OSIPP Discussion Paper : DP-2013-E-003

Public Health Insurance in Vietnam towards Universal Coverage:
Identifying the challenges, issues, and problems in its design andorganizational practices
March 24, 2013
Midori Matsushima*
Assistant Professor, Osaka University of Commerce

Hiroyuki Yamada
Assistant Professor, Osaka School of International Public Policy (OSIPP)【Keywords】Health Insurance, universal coverage, Vietnam【Abstract】Vietnam is attempting to achieve universal health insurance coverage by
2014. Despite great progress, the country faces some challenges, issues and problems.
This paper reviewed official documents, existing reports, and related literature toaddress: (1) grand design for achieving universal health coverage, (2) current insurance
coverage, (3) health insurance premium and subsidies by the government, (4) benefit
package and payment rule, and (5) organizational practices. From the review, it became
apparent that the insurance system is broadly speaking complex and there are hugeambiguities, which seems hindering universal coverage of health insurance. Also,
hidden distorted incentives and lack of financial stability are the main challenges in thecurrent public health insurance system in the country.

* Address: 4-1-10 Mikuriyasakae-machi,Higashiosaka-shi, Osaka 577-8505, JAPAN
Tel/Fax: +81-(0)6-6785-6246

E-mail: midori@daishodai.ac.jp[Acknowledgments]This work was supported by the Japanese Ministry of Education, Culture, Sports,
Science and Technology (a Grant-in-Aid for Scientific Research)[24402018].

1

1.

Introduction
Many emerging and developing countries are in the process of improving their publichealthcare system while having made efforts in implementing health financing reforms. Somecountries have been attempting to advance even further toward the ultimate goal of universal
health insurance coverage1. Vietnam is no exception. Ekman et al. (2008) reported the progressof the government’s attempt to expand the coverage of public health insurance in Vietnam.
Since then, the Vietnamese government has placed further emphasis on this issue and it now has
a grand design and time line to achieve universal health insurance coverage by 2014. Hence,various dynamic changes have occurred in the public health insurance system of Vietnam inrecent years, especially, since the report by Ekman et al. (2008). From the experiences ofadvanced countries, designing a public health insurance system that is robust in the initial stage
is crucial because an institution such as a health insurance system could become permanent andmany advanced countries are now suffering from difficult public healthcare reforms in terms of
how to contain increasing health-related expenses that jeopardize financial sustainability2. A
study of the Vietnam case will therefore be educational for other developing and emerging
countries as well.
This paper aims to review official documents, existing reports, and related literature toaddress the following issues: (1) grand design for achieving universal health coverage, (2)current insurance coverage, (3) health insurance premium and subsidies by the government, (4)benefit package and payment rule, and (5) organizational practices (insurance administrationand health service delivery).
After the review, we identified at least six serious problems and challenges. First,“universal” coverage does not imply “fully compulsory” coverage of the targeted groups
because many people are still uninsured even if they are defined as being in the “compulsory”
groups. This is because they are supposed to pay the health insurance premium, but they do not.
Second, as a result of the first point, there are many typical incentive problems, such as adverse
selection and moral hazard, which are discussed in the literature of health and development
1

According to the WHO (2012), Universal coverage (UC), or universal health coverage (UHC), is defined as
ensuring that all people have access to necessary promotive, preventive, curative and rehabilitative health services, of
sufficient quality to be effective, while also ensuring that the use of these services does not expose the user tofinancial hardship.
2

See Clements et al. (2012) for instance.

WHO (2010) broadly discusses difficulties in health system financing.

