HEALTH INSURANCE IN VIETNAM: HEALTH CARE REFORM IN A POST-SOCIALIST CONTEXT

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1 HEALTH INSURANCE IN VIETNAM: HEALTH CARE REFORM IN A POST-SOCIALIST CONTEXT By Amy Dao, Columbia University Vietnam s economic and social reform program in 1986 called Đổi Mới (Renovation) signaled the country s transition from a centrally-planned socialist economy to a market economy, resulting in the deregulation and decentralization of the health care industry. Consequently, reform produced adverse effects on health care utilization such as the proliferation of out-of-pocket payments, catastrophic spending and delayed care (Chaudhuri 2008; Dao 2008; Falkenberg, et al. 2000; Landinsky, et al. 2000; Segall, et al. 2000; Wagstaff 2008; Xu, et al. 2003). In order manage the negative effects of privatization, the Vietnamese government instituted health insurance in 1992 with the goal of providing universal health coverage (Lieberman and Wagstaff 2009). The literature on health insurance in Vietnam, largely produced within the public health and economics disciplines, focuses on intervention strategies and financial evaluation of programs (Ensor 1995; Ensor 1999; Jowett 2003a; Jowett 2003b). These reports highlight further study in Vietnam for its positive health indicators given its low per capita income and praise economic liberalization as a key factor in the steps towards modern governance (Adams 2005; Giang 2008; Health Systems 20/ ; World Bank 2005). While the country experienced increases in GDP and improvements in health statistics, the economic shift has also yielded increasing inequality as the gap between the top income and the lowest income population is larger than it has ever been historically (Ekman, et al. 2008). A World Bank report stated that social policies specifically in health are important to minimize disparity within the population during Vietnam s early stages of transition (World Bank 2003). Although Vietnam s health care financing system generally follows the social health insurance model, in which funding for health is financed through payroll taxes of the employed, there are many ways in which a mixed method of financing plays out on the ground level. The structure of the public health insurance system consists of four programs that cover different segments of the population (Ekman, et al. 2008). The Social Health Insurance (SHI) program targets the formally employed, retirees, disabled, and meritorious people. The Health Care Funds for the Poor (HCFP) program covers the poor, ethnic minorities and inhabitants of disadvantaged communities. There is also a program for free health care for children under 6 years of age which makes up the last of the three programs that represent the compulsory portion of the health insurance system (Compulsory Health Insurance - CHI). Finally, there is the Voluntary Health Insurance (VHI) which covers the self-employed, informal sector employees, dependents of the compulsory health insurance members, students and school children. The main goal of a financing system is to raise adequate funds for health in a way that ensures that people can access needed services, while being protected from financial catastrophe or impoverishment relating to payment for health services (World Health Organization 2007). In other words, it is important for health systems to achieve equity in financing and health care. A key indicator for whether or not countries are meeting these objectives is by examining what proportion of the population has access to health insurance. Although the level of coverage continues to grow annually, the current system covers only 58.2% of the Vietnamese population as of reports in 2009 (Tangcharoensathien 2011; World Representative Office in Vietnam 2011). Given that the social health insurance model is predicated on the idea that enrollment is

