few equipped with social work qualifications. If the government is committed to changing the role of these centers, a substantial investment in either recruitment or training, as well as in physical infrastructure and equipment will be required. Surprisingly most staff at social protection centers expressed high levels of satisfaction with the infrastructure, working conditions and the services they provide. This may indicate that the staffs are not aware that they have a role beyond basic care and health care which is

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currently not delivered. Clearly the staffs are very committed to their clients, which is very positive, and should make reform easier. DOLISA offices do acknowledge difficulties in providing services to persons with disabilities, citing lack of resources, infrastructure and trained staff as the key challenges. Staff training does seem to be a problem in this sector, with a large number of commune and district level staff having only school graduation and no specific training to support persons with disabilities. It seems that investment in qualified staff is improving since this survey was conducted, with the recruitment of more qualified social workers and the establishment of social work centers in some provinces. This effort in upgrading DOLISA staff needs to continue and expand.

7.4. Access and knowledge of persons with disabilities The survey of persons with disabilities provides more accurate information than the service provider survey, as it was done as interviews rather than self-administered questionnaires. It is worth noting however that the majority of the interviews were done with family members rather than the individual with a disability themselves, thus opinions expressed may well not be the opinions of the persons with disabilities, but rather their family member/carer. The survey, while it is not representative of the total population of persons with disabilities, does provide very useful information about those persons with disabilities who have some connection with DOLISA. The population surveyed is generally not well educated, and have low incomes. Most are receiving a welfare payment. Around 20% of the sample cannot independently conduct daily living activities and around 15% cannot move around the house without assistance.

7.4.1. Situation of families with a disabled member Persons with disabilities and their families are facing extremely difficult conditions. Most families reported that even the most basic functions of care for their disabled family members were either difficult or very difficult. For example, 80% of families have difficulties providing food, clothes and accommodation, 88% face difficulties in healthcare, 77% in rehabilitation, 70% of families face difficulties helping their disabled children access education and 79% of families struggle to assist their disabled members with activities of daily life. For more specialized care and assistance such as psychological assistance, legal assistance or vocational training families are facing particular difficulties. The main reason families are facing these difficulties is poverty and the cost of services (or transport, accommodation to access services) but also due to a lack of knowledge, awareness and understanding of how to access services. Addressing this lack of knowledge should be prioritized through public awareness campaigns about the availability of services. It is also possible that families are facing difficulties in accessing services for their disabled members because the service simply isn’t available. Given the findings regarding the lack of services for people with intellectual and sensory disabilities, and those with mental health

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problems, it’s likely that even if families tried to access services and had money to pay, they would not be able to find appropriate services. Overall, persons with disabilities in urban areas are better serviced than those in rural or peri-urban areas. Persons with disabilities indicate that they mainly access services at the local level, i.e. the commune level, however much of the disability service infrastructure such as hospitals and inclusive and special schools is based at provincial centers. This poses a significant problem for access since many persons with disabilities face difficulties in accessing transport and many families with a disabled member are very poor and cannot afford to regularly travel to central services.

7.4.2. Knowledge of services by persons with disabilities and their families

The knowledge about and access to of health services is very poor. Other than commune health services, less than 50% of persons with disabilities knew about or had accessed any other kind of health service, including CBR, provincial and even district hospitals. It is particularly concerning that persons with disabilities and family members indicate that they are unaware of community based rehabilitation services in their area. All three provinces surveyed do have a CBR program, but it seems it has either not reached the families surveyed, or if they have received a CBR visit they don’t know the name of it. Persons with disabilities and their family members are also very unaware of educational services. Even at the commune level, people didn’t know about any inclusive schools indicating a lack of awareness of the inclusive education policy among persons with disabilities. There is a need for more outreach by schools and education sector to educate families about the options available for the education of their children. Knowledge of social/employment services is also poor, although reassuringly quite a large percentage of persons with disabilities did know about their local DPO, despite the fact that neither Vinh Long nor Quang Tri have provincial level DPOs.

7.4.3. Are the needs of persons with disabilities being met? The needs of persons with disabilities are not being met, according to this survey. Even though this is not a representative sample of persons with disabilities, it is a sample of people from DOLISA lists, thus they have had some involvement with the disability service system, and even these people indicate widespread unmet need. In terms of health, health insurance, diagnosis and basic health care are relatively well serviced. Unmet needs are in the areas of surgery, orthopedic and other assistive devices and equipment, hospital based rehabilitation and referrals to other levels for treatment.

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Persons with disabilities have little access to social/employment services, although the most common service provided by DOLISA is a monthly social protection payment, less than 65% of the people surveyed who need such support have received it. It was striking in the survey of persons with disabilities and family members that expectations were very low. Only a very small number of people expressed that they needed vocational training services, employment assistance, social work, and an even smaller number of these had been able to access such services. This indicates very low expectations about integration on the behalf of persons with disabilities themselves and their family members. Unless these attitudes change and people demand services that can help them integrate and live independent lives, the service provision is unlikely to improve. Most of the persons with disabilities who were interviewed have not had to pay for the social support services they receive because they are in receipt of a benefit/health care card, however they were also not happy with the quality of service required. The majority has used their own or family’s income to pay for services, and 16% have had to take out a loan to pay for necessary services. These interviews with persons with disabilities paint quite a poor picture of the access to and satisfaction with the service delivery system. This group at least has low awareness of their rights and the services they’re entitled to, low expectations of what services they should receive, and limited access to assistance from the government. Families seem to provide the basic care and welfare for the majority of persons with disabilities interviewed with very little external assistance, and facing great difficulties. The ability of the persons with disabilities to integrate into life and work is extremely limited – many do not even participate in family activities let alone integrate into society as full members.

