LUẬN văn THẠC sĩ removing barriers for people living with HIV in accessing and utilizing social health insurance in vietnam

VIETNAM NATIONAL UNIVERSITY, HANOI VIETNAM JAPAN UNIVERSITY NGUYEN KIEU AN REMOVING BARRIERS FOR PEOPLE LIVING WITH HIV IN ACCESSING AND UTILIZING SOCIAL HEALTH INSURANCE IN VIETNAM MASTER’S THESIS Hanoi, 2019 LUAN VAN CHAT LUONG download : add luanvanchat@agmail.com VIETNAM NATIONAL UNIVERSITY, HANOI VIETNAM JAPAN UNIVERSITY NGUYEN KIEU AN REMOVING BARRIERS FOR PEOPLE LIVING WITH HIV IN ACCESSING AND UTILIZING SOCIAL HEALTH INSURANCE IN VIETNAM MAJOR: PUBLIC POLICY CODE: 17110073 RESEARCH SUPERVISOR: Prof Dr BUI THE CUONG Hanoi, 2019 LUAN VAN CHAT LUONG download : add luanvanchat@agmail.com Table of contents Abbreviations List of tables CHAPTER 1: INTRODUCTION AND BACKGROUND INFORMATION 1.1 Introduction 1.2 Country background – Vietnam 1.3 HIV situation and financing in Vietnam .3 1.3.1 Overview of HIV/AIDS epidemic and PLHIV .3 1.3.2 HIV policies and financing 1.3.3 Social Health Insurance in relation to HIV treatment 1.4 Literature review .9 1.5 Research rationale and objectives 10 1.6 Research questions .11 1.7 Research significance 11 CHAPTER 2: METHODOLOGY 12 2.1 Research methods 12 2.2 Research setting .12 2.3 Data collection measures .13 2.4 Data analysis 14 CHAPTER 3: RESEARCH FINDINGS 15 3.1 General information 15 3.2 Reasons PLHIV not buying SHI 17 3.3 Barriers in accessing SHI 20 3.4 Ability and willingness to buy SHI .21 3.3 PLHIV’s use of SHI .22 3.5 Barriers in utilizing SHI 23 CHAPTER 4: DISCUSSION 25 4.1 Key findings 25 4.2 Discussion .25 4.3 Recommendations 27 CHAPTER 5: CONCLUSION 29 5.1 Summary .29 5.2 Limitations of the study .29 References 30 Appendixes 33 Appendix Questionnaire for PLHIV 33 LUAN VAN CHAT LUONG download : add luanvanchat@agmail.com Abbreviations AIDS Acquired Immunodeficiency Syndrome ART Antiretroviral Therapy ARV Antiretroviral HIV Human Immunodeficiency Virus MOH Ministry of Health PLHIV People living with HIV SHI Social Health Insurance UNAIDS Joint United Nations Program on HIV/AIDS UNDP United Nations Development Program VAAC Vietnam Administration on HIV/AIDS Control VND Vietnamese Dong WHO World Health Organization LUAN VAN CHAT LUONG download : add luanvanchat@agmail.com List of tables Table 1: PLHIV by gender and possession of SHI Table 2: PLHIV by age and possession of SHI Table 3: PLHIV by location and possession of SHI Table 4: Means to access SHI Table 5: Reasons PLHIV not buy SHI Table 6: Barriers for PLHIV to access SHI Table 7: Ability of PLHIV to buy SHI Table 8: Willingness of PLHIV to buy SHI Table 9: Most recent use of SHI Table 10: Most recent service to use SHI Table 11: Barriers for PLHIV to utilize SHI Table 12: PLHIV’s wanted services not covered by SHI LUAN VAN CHAT LUONG download : add luanvanchat@agmail.com CHAPTER 1: INTRODUCTION AND BACKGROUND INFORMATION 1.1 Introduction Human Immunodeficiency Virus and Acquired Immunodeficiency Syndrome (HIV/AIDS) is one of the major public health problems in the world (UNAIDS, 2018) In 2017, the Joint United Nations Program on HIV/AIDS (UNAIDS) estimated that there were 36.9 million people living with HIV (PLHIV) worldwide Vietnam, with a population of 95.5 million people and a Gross Domestic Product (GDP) per capita of USD 2,389 (World Bank), has a number of PLHIV reportedly to be 208,371 according to the Vietnam Administration on HIV/AIDS Control Even though a cure is yet to be found for the disease, accessing to antiretroviral therapy (ART) – a combination of drugs that suppresses and stops the progression of HIV - can help improve the life expectancy of PLHIV and help them to lead a healthy and productive life (Oguntibeju, 2012; Nakagawa F, 2013) That said the treatment requires lifelong commitment and often is out-of-reach financially for PLHIV, especially those in low and middle-income countries (Clayden, 2013) In the last decades, ART in Vietnam was provided free-of-charge mainly through international funding and programs (Downie, 2017) However, as Vietnam became a lower-middle income country, external funding for HIV programs, including procurement of ART