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 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 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 1.3.1 Overview of HIV/AIDS epidemic and PLHIV 1.3.2 HIV policies and financing 1.3.3 Social Health Insurance in relation to HIV treatment 1.4 Literature review 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 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 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 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 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 km 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 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 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 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 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, 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 Not willing to buy SHI Total 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 to months ago to 12 months ago More than 12 months ago Never use Total 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 ARV treatment 22 Digestive problems Tuberculosis examination and treatment Others Total 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 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 The service(s) needed was not covered by SHI Others Total 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 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 Methadone treatment Hepatitis C testing, genotyping and treatment Total 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 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 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 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 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 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 References How VN will control AIDS absent foreign funds (2017) Retrieved December 26, 2018, from vietnamnews.vn: 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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 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 □ □ □ SHI □ □ I don’t care I don’t think it is necessary I am afraid I will be stigmatize or discriminated against when using 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 9b Why were you given SHI free-of-charge? (choose all that apply) □ □ □ □ 10 □ □ □ □ □ 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:………………………………………) 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 □ □ 12b) □ The medicines paid by SHI were of lower quality The service(s) I wished to use was not covered by SHI (move to Others (Specify……………………………….) 12b What was the service(s) you wished to use that was not covered by SHI? 35 .. .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