Ethnic Minority Development Plan MHSP

SOCIALISTREPUBLIC OF VIETNAM

MINISTRY OF HEALTH

MEKONG HEALTH SUPPORT PROJECT

ETHNIC MINORITY DEVELOPMENT PLAN

HANOI, JANUARY 2006

ABBREVIATION

EM / Ethnic Minority
MHSP / Mekong Health Support Project
MRD / MekongRiver Delta
PPMU / Provincial Project Management Unit
CPMU / Central Project Management Unit
CEMMA / Committee for Ethnic Minority and Mountainous Areas
CEM / Committee for Ethnic Minority
EMDP / Ethnic Minority Development Plan
VLSS / Vietnam Living Standard Survey
GSO / GeneralStatisticsOrganization of Vietnam
MOLISA / Ministry of Labor, War Invalid and Social Affaire
M&E / Monitoring and Evaluation

Table of Content

Introduction......

I. Policy framework......

II. Social and economic overview......

III. Positive and negative effects......

IV. Mitigation and development plan......

V. Baseline information collection......

VI. Institutional arrangement......

VII. Grievance and Complaints Mechanism......

VIII. Monitoring and evaluation activities......

IX. Cost estimation for EMDP......

Appendix......

I. The issues emerging from healthcare for the poor fund’s implementation and the effects to EM groups-conclusion from group discussion

II. Selected comparisons between Khmer and Kinh people in MRD......

II. Questionnaire for group discussion with EM people......

III. Some picture of group discussion......

List of tables

Table 1: EM groups in MRD......

Table 2: Khmer population in MRD......

Table 3: Poverty incidence in Khmer community......

Table 4: Income composition of Khmer people......

Table 5: Source of income of Khmer......

Table 6: Where did you go when you get sick?......

Table 7: Estimated budget (US$)......

Introduction

Mekong River Delta (MKD) includes 12 provinces and 1 city, occupying 12% natural area and 21% population of Vietnam. The region plays an important role in the agricultural development, producing 51% paddy rice and the largest share of agro-product export.
Although MKD has witnessed remarkable achievements in economic growth and poverty reduction, many problems have remained as constraints on the sustainable development e.g. poor infrastructure, poor human capital, backward production etc. The problems are believed severer in ethnic minority (EM) communities.
There are three ethnic minority (EM) groups, in addition to Kinh people, in the region, namely Hoa, Cham, and Khmer, of which Khmer occupies the largest proportion. Majority of Khmer population are the poor.
Mekong Health Support Project is included in the Country Assistant Strategy (2003-2006) of the World Bank to Vietnam. The purpose of the Project is to achieve medium term health gains in the region especially for the poor. The Project consists of four components, including: (1)upgrading the medical equipment; (2) training medical staff; (3) supporting the healthcare fund for the poor and; (4) project management. This Ethnic Minority Development Plan (EMDP) - aims at ensuring the meaningful and culturallyappropriate involvement of EM groups, especially Khmer people in the Mekong Health Support Project. It is also to ensure adverse effects (if any) are avoided, minimized, mitigated, or compensated for.
Besides introduction, the report includes four sections: Fist section provides the framework overview of policy toward ethnic minority and particular those applying for MRD; second section is for summarizing the social and economic situation of the ethnic minorities people in the region; section three presents the positive and possible negative effects that may occur during the project implementation; section four is institutional arrangement that also contains a set of measures to ensure that the ethnic minority group’s people receive social and economic benefits that are culturally appropriate as well as to avoid, minimize mitigate or compensate for the adverse effect that may potentially occur during the project’s implementation; section five will give a set of plan related with M&E activities, and the last, section six provides the cost estimation and financing plan for EMDP implementation.