medicines has been withdrawn dramatically (MOH, 2014) The Government of Vietnam, thus, deems transitioning from foreign funded programs to a more sustainably financing mechanism, in which HIV care and treatment is covered by Social Health Insurance (SHI) as a priority It is reflected in the Law on Health Insurance in 2008 and 2014, and the recent LUAN VAN CHAT LUONG download : add luanvanchat@agmail.com Circular No.27/2018 of the Minister of Health on guiding the implementation of health insurance for HIV treatment Various decrees and circulars also support this strategy Nevertheless, Nguyen and Wilson (2017) point out that cost of insurance premiums is a barrier for the near-poor to access to SHI More specifically, Nguyen et al (2017) find that a high proportion of PLHIV was not covered by SHI for which financial difficulty and lack of information are the underlying reasons It is noted that previous studies and researches mostly focus on access to SHI while to be able to utilize SHI in practice poses other challenges for PLHIV This study, therefore, attempts to provide additional data and a better insight of existing barriers for PLHIV in accessing and utilizing SHI in Vietnam It is also hoped to generate feasible recommendations to remove such barriers to contribute toward improving the quality of life of PLHIV and social equality in the country 1.2 Country background – Vietnam The Socialist Republic of Vietnam is located in Southeast Asia It is bordered by China, Laos and Cambodia, with a long coastline that connects to the East Sea The country covers approximately 331,212 km2 and has a population of 95.5 million from 54 different ethnic groups (World Bank) Since its political and economic reform in 1986, the country has made a remarkable transformation with a GDP growth rate ranked among the fastest globally (ICAEW, 2018) The renovation allowed the country to open its previously isolated market to welcome favorable bilateral and multilateral trade agreements as well as expand its diplomatic relations, namely joining ASEAN in 1995, APEC in 1998 Subsequently, in 2011, Vietnam was categorized as a lower middle-income country, having reduced its poverty LUAN VAN CHAT LUONG download : add luanvanchat@agmail.com headcount from 58% in the early 1990s to 14.5% in 2008 (UNDP) At the moment, Vietnam’s GDP per capita is around USD 2,389 (World Bank) The social and human aspects of Vietnam have also experienced positive progress over the years The country’s Human Development Index value was 0.694 in 2017, which is 46.1% higher than the value of 0.475 in 1990 This puts the country in the medium human development category – positioning at 116/189 countries in the world (UNDP, 2018) Vietnamese are expected to live longer with life expectancy at birth at 76.5 years for 2017 (UNDP, 2018) Child health also gets better with under-5 mortality, infant mortality and malnutrition rates all drop significantly (WHO) Despite such improvements, inequality grows larger and quicker in several dimensions Taylor (2004) states that wealth gaps exist between geographical regions, Hanoi and Ho Chi Minh city, for instance, have income per capita two to five times more than some remote and rural provinces He also mentions the discrepancies between women and men, where in women are less likely to attend secondary school and university, hence less likely to be in salaried employment, and even when they are, their hourly wage tends to be lesser These issues are reaffirmed in a more recent report by Oxfam (2017) The same report also emphasizes inequalities in economic as well as standard of living between different ethnic groups and disadvantaged populations Similarly, inequality of opportunity due to discrimination based on disability and HIV status is most severe, according to the 2015 Justice Index by UNDP 1.3 HIV situation and financing in Vietnam 1.3.1 Overview of HIV/AIDS epidemic and PLHIV Having the first HIV case detected in December 1990, by the 3rd quarter of 2017, it was estimated that there were 208,371 people living with HIV in the LUAN VAN CHAT LUONG download : add luanvanchat@agmail.com country (VAAC, 