2

economics. These problems appeared among people in the voluntary groups as well. Third, thecurrent system is very complicated largely because the enrolment criteria are mainly based noton the individual but on the family. For instance, in order to determine the eligibility of anindividual for the public health insurance scheme, the commune must be involved as well as
several government bodies. Fourth, there are various ambiguities in the system. For instance,
how to judge whether an individual is near poor in an agrarian economy in rural areas where
harvested crops are for self-consumption. Fifth, the greater degree of autonomy of hospital
directors with insufficient regulations and a fee-for-service (FFS) payment system could raise
concerns over supplier-induced demand and financial sustainability of the health insurance
system as a whole. Finally, given the current system outlined above and greater expansion of thecompulsory group with subsidies, financial stability may be faced with major challenges incoming years.
Although our paper focuses on the health insurance system of Vietnam, we believe thefindings obtained here are very helpful for other emerging and developing countries indesigning financially sustainable and clear-cut health insurance systems. At the same time, ourfindings will provide some guidance to empirical researches on the utilization of formal publichealth insurance, behaviours of health facilities (and their workers), and financial sustainability.
The remainder of the paper is organized as follows. The next section overviews the
economy and health situation of Vietnam. Section 3 reviews its health insurance policies
between 1992 and 2014. Section 4 provides details of the health insurance system such as
premiums, subsidies, and benefits. Section 5 discusses the organizational structure: from top tobottom. Concerns on financial stability are explored in Section 6 and conclusions are drawn in
Section 7.

2. Background
Since the introduction of the economic policy “doi moi” in 1986, Vietnam has experienced
rapid and continuous economic growth. Although the economic crisis, which started in 2008,
had a negative impact on Vietnam by decreasing the GDP growth rate from 8.5% in 2007 to
5.3% in 2009, the Gross National Income per capita (PPP International dollars) has growncontinuously (World Bank, Database). Moreover, the poverty rate is lower than economicallymore advanced neighbouring countries such as the Philippines, Indonesia and China.

3

Vietnam has made huge progress in its health profile as well as its economic growth. In
2011, life expectancy at birth was 75.2 years, which is longer than those in economically moredeveloped nations in the region such as Malaysia, China, and Thailand. In the case of Malaysia,
its Gross National Income per capita (PPP International dollars) is 4.5 times higher than that ofVietnam. Also, the under-five mortality rate (per 1,000 live births) was 24 in 2011, which issignificantly lower than that of Indonesia and the Philippines (World Health Organization 2011).
Despite the great progress made in health profile, there has been growing concern
regarding the people’s burden on health spending. In Vietnam, the private health expenditure issignificantly higher than that of the government. In 2009, the private health expenditureaccounted for more than 60% of the total health expenditure (World Health Organization 2011).
The problem is that a large portion of the private expenditure comes from households’
out-of-pocket payment (OOP). According to Lieberman and Wagstaff (2009), more than 15% of
Vietnamese people spent over 25% of their discretionary income on their health. Spending sucha proportion of income creates vulnerability among sick people, and is claimed to be a majorrisk factor of income poverty3. In order to improve this situation, in 2009, the Vietnamese
government declared the implementation of universal health insurance by 2014, and since 2010,
the government has been working towards universal coverage with the Vietnam Social Security
which is a government-affiliated agency responsible for implementing health insurance policy.
Although the coverage rate has increased steadily, the government is currently facing challenges
to reach the entire population due to issues surrounding the design of the scheme, organizational
practice and health service delivery. Also, the government has to consider the sustainability offinancing health insurance as the OOP has been the main income source of the healthadministration for years.

3. Overview of health insurance policies and insurance coverage (1992-2014)
3.1. Health insurance policies: 1992-2007
The foundations of Vietnam’s health insurance system were established between 1992 and1998 in order to achieve improved health of the people. Figure 1 presents the timeline and theroadmap of health insurance universal coverage.

3

See Gertler and Gruber (2001) for instance.

