Decision No. 153/2006/QĐ-TTg Approving the Master Plan for the Overall Development of the Health System in Vietnam until 2010 and Vision until 2020

Pursuant to …;

Approving the Master Plan for the Development of the Health System in Vietnam for the period up to 2010 and Vision to 2020 Period up to 2010 and Vision to 2020

____________________

PRIME MINISTER

Pursuant to the Law on Organization of the Government dated December 25, 2001;

Pursuant to the Law on Health Protection for the People promulgated on June 30, 1989;

Pursuant to Decree No. 49/2003/NĐ-CP dated May 15, 2003 of the Government stipulating the functions, tasks, powers, and organizational structure of the Ministry of Health;

Considering the proposal of the Minister of Health.

Pursuant to …;

Article 1. Approves the Master Plan for the Development of the Health System in Vietnam for the period up to 2010 and Vision to 2020 with the main contents as follows:

1. The health system under this master plan includes a network providing preventive healthcare services, primary healthcare, outpatient and inpatient care, and rehabilitation services, a network producing, circulating, distributing, and supplying medicines.

2. General Objective: To build a modern and complete health system in Vietnam that gradually approaches equity, efficiency, and development; to meet the increasing and diverse needs of the people for health protection, care, and improvement; to reduce morbidity, disability, and mortality rates, increase life expectancy, and improve quality of life; to achieve and exceed the targets set out in the National Health Care and Health Protection Strategy for the period 2001-2010.

3. Specific Objectives:

a) Investment in developing a preventive healthcare network capable of forecasting, monitoring, detecting, and controlling diseases, thereby reducing morbidity and mortality rates caused by diseases and disabilities, including the following main contents:

- Proactively and positively prevent epidemics, not allowing large-scale outbreaks to occur.

- Forecasting, controlling, and containing dangerous infectious diseases and agents causing epidemics, especially newly emerging diseases.

- Preventing and controlling non-communicable diseases and accidents causing injuries.

- Controlling the number of people infected with HIV/AIDS below 0.3% of the population by 2010 and ensuring it does not increase in subsequent years.

b) Investment and restructuring the network of outpatient and inpatient care and rehabilitation services towards:

- Developing a network of outpatient and inpatient care according to community clusters without regard to administrative boundaries; local medical units are managed by sectors to ensure that all citizens can conveniently access healthcare services at various levels.

- Ensuring the systemic nature and continuity in the specialized activities of each treatment level and balanced, reasonable development between general hospitals and specialized hospitals.

- Gradually relocating infectious disease treatment facilities to suitable areas.

- New hospitals must be consistent with overall planning and economic and social development plans of the locality. Ensuring adequate conditions for handling medical waste and infection control capabilities at hospitals so that medical examination and treatment activities do not affect the public and living environment.

- Striving to reach 20.5 hospital beds per ten thousand people (excluding village health station beds) by 2010 (including 2 beds from private hospitals) and 25 beds per ten thousand people by 2020 (including 5 beds from private hospitals).

- Consolidating and modernizing existing traditional medicine hospitals at the central level to meet Class I hospital standards; building traditional medicine hospitals in provinces where they do not exist, serving both as treatment centers and practical training bases for traditional medicine healthcare staff.

c) Consolidating and improving the primary healthcare network, enhancing the accessibility of the public to essential healthcare services. By 2010, ensuring that almost all communes have permanent health stations and 80% of communes meet national standards for commune-level healthcare.

d) Developing the pharmaceutical industry into a leading economic and technical sector. Vigorously developing the pharmaceutical industry, enhancing domestic drug production capacity, prioritizing high-tech formulations. Planning and developing medicinal plant regions and chemical raw material production facilities. Consolidating and developing the distribution and supply network to ensure regular, sufficient, and quality drug supplies at reasonable prices and stabilize the market for drugs for prevention and treatment. Promoting research and production of vaccines and medical products. Ensuring food safety, preventing and mitigating food poisoning and foodborne illnesses.

