UHC Moving toward Viet Nam - World Bank Documents
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Public Disclosure Authorized
Moving toward
UHC
Viet Nam
Public Disclosure Authorized
NATIONAL I N I T I AT I V ES, KEY CHALLENGES, AND
THE ROLE OF COLLABORATIVE ACTIVITIES
Public Disclosure Authorized
re Authorized
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 5Moving 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 7Moving 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 9Moving 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 11Moving 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:
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