2017) Among those, 22% was female and 78% was male Although the number of new HIV cases has been reduced over the years, it has been persistently staying around 12,000 to 14,000 people become infected every year, and AIDS-related deaths is around 12,000, according to the Joint United Nations Programme on HIV/AIDS HIV in Viet Nam is considered a concentrated epidemic – meaning while transmission rate among the general population is relatively low (below 0.4% among adults), the rate is much higher among high-risk populations, typified by people who use drugs, men who have sex with men and sex workers (UNAIDS) UNAIDS reports that most of PLHIV in Vietnam lives in large cities and mountainous provinces It is noted by Nguyen et al (2008) that despite being increasingly at risk of HIV transmission, women in Vietnam are often under-protected due to lack of awareness, not getting tested and lack of preventive measures In a report published by Vietnam Network of People Living with HIV (2015), 20% of HIV-positive respondents reported being unemployed; households of PLHIV have monthly income of above VND million (~ USD 216) are 54%, 38% between VND -5 million (~ USD 86 - 216) and 8% under VND million (~ USD 86)1 Accessing to antiretroviral therapy (ART) – a combination of drugs that suppresses and stops the progression of HIV - can help improve the life expectancy of PLHIV and help them to lead a healthy and productive life (Oguntibeju, 2012; Nakagawa F, 2013) The treatment requires life-long commitment meaning patients need to take the medication regularly as well as being adherence to appointed check-ups and testing Not taking ARV puts The survey was conducted among 1625 participants from Hanoi, Haiphong, Dien Bien, Can Tho and Ho Chi Minh city LUAN VAN CHAT LUONG download : add luanvanchat@agmail.com PLHIV at risk of opportunistic infections and progression to AIDS However, only half of the people who need treatment has access to ART in the country (VAAC, 2017; UNAIDS; WHO) Furthermore, even though the 2006 Law on HIV/AIDS Prevention and Control forbid stigma and discrimination against PLHIV, it is reported that many still face problems in getting a job, being treated unfairly in the workplace as well as experience discrimination in healthcare setting (Doan et al, 2008; Khuat, Nguyen, & Ogden, 2004; Lim et al, 2013) 1.3.2 HIV policies and financing National programs to control HIV were set up in the early 1990s Since then, huge efforts have been made to control the rate of infection, reduce mortality and improve the livelihood of those affected In 1995, an Ordinance on HIV/AIDS prevention and control was adopted by the National Assembly – it acted as the first legal framework for HIV intervention efforts in the country This early period of the HIV response relied heavily on compulsory testing, coerced rehabilitation of and stigmatized propaganda about HIV high-risk groups In 2004, a National Strategy on HIV/AIDS for 2004 – 2010 with a vision to 2020 was put in place, which adopted international best practices and recommendations on HIV prevention, care, support and treatment This strategy embraced the concept of harm reduction, encouraged information campaigns and voluntary testing and counseling instead of mandatory HIV testing Then, the 2006 Law on HIV/AIDS Prevention and Control emphasized the principle of no stigma and discrimination against PLHIV These changes have shown the country’s “gradual shift from a punitive approach to a more human rights-based approach” (as commented by the Inter-Parliamentary Union Advisory Group, LUAN VAN CHAT LUONG download : add luanvanchat@agmail.com A female interviewee from Ho Chi Minh City said that she was able to buy SHI for herself, but if she had had to buy for her whole family of five, she would not have afforded that much money because the day-to-day feeding of her children was already a challenge Another female interviewee from Bac Giang also shared a similar situation “When I brought my husband to the place (selling SHI), they looked over our household book to see how many people has had SHI and who has not then ask us to buy for them” Lack of identification