4. Contents of the Development of the Health System in Vietnam:

Developing the health system in Vietnam towards strengthening socialization of health work, with state health playing a dominant role; gradually meeting the needs of health protection, care, and improvement for the people with increasingly higher quality, appropriate to economic and social conditions; aiming for equity and efficiency in the provision and use of health services.

a) Consolidating and developing the preventive healthcare network:

- Central and regional level:

+ Continuing to develop and enhance the capacity of central and regional preventive healthcare facilities with the function of leading or regional units to effectively perform research, forecasting, monitoring, detecting, and controlling diseases, particularly dangerous and new diseases;

+ Upgrading biosafety laboratories at the National Institute of Hygiene and Epidemiology, Ho Chi Minh City Pasteur Institute, Nha Trang Pasteur Institute, and Western Highlands Hygiene and Epidemiology Institute to international standard level 3. By 2020, at least one laboratory should reach international standard level 4.

+ Upgrading two insecticide and bactericide testing rooms in the North and South regions with synchronized and modern equipment to meet Vietnamese standards by 2010 and international standards after 2010.

- Provincial level:

+ Ensuring that 100% of provincial preventive healthcare centers have laboratories meeting biosafety level 1 standards. In representative provinces and major cities, constructing provincial preventive healthcare center laboratories meeting biosafety level 2 standards capable of monitoring and detecting epidemics and performing all tests required for specialized activities.

+ Investing in developing and enhancing the capacity of international health quarantine centers to meet international health quarantine requirements.

+ Developing and improving occupational health centers of ministries, sectors, and provinces with large industrial zones; unifying their name as Occupational Health and Environmental Protection Centers.

+ Complete reproductive health protection centers, provincial health communication and education centers under centrally governed cities.

+ Maintain and upgrade existing malaria prevention and control centers in provinces with high malaria incidence rates. After 2010, if a province has a new malaria case rate lower than 100 patients per 100,000 people for at least five consecutive years, the malaria prevention and control center will be merged into the provincial preventive healthcare center.

+ Gradually merge existing social disease prevention and control centers into provincial preventive healthcare centers or general hospitals in provinces.

+ Establish and complete HIV/AIDS prevention and control centers in all centrally governed cities and provinces.

- District level:

Build and develop district preventive healthcare centers capable of performing tasks such as epidemiological surveillance, hygiene and disease prevention, HIV/AIDS monitoring and prevention, health education and communication, reproductive health care, and healthy village construction.

b) Develop the network of medical examination, treatment, and rehabilitation services:

- Form a network of medical examination and treatment facilities according to technical levels from low to high, ensuring continuity in professional levels. Each facility provides medical examination and treatment services for a community cluster (independent of administrative boundaries), ensuring compliance with hospital classification standards set by the Ministry of Health for each level:

+ Level 1: Includes hospitals meeting Class III standards, including district hospitals, regional multi-disciplinary hospitals serving multiple districts, some specialized hospitals, and private hospitals, providing basic medical examination and treatment services; receiving patients from the community or primary healthcare stations.

. Each district or inter-district community cluster has one district hospital or regional multi-disciplinary hospital. The bed capacity of Level 1 ranges from 50 to 200 beds, adjusted according to geographic conditions and population density, with a ratio of one bed serving between 1,500 to 1,700 people.

. Maintain and develop regional multi-disciplinary clinics under district hospitals in mountainous, remote, and far-flung areas, ensuring basic healthcare services for local residents.

. By 2010, multi-disciplinary hospitals in towns and those belonging to provincial cities will be converted into multi-disciplinary clinics or specialized hospitals.

+ Level 2: Includes provincial and centrally governed city multi-disciplinary and specialized hospitals, private hospitals, and some specialized hospitals in centrally governed cities meeting Class II standards or higher; providing specialized medical examination and treatment services, meeting most healthcare needs of the population in the area; serving as practical training sites for medical and pharmaceutical students in the province or city.

. Each province must have at least one multi-disciplinary hospital with a capacity of 300 to 800 beds, determined based on a ratio of one bed serving between 1,600 to 1,800 people.

. Develop specialized hospitals in provinces and centrally governed cities according to the need for specialized medical examination and treatment. Provinces and centrally governed cities with over one million inhabitants may establish specialized hospitals such as obstetrics-gynecology, pediatrics, rehabilitation.

. Develop traditional medicine hospitals in provinces, ensuring each province has one traditional medicine hospital with a capacity of 50 to 150 beds.

. Construct tuberculosis and lung disease hospitals in provinces with a tuberculosis incidence rate of 120 cases per 100,000 people or more, where more than 50% of patients have positive AFB tests.

