Vietnam Health Insurance Architecture of HI system HI Coverage expansion The evolution of SHI in Viet Nam Family-based subsidy (2014) The HI contribution will be reduced for every extra family member
Reference wage (2016) 1,210,000 percentage of HI contribution 4.50% Maximum HI contribution per month (VND) 54,450 HI contribution Monthly State subsidy 1st member 54,450 0% 0 2nd member 38,115 30% 16,335 3rd member 32,670 40% 21,780 4th member 27,225 50% 27,225 5th member 21,780 60% 32,670 Who is covered and yet to be covered
• Already covered • Formal sector workers, • Children under 6 (100% subsidized) • The poorest (100% subsidized) • Near poor (70% subsidized, some local government 10-20% subsidized) • Full-time students (30% subsidized) • Social insurance pensioners (paid by employers 3% salary, employee: 1.5%) • Beneficiaries of social assistance programmes (farmers, fishers with low income) • To be covered • near-poor, migrants, older persons who are not entitled to social assistance nor social insurance pensions, informal sector workers Sources of Financing for SHI Revenues Health financing mechanism
• Has evolved from tax-based to a mix of three main sources • Government revenue • infrastructure development, • recurrent spending, mainly at provincial level, and • social health insurance subsidies • Social health insurance contributions, and • Out-of-pocket payments. SHI contribution to Heal expenditure low SHI package
• Services covered • Ambulatory care (examination and treatment) • Rehabilitation • Advanced diagnostic and curative services, regular pregnancy check-ups, birth-giving and travelling expenses from commune or district hospitals to higher-level hospitals in some cases • Services not covered • Medical costs covered by other sources, routine health check-up, family planning services, infertility treatment, aesthetic services, occupational diseases, work related accidents; suicide, self-harm activities, substance abuse, consequences of law violation How the cost is covered
• The level of the costs covered by the SHI depends on the group with a variation of 100% - 95% - 80% of the total health expenditure. • No co-payment charged for services provided at commune health stations (only outpatient), including child delivery services. • For insured patients who bypass lower-level referral facilities, the co- payments will be higher Provider payment methods • Capitation • Mainly at district hospitals: above 60% • Some provincial hospitals and equivalent: 73 (13.4%) • Diagnostic-related groups (DRGs) • Pilot in 02 hospitals (Hanoi) • From 2015 - 2016: Pilot in one Province (based on Thai -DRG); 2017 -2018: expand to 5 Provinces. From 2019 for all country • Fee-for-service • The rest Challenges
• Enrolment rates remain low even amongst those enrolment is compulsory, such as the formal sector, and despite large increases in the partial subsidy extended to the near-poor. • In 2010, when nearly 60% of the population was already enrolled, their out-of- pocket (OOP) share in health expenses was still almost 60%. High OOP payments leave households exposed to financial risk. • Quality of services • Issues • Moral hazard in 100% subsidized group and • Adverse selection in no subsidized group • High administrative costs: annual card issuance; classification of HHs The coverage gap
• Enrollment rates % population OOP still high
• OOP share of Total Health Spending and SHI Coverage in Vietnam OOP still high
• OOP Share of Spending in Vietnam and Other EAP Countries (2011) Roap map of reforms
• Expanding the breadth of coverage: • Substantially increase general revenue financing to subsidize enrolment for the near poor and/or informal sector; • Enhance information, education and communication about health insurance to both providers and beneficiaries; • Encourage family enrolment; and • Enforce enrolment compliance in the mandatory enrolment group, particularly formal sector workers. - Improving equity and financial protection - Strengthen implementation of the co-payment policy, including grievance mechanisms; - Further reduce or waive co-payments for the poor and vulnerable groups such as ethnic minorities; and - Introduce catastrophic cost coverage. Roap map of reforms
• Strengthening health financing arrangements for Social Health Insurance (SHI) • Generate additional revenues by raising tobacco taxes and gradually increasing the premium contribution rate; • Rationalize and cost out the benefits package; • Reduce inefficiencies arising from the current mix of provider payment mechanisms; and • De-fragment the procurement of and payment for pharmaceuticals. • Strengthening Organization, Management and Governance of SHI • Define the objectives of UC more clearly, and revise and define the roles and mandates of key agencies; • Strengthen the organization of SHI by putting in place a specialized SHI Division and eventually SHI Agency; • Strengthen SHI management arrangements • Strengthen SHI governance and accountability by clearly specifying financial accounting arrangements, conflict resolution arrangements and penalties.