Designing and Testing a Social Prescribing Pilot in Viet Nam: From Co-Design to Safe Implementation and Iterative Learning

Designing and Testing a Social Prescribing Pilot in Viet Nam: From Co-Design to Safe Implementation and Iterative Learning

Category: Implementation & Practice

A social prescribing pilot can fail even when the idea behind it is good. The target population may be appropriate, community resources may exist, clinicians may support the concept and a navigator may be ready to help. Yet referrals may never happen because the workflow is unclear. Community organizations may receive people whose needs fall outside what they can reasonably provide. Staff may understand the pathway differently. People may agree to a referral but never make the connection. Data may be collected without anyone knowing what decisions those data are supposed to inform.

This is why a pilot should not simply be treated as a smaller version of a future program. Its purpose is to learn. A responsible pilot asks whether a proposed pathway can operate in a real setting: whether people understand and accept it, whether staff can use it, whether roles are clear, whether community organizations have enough capacity, whether information moves appropriately, whether unsuccessful connections become visible, whether safety concerns can be escalated, and whether the pathway can adapt when reality differs from the original design.

For Viet Nam, this learning function is particularly important. Social prescribing has not been established as a national model, and peer-reviewed Vietnamese evidence remains very limited. A Western Pacific scoping review published in 2026 included 42 peer-reviewed studies and 13 grey-literature sources, with only one of the peer-reviewed studies from Viet Nam. Its searches were completed on 1 November 2024, so the review should not be interpreted as a complete picture of everything that may have developed since then. Across the region, social-prescribing models also differed considerably in funding, workforce, referral processes and community infrastructure.

A larger global scoping review published in 2026 provides an even broader perspective. It included 115 peer-reviewed empirical studies from 16 countries, with approximately 64% originating from the United Kingdom. Implementation was shaped by factors such as referral pathways, relationships, cross-sector coordination, workforce capacity and the strength of community resources, while recurring barriers included socioeconomic disadvantage, unstable funding, limited community-sector capacity and workforce pressures.

The implication for Viet Nam is not that social prescribing must wait until perfect evidence exists. It is that early implementation should be designed to generate useful local knowledge rather than assume that an international model will transfer unchanged.

Start with a problem, not a program

The first decision should not be which international social-prescribing model to reproduce. It should be which problem is important enough, bounded enough and practical enough to learn from.

A hospital might notice that selected older people return home after discharge with social isolation, caregiver strain or difficulty reconnecting with everyday activities. A primary or ambulatory care setting might repeatedly encounter people with long-term conditions whose health management is affected by loneliness, transport barriers or weak social support. Another service may see people who repeatedly struggle to navigate existing community or social resources.

Any of these could potentially become a pilot use case, but not every social problem belongs in social prescribing. Some needs require clinical treatment, professional social work or other formal and specialized services. A pilot therefore needs to define those boundaries before referrals begin.

An early pilot should also avoid becoming so broad that nobody can tell what is actually being tested. “People with social needs” is usually too vague. It is more useful to define a setting, a population, a referral opportunity and a manageable range of needs clearly enough that the pathway can be observed and evaluated.

This does not mean selecting only easy cases. A pilot that excludes every form of complexity may work smoothly while teaching little about real-world implementation. At the same time, beginning with the highest-risk and most complex population may place too much responsibility on a pathway that has not yet established its relationships, workforce or escalation processes. The right starting point is usually a manageable but meaningful implementation problem.

WHO's Western Pacific social-prescribing toolkit was designed to support local implementation and includes materials that can be adapted to local context rather than prescribing one universal model. That principle is particularly appropriate for Viet Nam.

Co-design a minimum viable pathway

Once the problem has been defined, the next question is not simply who will deliver the pilot. It is who needs to help shape it.

People who may use the pathway, caregivers where appropriate, clinicians, social workers, navigators, operational staff and community organizations each see different parts of the process. A referral pathway that looks simple to a hospital team may create substantial work for the organization receiving referrals. A community activity that professionals consider appropriate may be inaccessible, unaffordable or simply unattractive to the people expected to attend.

