February 7, 2003
Phuong Thi Thu Huong
Ministry of Health, Vietnam
Dramatic Population Change
At the time of the April 1, 1999 Census, the population of Vietnam stood at just over 76 million, making it the 13th largest country in the world. From 1979 to 1999, nearly 24 million people were added to the country’s population. But, despite the addition of over 1 million people per year, the rate of growth of Vietnam’s population has been slowing dramatically. By the end of the 1990s, the growth rate declined to its lowest point since reunification of the north and south in 1975: 1.4 percent per year in 2000.
From 1979 to 1989, the country’s population increased by 22.7 percent, but from 1989 to 1999 the increase declined to 18.5 percent. This reduction can be traced to the rapidly growing desire of many couples to limit their family size to two children.
During the 1990s, Vietnam experienced a sharp decline in its population growth rate: from nearly 2 percent at that beginning of the decade to 1.4 percent by 2000. The significance of this change can be appreciated when we think of population growth rate in terms of its “doubling time.” A growth rate of 2 percent, if maintained, would double a population in 35 years, but a rate of 1.4 percent would require 50 years. Given the steady decline in the country’s birth rate, a continued decrease in the rate of population growth in the coming years is highly likely.
In 1979, Vietnam’s age and sex distribution exhibited the classic broad base of a country with a history of high fertility. The three widest bars at the base of the pyramid, representing the youngest age groups of 0-14 years, accounted for 43 percent of the population, a very young age distribution. About 20 years later, that proportion had dropped to 32 percent, still a comparatively young population. A very striking feature of Vietnam’s age structure in 2000 is the fact that the two “youngest” bars are smaller than the ones just above. As a result, the age structure itself virtually assures slower future population growth as these younger people move up the pyramid, reducing the number of potential parents.
Population by Age and Sex, Vietnam 2000
Source: Ministry of Health, Health Statistical Yearbook 2000.
Population density has always been a concern in Vietnam, particularly in the Red River Delta (in the northeast) which is by far the most densely populated region with 1,136 people per square kilometer in 1999. Over the last decade, national population density increased by 37 people per square kilometer. The country’s population density makes it one of the most densely populated countries in Southeast Asia and in the world.
The decline in fertility has been one of the most important demographic changes in recent years. The total fertility rate (TFR), or the average number of children a woman would have in her lifetime given prevailing birth rates, declined to 2.3 by 1999. This is nearly the level at which each couple “replaces” themselves so that population growth ultimately falls to zero. The dramatic nature of the decline is evident when we compare the current TFR to that of 1979: nearly 5 children per woman.
Despite the current low birth rate level, there remain wide regional disparities across the country. Fertility in the Red River Delta and in the southeast is the country’s lowest, in part due to the presence of Vietnam’s largest cities, Hanoi and Ho Chi Minh City, respectively. Birth rates are nearly always lower in urban areas than in rural areas. It is in the hill regions where fertility remains the highest, notably the Central Highlands and the northwest.
Dependency ratios are the number of children (ages 0-14) or the number of elderly above the typical retirement age (defined here as age 60) per 1,000 people of working age (15-59). Both young and elderly may be combined into a single dependency ratio — the aged-child dependency ratio. In Vietnam, the number of children per 1,000 people ages 15-59 (the child dependency ratio) has declined steadily since 1979, as would be expected given the decrease in the birth rate. The number of elderly per 1,000 people ages 15-59 (the aged dependency ratio) has remained stable since 1979, but is projected to increase from 14 in 1999 to almost 17 by 2024.
Health Improvements and Challenges
A key indicator of overall health conditions, life expectancy at birth has now risen to a high level in Vietnam. A newborn girl can now expect to live about 70 years, placing Vietnam on par with other Southeast Asian nations such as Indonesia, the Philippines, and Thailand. Surprisingly, census estimates suggest a more rapid gain during the 1990s for boys, whose life expectancy increased a full 3.5 years in one decade.
During the 1990s, the level of infant mortality showed a consistent decline — from 44.5 deaths to infants under age 1 per 1,000 births in 1989 to 36.7 in 1999. Most notable is the improvement in urban areas where infant mortality fell by nearly half between the 1989 and 1999 censuses. The greater challenge in reducing infant mortality lies in the rural areas, which recorded a decline of only 7 percent over the same period.
