Moving toward UHC Viet Nam NATIONAL I N I T I AT I V ES, KEY CHALLENGES, AND THE ROLE OF COLLABORATIVE ACTIVITIES Moving toward UHC: Viet Nam Viet Nam’s snapshot 1 Viet Nam’s snapshot Existing national plans and policies to achieve UHC 2 72+28+C Key challenges on the way to UHC 4 UHC Service Coverage Results of Joint External Evaluation Collaborative efforts to accelerate progress toward UHC 10 Index (SDG 3.8.1, 2015) of core capacities for pandemic preparedness (JEE, 2016) 72% References and definitions 12 Score (for capacity) # of indicators (out of 48) 5 Sustainable 0 4 Demonstrated 8 Catastrophic OOP health expenditure incidence at the 10% threshold 3 Developed 25 (SDG 3.8.2, 2011) 2 Limited 15 9.8% of households 1 No capacity 0 Health results Performance of service delivery – selected indicators LMIC Maternal Mortality Under-Five Mortality (PHCPI, 2014-2015) Viet Nam average Ratio (WHO) Rate (WHO) Per 100,000 Live Births Per 1,000 Live Births Care-seeking for symptoms of pneumonia 81% 61.5% Dropout rate between 1st and 3rd DTP vaccination 1% 7.5% Access barriers due to 139 140 treatment costs NO DATA 47.4% 54 47 Access barriers due to distance NO DATA 35.8% 1990 2015 1990 2015 70 (SDG target) 25 (SDG target) Treatment success rate for new TB cases 91% 80.1% Life Expectancy Wealth Differential at Birth (WHO) in Under-Five Mortality (PHCPI) Provider absence rate NO DATA 28.9% 73 76 Caseload per provider NO DATA 9 37.7 per day Diagnostic accuracy NO DATA 47.9% More deaths in lowest than highest wealth quintile Adherence to 2000 2015 per 1,000 live births clinical guidelines NO DATA 33.6% See page 12 for References and Definitions. 1 Moving toward UHC: Viet Nam Moving toward UHC: Viet Nam Existing national plans and policies to achieve universal health coverage (UHC) SERVICE DELIVERY REFORMS (OHSP) 2016–2020 was approved; this is aligned and equity, while health insurance covers group—there are plans to update this to reflect Strengthening the grassroots health care with international and regional initiatives such curative care. the health-related sustainable development goals system. The newly issued 2017 Communist as the International Health Regulations (IHR, (SDGs). In 2016, an MOH plan for application of Party Resolution on People’s Health Protection, 2005) and the Asia Pacific Strategy for Emerging GOVERNANCE REFORMS information technology in the health sector was Care, and Improvement reorients the health Diseases (APSED, 2010). There are also National Reorganization of the health system. issued. Web-based administration and specific system toward prevention and a foundation Action Plans for antimicrobial resistance, Preventive medicine activities are being databases are also being developed to support of grassroots care (district level and below). reduction of antibiotic use in livestock and consolidated under a national and provincial this system. The National Health Strategy 2011–2020 also aquaculture production, and rabies control Centers for Disease Control model to ensure gives prominence to renovating primary care and elimination. The Viet Nam One Health greater coordination and enhance allocative Strengthening stakeholder involvement. For a to achieve national health goals, and in 2016 Partnership for Zoonoses (OHP) was launched efficiency across various functions. At the full decade, the MOH and the Health Partnership the Prime Minister issued a master plan for in 2016 with 27 national and international grassroots level, the fragmentation of curative Group (HPG) have collaborated to produce the developing the grassroots health system. Family partners. and preventive care is being tackled by Joint Annual Health Reviews which provide up- medicine principles are being introduced reintegrating district health centers and district to-date information on the health system, serve to strengthen primary care, particularly at HEALTH FINANCING REFORMS hospitals, which together will be responsible for as an accountability mechanism for the 5-year commune health stations (CHSs), to respond to Health insurance coverage. Viet Nam managing CHSs. and annual plans, and contribute to priority- rapid population aging and noncommunicable enshrined universal social health insurance setting processes. HPG meetings are held to diseases (NCDs). (SHI) coverage in its 2013 Constitution. The Health information systems. The MOH strengthen health and intersectoral coordination Prime Minister and Communist Party have has approved a Health Information System with other ministries, provinces, international Investing in skilled health workers. The set national SHI targets of over 90% coverage Development Strategic Plan for 2014–2020 organizations, and local and international NGOs. Ministry of Health (MOH) has a comprehensive by 2020 and 95% coverage by 2025. Coverage and issued a set of 88 core health indicators The HPG also provides advice to the Ministry on human resource development plan for roadmaps and provincial-level targets to be disaggregated by gender, region, and ethnic major health policy issues. 