Building Research Capacity in Vietnam: A Thematic Assessment of Infrastructure and Barriers Across Major Academic Surgical Centers

Surgery was declared “an indivisible, indispensable part of health care” at the 2015 Lancet Commission, recognizing surgical care as an integral global health priority and invigorating international effort to increase investment in building surgical health systems worldwide [1],[2]. Critical to the sustainability of these systems is the development of a strong research environment, as it guides clinical practice and informs investment strategies influencing policy within hospital systems [3]. Thus, building research capacity in low- and middle-income countries (LMICs) is a global health imperative [2]. However, research productivity in LMICs lags significantly behind high-income countries (HICs), creating disparities that lead to misalignment of priorities and investments that hinder health system development [4].

The reclassification of Vietnam’s status from a low-income country to a lower-middle-income country by the World Bank in 2010 highlights the country’s rapid development, making its health system challenges of particular relevance [5]. The country’s economic growth is accompanied by its rapid health transition, characterized by rising unmet demands for complex surgical services and increasing investments in tertiary and subspecialty care [6,7]. Several academic hospitals in Vietnam function as tertiary referral centers, managing the country’s most complex patients while serving as primary sites for graduate medical education and research [8–11]. Despite the immense clinical volume and status as top academic teaching institutions, high-impact international research output remains notably limited [12–14]. Historically, low academic productivity in LMICs is attributed to complex, systemic obstacles including insufficient financial resources and an overall limited research environment [15–17].

Nevertheless, underlying causes are rarely generalizable across borders and must be understood within Vietnam’s academic and health systems context. Prior work has examined research capacity within Vietnam’s broader medical and public health landscape, citing limited methodological training and reliance on foreign funding, as nearly 70% of the country’s research budget originates from institutions overseas [18,19]. While these findings provide important historical context, no comprehensive multi-institutional assessment has examined Vietnam’s academic research infrastructure specifically within surgery. Therefore, the primary objective of this study was to explore major academic institutions in Vietnam to (1) characterize the baseline surgical academic environment, research capacity, and future priorities; (2) identify key barriers to producing high-quality research; and (3) propose evidence-informed strategies and recommendations for strengthening sustainable surgical research capacity within Vietnam’s tertiary academic hospitals.

Study Design

A qualitative study design using semi-structured interviews was utilized to explore stakeholder perspectives on research infrastructure in Vietnam’s leading academic surgical institutions. This methodology captures nuanced, contextualized data regarding the participants’ perceptions on institutional culture while also ensuring consistency across diverse participant groups. Based on existing literature regarding qualitative research interview design and guided by the validated Consolidated Criteria for Reporting Qualitative Research (COREQ) framework, the interview guide covered research practices, infrastructure, and barriers [20,21] [Appendix A]. The interview was pilot tested by local collaborators for cultural appropriateness with language adjustments for clarity. Interview data were subsequently thematically analyzed.

Study Setting

This study was conducted during a two-week on-site visit in September 2025 to three major academic hospitals: (1) Viet Duc University Hospital, (2) Bach Mai Hospital, and (3) City Children’s Hospital. These institutions were selected given their designations as the nation’s premier surgical center, major academic referral institution, and tertiary pediatric specialty hospital, respectively. Viet Duc University Hospital and Bach Mai Hospital are both teaching hospitals affiliated with the nation’s top medical schools (e.g., Hanoi Medical University, Vietnam National University-Hanoi) in the northern capital city, while City Children’s Hospital is a teaching hospital serving multiple medical universities (e.g., Ho Chi Minh City [HCMC] University of Medicine & Pharmacy, Vietnam National University-HCMC) in the country’s largest city located in the south. Attending surgeons at all three hospitals hold academic appointments and are involved in trainee education. These qualities allow for high clinical volume and complexity, academic teaching, and subspecialty care that are characteristic of the country’s academic research environment.