Infant mortality rates are uneven throughout the country. In cities, such as Hanoi and Ho Chi Minh City, infant mortality rates are low, approaching those of some European countries. But, in some provinces, particularly in ethnic minority regions, infant mortality rates are among some of the world’s highest. This may be related to obstacles in health care delivery due to the difficult terrain and to larger family sizes.
Vaccination rates are often taken as good indicators of the health of young children, and Vietnam has made steady progress in this area. Three out of 4 children age 10 and under have been immunized against polio, measles, diphtheria, pertussis, tetanus, and tuberculosis. This represents a nearly 50 percent increase in coverage rates between 1993 and 1998.
Although the prevalence of HIV/AIDS in Vietnam has not been high compared with many other developing countries, the situation is now changing rapidly. The first officially reported case of HIV/AIDS was in 1991. By 2001, the number had climbed to over 43,000, with about 3,560 people having died from the disease. More troubling, however, is the increasing number of new cases reported each year. In 1999 there were about 22,816 people infected with HIV/AIDS, up from less than 4,000 in 1995. Alarming data reported for 2001 show that the number of infected people nearly doubled over that of 1999. HIV/AIDS has now become a serious — and rapidly accelerating — national health crisis. The situation is even more severe when one considers that, in many countries, the true number of cases is probably much higher than reported.
Reported HIV/AIDS Cases in Vietnam, 1991-2001
Source: 1997 Demographic and Health Survey.
Improving Education Rates, Lowering Poverty Rates
Overall, more than 9 out of 10 adults lack any type of educational qualification, although there has been a small improvement since the 1989 Census: In 1989 92.7 percent of adults lacked qualification, falling slightly to 91.5 percent in 1999. For those with qualifications, the largest increase was among those with undergraduate or higher training, a group that increased from 1.8 percent to 3.0 percent of the population. This is the type of progress that must be continued if Vietnam is to reach its development goals and increase its participation in global trade and commerce.
Economic growth maintained a very high rate throughout the 1990s. At the current average annual growth rate of about 7 percent, Vietnam’s economic output would double every 10 years. From 1991 to 2000, average gross domestic product per capita rose from 2,076,576 VND (US$135) to 3,531,661 VND (US$229) (at constant 1994 prices), a substantial increase over a nine-year period that suggests continued increase in Vietnam’s living standards.
As a likely consequence of economic growth, there has been a rapid decrease in the proportion of the population living below the poverty line during the 1990s. (The poverty line was 1,789,871 VND (US$116) in 1998.) The decrease has been observed in every region nationwide. By far the most dramatic has been the improvement in the southeast where the percentage of people living in poverty dropped from 32.7 percent in 1993 to 7.6 percent in 1998. The decrease in poverty may be taken as another signal that economic development is well underway in the country.
Abortion Rates High Despite Availability of Contraceptives
Fertility decline in Vietnam is apparent in the majority of the childbearing age groups of women. This decrease has been most rapid among older women of childbearing age, a pattern often observed during a period of decline in birth rates. Among the youngest women, however, there has been comparatively little change in the childbearing rate.
The reproductive health of women is based on many factors, including the age at which childbearing begins. Most childbearing in the country takes place within formal marriage, and Vietnam women typically do not enter marriage until well after age 20. In fact, only half of women marry before age 25. The age pattern of marriage has been consistent in recent years.
Contraceptive use has risen steadily in Vietnam since the late 1980s, as shown clearly by the 1988 and 1997 Demographic and Health Surveys (DHS). Almost three-quarters of women use some form of family planning and nearly 6 out of 10 use a modern form (such as the pill, IUD, sterilization, or condom).
Nearly 70 percent of women using modern contraception reported using the IUD in the 1997 DHS. This figure was nearly 90 percent during the 1988 DHS, so it is clear that the types of methods used have become somewhat more varied. Condom use has increased from about 1 percent of couples to nearly 6 percent today. Nationally, contraceptive use is highest in the north and tends to decrease as one moves south; traditional methods are somewhat more common in the south, as well. The proportion of modern contraceptive users using the IUD is also lower in the south.
