Based on the results from the 82 percent participation rate from the 2,012 MMT patients, service satisfaction did initially drop after the co-pay was rolled out but evened out over th[r]
(1)EFFECTS OF THE TRANSITION FROM A FREE-SERVICE MODEL TO A CO-PAY MODEL IN THE METHADONE MAINTENANCE TREATMENT PROGRAM
USAID SMART TA Technical Report Hai Phong, Vietnam, 2013-2014
RESEARCH TEAM
Nguyen To Nhu, MD, PhD
Principal Investigator
(2)(3)CONTEXT
The National Methadone Maintenance Treatment (MMT) program, offering voluntary outpatient opioid replacement therapy, was launched in Vietnam in 2008 After years of successful program outcomes, and in light of reducing international funding to Vietnam, the Government of Vietnam has taken steps to ensure the program’s long-term financial sustainability This includes shifting from a free-service model to a co-pay mechanism, in which local governments and patients are responsible for a major share of the operational costs In Hai Phong specifically, the People’s Committee issued Decision 2574/QD-UBND instituting a temporary 10,000 VND (0.49 USD) fee per day, which took effect on January 1, 2014 with an 80 percent subsidy for disadvantaged or impoverished patients
In response to concerns that the new fee policy would cause patients to drop out of the program, use opioids concurrently or feel dissatisfied with the service, a qualitative and quantitative study was conducted in nine MMT clinics
METHODOLOGY
This study utilized a mixed-method design combining time-trend analysis, serial cross-sectional surveys, focus group discussions and in-depth interviews Five rounds of surveys were sent to MMT patients with an 82 percent participation rate (sample size = 2,102) Focus group discussions were held with clinic staff and in-depth interviews were carried out with MMT patients who had dropped out of the program voluntarily
(4)FINDINGS
DROPOUT AND MISSED DOSES
Although there was a statistically significant change in the average monthly dropout rate between 2013 and 2014, it was only a 0.3 percent increase and cannot be attributed solely to the payment installation in light of the limited scope of this survey. There was only a two percent drop in the number of patients across all nine clinics in 2014, so any effect the co-pay model had on dropout rates was marginal, if at all
“The number of patients who quit for financial reasons that we were aware of was just 3-4 cases Before stopping treatment, they hadn’t paid for several months, then quit It was not that we refused to serve them, but that they felt embarrassed until they decided to quit.”
(Counselor, Q1)
There was also a small effect on the number of missed doses Patients would skip doses on the days when they were not able to pay, though denying treatment was not part of the new model
“According to our report, dose skipping is more and more common.”
(Counselor, Q5)
“We don’t turn patients away, but they are self-aware and if they don’t have the money, they don’t come.”
(Nurse, H4)
(5)PATIENT SATISFACTION
To evaluate any changes in patient satisfaction after the institution of fee collection, a survey was sent out every three months throughout the trial year for a total of five surveys Based on the results from the 82 percent participation rate from the 2,012 MMT patients, service satisfaction did initially drop after the co-pay was rolled out but evened out over the course of the survey collection.
Other changes were seen in patient attitudes towards MMT staff, with increased agitation, aggressiveness and theft
“There have been some issues Attitudes of patients towards clinic staff have changed Previously, all clinic services were free and there was no problem with the relationship [between patients and staff] Now that a treatment fee is collected, we have to remind patients often Regular reminders annoy patients, and once they’re annoyed they heap insults on us.”
(Nurse, Q2)
“When we tried to stop treatment for some patients because they did not pay their treatment fee, some became aggressive and threatened us.”
(Receptionist, H3)
Clinic Average participation rate for surveys (n=2,102)
An Duong 77%
An Hung 91%
An Lao 82%
Duong Kinh 84%
Hai An 87%
Hong Bang 80%
Le Chan 93%
Ngo Quyen 80%
Thuy Nguyen 67%
TOTAL 82%
(6)FIGURE 1
Proportions of patients unsatisfied with services at nine MMT clinics in Hai Phong, based on results of five serial surveys from February 2014 to February 2015.
Medical examination Reception-administration
Counseling Methadone dispensing Security
Cleaning
Survey 1 Survey 2 Survey 3 Survey 4 Survey 5
12 10
Despite some limitations and difficulties, providers held that the collection of partial treatment costs helps improve staff incomes and working conditions, which in turn help improve service quality
“For long-term operation of the MMT program, socialization is a must If the patient wants to be in long-term treatment, they must pay a portion of the treatment costs.”
(Head of clinic, H4)
WILLINGNESS TO PAY
(7)ACKNOWLEDGMENTS
This research was made possible through support from USAID Vietnam under the project agreement # AID-486-A-11-00011 “Sustainable Management of the HIV/AIDS Response and Transition to Technical Assistance” (SMART TA) program The research team included Dr Nguyen Binh Nguyen, Dr Pham Le Huy, Vuong Thi Anh Thu and Nguyen Quynh Huong and was guided by Dr Nguyen To Nhu Special appreciation is also extended to the Vietnam Administration of HIV/AIDS Control (VAAC), USAID team, PEPFAR MMT Technical Working Group in Vietnam, Department of Harm Reduction VAAC, Hai Phong Provincial AIDS Center, Hai Phong Department of Health and the nine methadone clinics and their patients that took part in this study
This report was made possible by the generous support of the American people through the United States Agency for International Development (USAID) The contents are the responsibility of FHI360 and not necessarily reflect the views of USAID or the United States Government.
For comments or questions, please contact: Dr Nguyen To Nhu, MD, PhD
Deputy Country Director, FHI 360 Vietnam Tonhu@fhi360.org
CONCLUSIONS
There were small changes in the dropout and missed-dose rates among MMT patients after the shift to a co-pay model, but there is not enough evidence to determine if these were a direct result of the fee collection There were also changes in patient satisfaction, though the dissatisfaction dissipated as people grew accustomed to the new system Patients are willing to pay for methadone overall, and instituting a fee for services does not have major impacts on the MMT care system
RECOMMENDATIONS
1 Set a regular monthly payment schedule, and explain the reasons for the shift clearly to avoid surprises and misunderstandings when collecting fees
2 Hire an accountant to address the significant administrative burden imposed on clinic staff during collection
3 In light of the 30 percent of patients experiencing substantial or extreme difficulty in paying for MMT, expand the categories eligible for subsidies, or simplify the process required to request subsidies Clarify enforcement mechanisms or protocols in instances of non-payment Providers were unsure whether to deny treatment or continue offering it, leading to confusion and unnecessary program dropouts
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