A 2026 review of inclusive co-design for social prescribing synthesized 52 sources and emphasized equity, diversity, relationship-centeredness, accessibility, participatory governance, attention to power differences and inclusive facilitation. Only a small proportion of the included literature was empirical, so co-design should not be presented as something proven to make social prescribing effective. Its practical value is different: it provides a structured way to challenge assumptions before they become embedded in the pathway.

Recent work using deliberative dialogues provides one example. Primary-care providers and community organizations worked together to identify feasible pathways, core components and implementation barriers. Viet Nam does not need to reproduce that method exactly. The more transferable lesson is that structured conversations can help participants distinguish what is essential, what is desirable and what is actually workable in the local setting.

For an early Vietnamese pilot, co-design should address practical questions before referrals begin. How does someone enter the pathway? Who determines that community-connected support is appropriate? Who has the first conversation? Who provides navigation? Which resources can simply be suggested, and which require a more formal referral relationship? What information genuinely needs to move between organizations? What happens when a service is full? What happens when the person declines the suggestion, cannot be contacted or never reaches the service? When should the pathway return someone to clinical care, professional social work or another formal service?

The pilot then needs a minimum viable pathway: enough structure to test whether its essential functions can operate without trying to build an entire system at once. Those functions may include eligibility, referral or entry, navigation, a sufficiently current community-resource base, appropriate information sharing, response from receiving organizations, follow-up of unsuccessful connections and clear escalation when someone's needs fall outside the pathway.

Technology may support these functions, but the first pilot does not require a sophisticated digital platform. A simple, well-governed workflow can teach more than an expensive system built before the pathway itself is understood. What matters is that the process is observable. If a referral disappears after it is sent, the pilot cannot learn why it failed. Important transitions should therefore be visible — for example, from eligible to offered, accepted, connected, contacted and engaged, or alternatively declined, unavailable, unsuitable or unresolved. The exact stages may vary; the principle is to know where people leave the pathway and why.

Build safety and escalation into the pathway before launch

Social prescribing connects people with non-clinical community support, but people entering the pathway may still have significant health, social or safety concerns. A navigator may encounter severe psychological distress, clinical deterioration, abuse, serious family difficulty, urgent financial hardship or another problem that cannot responsibly be addressed through a community activity alone.

A pilot therefore needs escalation processes before these situations occur. The pathway should clarify what falls within community navigation, what belongs to professional social work, what requires clinical assessment and what requires urgent action through existing organizational procedures. A community organization should not become responsible for managing clinical or professional risks simply because someone has been referred there.

Safety also includes problems created or exposed by the pathway itself. A person may be connected to an unsuitable resource, misunderstand why information was shared, disclose sensitive information to the wrong organization or become distressed during the navigation process. Not every adverse experience will be caused by social prescribing, but a pilot still needs a way to recognize, document and review safety concerns, complaints, unexpected events and near misses.

A useful question is therefore: Can this pathway fail safely? That is more realistic than assuming every referral will succeed.

Clear role boundaries are part of safety. A navigator should know what they can do, what they should not do and whom to contact when a situation exceeds their role. Community partners need the same clarity. The pilot should also specify what happens outside ordinary working hours, what constitutes an urgent concern, who retains clinical responsibility where relevant, and how concerns are documented without turning community organizations into extensions of clinical services. Goodwill matters, but it is not a substitute for governance.

Test whether the pathway fits real workflow

A pathway can be highly acceptable in principle and still be difficult to implement in everyday practice.

The 2026 Australian RISE UP pilot illustrates this particularly well. The model was introduced within a pediatric allied-health intake service. Among the 109 parents and caregivers who answered the acceptability question, 106 - 97.2% - considered the model acceptable. Staff experience was much less positive: staff acceptability was 55.8% and feasibility 64.3%. Reported barriers included competing workload demands, staff shortages, workflow and information-technology issues, and cultural fit.

This difference matters. A pilot cannot be judged only by asking whether people receiving support like the idea. The people expected to make the pathway work every day must also be able to deliver it.