The need for regular checkups during pregnancy is well established for the health of both mother and child and to discover any potential problems that might arise during delivery. Monthly visits are the recommended practice and, while Vietnam does fall far short of that goal, there has been an encouraging upward trend in Ministry of Health data. The number of prenatal visits has doubled since 1992 from an average of less than one or two.
Qualified medical care available at delivery is also essential for the health of mother and baby. In Vietnam, just over three-fourths of births occur with the assistance of a trained attendant. About one-fourth are attended by doctors and an additional half by a nurse, midwife, or doctor’s assistant. About 6 in 10 births take place in a health facility, but the large proportion that occur at home or elsewhere remains a concern.
In Vietnam, abortion services, including menstrual regulation, are readily available in public and private facilities. It is evident from survey data that women in Vietnam often resort to abortion because of a lack of contraception and contraceptive failure. It is estimated that the average Vietnam woman has about 1.3 abortions in her lifetime. Abortion rates vary widely by region, with the highest rates generally reported in the northern part of the country in the 1997 DHS.
The number of abortions reported by the Ministry of Health has declined steadily in the 1990s. In 2000 the number of abortions was half of that eight years earlier. Reducing the number of abortions is clearly beneficial to women’s reproductive health and is a direct result of the rise in contraceptive use and the subsequent avoidance of unplanned pregnancies. It is well known, however, that these data do not include many abortions performed privately, a type of pregnancy termination often used by younger, single women.
Total Abortion Rate in Vietnam, 1997
Source: 1997 Demographic and Health Survey.
Urban Areas Attracting Migrants
The pace of urbanization in Vietnam has accelerated in the past 10 years after showing little growth between 1979 and 1989. The percentages hide the growth of the urban population, however. From 1979 to 1999 the urban population rose from 10.1 million to 18.1 million. While rapid urbanization can create new challenges to cities for housing and transportation, it is often seen as a key indicator of and contributor to economic development. Still, Vietnam remains relatively rural compared to other Southeast Asian nations.
As Vietnam continues to develop, it is to be expected that the population distribution will shift from rural to urban areas as well as to the new economic zones. By region, the pattern of migratory movements has been generally consistent, as reported in both the 1989 and 1999 censuses. Only two regions have received a net balance of in-migrants: the southeast and the Central Highlands. Overall, there has been a consistent net flow of migrants from the northern parts of the country to the southern.
Looking at migration by province provides a clearer picture of the destination of migrants. There are essentially four areas of primary attraction to migrants: the urban areas of Ho Chi Minh City, Hanoi, Da Nang, and the Central Highlands region. Ho Chi Minh City alone received a net balance of over 400,000 migrants between 1994 and 1999, while its neighboring provinces, such as Binh Phuoc, Ba Ria-Vung Tau, and Dong Nai, also proved attractive to new residents. In contrast, provinces adjacent to Hanoi, the only Red River province to attract migrants, did not experience a net flow of migrants.
Partially as a result of higher life expectancy, the number of people 60 years old and older has risen remarkably. In 1979 there were 3.7 million elderly people, making up 6.7 percent of the total population. This figure rose to 4.6 million in 1989 and then jumped to 6.2 million in 1999, 8.1 percent of the total. Almost 60 percent of the elderly are female and about four-fifths of elderly people live in rural areas.
The Red River Delta has the highest percentage of elderly. Six out of eight provinces (Hai Duong, Hung Yen, Ha Nam, Nam Dinh, Thai Binh, Ninh Binh, Ha Tinh, and Quang Nam) with the highest percentages of elderly people (10 percent and over in 1999) are found in this region.
The health status of the elderly has greatly improved in the past few decades, but it remains one of their most significant concerns. In the 1999 Survey on the Living Condition of the Elderly, the percentage of older people who reported they were in good health dropped from 17.3 percent for people 60-64 years old to just 4.7 percent for people 75 and older. The percentage of older people who said their health condition was bad rose from 26.2 percent to 63.7 percent for those same age groups.