Participant Selection

Purposive sampling identified key stakeholders with relevant institutional roles involved in academic research [22]. Full inclusion and exclusion criteria are detailed in Figure 1.

Data Collection & Analysis

Semi-structured interviews (45–90 min) were conducted in Vietnamese with a translator [Appendices B, C] who clarified as needed. Interviews were manually transcribed in English verbatim with minimal edits for clarity and/or in situations where no literal English translation existed.  Interview contents were reviewed by the investigator and participant with translator for accuracy. Participants identified main takeaways at the conclusion of each interview.  Transcripts were analyzed using a thematic analysis approach. Thematic coding was done independently and manually by two investigators generating initial codes to capture emerging concepts, which was then compared and grouped into broader themes such as infrastructure, mentorship, and barriers [23]. Discrepancies were resolved through discussion with the primary investigator making final determinations on major and minor themes. Representative quotes were selected. Qualitative methodological rigor was supported via reflexivity on research bias and data interpretation, code-recode strategy to confirm coding reliability, and transparent sampling rationale with data triangulation through deliberate recruitment of diverse participants across training, roles, and departmental and institutional affiliations across different timepoints [24]. Theme frequency (%) reflects the proportion of participants who cited a given theme as a barrier during their interview.

Ethical Considerations

This study was approved as exempt by the Institutional Review Board (IRB) at the University of Colorado [Protocol ID: 25-2485]. Since no patients or clinical data were involved, the IRB Secretary at Viet Duc University Hospital, the study’s primary institutional partner, indicated that separate local ethics review was not required; this was extended to Bach Mai Hospital and City Children’s Hospital given their identical study design. Prior to participation, the investigator explained the study’s objectives and informed participants that (1) participation was voluntary, (2) they could withdraw at any time without penalty, (3) responses would remain confidential, and (4) they could review and correct their transcripts as necessary. Informed consent was provided in English and Vietnamese and obtained before each interview.

Participant Characteristics

Eighteen semi-structured interviews were conducted spanning faculty and administrative roles, surgical specialties, and level of training. Participants included nine attending surgeons, seven surgical residents, one clinical administrator, and one chief nursing officer. Specialties included plastic surgery, orthopedic surgery, general surgery, and neurosurgery.

Table 1 highlights the participant demographics and institutional roles.

Major Themes

Participants across all specialties, roles, and institutions consistently reported systemic constraints hindering academic productivity and research output. Thematic analysis yielded three major themes: (1) insufficient formal research training, (2) systemic or infrastructure constraints, and (3) limited mentorship capacity.

Theme 1: Insufficient Formal Research Training

Insufficient formal research training was consistently reported across all roles and levels of training, cited by 94% of participants. Challenges in research training included high-impact study design, statistical analysis, and manuscript preparation. While interest in conducting more methodologically robust studies is high, the current academic environment provides limited formal training beyond the fundamental competencies to produce research at a higher level. Participants reported that the current research landscape is disproportionately dominated by retrospective studies like case reports and case series through chart review. One faculty surgeon noted that only 10% of incoming residents had prior research experience. Furthermore, formal research instruction within the residency curriculum is limited. A clinical research administrator explained, “Research training is done informally through their personal mentors.” Supplemental didactic material covers general concepts such as types of research, biostatistics, sampling, and implementation science. Residents are only familiar with general concepts; they are aware of their knowledge gaps regarding the study design and methodology necessary for high-level prospective studies, like cohort studies or randomized controlled trials, as well as selection of the appropriate statistical tools required for analysis of different data sets. Additionally, attending faculty and research administrators cite difficulty in helping trainees prepare manuscripts for international English-speaking journals, noting limited access and challenges navigating the peer review process.

Theme 2: Infrastructure Constraints

Beyond individual research knowledge deficits, 89% of participants identified structural constraints within the academic hospital system that limit research productivity. These constraints were multifactorial and impact data management, funding, and access to resources.