document 26% also reported not being able to buy SHI due to lack of Identification Card; 7% not have family-register book and 5% not have a permanent residential registration Lack of information Another barrier reported was the fact that information is either not available and/or not clearly communicated to this population This leads to PLHIV not knowing how to buy SHI 3.4 Ability and willingness to buy SHI When asked if 702,000 VND per year is required, is it possible for PLHIV to buy health insurance, 89% of respondents said they did not have this ability Table 7: Ability of PLHIV to buy SHI Cannot afford SHI for a year 87 (89%) Can afford SHI for a year 12 (12%) Total 99 (100%) 21 LUAN VAN CHAT LUONG download : add luanvanchat@agmail.com However, in order to explore the willingness to buy social health insurance from PLHIV participating in the survey, the question "If you have enough money, are you willing to buy SHI?" was asked 93% of respondents said they are willing to buy Table 8: Willingness of PLHIV to buy SHI Willing to buy SHI 91 (93%) Not willing to buy SHI (7%) Total 98 (100%) 3.3 PLHIV’s use of SHI For those currently having SHI, 38% reported never use the card, which accounted for the largest proportion The rest who have used their SHI card for services – their time of use varies but not too different Table 9: Most recent use of SHI Within a month 16 (16%) to months ago 21 (22%) to 12 months ago 13 (13%) More than 12 months ago 11 (11%) Never use 37 (38%) Total 98 (100%) The reasons for SHI use of participants were also explored The results show that PLHIV use SHI for not one single reason but mostly for general check-up (23%) and ARV treatment (12% ) Table 10: Most recent service to use SHI General health check-up 22 (23%) ARV treatment 11 (12%) 22 LUAN VAN CHAT LUONG download : add luanvanchat@agmail.com Digestive problems 10 (11%) Tuberculosis examination and treatment (9%) Others Total 98 (100%) 3.5 Barriers in utilizing SHI When exploring barriers to utilizing SHI, the issue of quality of services and medications provided under the SHI scheme came up often Table 11: Barriers for PLHIV to utilize SHI Face no barrier/problem 25 (22%) The process for reimbursement is time-consuming, 17 (15%) complicated Current place of living is different from the SHI initial (5%) registration place Being looked down upon, the quality of care received 14 (12%) was lower than those who use non-SHI services Being stigmatized and/or discriminated against because 16 (14%) of HIV status/gender The medicines paid by SHI were of lower quality 25 (22%) The service(s) needed was not covered by SHI 10 (9%) Others (1%) Total 114 (100%) From Table 10, 78% did not find satisfactory with the quality of services provided Specifically, 15% complained about the time-consuming and complicatedness of reimbursement procedures; 12% reported being looked down upon and received lower quality of services when using SHI; 14% felt stigmatized and discriminated against because of their HIV status or gender; a 23 LUAN VAN CHAT LUONG download : add luanvanchat@agmail.com high number of participants (22%) also felt that the medicines provided by SHI were of lower quality Table 12: PLHIV’s wanted services not covered by SHI HIV-related testing (26%) Methadone treatment (26%) Hepatitis C testing, genotyping and treatment 15 (48%) Total 31 (100%) Besides, participants also mentioned other necessary services they wished to use but currently not provided by SHI, namely HIV-related testing (complete blood count, testing for CD4 counts, HIV viral load), Methadone treatment, Hepatitis C testing, genotyping and treatment 24 LUAN VAN CHAT LUONG download : add luanvanchat@agmail.com CHAPTER 4: DISCUSSION 4.1 Key findings First of all, the survey shows that the coverage of social health insurance among PLHIV is still low, 51% not yet have a health insurance card Secondly, the biggest barriers for PLHIV to access to SHI is due to lack of money thus making procurement of SHI impossible and/or interrupted Following reasons are fear of stigma and discrimination, fear of disclosing of identity, regulation requiring buying SHI by