2012–2020. Recent efforts have focused incorporated into annual plans will help local on strengthening preservice training and authorities achieve these targets. developing competency-based curricula for doctors and nurses, as well as upgrading general Shifting from supply-side to demand-side doctors to family doctors and expanding the subsidies. Supply-side subsidies to health scope of their primary care responsibilities. facilities are being phased out by setting health The number of establishments accredited to service charges at full cost-recovery rates, while Viet Nam enshrined universal social health provide continuing medical education (CME) demand-side subsidies have been introduced is increasing, and professional mentoring is in the form of state budget payments of SHI insurance (SHI) coverage in its 2013 Constitution. used to strengthen competencies in lower-level facilities. New regulations under consideration premiums for disadvantaged or “meritorious” individuals. A transition from state budget The government of Viet Nam has set national include the creation of a Medical Council and toward health insurance financing of disease- SHI targets of over 90% coverage by 2020 and requirements for licensing exams alongside periodic renewal of professional licenses. specific programs, like HIV and TB, is also underway. State budget spending on health 95% coverage by 2025. continues to increase, including as a share of Pandemic preparedness. In 2016, the Viet Nam the overall budget, and is increasingly directed One Health Strategic Plan for Zoonotic Diseases toward public health, preventive measures, 2 3 Moving toward UHC: Viet Nam Moving toward UHC: Viet Nam Key challenges on the way to UHC WEAKNESSES AND BOTTLENECKS Quality of care. Quality assurance systems have IN SERVICE DELIVERY been set up in all hospitals; national protocols Coverage of essential health services. Viet and guidelines have been developed for many Nam is considered one of 10 “fast-track medical conditions and are being applied in countries” for national performance on the hospitals; and health professional education health-related MDGs, but it faces regional reform is shifting toward competency-based and ethnic disparities. The full immunization training, from undergraduate through to and skilled birth attendance rates are well postgraduate levels. Nevertheless, in this over 90%; government investments have hospital-centric system, the CHS does not yet extended and upgraded the network of district satisfy the primary care needs of the population: and provincial hospitals; and existing CHSs staff often have inadequate competencies, lack cover 99% of administrative jurisdictions in expertise in areas such as basic first aid and the country. However, there are substantial screening and management of NCDs, and have and persistent geographic, ethnic, and living few opportunities for continuing education; the standards disparities in health outcomes list of pharmaceuticals that they can dispense is including malnutrition, maternal and under-5 limited; and few basic medical tests or imaging mortality, and access to essential services, such services are available. Consequently, patients as antenatal care. There are also substantial lack confidence in the quality of primary care deficits in health facility capacity in rural facilities, often choosing to seek care at higher- (mountainous and coastal) areas, particularly level hospitals despite substantially higher shortages of well-qualified and experienced staff. co-payments and inconvenience. Viet
Nam is considered one of 10 “fast-track countries” for its strong national performance on the health-related MDGs, but it faces regional
and ethnic disparities. 4 5 Moving toward UHC: Viet Nam Moving toward UHC: Viet Nam and borrowing constraints making efficiency The SHI benefits package of essential health imperative, particularly in the face of rapid services covers a broad range of services, population aging and the availability of new, including ambulatory care, rehabilitation, more costly technologies. Provider payment advanced diagnostics, and curative services. arrangements do not incentivize providers to However, about one-fifth of the population still focus on cost-effectiveness, resulting in overuse lacks SHI coverage, mainly the self-employed of high-tech services. Increases in prices, coupled or employees of small enterprises. Insured with the expanded scope of the SHI package, individuals, even those who are not required translate into greater costs to be reimbursed by to pay co-payments, still face burdensome the SHI fund without a commensurate increase and unpredictable out-of-pocket (OOP) in resources. At the system level, the large share payments, including fees for equipment of public subsidies allocated to secondary provided by private investors, drugs outside and tertiary hospitals diverts funds from of the insurance formulary, and costs of strengthening primary and preventive care. transportation, food, and accommodations for family members accompanying patients. Financial protection and targeted assistance to There are also large inequalities in access to disadvantaged groups. Viet Nam ensures quality services in the benefit package between that a large share of the population is covered the poor and nonpoor. Some important health by a fairly generous package of services. The interventions, such as disease screening Health Insurance Law (2014) entitles many among asymptomatic individuals, smoking groups to fully subsidized SHI, including the cessation, or substance abuse treatments, are poor, near-poor who have recently escaped neglected because they are covered by neither poverty, children under six, ethnic minorities state budget nor SHI. There is also a risk in disadvantaged regions, and social assistance that groups targeted in the national health beneficiaries. In addition, school children, programs for HIV and TB may fall between the the near-poor, and average and lower income cracks during the transition from government farmers are entitled to partial subsidies. subsidy to SHI coverage for these conditions. Pandemic preparedness. A 2016 Joint External THE STATE OF HEALTH FINANCING Evaluation (JEE) of the International Health Overall funding for health. Viet Nam’s health Regulations (IHR) core capacities revealed that spending continues to grow, but allocative 63% Viet Nam has many of the necessary systems and technical efficiency could be substantially and processes established, but also identified improved to attain greater health improvements key areas for improvement and a general need with existing funds. Between 1995 and 2014, Between 1995 and 2014, out-of-pocket 37% to enhance the sustainability of established total health expenditure increased steadily, capacities. Areas where current capacities from 5.2% to 7.1% of GDP (WDI, 2017). State are most limited are: measures to combat budget spending on health rose from 7.9% to spending has fallen in relative terms, antimicrobial resistance; development and implementation of a preparedness and response 14.2% of government spending over the same period (WDI, 2017). Out-of-pocket spending from 63% to 37% of total health plan, with priority risks and resources mapped; has continued to increase in absolute terms, expenditure (WDI, 2017). 