Removing barriers for people living with HIV in accessing and utilizing social health insurance in Vietnam

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 househ[r]

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

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

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

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

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

1 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

2 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)

3 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

4 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

1 The survey was conducted among 1625 participants from Hanoi, Haiphong, Dien Bien, Can Tho

5 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

6 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)

7 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)

8 budget covers partially or fully for more beneficiaries, specifically 100% health insurance premium cost for the poor, ethnic minorities and children under years old; up to 95% for the near-poor and retired people, and up to 80% for others (Nguyen, et al., 2017) This has resulted in a reduction of household’s out-of-pocket money for medical expenses from 62.9% in 1998 to 48.5% in 2012 and to 44.3% in 2013 (MOH, 2016); and an increase in the number of persons participated in social health insurance of over 75.9 million, accounting for 81% of the population (General statistics office, 2017)

As of 2017, the concept of “voluntary health insurance” is replaced by the regulation of “health insurance by household” meaning any individual that is not under the compulsory and/or special categories (the employed, those in military/police force, the poor, the near-poor, students, children under years old etc.) will be required to join under this category The health insurance premium for this “household” category is set at VND 702,000/ person/ year, and is reduced for each family member joining after This is an effort of the government to increase health insurance coverage

9

1.4 Literature review

PLHIV’s accessibility to Social Health Insurance

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)

10 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)

1.5 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

11

1.6 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?

1.7 Research significance

12 CHAPTER 2: METHODOLOGY

2.1 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 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

2.2 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

13  Central region: Lam Dong, Khanh Hoa;

 Southern region: Binh Duong

Survey participants by current place of living

No City/Province Number of participants

1 Dien Bien 10

2 Son La 16

3 Bac Giang

4 Bac Ninh

5 Phu Tho 11

6 Hanoi 26

7 Ho Chi Minh city 17

8 Thai Nguyen 18

9 Hai Duong 37

10 Vinh Phuc 17

11 Lam Dong 19

12 Nha Trang (Khanh Hoa) 12

13 Binh Duong

Total 200

2.3 Data collection measures

Quantitative data

A questionnaire survey was designed with parts:

 Part 1: General information of all participants, including their current living location, gender and age

14  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

Qualitative data

5 focus group discussions were conducted between groups of to participants following a guide A total of 15 people was interviewed, among them have had social health insurance and 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

2.4 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

15 CHAPTER 3: RESEARCH FINDINGS

3.1 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 (2%) identifies themselves as transgender

Table 1: PLHIV by gender and possession of SHI

Do not have SHI Have SHI Total

Male 92 (46%) 71 (36%) 163 (82%)

Female 10 (5%) 24 (12%) 34 (17%)

Transgender - (2%) (2%)

Total 102 (51%) 98 (49%) 200 (100%)

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 not have enough information about SHI

Table 2: PLHIV by age and possession of SHI

Do not have SHI Have SHI Total

Under 24 years old (4%) (2%) 11 (6%)

From 24 to 50 years old

93 (46%) 91 (45%) 184 (91%)

Above 50 years old (1%) (2%) (3%)

Total 102 (51%) 98 (49%) 200 (100%)

16 Table 3: PLHIV by location and possession of SHI

Do not have SHI

Have SHI Total

Large city 13 (7%) 30 (16%) 43 (22%)

Northern Delta Region 45 (23%) 18 (9%) 63 (32%)

Mountainous and remote area 24 (12%) 31 (15%) 55 (27%)

Central region 14 (7%) 17 (8%) 31 (15%)

Southern region (3%) (1%) (4%)

Total 102 (51%) 98 (49%) 200 (100%)

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

Bought their own 73 (75%)

Given free-of- charge

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)

25 (25%) 18 (18%)

2 (2%) 1 (1%) 4 (4%)

Total 98 (100%)

17 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

3.2 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 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 not buy SHI

Do not have money 91 (45%)

Afraid to be stigmatized and discriminated against when using SHI

41 (20%)

Do not care 23 (11%)

Do not think it is necessary 23 (11%)

Have difficulties buying SHI 23 (11%)

18

Total 206 (100%)

Financial constraints

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

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

19 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 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 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

Lack of awareness

Two other reasons PLHIV said they 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

20

3.3 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)

32 (13%)

Do not live with their family so the regulation of buying SHI by household make it more difficult

32 (13%)

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 (2%)

Others (1%)

Total 241 (100%)

When ask to elaborate barriers to accessing SHI, besides the same abovementioned reasons PLHIV 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

21 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%)

22 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%)

1 to months ago 21 (22%)

6 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%)

23

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, complicated

17 (15%)

Current place of living is different from the SHI initial registration place

6 (5%)

Being looked down upon, the quality of care received was lower than those who use non-SHI services

14 (12%)

Being stigmatized and/or discriminated against because of HIV status/gender

16 (14%)

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%)

24 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

25 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

26 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

27 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

28 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

29 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

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33 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

1 Where are you currently living? (Which city/province?) ………

2 Gender:

□ Male

□ Female

□ Transgender 3 How old are you?

□ Under 24 years old

□ From 24 to 50 years old

□ Above 50 years old

B – QUESTIONS REGARDING SOCIAL HEALTH INSURANCE 4 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 5 Why you not buy SHI? (choose all that apply)

34

□ 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:………)

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 have Identification Card

□ I don’t know how to buy SHI / Lack of information

□ SHI officials make it hard for me

□ Others (specify………)

7 With your current financial capacity, you have enough money to buy SHI for one year (~ VND 702,000)?

□ Yes

□ No

8 If you have enough money, are you willing to buy SHI?

□ Yes

□ No

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)

35 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

□ 1 to months ago

□ 6 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?