Removing barriers for people living with HIV in accessing and utilizing social health insurance in Vietnam

VIETNAM NATIONAL UNIVERSITY, HANOI VIETNAM JAPAN UNIVERSITY NGUYEN KIEU AN REMOVING BARRIERS FOR PEOPLE LIVING WITH HIV IN ACCESSING AND UTILIZING SOCIAL HEALTH INSURANCE IN VIETNAM

VIETNAM NATIONAL UNIVERSITY, HANOI

VIETNAM JAPAN UNIVERSITY

NGUYEN KIEU AN

REMOVING BARRIERS FOR PEOPLE LIVING WITH HIV IN ACCESSING AND UTILIZING SOCIAL HEALTH INSURANCE

IN VIETNAM

MASTER’S THESIS

Hanoi, 2019

VIETNAM NATIONAL UNIVERSITY, HANOI

VIETNAM JAPAN UNIVERSITY

NGUYEN KIEU AN

REMOVING BARRIERS FOR PEOPLE LIVING WITH HIV IN ACCESSING AND UTILIZING SOCIAL HEALTH INSURANCE

Table of contents

Abbreviations

List of tables

CHAPTER 1: INTRODUCTION AND BACKGROUND INFORMATION 1

1.1 Introduction 1

1.2 Country background – Vietnam 2

1.3 HIV situation and financing in Vietnam 3

1.3.1 Overview of HIV/AIDS epidemic and PLHIV 3

1.3.2 HIV policies and financing 5

1.3.3 Social Health Insurance in relation to HIV treatment 7

1.4 Literature review 9

1.5 Research rationale and objectives 10

1.6 Research questions 11

1.7 Research significance 11

CHAPTER 2: METHODOLOGY 12

2.1 Research methods 12

2.2 Research setting 12

2.3 Data collection measures 13

2.4 Data analysis 14

CHAPTER 3: RESEARCH FINDINGS 15

3.1 General information 15

3.2 Reasons PLHIV not buying SHI 17

3.3 Barriers in accessing SHI 20

3.4 Ability and willingness to buy SHI 21

3.3 PLHIV’s use of SHI 22

3.5 Barriers in utilizing SHI 23

CHAPTER 4: DISCUSSION 25

4.1 Key findings 25

4.2 Discussion 25

4.3 Recommendations 27

CHAPTER 5: CONCLUSION 29

5.1 Summary 29

5.2 Limitations of the study 29

References 30

Appendixes 33

Appendix 1 Questionnaire for PLHIV 33

Abbreviations

AIDS Acquired Immunodeficiency Syndrome

ART Antiretroviral Therapy

ARV Antiretroviral

HIV Human Immunodeficiency Virus

MOH Ministry of Health

PLHIV People living with HIV

SHI Social Health Insurance

UNAIDS Joint United Nations Program on HIV/AIDS

UNDP United Nations Development Program

VAAC Vietnam Administration on HIV/AIDS Control

WHO World Health Organization

List of tables

Table 1: PLHIV by gender and possession of SHI

Table 2: PLHIV by age and possession of SHI

Table 3: PLHIV by location and possession of SHI

Table 4: Means to access SHI

Table 5: Reasons PLHIV do not buy SHI

Table 6: Barriers for PLHIV to access SHI

Table 7: Ability of PLHIV to buy SHI

Table 8: Willingness of PLHIV to buy SHI

Table 9: Most recent use of SHI

Table 10: Most recent service to use SHI

Table 11: Barriers for PLHIV to utilize SHI

Table 12: PLHIV’s wanted services not covered by SHI

Even though a cure is yet to be found for the disease, accessing to antiretroviral therapy (ART) – a combination of drugs that suppresses and stops the progression of HIV - can help improve the life expectancy of PLHIV and help them to lead a healthy and productive life (Oguntibeju, 2012; Nakagawa F, 2013) That said the treatment requires lifelong commitment and often is out-of-reach financially for PLHIV, especially those in low and middle-income countries (Clayden, 2013) In the last decades, ART in Vietnam was provided free-of-charge mainly through international funding and programs (Downie, 2017) However, as Vietnam became a lower-middle income country, external funding for HIV programs, including procurement

of ART medicines has been withdrawn dramatically (MOH, 2014) The Government of Vietnam, thus, deems transitioning from foreign funded programs to a more sustainably financing mechanism, in which HIV care and treatment is covered by Social Health Insurance (SHI) as a priority It is reflected in the Law on Health Insurance in 2008 and 2014, and the recent

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Circular No.27/2018 of the Minister of Health on guiding the implementation

of health insurance for HIV treatment Various decrees and circulars also support this strategy

