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USAID’s Health Finance and Governance (HFG)
project helps to improve health in developing
countries by expanding people’s access to health care.
Led by Abt Associates, the project team works with
partner countries to increase their domestic resources
for health, manage those precious resources more
effectively, and make wise purchasing decisions.
HFG VIETNAM
FINAL REPORT @HFG,ImagebyLinhPham
The Health Finance and Governance (HFG) Project works
to address some of the greatest challenges facing health
systems today. Drawing on the latest research, the project
implements strategies to help countries increase their
domestic resources for health, manage those precious
resources more effectively, and make wise purchasing
decisions.The project also assists countries in developing
robust governance systems to ensure that financial
investments for health achieve their intended results.
With activities in more than 40 countries, HFG
collaborates with health stakeholders to protect families
from catastrophic health care costs, expand access to
priority services – such as maternal and child health care –
and ensure equitable population coverage through:
•	 Improving financing by mobilizing domestic resources,
reducing financial barriers, expanding health insurance,
and implementing provider payment systems;
•	 Enhancing governance for better health system
management and greater accountability and transparency;
•	 Improving management and operations systems to
advance the delivery and effectiveness of health care,
for example, through mobile money and public financial
management; and
•	 Advancing techniques to measure progress in health
systems performance, especially around universal
health coverage.
The HFG project (2012-2018) is funded by the U.S.Agency
for International Development (USAID) and is led by Abt
Associates in collaboration with Avenir Health, Broad
Branch Associates, Development Alternatives Inc., the
Johns Hopkins Bloomberg School of Public Health, Results
for Development Institute, RTI International, and Training
Resources Group, Inc.
The project is funded under USAID cooperative
agreement AID-OAA-A-12-00080.
To learn more, visit www.hfgproject.org
ABOUT THE HEALTH FINANCE AND
GOVERNANCE PROJECT 2012-2018
HFG’S COMPREHENSIVE TECHNICAL SUPPORT TO
THE FINANCING TRANSITION OF THE HIV RESPONSE
Integration of
outpatient clinics
Increased PLHIV
and service
coverage of SHI
Centralized ARV
procurement
Advancing financial
sustainability for
PLHIV, providers,
and SHI
SUCCESSFUL
TRANSITION
Establishing social health insurance (SHI) as the primary
financing mechanism for the HIV response
CanTho Tien Giang
HCMC
Dong Nai
Tay Ninh
PhuTho
Ha Noi
Ha Phong
Thai Binh
Ninh Binh
Hoa Binh
Original
HFG provinces
added in 2017
Provinces
added in
response to
new PEPFAR
2-region focus
2018
Original
HFG provinces
since 2015
HFG VIETNAM FINAL REPORT | HEALTH FINANCE AND GOVERNANCE PROJECT (2012-2018) 1
CHALLENGES
USAID’s Health Finance and Governance (HFG)
project began its work inVietnam in 2014.At that
time, all aspects of the country’s HIV response—
prevention, treatment, and care—depended
overwhelmingly (>70%) on international donor
funding (Ministry of Health 2018), primarily from
the President’s Emergency Plan for AIDS Relief
(PEPFAR) and the Global Fund. However, with
Vietnam’s graduation to middle-income country
status and evidence that the HIV epidemic was
slowing in terms of the number of new infections,
donors began to reduce their support and
inform the Government ofVietnam (GVN) about
timelines for withdrawal from the country.
With these projected declines in donor funding,
the GVN had a pressing need to develop
sustainable financing for a seamless continuation
of HIV programs.A principal challenge was to
ensure continuous antiretroviral treatment
(ART) for the ~130,000 existing patients and
to further expand treatment coverage to
achieve epidemic control through treatment as
prevention. Consequently, increasing domestic
resource mobilization for the HIV response
became an overarching goal for the GVN.
The GVN had, by 2014, decided that the
country’s social health insurance (SHI) scheme
would be the primary financing mechanism
and method of domestic resource mobilization
as donors withdrew, but the feasibility and
sustainability of this strategy had not been
established and key dimensions of the transition
remained largely unplanned.These included
conversion of donor-funded (funded primarily
by PEPFAR and the Global Fund) HIV outpatient
clinics (OPCs) to the public health system with
SHI coverage and reimbursement for services;
centralized procurement of antiretroviral (ARV)
drugs to replace donor-funded mechanisms;
increased SHI coverage of people living with HIV
(PLHIV) and expansion of HIV services covered
by SHI; and measures to ensure the sustainability
of the transitioned HIV response for patients,
providers, and the SHI fund.
CHANGE
HFG became the primary provider of technical
assistance to the GVN on the financing transition
of the country’s HIV response.The project
worked closely with USAID and the Ministry of
Health (MOH),Vietnam Social Security (VSS), and
other key government agencies to design and
deliver a portfolio of technical support at the
central level and in nine provinces.This support
has helpedVietnam to advance toward a timely
and successful financing transition.
HFG assisted the GVN to make significant
progress in all five elements that comprise a
comprehensive transitional strategy (see graphic
on the previous page): confirmation of the GVN’s
choice of SHI as the primary financing mechanism;
full integration of treatment facilities into SHI;
full SHI coverage among PLHIV and expansion
of HIV services covered by SHI; preparation
of the government apparatus for centralized
procurement of ARV drugs; and sustainability
of the transitioned HIV response for PLHIV,
providers, and the SHI fund.
These HFG contributions, produced in 2014–2015,
helped demonstrate the feasibility of, and solidify
the GVN’s commitment to, SHI as the primary
financing mechanism for the transitioned HIV
response. For the remainder of the project, HFG
provided technical support to the GVN at the
central level and in nine provinces to implement
the key elements for successful transition of HIV
services inVietnam.
HFG OVERVIEW IN VIETNAM
HFG VIETNAM FINAL REPORT | HEALTH FINANCE AND GOVERNANCE PROJECT (2012-2018)2
The HFG project developed critical evidence
to solidify the GVN’s choice of SHI as the
primary financing mechanism for HIV services.
In cooperation with the MOH and theVietnam
Administration for HIV/AIDS Control (VAAC),
HFG identified and answered three major
questions on the feasibility of SHI for funding
the HIV response, as shown in the table below.
PROJECTED FUNDING FOR ART COVERAGE IN VIETNAM
Questions onTransitioning the
HIV Response
How HFG Answered
Can the SHI fund afford to cover HIV
services?
HFG developed an SHI liability model, which
showed that the SHI fund could easily absorb
the projected costs of covering HIV services.
How will the parallel system of donor-
funded HIV outpatient clinics be
systematically integrated into the public
health system and SHI scheme?
HFG developed a standardized, step-wise
approach to OPC integration, demonstrating
that it was feasible for theVAAC and provinces
to integrate OPCs into SHI and enable future
reimbursement of their services.
What mechanisms can the GVN use for
centralized procurement of ARV drugs?
HFG produced a report on options for a
central procurement unit and procedures for
centralized bidding to procure ARVs.