Respect for the elderly is a fundamental, traditional value in Vietnam. Older people have an important role to play and make significant contributions to the development of the community through their experiences and abilities. The government has paid considerable attention to care for the elderly and this is well reflected in many legislative documents. The 1992 Constitution stipulates that “Parents are responsible for educating children to become good citizens. Children have the responsibility to respect and to provide care for their parents and grandparents” (Article 64). “Old people, disabled, and orphan children are supported by the State and society” (Article 87). According to the Law of Protection of People’s Health, “Old people are given priority in health care and opportunities to make contributions to society in keeping with their overall health” (Article 41).
Since its foundation in May 1995, the Vietnam Association of the Elderly has grown rapidly, with 6 million members, and has expanded its activities in every community. To further promote the roles of and care for the elderly, the Ordinance on the Elderly was approved by the National Assembly on April 28, 2000. This is the first time such a comprehensive policy dealing with issues of older people has been promulgated in Vietnam.
Gender Equality and Empowerment of Women
Along with the overall socioeconomic achievements gained since the reforms of the mid-1980s, women’s status and gender equality in Vietnam have also been greatly improved. Females have drawn nearly even with males in literacy, a sharp divergence from the past, when only two-thirds of women ages 50 and over could read or write.
In particular, more efforts have been devoted to women’s reproductive health since 1994. This has resulted in significant improvements in a number of important women’s reproductive health indictors.
Men’s participation in family planning practice, however, remains modest. Male sterilization is much lower than female (0.5 percent vs. 6.3 percent, 1997 DHS). As a result, the National Population Strategy 2001-2010 cites gender equality as an important factor in the achievement of replacement-level fertility, a better quality of life, and sustainable development.
Gender inequality still exists in many respects. Despite a high rate of female literacy, women’s educational attainment remains lower than that of men at all levels, with the gap wider at the higher levels. The percentage of women ages 15 and over who never attended school is nearly triple that of men.
Women’s participation in the paid labor force rivals that of men, rising to over 80 percent of women in their 20s. It is clear from the graph that, once a woman begins to work in Vietnam, her involvement in economic activity is continuous and not interrupted by raising children. In addition to those involved in paid labor, many women report “household work” as a major activity. Girls also appear to enter the labor force somewhat earlier than boys, most likely due to leaving school at earlier ages.
Over the long term, the gap in educational qualification between men and women has narrowed dramatically. In the population ages 55 and older, men are five times more likely to hold an educational qualification but, in the younger age groups, the male rate is only about 1.5 times that of females. In fact, the level of equality of women in Vietnamese society and in the labor force has often been observed. Despite the improvement in the rate for those under age 55, however, there is little evidence that the gap in qualifications has continued to close. It is interesting to note that, while men and women are nearly equal in the youngest age group (15-49), it may be expected that the male advantage will widen with time since men have a marked advantage in college and university qualifications.
This advantage also has an effect on the comparative income of men and women. Survey data have shown that men’s income is about 1.5 times that of women.
Even though women have gained greater workplace parity with men, this is not always followed by equal financial compensation. This can be a complex issue resulting from the types of occupations men and women are likely to pursue, qualifications held, whether work is full- or part-time, and to the fact that men have traditionally held many higher positions.
Not only do women supply a virtually equal share to the labor force, but they have gained a rapidly growing voice in national affairs. Vietnam now has the highest percentage of female parliamentarians in Asia. By the late 1990s, women made up 26 percent of the National Assembly and nearly 90 percent of those had a higher education.
The total land area of Vietnam is 329,241 km2. Population density rose from 160 people per km2 in 1979 to 195 in 1989 and to 232 in 1999. Density is the highest in the Red River Delta (1,136 people per km2) and lowest in the northwest with only 62 people per km2. Agricultural land per capita decreased from 0.25 hectares in 1943 to 0.10 ha in 1995.
Rapid population growth, migration, and urbanization in Vietnam have placed new pressure on the environment, particularly as a result of patterns of land use, forest exploitation, and depletion of water resources. It is estimated that forest coverage in 1943 amounted to 43 percent of the country. Today, natural forest cover amounts to about 28 percent, or about 9.4 million ha. Each year, natural forest cover is lost to such activities as illegal cutting and forest fires. In many years, however, replanting programs have resulted in a net gain in the total forest area. Because of past deforestation and illegal hunting, many species of mammals and flora have disappeared.