Nevertheless, Nguyen and Wilson (2017) point out that cost of insurance premiums is a barrier for the near-poor to access to SHI More specifically, Nguyen et al (2017) find that a high proportion of PLHIV was not covered by SHI for which financial difficulty and lack of information are the underlying reasons It is noted that previous studies and researches mostly focus on access to SHI while to be able to utilize SHI in practice poses other challenges for PLHIV This study, therefore, attempts to provide additional data and a better insight of existing barriers for PLHIV in accessing and utilizing SHI in Vietnam It is also hoped to generate feasible recommendations to remove such barriers to contribute toward improving the quality of life of PLHIV and social equality in the country

1.2 Country background – Vietnam

The Socialist Republic of Vietnam is located in Southeast Asia It is bordered

by China, Laos and Cambodia, with a long coastline that connects to the East Sea The country covers approximately 331,212 km2 and has a population of 95.5 million from 54 different ethnic groups (World Bank)

Since its political and economic reform in 1986, the country has made a remarkable transformation with a GDP growth rate ranked among the fastest globally (ICAEW, 2018) The renovation allowed the country to open its previously isolated market to welcome favorable bilateral and multilateral trade agreements as well as expand its diplomatic relations, namely joining ASEAN in 1995, APEC in 1998 Subsequently, in 2011, Vietnam was categorized as a lower middle-income country, having reduced its poverty

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headcount from 58% in the early 1990s to 14.5% in 2008 (UNDP) At the

moment, Vietnam’s GDP per capita is around USD 2,389 (World Bank)

The social and human aspects of Vietnam have also experienced positive

progress over the years The country’s Human Development Index value was

0.694 in 2017, which is 46.1% higher than the value of 0.475 in 1990 This

puts the country in the medium human development category – positioning at

116/189 countries in the world (UNDP, 2018) Vietnamese are expected to

live longer with life expectancy at birth at 76.5 years for 2017 (UNDP, 2018)

Child health also gets better with under-5 mortality, infant mortality and

malnutrition rates all drop significantly (WHO)

Despite such improvements, inequality grows larger and quicker in several

dimensions Taylor (2004) states that wealth gaps exist between geographical

regions, Hanoi and Ho Chi Minh city, for instance, have income per capita

two to five times more than some remote and rural provinces He also

mentions the discrepancies between women and men, where in women are

less likely to attend secondary school and university, hence less likely to be in

salaried employment, and even when they are, their hourly wage tends to be

lesser These issues are reaffirmed in a more recent report by Oxfam (2017)

The same report also emphasizes inequalities in economic as well as standard

of living between different ethnic groups and disadvantaged populations

Similarly, inequality of opportunity due to discrimination based on disability

and HIV status is most severe, according to the 2015 Justice Index by UNDP

1.3 HIV situation and financing in Vietnam

1.3.1 Overview of HIV/AIDS epidemic and PLHIV

Having the first HIV case detected in December 1990, by the 3rd quarter of

2017, it was estimated that there were 208,371 people living with HIV in the

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country (VAAC, 2017) Among those, 22% was female and 78% was male Although the number of new HIV cases has been reduced over the years, it has been persistently staying around 12,000 to 14,000 people become infected every year, and AIDS-related deaths is around 12,000, according to the Joint United Nations Programme on HIV/AIDS

HIV in Viet Nam is considered a concentrated epidemic – meaning while transmission rate among the general population is relatively low (below 0.4% among adults), the rate is much higher among high-risk populations, typified

by people who use drugs, men who have sex with men and sex workers (UNAIDS) UNAIDS reports that most of PLHIV in Vietnam lives in large cities and mountainous provinces It is noted by Nguyen et al (2008) that despite being increasingly at risk of HIV transmission, women in Vietnam are often under-protected due to lack of awareness, not getting tested and lack of preventive measures

In a report published by Vietnam Network of People Living with HIV (2015), 20% of HIV-positive respondents reported being unemployed; households of PLHIV have monthly income of above VND 5 million (~ USD 216) are 54%, 38% between VND 2 -5 million (~ USD 86 - 216) and 8% under VND 2 million (~ USD 86)1

Accessing to antiretroviral therapy (ART) – a combination of drugs that suppresses and stops the progression of HIV - can help improve the life expectancy of PLHIV and help them to lead a healthy and productive life (Oguntibeju, 2012; Nakagawa F, 2013) The treatment requires life-long commitment meaning patients need to take the medication regularly as well as being adherence to appointed check-ups and testing Not taking ARV puts

1 The survey was conducted among 1625 participants from Hanoi, Haiphong, Dien Bien, Can Tho and Ho Chi Minh city

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PLHIV at risk of opportunistic infections and progression to AIDS However, only half of the people who need treatment has access to ART in the country (VAAC, 2017; UNAIDS; WHO)

Furthermore, even though the 2006 Law on HIV/AIDS Prevention and Control forbid stigma and discrimination against PLHIV, it is reported that many still face problems in getting a job, being treated unfairly in the workplace as well as experience discrimination in healthcare setting (Doan et

al, 2008; Khuat, Nguyen, & Ogden, 2004; Lim et al, 2013)