DEMONSTRATING THE FEASIBILITY OF SHI
AS THE PRIMARY FINANCING MECHANISM
FOR A TRANSITIONED HIV RESPONSE
HFG VIETNAM FINAL REPORT | HEALTH FINANCE AND GOVERNANCE PROJECT (2012-2018) 3
“I highly appreciate the support from
HFG on providing HIV services and
getting reimbursement through the SHI
system.Together with the on-site technical
assistance - visits to facilities, HFG supported
the Department of Health and the Provincial
HIV/AIDS Center in organizing an OPC
integration sharing workshop for all facilities
on March 2017, then follow-up technical
assistance support to individual facilities.”
~ Ngo Thi Hong, Head of Care and Treatment, Ninh
Binh Provincial HIV/AIDS Center
RESULT AREA 1
More than 80 percent of the HIV OPCs in nine provinces integrated into the
public health system and SHI scheme
HFG provided technical assistance on OPC
integration to the MOH and nine provinces,
enabling the provinces to achieve full integration
of more than 80 percent of their treatment
facilities by September 2018.As a result of this
effort, delivery of ART and related services is being
shifted from donor-funded OPCs to an integrated
system of clinics in provincial and district hospitals
and district and commune health centers, with
reimbursement through SHI.Among the nine
HFG-supported provinces are Hanoi and Ho Chi
Minh City, the two provinces with the highest HIV
burden. More than 51,000 ART patients (~46% of
the total inVietnam) at 118 facilities will benefit
from OPC integration in HFG’s nine provinces.
The legal requirement that only services provided
in curative settings qualify for SHI reimbursement
posed a major challenge in the beginning for the
integration of HIV treatment into SHI, because
most HIV patients were being served in single-
function facilities—mainly donor-funded OPCs—
that were part of the preventive medicine system.
HFG supportedVAAC,VSS, and MOH to overcome
this obstacle and assisted provincial departments
of health and treatment facilities to achieve the
key integration steps for SHI contracting and
reimbursement of HIV services.This involved
enabling single-function facilities to qualify for SHI
contracts and reimbursement or assisting with
transfer of their patients to qualified clinics.
HFG also provided technical assistance at the
national level, including development of an OPC
integration monitoring tool and ongoing assessment
of transition progress.The project devised a
national dashboard of key integration progress
indicators, which helpedVAAC monitor and update
OPC integration progress and identify provinces
and facilities in need of additional support.
MAKING A DIFFERENCE
@HFG,ImagebyLinhPham
HFG VIETNAM FINAL REPORT | HEALTH FINANCE AND GOVERNANCE PROJECT (2012-2018)4
STRONG PROGRESS OF OPC INTEGRATION IN NINE HFG-SUPPORTED PROVINCES
@HFG,ImagebyLinhPham
HFG VIETNAM FINAL REPORT | HEALTH FINANCE AND GOVERNANCE PROJECT (2012-2018) 5
“Now I totally believe that I have
enough knowledge and skills and I
am confident to provide counseling
for PLHIV regarding ARV treatment
and sustainable financing support for
PLHIV through SHI.”
~ NguyenThe Anh (center), Director of Qua
Lac Commune Health Station, Nho Quan
District, after participating in a training
RESULT AREA 2
More than two-fold increase in SHI coverage of PLHIV and
expansion of HIV services covered by SHI
For SHI to be an effective financing mechanism for
the HIV response, it is imperative that PLHIV be
enrolled and that SHI cover a comprehensive set
of HIV services.The HFG project supported the
GVN in meeting these requirements.
Increasing enrollment of PLHIV in SHI
At the start of HFG’s work inVietnam, only about
40 percent of ART patients were enrolled in SHI.
We helped increase that coverage to 81 percent in
the nine HFG provinces.
The GVN’s Decision 2188 of November 2016
stated that provincial funding be used to provide
free SHI cards to all PLHIV, but many challenges
stood in the way of achieving 100 percent
coverage.These included budget shortages in
some provinces, difficulties in reaching un-enrolled
PLHIV in communities, lack of understanding
among some PLHIV about the procedures and
advantages of SHI enrollment, and PLHIV’s fear
of losing confidentiality by enrolling in SHI and
the resulting potential for stigmatization and
discrimination in their families and communities
and in integrated treatment facilities.
HFG’s technical assistance enabled the nine
supported provinces to tackle these challenges
and achieve solid progress on SHI enrollment
of PLHIV. Our support included classification
and listing of PLHIV’s SHI status; advocacy
for provincial support for SHI premiums; and
collaboration with USAID’s Healthy Markets
project to increase SHI enrollment among key
populations through print materials, social media
messages, and training of counselors for PLHIV in
community-based organizations and community
health facilities.
@HFG,ImagebyLinhPham
HFG VIETNAM FINAL REPORT | HEALTH FINANCE AND GOVERNANCE PROJECT (2012-2018)6
AIDS
Deaths
DEATHS AVERTED DUE TO INCREASED SHI COVERAGE
Expanding the HIV services covered
by SHI
HFG also provided the GVN with technical
support and evidence for expansion of SHI-
covered HIV services, another key element in
successful transition of the HIV response. PLHIV
may be reluctant to enroll in SHI if they are not
certain that all HIV services will be covered. In
fact, viral load testing is only gradually coming
under SHI in 2018 and, pursuant to revised GVN
policy,ARV drugs will remain free to all patients
in all treatment facilities through support from
international donors andVietnam’s National Target
Program until the end of 2018 and will come under
SHI in about 190 facilities in January 2019. PEPFAR
drug stocks and Global Fund support will continue
to support free ARVs in many facilities in 2019 and
for a few years beyond.ARVs and viral load testing
are the most costly components of HIV treatment.
As a step toward increased service coverage, HFG
supported the MOH to develop a basic health
service package that included a comprehensive set
of HIV services to be paid for by health insurance.
This contributed to improving the accessibility,
affordability, and quality of care provided by
devolving important service elements, including
dispensing of ARV medications, to the commune
level, as required by Circular No 39/2017/TT-BYT,
October 18, 2017, which HFG helped draft.
Supporting inclusion of preventive
services in SHI
Prevention is a critical part of the overall HIV
response, butVietnam’s Law on Health Insurance
restricts coverage to curative services; coverage
of preventive and addiction treatment services
is prohibited. Preventive and addiction treatment
services currently depend on donors and the
National Target Program on Health, but donors
are reducing their support and the budget for
the National Target Program’s budget for such
services has been cut.
HFG is working to bring preventive services under
SHI.We are supporting the MOH to conduct an
assessment of three years of implementation of
the current SHI law and make recommendations
for revising the Law on Health Insurance in
2019. HFG also supported the development of
evidence to advocate for inclusion of selected
HIV prevention services in the revised SHI law,
including a review of international evidence of the
economic benefits of these interventions and cost
estimates for their implementation and coverage
by SHI inVietnam.
