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

5 1.3.3 Social Health Insurance in relation to HIV treatment.... People living with HIV Social Health Insurance Joint United Nations Program on HIV/AIDS United Nations Development Progra

VIETNAM NATIONAL UNIVERSITY, HANOI

VIETNAM JAPAN UNIVERSITY

VIETNAM NATIONAL UNIVERSITY, HANOI

VIETNAM JAPAN UNIVERSITY

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

People living with HIV Social Health Insurance Joint United Nations Program on HIV/AIDS United Nations Development Program

Vietnam Administration on HIV/AIDS Control

Vietnamese Dong World Health Organization

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

CHAPTER 1: INTRODUCTION AND BACKGROUND

INFORMATION 1.1 Introduction

Human Immunodeficiency Virus and Acquired Immunodeficiency Syndrome(HIV/AIDS) is one of the major public health problems in the world(UNAIDS, 2018) In 2017, the Joint United Nations Program on HIV/AIDS(UNAIDS) estimated that there were 36.9 million people living with HIV(PLHIV) worldwide Vietnam, with a population of 95.5 million people and aGross Domestic Product (GDP) per capita of USD 2,389 (World Bank), has anumber of PLHIV reportedly to be 208,371 according to the VietnamAdministration on HIV/AIDS Control

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

of ART medicines has been withdrawn dramatically (MOH, 2014) TheGovernment of Vietnam, thus, deems transitioning from foreign fundedprograms to a more sustainably financing mechanism, in which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

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

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

Nevertheless, Nguyen and Wilson (2017) point out that cost of insurancepremiums 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 bySHI for which financial difficulty and lack of information are the underlyingreasons It is noted that previous studies and researches mostly focus onaccess to SHI while to be able to utilize SHI in practice poses other challengesfor PLHIV This study, therefore, attempts to provide additional data and abetter insight of existing barriers for PLHIV in accessing and utilizing SHI inVietnam It is also hoped to generate feasible recommendations to removesuch barriers to contribute toward improving the quality of life of PLHIV andsocial 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 EastSea The country covers approximately 331,212 km2 and has a population of95.5 million from 54 different ethnic groups (World Bank)

Since its political and economic reform in 1986, the country has made aremarkable transformation with a GDP growth rate ranked among the fastestglobally (ICAEW, 2018) The renovation allowed the country to open itspreviously isolated market to welcome favorable bilateral and multilateraltrade agreements as well as expand its diplomatic relations, namely joiningASEAN in 1995, APEC in 1998 Subsequently, in 2011, Vietnam wascategorized as a lower middle-income country, having reduced its poverty

headcount from 58% in the early 1990s to 14.5% in 2008 (UNDP) At themoment, Vietnam’s GDP per capita is around USD 2,389 (World Bank).The social and human aspects of Vietnam have also experienced positiveprogress over the years The country’s Human Development Index value was0.694 in 2017, which is 46.1% higher than the value of 0.475 in 1990 Thisputs the country in the medium human development category – positioning at116/189 countries in the world (UNDP, 2018) Vietnamese are expected tolive 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 andmalnutrition rates all drop significantly (WHO).

Despite such improvements, inequality grows larger and quicker in severaldimensions Taylor (2004) states that wealth gaps exist between geographicalregions, Hanoi and Ho Chi Minh city, for instance, have income per capitatwo to five times more than some remote and rural provinces He alsomentions the discrepancies between women and men, where in women areless likely to attend secondary school and university, hence less likely to be insalaried employment, and even when they are, their hourly wage tends to belesser 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 disabilityand 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

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, ithas been persistently staying around 12,000 to 14,000 people become infectedevery year, and AIDS-related deaths is around 12,000, according to the JointUnited Nations Programme on HIV/AIDS.

HIV in Viet Nam is considered a concentrated epidemic – meaning whiletransmission 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 largecities and mountainous provinces It is noted by Nguyen et al (2008) thatdespite being increasingly at risk of HIV transmission, women in Vietnam areoften under-protected due to lack of awareness, not getting tested and lack ofpreventive measures

In a report published by Vietnam Network of People Living with HIV (2015),20% of HIV-positive respondents reported being unemployed; households ofPLHIV 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 2million (~ USD 86)1

Accessing to antiretroviral therapy (ART) – a combination of drugs thatsuppresses and stops the progression of HIV - can help improve the lifeexpectancy of PLHIV and help them to lead a healthy and productive life(Oguntibeju, 2012; Nakagawa F, 2013) The treatment requires life-longcommitment meaning patients need to take the medication regularly as well asbeing 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.

