MINUTES
WORKSHOP TO GET FEEDBACK ON JAHR 2013
Time:8:30-16:30, 22 May 2013
Location:Song Hong Hotel, Vinh Yen, Vinh Phuc
Chairman:Dr. Nguyen Hoang Long, PhD. Deputy director of Department of Planning and Finance, Ministry of Health
Participants:
Vietnamese:
-Ministry of Health units: Department of Planning and Finance, Department of Health Insurance, Department of Organization and Manpower, Department of Maternal and Child Health, Legal Department, Vietnam Administration of Medical Services, Drug Administration of Vietnam, Information technology Administration, Ministry of Health Cabinet, Health Strategy and Policy Institute, Hanoi Medical University, Hanoi School of Public Health, Vietnam-Cuba Hospital, Central Endocrinology Hospital.
- Ministries/sectoral agencies: Vietnam Social Security
- Other units: Vietnam Health Economics Association
Development partners: WHO, World Bank, Delegation of the European Union to Vietnam, United States Embassy, Pathfinder, GIZ, JICA, UNFPA.
Objective of the Workshop:
Discussion and contribution of ideas for the draft sections on “Striving towards Universal health coverage” of the JAHR 2013.
Detailed contents of the Workshop:
Morning:
1. Dr. Nguyen Hoang Long, PhD,began the workshop and introduced the agenda. He covered the objective, JAHR development process, structure and topic of the JAHR report. Part II of the JAHR 2013 report is focused on universal health coverage. The Workshop on this day aims to gather comments and feedback to finalize these contents.
2. Dr. Tran Van Tien, PhD, presented some concepts about universal health coverage and the analytical framework used in the JAHR 2013 report.
3. Dr. Nguyen Khanh Phuong, PhD, presented contents on financial protection in universal health coverage, including five main issues: reduction of household out-of-pocket payments; financial protection for the poor and other vulnerable groups; social health insurance; mobilizing resources for health; using financial resources effectively, and reforming provider payments.
4. General discussion of Financial protection in universal health coverage was led by Dr. Tran Van Tien, PhD along with the other national consultants.
Attendees provided feedback on the draft report, particularly on the priorities and solutions.
- Kari Hurt, World Bank:
Congratulations to the JAHR team for presenting a clearly designed report framework. Let me make a few comments:
+ Related to the theoretical framework in relation to the level and scope of coverage, to some extent it will be necessary to consider what tradeoffs must be made between the three dimensions of coverage. There is a need to consult with experience in other countries, to ensure participation of different sectoral agencies and levels of the health system in the process of developing and discussing policies. There is a need to see clearly the roles and assignment of responsibility for all stakeholders.
+ Second point: What is the basis for us to rely on to achieve UHC – economics, allocation of state budget, human resources? There is a need for economic analysis to see more clearly what needs to happen and how it should happen in order to mobilize adequate resources. Increasing the state budget by 0.8% of GDP seems to be not enough, but increasing by 1% of GDP is likely to be difficult. There will be a need for discussions with other ministries and sectors in order to increase it to this level. At the same time, it is necessary to examine what percentage of public spending is reserved for examination and treatment.
+ Many efforts are needed to achieve universal health coverage. Among the priority issues there is a need to determine the level of priority, a roadmap, as well as amount of resources needed for each priority. It is also necessary to see what are the problems, the challenges that we need to address. When looking at the list of priorities, if we expand coverage what priorities do we need to implement, and how can we communicate these priorities. With the near poor and other vulnerable groups, there is a need for a clear orientation for these groups.
+ In terms of effectiveness it is important to clarify what is the contents of the spending, how do the people use the subsidies: drugs, high tech services? There is a need to use tools like cost effectiveness analysis, health technology assessment, practice and provider monitor (PPM) and pay attention to tax policies, incentives for service providers.
- Socorro Escalantes, WHO:
This year’s JAHR has seen major progress in preparation.
+ In particular, we want to propose interventions for the poor, ethnic minorities and other vulnerable groups. Data indicate that the poor and vulnerable have high health insurance coverage, but their health indicators, use of services and financial protection remain lower.
+ High direct health spending by the people leads to substantial impoverishment and this leads to negative impacts on health. There is a need for greater analysis of out-of-pocket payments and their impacts on people’s health, especially for vulnerable groups. Why do the poor and ethnic minorities have to spend so much on transportation?
