FINANCIAL ANALYSIS I. FINANCIAL SUSTAINABILITY. 1. Counterpart Funds

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1 Health Human Resources Sector Development Program (RRP VIE ) I. FINANCIAL SUSTAINABILITY 1. Counterpart Funds FINANCIAL ANALYSIS 1. The proposed program loan is for $30 million and the project loan is for $30 million. In addition, the Australian Agency for International Development (AusAID) will provide grant funds in the amount of approximately $11 million and the Government is expected to provide counterpart funds in the amount of $5.3 million (10% of total costs) over the 5-year life of the project. Counterpart funds for the activities under the project loan are on average $1.0 million per year (equivalent to about 0.11% of annual state budget spending on health in 2006). All incremental operation and maintenance costs are to be borne by the Government. Duties and taxes account for 69% of all counterpart funding for the project. 2. Financial Risk Assessment 2. The program is subject to both external and program-specific risks. However, these risks are deemed to be low and mitigation measures can be taken to reduce them. 1 II. HEALTH SECTOR RESOURCE ALLOCATION 3. Health spending in Viet Nam is equal to approximately 5% to 6% of gross domestic product (GDP); it has grown steadily in recent years from about 5.4% of GDP in 1999 to 6.6% of GDP in Overall health spending is comparable to that in other low- and middle-income countries, but the state budget expenditure on health care (central budget, local budget, and government purchase of health insurance) accounts for only about 32% of total health expenditure and is very low compared to similar low- and middle-income countries. State health spending accounted for only about 6.4% of state budget expenditures in Although the state budget devoted to health in Viet Nam has been low in recent years, there are indications spending is increasing. State spending on health remained almost constant in real terms from 2002 to 2005, but preliminary national health accounts estimates indicate an increase of some 44% between 2005 and 2006, which is attributed largely to substantial budget increases for the purchase of health insurance for the poor, for exemptions in health care costs of children under age 6 and for government investments in infrastructure at the district level. In addition, National Assembly Resolution No. 18/2008/NQ-QH12 made a strong commitment to additional state budget allocations to the health sector in the future, with greater attention to addressing the needs of disadvantaged people and regions See Risk Assessment and Management, Appendix 2 World Health Organization, World Health Statistics. Geneva: WHO 3 The term state health spending as used here includes only central and local budget spending and government contributions to the health insurance fund to purchase health insurance for policy beneficiaries and government staff. 4 Resolution No. 18/2008/QH12 addresses strengthening implementation of social mobilization policies to improve the quality of health care for the people. The Resolution resolved to increase the share of annual state budget allocations for health, ensuring that the rate of increase in budget spending on health exceeds the average rate of increase of overall state budget spending.

2 2 5. The Joint Annual Health Review provides estimates of changes in the structure of health spending from 2002 through 2010 (figure below). The data are taken from the finalized account information in the National Health Accounts, data are estimates, and the data are projections, based on a number of assumptions. First, the Vietnamese economy will overcome the recession in 2008 and develop and grow with some stability in the following years. Second, local state budget for health will increase substantially (especially for investments in basic infrastructure construction to upgrade health facilities at district and commune levels, and in disadvantaged areas, through issuing government bonds). Third, the central budget allocation will continue to increase, reaching 8.5% of total health expenditure in Fourth, the health insurance fund will grow rapidly through state subsidization of the poor, near-poor, and greater compliance by the formal sector. Fifth, public health expenditures will grow faster than household direct out-of-pocket spending. Sixth, the government will issue sound policies to control medical service costs and drug costs, in both private and public sectors. 6. The data shown in the figure below indicate that with these somewhat optimistic assumptions total national health expenditure will increase to meet the growing needs of the population, and public spending (which is defined to include the state budget, health insurance and official development assistance) as a proportion of total health expenditure will also increase. If Viet Nam sustains this trend, it is projected that by 2015, public health expenditure will account for over 50% and become the key financial resource in health financing, helping to achieve greater equity in health financing. Projected Trends in the Structure of Viet Nam Health Expenditures, Source: Joint Annual Health Review 2008, Ministry of Health and Health Partnership Group. ODA = official development assistance. 5 Ministry of Health and Health Partnership Group Joint Annual Health Review 2008 Health Financing in Viet Nam. Ha Noi. This is the latest published data available published by the Government of Viet Nam.