+ Level 3: Includes hospitals meeting Class I or special class standards, implementing advanced specialized techniques, scientific research, and serving as practical training sites for university medical and pharmaceutical students.

. Maintain and develop existing central multi-disciplinary hospitals with capacities ranging from 500 to 1,500 beds. By 2010, central multi-disciplinary hospitals not meeting Class I standards will be transferred to provincial or city management.

. Continue to strengthen and upgrade existing specialized hospitals, developing additional specialized hospitals to meet the growing demand for specialized medical examination and treatment.

- Focus investment and completion of specialized healthcare centers in Hanoi, Ho Chi Minh City, Hue-Danang. Actively prepare necessary conditions for investment and construction of a specialized healthcare center in Can Tho after 2010.

- Prioritize investment in building complete multi-disciplinary hospitals in Son La, Thai Nguyen, Hai Phong, Nam Dinh, Nghe An, Binh Dinh, Khanh Hoa, Dak Lak, Kien Giang, and Tien Giang with capacities ranging from 500 to 1,000 beds, capable of meeting the medical examination and treatment needs of the population in the region with high professional quality and modern technology.

- Strengthen and develop rehabilitation hospitals in provinces and cities and within ministries and sectors based on self-sufficiency, balancing budgets for effective hospital operations (excluding rehabilitation facilities for war veterans and disabled veterans) to meet the increasing demand for rehabilitation among the population and workers.

- Continue to invest in developing and expanding the emergency patient transport network across all residential areas.

c) Consolidate and improve the primary healthcare network:

- Continue to consolidate and improve the primary healthcare network in terms of infrastructure, equipment, and healthcare personnel, enhancing the quality of primary healthcare services, meeting the basic healthcare needs of the entire population, and performing simple techniques in the diagnosis and treatment of certain specialized diseases related to eyes, teeth, ears-nose-throat, reproductive health, and child health.

- Strengthen the organization, network, and professional activities of commune health centers. By 2010, most communes and wards will have sturdy health stations suitable for economic, geographic, ecological conditions, and the medical examination and treatment needs of the local population.

- Ensure that 80% of commune health stations have doctors, with 100% of health stations in plains areas and 60% of those in mountainous regions having doctors; 100% of commune health stations have midwives or medical assistants specializing in obstetrics and pediatrics, of which 80% are high school-trained midwives; 80% of commune health stations have staff for traditional medicine work; on average, each commune health station staff member serves from 1,000 to 1,200 people. Ensure that there are at least five health workers as defined by the Ministry of Health for each commune health station. In large cities, the number of health station staff is balanced according to a ratio of one staff member for every 1,400 to 1,500 residents. Strive to achieve national standards for commune health by the end of 2010 in 80% of communes nationwide.

- Ensure that each village or hamlet has one to two health workers with a level of training from basic medical education or higher working.

- Enterprises with between 200 and less than 500 workers must have one to three health workers serving them. Enterprises with 500 workers or more must establish their own health stations.

- Ensure that each general secondary school has one to two health workers serving it. Universities, colleges, and vocational schools have their own health stations.

d) Strengthen and enhance the capacity of state management in pharmaceuticals, develop production, circulation, distribution, and supply systems for medicines. Ensure food safety and cosmetic safety.

- Improve and enhance the capacity of state management in pharmaceuticals, food safety, and cosmetics from central to local levels.

+ Improve the Department of Pharmaceutical Management, Food Safety, and Cosmetics; build and complete the functions and responsibilities of the Testing Center for Pharmaceuticals, Food Safety, and Cosmetics at provincial health departments.

+ By 2008, establish 2 to 3 Regional Testing Centers for Pharmaceuticals, Food Safety, and Cosmetics with sufficient capacity to perform assigned tasks; 2 to 3 Regional Centers for Bioequivalence Testing and Drug Bioavailability Assessment; establish several Regional Centers for drug information and adverse reaction monitoring in major cities across the country.

+ Establish the National Institute of Food Safety Testing based on developing the Food Safety Testing Center currently located at the Institute of Nutrition. Build 3 Food Safety Testing Centers in the northern mountainous region, central region, Mekong Delta, and Ho Chi Minh City to meet Good Laboratory Practice (GLP) standards by 2010.

+ Consolidate state management agencies at all levels for pharmaceuticals, food safety, and cosmetics.

