INTRODUCTION AND BACKGROUND INFORMATION
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a lower-middle income country, external funding for HIV programs, including procurement of ART medicines has been withdrawn dramatically (MOH, 2014) The Government of Vietnam, thus, deems transitioning from foreign funded programs to a more sustainably financing mechanism, in which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
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.
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 km 2 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 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.
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 3 rd quarter of
2017, it was estimated that there were 208,371 people living with HIV in the 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 5 million (~ USD 216) are 54%, 38% between VND 2 -5 million (~ USD 86 - 216) and 8% under VND 2 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
1 The survey was conducted among 1625 participants from Hanoi, Haiphong, Dien Bien, Can Tho and Ho Chi Minh city
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)
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,
2014; Pham et al, 2010) Later, the 2008 Law on Health Insurance removed the diagnosis and treatment of HIV from the list of exceptions for health insurance coverage The Law was again amended in 2014 to further adapt to the changing strategy and needs for HIV treatment
In addition, Vietnam is also committed to several international documents and strategies related to HIV/AIDS prevention and PLHIV, namely the 2001 UNGASS Declaration on HIV/AIDS which recognizes the fundamental rights of PLHIV and the importance of “access to medicines”; and the “90-90-90” target which aims for 90% of PLHIV to know their status, among those 90% will receive ART and among those 90% will have viral suppression by 2020
Financially, the Government of Vietnam has been increasing budget for HIV interventions and programs over the years However, it is still heavily dependent on international donor contributions – with more than 70% of the overall financing coming from external sources (MOH cited by PEPFAR,
2018) More importantly, almost 90% of ART medicines in the country come from two big international donors – PEPFAR and the Global Fund, both of whom have plan to either discontinue or uncertain about future aid commitments (vietnamnews.vn)
In response to the reality that ART in Vietnam will no longer be provided free-of-charge through international funding and programs, the Government has strategized to secure the medicine procurement through funds from the national Social Health Insurance (Downie, 2017) It is estimated that SHI coverage needs to increase to 80% by 2020 to potentially cover 52% of HIV treatment payment needs (USAID, 2015)
1.3.3 Social Health Insurance in relation to HIV treatment
It is proven that health insurance plays a crucial role in reducing financial burden and acts as a protective measure for people against unexpected health costs Several high-income and middle-income countries such as Brazil, Mexico, Thailand and Taiwan have had health insurance scheme in place to cover for HIV services (UNAIDS, 2012)
As for Vietnam, the concept of health insurance was first mentioned in the country’s Constitution in 1992 It was the most important basis for the formation of health insurance system and the implementation of health insurance policies in the country In the same year, the Health Insurance Regulation was promulgated with coverage limited to government officials and formal workers At the time, voluntary participation was not clearly regulated
After 15 years of implementation, policies and regulations surrounding SHI have been revised and/or amended several times in order to expand the coverage and to better cope with the country’s development stages The number of people participating in health insurance had increased over the years Nevertheless, by 2008, the number of people participating in health insurance was only 37.7 million, accounting for 43.76% of the population (MOH, 2012)
Literature review
Clayden (2013) says that prices of ARV in some low and middle-income countries including Vietnam, is actually much higher than that of African nations This and the fact that even with free-of-charge ART, PLHIV in Vietnam still have to face with other out-of-pocket payments that is
“catastrophic” and may hinder their access to treatment (Tran, et al., 2012)
This statement is supported by another study by Nguyen et al (2014) in which, given free ART, 10.5% of participants were still unable to access the treatment due to inability to pay for the associated expenditures (such as testing and travel costs); and 16.2% could only partially afford these costs
This raises further importance of PLHIV’s accessibility to SHI in order to access and/or maintain their ARV treatment in the context of withdrawing international funding
Nguyen and Wilson (2017) find that level of enrollment in SHI among the near-poor was associated with cost of insurance premiums, knowledge of insurance benefits, and overall affordability Financial constraints again were concluded as the reason for majority of opioid-addicted patients in Northern provinces of Vietnam, many of whom are HIV-positive, to access to SHI (Tran et al, 2017)
Besides financial difficulty, Nguyen et al (2017) also find that a high proportion of PLHIV was not covered by SHI due to lack of information The researchers comment that PLHIV might not be willing to buy SHI because they do not fully understand its benefits and so have the feeling of difficulty when buying and using it
Furthermore, even though stigma and discrimination has not been clearly pointed out as factors hindering access and utilization of Vietnamese PLHIV to SHI, previous literature, both in the world and in the context of Vietnam, has shown that stigma and discrimination are factors that prevent PLHIV to access to care and treatment (Feyissa et al., 2019; Tran et al., 2019).