Theme 2a: Data Management

A key limitation identified by both surgeons and administrators was the logistical challenge of data management. While Vietnam’s hospitals are actively transitioning to electronic medical records (EMR), progress is variable and remains incomplete across institutions and departments. At present, a dual-record approach is used to maintain both paper and electronic versions during the transition process, which has persisted for years with each hospital maintaining its own confidential database. When asked about the transition progress, one resident stated, “We’re about halfway done, but it may take several more years to complete.” Information relevant for research remains scattered across paper charts across disparate departmental databases in physical storage systems. One senior faculty researcher noted, “The data is there, but finding and analyzing it is a huge undertaking … Time consumed increases exponentially if you want a good number of patients for a high-powered study.” Another researcher commented on the feasibility of large-scale retrospective studies and longitudinal patient tracking, describing his labor-intensive process of manually locating patient contact information with a considerable number lost to follow-up, particularly among those without reliable phone or email access, or traveling from remote farming communities. The absence of a centralized, searchable storage system linking departmental archives was and continues to be a major barrier.

Theme 2b: Funding

Funding is a pervasive limitation. Internal funding avenues for research are scarce, often forcing researchers to bear out-of-pocket expenses to cover basic costs including translation, statistical analysis support, and publication. Despite subsidized publication fees for research conducted in LMICs, costs remain prohibitively high especially among junior faculty. Governmental funding through grants from the Ministry of Health is available, but access is challenging due to its tiered structure. Research funding is allocated at multiple levels – institutional, local city or provincial, Ministry or central government – with higher levels offering greater maximum funding but also requiring more complex methodology, ranging from $250 USD for lower-tier projects up to $100,000 for those sponsored by the Ministry of Health. This route is competitive and highly regulated. Given this constraint, others have turned to private sources of funding backed by industry sponsors. However, private companies are also more likely to invest in larger, multi-institutional clinical trials while opportunities for independent smaller-scale studies led by junior faculty remain limited.

Theme 2c: Institutional Support

Access to scientific literature is also constrained. Researchers cite limited access to standard scientific publication databases such as PubMed and other high-impact international journal subscriptions, hindering their ability to stay up to date on literature relevant to their research in addition to limiting the reach of their own work. Instead, most hospitals use Vietnamese national journals with only a select few universities offering limited international journal access. Researchers often rely on free resources provided by the World Health Organization or, as one stated, “I have requested PubMed accounts from colleagues affiliated with international universities,” relationships built through established mission-based work from Western academic partners.

Compounding these challenges is the issue of human resources. There is a scarcity of specialized departmental roles including biostatisticians, data analysts, lab managers, and public health personnel. There are 3-4 administrative staff at one time managing an entire hospital system. Furthermore, variable English proficiency among the staff along with the nuanced and complex language of academic writing hinders researchers’ ability to conduct a literature search or prepare effective manuscripts.

Theme 3: Limited Mentorship Capacity

Participants at all levels emphasize the value of mentorship, but 83% acknowledge its limitations given systemic constraints. This barrier was directly attributed to clinical responsibilities placed upon faculty. Attending surgeons and departmental leaders cited overwhelming clinical and administrative duties consuming their professional hours, preventing them from providing necessary longitudinal resident supervision for project development, data analysis, and manuscript writing. One attending and research administrator said, “We are very well-trained clinicians, but not as good of researchers. Not many people can play a dual role as physician-scientists here” as there is no built-in administrative time.

The lack of protected research time was present for both mentors and mentees. Despite interest in a formal structured mentorship program with dedicated research time, residents feel pressured to prioritize their clinical coursework. Residents often sought assistance informally and opportunistically as their mentors’ schedules allow. Thus, progress depended on the availability and interests of specific individual attendings, leading to inconsistent opportunities across departments. Mentorship was described as reactive and focused more on immediate clinical issues rather than proactive with structured guidance. Thus, research activity was relegated to time off after demanding clinical shifts. This burden on competing priorities is underscored by one resident’s admission that, “We are still working with data from 2006 that needs to be published.” Although limited by clinical duties, faculty assistance substantially aids research by financially onboarding key personnel such as statisticians and data managers, as well as medical student volunteers, to advance the project when residents are unavailable.

