2013年-世界发展银行全球_Integrating_the_Poor_into_Universal_Health_Coverage_in_Vietnam_36页_1mb

报告摘要

Summary of UNICO Studies Series 24: Integrating the Poor into Universal Health Coverage in Vietnam

Core Content

This case study explores the challenges faced in integrating the poor into Vietnam's Universal Health Coverage (UHC) program through Social Health Insurance (SHI). Despite high enrollment rates among the poor, effective coverage and financial protection remain elusive. The study highlights the structural and institutional issues that hinder equitable access to health services and the financial sustainability of the UHC program.

Main Objectives

To assess the key features of Vietnam's SHI system.
To identify the impediments to integrating the poor into universal health coverage.
To contribute to the global UHC movement by providing insights into implementation challenges and potential solutions.

Key Findings

High Enrollment Rates, Limited Coverage

By 2011, 97% of the poor in Vietnam were enrolled in SHI.
However, this high enrollment has not translated into effective financial protection or equitable access to health services.

Fragmentation of Risk Pools and Revenues

The SHI system is fragmented, with different funding sources and risk pools.
Poorer groups and provinces subsidize richer ones, leading to inequities in resource allocation.
Capitation-based funding for primary care has exacerbated this fragmentation.

Persistent Out-of-Pocket (OOP) Payments

OOP payments remain high and persistent, undermining financial protection for the poor.
These payments are driven by fee-for-service mechanisms, hospital autonomy, and weak governance.
Balance billing and informal payments further increase the financial burden on the poor.

Inequitable Distribution of Subsidies

Public hospital subsidies disproportionately benefit wealthier individuals and groups.
Non-hospital services (e.g., commune health stations) are more pro-poor, while hospital services are pro-rich.
The poor have limited access to hospital services due to high OOP costs and inadequate subsidies.

Provider Behavior and Revenue-Enhancing Practices

Fee-for-service payment systems and hospital autonomy create strong incentives for providers to increase service provision.
Hospitals engage in revenue-enhancing practices such as:
- Profit-sharing schemes among staff.
- "Social mobilization" where staff pool money to invest in equipment.
- High prescription rates and inflated drug prices, even though hospitals are not allowed to charge margins on drug sales.
These practices contribute to rising OOP payments and inefficiencies in the health system.

Targeting and Enrollment Challenges

The identification of the poor is managed by MOLISA and provincial DOLISAs using a nationally defined scoring table.
The process is annual and involves community meetings and economic surveys.
Enrollment is mandatory and automatic for the poor, but there are reports of fraud in the identification and issuance of health insurance cards.
VSS lacks the capacity to inspect or address fraudulent activities, and inspections are limited to public agencies.

Key Policies and Reforms

SHI Law (2009): Mandates compulsory enrollment for children under six, the elderly, the poor, and the near-poor.
Master Plan (2012): Aims for 80% coverage by 2020.
Capitation-Based Funding: Used for primary care services, with rates calculated based on historical utilization and adjusted annually.
Fee-for-Service: Applied to secondary and tertiary hospitals and high-cost services.
Subsidies: Government provides subsidies for the poor and near-poor, but these are not effectively reaching the intended beneficiaries.

Key Challenges

Fragmented Risk Pools: Poor and vulnerable groups are not adequately pooled with the rest of the population.
Inequitable Resource Allocation: Subsidies and funding mechanisms favor the wealthy and urban areas.
Weak Cost Containment: Fee-for-service and hospital autonomy contribute to rising costs and OOP payments.
Ineffective Targeting: Despite mandatory enrollment, there are issues with the accuracy and integrity of the targeting process.
Limited Institutional Capacity: VSS lacks the authority and resources to enforce rules and address fraud.

Potential Good Practices

Mandatory Enrollment: Ensures near-universal coverage for the poor.
Tax Financing: Substantial government support through tax financing helps cover insurance premiums.
Capitation System: Provides a structured approach to funding primary care services.
Comprehensive Benefits Package: Includes a wide range of services from ambulatory care to advanced diagnostics and curative services.

Conclusion and Pending Agenda

The SHI system in Vietnam has made significant progress in enrollment but faces serious challenges in ensuring equitable access and financial protection for the poor.
The case study concludes that while there are promising elements in the SHI design, flaws in implementation and policy design continue to hinder progress.
The pending agenda includes improving the targeting process, enhancing cost containment mechanisms, and strengthening institutional capacity to manage the SHI system effectively.

Figures and Tables

Figures

Figure 1: SHI Coverage in Terms of Enrolment as a Percent of the Population (2001-2011)
Figure 2: Health Expenditure Trends and Composition, 2001-10
Figure 3: Sources of Financing for SHI Revenues
Figure 4: National Health System Financing Flows
Figure 5: Average Capitation Rates (VND) by Region, 2011
Figure 6: Share of Poor Households Experiencing Catastrophic Impact and Impoverishment among the Poor
Figure 7: Concentration Indexes for Total Health Subsidies, 2006-10
Figure 8: Concentration Indexes for Supply-Side and Total Subsidies for Hospital Services, 2006-10

Tables

Table 1: SHI Benefits Package
Table 2: Potential Good Practices in Vietnam's SHI and Challenges to Implementation

Key Stakeholders

Ministry of Health (MOH): Responsible for policy formulation, monitoring, and evaluation.
Vietnam Social Security (VSS): Manages SHI funds and purchases services.
Ministry of Labor, Invalids and Social Affairs (MOLISA): Identifies the poor.
Provincial Departments of Labor, Invalids and Social Affairs (DOLISA): Assist in the identification of the poor at the provincial level.
Ministry of Finance (MOF): Allocates and transfers funds to VSS.