The same study identified another important issue. During the data-collection period, approximately 728 families contacted the service and 144 were offered RISE UP. Not every family contacting a service should automatically be assumed to be eligible, but the authors nevertheless identified a reach gap and raised concerns about representation, including relatively low representation of families speaking languages other than English compared with the surrounding population.

This is a useful warning for Viet Nam. A pathway can appear successful among the people who enter it while systematically missing others before they ever reach the first step.

Workflow problems can arise anywhere. Referral criteria that require lengthy assessment may be unrealistic during a busy consultation. A navigator may receive too many referrals to provide meaningful support. Community partners may be asked for feedback they do not have the administrative capacity to provide. Clinicians may stop referring because they never learn what happened. A digital platform may add another login rather than simplify the process. These are not minor implementation details; they often determine whether the pathway survives after initial enthusiasm fades.

A 2026 Danish ethnographic study makes this even clearer. Researchers conducted 68 days of participant observation during the early implementation of a social-prescribing model. Implementation work was distributed among general practitioners, link workers, a Volunteer Centre and the DaneAge Association rather than being carried by one role. The researchers identified five cross-cutting mechanism families: legitimacy; standardization and normalization; relational sense-making and trust-building; network weaving and coalition formation; and knowledge visibility and mobilization.

The study did not test whether the Danish model improved health outcomes, and its organizational structure should not be treated as a template for Viet Nam. Its more transferable insight is that social prescribing is a multi-actor, system-embedded implementation process, not simply a referral technique that one enthusiastic navigator can maintain alone.

For a Vietnamese pilot, responsibilities should therefore be distributed deliberately. Someone needs organizational authority. Someone needs to own the operational pathway. Someone needs to provide navigation. Someone needs to maintain community relationships and resource information. Someone needs to review implementation data and emerging problems. Clinical and professional escalation should remain with the appropriate responsible services. In a small pilot, one person may perform several of these functions, but the functions themselves still need to exist.

Measure implementation, reach, equity and community burden before claiming effectiveness

A common pilot mistake is to collect several well-being measures, observe improvement and conclude that social prescribing worked. Small pilots are rarely designed to establish effectiveness.

People who accept the pathway may differ from those who decline it. Outcomes may change for unrelated reasons. Participants who remain at follow-up may differ from those who disappear. Without an appropriate comparison design and sufficient statistical power, a change in well-being does not establish that the pilot caused it.

This does not mean health or well-being outcomes should never be measured. They may provide useful preliminary signals. But the first question is more fundamental: Can the pathway actually be implemented?

Implementation science provides useful concepts here. Proctor and colleagues distinguish implementation outcomes from service and patient outcomes, including acceptability, adoption, appropriateness, feasibility, fidelity, implementation cost, penetration and sustainability.

An early Vietnamese pilot does not need to measure every domain. A practical core might focus on whether the pathway is acceptable to people, staff and community partners; whether it is appropriate for the population and setting; whether it is feasible within real workflows and available community capacity; whether intended referrers actually adopt it; and whether its essential functions are delivered consistently enough to know what is being tested.

Alongside these implementation outcomes, reach and equity need explicit attention. Who was potentially eligible? Who was actually offered the pathway? Who accepted? Who reached a community resource? Who remained engaged? Who was missed or lost along the way? Do important differences appear by age, location, disability, socioeconomic circumstances, language or digital access? The choice of equity variables should be relevant to the pilot rather than becoming an excuse to collect every available piece of personal information.

The denominator matters. High satisfaction among a small group tells a very different story if most potentially eligible people were never offered the pathway.

The community side needs to be measured as carefully as the healthcare side. Are organizations receiving referrals that fit what they actually provide? Do they have capacity? Are they receiving enough information to respond appropriately without being sent unnecessary information? Has the pilot created significant unpaid or administrative work? Can they contact the navigator easily when someone's needs do not match the resource?

Community capacity is not unlimited. A healthcare referral process that appears efficient while overwhelming the organizations receiving referrals is not a successful community-connected pathway. A 2026 global review identified limited community-sector capacity, unstable funding and workforce pressures among recurring barriers to social-prescribing implementation. A Vietnamese pilot should therefore monitor not only how many people are connected but also what those connections require from the community.