+ Related to effectiveness of health insurance, there is a need to consider why these groups choose to bypass lower levels and seek care at higher levels, to what extent should providers be accountable for this situation. There is a need to focus on the poor, the vulnerable. How can we improve the effectiveness in use of resources for health care while at the same time imposing policies to control costs.In hospitals how are payments made, what kind of cost recovery are we achieving when for the same drugs, same services, the facilities at higher levels receive higher payments than at lower levels. The price for the same drug should be the same across levels of facilities. There is a need for clear clinical guidelines for treatment.
+ Health spending share of GDP, the total spending and per capita spending are all higher than many other countries, but the challenge is if we increase spending even more, what would we spend on, when. would it be an increase in health care for the people or for purchase of more equipment. 72% of health insurance reimbursements are for non-essential medicines. There is a need to control costs of selected medicines. In the future, it will be important to analyze more deeply what state spending is buying.
- Nguyễn Hoàng Long, PhD:
The section presented by Nguyen Khanh Phuong is a synthesis of 5 different sections written by different authors, but there is a need for greater linkages between sections, perhaps with some diagrams to show those linkages and how they lead to financial protection in universal health care: goals, mechanisms, impact, challenges. The group writing the sections have many assertions about reasonable financing, but it is difficult because there is a lack of nationally representative studies, so on one hand, there is a need to try to find materials to illustrate the situation, but on the other hand when citing it is necessary to make clear the sources and scope of the research.The figure for 500 thousand households, or about 2 million people falling into poverty due to health spending, does that really reflect the current situation?
In the priorities section, there is a need to examine previous priorities that were reported in the JAHR on health financing in 2009 (actually the JAHR on health financing was in 2008) in order to link up and continue discussions from previous years. Second, for various scenarios of increasing health spending: if we want to achieve universal health care there is a need to increase health spending by 0.8 to 1% of GDP, and there is a need to state that with such an increase in spending, what benefits will be achieved for health. This is difficult, but if it can be done it will be more persuasive. Health insurance coverage is already quite good, but why is financial protection so low? People with health insurance still face financial difficulties. Indirect costs when poor people seek medical care account for an additional 50% of total health care costs.There is a need for analysis and deeper recommendations on financial protection.
- Robert Hynderick, Delegation of the European Union to Vietnam:
Thank you to the group of national experts who continue to prepare reports that are increasingly complete, well structured, full of information, clear and concrete.
On behalf of the EC, we consider the JAHR as an important process that has reflected achievements, priorities and has involved the participation of many development partners. There has been progress, but there is a need for even greater depth of analysis on strengths and weaknesses from research studies, recommendations, in order to better see what needs to be improved, what has been improved, and where we are now. There is a need to concretize even further the issues we are facing. We have a list of causes, but no indication of which cause was more important than another. There is a need to find the main, leading causes. For example, impoverishment related to health spending, why do the poor face impoverishment more than the non-poor?Some reasons such as unavailability of services, or packages of services, cultural issues,…which is more important? There is a need for ideas about important causes. The poor are still facing heavier health burdens (30% of the poor face catastrophic spending) but this gap has not yet been deeply analyzed. What is the reasonfor the low effectiveness in use of the health insurance fund, what are solutions for this problem? Cost-effectiveness has been identified as an important issue, but the reason for the problem has not yet been deeply analyzed and solutions have not been found that are tightly linked to these causes.Among solutions proposed such as provider payments to control costs through capitation, DRG, these are big issues, and they need to be considered more concretely, along with a roadmap of each step that needs to be undertaken. One very important aspect that has been reiterated is that UHC requires comprehensive primary health care provision. We see that the concepts proposed are not yet consistent, such as grassroots level (which refers to administrative areas), basic health services, primary health care and system and network, which seem to be used more or less interchangeably.
- Lương Chí Thành, PhD-Deputy director of the Health Information Technology Administration:
I agree with Dr. Long’s comment on the data used that are not consistent, and the lack of nationally representative research. For example, health spending share of GDP, if we calculated it at 95 USD/person x 90 million people and divide by GDP that is approximately 210 billion USD, which would only be about 4% of GDP. The terminology used is not consistent, for example on page 49, it indicates that out-of-pocket spending is private spending, but in a lower section it indicates that OOP is approximately 92% of private spending. Some of the priority issues seem to be more assertions than a real assessment. There is a need for research programs to fill in gaps in scientific evidence.
- Nguyễn Thị Khánh Phương, PhD
A quick calculation shows that health spending/GDP is approximately 6.1% (95 USD/1540 USD).