2 mandatory to ensure access for all, the Vietnamese health insurance system continues to face many challenges in achieving universal coverage. First, the design of the health insurance schemes allows for a high level of fragmentation, meaning that there are a large number of funding pools that often inhibit income and risk crosssubsidization (McIntyre 2008). System-wide efficiencies also include the overlapping of administrative tasks and procedures that unnecessarily drain scarce resources in low-income countries (World Health Organization 2010a). Within the current system, there are three funding pools: the SHI is funded through payroll taxes of employees and employers, the HCFP and children under six programs are financed through general tax based revenues and the VHI paid through individual private premiums. While the SHI and VHI are collected separately, but pooled nationally, the HCFP risk pool is pooled by province and thus fragmented in that a surplus in one pool cannot be used to subsidize a deficit in another (Nguyen and Leung 2003). Additionally, while the Vietnam Social Security (VSS) agency is responsible for issuing insurance cards, different roles and procedures are followed for each of the three different funding schemes. For SHI, VSS collects premiums and issues insurance cards to employees, and for HCFP, province-level management boards purchase cards from VSS. Lastly, for VHI, eligible individuals and organizations must purchase their own cards from VSS (Ekman, et al. 2008). The different arrangements for accessing insurance alone involve multiple administrative levels which can lead to inefficiency. Most notably, the proliferation of out of pocket payments as a consequence of market reform continues to be the primary method for which to finance health in Vietnam. As of 2009, out of pocket payments constituted 55.24% of Vietnam s total expenditures on health which is considered one of the highest proportions compared to other countries (Global Health Observatory 2009). It has been widely acknowledged that out of pocket payments are considered the least equitable form of payment for services because it creates financial barriers to accessing health services (Chaudhuri and Roy 2008; World Health Organization 2010b). In a study that compared 59 other countries, Vietnam had the highest incidence of catastrophic health spending from out of pocket payments, which has been estimated at over 10.5 percent (Wagstaff 2008; Xu, et al. 2003). Per capita utilization rates have also decreased significantly due to the institution of user fees post-đổi Mới especially for poor households which contributes to the growing social economic inequities that are contrary to social health insurance (Chaudhuri 2008; Segall, et al. 2002). Research so far suggests that health financing especially for the poor has increased access to health care and reduced the risk of financial catastrophe due to health expenditures (Axelson, et al. 2009), which raises the questions regarding the basis for this disjuncture. Despite the relatively low population coverage rate, Vietnam s Ministry of Health has made intentional efforts towards achieving equity through instituting the Health Care Funds for the Poor program. Recognizing the disproportionate patterns in the enrollment and utilization of services, in that health systems oftentimes end up providing more and higher quality services to the well off, while the disadvantaged and those with the most need receive the least amount of services or are the last to be reached (Gwatkin, et al. 2004; Gwatkin 2011), the Vietnamese Ministry of Health established the HCFP program in 2002 to combat systematic inequity and to incorporate the poor in the health system in a more deliberate manner. Studies have reported that 100 percent of the target population is currently covered under this scheme although it is unclear how the target population of the poor is defined (Tangcharoensathien 2011). Vietnam s insurance scheme represents an exemplar case study for which to study the dynamics of squeezing in the middle, which refers to the ability to cover the non-poor or the

3 not so poor informal sector that exists between the top layer of formal sector employees and the bottom layer of the poor (Tangcharoensathien 2011). While studies have found that 100 percent of the formal sector participates in the health insurance scheme, only 20 percent of the private and informal sector contribute to the insurance scheme. This is becomes most problematic because oftentimes salaries from private and informal sector are much higher than in the public sector (Giang 2008). In examining the willingness to pay for VHI in the informal rural sectors who have generally not enrolled, investigators found that non-health expectations such as client perceptions of quality, transportation and payments in the form of gifts greatly influenced the perception of health insurance (Lofgren, et al. 2008). Additionally, positive provider-patient relationship was also a variable in determining enrollment and use of schemes (Duong 2004). While initial information regarding the ground level experiences of health insurance in Vietnam needs to be explored further, the case provides a nexus for which to study several theoretical questions of interest to anthropologist: 1) What are the processes that give meaning to Vietnamese experiences and understandings of health insurance within a post-socialist context? 2) With the introduction of pre-payment schemes account for future, how has risk become re-conceptualized regarding health? References: Adams, Susan J Vietnam's Health Care System: A Macroeconomic Perspective. In International Symposium on Health Care Systems in Asia. Hitotsubashi University, Tokyo Axelson, Henrik, et al Health Financing for the Poor Produces Promising Short-term Effects on Utilization and Out-of-pocket Expenditure: Evidence From Vietnam. Internation Journal for Equity in Health 8(20). Chaudhuri, A Changes in out-of-pocket payments for healthcare in Vietnam and its impact on equity in payments, Health policy (Amsterdam) 88(1):38. Chaudhuri, Anoshua, and Kakoli Roy 2008 Changes in out-of-pocket payments for healthcare in Vietnam and its impact on equity in payments, Health Policy 88: Dao, H. T User fees and health service utilization in Vietnam: How to protect the poor? Public health (London) 122(10):1068. Duong, D. V Utilization of delivery services at the primary health care level in rural Vietnam. Social science & medicine (1982) 59(12):2585. Ekman, Bjorn, et al Health Insurance Reform in Vietnam: A Review of Recent Developments and Future Challenges. Health Policy and Planning 23:

4 Ensor, Tim 1995 Introducing health insurance in Vietnam. Health Policy and Planning 10(2): Developing health insurance in transitional Asia. Social science & medicine (1982) 48(7):871. Falkenberg, T., et al Pharmaceutical sector in transition--a cross sectional study in Vietnam. Giang, Thanh Long 2008 Vietnam: Social Health Insurance in Vietnam-Current issues and policy recommendations. ILO Subregional Office for East Asia. Global Health Observatory 2009 World Health Organization - Global Health Observatory (GHO) Gwatkin, D.R., A. Bhuiya, and C.G. Victora 2004 Making health systems more equitable. The Lancet 364(9441): Gwatkin, Davidson R Universal health coverage: friend or foe of health equity? The Lancet (British edition) 377(9784): Health Systems 20/ Vietnam: Health Systems Report. Jowett, Matthew 2003a Do informal risk sharing networks crowd out public voluntary health insurance? Evidence from Vietnam. Applied economics 35(10): b The impact of public voluntary health insurance on private health expenditures in Vietnam. Social science & medicine (1982) 56(2):333. Landinsky, Judith, Hoang Thuy Nguyen, and Nancy Volk 2000 Changes in Health Care System of Vietnam in Response to the Emerging Market Economy. Journal of Public Health Policy 21(1): Lieberman, Samuel S., and A. Wagstaff 2009 Health Financing and Delivery in Vietnam: Looking Forward. Washington, DC: The International Bank for Reconstruction and Development. Lofgren, Curt, et al People's willingness to pay for health insurance in rural Vietnam. Cost effectiveness and resource allocation 6. McIntyre, D Beyond fragmentation and towards universal coverage: insights from Ghana, South Africa and the United Republic of Tanzania. Bulletin of the WOrld Health Organization 86(11):871. Nguyen, Trong-Ha, and Suiwah Leung 2003 Recent advances in social health insurance in Vietnam: A comprehensive review of recent health insurance regulations. Segall, Malcolm, et al Economic transition should come with a health warning: the case of Vietnam. Journal of Epidemiology and Community Health 56(7):

5 Segall, Malcolm, et al Health Care Seeking By the Poor in Transitional Economies: The Case of Vietnam. Institute of Development Studies. Tangcharoensathien, V Health-financing reforms in southeast Asia: challenges in achieving universal coverage. The Lancet (British edition). Wagstaff, A Measuring financial protection in health. Volume 4554: World Bank Publications. World Bank 2003 Vietnam Delivering on Its Promise- Development Report 2003: Poverty Reduction and Economic Management Unit East Asia and Pacific Region Vietnam Development Report 2005: Governance: Poverty Reduction and Economic Management Unit East Asia and Pacific Region. World Health Organization 2007 Everybody's business: strengthening health systems to improve health outcomes: WHO's framework for action. Geneva: WHO Press. 2010a Fragmentation in pooling arrangements. Technical Brief Series- Brief No b Health Systems Financing: The path to universal coverage. ISBN World Health Organization. World Representative Office in Vietnam 2011 Health Financing. Xu, K., et al Household catastrophic health expenditure: a multicountry analysis. The Lancet 362(9378):

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