PROJECTED AIDS DEATHS
2,536 DEATHS AVERTED
Current ART Funding
Expansion of SHI
15K
14K
13K
12K
11K
10K
2017 2018 2019 2020 2021 2022
HFG VIETNAM FINAL REPORT | HEALTH FINANCE AND GOVERNANCE PROJECT (2012-2018) 7
RESULT AREA 3
The Government of Vietnam prepared for centralized
procurement of ARV drugs
To sustain HIV treatment in the wake of declining
donor funding, the GVN must cover about 26
percent of the ARV drugs in 2019 through SHI
and direct budget support, increasing to almost
60 percent in 2020 and to 100 percent when the
Global Fund phases out a few years later. HFG’s
support—including development of required legal
documents and technical assistance on bidding
procedures and monitoring of fund flows—
helped the GVN advance toward government-led,
centralized procurement of ARV drugs.
Procurement of ARV drugs will require the
largest share of GVN expenditures on HIV
services as the government takes responsibility
for the HIV response. HFG advocated for ARV
procurement through SHI funds and supported
resolution of administrative and legal challenges,
such as the need to designate a centralized
procurement unit at the MOH, establish the
legal basis for centralized ARV procurement, and
define the relationship between VAAC and VSS
and their responsibilities for fund flows and the
ARV supply chain.
A major obstacle was that SHI was designed
to provide reimbursement after services were
delivered rather than to advance funding before
service delivery. HFG provided the GVN with
policy options for, and evidence on, the viability
of using the SHI fund to advance payment for
centralized procurement of ARVs and clear
HIV patients pick up their medications at a pharmacy.
Even though ARV drugs will not come under SHI until
January 2019, facilities in Ninh Binh are requiring patients
to present their SHI cards to ensure readiness for the
transition.
@HFG,ImagebyLinhPham
HFG VIETNAM FINAL REPORT | HEALTH FINANCE AND GOVERNANCE PROJECT (2012-2018)8
procedures for quantification, reimbursement,
and liquidation.This support, in turn, informed the
GVN’s development and promulgation of key legal
documents, which HFG helped draft, including
Decision 2188 (November 15, 2016) and Circular
28/2017/TT-BYT (June 26, 2017). Circular 28
provided for advance payment for ARV drugs from
the SHI fund.
In July 2017, the GVN announced that the
MOH’s Central Procurement Unit would manage
procurement of ARVs and delayed the coverage
of ARVs by SHI until January 2019.To help
address these changes, HFG supportedVAAC
to revise Circular 28 and built the capacity of
the Central Procurement Unit and provincial
stakeholders.Additionally, we are assisting GVN
agencies in monitoring the flow of funds for ARV
procurement and settlement, while the USAID
Global Health Supply Chain-Procurement and
Supply Management (PSM) project takes the lead
on the supply chain and flow of ARV drugs.
FLOW OF FUNDS REQUIRED BY CIRCULAR 28 FOR CENTRALIZED ARV PROCUREMENT
SUPPLIER(S)
CONTRACTING
UNIT CU/VSS
VAAC/CPU
VIETNAM
SOCIAL
SECURITY
•	 First legal document establishing and regulating
centralized procurement and payment for ARV and SHI
•	 Requires and provides guidance on ARV
copayment subsidies for PLHIV
BIDDING
VAAC/CPU
HEALTH
FACILITIES
ARV
Quantification
ARV
Quantification
ARV
Distribution
PSS
(Where signed
contract)
Framework
Agreement
CONTRACTING
HFG VIETNAM FINAL REPORT | HEALTH FINANCE AND GOVERNANCE PROJECT (2012-2018) 9
RESULT AREA 4
Sustainability of the HIV response advanced for PLHIV,
providers, and the SHI fund
Successful transition of the HIV response requires
that the new arrangements be financially sustainable
for all stakeholders: PLHIV, health providers, and
the SHI scheme itself.The HFG project provided
technical assistance and tools to helpVietnam move
toward a sustainable response.
Sustainable services for PLHIV
To have SHI cover their HIV services, PLHIV need
to enroll and pay the required SHI premium and the
established copayments for services.Vietnam’s Law
on Health Insurance fully exempts from premiums
and copayments only those certified as “poor” or
falling into certain other designated groups who
are covered by certain special funds or provincial
budgets; the “near-poor” must pay a copayment
of 5 percent of the cost of the covered service,
and all others must pay the full premium and a 20
percent copayment. HFG’s analysis showed that
existing subsidies would protect an estimated 26
percent of the economically disadvantaged PLHIV
on treatment.A large number of patients, especially
people who use drugs and members of other key
populations, although not officially poor, would face
economic hardship if confronted with a lifetime of
payments for their treatment.This hardship might
negatively affect care seeking behavior, treatment
retention, and adherence, which could reduce
Vietnam’s chances of reaching its stated 90-90-95
goals and controlling the HIV epidemic through
treatment as prevention.To address this coverage
gap, we assisted the MOH in developing Circular
28 (June 29, 2017), which formed the legal basis for
universal free access to SHI for PLHIV and subsidies
for copayments related to ART.
However, financial protection of patients, in turn,
depends on provinces allocating budget from funds
“I must say that without the SHI card, I
might have died already… I sometimes
got serious illnesses for which I needed
to be admitted to hospital.Thanks to the
SHI card, my life has been saved until this
moment.As I am from a poor household,
SHI has covered… almost 100 percent of
my treatment..”
~ An ART patient from Ninh Binh province
@HFG,ImagebyLinhPham
HFG VIETNAM FINAL REPORT | HEALTH FINANCE AND GOVERNANCE PROJECT (2012-2018)10
for the poor, funds for HIV and other dangerous
diseases, and other special funds to support
premiums and co-payments. HFG helpedVAAC
design and test a replicable model of guidelines
and procedures for subsidizing premiums and
ART copayments for all PLHIV in need of financial
aid in four provinces. HFG also helped the pilot
provinces to advocate for provincial funding
of the subsidies.Where provincial funding falls
short of the need, the difference will be made
up from Global Fund Catalytic Funds or PEPFAR
performance-based incentive payments.As the
subsidies are implemented in 2019,Abt Associates,
which implemented the HFG project globally, will
provide intensive technical assistance to provincial
and facility staff and carefully monitor the model’s
implementation. Positive evidence from this
monitoring could be used to urge provinces to
assume full financial support of the subsidies and
other provinces to adopt the model.
Sustainable financing for HIV service
providers
HFG’s support in this area began with helping
facilities obtain SHI contracts and qualify for
reimbursement under SHI.We subsequently
provided technical support toVSS to harmonize
information systems that will ensure prompt and
efficient reimbursement to facilities for their HIV
services and avoid duplicate reimbursement for
ARV drugs and other abuses of SHI.
Sustainability of the SHI fund for HIV
services coverage
HFG developed tools and evidence to support
the sustainability of the SHI fund’s coverage of
the full range of HIV services, and built the GVN’s
capacity to employ these tools independently in
future.With our support, the MOH developed
National Health Accounts to track health
expenditures for 2013–2015, with a separate
sub-analysis to track HIV expenditures.This
provided a retrospective analysis of trends in HIV
expenditures from all sources, including donors,
to provide estimates of HIV financing needs ahead
of the transition to SHI as the primary mechanism
for funding the HIV response.