household, lack of necessary identification documents, and unawareness of the importance of health insurance Thirdly, 78% of PLHIV with social health insurance said that they were not satisfied with the quality of services when using SHI The reasons for their dissatisfaction include: poor quality of medication, discrimination, complicated reimbursement procedures, and some necessary services not covered by SHI Fourthly, even though PLHIV reportedly have a huge need to buy SHI, with the current health insurance premium of about 702,000 vnd a year, 89% of PLHIV are unable to pay 4.2 Discussion Despite lots of efforts spent by the government, social health insurance agency, non-governmental organizations and the community to advocate for PLHIV’s access to SHI in order to ensure their financial security and protection should the needs for health services arise, result from this study shows that many PLHIV either are reluctant to buy or not have enough information about SHI 25 LUAN VAN CHAT LUONG download : add luanvanchat@agmail.com The majority of non-SHI respondents in the survey said that the biggest barrier preventing them from accessing social health insurance is financial issues As previous literature show PLHIV are often employed or having low income Finance remains and will always be a difficulty for them Another important barrier to HIV prevention in Vietnam for many years is stigma It can be seen that PLHIV's fear of disclosing their identity is a consequence of fear of stigma The study noted examples of discrimination in the community and even in health setting In addition to being exposed to non-positive attitudes, when coming to health facilities, oftentimes PLHIV could even be denied services This creates a challenge not just for PLHIV but also SHI agency since PLHIV may not want to buy or may not want to use health insurance Besides a number of barriers in accessing SHI for PLHIV similarly identified by prior researches including financial constraints and stigma and discrimination, the study offers new finding in term of conflicting understanding of the regulation of buying SHI by household that has created difficulty for PLHIV in accessing SHI The Health Insurance Law stipulates that all family members participate in health insurance, and the rate of payment from the second person onwards will be deducted However, the Circular 1018/TTg-KGVX dated June 10, 2016 on the purchase of health insurance card by households clearly stated that individual purchasers will not be entitled to a deduction It means that people can buy health insurance individually and will have to accept no deductions From the survey and focus discussions, however, PLHIV are still being required to buy SHI for all household members at one time Thus, it is necessary to re-disseminate information to localities and people in charge to understand and follow the 26 LUAN VAN CHAT LUONG download : add luanvanchat@agmail.com abovementioned Law and Circular in order to facilitate the procurement of SHI In addition, it is found that the lack of identification document including ID card, family-register book and permanent residential registration also hinder PLHIV’s ability to access and utilize SHI Various reasons are behind this situation, including background (being drug user, going to prisons), living situation (immigrants, loss due to moving, not being in touch with family) etc This issue is harder to solve since it requires reviewing individual cases and advise and guide can be given individually depending on specific circumstances Having said that, solving this issue will not only facilitate PLHIV in accessing and utilizing SHI but also fulfill their human right and allow them better engage in other social activities and services 4.3 Recommendations Based on the identified barriers for PLHIV in accessing and utilizing Social Health Insurance, some recommendations could be drawn to remove such barriers: Strengthen communication regarding SHI policies Lack of information and not being aware of the benefits of SHI have resulted in many people not buying and using SHI Moreover, due to the complex nature of health insurance