4Universal
Coverage
Rema ining

Law on HI
Fa rmers, workers in the sectorsof a gri culture, forestry, fi shery,a nd salt producers

Decree 63

Students and pupiles

Decree 58

Children under 6 and near poor people
Empl oyees at non-state owned enterprises having less than 10 workers,
cooperative, a nd l egal entities, the poor and veterans

Decree 299

Member of the Congress and People's Council; pre -school teachers, meritorious people,
s oci ally protected people; dependents of army officer s and soldiers; foreign s tudents i n
Vi etnam

Employees and employers in enterprises having more than 10 workers, civil servant, pensioner,socially aided people, staff of international representative organizations in Vietnam

1992

1998

2005

2009

2010

2012

2014

Figure1: Timeline and roadmap of universal health insurance coverage (Created by the author
using information from Libermann and Wagstaff 2009, Tran et. al 2011, VSS 2010)

As the figure shows, Decree No.299/HDBT was issued by the Council of Ministers in1992 aiming to cover workers at state owned and non-state owned enterprises with more than 10
workers, pensioners, socially disadvantaged people, and staff of international representative
organizations in the country. In 1994, Decree No 95/1994/ND-CP was issued stating that thepoor should benefit from user fee exemption, and are entitled to free medical treatment. The
major success of this period was nearly 100% coverage of the target population. However, thefailure was that user fee exemption for the poor caused huge difficulties for health facilities’
finance because the government could not provide extra funding to health facilities to exempt
patients from paying fees.
In 1998, the issue of Decree No 58/1998/ND-CP attempted to cover more people as acompulsory group including members of the Congress and People’s Council, pre-school
teachers, dependents of army officers and soldiers, foreign students, meritorious people, andsocially protected people. As the policy for the poor, Circular No.05/1999 was issued in 1999,
which legalized provinces to use their budget to enrol at least 30% of the poor in thecompulsory health insurance scheme. In 2002, Decision No. 139/2003/QD-TTg introduced the5Health Care Fund for the Poor (HCFP) in every province in order to allow the poor and ethnic
minorities to enrol in the health insurance scheme or to provide the poor with free medical
treatment. However, this has created administrative problems. At the administrative level, it wasdifficult to identify the poor. Hence some of the poor were unable to enjoy the benefit (Tran et al.
2011).
To improve the health insurance system, in 2005, Decree No. 63/2005/ND-CP was
introduced for the expansion of compulsory enrolment to workers of non-state owned
companies with less than 10 employees. This also included the ethnic minorities and the poor
who were entitled to benefits provided in Decision No. 39/2002/QD-CP. Hence, the user fee
exemption for the poor including ethnic minorities was no longer implemented; instead, every
poor person and ethnic minority was enrolled in the health insurance scheme. In 2007, Joint
Circular No. 06/2007/TTLB-BYT-BTC was introduced, which was to guide the voluntary
participation in the health insurance scheme. By this period, several impact evaluations had
been conducted. As positive findings, researchers reported that the health insurance has reduced
out-of-pocket payments and improved catastrophic payments (Sepehri et al. 2006, Wagstaff
2005, Wagstaff 2010). Despite these positive findings, challenges were also addressed. Sepehri
et al. (2006) and Chang and Trevidi (2003) found that the utilization of healthcare centers andhospital length of stay have increased due to supplier-induced demand. Also, financial
sustainability was indicated as one of the key challenges. The health insurance fund began torun at a deficit. That is why, in addition to economic development, the government was advised
to create other means of collecting more revenues (Ekman et al. 2008, Liberman and Wagstaff
2009). Additionally, difficulties of expanding the coverage were addressed because of theregistration systems being mainly individual based (Tran et al. 2011), and rural and informal
workers are unwilling to join the insurance scheme (Ekman et al. 2008).
3.2. Health insurance policies (2008-2014) and the coverage rates
Despite the concern over financial sustainability, the government enacted the Law on Health
Insurance in 2008, and it became effective in 2009, aiming to achieve universal health insurance
coverage by 2014. Under the provision of the Law, children under 6 years old and the near poor
became a compulsory group. Also, students and pupils, who used to be in the voluntary group,
were included by January 2010. Additionally, farmers, workers in the sectors of agriculture,
forestry, fishery, and salt producers are targeted to be included by January 2012. These6

inclusions however, are expected to further increase the burden on finances. Also, as will be
discussed later in more detail, the benefit packages remain broad and undefined.
Since 1992, the insurance coverage rate has increased significantly. In 1993, only 5.4%
was covered, and by 2010, the figure had grown to 59.64%. Furthermore, the coverage rate is
expected to grow even further after 2011.