I. Policy framework

The equality of ethnic minority group is clearly stipulated in Vietnam Constitution (1992): “The SocialRepublic of Vietnam is a united nation having many nationalities. The state implements a policy of equality and unity and supports the cultures of all nationalities and prohibits discrimination and separation. Each nationality has the right to use its own language and characters to perceive their culture and to improve its own traditions and customs. The State carries out a policy to develop thoroughly and gradually improve the quality of life of ethnic minorities in Vietnam physically and culturally”
In 1994 the Committee for Ethnic Minorities and Mountainous Areas (CEMMA) were established directly operating under the Government Office. This organization is assigned as coordinator for programs, policies supporting ethnic minorities. Currently this organization is renamed as Committee for Ethnic Minorities (CEM)
In 1995, the Framework for External Assistance to Ethnic Minority Development was enacted. It introduced a new strategy for ethnic minority development within the government policy on growth and poverty reduction.
Decision 135, issued in 1998 sets up a program focusing on poverty alleviation in disadvantaged areas. The major objectives of the program are: (i) rapidly improving the living of ethnic minority people in extremely poor communes; (ii) creating favorable conditions for economic development in these areas in order to surmount poverty, backward and slow development, (iii) integrating EM groups in development of the whole country.
Decision 173/2001/QD-TTg issued by the Prime Minister in 2001 provides a comprehensive development program for the region, by which the government concentrates on improving infrastructure-the biggest problem. The Program also intends to build house for the poor, especially for the poor Khmer to help them to overcome persistent difficulties. Furthermore, by this Decision, the Government continues to subsidize and/or provide freely a number of necessary commodities like medicines, textbooks, tuition fees for primary school students, and seeds for cropping.
The Decision 139/2002/QD-TTg aims at supporting healthcare for the poor by issuing card for free healthcare or buying health insurance card for the poor. Although it is not having directly targeted the EM people, the policy is widely believed to have great impact because large proportion of the poor people in the region is EM people.
Decision 19/2005/QD-TTg approves a project of building market places and commercial centers for 13 provinces in MRD. By that 78 commercial centers and rural markets shall be built serving for agro-product consumption in the region. The Decision is said to boost up market economy in MRD and by doing so to improve living condition of the poor, especially those in remote areas.
In summary, EM communities in MRD have received remarkably favorable policies. Although some of them do not directly address to ethnic minorities but the poor in general, they are believed to have great impact on the livelihood of large number of EM people.
Vietnam’s legal policy on EMs is more or less similar with what is specified by the World Bank policy on Indigenous Peoples OD 4.20, therefore no supplementary policy provisions will be necessary in MHSP. This development plan is then designed to ensure the meaningful participation of the ethnic people in the MHSP and that they receive culturally appropriate benefits from the project

II. Social and economic overview

MRD’s population is characterizedby a mixture of various groups of people. Kinh occupies the largest share, about 87.64%, followed by the Khmer, Hoa and Cham (Table1). There are also some EM groups migrated from the North, including Tay, Nung, etc, however, they share a very small proportion (0.04%) and locating sparsely in the region.

Table 1: EM groups in MRD

Ethnic minorities (people) / % of the region population
EM groups / 1,714,735 / 12.36
In which: Khmer / 1,085,286 / 10.30

Hoa

/ 202,270 / 1.90

Cham

/ 13,137 / 0.12

Others

/ 4,837 / 0.04

Source: Committee of Ethnic Minority, Figures in 2003

Hoa people are believed to be similar to the Kinh in term of social and economic background. They show their competence in commercial activities and have close relationship to other communities. Unlike other groups, Hoa people normally inhabit in the relatively developed areas for instance towns and commercially developed center in Long An, Can Tho, An Giang, Tien Giang etc
The majority of Cham in MRD is living in An Giang, and slightly isolated from Kinh communities. They embrace Muslim that is thought to be a clear distinction from Cham people in Binh Thuan where most of them follow CaoDai religion. Cham are said to be hard-working and performing fairly successfully with small businesses. To some extent, they are not inferior to Kinh people. Evidences from group discussion with Cham in An Giang show that they have remarkably good production skills, good knowledge about agro-extension services, land management, and credit policies and well-organizing. Although they use their own language within their family and community they show good communication to Kinh people by their good speaking Kinh language that is said due to their popular job as small trader. Probably, the biggest problem of Cham communities is their environmental and sanitary condition that results from their living custom. So far, quite few of Cham households have sanitarytoilet. Some are still breeding cows below their house’s basement. Such sanitary habits make them prone to communicable diseases. This situation suggests the role of grass-root healthcare institution as well as good information dissemination to Cham community to awaken their sanitary habit
Khmer occupy the largest share of EMs in the region. Due to the development level and historical reasons they differ from Khmer in Cambodia, although they are said to have the same origin with Cambodia’s Khmer. Of 12 provinces, Soc Trang and Tra Vinh have the largest proportions of Khmer (table 2) than others. Slightly differ from other EM group, Khmer live substantially mixed with Kinh people, although in some provinces they seem to concentrate in only one or two districts. For instance, in An Giang they occupy about 4-5% population andare largely found in Tri Ton, and Dinh Bien that are mountainous and remote districts.
Khmer have long history and plentiful culture. The major share of Khmer embraces Buddhism and therefore visiting Buddhist pagoda is a very important cultural activity. In MRD, there are about 500 pagodas; some have almost 500-years of age. Opinions of Buddish monks are highly respected and plays very important role in sprit life of Khmer.