policies, conflicting understanding of the policy is also preventing people, especially PLHIV in accessing to SHI Thus, it is crucial to provide correct information to raise the level of knowledge for the people and agency in charge in on the following aspects: the role of SHI in socio-economic development and social security; benefits of SHI; legal conditions and procedures to participate in and use SHI 27 LUAN VAN CHAT LUONG download : add luanvanchat@agmail.com Information and communication channels should also be diversified and targeted for different populations, such as PLHIV and other vulnerable groups Reduce stigma and discrimination against HIV and PLHIV This issue goes beyond the ability to access and utilize SHI yet it is one of the most important factor affecting the social inclusion and quality of life of PLHIV By improving social perception of HIV and PLHIV, it allows PLHIV to better engage in social activities, seeking employment and accessing to services It is even more important that stigma and discrimination against PLHIV be strictly regulated in health setting so that PLHIV are not discouraged from seeking health services and utilizing SHI 28 LUAN VAN CHAT LUONG download : add luanvanchat@agmail.com CHAPTER 5: CONCLUSION 5.1 Summary The study found that a high number of PLHIV are not covered by Social Health Insurance despite a strong willingness and need to buy it Barriers for PLHIV to access to SHI is due to lack of money, fear of stigma and discrimination, fear of disclosing of identity, regulation requiring buying SHI by household, lack of necessary identification documents, and unawareness of the importance of health insurance Barriers for PLHIV in utilizing SHI are also determined including poor quality of medication, discrimination, complicated reimbursement procedures, and some necessary services not covered by SHI The study offers new findings in term of conflicting understanding of legal policy and lack of identification document which hinder PLHIV’s ability to access and utilize SHI Recommendations regarding strengthening of communication about SHI policies and reducing stigma and discrimination against PLHIV are given 5.2 Limitations of the study  Quantitative data collected through self-reporting might be affected by biases such as misunderstanding of questions, exaggeration and/or reluctant in revealing information  Qualitative data was collected limited number of participants  Representativeness of data was limited in terms of demographic, gender and age  Some factors were not explored including income and occupation of PLHIV 29 LUAN VAN CHAT LUONG download : add luanvanchat@agmail.com References How VN will control AIDS absent foreign funds (2017) Retrieved December 26, 2018, from vietnamnews.vn: https://vietnamnews.vn/society/health/372704/how-vn-will-control-aidsabsent-foreign-funds.html Clayden, P (2013) High prices for antiretrovirals in middle-income countries outside Africa 7th IAS Conference on HIV pathogenesis, treatment and prevention Kuala Lumpur: IAS Doan, T M., Brickley, D B., Dang, T N., Colby, D J., Sohn, A H., Nguyen, Q T., et al (2008) A Qualitative Study of Stigma and Discrimination against People Living with HIV in Ho Chi Minh City, Vietnam Downie, R (2017) Advancing Country Partnerships on HIV/AIDS, Feyissa, G T., Lockwood, C., Woldie, M., & Munn, Z (2019) Reducing HIVrelated stigma and discrimination in healthcare settings: A systematic review of quantitative evidence General statistics office (2017) Statistical summary book of Vietnam ICAEW (2018) Retrieved December 26, 2018, from www.icaew.com: https://www.icaew.com/technical/economy/economic-insight/economicinsight-south-east-asia Inter-Parliamentary Union (2014) HIV and AIDS in Viet Nam – facing the challenges Khuat, T H., Nguyen, T V., & Ogden, J (2004) Understanding HIV and AIDSrelated stigma and discrimination in Vietnam Lim, T., Zelaya, C., Latkin, C., Quan, V., Frangakis, C., Ha, T., et al (2013) Individual-level socioeconomic status and community-level inequality as determinants of stigma towards persons living with HIV who inject drugs in Thai Nguyen, Vietnam MOH (2012) Health