A water supply from a safe source is a basic human need. By 1999, nearly 80 percent of the population had access to a supply of hygienic water, a major public health advance. Across provinces, however, there are wide disparities. Very low access to safe water is still pervasive in more mountainous and remote provinces, as well as in the Mekong region.
Vietnam faces a challenge familiar to many developing countries: the rapid proliferation of motor vehicles, particularly in its cities. As personal incomes grow and vehicles become more affordable, problems associated with pollution have emerged as a major urban issue. In many cities, pollution levels are many more times above the acceptable national standard. One solution that will likely emerge will be major improvements in public transportation systems so that such systems can compete with the appeal and convenience of motor vehicles.
Perspectives and Challenges
If fertility decline continues at the current rate, Vietnam will achieve fertility at the replacement level (2.1) by 2005. According to the medium population projection, the population of Vietnam will reach 100 million in the next 25 years and will stabilize at 120 million by the middle of this century.
Vietnam has clearly made significant progress in slowing its once rapidly growing population growth. New population challenges, however, are emerging for sustainable national development. The Vietnam Population Strategy 2001-2010 has identified a number of major challenges:
- Although the fertility rate has declined continuously in the past decades, Vietnam’s population remains large. In addition, a young age structure and future increases in the number of women of reproductive age will result in significant potential for population growth, which is far from over. Current projections anticipate an annual increase of about 1 million people per year for the next two decades. It should be noted that this projection assumes a continued decrease in the national birth rate. Should birth rate decline be slower than assumed, however, population growth would be even larger.
- Overall, the current TFR of 2.3 is quite close to replacement level fertility, but the birth rate differs greatly among the provinces. Only one-third of 61 cities and provinces have reached the replacement fertility level or lower, while fertility remains high in the Northern Uplands, Central Coast, and Central Highlands. Other issues, including only moderate prevalence of modern contraceptive methods, unplanned pregnancies, and abortions — especially among adolescents — have become issues of great concern at a time of declining investment in the population program. There is no guarantee that the reduction in fertility observed so far is permanent. A high proportion of three or more births and a continued preference for large families, particularly by males, could cause a reversal of birth rate trends.
- Due to the rapid reduction in fertility and the increase in life expectancy, the population of Vietnam has begun to experience an accelerating process of aging. The population under age 15 will decrease from 25 million in 1999 to 21 million in 2010. Despite the decrease, this is still a large number of young people who will need education and employment. Over the same period, the population ages 60 and older will increase from 6.2 million to 6.9 million, creating greater needs for social security and health care services. This increase in the elderly population will only be the beginning of a sharp rise in the size of this group who, in 2020 will approach 11 million. Such an increase in this age group is unprecedented in Vietnam. The population in the prime working ages (15-59) will go from 45 million to 59 million — a huge potential for the country if these are workers well prepared for new roles in Vietnam’s new economy.
- But the quality of life is still low. Eight percent of newborns weigh less then 2,500 grams and 36.7 percent of children under 5 are malnourished. It is also important to note that 1.5 percent of the total population is physically and intellectually disabled. The number of new cases of HIV has been rising quickly each year, meaning that the time to act to avoid a devastating national pandemic is now. The mean number of years of schooling per person needs improvement — only 6.2 years recorded during 1997-1998. Skilled workers make up only 20 percent of the labor force, compared to 50 percent and more in other countries. Only 2.9 percent of the population has a higher education.
- Far beyond their positive effects, spontaneous migration and the seasonal movement of the labor force are making it difficult to provide basic social services, while worsening the environmental situation.
It is clear that Vietnam stands on the threshold of a new era. On the surface, the demographic transition in terms of total fertility rate is nearing completion. That, however, is partly due to an unacceptably high rate of abortion, so that the overall condition of reproductive health of women in Vietnam remains a serious issue. A primary goal of Vietnam’s family planning program should now be focused on reducing unplanned pregnancies. Economically, Vietnam is clearly moving toward a more diverse economy, one that produces products for a waiting export market. At the same time, the labor force largely remains dependent on agriculture, lacking the skills so badly needed for a modern economy. Education, therefore, will be key to Vietnam’s future.