Research rationale and objectives
Vietnam continues to show its strong commitment to both ending the AIDS epidemic and improving quality of life of PLHIV, which can be achieved by having a sustainable health financing mechanism Increasing the rate of health insurance coverage among PLHIV as well as ensuring they can effectively use health insurance to engage in treatment are important steps towards this goal However, barriers might exist that hinder PLHIV’s accessibility to and utilization of social health insurance
Although previous studies and researches have identified a number of obstacles hindering PLHIV’s ability to access to social health insurance including financial difficulties, other aspects related to PLHIV’s experience in buying and using social health insurance are not yet addressed and can be explored to further the understanding of the actual issues faced by PLHIV
This study, therefore, aims to:
Provide an understanding of the situation and urgent needs to support people living with HIV in Vietnam through social health insurance 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 to remove such barriers and thus improve the accessibility to and utilization of social health insurance of people living with HIV.
Research questions
This study seeks to answer the following questions:
What are the current barriers for PLHIV in accessing SHI in Vietnam?
What are the current barriers for PLHIV in utilizing HI in Vietnam?
What are the recommendations to remove such barriers?
Research significance
Findings from this study will contribute additional data and knowledge on 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.
METHODOLOGY
Research methods
The study was implemented during a larger research conducted by the Center for Supporting Community Development Initiatives where the author interned This Center focuses on working with vulnerable populations, including those living with and affected by HIV/AIDS It had helped the author collect data from more participants from different cities/provinces
The study was conducted using a mixture of quantitative and qualitative methods This enable the author to both extract information from a large sample of people as well as explore further specific areas of interest
Quantitative data was collected through a self-reported questionnaire survey given to 200 HIV-positive people in 13 cities/provinces; while qualitative data was collected through 5 focus group discussions and observations with 15 participants
The questionnaire as well as discussions given were in Vietnamese
Translation from Vietnamese to English was done later for both data collected through the questionnaire survey as well as answers from focus group discussions.
Research setting
The study was conducted in different cities/provinces from different regions in order to ensure the representativeness of participants, including:
Large city: Hanoi, Ho Chi Minh city;
Northern Delta Region: Bac Giang, Bac Ninh, Vinh Phuc, Hai Duong;
Mountainous and remote area: Dien Bien, Son La, Phu Tho, Thai Nguyen;
Central region: Lam Dong, Khanh Hoa;
Survey participants by current place of living
No City/Province Number of participants
Data collection measures
A questionnaire survey was designed with 3 parts:
Part 1: General information of all participants, including their current living location, gender and age
Part 2: For those who do not have social health insurance, asking about their experience in accessing SHI – including the reasons they do not and/or cannot buy SHI, barriers faced when accessing SHI, their financial ability and willingness to buy SHI;
Part 3: For those who have had social health insurance, asking about how they can access to SHI, their use of SHI, and barriers faced when utilizing SHI
5 focus group discussions were conducted between groups of 3 to 5 participants following a guide A total of 15 people was interviewed, among them 9 have had social health insurance and 6 have not The discussions are recorded only for the purpose of analyzing data and will be destroyed once transcribed to ensure the confidentiality of the participants.