We further advanced the GVN’s awareness and
understanding of future financing needs through
updated estimates of HIV liability for the SHI fund
during 2018–2020, when the full transition to
SHI takes effect. Our projection model revealed
that even with the addition of ARV drugs and
viral load testing, HIV-related service costs would
represent less than 1 percent of the total liabilities
for the SHI fund during 2018–2020.This analysis
has helped to convince the MOH andVSS of the
feasibility and future sustainability of SHI coverage
for HIV services.
@HFG,ImagebyLinhPham
HFG VIETNAM FINAL REPORT | HEALTH FINANCE AND GOVERNANCE PROJECT (2012-2018) 11
SUSTAINABILITY
The HFG project contributed to the continuation
and sustainability of the transition to a GVN-
funded and -operated HIV response in several
ways.We transferred the skills and tools used to
develop evidence of sustainability, including the
National Health Accounts and SHI projection
models, to the GVN for use in future financial
planning of HIV programs and advocacy for
increased domestic resource mobilization at the
central and provincial levels.We carried out the
handover through written manuals and guidelines,
hands-on training, and user-friendly software.
Building on our success and experiences in
nine provinces, we adapted our work plan to
incorporate several additional provinces listed in
PEPFAR’s new two-region focus.We have included
in the pilot of the ARV copayment subsidy model
the Tien Giang and Tay Ninh provinces, which are
home to more than 3,000 HIV patients and belong
to PEPFAR’s Ho Chi Minh City metropolitan
region.The two new PEPFAR regions have more
than half of all PLHIV inVietnam and a regional
strategy of intensive case finding, enrollment
in ART, and coverage for the full range of HIV
services through SHI. HFG’s support to provinces
acrossVietnam is strengthening the country’s
efforts to achieve its 90-90-95 goals by the year
2020 and, ultimately, control the HIV epidemic.
Although many challenges to the HIV transition
in Vietnam have been overcome, several
remain.The table below lists the continuing
challenges and activities needed in four key
areas to strengthen Vietnam’s HIV response.Abt
Associates will address many of these challenges
and carry out many of the needed activities
under a recently awarded two-year bilateral
contract with USAID, called the Sustainable
Financing for HIV Activity (SFHA).
LOOKING FORWARD
@HFG,ImagebyLinhPham
HFG VIETNAM FINAL REPORT | HEALTH FINANCE AND GOVERNANCE PROJECT (2012-2018)12
REMAINING WORK FOR TRANSITION OF THE HIV RESPONSE INVIETNAM
1. Final and full integration of HIV
OPCs into the public health system
and the SHI scheme
Continuing challenges:
•	 Global Fund-supported facilities are still
offering free services, which may prevent
newly contracted SHI facilities from attracting
patients.
•	 Some preventive medicine center-based
OPCs do not yet have SHI contracts.
•	 Some facilities with SHI contracts are not yet
obtaining reimbursement through SHI.
Technical support needed:
•	 OPC integration assistance to facilities
withoutVSS contracts and SHI
reimbursement.
•	 Continuing training and capacity building of
VSS, Provincial Social Security, and facilities
on SHI enrollment, claim, and reimbursement
processes.
•	 Continued improvement ofVSS information
systems for reimbursement tracking and
patient management.
•	 Expansion of technical assistance to new
provinces in PEPFAR’s two-region focus,
including Tay Ninh and Tien Giang
2. Expansion of HIV services covered
under SHI
Continuing challenges:
•	 Procurement and availability of ARVs through
SHI must be timed to avoid any supply gaps
that could cause patients to lose treatment.
•	 The Law on Health Insurance prohibits
coverage of any prevention or addiction
treatment services.
Technical support needed:
•	 Continued technical assistance and capacity-
building support to the Central Procurement
Unit, the MOH, and provinces on ARV
centralized procurement.
•	 Development of annually updated ARV
quantification and budgeting for centralized
ARV procurement
•	 Continued monitoring of the flows of money for
ARV procurement, distribution, and liquidation.
•	 Completion of the assessment of the Law on
Health Insurance and recommendations for
its revision in 2020.
•	 Evidence and advocacy to support SHI coverage
of HIV prevention and addiction treatment in
the revised Law on Health Insurance.
3. Expansion of SHI coverage of PLHIV
Continuing challenges:
•	 Gaps in SHI coverage remain, particularly
among key populations, migrant workers, and
undocumented residents.
•	 Some HIV patients may endure financial
hardship through out-of-pocket expenditure
as they move from free-of-charge OPCs to
public health facilities.
Technical support needed:
•	 Continued training of HIV counselors on
enrollment in SHI and ART
•	 Development of consistent and universally
implemented solutions to problems of PLHIV
lacking the required ID papers for SHI or ART
enrollment and their referral across provinces
and levels of facilities
•	 Scale up of SHI premium and ARV copayment
subsidies to ensure equitable and sustainable
PLHIV access to treatment and other HIV services
4. Financing strategies beyond SHI
•	 Exploration of and advocacy for innovative
financing strategies for HIV services, including
performance-based incentives, health
promotion funds supported by “sin taxes”
on alcohol and tobacco, and contracting with
civil society organizations for outreach, case
management, and treatment support services
HFG VIETNAM FINAL REPORT | HEALTH FINANCE AND GOVERNANCE PROJECT (2012-2018) 13
LESSONS LEARNED
The HFG project focused rigorously on capturing
and documenting the lessons learned over
the course of the project’s implementation.
Our health financing and governance experts
published a paper on the lessons from the
project’s implementation experience in Vietnam
(Todini et al. 2018). Excerpts from the paper,
summarizing the project’s learning in Vietnam, are
presented below.
Working within national policy. A main
source of delay in supporting the GVN’s policy
on HIV financing was the lack of clarity on policy
objectives related to the ongoing health financing
reform efforts.Working with the MOH and VSS,
we found that framing the discussion on HIV
under the umbrella of universal health coverage
allowed us to provide effective technical
assistance.
Having clear understanding of the different
stakeholders’ objectives. HFG focused on
increasing domestic resource mobilization for
the HIV response through SHI. Sticking to this
goal made all decision-making at the project
level much easier, and progress accelerated once
PEPFAR started providing deadlines and clear
estimates of decreasing funding.
Delivering evidence in simple and
understandable ways. HFG produced a
number of studies and documents. Delivery of
this information in a language that was accessible
for decision makers led to acceptance of the SHI
mechanism for HIV and the definition of an SHI
benefit package to include HIV services.
Recognizing that the need for evidence is
cyclical, not linear. It may be tempting to see
the inputs of evidence and technical assistance as
we view medical interventions: a shot of National
Health Accounts, a few pills of international
experience, an intravenous dose of health
financing via PowerPoint presentations, and the
“patients” will be cured of their weak capacity,
lack of knowledge, and blurred long-term vision.
In reality, our work alone cannot “fix” weak
health systems. In order to have real, long-term
impact, it has to be part of a continuous cycle
of evidence-based evaluation, decision-making,
action, and reevaluation.
Being flexible, learning, and adapting. A key to
our success was using an “opportunistic” approach
to technical assistance. Designing activities and
getting them approved requires time; often, the
approaches, topics, and models of assistance can
quickly become obsolete and lose relevance in the
eyes of the target audience. Keeping the program
flexible, to respond quickly to the shifts and sudden
changes due to governmental politics and moving
targets, is invaluable.
