When Lisa Cosimi first moved to Vietnam 20 years ago, after finishing an infectious diseases fellowship at Harvard, she was interested in studying ways in which southeast Asian countries’ health care systems might be improved and how the quality of health care in resource-limited settings could be enhanced.
Cosimi focused on improving HIV care and treatment, working in hospitals and clinics in Vietnam to train physicians, nurses, and pharmacists on how to provide more comprehensive care for patients and prevent the spread of infection.
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“It was less than 1 percent of the population, but in certain high risk groups, specifically people who used injection drugs, there was a growing epidemic. And it seemed that Vietnam was at an inflection point, where things were about to worsen,” said Cosimi, now an assistant professor of medicine at Harvard Medical School.
After two years in Vietnam, Cosimi joined the U.S. Centers for Disease Control and Prevention to lead the scale-up of HIV treatment in clinics in Vietnam under the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR). Vietnam is the only country in Southeast Asia to participate in the program, which has spanned two decades, invested more than $100 billion in the global HIV/AIDS response, and saved 25 million lives in more than 50 countries.
During this time, Cosimi continued to work with Harvard physicians, including Eric Krakauer, HMS associate professor of global health and social medicine in the Blavatnik Institute at HMS, and Howard Libman, now HMS professor of medicine, emeritus, who were training and providing continuing medical education to Vietnamese physicians working in these same HIV treatment clinics and developing closer ties with leadership at the country’s medical schools.
Through the work being done in the HIV clinics, Cosimi and a few others came to the conclusion that real progress would be made in Vietnam not solely by training health care workers in clinics and hospitals, but by helping the country achieve systemic change in its health care sector.
“We increasingly recognized that true, sustainable improvement in health outcomes would need to include much more than education and resources to treat a specific disease: it would require improving the broader health system. That involves improving quality of care for any patient walking into a clinic or hospital and across the system. And that has become the basis of our ongoing work,” Cosimi said.
Responding to multiple diseases
Cosimi’s initial work expanded to developing health systems that could address the whole person, because a patient might be dealing with malaria, heart disease, and hypertension simultaneously. The focus changed to creating person-centered care systems that could provide holistic treatment.
That meant revamping the country’s medical education system, something the nation’s leadership also wanted to do because Vietnam’s population and economy were rapidly growing, disease patterns were shifting, and population demographics were aging, causing increasing demands for quality health care. Additionally, medical school curricula hadn’t adapted to the changing needs of new learners and the rapid evolution of medical science.
“Even in the more established universities, you had curricula that hadn’t comprehensively changed in decades. Most classes were delivered with a single lecturer in the front of a classroom, delivering material that hadn’t been changed in a very long time, with class sizes that were getting bigger and bigger,” Cosimi said. “When we talked to both the doctors and educators one-on-one, they all said yes, we need to do this better.”
Cosimi and her colleagues approached David Golan, dean for research operations and global programs and the George R. Minot Professor of Medicine at HMS.
“What they said is, we want to keep doing our HIV/AIDS work, but we’ve also been approached by our Vietnamese university partners to work with the medical schools on medical education curriculum reform, starting with one medical school in particular, the University of Medicine and Pharmacy at Ho Chi Minh City [UMP], to reform their medical education curriculum,” recalled Golan.
“This work required many hands, some from the HMS Quad and some from the HMS-affiliated teaching hospitals, who became involved in an intensive effort to design a major curriculum reform effort,” he said.
One of those people was David Duong, now an HMS instructor in global health and social medicine and the director of the HMS Program in Global Primary Care and Social Change. Duong had first gone to Vietnam as an HMS medical student with a particular interest in medical education and health system reforms.
The U.S. government, through USAID, also had an interest in supporting Vietnam’s curriculum reform efforts and, in 2016, provided a five-year, $7 million grant, the Improving Access, Curriculum and Teaching in Medical Education and Emerging Diseases Alliance (IMPACT MED Alliance). The funding was matched by private sector partners, such as Microsoft, Samsung, and Novartis. The Vietnamese Ministry of Health also borrowed money from the World Bank to support the initiative.
About eight years ago, the HMS team began providing faculty development workshops to medical school educators at UMP. At one early session, Golan said, more than 200 medical school faculty crowded a conference room in Ho Chi Minh City on a Saturday to take advantage of the HMS training sessions.
Organizing that meeting was then vice rector of UMP, Professor Tran Diep Tuan, who was pivotal to medical education reform both at his university and in the country, and then Vice Minister of Health, Professor Le Quang Cuong, who championed medical education reform and became the principal architect for reform on the national level, expanding the effort from UMP to other medical schools in the country.
New agreement
Harvard eventually drafted an agreement with the Vietnam Ministry of Health for a formal research, education, and training partnership now called the Partnership for Health Advancement in Vietnam (HAIVN).