This is further complicated by Vietnam’s promotion structure which prioritizes research productivity for career advancement. Attendings at all levels noted that full professorship, the pinnacle of academic achievement, is only attained after authorship of a medical textbook. Authorship serves as the benchmark by which their worth is measured, both by colleagues and patients, tying their professional standing directly to research productivity.

This study provides a baseline assessment of the research infrastructure at Vietnam’s leading tertiary hospitals, elucidating barriers impeding academic output. These barriers fall under three domains: insufficient formal research training, infrastructure constraints, and limited mentorship capacity. These interconnected themes highlight the complex dynamics of a rapidly developing nation’s health system. Achieving and sustaining the same trajectory desired for research productivity requires targeted interventions at the systemic level.

The consensus among participants regarding systemic barriers to research productivity is not surprising, as it is consistent with academic centers in other growing nations in Asia and Africa [25]. A surgical research capacity assessment in Nigeria similarly identified time constraints, funding limitations, and difficulty securing research collaborators as persistent barriers [26], while a multi-country qualitative study on research capacity across Ethiopia, Cameroon, and Sri Lanka found training, technical skills, and institutional strengthening were necessary but frequently absent conditions for locally-led research [27]. These parallels suggest that while our findings are specific to Vietnam’s surgical academic context, they reflect broader, systemic patterns observed across LMIC settings.

An important consideration is that LMICs have a disproportionately high population density compared to HICs, especially in urban centers where these centers are concentrated [28]. In such settings, the immediate need to have clinicians meet the demand of high-intensity patient volumes is paramount and necessarily supersedes priority for alternative scholarly work. Thus, the disproportionate output of case reports and retrospective studies as compared to prospective studies produced by Vietnamese academic centers appears to not only stem from a lack of pedagogical knowledge, but also from practical necessity. This necessity may contribute to a systemic barrier, limiting capacity for mentorship that may be tied to the absence of protected administrative and research time. Demands placed on clinical faculty can make longitudinal research mentorship challenging. Given the status of these hospitals as tertiary referral centers for most of Vietnam’s population, this is unsurprising.

This tension is compounded by a promotion structure that ties career advancement and even patients’ perceived confidence in a surgeon directly to research productivity. Patients tend to consider academic surgeons as the most capable and will wait longer for an appointment with them. Academic preference by both colleagues and patients underscores how deeply research reputation permeates into surgeons’ livelihoods, despite institutions’ limited investment in the time or infrastructure needed to meet that expectation. The result reveals a structural bottleneck: strong professional incentive to produce research but insufficient institutional support to do so, which may leave many surgeons unable to progress beyond junior academic rank.

Regardless of clinical volume, however, it is also true that the lack of proficiency in advanced study design, methodology, biostatistics, and even ethical considerations required for high-powered prospective research may limit production of clinical trials and other studies of similar caliber. This may reflect a reinforcing cycle: without producing high-impact studies, researchers may struggle to publish in high-impact international journals or secure competitive funding from institutional, governmental, or private stakeholders [29]. Insufficient funds may in turn prevent researchers from fully covering the incurred costs of a highly complex study such as recruitment; dedicated research personnel; quality assurance; and any necessary procedures, diagnostics, or monitoring. Consequently, retrospective studies may be a more accessible route to academic success, leveraging the hospital’s high case volumes to produce more feasible case reports and case series. These studies often lack the methodological rigor necessary for publication in high-impact journals or drive significant changes in policy, demonstrating how limited funding is associated with decreased research productivity in LMICs [30]. Notably, high case volumes can be an advantage when paired with sufficient institutional investment. One Indian hospital leveraged its case volume and complexity to become internationally recognized in trauma and reconstructive microsurgery with a substantial international publication record [31]. This success was attributed to institutional investment in strict quality metrics and transparency in data management. Vietnam holds similar potential if matched with investments in research infrastructure and training.