Table 2: Khmer population in MRD

Provinces / Population (1000) / In which Khmer (%) / Khmer Household
Soc Trang / 1168 / 29.78 / 68206
Tra Vinh / 965.7 / 30.86 / 58146
Kien Giang / 1600.7 / 12.8 / 34574
An Giang / 2054.0 / 4.23 / 17168
Can Tho / 754.59 / 8.20 / 11549
Vinh Long / 1893.3 / 1.90 / 6248
Ca Mau / 1017.0 / 2.23 / 4784
Total / 1165.8 / 2.49 / 5076

Source: Report from Committee for Ethnic Minority, 2003

Khmer have their own language and script. Some Khmer people can speak but can not write. Khmer writing is mainly taught by Buddhist monks in pagodas. In order to reserve and protect Khmer language, the government initiated a program for teaching Khmer language in primary schools, however, only some provinces and districts in the region are able to arrange that.
Despite of many attempts of the government to help Khmer to improve their education, poor education has yet been one of critically severe problem. Figure from Population Census 1999 reveal that among over 5 aged people about 30% have never been in school while it is 7.4% and 13.3% for Kinh and Hoa groups respectively. The ratio of Khmer children going to kindergarten is only 1.18%. The census also shows that 98.9% of Khmer labor force does not have any professionalworking skill.
Poverty incidence has been high among the Khmer communities. Table 3 provides poverty situation of Khmer in the region (based on the poverty line issued by the MOLISA). It shows that the poverty rate among Khmer is noticeably higher than the average. In some provinces like Soc Trang, Ca Mau the poverty rates are severely higher than other provinces.

Table 3: Poverty incidence in Khmer community

2001 / 2002 / 2004 (Fist half year)*
Khmer / Khmer / Khmer / Overall
Soc Trang / 42.91 / 38.00 / 27.38 / 17.55
Tra Vinh / 35.53 / 34.81 / 33.92 / 15.45
Kien Giang / 27.92 / 24.96 / 26.5 / 7.26
An Giang / 21.88 / 20.98 / 12.27 / 3.5
Bac Lieu / 39.31 / 33.5 / 28.95 / 6.7
Can Tho / 31.51 / 27.29 / 21.38 / 2.52
Vinh Long / 33.61 / 33.61 / 31.1 / 4.44
Ca Mau / 39.22 / 39.22 / 28 / 7.8
Total / 35.66 / 32.64 / 26.99 / 6.2

Source: Figures in 2001-2002 is from Son Phuoc Hoan, 2003 “Situation and solutions for improving policy

for Khmer in MRD”; * Figure in 2004 is from CEMMA, 2004

Figures from GSO show that EM people seem to be left aside in the fight against poverty. Calculation from VLSS shows that while poverty among Kinh and Chinese groups in rural area in MRD reduced as much as 39% from 1998 to 2001,the poverty rate reduction of other ethnic groups was only by 10%[1]. By end of 2001 the poverty ratio among Khmer was some 32.6% whereas it was only 23% for the whole region.As an example, the poverty rate of Soc Trang reduced from 64.4% in 1999 to 28% while the poverty reduction rate among the Khmer remains at some 43% in 2002. In 2001-2002, out of 7,204 poor households escaped from the poverty there were only 565 Khmer households, just about 7.8% (MPDA, 2004[2])
There are a number of reasons attributing to the high poverty of Khmer. In general there are so many reasons, namely: (1) Poor education and vocational training, for instance, in Soc Trang, only 0.2% Khmer have technical and professional qualification while for other group it is about 3%; (2) Inappropriate production and consumption customs; (3) Poor accessibility to factor markets e.g. credit, land or market.
One of other distinctive characteristics of Khmer is that theirlivelihoodsisclosely linkedtohired employment in agricultural sector that requires them a lot of travel far from their residence. Large number of interviewed Khmer in Soc Trang expressed that due to landless or small land they usually have to work for their neighbor or to travel away from home even to Dong Thap, An Giang for seeking employment. Evidence from VLSS 2001 is consistent that nearly half of Khmer’s income is from hired employment that is contrast with income proportion of Kinh people.