statistics yearbook 2012 MOH (2014) Optimizing Viet Nam’s HIV Response: An Investment Case, 11 MOH (2016) Vietnam 2013 General Health Accounts and Disease Expenditures with Sub-Analysis of 2013 HIV/AIDS Expenditure MOH (2018, Octorber 26) Circular No.27/2018/TT-BYT on guiding the implementation of health insurance for HIV treatment Hanoi, Vietnam: Ministry of Health MOH (2019) Sự kiện “Những bệnh nhân HIV/AIDS điều trị thuốc ARV từ nguồn BHYT” Retrieved March 20, 2019, from moh.gov.vn: http://moh.gov.vn/web/tin-noi-bat/content/su-kien-nhung-benh-nhan-hivaids-au-tien-ieu-tri-bang-thuoc-arv-tu-nguon-bhyt Nakagawa, F., May, M., & Phillips, A (2013) Life expectancy living with HIV: recent estimates and future implications 30 LUAN VAN CHAT LUONG download : add luanvanchat@agmail.com Nguyen, D., & Wilson, A (2017) Coverage of health insurance among the nearpoor in rural Vietnam and associated factors Nguyen, L T., Tran, B X., Tran, C T., Le, H T., & Tran, S V (2014) The cost of antiretroviral treatment service for patients with HIV/AIDS in a central outpatient clinic in Vietnam Nguyen, Q L., Phan, T V., Tran, B X., Nguyen, L H., Ngo, C., Phan, H T., et al (2017) Health insurance for patients with HIV/AIDS in Vietnam: coverage and barriers Nguyen, T A., Oosterhoff, P., Hardon, A., Tran, H N., Coutinho, R A., & Wright, P (2008) A hidden HIV epidemic among women in Vietnam NIHE (2014) HIV/STI Integrated Biological and Behavioral Surveilance (IBBS) in Vietnam Results from round III 2013 and trends across three rounds (20052009-2013) of surveys Ministry of Health Oguntibeju, O O (2012) Quality of life of people living with HIV and AIDS and antiretroviral therapy Oxfam (2017) Even it up How to tackle inequality in Vietnam Hanoi: Oxfam PEPFAR (2018) Country Operational Plan Vietnam COP 2018 Strategic Direction Summary Pham, N H., Pharris, A., Nguyen, T H., Nguyen, T K., Brugha, R., & Thorson, A (2010) The evolution of HIV policy in Vietnam: from punitive control measures to a more rights-based approach Taylor, P (2004) Social inequality in Vietnam and the challenges to reform Singapore: Institute of Southeast Asian Studies Tran, B X., Boggiano, V L., Nguyen, C T., Nguyen, L H., Nguyen, A T., & Latkin, C A (2017) Barriers to accessing and using health insurance cards among methadone maintenance treatment patients in northern Vietnam Tran, B X., Duong, A T., Nguyen, L T., Hwang, J., Nguyen, B T., Nguyen, Q T., et al (2012) Financial burden of health care for HIV/AIDS patients in Vietnam Tran, B X., Than, P Q., Tran, T T., Nguyen, C T., & Latkin, C A (2019) Changing Sources of Stigma against Patients with HIV/AIDS in the Rapid Expansion of Antiretroviral Treatment Services in Vietnam UNAIDS (n.d.) Retrieved December 28, 2018, from www.unaids.org: http://www.unaids.org/en/regionscountries/countries/vietnam UNAIDS (2012) Expanding long term financing options for HIV in Vietnam UNAIDS (2018) Global AIDS update 2018: Miles to go Closing gaps, breaking barriers, righting injustices, 24 UNAIDS (2018) Global HIV & AIDS statistics - 2018 fact sheet Retrieved December 26, 2018, from http://www.unaids.org/en/resources/fact-sheet UNDP (2016) 2015 Justice Index Towards a justice system for the people 31 LUAN VAN CHAT LUONG download : add luanvanchat@agmail.com UNDP (2018) Human Development Indices and Indicators: 2018 Statistical Update - Vietnam, UNDP (n.d.) www.vn.undp.org Retrieved December 26, 2018, from http://www.vn.undp.org/content/vietnam/en/home/countryinfo.html USAID (2015) Sustaining HIV/AIDS Treatment Services: Estimating the Health Insurance Liability in Vietnam for Treatment of HIV/AIDS in Vietnam VAAC (2014) Census on social health insurance among people living with HIV on treatment VAAC (2017) Báo cáo công tác phòng, chống HIV/AIDS năm 2017 nhiệm vụ trọng tâm năm 2018 Hanoi: Ministry of Health Vietnam Network of People Living with HIV (VNP+) (2015) Stigma Index WHO (n.d.) Retrieved December 26, 2018, from http://www.wpro.who.int: http://www.wpro.who.int/vietnam/topics/child_health/factsheet/en/ World Bank (n.d.) data.worldbank.org Retrieved December 26, 2018, from https://data.worldbank.org/country/vietnam 