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 Vũ Thị Minh Hạnh, Phan Thanh Cẩm*, Nguyễn Đình Thuyên*, Nguyễn Kim Anh*, Phan Sỹ Anh**, Trần Thị Hồng Cẩm, Hoàng Thị Mỹ Hạnh, Vũ Thị Mai Anh,Trần Vũ Hiệp, Nguyễn Việt Hà, Trịnh Thị Sang, Nguyễn Văn Hùng

* Social Affairs Department, Central Education and communication Committee
** Dong Nai provincial Education and communication Committee
Place of publication: Ministry of Health
Year of publication:  2011

On Sep. 7, 2009, the central Party Secretariat released Directive 38-CT/TW on “Strengthening health insurance in the new context” aiming to enhance enforcement of the HI Law in practice and contribute to social security and equity in health care. To provide a timely interim review of the success story and to find challenges and drawbacks as the Directive is translated to real life, to come up with ways to further improve performance and enforcement in the immediate future, a review of the “Two years of implementing the Party Secretariat’s Directive 38-CT/TW on strengthening health insurance in the new context” is needed.
1. To review the organizational and implementing arrangements of Directive 38-CT/TW of Party committees and governments in selected provinces nationwide;
2. To identify barriers and challenges in the implementation of Directive 38-CT/TW, whereby drawing out recommendations for improvement of enforcement performance in real life.
Location and methodology: Case study, cross-sectional description, combined with quantitative and qualitative data collecting methods. Survey sites encompass Ha Giang, Quang Tri and Lam Dong provinces.
Findings and discussions
Current status of awareness and implementation of Directive 38-CT/TW
Orientation and awareness: 60% of the provinces/cities successfully disseminated and communicated the key instructions of the Directive among various Party committees, governments and mass organizations in 2009, with another 11.1% in 2010 and more than 30% in 2011. Coverage in the orientation of Directive 38-CT/TW reached 100% in the provinces, 97.2% in districts/towns/cities, and 95.8% in communes/wards. Directive 38-CT/TW has now been widely disseminated among public officials, Party members and the community.
At the national level, Guideline No. 90-HD/BTGTW-BCSĐBYT-BCS ĐBHXHVN was released to support orientation of the Directive. An Giang province and Hochiminh city are areas where leadership and guiding documents were introduced in the highest number and consistency. There are now 10 municipal level Party committees that have not released their leadership guidelines. Three other provinces have entirely relied on local line agencies in the implementation of the Directive.  
Completion of core missions in the leadership principle of Directive 38-CT/TW: More than 94% of the public have heard/known about HI. Members of the public who know exactly what benefits they are entitled to when using a HI card are not high in percentage (only >20% to >30%). HI-related education remains lackluster. The HI fund has been managed in the provinces by different beneficiary groups, levels of care and types of medical services received to help maintain the fund’s balance. Many provinces have raised supporting funds to help widen local HI coverage with locally available resources. The Ministry of Health has also released various guidelines to promote medical practices’ formality renovation and service quality improve to better cater to the needs of health insured clients. 
Monitoring and evaluation in the implementation of Directive 38-CT/TW: While audit and monitoring of Directive 38-CT/TW have been emphasized, the process seems non-formulaic, as findings and evaluation outcomes remain poorly presented and inconsistent between different provinces. Audit, monitoring and evaluation results lack details both in terms of substance and target groups, and fail to pinpoint areas of improvement.
Findings and initial impact
The awareness of Party committees and governments on HI has been increasingly improved. Most of the interviewees correctly understand the aims and importance of HI.
HI-based health service providers are increasing, especially at the population level. Public medical practices having a medical service delivery agreement with the HI fund have increased in number by 113.3%, while non-public facilities having subscribed to HI grew by 162.5%.
The quality of HI-related service delivery has been improved over time. Advocacy and education of HI have been ongoing right where medical services are delivered. In respect of waiting time for different steps in the service delivery process at health services, most patients rate it as fast and medium. HI reimbursement procedures are reported as good (43.5%) and normal (41.9%). Health workers’ attitude of service toward health insured patients are rated as indifferent, good and very good, especially with the doctors (12%). HI-based medicine has been provided and rated as normal and sufficient, both in terms of categories (44% and 39.9$ respectively), and quantity (45.8% and 37.7% respectively).
HI coverage has been extended to most community members. HI card holders have the highest number in Ha Giang (>90%), followed by Quang Tri (>84%), and lowest in Lam Dong (54.7%). Voluntary HI cards are increasing over the years. Primary HI cards at the commune level increased to 160% in the 8 first months of 2011 over 2010, and 215% over 2009. The number of visit by health insured outpatients also increased from 50.08% in 2008 to 57.51% in 2009 and 65.33% in 2010. The number of health insured inpatients/visits was also on an upward trend from 2008 to 2010 with increasing pace.
Limitations and challenges
Orientation and dissemination of Directive 38-CT/TW: not yet truly on a consistent and far-reaching level at all Party committees, especially at the population level; A number of provinces seem slow to get up to speed, and messages delivered in orientation remained generic and cursory. Supervision and monitoring of Party committees in this regard received inadequate emphasis.
Implementation: Enactment of leadership and guiding documents remains in misalignment. Education on HI has not been ramped up to the right level or the right scale and detail levels. Some measures to enlarge the card base among the target groups are not desirable. Issuance of HI cards to the poor in some places has shown signs of spontaneity and non-compliance. Awareness changes among public officials, Party members and the community on the benefits of the HI card and related regulations are less than expected. A large portion of the public is not yet ready to enroll into voluntary HI, especially the near-poor. The cooperation of HI and a number of health facilities in responding to current questions lack integrity and regularity, while HI payment verifying manpower is in shortage. HI-based health care in many places are not up to the standard expected by the patients, letting down the attractiveness of HI. A few HI-based medical practices tend to overprescribe medication and hi-tech services, while the frequency of HI card use by health workers is higher than the overall average.
Outstanding gaps: The current user fee scheme seems no longer relevant, but is slow to change. Level segregation and designated lists of surgeries and medical procedures are slow to be updated, making it difficult to determine HI expenses. The adoption of codes of conduct and etiquette in various service sites has been less than optimal. The frequently changing HI software makes it difficult for health providers to update, use and manage data. Disposable resources for HI education, promotion and advocacy remain very limited. The awareness on the importance of HI and affordability of various portions of the public are low. 
The leadership and supervising role of the Party from the national down to the ground levels needs to be strengthened, with an emphasis on the leader’s accountability. Detailed assignments and responsibilities should be defined for all levels and line agencies in the dissemination and implementation of Directive 38-CT/TW and HI Law, and related legislation. A strong focus should be placed on HI education and advocacy targeting Party committees, governments and the community. A specific information and communication project for Directive 38-CT/TW and HI Law should be in place to improve ownership in terms of resources and implementation planning. Self-motivated and active participation of various line agencies and civil society, especially from the population level, should be welcomed. HI education needs to be incorporated in the related national target program to keep the villages well informed. Target groups for information and communication should be pinpointed. Communication messages and forms need to be enriched to cater to the needs of different groups. HI-related public governance needs to be further strengthened. Steps should be taken to improve the quality of HI-based health care and patients’ satisfaction, whereby increasing the attractiveness of HI to the community. An universal approach in HI promotion through specific community-based actions as part of the movement of universal unity in building cultural neighborhood needs to be in motion.

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