Targeting key decision makers at all
levels. Political commitment from the top is
necessary but not sufficient. Champions at all
levels are needed, but not all of them will be
useful or fully engaged. In a situation defined
by constrained resources, the implementer
should focus on targeting the right people for
advocacy, capacity building, and partnership.
HFG relied on a systematic and ongoing analysis
of individual stakeholders and their potential
roles as positive influencers.
REFERENCES
Ministry of Health. 2018. National Health Accounts, 2013-2015. Government ofVietnam.
Nazzareno Todini,Theodore M. Hammett  Robert Fryatt. 2018. Integrating HIV/AIDS inVietnam’s Social
Health Insurance Scheme: Experience and Lessons from the Health Finance and Governance Project, 2014–
2017, Health Systems  Reform, 4:2, 114-124, DOI:10.1080/23288604.2018.1440346.
HFG Vietnam Final Report

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HFG Vietnam Final Report

  • 1. USAID’s Health Finance and Governance (HFG) project helps to improve health in developing countries by expanding people’s access to health care. Led by Abt Associates, the project team works with partner countries to increase their domestic resources for health, manage those precious resources more effectively, and make wise purchasing decisions. HFG VIETNAM FINAL REPORT @HFG,ImagebyLinhPham
  • 2. The Health Finance and Governance (HFG) Project works to address some of the greatest challenges facing health systems today. Drawing on the latest research, the project implements strategies to help countries increase their domestic resources for health, manage those precious resources more effectively, and make wise purchasing decisions.The project also assists countries in developing robust governance systems to ensure that financial investments for health achieve their intended results. With activities in more than 40 countries, HFG collaborates with health stakeholders to protect families from catastrophic health care costs, expand access to priority services – such as maternal and child health care – and ensure equitable population coverage through: • Improving financing by mobilizing domestic resources, reducing financial barriers, expanding health insurance, and implementing provider payment systems; • Enhancing governance for better health system management and greater accountability and transparency; • Improving management and operations systems to advance the delivery and effectiveness of health care, for example, through mobile money and public financial management; and • Advancing techniques to measure progress in health systems performance, especially around universal health coverage. The HFG project (2012-2018) is funded by the U.S.Agency for International Development (USAID) and is led by Abt Associates in collaboration with Avenir Health, Broad Branch Associates, Development Alternatives Inc., the Johns Hopkins Bloomberg School of Public Health, Results for Development Institute, RTI International, and Training Resources Group, Inc. The project is funded under USAID cooperative agreement AID-OAA-A-12-00080. To learn more, visit www.hfgproject.org ABOUT THE HEALTH FINANCE AND GOVERNANCE PROJECT 2012-2018 HFG’S COMPREHENSIVE TECHNICAL SUPPORT TO THE FINANCING TRANSITION OF THE HIV RESPONSE Integration of outpatient clinics Increased PLHIV and service coverage of SHI Centralized ARV procurement Advancing financial sustainability for PLHIV, providers, and SHI SUCCESSFUL TRANSITION Establishing social health insurance (SHI) as the primary financing mechanism for the HIV response CanTho Tien Giang HCMC Dong Nai Tay Ninh PhuTho Ha Noi Ha Phong Thai Binh Ninh Binh Hoa Binh Original HFG provinces added in 2017 Provinces added in response to new PEPFAR 2-region focus 2018 Original HFG provinces since 2015
  • 3. HFG VIETNAM FINAL REPORT | HEALTH FINANCE AND GOVERNANCE PROJECT (2012-2018) 1 CHALLENGES USAID’s Health Finance and Governance (HFG) project began its work inVietnam in 2014.At that time, all aspects of the country’s HIV response— prevention, treatment, and care—depended overwhelmingly (>70%) on international donor funding (Ministry of Health 2018), primarily from the President’s Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund. However, with Vietnam’s graduation to middle-income country status and evidence that the HIV epidemic was slowing in terms of the number of new infections, donors began to reduce their support and inform the Government ofVietnam (GVN) about timelines for withdrawal from the country. With these projected declines in donor funding, the GVN had a pressing need to develop sustainable financing for a seamless continuation of HIV programs.A principal challenge was to ensure continuous antiretroviral treatment (ART) for the ~130,000 existing patients and to further expand treatment coverage to achieve epidemic control through treatment as prevention. Consequently, increasing domestic resource mobilization for the HIV response became an overarching goal for the GVN. The GVN had, by 2014, decided that the country’s social health insurance (SHI) scheme would be the primary financing mechanism and method of domestic resource mobilization as donors withdrew, but the feasibility and sustainability of this strategy had not been established and key dimensions of the transition remained largely unplanned.These included conversion of donor-funded (funded primarily by PEPFAR and the Global Fund) HIV outpatient clinics (OPCs) to the public health system with SHI coverage and reimbursement for services; centralized procurement of antiretroviral (ARV) drugs to replace donor-funded mechanisms; increased SHI coverage of people living with HIV (PLHIV) and expansion of HIV services covered by SHI; and measures to ensure the sustainability of the transitioned HIV response for patients, providers, and the SHI fund. CHANGE HFG became the primary provider of technical assistance to the GVN on the financing transition of the country’s HIV response.The project worked closely with USAID and the Ministry of Health (MOH),Vietnam Social Security (VSS), and other key government agencies to design and deliver a portfolio of technical support at the central level and in nine provinces.This support has helpedVietnam to advance toward a timely and successful financing transition. HFG assisted the GVN to make significant progress in all five elements that comprise a comprehensive transitional strategy (see graphic on the previous page): confirmation of the GVN’s choice of SHI as the primary financing mechanism; full integration of treatment facilities into SHI; full SHI coverage among PLHIV and expansion of HIV services covered by SHI; preparation of the government apparatus for centralized procurement of ARV drugs; and sustainability of the transitioned HIV response for PLHIV, providers, and the SHI fund. These HFG contributions, produced in 2014–2015, helped demonstrate the feasibility of, and solidify the GVN’s commitment to, SHI as the primary financing mechanism for the transitioned HIV response. For the remainder of the project, HFG provided technical support to the GVN at the central level and in nine provinces to implement the key elements for successful transition of HIV services inVietnam. HFG OVERVIEW IN VIETNAM
  • 4. HFG VIETNAM FINAL REPORT | HEALTH FINANCE AND GOVERNANCE PROJECT (2012-2018)2 The HFG project developed critical evidence to solidify the GVN’s choice of SHI as the primary financing mechanism for HIV services. In cooperation with the MOH and theVietnam Administration for HIV/AIDS Control (VAAC), HFG identified and answered three major questions on the feasibility of SHI for funding the HIV response, as shown in the table below. PROJECTED FUNDING FOR ART COVERAGE IN VIETNAM Questions onTransitioning the HIV Response How HFG Answered Can the SHI fund afford to cover HIV services? HFG developed an SHI liability model, which showed that the SHI fund could easily absorb the projected costs of covering HIV services. How will the parallel system of donor- funded HIV outpatient clinics be systematically integrated into the public health system and SHI scheme? HFG developed a standardized, step-wise approach to OPC integration, demonstrating that it was feasible for theVAAC and provinces to integrate OPCs into SHI and enable future reimbursement of their services. What mechanisms can the GVN use for centralized procurement of ARV drugs? HFG produced a report on options for a central procurement unit and procedures for centralized bidding to procure ARVs. DEMONSTRATING THE FEASIBILITY OF SHI AS THE PRIMARY FINANCING MECHANISM FOR A TRANSITIONED HIV RESPONSE