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 andControl forbid stigma and discrimination against PLHIV, it is reported thatmany still face problems in getting a job, being treated unfairly in theworkplace 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 mortalityand improve the livelihood of those affected

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

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

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

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

In addition, Vietnam is also committed to several international documents andstrategies related to HIV/AIDS prevention and PLHIV, namely the 2001UNGASS 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 HIVinterventions and programs over the years However, it is still heavilydependent on international donor contributions – with more than 70% of theoverall financing coming from external sources (MOH cited by PEPFAR,2018) More importantly, almost 90% of ART medicines in the country comefrom two big international donors – PEPFAR and the Global Fund, both ofwhom have plan to either discontinue or uncertain about future aidcommitments (vietnamnews.vn)

In response to the reality that ART in Vietnam will no longer be providedfree-of-charge through international funding and programs, the Governmenthas strategized to secure the medicine procurement through funds from thenational Social Health Insurance (Downie, 2017) It is estimated that SHIcoverage needs to increase to 80% by 2020 to potentially cover 52% of HIVtreatment payment needs (USAID, 2015)

1.3.3 Social Health Insurance in relation to HIV treatment

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

As for Vietnam, the concept of health insurance was first mentioned in thecountry’s Constitution in 1992 It was the most important basis for theformation of health insurance system and the implementation of healthinsurance policies in the country In the same year, the Health InsuranceRegulation was promulgated with coverage limited to government officialsand formal workers At the time, voluntary participation was not clearlyregulated

After 15 years of implementation, policies and regulations surrounding SHIhave been revised and/or amended several times in order to expand thecoverage and to better cope with the country’s development stages Thenumber of people participating in health insurance had increased over theyears Nevertheless, by 2008, the number of people participating in healthinsurance 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 onHealth Insurance marks the government’s aim toward universal healthcoverage With the established policy and system, a number of amendmentswas added, regulating the compulsoriness of social health insurance Itscompulsory membership has been expanded to include formal workers, thepoor, the near-poor, elderly, and children under 6 years old Government

budget covers partially or fully for more beneficiaries, specifically 100%health insurance premium cost for the poor, ethnic minorities and childrenunder 6 years old; up to 95% for the near-poor and retired people, and up to80% for others (Nguyen, et al., 2017) This has resulted in a reduction ofhousehold’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 thenumber 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 theregulation of “health insurance by household” meaning any individual that isnot under the compulsory and/or special categories (the employed, those inmilitary/police force, the poor, the near-poor, students, children under 6 yearsold etc.) will be required to join under this category The health insurancepremium 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 thegovernment to increase health insurance coverage

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

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

1.4 Literature review

PLHIV’s accessibility to Social Health Insurance

Clayden (2013) says that prices of ARV in some low and middle-incomecountries including Vietnam, is actually much higher than that of Africannations This and the fact that even with free-of-charge ART, PLHIV inVietnam 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) inwhich, given free ART, 10.5% of participants were still unable to access thetreatment due to inability to pay for the associated expenditures (such astesting and travel costs); and 16.2% could only partially afford these costs.This raises further importance of PLHIV’s accessibility to SHI in order toaccess and/or maintain their ARV treatment in the context of withdrawinginternational funding

Nguyen and Wilson (2017) find that level of enrollment in SHI among thenear-poor was associated with cost of insurance premiums, knowledge ofinsurance benefits, and overall affordability Financial constraints again wereconcluded as the reason for majority of opioid-addicted patients in Northernprovinces 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 highproportion of PLHIV was not covered by SHI due to lack of information Theresearchers comment that PLHIV might not be willing to buy SHI becausethey do not fully understand its benefits and so have the feeling of difficultywhen buying and using it

Furthermore, even though stigma and discrimination has not been clearlypointed out as factors hindering access and utilization of Vietnamese PLHIV

to SHI, previous literature, both in the world and in the context of Vietnam,has shown that stigma and discrimination are factors that prevent PLHIV toaccess to care and treatment (Feyissa et al., 2019; Tran et al., 2019)

1.5 Research rationale and objectives

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

Although previous studies and researches have identified a number ofobstacles hindering PLHIV’s ability to access to social health insuranceincluding financial difficulties, other aspects related to PLHIV’s experience inbuying and using social health insurance are not yet addressed and can beexplored 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 supportpeople 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 theaccessibility 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?

CHAPTER 2: METHODOLOGY 2.1 Research methods

The study was implemented during a larger research conducted by the Centerfor Supporting Community Development Initiatives where the authorinterned This Center focuses on working with vulnerable populations,including those living with and affected by HIV/AIDS It had helped theauthor collect data from more participants from different cities/provinces.The study was conducted using a mixture of quantitative and qualitativemethods This enable the author to both extract information from a largesample of people as well as explore further specific areas of interest.Quantitative data was collected through a self-reported questionnaire surveygiven to 200 HIV-positive people in 13 cities/provinces; while qualitative datawas collected through 5 focus group discussions and observations with 15participants

The questionnaire as well as discussions given were in Vietnamese.Translation from Vietnamese to English was done later for both data collectedthrough the questionnaire survey as well as answers from focus groupdiscussions

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;

 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 abouttheir experience in accessing SHI – including the reasons they do not and/or cannotbuy SHI, barriers faced when accessing SHI, their financial ability and willingness

to buy SHI;

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

Qualitative data

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

2.4 Data analysis

Data collected from the questionnaire survey was converted from the hardcopies into excel spread sheets while answers from the focus groupdiscussions was transcribed from the records into word file for analysis

CHAPTER 3: RESEARCH FINDINGS 3.1 General information

A total of 200 people living with HIV was given the self-reportedquestionnaire They are currently living in 13 cities/provinces of Vietnam.Among the participants, 163 (82%) are male, 34 (17%) are female and 3 (2%)identifies themselves as transgender

Table 1: PLHIV by gender and possession of SHI

Table 2: PLHIV by age and possession of SHI