3 3 III. POLICY MATRIX ACTIONS AND ADJUSTMENT COSTS 7. The policy matrix in Appendix 4 outlines the proposed policy actions that will trigger the release of program loan tranches. Achieving the conditions for the release of funds, and implementing the institutional reforms outlined by the policy actions will have a direct cost impact on the government. The adjustment costs related to the policy actions, over the 5 years covered by the program design are estimated to be approximately $12 million per year. This represents 1.3% of current annual state health expenditures. 8. The three proposed policy actions that will have the most significant cost implications are (i) implementation of several human resource-related provisions in the Law on Examination and Treatment (LET); (ii) implementation of the master plan for organizing and developing the health human resources training network; and (iii) the need for increasing budget allocations to the health sector. 9. The following sections describe these three actions and outline the estimated adjustment costs. 1. Implementation of the Law on Examination and Treatment 10. Provisions in the LET relating to health human resources include: the accreditation of health workforce training programs, the registration and licensure of health facilities and health professionals, a disciplinary system for health professionals, and a consumer rights standard and complaints mechanism. The recurrent costs to the government of these LET components after the adjustment period are estimated to be $26.5 million, accounting for approximately 3% of state budget health spending in The breakdown by component is given in Table 1. Table 1: Estimated Annual Implementation Costs for Three Key Components of the LET ($ million) Component Annual Cost Notes 1. Health Professional Registration and Certification - Medical council is self funding after the adjustment period 2. Facilities Licensing 1.5 Cost of monitoring and issuing licenses in public sector (private sector is self funding) 3. Accreditation 25.0 Accreditation fees in public sector (excluding cost of upgrading to meet accreditation standards) Total 26.5 Source: ADB Technical Assistance to Viet Nam for Preparing Support for the Health Systems Development Program. Manila (TA 7029-VIE, $500,000, approved on 11 December, financed by the Japan Special Fund). 2. Master Plan for Upgrading of Teaching Institutions 11. The master plan for upgrading of teaching institutions was submitted to the Prime Minister and while the final cost of all components has not been determined estimates of the future cost of implementing the plan can be made based on training institution needs (Table 2).

4 4 Training Facility Table 2: Cost Estimates for Training Facility Investments ($ million) Upgrade Cost per Number of Facility a Facilities Total Cost Universities Colleges and Secondary Schools Total a Facility upgrade costs were provided by the universities and reviewed during loan preparation. Source: ADB Technical Assistance to Viet Nam for Preparing Support for the Health Systems Development Program. Manila (TA 7029-VIE, $500,000, approved on 11 December, financed by the Japan Special Fund). 3. Increasing State Budget Allocations to Health 12. National Assembly Resolution Number 18 of 2008 states that the growth in the annual government health budget should be greater than the average annual increase in the overall government budget. The implications of this resolution, based on recent growth patterns in the government budget, are outlined in Table 3. Given the growth pattern for the overall government budget, even a modest 0.05% increment in the growth of the health budget would result in a yearly cost to the government of $4.2 million. A conservative estimate of the cost to the government over 5 years (the lifespan of the sector development program) is $21.0 million. Table 3: Cost of Increasing State Expenditure on Health Expenditure Area Indicator Total government expenditure 2006 $19.23 billion Growth in government budget % Total government expenditure on health $850 million Growth in government budget for health % Estimated government budget 2009 $29.60 billion Estimated growth in government budget % Estimated government budget on health in 2009 if growth is at the $981.8 million same rate (15.5%) as overall government budget growth: Estimated government budget on health in 2009 if growth is greater $986.0 million than the growth rate of overall government budget 0.5% greater or equal to 16.0% as required by National Assembly Resolution The estimated cost i.e., increment over what any expected budget $4.2 million/annum increase of the National Assembly Resolution 1 Excluding official development assistance (ODA). Source: General Statistics Office National Accounts Statistics, State Budget Expenditure Final Accounts, from This is latest published GoVN data. 4. Program Loan Adjustment Costs in Summary 13. The proposed value of the program loan $30 million is well justified by the estimated costs of key policy actions that will be required for program loan fund release. The implementation of the master plan on upgrading of teaching institutions alone will cost the government an estimated $260 million to fully implement. The project loan will provide a small contribution ($18.6 million or 7.1%) towards this and the rapid availability of this funding is expected to help in staring implementation, in setting standards for procurement methods and equipment quality, and in building the capacity to roll out implementation across the full range of institutions that need the investment and upgrading. The LET is modestly estimated to have an

5 ongoing cost of more than $26 million per year, largely in ensuring public health service institutions are fully accredited and licensed. While the cost of implementing the National Assembly resolution regarding accelerated growth in the state s spending on health can only be estimated, it is clear that this will have a real and ongoing cost to the government, even if implemented at a very modest level (0.05% over and above regular annual budget increases). 5