- Plan and develop the pharmaceutical industry into a leading economic and technical sector towards industrialization and modernization.

+ Plan and develop comprehensively in terms of drug manufacturing industry, drug production from medicinal herbs, key cultivation and planting areas of medicinal herbs, chemical raw material and antibiotic raw material production industries for drugs.

+ Plan, reorganize, and develop the drug distribution and supply system, ensuring a stable drug market with reasonable prices, and guaranteeing quality to serve disease prevention and treatment for the population.

5. Main solutions:

a) On finance:

- Create a breakthrough in increasing the speed of investment from the state budget for the healthcare sector to upgrade healthcare facilities; prioritizing the consolidation and improvement of the primary healthcare network, preventive healthcare, provincial and district general hospitals, especially in the Central Highlands, northern mountainous region, central region, and Mekong Delta. Ensure funding to implement state policies on healthcare for persons who have rendered meritorious service to the revolution, the poor, children under six years old, and other social policy beneficiaries.

- Amend regular expenditure quotas from the state budget for the healthcare sector in favor of mountainous provinces, remote, deep, and difficult areas.

- Gradually shift from the state providing funds for the regular operations of healthcare facilities to directly providing funds to beneficiaries using healthcare services through health insurance; with the principle of facilitating healthcare service users and ease of implementation. Develop hospital fee policies based on accurately and fully covering direct costs for patients.

- Study and supplement, amend healthcare preventive service fee and charge policies for services allowed by the state, based on the principle of partially offsetting basic costs to create additional sources of investment for preventive healthcare.

- Increase investment in enterprises producing drug raw materials, essential drugs, and drugs supplied to national target programs on healthcare using preferential credit capital. Develop policies to encourage investment in research and production of specialized and therapeutic drugs.

Investment projects in the healthcare sector and drug production enjoy forms of state support for development investment credit as prescribed. There are preferential policies on capital, land, tax, and technology for research and production facilities of drugs and equipment serving the pharmaceutical industry, particularly for those researching and producing types of drugs and equipment not yet produced domestically.

- Strengthen international cooperation to attract investment capital for the healthcare sector.

- Implement socialization in the healthcare sector according to Resolution No. 05/2005/NQ-CP dated April 18, 2005 of the Government on accelerating socialization in educational, healthcare, cultural, and sports activities. Encourage the development of non-public healthcare service providers according to Decree No. 53/2006/NĐ-CP dated May 25, 2006 of the Government. Strengthen propaganda and mobilization to solicit contributions from organizations and individuals both within and outside the country for healthcare work.

- Promote the delegation of autonomy and responsibility for task implementation, organizational structure, staffing, and finance to public healthcare facilities according to Decree No. 43/2006/NĐ-CP dated April 25, 2006 to promote dynamism, creativity, enhance responsibility, and improve the effectiveness of operations.

- Strengthen management and utilization of financial resources invested in healthcare for intended purposes and to achieve high efficiency.

b) On human resources:

Develop a balanced and reasonable health workforce. Ensure basic targets are met: over 7 doctors/10,000 population by 2010 and over 8 doctors/10,000 population by 2020; 1 university-level pharmacist/10,000 population by 2010 and 2-2.5 university-level pharmacists/10,000 population by 2020, with at least 1-3 university-level pharmacists in district level; ensure the ratio of healthcare staff at medical examination and treatment facilities is 3.5 nurses/1 doctor. Develop a high-quality health workforce, postgraduate healthcare staff to supply healthcare facilities. Supplement pharmacy technicians for commune health stations to ensure human resources for drug supply at the commune level.

Issue the planning of the network of healthcare personnel training institutions, establish reasonable standards, norms, and workforce structures to improve the quality and efficiency of healthcare activities. Reorganize, expand, and upgrade training facilities to meet the quantity and quality requirements of healthcare personnel according to the healthcare sector development plan. Invest in infrastructure, equipment, develop faculty and teacher teams; establish quality assessment criteria, standardize faculty and teacher teams at medical and pharmaceutical schools to meet the quantity and quality requirements of medical, pharmaceutical, nursing, and midwifery personnel.

Build two healthcare personnel training centers in Hanoi and Ho Chi Minh City on par with advanced countries in the region. Establish operational mechanisms for these centers to be able to collaborate with some foreign universities in specialized fields and healthcare management.