That information may lead the pilot to narrow eligibility, stagger referrals, strengthen selected partnerships, identify additional community assets or invest in capacity before expansion. Learning that the first design needs to change is not evidence that the pilot has failed. It is one of the main reasons for running a pilot in the first place.

Use data for iterative learning, and decide in advance what happens next

A pilot should expect to change. If nothing changes after the first real cases, the original design may have been unusually well matched to reality, or the project may not be examining implementation closely enough.

A practical learning cycle is straightforward: run the pathway on a manageable scale, examine what happened, identify where reality differed from expectations, make a justified adjustment and test again.

The aim is not uncontrolled change. Some elements should remain stable enough to know what is being tested, including the purpose of the pathway, professional boundaries, core safety requirements, basic navigation functions and essential information needs. Other elements may adapt, such as the wording of eligibility criteria, timing of follow-up, communication channels, training materials, resource categories or the way community organizations communicate capacity.

This creates a useful distinction between core functions and adaptable forms. A core function may be that an unsuccessful connection becomes visible to someone responsible for follow-up. The form could be a digital status field, telephone call, secure message or manual tracker depending on the setting. The pilot should preserve the function while learning which form works locally.

The team should also decide before implementation what kinds of findings would justify continuing, modifying, pausing or stopping the pathway. Without predefined decision questions, almost any result can later be described as encouraging.

Those questions might include whether the pathway is sufficiently acceptable, feasible and appropriate; whether staff can deliver it without unreasonable disruption; whether community organizations can support it; whether intended connections actually occur; whether unsuccessful connections are recognized and followed up; whether serious safety concerns have emerged; whether the intended population is being reached reasonably and equitably; and whether community capacity is sufficient for the next stage.

There is no universal numerical threshold that SPVN should prescribe for these questions. Appropriate thresholds depend on the setting, population, risk and stage of development. But the possible decisions can still be explicit: continue, because the pathway appears workable; adapt and retest, because important problems appear solvable; pause, because safety, capacity, equity or workflow requires substantial redesign; or stop, because the pathway is inappropriate or the conditions required for it do not exist.

A pilot does not have to lead to scale-up to be successful. Discovering that something should not be expanded can be one of the most valuable outcomes of a well-designed pilot.

Work within Viet Nam's existing professional and legal framework

A Vietnamese social-prescribing pilot does not operate in a regulatory vacuum simply because there is currently no separate national legal framework establishing social prescribing as a distinct model.

Decree No. 110/2024/ND-CP on Social Work, effective from 15 October 2024, establishes the national regulatory framework for social work. Under the Decree, from 1 January 2027, people practicing social work will be required to hold the applicable social-work practice registration certificate in accordance with its provisions.

Circular No. 51/2024/TT-BYT, effective from 1 March 2025, regulates the implementation of social work in medical examination and treatment establishments and applies specifically to establishments licensed to operate in the form of hospitals. In July 2026, Decision No. 1975/QĐ-BYT formally corrected the document number from Circular No. 51/TT-BYT to Circular No. 51/2024/TT-BYT.

Circular No. 29/2026/TT-BYT, effective from 25 August 2026, provides further detail on social-work practice requirements under Decree No. 110/2024/ND-CP and on the updating of professional social-work knowledge.

These instruments do not establish social prescribing. They nevertheless matter when a hospital pilot introduces navigation or support functions that may overlap with professional social work. A navigator role should not simply rename activities that legally or professionally belong within social-work practice, and social prescribing should not become a route around clinical, social-work or other professional responsibilities.

Where the actual activities of a proposed role fall within social-work practice governed by Decree No. 110/2024/ND-CP, the applicable requirements need to be respected. Conversely, a community navigator who helps people identify and connect with appropriate community resources should not automatically be treated as a social-work practitioner merely because the role involves navigation or support. The distinction should be based on what the person actually does, not simply the title used.

Data governance is equally important. Law No. 91/2025/QH15 on Personal Data Protection and Decree No. 356/2025/ND-CP have both been in force since 1 January 2026. Decree No. 356/2025/ND-CP includes health status within the categories of sensitive personal data. A pilot collecting, using or sharing identifiable information therefore needs to determine what information is genuinely necessary, why it is being processed, which organizations and people may access it, how it moves between them, how long it should be retained, how it is protected, and which consent and other legal requirements apply to the particular processing activities involved.

