4.1 Overview of the research topic 21
4.1.1 Background of health insurance in Vietnam and the MRD 21
Since 1992 - Ministry of Health issued Directive No. 05/BHYT/CT to implement the policy of health insurance from central to local level. By the end of 1992, health insurance schemes had been completed in 38 provinces and cities. At first, the number of people participating in health insurance is very limited.
By 1994, health insurance coverage had ranged from central to local, including health insurance agencies in 53 provinces and four sectors, namely Transportation, Petroleum, Coal, and Rubber.
In 1996, health insurance remained independent in each locality. As the socio- economic conditions in each locality are different, resulting in budget deficits and inadequate localities, many localities are in a state of overspending.
By 1997, the state of overspending had occurred in most of the localities, which was caused by the fact that fees remained unchanged while the price of medical care increased, drug price rose and health insurance premium was not up to the reality.
In 1998, Decree No. 58/1998 /ND-CP was issued to regulate the rights and responsibilities of participants in health insurance and renovation of management policies.
Also from this decree, the health insurance system was unified from central to local level. The new regulation is seen as a success because the number of people participating in health insurance increases significantly, especially compared to the number of people participating in voluntary health insurance.
In 1999, 80% and 20% of co-payment schemes were used for health insurance, which provided patients with a health insurance policy and financial autonomy. Also in 1999, the Ministry of Health, the Ministry of Labor, Invalids and Social Affairs issued Circular No.
05/1999/TTLT-BLDTBXH-BYT-BTC guiding the provision of partial free medical treatment to poor persons. This is the basis for the implementation of health insurance policy for the poor.
Also in this decade, health insurance faced competition from other insurance companies like DAI-ICHI, Manulife, Prudential, licensed and operated in Vietnam, creating fierce competition in the health insurance market. In order to increase competitiveness, health insurance reforms the operating mechanism. On January, 2002, the Prime Minister issued Decision No. 20/2002/QD-TTg on the merger of Vietnamese Health Insurance into Vietnam
Social Insurance. This merger has created the strength as well as the mobilization of many resources to expand the policy beneficiaries. In 2004, 3.5 million poor people were granted health insurance.
In order to reach universal health insurance, in 2003, the Joint Circular No.
77/2003/TTLT-BTC-BYT was promulgated to guide the implementation of voluntary health insurance for all subjects, especially pupils, students and households union. At the same time, Decree 63/2005/ND-CP was promulgated about the scope and benefits of health insurance under which more than 1,000 health technology services were covered by health insurance.
In 2008, the Vietnamese Parliament approved legislation 25/2008/QH12 on health insurance. The law refers to the rules of participation, budget, fund management. The introduction of the Health Insurance Law has brought encouraging results. According to the monitoring report of the Standing Committee of the National Parliament on the results of monitoring the implementation of health insurance policy and legislation for the period of 2009-2012, the proportion of the population participating in health insurance increased from 58.2% (2009) to 66.8% (2012). Thus, after four years of implementation of the Law, 8.6% of the population participated in health insurance, equivalent to 9.24 million people, on average an increase of 2.8% per year.
4.1.1.2The achievements and the challenges of health insurance in Vietnam
Throughout the process of formation and development, health insurance has achieved certain achievements such as expanding the coverage of health insurance, expanding benefits, services and especially health care for the poor. According to statistics, in 1993, 3.8 million people nationwide covered by health insurance, accounting for 5.4% of the national population. In 2012, nearly 60 million people participated in health insurance, accounting nearly 70% of the population of the country. Compared with other countries, this ratio is higher than other countries such as Paraguay 17%, India 11%, Indonesia 63%. Health insurance also strives to ensure the rights of cardholders and to closely manage health insurance funds. Circular No. 03/2006 / TTLT-BYT- BTC-BLDTB&XH of the Ministry of Health, the Ministry of Finance, the Ministry of Labor, Invalids and Social Affairs has provided specific regulations on hospital price bracket, list of drugs and medical supplies as well as other policies. Relevant as a matter of crossing, referral. The application of the minimum health insurance premium/maximum price level has ensured the socio-economic performance of regional differences and fairness among beneficiaries.
However, besides the achievements achieved by health insurance, there are many challenges, especially the quality of health services provided by health insurance card holders, cumbersome procedures, and confused management of health insurance funds. According to a report by the National Parliament, up to 50% of current payers participating in compulsory health insurance will not participate in health insurance if the law stipulates the intention to participate in health insurance is voluntary. This shows that the quality of health insurance is poor and does not meet the wishes of cardholders. In most hospitals, there is a clinic or service clinic where patients are better cared for, resulting in very limited benefits for patients using health insurance cards. In central hospitals, many patients using health insurance cards have to wait 2-3 days to get a medical examination, while if using the service, they will be examined in the day. According to Decree 62/2009 of the Government, the reserve fund for medical examination and treatment of health insurance is used to supplement the local deficit.
At suburban or mountainous provinces, where medical equipment is in short supply, the list of drugs is low, subclinical abuse is occurring in major cities and the high cost of foreign drugs are used, leading to the overspending of the health insurance fund, must be compensated by the reserve fund.
The management of health insurance funds remains inadequate, leading to confusion in the monitoring, evaluation, use of drugs and the use of paraclinical diagnostic services. The most common misuse is that tests, ultrasound, x-rays where up to 100% of all visits are using these indications. As a result, many local health insurance funds have been over-spending for a long time.
Over 20 years of establishment and development, Vietnam's health insurance has achieved some achievements and also many challenges. First of all, with the efforts of the government and departments, the proportion of people with health insurance cards reaches nearly 70% of the national population and this is an encouraging accomplishment. However, the latter is more difficult. Although the health insurance system in Vietnam is strictly organized, from central to local levels with sufficient mechanisms of operation and monitoring mechanisms, there are many limitations, but typically quality and attitudes service. Improvements of the quality of health care through a health insurance card should be made soon by two reason, the health insurance market has many competitors and the trust of health insurance buyers.
4.1.1.3The achievements and the challenges of health insurance in the MRD
According to Mai Duc Thang1, Deputy Head of the Vietnam Social Insurance, the MRD has a population of about 18 million people (about 21% of the national population). In comparison with the region's development potential, the development of beneficiaries and implementation of social insurance, health insurance policies for people is still limited, inadequate; the proportion of health insurance coverage, the number of employees participating in social insurance is lower than the general level of the country.
According to the report of Vietnam Social Insurance, up to 31 August, 2017, the number of people participating in health insurance in the MRD is 14,299,918 people, and the coverage of health insurance is 79.9% compared with the population of the region, an increase of 665,673 people (increase 4.88% compared to 2016); accounting for 15.31% of the national coverage. However, the proportion of people participating in health insurance in some provinces is very low; six of the 13 provinces and cities have not yet completed health insurance coverage under the Prime Minister's Decision No. 1167/QD-TTG. The rate of participation in health insurance is low, focusing on groups of households, groups eligible for state subsidy, workers in enterprises. Voluntary social insurance participants are much lower than the potential beneficiaries of the MRD. In 2016, this figure dropped to only 21,325 people, equal to 55% of 2015, due to policy changes leading to the number of non-specialized staff in communes, wards and townships moving from voluntary social insurance to participate in compulsory social insurance; in the first eight months of 2017, the number of people participating in voluntary social insurance is 21,794, an increase of 2% compared to 2016.
In fact, there are still about 4 million people who have not participated in health insurance, and most farmers in this area have not participated in voluntary social insurance.
Developing social insurance, health insurance is considered an important task, the essential supportive point to help the MRD development in the direction of sustainability.