Develop plans to selectively upgrade some provincial and urban secondary medical and pharmaceutical schools to higher vocational medical and pharmaceutical schools.

Strengthen the training of pharmaceutical personnel through various forms to meet the quantity and quality requirements of pharmaceutical personnel for state management agencies, public health facilities, and pharmaceutical enterprises.

Organize short-term training courses on management for healthcare personnel, particularly hospital management.

Develop a plan to train healthcare personnel with high professional and technical skills for provincial and central-level healthcare service providers.

Develop a plan for sponsored training and targeted training for children of ethnic minorities in the northern mountainous region, central region, and Mekong Delta. Provincial People's Committees in the northern mountainous region, central region, and Mekong Delta have the responsibility to create a pool of applicants from ethnic minority children to ensure they have the necessary conditions and are trained appropriately according to needs and levels.

Continue to implement the plan for sponsored training of doctors in the Central Highlands region.

Develop and propose policies for selecting, training, utilizing, and rewarding highly qualified personnel in the healthcare sector. Promote sending healthcare personnel abroad for advanced training using state funds, foreign aid; encourage healthcare personnel to self-fund advanced training.

Enact preferential policies for healthcare personnel, especially grassroots-level healthcare personnel, those working in mountainous areas, remote areas, difficult areas, border areas, and islands. Develop and implement rotation plans; service obligation systems for newly graduated doctors in mountainous areas, remote areas, and difficult areas. Ensure appropriate allowances and rewards for personnel sent to reinforce lower levels.

Implement social insurance and health insurance systems for personnel working at commune health stations. Establish mechanisms to apply insurance systems for cases of occupational accidents involving healthcare personnel while on duty.

c) Develop science and technology:

Build national and international standard laboratories in Hanoi and Ho Chi Minh City for biological safety, drug testing, food safety, vaccine and medical product certification, and medical equipment calibration.

Develop genetic and molecular biology technologies, tissue culture and cloning technologies to serve drug production, vaccine, and medical product production.

Develop and apply information technology in management and operations in the medical-pharmaceutical field.

Focus on environmental sanitation work. Research, apply, and absorb modern technology to treat medical waste, invest in anti-infection efforts in healthcare facilities, preventive healthcare facilities, pharmaceutical production facilities, and bioproduct manufacturing facilities to prevent the spread of disease-causing agents to surrounding environments.

d) Supply medical equipment to healthcare facilities:

- Expand the production of common medical equipment, promote the production of high-tech medical equipment.

- Encourage joint ventures, partnerships, and technology transfer with reputable global medical equipment manufacturers.

- Develop a focused medical equipment manufacturing industry to meet domestic usage needs, improve product quality towards export.

By 2010, medical equipment production facilities must meet minimum standards of ISO or equivalent; complete privatization. Ensure domestic production meets 60% of the demand for common medical equipment and 80% by 2020.

đ) Enhance international cooperation:

Strengthen multilateral and bilateral cooperation with international organizations, non-governmental organizations, international banking organizations, and governments that have supported or are supporting Vietnam.

Improve mechanisms for receiving, utilizing, supervising, and strictly monitoring foreign aid to maximize effectiveness. Develop key investment projects to attract investment, develop regional healthcare, provincial and district healthcare, and each field during different development stages.

Mobilize non-reimbursable aid to support healthcare services for the poor, children, disabled persons, and prevention and control of dangerous diseases such as tuberculosis, malaria, HIV/AIDS, and emerging diseases.

Expand bilateral and multilateral cooperation in the development and application of advanced medical and pharmaceutical technologies. Enhance training for healthcare personnel in developed countries to quickly absorb and effectively apply the latest scientific achievements in medicine worldwide.

Encourage the acceptance of non-repayable aid for the construction of health policy development and scientific research.

Expand joint ventures and collaborations with foreign organizations and individuals participating in investment in various fields of domestic healthcare, aiming towards exporting certain medicines and healthcare services.

e) Management solutions:

Vigorously reform administrative procedures, perfect the legal system on healthcare in line with the country's socio-economic development situation.

Improve the state management agency system in healthcare from central to local levels and enhance the capacity for health inspection and audit activities.

Enhance knowledge of state management and awareness of compliance with laws among healthcare officials. Effectively implement democratic regulations at all healthcare facilities, build and promote competitive movements, particularly the establishment of exemplary units and individuals in the industry.

