UHC Moving toward Viet Nam - World Bank Documents

 
UHC Moving toward Viet Nam - World Bank Documents
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                               Moving toward

                               UHC
                               Viet Nam
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                               NATIONAL I N I T I AT I V ES, KEY CHALLENGES, AND
                               THE ROLE OF COLLABORATIVE ACTIVITIES
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re Authorized
UHC Moving toward Viet Nam - World Bank Documents
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
UHC Moving toward Viet Nam - World Bank Documents
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
UHC Moving toward Viet Nam - World Bank Documents
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

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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:

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