Cosimi, based at Brigham and Women’s Hospital, is its director, and Todd Pollack, HMS assistant professor of medicine, part-time, at Beth Israel Deaconess Medical Center, is its medical director. Pollack had been the country director for the past 13 years. Duong is associate director.
In Vietnam, the partnership is led by Nguyen Quang Trung, a physician and the new country director, alongside a staff of more than 30, all committed to strengthening the health care system through research, training, and quality improvement.
The partnership has grown to involve national and provincial government institutions and 10 Vietnam-based medical schools, hospitals, and clinics and has expanded to include partners in Laos, Cambodia, and the Philippines.
The curriculum reform effort has been so effective that the U.S. government recently provided an additional $8 million for five more years. Experience from this effort has led to an increased focus on collaborating with Vietnam to strengthen its wider primary health care system.
“There’s currently a global shortage of primary care physicians,” said Duong. “We worked with the primary care educators in Boston at the HMS Center for Primary Care and the medical educators in Vietnam. We co-developed a new curriculum for primary care training, which then can be modeled again in other resource-limited settings.”
In November 2022, Golan attended the UMP graduation celebrating the school’s, and the nation’s, first class to complete the new six-year curriculum. Also attending the ceremony was Vietnam’s Minister of Health Dao Hong Lan.
Golan and Lan both acknowledged the importance of Harvard’s partnership with Vietnam and its activities to strengthen the health care sector there over the past 20 years. Golan also met with U.S. Ambassador to Vietnam Marc E. Knapper, and senior leadership from USAID and the CDC, each of which has provided funding and grant support for the work in Vietnam.
“The U.S. government very much appreciates this project, which brings together academic colleagues and medical educators at Harvard and throughout Vietnam,” Golan said. “The U.S. government wants to support relations between the two countries, including through academic partnerships, such as HAIVN.”
The direct benefit of the partnership to Harvard is the opportunities the partnership affords to HMS faculty, trainees, and students interested in global health, education, training, and research. These opportunities are especially valuable in low- and middle-income countries, which are beginning to see increases in the incidence of cancer, heart disease, and other non-communicable illnesses.
“One of the reasons that top global health faculty are recruited to Harvard is because we have opportunities like this for them to pursue their interest in working across the globe to strengthen health systems and study other health systems,” said Golan.
Collaborative programs
The work in Vietnam has underscored the importance of learning from other countries. During the pandemic, with Pollack living in Vietnam, HAIVN, in collaboration with the Ministry of Health and UMP, launched a program to train Vietnam’s medical students and health care professionals in COVID-19 screening, detection, and management, with a focus on contact tracing and community-based care.
“I believe that collaborative programs like ours were able to contribute to Vietnam’s successful control of the pandemic,” said Duong. “Our programs engaged at the hospital, university, and community levels to support infection control, contact tracing, and other COVID-related initiatives. Our existing relationships with the government of Vietnam and institutions across the country enabled this rapid and timely response during this unprecedented challenge.”
“We saw with the COVID-19 pandemic that existing relationships, built on trust and shared commitment, are of critical importance in our global effort to effectively respond. You can’t just wait until an emergency and then say we want to work with you,” he added.
The training program in Vietnam has also led to innovations in care delivery in the U.S. Led by Pollack, HMS and Vietnamese faculty paired telehealth with clinical mentoring and coaching in clinics several years before the onset of the COVID pandemic to enable primary care doctors in remote areas of Vietnam to provide medications and manage HIV/AIDS care and treatment.
The Center for Primary Care was then able to use a similar model to support rural primary care in the U.S. in places like Arkansas, West Virginia, and Oklahoma, with funding from the Human Resources and Services Administration’s program Technology Enabled Education for Community Health (TEECH), said Duong.
“The general idea that the world is connected, and that health care is connected, and that illnesses in one country can clearly migrate to other countries, has been demonstrated in abundance over the past three years,” Golan said.
Last fall, HAIVN announced a new public–private initiative with Gilead Sciences, Inc., which is embarking on a multiyear pilot program to address barriers that limit the diagnosis and care of viral hepatitis at primary health care facilities in Vietnam and the Philippines, each of which has a high prevalence of hepatitis B and C.
The focus of the program will be on developing new, community-based models of care and on training nonspecialist primary health care providers, incorporating education, screening, diagnosis, and linkage into care for hepatitis B and C at routine patient visits for at-risk populations through a person-centered approach. An innovative component of this model is that it is being co-designed with patients.
Gilead and HAIVN will also aim to strengthen primary health care systems in general by working to enhance coordination among specialists, primary care providers, and patients.
“We need to be able to work together because, as we have seen, what starts off in one country will end up in Atlanta, will end up in Seattle, within a matter of days if not hours,” said Duong.
“We need global approaches to these problems. Underpinning any global approach is trust, which is what we have developed over the past 20 years of Harvard in Vietnam and will continue to strengthen over the next 20 years,” he said.