70

Law on HI
Decree 63

Pecentage of the insured (%)

60

58.2 59.64
50
47.1
44.7

40

43.8

Decree 58
30

28.8

22.8

20
20.7

17
10
10
1993

13

13

14

15

6

5

0

12

13

1994

1995

1996

1997

1998

1999

2000

2001 2002
year

2003

2004

2005

2006

2007

2008

2009

2010

Figure2: Trend in health insurance coverage (1993-2010)
Created by the author using information from VSS (2010) and Tran et al. (2011)

When looking at the breakdown of the insured population, it becomes apparent that evencompulsory groups are not fully covered. Employees of private enterprises have a low
enrolment rate despite the existence of the Law on Enterprise. According to the law, thecompanies are responsible for registering employees contracted for more than 3 months insocial security. Nonetheless, nearly 50% of enterprises fail to provide the health insurance totheir workers. This is due to weak enforcement measures, collusion between employees andemployers in reporting monthly salary and buying health insurance, and lack of knowledge on
health insurance and its benefits (Liberman and Wagstaff 2009, Ha 2011).
Additionally, while the most vulnerable people are mostly covered such as the poor andrecipients of social allowance, about 20% (1,920,000) of children under 6 years old remain
uninsured even though their enrolment costs are fully paid by the state budget. Also, the7coverage rate for the near poor is only 11.38% even though the insured are eligible for at least
50% of subsidies.4 Additionally, the coverage for the unemployed remains zero. Hence, there
are still many vulnerable people left without health insurance.

Table1. Breakdown of the insured population in 2010
targetcoveredpercent
populations
peoplecovered(%)(thousand) (thousand)target groups
Total
Compulsory groups
employees of enterprises and other companies
civil servantsforeign students
part-time officers at communal level
pensioners
recipients of social allowances
unemployed people
local authorities
meritorious people
veterans
members of national assembly and people's council
privileged social groups
the poor
dependents of meritorious people
dependents of army and police officers
children under 6near poor people
students and pupils
Voluntary groups
relatives of employees
farmers, self-employees, and members of cooperatives

85,666
67,114
11,911
3,142
3
182
920
1,305
80
41
2,113
374
123
843
13,945869
1,281
10,103
6,081
13,79818,552
6,820
11,73251,09347,176
6,361
3,142
3
0
920
1,254
0
40
2,113
350
119
384
13,511
0
297
8,183
692
9,807
3,917
0
3,917

59.64
70.29
53.40
100.00100.000.00
100.00
96.09
0.00
97.56
100.00
93.58
96.75
45.55
96.89
0.00
23.19
81.00
11.38
71.08
21.11
0.00
33.39

Source VSS (2011) cited in Tran et al. (2011). Calculation was adjusted.
4

In Vietnam, the poverty line is set by the government for a specific period of time depending on the socioeconomic

situation at that time. During the past decade, the government adjusted the poverty line three times: in 2005, in 2009,and in 2011. The latest decision of the government in 2011 has set the poverty line as shown in the Table below.
Table. National poverty line for 2011-2015

group
poor household
near poor household

Income per capita per month (VND)
rural
urban
400,000
500,000
401,000-520,000 501,000-650,000

Note: VND400,000 VND is about 20 US$ (on 2/9/2012)
Source: Decision No 09/2011/QD-TTg

8

4. Design of health insurance scheme
This section examines the grand design of the health insurance scheme; mainly premiums,
subsidies and benefit.
4.1 Health insurance premiums and subsidies
A different contribution rate applies depending on the enrolee’s status. One of thefundamental issues is that the enrolment of the most compulsory schemes is not family but
individual based. This increases the complexity for the enrolment criteria and process, whichhinders the increase of the coverage.(5 )Also, the complexity of the categorizations forpremiums creates administrative difficulties. Currently, there are 7 different categories for thepremium rate. By 2014, the number of categories will increase to 11. The rates of the premiums
and subsidies are also shown in Table 2 below. These rates became effective on 1st January2010 unless otherwise stated.