A pilot should resist collecting information simply because it might become interesting for evaluation later. Collect what the pathway genuinely needs, and govern it well.

Research governance should also be considered separately from routine service implementation or quality improvement. If a pilot is designed and conducted as research involving human participants, or otherwise falls within applicable institutional research-ethics requirements, the appropriate ethical and institutional review should be obtained. Calling something a “pilot” does not by itself determine whether it is research, quality improvement or service implementation; that depends on its actual purpose, methods and governance.

What could an early Vietnamese pilot look like?

There is no single correct model, but an early pilot can be deliberately simple. It might begin with one clearly defined problem, one setting and one manageable population. The organization would first understand the current journey rather than immediately create a new one. People who use the relevant services, professionals and community partners would help shape the pathway. Existing community assets would be mapped, and a manageable number of resources would be verified sufficiently for real navigation.

Before the first real case begins, the pilot would define eligibility, referral or entry routes, navigation responsibilities, professional boundaries, escalation processes, information sharing, follow-up and the essential implementation measures. The pathway would then be tested with a limited number of people rather than launched across an entire organization.

Early cases should usually receive closer follow-up than may eventually be necessary. This is deliberate. The aim is to observe where the process breaks: whether referrals are appropriate, whether people understand what they have agreed to, whether community organizations respond, whether navigators can manage the workload, whether information is sufficient, whether connections actually occur, whether unsuccessful connections become visible and whether safety concerns emerge.

The team should review those cases and implementation data regularly. Some problems will require minor adjustments. Others may reveal that a basic assumption was wrong. Only when the pilot demonstrates reasonable acceptability, appropriateness, feasibility, safety, equity and operational reliability should expansion be considered.

Even then, expansion does not simply mean increasing referral numbers. More participants require more navigation capacity. More referrals require more community capacity. More organizations require stronger relationships and governance. More data require stronger information systems. Scale changes the system, so the conditions that supported a small pilot need to be reassessed rather than assumed to remain adequate.

A pilot should leave behind more knowledge than it started with

The most important product of a social-prescribing pilot is not the number of referrals made. It is what the organization learns.

At the end of a useful pilot, the team should understand more clearly who is being reached and who is not, what navigators actually need to do, which community resources are workable partners, where connections fail, what information needs to move, where professional boundaries sit, what workload is created, what safety problems can arise and what infrastructure would be required for a larger implementation. It should also understand what remains unknown.

Recent evidence increasingly supports this way of thinking about social prescribing. The global 2026 review shows how strongly implementation depends on relationships, community capacity, workforce and context. The Danish implementation study similarly demonstrates that embedding a social-prescribing pathway requires legitimacy, trust, coordination, network building and ongoing learning across multiple actors rather than one transferable implementation technique.

For Viet Nam, this argues against moving directly from international enthusiasm to large-scale implementation. A more responsible sequence is to understand the local problem, co-design a workable pathway, establish safe boundaries, test it with real people, measure implementation honestly, learn from failures as well as successes, adapt, and only then decide whether expansion is justified.

A pilot does not need to prove that social prescribing works everywhere. It needs to answer a more immediate and useful question:

Can this particular form of community-connected care work safely, acceptably and practically here, for these people, with these organizations and these community resources?

If the answer is not yet clear, the next step is not necessarily to abandon the idea. It is to understand what needs to change. That is what makes a pilot a process of responsible implementation and iterative learning, rather than simply a small program waiting to become bigger.

References

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9. Government of Viet Nam. Decree No. 110/2024/ND-CP on Social Work. Effective 15 October 2024.

10. Ministry of Health of Viet Nam. Circular No. 51/2024/TT-BYT on the implementation of social work in medical examination and treatment establishments. Effective 1 March 2025.

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14. Government of Viet Nam. Decree No. 356/2025/ND-CP detailing certain articles and measures for implementation of the Law on Personal Data Protection. Effective 1 January 2026.