6. Implementation roadmap:

a) Period 2006 - 2007:

- Focus on consolidating, arranging, and implementing the establishment of new units: HIV/AIDS Prevention Centers in provinces and cities; District Health Prevention Centers.

- Invest in upgrading district hospitals and regional general hospitals according to Decision No. 225/2005/QD-TTg dated September 15, 2005 of the Prime Minister.

- Develop and implement investment projects for regional general hospitals and provincial general hospitals. Prioritize funding for projects approved by competent authorities for investment decisions.

- Develop plans to relocate infectious disease treatment hospitals to suitable areas.

- Develop plans to enhance infection control capabilities in hospitals.

- Concentrate investments in three specialized healthcare centers.

- Invest in upgrading and building new research, production, testing, and certification facilities for vaccines and medical products.

- Develop plans to establish and upgrade laboratories for biosafety and food safety at central and provincial levels.

- Establish 2-3 regional drug testing centers, food safety, and cosmetic centers.

- Establish 2-3 regional bioequivalence testing centers and drug bioavailability assessment centers.

- Establish several regional drug information centers and adverse reaction monitoring centers in major cities.

- Develop detailed plans for the development of the pharmaceutical industry to be submitted to the Prime Minister for consideration and decision.

- Improve the organizational structure, functions, and responsibilities of the drug administration, food safety, and cosmetic management system from central to local levels.

b) Period 2008 - 2010:

- Complete the construction of district hospitals and regional general hospitals. Accelerate the progress of constructing regional general hospitals, provincial hospitals, and three specialized healthcare centers.

- Continue to upgrade provincial-level health prevention centers.

- Invest in upgrading medical and pharmaceutical schools. Build two healthcare personnel training centers in Hanoi and Ho Chi Minh City.

- Continue to invest in unfinished projects during the 2006-2007 period and other projects specified in the planning until 2010.

- Perfect and develop the drug distribution and supply system.

c) Period 2011 - 2020:

- Invest in developing the specialized healthcare center in Can Tho.

- Continue to complete specialized healthcare centers; high-tech healthcare centers in regions and central and local healthcare facilities to meet the needs of protecting, caring for, and improving people's health.

Article 2. Implementation

The Ministry of Health is the main authority, coordinating with relevant ministries, sectors, and People's Committees of provinces and centrally-administered cities to develop programs, plans for implementation, and organize inspections of the planning implementation; regularly compile results and report to the Prime Minister.

The Ministry of Health is tasked with:

- Leading and coordinating with relevant ministries, sectors, and agencies to develop and submit to the Prime Minister for approval the Planning for Developing the Healthcare Service Network.

- Coordinating with the Ministry of Education and Training to develop and submit to the Prime Minister for approval the Planning for Developing Human Resources in Healthcare.

- Coordinating with the Ministry of Home Affairs and relevant ministries, sectors to develop proposals to consolidate organizations to enhance state management capacity in drug administration, food safety, and cosmetics, to be submitted to the Prime Minister for consideration and decision.

The Ministry of Planning and Investment is responsible for allocating and balancing resources for healthcare investment to implement the planning according to schedule. Monitor the implementation of the planning nationwide.

The Ministry of Finance is responsible for ensuring the state budget allocation for healthcare according to the five-year plan and annually. Coordinate with the Ministry of Health to balance the budget for the entire sector and for priority areas in the planning.

Ministries and sectors are responsible for coordinating with the Ministry of Health to allocate resources within their sectors for the development, consolidation, and improvement of quality of affiliated healthcare facilities.

The Chairman of the People's Committee of provinces and centrally-administered cities is responsible for directing and organizing the implementation of the overall planning for the development of the healthcare system within their respective provinces and cities.

Article 3. This Decision shall take effect fifteen days after its publication in the Official Gazette. This Decision does not apply to the healthcare system of the Ministry of Defense and the Ministry of Public Security.

Article 4. THE MINISTERS, HEADS OF GOVERNMENT-LEVEL MINISTRIES, HEADS OF GOVERNMENT-LEVEL AGENCIES, AND CHAIRMEN OF PROVINCE AND CITY PEOPLE'S COMMITTEES DIRECTLY UNDER THE CENTRAL GOVERNMENT SHALL BE RESPONSIBLE FOR ENFORCING THIS DECISION./.