1995 2014 linking public health and security authorities; but has fallen in relative terms, from 63% to medical countermeasures and personnel 37% of total health expenditure (WDI, 2017). deployment; and mechanisms to detect and Continued growth in health spending will be manage chemical events. difficult to maintain due to government budget 6 7 Moving toward UHC: Viet Nam Moving toward UHC: Viet Nam Health information systems. Major efforts records are under way. Despite the rapid are under way to increase the application of adoption of information technology, rules Despite the rapid adoption of information information technology in the health sector and on how health information can be used, by clinical management. Websites for the Ministry, whom, and for what purposes have not yet technology, almost no data are available about local health authorities, and facilities are been developed. Sharing of information the private health sector, which makes increasingly used to disseminate information. Various agencies and units of the health across departments remains weak. The MOH’s dissemination of health statistics a substantial contribution to outpatient care. sector collect vast amounts of administrative is typically delayed, with inconsistencies data, including on health professional in estimates over time. Consequently, the registration, infectious disease surveillance, use of data for policy making, regulation, and pharmaceutical prices. VSS now has a and planning remains weak. Almost no consolidated database to facilitate electronic data are available about the private health claims processing, from the lowest level of care. sector, despite its substantial contribution to Discussions to create unique electronic patient outpatient care. GOVERNANCE CHALLENGES integrated into curative care services because Reorienting the health system away from of policies that assign these roles to different the current hospital-centric model toward agencies and financial incentives that favor PHC. Despite major efforts to refocus the curative interventions at the expense of health system on primary care, prevention, and prevention. health promotion, resource flows and policies still favor secondary and tertiary care. Policies Role of the MOH and Provincial Health calling for capital investments in district Departments. Current organizational reforms hospitals and CHSs, mentoring arrangements in the health sector focus on consolidating to strengthen competencies of district hospital the units working on preventive medicine staff, and the expansion of services covered by (e.g., HIV/AIDS control centers, reproductive health insurance at lower-level facilities have health centers, etc.) and reintegrating district- begun to strengthen primary care. However, level preventive and curative care units. The the health system remains strongly hospital- regulatory function in health insurance has centric. In the absence of a strong regulatory been separated from the operational and framework for supervision and control of payment functions, with health insurance hospitals, the “socialization” policy and policy making residing with the MOH while public-private partnership (PPP) arrangements payment is the responsibility of Viet Nam (in place to recover capital investments from Social Security (VSS). Despite these reforms, private investors, including hospital staff) are as both a regulator/steward of the system further aggravating the overuse of high-tech and a provider of services through direct health services. At the same time, the CHS level management of government health facilities, is under resourced: staff tend to have poorer MOH policies and resource allocations qualifications, the facility is authorized to conflict with the need for income generation provide only a limited scope of services, and for its health facilities. Also, private health CHS budgets are highly dependent on local facilities face regulations and enforcement budget allocations (with health insurance that can be more (or less) stringent than the reimbursements accruing to the district even if public sector (depending on the area). The services are delivered at the CHS). Patients are MOH has also faced substantial difficulties often referred upward, but then are retained at in advocating for measures outside of the the hospital rather than being sent back to the health sector to enhance population health; CHS for follow-up. Preventive and promotive more attention needs to be paid to promoting health measures have been inadequately health in all sectors. 8 9 Moving toward UHC: Viet Nam Moving toward UHC: Viet Nam Collaborative efforts to accelerate progress The PHRD program, financed by the