  • 5. HFG VIETNAM FINAL REPORT | HEALTH FINANCE AND GOVERNANCE PROJECT (2012-2018) 3 “I highly appreciate the support from HFG on providing HIV services and getting reimbursement through the SHI system.Together with the on-site technical assistance - visits to facilities, HFG supported the Department of Health and the Provincial HIV/AIDS Center in organizing an OPC integration sharing workshop for all facilities on March 2017, then follow-up technical assistance support to individual facilities.” ~ Ngo Thi Hong, Head of Care and Treatment, Ninh Binh Provincial HIV/AIDS Center RESULT AREA 1 More than 80 percent of the HIV OPCs in nine provinces integrated into the public health system and SHI scheme HFG provided technical assistance on OPC integration to the MOH and nine provinces, enabling the provinces to achieve full integration of more than 80 percent of their treatment facilities by September 2018.As a result of this effort, delivery of ART and related services is being shifted from donor-funded OPCs to an integrated system of clinics in provincial and district hospitals and district and commune health centers, with reimbursement through SHI.Among the nine HFG-supported provinces are Hanoi and Ho Chi Minh City, the two provinces with the highest HIV burden. More than 51,000 ART patients (~46% of the total inVietnam) at 118 facilities will benefit from OPC integration in HFG’s nine provinces. The legal requirement that only services provided in curative settings qualify for SHI reimbursement posed a major challenge in the beginning for the integration of HIV treatment into SHI, because most HIV patients were being served in single- function facilities—mainly donor-funded OPCs— that were part of the preventive medicine system. HFG supportedVAAC,VSS, and MOH to overcome this obstacle and assisted provincial departments of health and treatment facilities to achieve the key integration steps for SHI contracting and reimbursement of HIV services.This involved enabling single-function facilities to qualify for SHI contracts and reimbursement or assisting with transfer of their patients to qualified clinics. HFG also provided technical assistance at the national level, including development of an OPC integration monitoring tool and ongoing assessment of transition progress.The project devised a national dashboard of key integration progress indicators, which helpedVAAC monitor and update OPC integration progress and identify provinces and facilities in need of additional support. MAKING A DIFFERENCE @HFG,ImagebyLinhPham
  • 6. HFG VIETNAM FINAL REPORT | HEALTH FINANCE AND GOVERNANCE PROJECT (2012-2018)4 STRONG PROGRESS OF OPC INTEGRATION IN NINE HFG-SUPPORTED PROVINCES @HFG,ImagebyLinhPham
  • 7. HFG VIETNAM FINAL REPORT | HEALTH FINANCE AND GOVERNANCE PROJECT (2012-2018) 5 “Now I totally believe that I have enough knowledge and skills and I am confident to provide counseling for PLHIV regarding ARV treatment and sustainable financing support for PLHIV through SHI.” ~ NguyenThe Anh (center), Director of Qua Lac Commune Health Station, Nho Quan District, after participating in a training RESULT AREA 2 More than two-fold increase in SHI coverage of PLHIV and expansion of HIV services covered by SHI For SHI to be an effective financing mechanism for the HIV response, it is imperative that PLHIV be enrolled and that SHI cover a comprehensive set of HIV services.The HFG project supported the GVN in meeting these requirements. Increasing enrollment of PLHIV in SHI At the start of HFG’s work inVietnam, only about 40 percent of ART patients were enrolled in SHI. We helped increase that coverage to 81 percent in the nine HFG provinces. The GVN’s Decision 2188 of November 2016 stated that provincial funding be used to provide free SHI cards to all PLHIV, but many challenges stood in the way of achieving 100 percent coverage.These included budget shortages in some provinces, difficulties in reaching un-enrolled PLHIV in communities, lack of understanding among some PLHIV about the procedures and advantages of SHI enrollment, and PLHIV’s fear of losing confidentiality by enrolling in SHI and the resulting potential for stigmatization and discrimination in their families and communities and in integrated treatment facilities. HFG’s technical assistance enabled the nine supported provinces to tackle these challenges and achieve solid progress on SHI enrollment of PLHIV. Our support included classification and listing of PLHIV’s SHI status; advocacy for provincial support for SHI premiums; and collaboration with USAID’s Healthy Markets project to increase SHI enrollment among key populations through print materials, social media messages, and training of counselors for PLHIV in community-based organizations and community health facilities. @HFG,ImagebyLinhPham
  • 8. HFG VIETNAM FINAL REPORT | HEALTH FINANCE AND GOVERNANCE PROJECT (2012-2018)6 AIDS Deaths DEATHS AVERTED DUE TO INCREASED SHI COVERAGE Expanding the HIV services covered by SHI HFG also provided the GVN with technical support and evidence for expansion of SHI- covered HIV services, another key element in successful transition of the HIV response. PLHIV may be reluctant to enroll in SHI if they are not certain that all HIV services will be covered. In fact, viral load testing is only gradually coming under SHI in 2018 and, pursuant to revised GVN policy,ARV drugs will remain free to all patients in all treatment facilities through support from international donors andVietnam’s National Target Program until the end of 2018 and will come under SHI in about 190 facilities in January 2019. PEPFAR drug stocks and Global Fund support will continue to support free ARVs in many facilities in 2019 and for a few years beyond.ARVs and viral load testing are the most costly components of HIV treatment. As a step toward increased service coverage, HFG supported the MOH to develop a basic health service package that included a comprehensive set of HIV services to be paid for by health insurance. This contributed to improving the accessibility, affordability, and quality of care provided by devolving important service elements, including dispensing of ARV medications, to the commune level, as required by Circular No 39/2017/TT-BYT, October 18, 2017, which HFG helped draft. Supporting inclusion of preventive services in SHI Prevention is a critical part of the overall HIV response, butVietnam’s Law on Health Insurance restricts coverage to curative services; coverage of preventive and addiction treatment services is prohibited. Preventive and addiction treatment services currently depend on donors and the National Target Program on Health, but donors are reducing their support and the budget for the National Target Program’s budget for such services has been cut. HFG is working to bring preventive services under SHI.We are supporting the MOH to conduct an assessment of three years of implementation of the current SHI law and make recommendations for revising the Law on Health Insurance in 2019. HFG also supported the development of evidence to advocate for inclusion of selected HIV prevention services in the revised SHI law, including a review of international evidence of the economic benefits of these interventions and cost estimates for their implementation and coverage by SHI inVietnam. PROJECTED AIDS DEATHS 2,536 DEATHS AVERTED Current ART Funding Expansion of SHI 15K 14K 13K 12K 11K 10K 2017 2018 2019 2020 2021 2022