7.5. Coordination Coordination between the three key sectors is poor, although it seems to be better at lower administrative levels (i.e. at commune level, at the IECs, at Social Protection Centers, etc). There is a need for greater cross-referrals between sectors, particularly in terms of early detection and identification, and disability determination. In addition, much of the coordination that was reported is in the form of meetings and sharing information, not for actual case management or referrals. The new ‘Social Work Centers’ (Trung tâm Công tác Xã hội) and the Disability Information System software developed with USAID support could potentially provide a vehicle for better coordination of activities. It seems that staff in each sector aren’t really sure how to coordinate their activities, or don’t see it as their responsibility. The remit of these social work centers should be expanded beyond just being DOLISA focused, to provide a central focus for the comprehensive service provision for persons with disabilities, better referrals to necessary services and sharing of activities and information among the three sectors.

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8. Recommendations Based on the findings of the survey, the following recommendations are made in order to improve the comprehensive service provision for persons with disabilities in Vietnam.

8.1. Policy

• A greater coordination role for NCCD in the development of laws and policies to ensure consistency with the overarching disability Law and CPRD, as well as consistency and no overlap in decrees, circulars, regulations developed at Ministerial level. NCCD should be involved in all legislative development processes related to persons with disabilities.

• Upgrade the capacity of NCCD to be able to provide appropriate legal and policy development advice to individual Ministries by recruiting legal experts or providing training for existing staff.

• Conduct mass education campaigns targeting persons with disabilities, their families and the community in general regarding the approach and content of the Disability Law and related policies.

• Conduct training and professional development for all staff (provincial, district and commune level) in the three key Ministries about the Disability Law, and the supportive legislation and policies in their field, as well as of the ‘Penalty decree’ (see below). Focus such training on new, detailed policies such as the regulations on disability determination, and on policies that go beyond social protection.

8.2. Data

• Develop a consistent definition of disability for the purpose of data collection, and harmonize data collection processes and practices. Discussions to develop the definition should include at minimum, MOLISA, MOH, MOET, GSO and representatives of persons with disabilities. It is recommended that an international approach such as the ICF is used, to enable comparison and collaboration with other countries.

• Develop a system whereby local level authorities of DOLISA, DOET and DOH can collect data about persons with disabilities; their needs and access to services, and use this data for planning and staff training purposes. The newly implemented Disability Information System (DIS) could provide an appropriate platform.

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8.3. Service Provision

• International donors and NGOs should make more effort to support the Vietnamese government’s attempts to increase services for people with sensory and intellectual impairments and mental health difficulties. Technical assistance and external resourcing will be necessary for Vietnam to develop appropriate services, with trained professionals.

• Increase investment in training specialized rehabilitation skills such as speech and

language therapy, occupational therapy, psychiatry, etc.

• Upgrade the professional skills of CBR workers, particularly in rehabilitation skills for those with sensory or intellectual impairments and mental health problems.

• Extend the CBR program within existing provinces, and to cover all provinces. • Extend the services of the CBR program to ensure comprehensive rehabilitation, not

just physical therapy. Improve the ability of community based CBR workers to refer persons with disabilities to necessary services such as education, vocational training, employment, specialized health services, etc.

8.4. Access and knowledge of persons with disabilities

• Invest in education of persons with disabilities and family members about their rights

to access all health, education and social services, and their right to live independently.

• Invest in educating persons with disabilities and family members about what

services are available and how to access them. The most cost effective way to achieve this is through mass media and local information services such as loudspeakers. Newspapers, magazines and internet seem not to be effective in reaching persons with disabilities and their families, so effort should be put into TV and local announcements in preference. Consideration should be given to effective ways of reaching hearing impaired people – this may require additional research. Use the network of DPOs for awareness raising and providing information about available services.

• More effort from sector staff to reach out to the community and provide accessible

information about what services they provide – especially through DPOs, special schools, and NGOs and other agencies who have access to persons with disabilities (The Blind Association, Social Protection Centers)

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8.5. Coordination

• Improve coordination of policy implementation and service provision through more inclusive provincial planning processes. Each province should involve, at minimum, DOLISA, DOET, DOH and representatives of persons with disabilities in their annual planning process required under the National Action Plan for Disability 2012-2020. The provincial plan should provide an overall framework for service provision that can then be translated into activity plans at each Ministry.

• Ensure every province has a Social Work Center (Trung tâm Công tác xã hội), and

pilot models of comprehensive service delivery through these facilities. Extend these Centers to include staff from DOH (CBR workers) and DOET (inclusive education staff), and provide information to all staff about the ‘case management’ approach piloted in Da Nang with USAID funding. Share the lessons of different approaches to case management and comprehensive service delivery with all provinces.

• Change the budgeting processes at national and provincial level to allocate specific

funding for persons with disabilities. Currently, all three sectors report that they do not receive dedicated funding for persons with disabilities. In order to ensure adequate funding for services, specific, dedicated funding should be available for key services such as social protection, inclusive education, vocational training, employment services, social work for persons with disabilities, CBR, detection and early intervention, and rehabilitation.

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Vietnam Assistance for the Handicapped

Supported by a grant from USAID

May 2015

In cooperation with

Ministry of Labor, Invalids and Social Affairs Ministry of Health

Ministry of Education and Training