Table2. Health insurance premium rate (as of January 2010)
Category

Rate

Subsidies

4.5% of monthly salaryNo subsidies

Compulsory groups
Formalsectorworkers,

Officers
100% paid by the social
Pensioners

4.5% of monthly pension
security agency

People on working capacity

100% paid by the social
4.5% of working capacity loss allowanceloss allowance

security agency
100% subsidy by the

Poor, Children under 6,
Meritorious people, Near

government (Near poor
4.5% of the monthly minimum salarypoor etc.

receiveatsubsidies

least50%
fromthegovernment)
100% paid by the social
The unemployed

4.5% of unemployment benefit
security agency
30%

Pupils and students

subsidybythe

3% of the monthly minimum salary
government

5

According to Tran et al. (2011), during drafting of the Health Insurance Law, shifting from individual basedenrolment to family based enrolment was suggested but the suggestion was not taken into consideration.

9

Voluntary groups
Every voluntary participant

4.5% of the monthly minimum salaryNo subsidies*From 2014 all voluntary groups are included in the compulsory groupHousehold

works

in

agricultural forestry, fishery30%

subsidybythe

4.5% of the monthly minimum salaryindustry(averagelivinggovernment

standard)
The prescribed rate for the first person; 90%,
Household

works

in

80%, 70% of the premium rate applicable toagricultural forestry, fishery

the first person, for the second, the third andindustry (near poor)

the fourth persons, respectively; 60% of the

No information

premium rate for the fifth person onwards.
Relativesofemployees

whom employees have tolook after and who live

4.5% of the monthly minimum salary

No information

together with them in thesame families
Relativesofemployees

The prescribed rate for the first person: 90%,

whom employees have to80%, 70% of the premium rate applicable torear and who live together

the first person, for the second, the third andwith them in the samethe fourth persons, respectively; 60% of thefamilies (near poor)

premium rate for the fifth person onwards.

No information

Source: VSS (2010)
As observed in Table 2, the premium rate varies depending on which category eachindividual belongs to, and the subsidies for some people are not clear and complicated. In
particular, the category of “Poor, Children under 6, Meritorious people, Near poor etc.” includes
17 detailed specifications as shown in Table3.
Table3. Subdivision of poor, children under 6, Meritorious people, near poor etc.
1. People on monthly social insurance allowance for labour accident or occupational disease
2. People on monthly allowance from state budget
3. Commune, ward or township cadres who have stopped working and are on monthly insurance
allowances/monthly allowance from state budget
4. People with meritorious service to the revolution10

5. War veterans as defined by the war veteran law
6. People who personally participated in the anti-US resistance war for national salvation under theGovernment's regulations
7. Incumbent National Assembly deputies and People's Council deputies at all levels
8. People on monthly social allowance as prescribed by law
9. Poor household members; ethnic minorities living in areas with difficult or exceptionally difficult
socio-economic conditions
10. Relatives of people with meritorious services to the revolution as prescribed by the law on
preferential treatment toward people with meritorious services to the revolution
11. Relatives of in-service officers, career army men of the People's Army, non-commissioned
officers and soldiers who are serving in the People's Army
12. Relatives of professional officers and non-commissioned officers and both officers andnon-commissioned officers specialized in technical areas who are serving in the people's security
force, non-commissioned officers and soldiers who are serving in the people's security force for agiven period
13. Relatives of career officers and army men conducting cipher work in the Government Cipher
Committee and those conducting cipher work and salaried according to the state payroll of People's
Army officers or the state payroll of People's Army career men who are neither army men nor
policemen
14. Children aged under 6 years
15. People who have donated parts of their bodies under the law on donation, taking andtransplantation of tissues and human organs and donation and taking of cadavers
16. Foreigners studying in Vietnam who are granted scholarships from the Vietnamese State's budget
17. Members of households living just above the poverty line (near poor).
Source: VSS (2010)

