OIG audit: Integration of HIV and TB treatment into Viet Nam’s national health insurance scheme presents challenges and risks
Treatment for HIV and TB is being integrated into Viet Nam’s national health insurance scheme as part of the government’s commitment to achieving universal health coverage (UHC). But the move is not without challenges and risks, according to the Office of the Inspector General (OIG), which released a report on its audit on Global Fund grants to Viet Nam on 20 August.
“There is a risk that some patients will not be able to access affordable and quality care through the health insurance,” the OIG said, “due to difficulties to enroll in the scheme and risk of increased loss-to-follow-up related to the transition process.”
Integration into the insurance scheme was the main focus of the audit. For the most part, the audit report was very laudatory. The OIG said that Viet Nam has made significant progress in reducing the burden of HIV, TB and malaria (see the last section of this article for details); and that financial management, internal control, governance and assurance mechanisms were all generally effective.
The OIG also noted that integration of HIV and TB treatment into the insurance scheme is a country-led initiative designed to improve the sustainability of Viet Nam’s health system.
The audit covered all five grants to Viet Nam from January 2015 to December 2017. See the table for a list of the grants.
|Comp.||Grant No.||Principal recipient|
|HIV||VNM-H-VAAC||Viet Nam Administration of HIV/AIDS Control|
|HIV||VNM-H-VUSTA||Viet Nam Union of Science and Technology Associations|
|Malaria||VNM-M-NIMPE||National Institute of Malariology, Parasitology and Entomology of the Ministry of Health of the Socialist Republic of Viet Nam|
|TB||VNM-T-NTP||Viet Nam National Lung Hospital (National Tuberculosis Program)|
|HSS||VTN-011-G10-S||Department of Planning and Finance, Ministry of Health|
Note: The links are to the Viet Nam grant pages on the Global Fund website.
In this article, we focus primarily on the health insurance issue.
Integration with health insurance
Integration into the health insurance scheme is going well, the OIG said: Both patients and service providers are being enrolled into the scheme, and activities are being implemented in a structured manner. The Viet Nam Administration for HIV/AIDS Control (VAAC), the principal recipient (PR) for one of Viet Nam’s two HIV grants, is leading this effort.
However, the OIG said, at the time of the audit, the Global Fund and VAAC had not yet completed a comprehensive risk analysis to capture how this change in implementation arrangements will impact access to affordable and quality treatment, especially for vulnerable populations. “If risks related to this change are not effectively anticipated and mitigated, some patients may be unable to access HIV treatment services that are transitioning to the health insurance reimbursement scheme,” the OIG stated.
HIV treatment services are currently provided free of charge to patients through government and donor funding. However, to benefit from the health insurance scheme, patients must enroll in the scheme; obtain services from a provider that has a contract for reimbursement under the scheme; pay an annual premium; and provide an up-front co-payment each time they access services. The OIG said that several challenges exist in both enrolling patients into the scheme and ensuring that they remain on treatment. The challenges include the following:
- the premiums and co-payments may be unaffordable for some patients, some of whom may not be able to access financial support provided by the government to cover these costs;
- patients who do not have a permanent address or an identity card (such as migrant and mobile populations) may have difficulty procuring insurance coverage;
- some patients will need to switch service providers, which they may be reluctant to do;
- members of stigmatized populations who may not want their serological status to be known may not want to enroll in the scheme; and
- it will take time for some service providers to meet all the criteria to enroll.
On the issue of costs, the Government of Viet Nam has instructed local governments to cover the costs of co-payments for the poor and near-poor populations. However, the OIG said, no assessment has been conducted of how much this would cost; nor has a comprehensive analysis been performed of the financial capacity of local governments to defray these costs.
(The OIG reported that the Global Fund is contributing $3.1 million for the 2018–2020 grant cycle to help offset the costs of health insurance premiums and co-payments for these populations. The funds are coming from the matching-funds stream of the Fund’s catalytic funding component.)
Another problem is that while integration is happening, the government is simultaneously scaling up antiretroviral treatment to achieve the 90-90-90 targets. The OIG believes that it may be challenging to scale up treatment while also going through the integration process, and that any treatment disruptions caused by integration would likely hamper the achievement of these targets.
In addition, procurement and supply chain arrangements will change as a result of the inclusion of HIV and TB services into the health insurance scheme. Procurement will be handled by the newly established National Drug Procurement Centre. However, the OIG noted, responsibilities related to supply management –– quantification, distribution and storage –– have not yet been assigned, despite the fact that some warehouses are already operating at or near full capacity.
According to the OIG, the country coordinating mechanism has not yet incorporated these integration issues in its discussion agenda or oversight activities.
The OIG also pointed out that the health insurance scheme does not cover HIV prevention activities. These activities will continue to be covered by governmental and other sources (such as Global Fund grant funds).
The OIG said that to address risks related to access to and affordability of quality care following the integration of HIV treatment services into the national health insurance, the Global Fund Secretariat will work with the PRs to establish a “high-level implementation plan.”
(A spokesperson for the Secretariat told Aidspan that the “high-level implementation plan” refers to a transition plan related to the withdrawal by PEPFAR from direct service delivery effective 30 September 2018. PEPFAR, the Government of Vietnam and the Global Fund have been working for three years to build the conditions for a smooth transition. The spokesperson said that the transition plan is in place and that the risks related to PEPFAR’s withdrawal from direct service delivery are being mitigated.)
Significant progress in responding to the epidemics
The OIG observed that Viet Nam’s progress in the fight against the three diseases is due, in part, to strong political commitment from the government, which has committed to ending the HIV and TB epidemics and eliminating malaria by 2030.
All of the Global Fund grants are meeting or exceeding expectations, the OIG stated. HIV-related deaths decreased by 21.8% between 2007 and 2017. HIV prevalence among key populations (except for men who have sex with men) has decreased steadily since 2005. (The HIV prevalence among men who have sex with men has increased recently –– from 6.7% in 2014 to 12.2% in 2017, the OIG said.)
Viet Nam has a strong HIV testing and counselling program, and a strong and innovative harm-reduction program, the OIG noted.
The Global Fund has been instrumental in building the role of civil society in the HIV response, the OIG observed. Whereas that role was previously very limited, there is now a civil society PR –– the Viet Nam Union of Science and Technology Associations (VUSTA) –– for one of the two HIV grants; three civil society sub-recipients; and 99 community-based organizations that provide HIV prevention and harm reduction programs and facilitate access to treatment for key populations.
With respect to TB, the OIG said that TB-related mortality, and TB prevalence and incidence have all decreased steadily since 1990. Viet Nam has introduced innovative approaches for TB detection and treatment, the OIG added.
Finally, concerning malaria, Viet Nam is entering the pre-elimination phase, the OIG reported. Between 2013 and 2017, confirmed malaria cases decreased from 17,128 to 4,548. In 2017, there were only six deaths due to malaria. Drugs to treat the disease are widely available. The OIG pointed out that the malaria disease response is supported by a strong network of community health workers.