The family planning program in Vietnam has gone through a long journey. It began as an unofficial program in 1963, was officially instituted through the Council of Ministers Decree No 162-HDBT/1988 and was further reinforced by Resolution 4/1993. The emphasis was solely on a two-child per couple policy with 3 to 5years of spacing [6]. The target population defined by policy makers in the 1980s consisted entirely of married women. The program did not encourage unmarried women to buy and use either condoms or contraceptive pills. Consequently, there were no family planning services, or even information, for young women who were interested in understanding how to use oral pills and their immediate and long-term side-effects. Women were also uncomfortable buying condoms, because the surrounding society perceived doing so as a sign of a casual approach to sexual relations. This situation explains why there was such a high rate of reliance on traditional methods until now, although women knew that traditional methods are less effective in preventing unwanted pregnancies [7]. Family planning policy makers at that time believed that the intrauterine device (IUD) was the most effective way to meet the official fertility targets of a two-children-per-couple policy with 3 to 5years of spacing. From the beginning, the family planning program in Vietnam relied heavily on IUDs. Strong campaigns to promote exclusive IUD use were conducted in the 1980s, followed in the mid-1990s by campaigns to promote female (tubal) sterilization [8]. Consequently, for decades, only one modern method, the IUD, predominated in Vietnam’s contraceptive method mix. Other modern methods such as pills, injectables and condoms have been given less attention [9].

During that era, the 6-year pre-service training for medical doctors and 3-year pre-service training for nurses/ midwives/physician assistants did not include academic curricula related to the VFP dimensions. An introductory family planning course of less than 20 hours was given to sixth-year medical students only. However, if a physician or nurse/ midwife/ physician assistant wanted to provide abortion services, they could undergo a 2-month certification course at the provincial reproductive health center after graduation. This certification course was an in-service training with similar course content for physicians and nurses/midwives/physician assistants [10].

Abortion services are legal in Vietnam, if provided through public or qualified private facilities, under a Decree that enabled privatization of the health sector in 1989 [10]. However, it is suspected that many abortion services were delivered without MOH certification because the provider’s qualifications, equipment, and facility sanitation did not meet standard medical requirements 10]. Between 1982 and 1994, induced abortions rose six-fold, leading Vietnam to be a country that has one of the highest abortion rates in the world (with over 1,000,000 abortions per year, or an average of 2.5 induced abortions in a woman’s reproductive life) [10,11]. Each year, approximately 500,000 abortions were reported in the public sector, and another one-third to one-half as many were performed in small health clinics which are suspected of contributing to high women’s death rates [4,10,12]. Limited contraceptive choices, improper use of modern contraceptives and reliance on withdrawal or periodic abstinence contributed to this situation [1,2,13]. Findings from a joint study led by the Ministry of Health/World Health Organization in 1999 concluded that ‘lack of counselling and comprehensive information on available contraceptive method mix’ were associated with the high abortion practices [14]. A multi-donor reproductive health project built a network of in-service trainings (clinical and management) for almost 2,000 health facilities at the national, provincial, district, and commune level in 17 provinces between 1994 and 2009, involving a total budget over 20 million dollars. The three dimensions of VFP – provision of family planning counselling, information on contraceptive method mix, and management skills to ensure availability – were included and adopted in the national standards and guidelines for counselling in regard to family planning and safe abortion [15].

Accessibility affects nonusers of modern methods and current users of traditional methods in Vietnam [8]. When women who preferred to buy contraceptive pills or condoms instead of IUDs did not receive adequate counseling on how to use oral pills nor adequate information about their immediate and long-term side-effects, they did not feel comfortable buying their preferred methods in the open market and thus they continue to use IUD or chose traditional methods. Figure1 evidences the fact that current use of IUD is still the predominant modern method in Vietnam. In addition, many Vietnamese family planning providers are still holding the same mindset planted by the IUD campaigns in the 1980s. They did not deliver VFP services seriously, and persisted in treating IUD as the method of attention instead of optimizing access to other modern methods. The attitude of family planning providers certainly will affect future VFP counselling and communication strategies. Policy-wise, increasing the availability of modern contraceptive methods other than IUDs, as well as providing quality information, will increase the use of effective modern family planning methods and decrease the use of traditional methods, leading to change the paradoxical situation of high use of contraceptives and high abortion in Viet Nam.

Performing VFP needs more time than the usual 3–5 minutes of provider-client interaction that is typical at the primary care level. A prerequisite of applying additional services such as VFP is a well-motivated workforce, according to a joint-study conducted by researchers from the Hanoi School of Public Health and the Royal Tropical Institute (KIT) in 2003 [21]. It is noteworthy that the data for the Dieleman et al. 2003 study were collected in two provinces adjacent to Thai Nguyen province (where data for our study were collected). This 2003 motivation study was the first of its kind that looked at rural health workers’ perceptions with respect to job motivation at commune and district health centers in rural areas of northern Vietnam [21]. They found that motivation is influenced by both financial and non-financial incentives (such as appreciation by supervisors, colleagues, and the community). Low salaries, difficult working conditions, and lack of communication skills were noted as discouraging factors. Health workers also tend to perceive supervision as control. In addition, selection for training is seen as opaque and unequal, and performance appraisal is not useful [21]. Although the Ministry of Health in Vietnam prioritizes development of a public health network to provide good quality services including family planning, their findings showed that there were still insufficient qualified and motivated human resources in rural areas.

Motivation, or an individual’s degree of willingness to exert and maintain an effort to achieve certain organizational goals, is a complex concept. It needs supervision, performance appraisal, career development, and appropriate training. Not all trainings are adequate and casual supervision visits achieve little. Apparently, in-service trainings by vertical health programs (such as the voluntary family planning dimensions) do not count as significant credit points in a health worker’s curriculum vitae; in fact, they tend to participate because these trainings pay per diems, so they are perceived merely as an income opportunity.

To some extent, the motivational problem found in performing voluntary family planning dimensions is not exclusive to Vietnam. A recent study (2011) that systematically reviews 80 studies from Africa and Asia and the Pacific on quality and performance of private and public ambulatory health care in low- and middle-income countries (published between 1970 and April 2009) concluded that raising the quality of care is a long-term effort. The government has an important role, but supervision, auditing with feedback and quality training have been found to be an effective combination [22].

In order to strenghthen current VFP services in Vietnam, new performance-based measures should be used to record the number of clients counseled and the number of clients given adequate information about IUD and other modern methods. Monitoring of these new measures should be recorded and reported in order to increase the knowledge and availability of all modern methods, not only IUD. Eventually, this will reduce the number of nonusers of pills and condoms and reduce the number of current users of traditional methods. More in-depth training materials about the three VFP dimensions should be incorporated in the pre-service training curricula for students of medicine, midwifery academics, and nurses. The government’s women’s empowerment program should participate in creating messages that encourage women to obtain information about efficacy of a method before choosing one. This change in orientation should make use of the national standards and guidelines on counselling to protect vo-luntarism in family planning, and will contribute to the government’s efforts to reduce abortion incidence, which will eventually change the paradoxical situation of high use of contraceptives and high abortion in Vietnam.