Table 4: Income composition of Khmerpeople

Unit: %

Khmer / Kinh
Wage employment / 42.8 / 32.12
Non-farm self employment / 14.00 / 19.61
Renting out land and assets / 0.58 / 0.48
Service and others / 6.66 / 9.44
Cultivation / 25.73 / 23.77
Livestock / 4.665 / 5.347
Aquaculture / 4.206 / 8.702
Forestry / 1.353 / 0.52
Total / 100.00 / 100.00

Source: Vietnam living standard survey 2002

MPDA, 2004 shows the understanding that the Khmer poor households have shifted from self-employed agricultural production to other economic activities or hiring out labour is very important to secure their livelihood. This situation implies that poverty reduction support measures aiming atagricultural production and self-employed farmer households are no longer appropriate toKhmer poor households, as they cannot directly improve their main livelihood. Instead,farmer household-targeted support measures are effective only for better-off and averagehouseholds.Unlike Khmer poor households, the Khmer average and better-off households earn their livelihoodmainly from agriculture. Rice production and animal husbandry are the major incomesources, making up 59% of the total income of better-off families and over 41% of averagehouseholds’ income. Better-off households earn higher income from agriculture.

Table 5: Source of income of Khmer

Unit %

Poor / Average / Better-off / General
Rice / 3.1 / 29 / 40.6 / 32.6
Fruit trees / 0.0 / 1.7 / 2.9 / 2.2
Secondary crops / 0.1 / 2.4 / 4.3 / 3.2
Husbandry / 2.4 / 12.3 / 18.3 / 14.7
Aquaculture / 0.0 / 0.2 / 1.5 / 0.9
Fishing / 0.0 / 0.6 / 0.1 / 0.2
Agricultural hired labour / 18.5 / 5.0 / 1.1 / 4.4
Off-farm / 43.7 / 10.8 / 2 / 9.7
Trade / 19.2 / 19.7 / 7.3 / 12.1
Salaries / 0.0 / 6.4 / 11 / 8.4
Others / 13 / 11.7 / 11 / 11.4

Source: Mekong Delta Poverty Analysis, Ausaid, 2004

Regarding to healthcare situation of EM people, there seems to be no difference in disease pattern between Kinh and EMs except for the fact that Khmer and Cham are potentially suffered more communicable diseases that are explained by bad environment and sanitary living habit. In addition, the ratio of Khmer accessing the healthcare service in village and commune clinics is significantly higher than that of Kinh people (see table 5). It suggests a more critical role of preventive medical and primary healthcare for EMs in the region.
A substantially positive point in the healthcare system in the region is that the commune healthcare clinic in many provinces has much improved in association with the policy of subsidizing necessary medicinethat lightensthe poor in general and EMs people in particular in using official healthcare system and reduced obsolete habit. Such policies also improve the awareness of EM people in keeping sanitary condition as well as preventing communicable diseases. The ratio of EM people using commune, village clinic is even higher than Kinh people (table 6)

Table 6: Where did you go when you get sick?

Khmer / Kinh / Total
Village healthcare station / 5.10 / 1.83 / 1.92
Commune clinics / 26.02 / 17.95 / 18.16
Zone healthcare station / 5.10 / 8.08 / 8.00
State hospital / 35.20 / 31.18 / 31.29
Private healthcare station / 26.02 / 39.07 / 38.73
Traditional medicines / 2.04 / 1.49 / 1.51
Others / 0.51 / 0.39 / 0.40
Total / 100.00 / 100.00 / 100.00

Source: Vietnam living standard survey 2001

The fieldwork suggests that poor income and poor knowledge attributed to Khmer people are major barrier hindering them to access the healthcare service at higher level. As an example, a number of patients who were interviewed confirmed that they never know any information about the fund for healthcare for the poor until they are advised by hospital staffs when they come to get treatment. More surprisingly, some of them, though already received the healthcare card do not know how to use it.The lack of information happens not only for EM people but the poor in general, however, it is clearly that due to the language barrier, EM people seem to suffer more. Furthermore, the cumbersome and bureaucratic procedures applying for the fund for healthcare for the poor, the shortcoming of the implementation process of those policies etcare also causing further barrier. For example bypass patients are not able to get refund or fees exemption; many name of poor household member is not included in the poor household’s certificate due to their absence at the time of selection; the problem of near-poor people is not well defined etc (see appendix).