Tran et al. (2011) also pointed out that these subdivisions mean that a multitude ofministries and agencies at different administrative levels are involved in the registration process.
For instance, formal sector employers are responsible for ensuring their workers have healthinsurance, the Ministry of Labour Invalids and Social Affairs (MOLISA) is responsible forenrolling the poor, and other groups on benefits provided by the Ministry of Labour. The
Ministry of Defence and the Ministry of Public Security are responsible for their workers.
Moreover, the commune people’s committee is responsible for identifying children under 6, andso forth. Because enrolment is not family but individual based, various ministries need to be
involved even just to enrol one family. For instance, formal sector workers are enrolled in thehealth insurance scheme by employers. However, housewives need to be identified as eligible
11persons by the responsible ministry for enrolment in the voluntary insurance scheme. Moreover,
if a couple has children under 6, the children need to be identified by the commune people’scommittees for their health insurance application.
These detailed subdivisions do not make the categorization easy. Rather, it makes it moredifficult to categorize one person into the group when there is no clear guideline on which
category should be treated as the priority. For instance, the unemployed are likely to be poor, but
the unemployed and the poor receive subsidies from different agencies. Hence, clear guidelines
and knowledgeable workers are essential.
Compulsory groups are required to pay the premiums every month. The voluntaryenrolees can choose to pay every 6 months or annually. For the first time, the enrolees have to
wait 30 days for the insurance to be valid for the basic treatment and 180 days fortechnologically advanced medical treatment. Once the insurance becomes valid, the continuous
payment allows people to receive the benefit whenever they have medical treatment. However,when the insured fails to pay on the due date, he/she can only use the health insurance card 30
days after the date of payment, and has to wait 180 days to be able to use the insurance fortechnologically advanced medical treatment (VSS 2010).
4.2 Benefit
The current benefit package is regulated based on the Social Health Insurance Law 2008.
Before the introduction of the law, there was already a claim that the benefit was too broad,
undefined and unappealing (Ekman et al. 2008). And, the problems have seemed to be inherited
to the Social Health Insurance law 2008.
4.2.1 Benefit for the basic treatment
The insurance is effective when the insured are provided with medical care at thecommunity health center or district hospital where they are registered, or higher level healthfacilities to which they are have been referred. Patients can choose to register at which
community health center or district hospital they wish to be treated within the given options by
the government (Ministry of Health 2009). If the insured preferred to be treated in othercommune health centers or district level hospitals, the insured have to pay the hospital directly,
and the OOP will be reimbursed later at their place of residence except in emergency cases. In
the case of an emergency, the treatment will be given for free. People can also use private clinics
with limited benefit from the health insurance scheme.
When the insured receives medical care at the registered health facilities, different benefits
apply depending on the category of the insured. Because the co-payment system has been inplace since January 2010, not all insured people can receive free medical consultation andtreatment, yet the insurance covers at least 80% of the medical cost (see Table 4). For the people
who are not covered for 100%, they have to pay the rest directly to the hospital (VSS 2010).
12

Table4. Benefit for basic medical services

For basic medical care services

100% medical consultation andtreatment costs●Specialized technical officers●Specialized technical noncommissioned officers●Professional officers●Professional non-commissioned
officers of the People's Public security●Meritorious persons●Children under 6

95% of medical consultation andtreatment costs

80% of the costs●Persons on pension or monthly working
capacity loss allowance●People on monthly social welfare
allowance as prescribed by law●Other categories of the insured●Poor household members; ethnic
minorities living in areas with difficult or
exceptionally difficult socio-economic
conditions*Ministry of Health coordinates with Ministry of Finance to adjust the level when there is a change in minimum wage