The interdependence between publication and funding demonstrates how academic and financial limitations can dictate research strategies. Infrastructure constraints may deepen these issues and highlight the current disconnect between clinical and research goals. In 2019, the Ministry of Health mandated the digitalization of patient medical records, modeling the global community in prioritizing health system strengthening [32,33], yet its fragmented implementation impacted research efficiency. The current dual-record system in variable stages of completion across different institutions may contribute to an inefficient academic environment. This is critical given that complete EMR integration has been shown to bolster health systems by improving clinical efficiency and safety while building foundational data infrastructure necessary for facilitating research productivity [34,35]. As it stands, hospital systems are investing resources by way of time, money, and personnel without the payoff of a data management system that can fuel research. Until the transfer of information is complete, the proven benefits of EMR implementation on a health system will remain unrealized and the EMR fails to act as the internal, centralized research infrastructure system it is designed to be. Additionally, restricted access to high-impact international journals and academic databases creates a second, external infrastructure barrier that may compound the internal infrastructure challenge of an incomplete EMR. This may isolate researchers, limiting dissemination of their work and discourse with the international community.

This access gap may extend beyond research to the bedside. Clinicians in LMICs may be unfamiliar with accessing and applying current primary literature in practice, instead relying on potentially outdated precedent. In Vietnam, high antimicrobial resistance is linked to inadequate antimicrobial stewardship and fewer than two-thirds of physicians are confident in the appropriateness of their own prescriptions [36,37]. This represents a growing gap between evolving evidence and clinical practice that may have implications beyond antimicrobial stewardship to surgical management.

Implications & Future Priorities

The results of this study inform three areas for targeted intervention that are likely to yield the greatest gains in Vietnam’s research productivity:

1. Formal Standardized Research Education

While participants expressed strong interest in conducting methodologically robust studies, the current structure provides minimal formal training beyond the core competencies required for independent research. Although research education exists, the depth of instruction in advanced topics remains insufficient. Academic hospitals must invest in training of both residents and faculty across three specific areas: First, methodology training could help trainees design studies capable of answering their own clinical research questions, moving beyond case reports and basic retrospective comparisons toward higher-level prospective studies and clinical trials. Second, data analysis training could address uncertainty in selecting statistical models appropriate to their study design. Third, training in the formal process of preparing manuscripts for international journals could provide familiarity with structural formatting requirements, figure generation, and navigation of the peer review process. The most feasible approach is supplementing existing didactic content and expand upon general concepts already in place. Dissemination of educational materials through both synchronous and asynchronous models can accommodate unpredictable clinical schedules. This targeted intervention may augment the skills needed to support strong prospective studies, increase the probability of securing institutional and government funding, and ultimately publication in high-impact international journals.

2. Investment in Research Infrastructure

Resources should be allocated to accelerate EMR implementation throughout the hospital system. Until this is complete, investigators may not effectively take advantage of the rich data pools available for research. Furthermore, academic institutions should prioritize funding for subscriptions to essential scientific databases. Several international programs (e.g., Hinari, Global Index Medicus) offer free or discounted rates for LMIC institutions and may represent a practical, low-cost option for expanding access [38,39]. Granting researchers access not only allows them to access high-quality studies conducted at academically prolific institutions across the world but also provides a methodological blueprint of complex studies for researchers to adapt into their own local context. However, access alone means little without training in how to interpret and apply this evidence into clinical practice. Efforts to expand database access should be paired with structured training in evidence-based medicine. Additionally, the ability to participate in global scientific discourse may provide local researchers with international exposure, encouraging collaboration and the generation of new ideas.