  • 9. HFG VIETNAM FINAL REPORT | HEALTH FINANCE AND GOVERNANCE PROJECT (2012-2018) 7 RESULT AREA 3 The Government of Vietnam prepared for centralized procurement of ARV drugs To sustain HIV treatment in the wake of declining donor funding, the GVN must cover about 26 percent of the ARV drugs in 2019 through SHI and direct budget support, increasing to almost 60 percent in 2020 and to 100 percent when the Global Fund phases out a few years later. HFG’s support—including development of required legal documents and technical assistance on bidding procedures and monitoring of fund flows— helped the GVN advance toward government-led, centralized procurement of ARV drugs. Procurement of ARV drugs will require the largest share of GVN expenditures on HIV services as the government takes responsibility for the HIV response. HFG advocated for ARV procurement through SHI funds and supported resolution of administrative and legal challenges, such as the need to designate a centralized procurement unit at the MOH, establish the legal basis for centralized ARV procurement, and define the relationship between VAAC and VSS and their responsibilities for fund flows and the ARV supply chain. A major obstacle was that SHI was designed to provide reimbursement after services were delivered rather than to advance funding before service delivery. HFG provided the GVN with policy options for, and evidence on, the viability of using the SHI fund to advance payment for centralized procurement of ARVs and clear HIV patients pick up their medications at a pharmacy. Even though ARV drugs will not come under SHI until January 2019, facilities in Ninh Binh are requiring patients to present their SHI cards to ensure readiness for the transition. @HFG,ImagebyLinhPham
  • 10. HFG VIETNAM FINAL REPORT | HEALTH FINANCE AND GOVERNANCE PROJECT (2012-2018)8 procedures for quantification, reimbursement, and liquidation.This support, in turn, informed the GVN’s development and promulgation of key legal documents, which HFG helped draft, including Decision 2188 (November 15, 2016) and Circular 28/2017/TT-BYT (June 26, 2017). Circular 28 provided for advance payment for ARV drugs from the SHI fund. In July 2017, the GVN announced that the MOH’s Central Procurement Unit would manage procurement of ARVs and delayed the coverage of ARVs by SHI until January 2019.To help address these changes, HFG supportedVAAC to revise Circular 28 and built the capacity of the Central Procurement Unit and provincial stakeholders.Additionally, we are assisting GVN agencies in monitoring the flow of funds for ARV procurement and settlement, while the USAID Global Health Supply Chain-Procurement and Supply Management (PSM) project takes the lead on the supply chain and flow of ARV drugs. FLOW OF FUNDS REQUIRED BY CIRCULAR 28 FOR CENTRALIZED ARV PROCUREMENT SUPPLIER(S) CONTRACTING UNIT CU/VSS VAAC/CPU VIETNAM SOCIAL SECURITY • First legal document establishing and regulating centralized procurement and payment for ARV and SHI • Requires and provides guidance on ARV copayment subsidies for PLHIV BIDDING VAAC/CPU HEALTH FACILITIES ARV Quantification ARV Quantification ARV Distribution PSS (Where signed contract) Framework Agreement CONTRACTING
  • 11. HFG VIETNAM FINAL REPORT | HEALTH FINANCE AND GOVERNANCE PROJECT (2012-2018) 9 RESULT AREA 4 Sustainability of the HIV response advanced for PLHIV, providers, and the SHI fund Successful transition of the HIV response requires that the new arrangements be financially sustainable for all stakeholders: PLHIV, health providers, and the SHI scheme itself.The HFG project provided technical assistance and tools to helpVietnam move toward a sustainable response. Sustainable services for PLHIV To have SHI cover their HIV services, PLHIV need to enroll and pay the required SHI premium and the established copayments for services.Vietnam’s Law on Health Insurance fully exempts from premiums and copayments only those certified as “poor” or falling into certain other designated groups who are covered by certain special funds or provincial budgets; the “near-poor” must pay a copayment of 5 percent of the cost of the covered service, and all others must pay the full premium and a 20 percent copayment. HFG’s analysis showed that existing subsidies would protect an estimated 26 percent of the economically disadvantaged PLHIV on treatment.A large number of patients, especially people who use drugs and members of other key populations, although not officially poor, would face economic hardship if confronted with a lifetime of payments for their treatment.This hardship might negatively affect care seeking behavior, treatment retention, and adherence, which could reduce Vietnam’s chances of reaching its stated 90-90-95 goals and controlling the HIV epidemic through treatment as prevention.To address this coverage gap, we assisted the MOH in developing Circular 28 (June 29, 2017), which formed the legal basis for universal free access to SHI for PLHIV and subsidies for copayments related to ART. However, financial protection of patients, in turn, depends on provinces allocating budget from funds “I must say that without the SHI card, I might have died already… I sometimes got serious illnesses for which I needed to be admitted to hospital.Thanks to the SHI card, my life has been saved until this moment.As I am from a poor household, SHI has covered… almost 100 percent of my treatment..” ~ An ART patient from Ninh Binh province @HFG,ImagebyLinhPham
  • 12. HFG VIETNAM FINAL REPORT | HEALTH FINANCE AND GOVERNANCE PROJECT (2012-2018)10 for the poor, funds for HIV and other dangerous diseases, and other special funds to support premiums and co-payments. HFG helpedVAAC design and test a replicable model of guidelines and procedures for subsidizing premiums and ART copayments for all PLHIV in need of financial aid in four provinces. HFG also helped the pilot provinces to advocate for provincial funding of the subsidies.Where provincial funding falls short of the need, the difference will be made up from Global Fund Catalytic Funds or PEPFAR performance-based incentive payments.As the subsidies are implemented in 2019,Abt Associates, which implemented the HFG project globally, will provide intensive technical assistance to provincial and facility staff and carefully monitor the model’s implementation. Positive evidence from this monitoring could be used to urge provinces to assume full financial support of the subsidies and other provinces to adopt the model. Sustainable financing for HIV service providers HFG’s support in this area began with helping facilities obtain SHI contracts and qualify for reimbursement under SHI.We subsequently provided technical support toVSS to harmonize information systems that will ensure prompt and efficient reimbursement to facilities for their HIV services and avoid duplicate reimbursement for ARV drugs and other abuses of SHI. Sustainability of the SHI fund for HIV services coverage HFG developed tools and evidence to support the sustainability of the SHI fund’s coverage of the full range of HIV services, and built the GVN’s capacity to employ these tools independently in future.With our support, the MOH developed National Health Accounts to track health expenditures for 2013–2015, with a separate sub-analysis to track HIV expenditures.This provided a retrospective analysis of trends in HIV expenditures from all sources, including donors, to provide estimates of HIV financing needs ahead of the transition to SHI as the primary mechanism for funding the HIV response. We further advanced the GVN’s awareness and understanding of future financing needs through updated estimates of HIV liability for the SHI fund during 2018–2020, when the full transition to SHI takes effect. Our projection model revealed that even with the addition of ARV drugs and viral load testing, HIV-related service costs would represent less than 1 percent of the total liabilities for the SHI fund during 2018–2020.This analysis has helped to convince the MOH andVSS of the feasibility and future sustainability of SHI coverage for HIV services. @HFG,ImagebyLinhPham
