Work package 8

Vietnam – The impact of extending the Vietnam Health Insurance Program to the poor and informal sector and reforms to provider payment systems

Background 

In Vietnam, following the introduction of user charges in the late 1980s, there has been extensive evidence of cost preventing people from using health services when they need them, and yet at the same time a large fraction of the population incurring health expenses that can be considered catastrophic. There is some evidence that a downwards trend in the incidence of catastrophic spending observed during the 1990s may have been reversed in the early 2000s.

The intervention

The government’s response has been the introduction of a social health insurance program. The scheme was introduced in 1993, and the government’s goal has been universal health insurance (UHI) by 2010. The scheme began with two components. The first was a mandatory social health insurance (SHI) scheme for formal sector workers. Contributions are linked to earnings and do not provide coverage for the contributor’s family. Pensioners and ‘people of merit’ are covered by the mandatory scheme at the State’s expense. The second component was a voluntary scheme, with a somewhat less generous benefit package, aimed at the rest of the population including contributors’ families. Payments to this scheme are flat-rate. Schoolchildren and students have become a key target group for this scheme. From the late 1990s onwards, the government increasingly targeted the poor. Provinces were encouraged to enrol poor households in the compulsory program at the State’s expense, or to provide free health care through a ‘free health certificate’ usable in government health facilities. In 2003, the government passed Decision 139 which provided central government resources, clear guidelines on eligibility and an injunction to enrol eligible households in the insurance scheme rather than provide them with free health care certificates. Decision 139 provided a strong impetus to the creation of a nationwide and fully subsidized scheme for Vietnam’s poor and otherwise disadvantaged.

Coverage in the various schemes has increased over the years. However, even now—nearly 15 years after the launch of the program—the majority of the population is still uncovered. There has been steady growth among formal sector workers and schoolchildren, and a dramatic increase in recent years among the poor. Voluntary enrolment among the non-student population has stayed low and shows no signs of growing. On present trends, Vietnam is most unlikely to come anywhere near achieving universal health insurance (UHI) by 2010 as planned.

Objectives

  1. To understand better the factors constraining enrolment in Vietnam’s health insurance scheme and hence Vietnam’s chances of hitting its goal of achieving UHI by 2010.
  2. To assess the scheme’s impacts on key outcomes, including use of services, the cost of care, the incidence of catastrophic health spending, and where possible health outcomes.
  3. To assess whether impacts are similar across different groups and if not why.
  4. To assess how impacts have changed over time, including, for example, how the impact of scheme for the poor has changed as it has matured.
  5. To see how the impact of the scheme varies according to how providers are paid and according to what measures are in place to promote quality care, specifically with respect to the long-awaited changes in the fee structure and the proposed increased use of payment methods other than FFS.