1.3.2 HIV policies and financing

National programs to control HIV were set up in the early 1990s Since then, huge efforts have been made to control the rate of infection, reduce mortality and improve the livelihood of those affected

In 1995, an Ordinance on HIV/AIDS prevention and control was adopted by the National Assembly – it acted as the first legal framework for HIV intervention efforts in the country This early period of the HIV response relied heavily on compulsory testing, coerced rehabilitation of and stigmatized propaganda about HIV high-risk groups In 2004, a National Strategy on HIV/AIDS for 2004 – 2010 with a vision to 2020 was put in place, which adopted international best practices and recommendations on HIV prevention, care, support and treatment This strategy embraced the concept of harm reduction, encouraged information campaigns and voluntary testing and counseling instead of mandatory HIV testing Then, the 2006 Law

on HIV/AIDS Prevention and Control emphasized the principle of no stigma and discrimination against PLHIV These changes have shown the country’s

“gradual shift from a punitive approach to a more human rights-based approach” (as commented by the Inter-Parliamentary Union Advisory Group,

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2014; Pham et al, 2010) Later, the 2008 Law on Health Insurance removed the diagnosis and treatment of HIV from the list of exceptions for health insurance coverage The Law was again amended in 2014 to further adapt to the changing strategy and needs for HIV treatment

In addition, Vietnam is also committed to several international documents and strategies related to HIV/AIDS prevention and PLHIV, namely the 2001 UNGASS Declaration on HIV/AIDS which recognizes the fundamental rights

of PLHIV and the importance of “access to medicines”; and the “90-90-90” target which aims for 90% of PLHIV to know their status, among those 90% will receive ART and among those 90% will have viral suppression by 2020 Financially, the Government of Vietnam has been increasing budget for HIV interventions and programs over the years However, it is still heavily dependent on international donor contributions – with more than 70% of the overall financing coming from external sources (MOH cited by PEPFAR, 2018) More importantly, almost 90% of ART medicines in the country come from two big international donors – PEPFAR and the Global Fund, both of whom have plan to either discontinue or uncertain about future aid commitments (vietnamnews.vn)

In response to the reality that ART in Vietnam will no longer be provided free-of-charge through international funding and programs, the Government has strategized to secure the medicine procurement through funds from the national Social Health Insurance (Downie, 2017) It is estimated that SHI coverage needs to increase to 80% by 2020 to potentially cover 52% of HIV treatment payment needs (USAID, 2015)

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1.3.3 Social Health Insurance in relation to HIV treatment

It is proven that health insurance plays a crucial role in reducing financial burden and acts as a protective measure for people against unexpected health costs Several high-income and middle-income countries such as Brazil, Mexico, Thailand and Taiwan have had health insurance scheme in place to cover for HIV services (UNAIDS, 2012)

As for Vietnam, the concept of health insurance was first mentioned in the country’s Constitution in 1992 It was the most important basis for the formation of health insurance system and the implementation of health insurance policies in the country In the same year, the Health Insurance Regulation was promulgated with coverage limited to government officials and formal workers At the time, voluntary participation was not clearly regulated

After 15 years of implementation, policies and regulations surrounding SHI have been revised and/or amended several times in order to expand the coverage and to better cope with the country’s development stages The number of people participating in health insurance had increased over the years Nevertheless, by 2008, the number of people participating in health insurance was only 37.7 million, accounting for 43.76% of the population (MOH, 2012)

In response, the approval of the abovementioned 2008 and 2014 Law on Health Insurance marks the government’s aim toward universal health coverage With the established policy and system, a number of amendments was added, regulating the compulsoriness of social health insurance Its compulsory membership has been expanded to include formal workers, the poor, the near-poor, elderly, and children under 6 years old Government

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budget covers partially or fully for more beneficiaries, specifically 100% health insurance premium cost for the poor, ethnic minorities and children under 6 years old; up to 95% for the near-poor and retired people, and up to 80% for others (Nguyen, et al., 2017) This has resulted in a reduction of household’s out-of-pocket money for medical expenses from 62.9% in 1998

to 48.5% in 2012 and to 44.3% in 2013 (MOH, 2016); and an increase in the number of persons participated in social health insurance of over 75.9 million, accounting for 81% of the population (General statistics office, 2017)

As of 2017, the concept of “voluntary health insurance” is replaced by the regulation of “health insurance by household” meaning any individual that is not under the compulsory and/or special categories (the employed, those in military/police force, the poor, the near-poor, students, children under 6 years old etc.) will be required to join under this category The health insurance premium for this “household” category is set at VND 702,000/ person/ year, and is reduced for each family member joining after This is an effort of the government to increase health insurance coverage