Data analysis
Data collected from the questionnaire survey was converted from the hard copies into excel spread sheets while answers from the focus group discussions was transcribed from the records into word file for analysis.
RESEARCH FINDINGS
General information
A total of 200 people living with HIV was given the self-reported questionnaire They are currently living in 13 cities/provinces of Vietnam
Among the participants, 163 (82%) are male, 34 (17%) are female and 3 (2%) identifies themselves as transgender
Table 1: PLHIV by gender and possession of SHI
Do not have SHI Have SHI Total
It is worth noted that more than half of those surveyed (51%) are currently not having SHI This result shows that many either are reluctant to buy or do not have enough information about SHI
Table 2: PLHIV by age and possession of SHI
Do not have SHI Have SHI Total
As for the age of the participants, majority (91%) of those surveyed are between 24 to 50 years old, only 6% and 3% are those under the age of 24 and above 50 years old respectively
Table 3: PLHIV by location and possession of SHI
As can be seen from table 3, the rate of PLHIV having SHI is highest in large city (Hanoi and Ho Chi Minh city) with the number of PLHIV having SHI more than double the number of non-SHI PLHIV Data also shows that among those currently having SHI in large city, majority (24) bought their own This could be attributed to better financial condition of those living in this location
Table 4: Means to access SHI
Household belong to the poor category Household has member(s) rendered great merit to the country
Household has member(s) in police/military force
Others (incl bought by employer)
For those who currently have SHI, the survey seeks to understand how they accessed to SHI Among the 98 participants that currently have SHI, 25 (25%) received SHI card free-of-charge due to mainly their household belongs to the poor category (18), their household has member(s) rendered great merit to the country (2), their household has member(s) in police/military force (1) and other reasons, including having SHI bought by their employer (4)
Majority of participants had to buy their own SHI (75%)
During the focus group discussions, all interviewed PLHIV reported receiving information about the prospect of ART medications to be covered by SHI from the clinics where they are being treated, through community support groups, and via the Internet etc The general opinion on this issue is positive; they are aware of and have the need to buy SHI Among the interviewees, however, few fully understand the benefits of health insurance (including those who have SHI) The reason driving them to buy SHI is a concern of discontinuing their HIV treatment.
Reasons PLHIV not buying SHI
Prior to the study, thorough literature review and informal discussions had taken place in order to generate suggestions for reasons PLHIV not buying SHI Several previous literatures have suggested the main reason PLHIV cannot or do not buy SHI was due to financial constraints, lack of information about SHI, and fear of stigma and discrimination However, as the results show, the barriers are much more diverse:
Table 5: Reasons PLHIV do not buy SHI
Afraid to be stigmatized and discriminated against when using SHI
Do not think it is necessary 23 (11%)
As can be seen clearly from the data collected, the majority (45%) of non-SHI respondents in the survey said that the biggest barrier preventing them from accessing social health insurance is financial issues
“I have heard many (PLHIV) complained Many of us have to take care of every day’s end-needs; having to pay for ART medicines is adding more burden to us For others, the money (to buy SHI) may not be much, but for us (it is)…” said a male interviewee from Bac Giang
Stigma and discrimination are also a highlight in the survey results (20%)
When asked about stigma and discrimination, participants reported that people using health insurance cards for medical examination often did not receive the same quality of service as those who voluntarily paid and paid more money Especially in the case of people living with HIV, the attitude of health workers towards them is much worse PLHIV also fear that health insurance cards with their personal information will make them identifiable to their village, community In the past, when PLHIV went for ART, they could use fake names or go to out-patient clinics that are far from their place of residence to receive medicines every month Now, if they use SHI card, they must take the medicine according to their place of residence and have to publicize the identity there
In addition, the interviewed PLHIV also expressed concern that their identity would be revealed if ART was to be provided through SHI, especially for those with employment Because of this, it is possible that PLHIV with SHI do not want to use the card Some even said that their employers purchased health insurance for them, but they did not use it because they were afraid to reveal their identity
“I know that a month's ART medications range from VND 1 to 1.5 million, but if letting SHI covers for that and I lose my job, I would rather pay for the medications” said a male interviewee from Ho Chi Minh city
“A friend of mine said that she would rather stop taking ART medications if it was paid for by SHI because she was working for a formal agency and they might find out (about her HIV status)" said a female interviewee from Bac Giang
“I am very reluctant to go to big hospitals When I go to a private hospital, I do not have to reveal my HIV status I rarely use SHI card since I am afraid of being discriminated against, so buying SHI is for naught” said a male interviewee from Hanoi
Two other reasons PLHIV said they do not buy SHI were that they did not care and found it unnecessary Communication on the benefits of health insurance, despite being implemented by many agencies, still does not seem to reach the marginalized groups; or the communication messages are not strong enough, suitable or targeted at these groups It is important to note that at the time of the survey, many participants might be on ART provided by international-funded programs or projects so they might not realize the importance of having SHI to sustain their treatment
A similar portion of participants also said that they had difficulties buying social health insurance.