Source: VSS (2010) Source: VSS (2010)
The transportation cost is also covered by the health insurance in accordance with Circular
09/2009/TTLT-BYT-BTC when the patients need to be transferred to another hospital with ahigher technical level in the same administration area due to emergency or technical reasons.
Nonetheless, these merits are limited to eligible persons, children under 6, people on monthly
social welfare allowance, the poor, ethnic minorities living in difficult socio-economic
conditions and the near poor (VSS 2010).
When the insured receive the medical treatment at a non-primary care provider or
non-affiliated hospitals of primary care providers determined by the Ministry of Health (except
for emergency cases), the cost will only be covered within the scope of their entitlement definedin Article 21 of the Law on Health Insurance depending on the grade of health facilities. The
grade is determined based on the level of services and facilities, which are announced by eachprovincial health department. Grade-I is the hospital with the best quality services followed bygrade-II, and grade-III. For grade-III, 70% of the medical costs will be covered. For grade-II,
50% of the medical costs will be covered, and for grade-I, 30% of the medical costs will becovered. At any medical treatment facilities, for each use of technologically advanced medical
treatment, the ceiling is defined as 40 months of the minimum monthly salary (VSS 2010).
4.2.2 Benefit for technologically advanced medical services
According to government Decision No. 36/2005/QD-BYT, there are 177 technologicallyadvanced medical services including dialysis, transplants, certain types of cancer treatment andcardiovascular operations etc. In practice, many technologically advanced medical services are
related to severe illnesses. Without treatment, such illnesses could be fatal.
13

For technologically advanced medical services, the regulation is even more specific, andthe ceiling applies to all insured people. Children under 6, revolutionary activists prior to 1st
January 1945, revolutionary activists between 1st January 1945 and 19th August 1945,
Vietnamese hero mothers, war invalids and beneficiaries of policies for war invalids, class-B
war invalids, disabled soldiers who have lost 81% or more of their working capacity, ill /injured
soldiers are treated for free when these patients are treated for recurring illnesses and diseases(VSS 2010).
Pensioners and people on monthly working capacity loss allowance, people on monthly
social welfare allowance as prescribed by law, poor household members, ethnic minorities
living in difficult socio-economic conditions are covered for 95% of the costs. Other insured
people are covered for 80% of the costs.
For any costly technologically advanced medical treatment, there is a ceiling on the
maximum benefit for the treatment of each episode, and the ceiling is defined as 40 months’
minimum salary. (VSS 2010, Tran et al. 2011). In 2012, the minimum salary is between
VND1.4 million to 2 million depending on residential area (Decree No. 70/2011/ND-CP).
Hence, the ceiling is equivalent to US$ 2,682.8 to US$ 3,838.8 (US$1=VND 20,865.50).
Because of this ceiling, technologically advanced treatment could cause extremely high OOP
expenditure.
4.2.3 Drugs
Many drugs are covered based on Decision No.5/2008/QD-BYT issued in 2008. Patients
can obtain these drugs at the health facilities at which they are registered by reimbursement. The
list includes 750 medicines and 237 traditional herbal medicines. Although the long list of
reimbursed drugs is in generally beneficial to the insured, there are a few concerns. Firstly, thelist is not created from a cost effectiveness perspective, and some drugs that are rarely used evenin highly developed countries are very expensive. Secondly, there is no monitoring or regulationof drug price. Hence, price setting of drugs is left to the discretion of the hospital, which often
leads to high drug prices. Thirdly, hospitals often lack drug stocks. Since reimbursement ofdrugs only applies to the purchase of drugs in the hospital where the insured are registered, there
are many cases in which patients cannot obtain the drugs that they need. When patients purchasedrugs from a private pharmacy, the cost must be covered by the OOP.
4.2.4 Non-eligible cases
There are 17 cases that are not eligible for health insurance coverage as indicated in Table
5. The cost for medical check-ups or medical examinations is not covered apart from screening
tests for the early diagnosis of some cancers because the government provides preventive carefor free to everyone regardless of whether they are insured or non-insured.

14

Table5.