32 LUAN VAN CHAT LUONG download : add luanvanchat@agmail.com Appendixes Appendix Questionnaire for PLHIV This questionnaire was used to collect PLHIV’s information, opinions and experiences with accessing and utilizing SHI Appendix is a translated version of the questionnaire used The actual questionnaire was given in Vietnamese Objective: To explore the barriers to accessing and utilizing Social Health Insurance Confidentiality: This questionnaire is completely anonymous – you will not be asked for personal information or identification Thank you for your participation A – GENERAL INFORMATION Where are you currently living? (Which city/province?) ………………………………………………… Gender: □ Male □ Female □ Transgender How old are you? □ Under 24 years old □ From 24 to 50 years old □ Above 50 years old B – QUESTIONS REGARDING SOCIAL HEALTH INSURANCE Do you currently have Social Health Insurance? □ No (go to Part I) □ Yes (go to Part II) PART I Experience with accessing Social Health Insurance Why you not buy SHI? (choose all that apply) □ I don’t have money 33 LUAN VAN CHAT LUONG download : add luanvanchat@agmail.com □ I don’t care □ I don’t think it is necessary □ I am afraid I will be stigmatize or discriminated against when using SHI □ I have difficulties buying SHI □ Others (specify:……………………………………………………) What are the barriers you face buying SHI? (choose all that apply) □ The place to buy SHI is far from where I live □ I don’t have enough money to buy SHI regularly □ I am afraid I will be stigmatized or discriminated against when using SHI (compare to non-SHI patients) □ I cannot buy SHI because I don’t have a permanent residential registration □ I don’t live with my family so the regulation of buying SHI by household make it more difficult □ I don’t have family-register book □ I don’t have Identification Card □ I don’t know how to buy SHI / Lack of information □ SHI officials make it hard for me □ Others (specify………………………………………) With your current financial capacity, you have enough money to buy SHI for one year (~ VND 702,000)? □ Yes □ No If you have enough money, are you willing to buy SHI? □ Yes □ No PART II Experience with utilizing Social Health Insurance Did you buy SHI or were it given free-of-charge? □ Bought on my own (go to 9) □ Was given free-of-charge (go to 9b) 34 LUAN VAN CHAT LUONG download : add luanvanchat@agmail.com 9b Why were you given SHI free-of-charge? (choose all that apply) □ My household belongs to the poor category □ My household has member(s) rendered great merit to the country □ My household has member(s) in police/military force □ Others (specify:………………………………………) 10 When was the last time you used SHI for health services? □ Within a month □ to months ago □ to 12 months ago □ More than 12 months ago □ Never use 11 The last time you used SHI, what service did you use it for? 12 What are the barriers you face when using SHI? (choose all that apply) □ I face no barrier/problem □ The process for reimbursement is time-consuming, complicated □ My current place of living is different from the SHI initial registration place □ I was looked down upon, the quality of care I received was lower than those who use non-SHI services □ I was stigmatized and/or discriminated against because of my HIV status/gender □ The medicines paid by SHI were of lower quality □ The service(s) I wished to use was not covered by SHI (move to 12b) □ Others (Specify……………………………….) 12b What was the service(s) you wished to use that was not covered by SHI? 35 LUAN VAN CHAT LUONG download : add luanvanchat@agmail.com .. .VIETNAM NATIONAL UNIVERSITY, HANOI VIETNAM JAPAN UNIVERSITY NGUYEN KIEU AN REMOVING BARRIERS FOR PEOPLE LIVING WITH HIV IN ACCESSING AND UTILIZING SOCIAL HEALTH INSURANCE IN VIETNAM MAJOR:... in the context of declining international aids;  Explore current barriers faced by people living with HIV in Vietnam to accessing and utilizing social health insurance; and  Provide recommendations... in practice poses other challenges for PLHIV This study, therefore, attempts to provide additional data and a better insight of existing barriers for PLHIV in accessing and utilizing SHI in Vietnam