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Researches Health financing

 Trần Thị Mai Oanh, Nguyễn Thị Thắng, Dương Huy Lương, 

Hoàng Thu Thủy, Nguyễn Hoàng Giang
Place of publication:  Health Strategy and Policy Institute
Year of publication :  2012
Health insurance (HI) in Vietnam is a vital health financing source contributing to equity in health. After more than 15 years the HI policy is in place, the rights and interests of the health insured have been expanded and guaranteed over time. Patients now have access to HI-related medical services right at the commune level, which contributes to medical cost saving. The HI-related medical service delivery process, however, is not flawless. In respect of service providers, especially commune health, the lack of consistency of the district level health system in different areas raises numerous barriers to HI-related medical care at commune health stations (CHSs). Added to that, the limitations of capacity, human resources and facilities of commune health centers are a major challenge to delivery of HI-related health services at the centers. On the users’ side, the need for medical care of HI card holders at the commune level is colossal. Yet, HI-related medical care at the commune level is still limited to outpatient consultation, prescription and drug dispensing. To incrementally improve the policy system in this regard to provide the regulatory platform for health financing reform through health insurance and canvass a roadmap toward universal HI by 2014, this study aims to seek answers to the following questions.
1. Describe the context of HI-related health service delivery at CHSs under the HI Law in specific sites;
2. Identify advantages and challenges in the implementation of HI-related health service delivery at CHSs under the HI Law; 
3. Assess CHSs’ responsiveness in terms of staffing, physical facilities, equipment and medication in delivery of health services to health insured patients; and recommend ways to improve the effectiveness of HI-related medical care at commune health centers.  
Descriptive cross-sectional study with analysis; Data collection through field survey combined with qualitative and quantitative analyses. 
Non probability sampling is used in 4 provinces representing the North, Central, South and Central Highland, namely Ha Nam, Khanh Hoa, Kien Giang and Gia Lai. In each of the provinces, 2 districts are selected, one of which with relatively strong HI-related health service delivery and the other lagging behind in HI-related health. In each the districts, 2 communes are selected for field surveys, one of which having a doctor and the other without a doctor. Both communes have started HI-related health service delivery.
Progress of HI-related health service delivery at CHSs under the HI Law in specific sites CHSs having HI-related health care in place account for a relatively high percentage (about 83-84%) in the 8 districts in the 4 participating provinces. There is no change of the number of CHSs offering HI-related health care over the years (2009, 2010 and H1/2011). 
The payment modes used for HI-related health expenses reimbursement at CHSs remain unchanged for before and after the HI Law is in effect, despite the change of HI reimbursement mode in district hospitals from fee-for-service to capitation under the HI Law. Of the four provinces, Ha Nam and Kien Giang have lower HI-related health expenditure cap for CHSs than the other two. 
HI card holders seeking medical care have a relatively high proportion. This ratio, however, tends to subside over time when the capitation scheme is applied. In Ha Nam province, a HI card holder seeks medical care at CHSs 3.1 times on average in 2009, but the figure sharply drops to 0.8 times in 2011. Health insured patients referred from CHSs to district hospitals take up a significant percentage in various areas. Survey findings indicate that the key explanations are the limited available of health services at the district and commune levels (staffing deficiency both in number and quality, lack of equipment, narrow drug list range), and the clients’ lack of trust in the quality of care at CHSs.  
Advantages and challenges in the implementation of HI-related health service delivery at CHSs under the HI Law
HI policies and schemes seem to lack consistency between different ministries, line agencies and local governments. 
Irrationality exists in the list of eligible procedures and services at the population level (transfusion, simple soft wound suturing and bone fracture immobilization are not classified, as cotton, tincture, gauze, syringe, transfusion lines and so on are not covered). 
Many regulations are not relevant to upland and remote areas, including: prescription (it is unclear who “non-health workers” are); referral (no specific commune-to-district referral forms are available); HI covered drug list (some types of medicines needed in emergency care are not allowed at health centers without a doctor, while they are very much needed in first aid before referral); delay in HI cards distribution.
CHSs’ responsiveness in terms of staffing, facilities, equipment and medication in service delivery to health insured patients
Equipment: There is serious shortage of equipment in CHSs compared to the existing norms.
List of eligible procedures at CHSs: Internal medicine-ICU-Anti-poisoning and maternity care are specialties that commune health workers said to have learned and can be done most skillfully at the centers. 
Medical staffing: A CHC has 5 staff members on average. 7/16 surveyed communes in the 4 provinces are adequately staffed in line with Circular 08. Only 4/16 communes report that their staffing structure and size are sufficient to meet operational needs. Only 7/16 of the surveyed communes have doctor at the CHC.
Assessment of drug use in the treatment of specific illnesses for health insured patients at CHSs: Drug use for treatment of acute respiratory infections for health insured patients remains flawed. The average number of prescribed drugs for acute respiratory infections is 3.64, double the number recommended by the World Health Organization (WHO). There is no combination of antibiotic use in upper respiratory tract infections at commune health centers. Beta-lactam antibiotics are most used for treatment of respiratory tract infection, at 87.6%. 21.1% of under-6 children are not provided with the types of drug suitable to their age. The average cost of a HI prescription is low and varies widely in a same province. 
The HI subscription rate in the 4 selected provinces remains modest.
CHSs offering HI-related health care in the 4 provinces take up a relatively high proportion (83-94%), with the lowest rate recorded in Khanh Hoa. There is no change of the number of CHSs offering HI health care before and after the HI Law is in effect.
Orientation and dissemination of the HI Law to the community remains to be improved. 
The payment modes used for HI-related health expenses reimbursement at CHSs remain unchanged for before and after the HI Law is in effect, despite the change of HI reimbursement mode in district hospitals from fee-for-service to capitation. 
HI-related health service delivery is facing huge challenges due to regulatory inconsistency between different ministries and line agencies, infrastructure, equipment and staffing of CHSs failing to meet the current needs, the clients’ trust in the CHCs remaining a question, delayed and sloppy issuance of HI cards in many places.
CHSs’ responsiveness to HI health service delivery remains limited, due to (i) lack of equipment; (ii) irrational, inadequate drug list to meet the clients’ needs and requirements; (iii) medical staff’s limitations due to lack of knowledge and regular updates; very poor ability to perform the designated procedures by levels of care; and (iv) a restricted reimbursement cap. 
The health sector needs to have clear mechanisms for supportive supervision of the commune level in a systematic way, since HI authorities are not adequately staffed for direct monitoring of service quality.
Research is needed on cutting paperwork, especially such formalities as referral recommendation letter or drug cost reimbursement to district level hospitals.
The equipment portfolio of CHSs needs to be screened to stay in line with the current regulations of the Ministry of Health. Changes should be made to regulations on CHSs’ available equipment and procedures, or other support should be provided to avoid the introduction of legislative documents that are difficult to enforce. 
More consistent measures are needed to improve the quality of care at CHSs, including training and updates to upgrade the quality of the staff, investment in infrastructure development, equipment, and medication to meet the target of universal health insurance coverage.


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