  • 13. HFG VIETNAM FINAL REPORT | HEALTH FINANCE AND GOVERNANCE PROJECT (2012-2018) 11 SUSTAINABILITY The HFG project contributed to the continuation and sustainability of the transition to a GVN- funded and -operated HIV response in several ways.We transferred the skills and tools used to develop evidence of sustainability, including the National Health Accounts and SHI projection models, to the GVN for use in future financial planning of HIV programs and advocacy for increased domestic resource mobilization at the central and provincial levels.We carried out the handover through written manuals and guidelines, hands-on training, and user-friendly software. Building on our success and experiences in nine provinces, we adapted our work plan to incorporate several additional provinces listed in PEPFAR’s new two-region focus.We have included in the pilot of the ARV copayment subsidy model the Tien Giang and Tay Ninh provinces, which are home to more than 3,000 HIV patients and belong to PEPFAR’s Ho Chi Minh City metropolitan region.The two new PEPFAR regions have more than half of all PLHIV inVietnam and a regional strategy of intensive case finding, enrollment in ART, and coverage for the full range of HIV services through SHI. HFG’s support to provinces acrossVietnam is strengthening the country’s efforts to achieve its 90-90-95 goals by the year 2020 and, ultimately, control the HIV epidemic. Although many challenges to the HIV transition in Vietnam have been overcome, several remain.The table below lists the continuing challenges and activities needed in four key areas to strengthen Vietnam’s HIV response.Abt Associates will address many of these challenges and carry out many of the needed activities under a recently awarded two-year bilateral contract with USAID, called the Sustainable Financing for HIV Activity (SFHA). LOOKING FORWARD @HFG,ImagebyLinhPham
  • 14. HFG VIETNAM FINAL REPORT | HEALTH FINANCE AND GOVERNANCE PROJECT (2012-2018)12 REMAINING WORK FOR TRANSITION OF THE HIV RESPONSE INVIETNAM 1. Final and full integration of HIV OPCs into the public health system and the SHI scheme Continuing challenges: • Global Fund-supported facilities are still offering free services, which may prevent newly contracted SHI facilities from attracting patients. • Some preventive medicine center-based OPCs do not yet have SHI contracts. • Some facilities with SHI contracts are not yet obtaining reimbursement through SHI. Technical support needed: • OPC integration assistance to facilities withoutVSS contracts and SHI reimbursement. • Continuing training and capacity building of VSS, Provincial Social Security, and facilities on SHI enrollment, claim, and reimbursement processes. • Continued improvement ofVSS information systems for reimbursement tracking and patient management. • Expansion of technical assistance to new provinces in PEPFAR’s two-region focus, including Tay Ninh and Tien Giang 2. Expansion of HIV services covered under SHI Continuing challenges: • Procurement and availability of ARVs through SHI must be timed to avoid any supply gaps that could cause patients to lose treatment. • The Law on Health Insurance prohibits coverage of any prevention or addiction treatment services. Technical support needed: • Continued technical assistance and capacity- building support to the Central Procurement Unit, the MOH, and provinces on ARV centralized procurement. • Development of annually updated ARV quantification and budgeting for centralized ARV procurement • Continued monitoring of the flows of money for ARV procurement, distribution, and liquidation. • Completion of the assessment of the Law on Health Insurance and recommendations for its revision in 2020. • Evidence and advocacy to support SHI coverage of HIV prevention and addiction treatment in the revised Law on Health Insurance. 3. Expansion of SHI coverage of PLHIV Continuing challenges: • Gaps in SHI coverage remain, particularly among key populations, migrant workers, and undocumented residents. • Some HIV patients may endure financial hardship through out-of-pocket expenditure as they move from free-of-charge OPCs to public health facilities. Technical support needed: • Continued training of HIV counselors on enrollment in SHI and ART • Development of consistent and universally implemented solutions to problems of PLHIV lacking the required ID papers for SHI or ART enrollment and their referral across provinces and levels of facilities • Scale up of SHI premium and ARV copayment subsidies to ensure equitable and sustainable PLHIV access to treatment and other HIV services 4. Financing strategies beyond SHI • Exploration of and advocacy for innovative financing strategies for HIV services, including performance-based incentives, health promotion funds supported by “sin taxes” on alcohol and tobacco, and contracting with civil society organizations for outreach, case management, and treatment support services
  • 15. HFG VIETNAM FINAL REPORT | HEALTH FINANCE AND GOVERNANCE PROJECT (2012-2018) 13 LESSONS LEARNED The HFG project focused rigorously on capturing and documenting the lessons learned over the course of the project’s implementation. Our health financing and governance experts published a paper on the lessons from the project’s implementation experience in Vietnam (Todini et al. 2018). Excerpts from the paper, summarizing the project’s learning in Vietnam, are presented below. Working within national policy. A main source of delay in supporting the GVN’s policy on HIV financing was the lack of clarity on policy objectives related to the ongoing health financing reform efforts.Working with the MOH and VSS, we found that framing the discussion on HIV under the umbrella of universal health coverage allowed us to provide effective technical assistance. Having clear understanding of the different stakeholders’ objectives. HFG focused on increasing domestic resource mobilization for the HIV response through SHI. Sticking to this goal made all decision-making at the project level much easier, and progress accelerated once PEPFAR started providing deadlines and clear estimates of decreasing funding. Delivering evidence in simple and understandable ways. HFG produced a number of studies and documents. Delivery of this information in a language that was accessible for decision makers led to acceptance of the SHI mechanism for HIV and the definition of an SHI benefit package to include HIV services. Recognizing that the need for evidence is cyclical, not linear. It may be tempting to see the inputs of evidence and technical assistance as we view medical interventions: a shot of National Health Accounts, a few pills of international experience, an intravenous dose of health financing via PowerPoint presentations, and the “patients” will be cured of their weak capacity, lack of knowledge, and blurred long-term vision. In reality, our work alone cannot “fix” weak health systems. In order to have real, long-term impact, it has to be part of a continuous cycle of evidence-based evaluation, decision-making, action, and reevaluation. Being flexible, learning, and adapting. A key to our success was using an “opportunistic” approach to technical assistance. Designing activities and getting them approved requires time; often, the approaches, topics, and models of assistance can quickly become obsolete and lose relevance in the eyes of the target audience. Keeping the program flexible, to respond quickly to the shifts and sudden changes due to governmental politics and moving targets, is invaluable. Targeting key decision makers at all levels. Political commitment from the top is necessary but not sufficient. Champions at all levels are needed, but not all of them will be useful or fully engaged. In a situation defined by constrained resources, the implementer should focus on targeting the right people for advocacy, capacity building, and partnership. HFG relied on a systematic and ongoing analysis of individual stakeholders and their potential roles as positive influencers. REFERENCES Ministry of Health. 2018. National Health Accounts, 2013-2015. Government ofVietnam. Nazzareno Todini,Theodore M. Hammett Robert Fryatt. 2018. Integrating HIV/AIDS inVietnam’s Social Health Insurance Scheme: Experience and Lessons from the Health Finance and Governance Project, 2014– 2017, Health Systems Reform, 4:2, 114-124, DOI:10.1080/23288604.2018.1440346.