government of toward UHC Japan and carried out by the World Bank, consists of two main activities: analytical and advisory work intended to enhance the efficiency with which EXISTING INITIATIVES SUPPORTED Partnership Group (convened by the MOH) BY EXTERNAL PARTNERS and the technical working groups of the health sector financing is used in Viet Nam, and a External partners are engaged in Viet Nam to MOH (e.g., on nutrition, reproductive health, set of activities intended to strengthen Viet Nam’s build national capacity and strengthen the human resources, information systems, health system. The Tokyo Joint UHC Initiative, health financing). Currently, the areas in preparedness for pandemic emergencies. supported by the government of Japan and which these partners are collaborating most led by the World Bank (WB), in collaboration closely are health financing reform (especially with the Japan International Cooperation provider payments), equity, grassroots Agency (JICA), United Nations Children’s Fund service delivery reform, human resource (UNICEF), and the World Health Organization development, and pandemic preparedness. (WHO), as well as the UHC Partnership led Other important partners include the by the WHO, and supported by the European European Union (EU), the Asian Development Commission and Luxembourg, are supporting Bank (ADB), the U.S. Agency for International PLANS FOR FUTURE provide analytical and advisory services to the Viet Nam government and strive to Development (USAID), the Centers for COLLABORATIVE WORK the government of Viet Nam to implement accelerate progress toward UHC. Cooperation Disease Control and Prevention (CDC), the key recommendations of the Joint External between these partners is close, facilitated by United Nations Population Fund (UNFPA), Policy and Human Resources Development Evaluation) and, in so doing, strengthen formal and informal coordination mechanisms. the Food and Agriculture Organization (FAO), (PHRD)-funded advisory support pandemic preparedness. The specific objectives Formal mechanisms include the Health and the government of Korea. The PHRD program, financed by the are to: (i) improve overall preparedness and government of Japan and carried out by the coordination of capacity for pandemic risk World Bank, consists of two main activities. reduction, and (ii) strengthen management First is analytical and advisory work intended to of specific priority sources of zoonotic and enhance the efficiency with which health sector pandemic risk. financing is used in Viet Nam. The objective is to help the Ministry of Finance, the Ministry of In carrying out these activities, the World Bank Planning and Investment, the Ministry of Health, and the government of Japan collaborate with Viet Nam Social Security and the provinces to (i) other agencies, including JICA, WHO, UNICEF, identify areas of the health system where money CDC, EU, and ADB, who also have current and is being spent without yielding substantial future engagements with the government of Viet improvements in health with a view to getting Nam in these areas. more value for money out of existing spending, and (ii) identify how, in a select subset of these Activities to improve efficiency in health areas, spending on activities with low returns to spending will also inform the design and health can be reduced, thus freeing up funds for implementation of an IDA-financed project activities with better returns. (which also benefits from a buy-down from the Global Financing Facility) that seeks to improve Second are a set of activities intended to the overall efficiency of the health system strengthen Viet Nam’s preparedness for through strengthening the capacity of primary pandemic emergencies. The objective is to care facilities. 10 11 Moving toward UHC: Viet Nam References & Definitions (page 1 indicators) UHC Service Coverage Index (2015) – Life Expectancy at Birth (2000-2015), WHO/World Bank index that combines 16 Maternal Mortality Ratio (1990-2015), tracer indicators into a single, composite Under-five Mortality Rate (1990-2015) – metric of the coverage of essential health WHO Global Health Observatory: services. For more information: WHO/World http://apps.who.int/gho/data/node.home Bank (2017). Tracking UHC: Second Global Monitoring Report. Wealth Differential in Under-five Mortality (Single data point, year varies by country) Catastrophic out-of-pocket (OOP) health – Indicator used by the Primary Health Care expenditure incidence at the 10% threshold Performance Initiative (PHCPI) to reflect equity (Single data point, year varies by country) – in health outcomes. For more information: WHO/World Bank data from Tracking UHC: https://phcperformanceinitiative.org/indicator/ Second Global Monitoring Report (2017). equity-under-five-mortality-wealth-differential Catastrophic expenditure defined as annual household health expenditures greater than Performance of service delivery – selected 10% of annual household total expenditures. indicators (Single data points, years vary by country) – Indicators used by the Primary Health Results of the Joint External Evaluation of Care Performance Initiative (PHCPI) to capture core capacities for pandemic preparedness various aspects of service delivery performance. (2016/17, year varies by country) – A voluntary, PHCPI synthesizes new and existing data from collaborative assessment of capacities to validated and internationally comparable prevent, detect, and respond to public health sources. For definitions of individual indicators: threats under the International Health https://phcperformanceinitiative.org/about-us/ Regulations (2005) and the Global Health our-indicators#/ Security Agenda. 48 indicators of pandemic preparedness are scored using five levels (1 is no capacity, 5 is sustainable capacity). https://www.ghsagenda.org/assessments Photo credits: Page 5, 9 & 10: Caryn Bredenkamp / World Bank Page 6: Dominic Chavez / World Bank Co-authored by: 12