Barriers in accessing SHI
Table 6: Barriers for PLHIV to access SHI
Do not have enough money to buy SHI regularly 77 (32%) Afraid to be stigmatized or discriminated against when using SHI (compare to non-SHI patients)
Do not live with their family so the regulation of buying SHI by household make it more difficult
Do not know how to buy SHI / Lack of information 27 (11%)
Do not have Identification Card 26 (11%)
Do not have family-register book 15 (7%)
The place to buy SHI is far from where I live 13 (5%)
Do not have a permanent residential registration 12 (5%)
SHI officials make it hard for me 5 (2%)
When ask to elaborate barriers to accessing SHI, besides the same abovementioned reasons PLHIV do not buy SHI which are not having enough money and afraid of stigma and discrimination, other factors also come up:
The regulation of buying SHI by household
The regulation of buying SHI by household seems to make it more difficult for PLHIV to access SHI
“I was directly told that I needed to buy SHI by household I can afford to buy for myself, I can't buy (SHI) for my whole family My wife’s family has
12 people (They said) even if I wanted to buy, I had to encourage my family (to buy SHI), otherwise I had to pay for all of them” said a male interviewee from Hanoi
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”
26% also reported not being able to buy SHI due to lack of Identification Card; 7% do not have family-register book and 5% do not have a permanent residential registration
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.
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%)
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
Not willing to buy SHI 7 (7%)
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
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
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
The process for reimbursement is time-consuming, complicated
Current place of living is different from the SHI initial registration place
Being looked down upon, the quality of care received was lower than those who use non-SHI services
Being stigmatized and/or discriminated against because 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%)
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 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
Hepatitis C testing, genotyping and treatment 15 (48%)
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.
DISCUSSION
Key findings
First of all, the survey shows that the coverage of social health insurance among PLHIV is still low, 51% do 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.
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 do not have enough information about SHI
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 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.
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
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.
CONCLUSION
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.
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
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Appendixes Appendix 1 Questionnaire for PLHIV
This questionnaire was used to collect PLHIV’s information, opinions and experiences with accessing and utilizing SHI Appendix 1 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
1 Where are you currently living? (Which city/province?)
B – QUESTIONS REGARDING SOCIAL HEALTH INSURANCE
4 Do you currently have Social Health Insurance?
□ Yes (go to Part II)
PART I Experience with accessing Social Health Insurance
5 Why do you not buy SHI? (choose all that apply)
□ I don’t think it is necessary
□ I am afraid I will be stigmatize or discriminated against when using SHI
6 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 know how to buy SHI / Lack of information
□ SHI officials make it hard for me
7 With your current financial capacity, do you have enough money to buy SHI for one year (~ VND 702,000)?
8 If you have enough money, are you willing to buy SHI?
PART II Experience with utilizing Social Health Insurance
9 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)