3. Programmatic Restructuring with Protected Research Time & Dedicated Support

The tension between clinical and academic responsibilities is ubiquitous globally but is acutely pronounced in Vietnam due to the absence of protected scholarly time. Research may become passive or neglected entirely when faculty and residents are constrained by heavy clinical duty. Implementation of a protected administrative time dedicated to research and mentoring is therefore recommended [40,41].

Strategic investment in human resources should be considered as the research ecosystem continues to grow. Management of a complex research lab that will produce an increasing number of high-quality studies and clinical trials will require support. Increased hiring of dedicated research staff such as biostatisticians, research coordinators, and lab managers can offload administrative burdens that currently fall upon faculty.

Ultimately, academic institutions may consider fundamentally restructuring the residency program to include dedicated research years, aligning with standards established in United States residency programs by the Accreditation Council for Graduate Medical Education (ACGME) [42]. While granting residents dedicated full-time work as researchers, it is also an investment supporting career development of residents and faculty as well as bolstering institutional visibility and academic prestige, potentially attracting high-quality medical school graduates and experienced faculty seeking to build their academic careers.

While several of these recommendations reflect challenges common across LMIC settings, they are grounded in context-specific findings from this study’s participants. For example, Vietnam’s ongoing transition to electronic medical records has created a dual-record system with institutions managing both paper and electronic charts simultaneously, an infrastructure challenge with direct implications for data management in Vietnamese hospitals. These recommendations reflect priorities specific to Vietnam’s current academic health system context, even where similar systemic imbalances are shared across other LMIC settings.

Limitations

This study has several limitations. This study relied on purposive sampling, but constrained by the investigators’ limited on-site duration. All participants were affiliated with tertiary referral institutions with a relatively small sample size, limiting the generalizability of these findings. This observational study gives potential for response bias, more specifically social desirability and central tendency biases. Interviews were conducted with translator assistance which may introduce interpretive variability. There is an inherent power differential between HIC investigators and LMIC participants, which may affect validity with accuracy of claims or frank candor despite assured confidentiality. Thematic saturation was not assessed given strong convergence between independently coded themes supporting consistency of our findings. Lastly, participant representation was also weighted toward Viet Duc University Hospital with limited representation from Bach Mai and City Children’s Hospitals; findings should not be interpreted as equally representative of all three institutions.

To mitigate these limitations, the study was initiated at the request of local stakeholders who identified capacity-building as a shared priority. Local collaborators were involved throughout study design including final review and approval of the interview guide. Investigators acknowledged their position as HIC-based researchers to participants, framing the work as a collaborative effort rather than an external evaluation. Following interviews, investigators debriefed to reflect on potential assumptions or biases and to confirm the accuracy of their interpretation of participant responses. Findings were similarly shared with local partners to validate interpretation.

The challenge for future research is in longitudinal research metrics and assessing measurable impacts of targeted interventions on research, education, and infrastructure.

High-quality research is increasingly recognized by Vietnam’s leading academic institutions as essential for propelling its hospitals onto the global stage. However, deeply interconnected systemic barriers remain. Key challenges include inadequate research training, limited mentorship, and underdeveloped research infrastructure. Addressing these gaps through informed intervention is critical. This includes formalizing research education, establishing protected research time with dedicated support staff, and investment in research infrastructure. Strengthening research productivity through these targeted strategies represents a critical component of sustainable capacity building in Vietnam’s academic hospitals and will serve to advance its position as a major contributor to international scientific discourse.

PDN is the Chief Medical Officer and AMD is the Director of Operations of Nuoy Reconstructive International, a non-governmental organization that has long-established relations with several of Vietnam’s top academic surgical institutions including those mentioned in this study. Nuoy has invested heavily in strengthening local education in craniofacial surgical care and building academic capacity. Specific to this manuscript, Nuoy has supported travel of investigators to the country through established relationships with Vietnam’s Ministry of Health.