Regarding HIV treatment, the 2008 Law on Health Insurance adds more benefits on preventive medicines including HIV screening and testing The

2014 Law on Health Insurance, along with following Circular No.27/2018 of the Minister of Health provide detailed guidance on the implementation of SHI for HIV treatment As a result, the Ministry of Health now aims to provide ARV treatment through SHI for 40,000 PLHIV by the end of 2019 (MOH, 2019) This target, by itself, is a challenge since an earlier countrywide survey shows that only around 30% of PLHIV has access to SHI (VAAC, 2014)

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1.4 Literature review

PLHIV’s accessibility to Social Health Insurance

Clayden (2013) says that prices of ARV in some low and middle-income countries including Vietnam, is actually much higher than that of African nations This and the fact that even with free-of-charge ART, PLHIV in Vietnam still have to face with other out-of-pocket payments that is

“catastrophic” and may hinder their access to treatment (Tran, et al., 2012) This statement is supported by another study by Nguyen et al (2014) in which, given free ART, 10.5% of participants were still unable to access the treatment due to inability to pay for the associated expenditures (such as testing and travel costs); and 16.2% could only partially afford these costs This raises further importance of PLHIV’s accessibility to SHI in order to access and/or maintain their ARV treatment in the context of withdrawing international funding

Nguyen and Wilson (2017) find that level of enrollment in SHI among the near-poor was associated with cost of insurance premiums, knowledge of insurance benefits, and overall affordability Financial constraints again were concluded as the reason for majority of opioid-addicted patients in Northern provinces of Vietnam, many of whom are HIV-positive, to access to SHI (Tran et al, 2017)

Besides financial difficulty, Nguyen et al (2017) also find that a high proportion of PLHIV was not covered by SHI due to lack of information The researchers comment that PLHIV might not be willing to buy SHI because they do not fully understand its benefits and so have the feeling of difficulty when buying and using it

1.5 Research rationale and objectives

Vietnam continues to show its strong commitment to both ending the AIDS epidemic and improving quality of life of PLHIV, which can be achieved by having a sustainable health financing mechanism Increasing the rate of health insurance coverage among PLHIV as well as ensuring they can effectively use health insurance to engage in treatment are important steps towards this goal However, barriers might exist that hinder PLHIV’s accessibility to and utilization of social health insurance

Although previous studies and researches have identified a number of obstacles hindering PLHIV’s ability to access to social health insurance including financial difficulties, other aspects related to PLHIV’s experience in buying and using social health insurance are not yet addressed and can be explored to further the understanding of the actual issues faced by PLHIV This study, therefore, aims to:

 Provide an understanding of the situation and urgent needs to support people living with HIV in Vietnam through social health insurance in the context of declining international aids;

 Explore current barriers faced by people living with HIV in Vietnam to accessing and utilizing social health insurance; and

 Provide recommendations to remove such barriers and thus improve the accessibility to and utilization of social health insurance of people living with HIV

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1.6 Research questions

This study seeks to answer the following questions:

 What are the current barriers for PLHIV in accessing SHI in Vietnam?

 What are the current barriers for PLHIV in utilizing HI in Vietnam?

 What are the recommendations to remove such barriers?

The questionnaire as well as discussions given were in Vietnamese Translation from Vietnamese to English was done later for both data collected through the questionnaire survey as well as answers from focus group discussions

2.2 Research setting

The study was conducted in different cities/provinces from different regions

in order to ensure the representativeness of participants, including:

 Large city: Hanoi, Ho Chi Minh city;

 Northern Delta Region: Bac Giang, Bac Ninh, Vinh Phuc, Hai Duong;

 Mountainous and remote area: Dien Bien, Son La, Phu Tho, Thai Nguyen;

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 Central region: Lam Dong, Khanh Hoa;

 Southern region: Binh Duong

Survey participants by current place of living

A questionnaire survey was designed with 3 parts:

 Part 1: General information of all participants, including their current living location, gender and age

 Part 2: For those who do not have social health insurance, asking about their experience in accessing SHI – including the reasons they do not and/or cannot buy SHI, barriers faced when accessing SHI, their financial ability and willingness to buy SHI;

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 Part 3: For those who have had social health insurance, asking about how they can access to SHI, their use of SHI, and barriers faced when utilizing SHI

Qualitative data

5 focus group discussions were conducted between groups of 3 to 5 participants following a guide A total of 15 people was interviewed, among them 9 have had social health insurance and 6 have not The discussions are recorded only for the purpose of analyzing data and will be destroyed once transcribed to ensure the confidentiality of the participants

2.4 Data analysis

Data collected from the questionnaire survey was converted from the hard copies into excel spread sheets while answers from the focus group discussions was transcribed from the records into word file for analysis

Table 1: PLHIV by gender and possession of SHI

Table 2: PLHIV by age and possession of SHI