- Assoc. Professor Hoàng Văn Minh
The OOP data is taken from the Household Living Standards Survey. The reasons for OOP are taken from discussions, not from surveys on causes. VHLSS data in ethnic minority regions is inadequate for separate analysis and assessment. Catastrophic spending rates in Vietnam are high because internationally indirect costs are often excluded (e.g. transportation costs).
- Ton van der Velden, Pathfinder:
Most of the analysis is based on major surveys like the VLSS, but there is a need for more concrete research. The national experts face difficulties in finding data to write the repot. We can propose recommendations in the JHAR for research programs in order to have more data to meet requirements for research on health financing.
- BS Le Thi Thanh Huyen, UNFPA:
There is a need to reconsider the different sections so the report can be more comprehensive in proposing solutions that when implemented may lead to major changes. With UHC there is a need to focus on equity in health care services. The MOH has already made an assessment and proposed solutions on equity. There is a need for information on why and how one can propose appropriate solutions. There is a need for more roles and coordination with other sectors, for example on financial assistance for transportation, yet there is a lack of participation of the transportation sector making it hard to implement.There is a need or more analysis on the role of health care providers, particularly we do not yet see the role of the private sector, in fact there are somewhat negative comments on the role of private health insurance.There is a need for clear division in the health system regarding which areas should allow the private sector to reduce the burden on the state, and in which areas the public sector should ensure coverage. For the elderly, there is a need for deeper analysis of what kind of support they need, what contents, which groups, especially the elderly in rural areas. In the recommendations there is a lack of contents to ensure financing for operating health services such as human resources, health information, monitoring and supervision. There is a need for financial assurance to run the health system, instead of using the term financial protection.
- Hoàng Thị Phượng, HSPI:
+ One of the objectives is to increase coverage, especially of the vulnerable, and we have paid attention to ensuring breadth of coverage, with less attention paid on increasing depth of coverage. In rural areas, people mainly access grassroots health services, with low service quality, leading to low use of health insurance fund and surpluses, while in urban areas there are always deep deficits.
+ Financial protection: A research study on amounts paid by households at health facilities indicated that out-of-pocket payments remain high, especially at central level facilities, of which only about 30% of out-of-pocket payments are co-payments and the rest are paid directly by the patient. One of the reasons for this is the implementation of social mobilization and financial autonomy. Therefore, how can we reduce out-of-pocket payments? There is an inherent conflict between financial autonomy and increasing revenues with the need to reduce out-of-pocket spending. Is there any solution that can separate increasing revenues of health workers from increasing facility revenues?
+ In the contents of the repot there is a need for more data to support the assertions about abuse of health services.
- Nguyễn HồngSơn, Vụ TCCB:
+ The general structure: There are many different health financing sources, the report is mixing up the different sources. Perhaps the authors should analyze each source to identify deficits in different sources in order to propose appropriate solutions for each source.
+ Some concepts and data need to be more precise. For example, the proportion of total health spending on health is reported at 31.32% (p. 85), while in another section it is indicated to be approximately 27% (p. 87), or total health spending in some section is reported to be increasing while in another section it is reported to be decreasing. There is also a need to be more consistent in how health spending is compared to GDP or to state budget health spending. (Phuong explained that these are two separate indicators, but perhaps it needs to be more clear in the text).
- PGS. Phạm Trọng Thanh:
In the priorities for health insurance, there is the issue of high health insurance coverage (67%), but the share of total health spending from health insurance is only 18%. There is a need to supplement explanations for this.
- TS. Nguyễn Hoàng Long:
There is a need for more time to reread more carefully the report so participants can contribute more ideas through e-mail. In OOP, 40% is related to self-medication, 30% is payment for private services, 30% is payment for public health care services. Therefore there is a need for recommendations on solutions for each of these problems. Health insurance for the poor and ethnic minorities has been slow, actually this is only the case for the near poor. Assertions about low effectiveness of using health insurance among the poor needs to be reassessed, with clear indicators to support such an assertion.
- PGS Nguyễn Duy Luật, Hanoi Medical University:
The JAHR is very important but has not yet been widely disseminated. There is a need for more copies for use in training and research establishments. The report this year focuses on an important topic, and needs to be tightly linked with the primary health care strategy of Alma Ata 1978 on health care for all by 2000. There is also the need to assess achievements of implementing primary health care and any remaining problems. Some comments need to be made clearer, for example “quality services”. Regarding assurance of financing, this is mainly related to medical examination and treatment, but inadequate attention has been paid to financing of prevention and promotion.
- Nguyễn Hoàng Longexplained further about the channels through which the JAHR has been disseminated including CD, printed version and through the Webpage jahr.org.vn