Non-eligible cases

1. Cases in which costs are paid by the state budget
2. Convalescence at sanatoria or convalescence establishments
3. Medical check-up
4. Prenatal tests and diagnosis for non-treatment purposes
5. Use of obstetric supportive techniques, family planning services or abortion services, except forcases of discontinuation of pregnancy due to fatal or maternal diseases
6. Use of aesthetic services
7. Treatment of squint, short-sightedness and refractive defects
8. Use of prostheses including artificial limbs, eyes, teeth, glasses, hearing aids or movement aids inmedical examination, treatment and function rehabilitation
9. Medical examination, treatment and function rehabilitation in the case of occupational diseases,
labor accidents or disasters
10. Medical examination and treatment in the case of suicide or self-inflicted injuries
11. Medical examination and treatment for addiction to drugs, alcohol or other habit-forming
substances
12. Medical examination and treatment of physical or mental injuries caused by the law-breaking
costs
13. Medical assessment, forensic examination, forensic examination, forensic mental examination
14. Participation in clinical trials or scientific research
15. Work injuries within the payment scope of employers according to legal regulation on work
accidents
16. Traffic accidents due to breaching of the law and others traffic accidents that are covered bywork injury scheme
17. Extra medical service costs (include medicines, medical materials, medical service) upon requestof the patient
Source VSS (2010)

Tran et al. (2011) shows some concern over these non-eligible cases, especially in thetreatment for traffic accidents. This is because the patients have to prove that the accident was
not a law violating act, which is rather difficult. When one is injured due to a traffic accident,
firstly the patients have to pay at the hospital, and the OOP will then be reimbursed later if thepatients can obtain an official statement issued by the police to prove that they did not violate
the

law,

which

is

requiredbytheregulation,

Inter-ministerial

CircularNo.

09/2009/TTLT-BYT-BTC. It is reported that many patients fail to obtain reimbursement because15the official statement lacks information to prove their right to be covered by the health insurance(Tran et al. 2011). In Vietnam, traffic accident is one of the leading causes of death, recording
about 15% per 1,000 deaths from traffic accidents in 2007 (World Health Organization,
Database). (6) Taking this situation into consideration, difficulty in using health insurance fortraffic accident injuries is an issue to be reviewed.
As was seen, the benefit package is broad when it comes to basic treatment; however,technologically advanced services and non-eligible cases are subject to detailed regulations. If
the patients cannot fully understand these regulations, they will not receive the maximum
benefit. Instead, this could work in the hospital’s favour by increasing their revenues throughthe provision of technologically advanced medical services unnecessarily or prescribing
expensive drugs. When a hospital abuses the system, the patients would perceive the healthinsurance as not providing attractive benefit, which hinders universal coverage.
5. Organizational practices
5.1. Administration
In order to achieve universal coverage, administrations need to be effective. The VSS is agovernmental policy implementing agency. For the health insurance, the Ministry of Financeand the Ministry of Health take the initiative with the government. Under the VSS, there areprovincial social security offices followed by district social security offices. Under the provisionof district social security offices, pay-agents and collection agents are employed. In order togive advice on management, provincial health departments of MOH work together with
provincial social security offices. District-level health facilities are also expected to cooperatewith provincial and district social security offices.

6

Death from traffic accident is defined as death within 24 hours of the crash.

16

Government

Management
council
MOH: State management
on health insurance
VSS

Provincial healthdepartment: advising state
management

MOF: Chair of fundmanagement council,
State managementof the fund

Provincial Social Security Offices

District Social Security Offices
District-level healthfacilities

Pay- agents/collection agents for health insurance

Figure3. Organizational structure of Vietnam social security
Source: Created by the author using information from VSS (2010) and Ha (2011)

However, there is no clear explanation on the more detailed role of each office. In particular,
the problem of information dissemination has been reported. It is reported by the Ministry of
Health (2011), cited in Ha (2011), that more than 30% of heads of households answered thatthey do not know about the Health Insurance Law, and more than 90% of heads of households
are unaware or have little knowledge about premium rates. Nguyen (2008) also reported theunder-utilization in health insurance due to lack of knowledge on the usage of health insurance.
5.2. Health service delivery
In Vietnam, hospitals enjoy great autonomy, which appears to have created someunfavourable situations for the insured. In 2006, Decree No. 43/2006/ND-CP was issued, which
gives a hospital director even greater autonomy including financial management, humanresource management, service delivery and even treatment fees within a band. The director can
decide additional salary, bonuses and allowances for the workers within the 71% of net revenue
as well as hiring and promoting workers. Consequently, a hospital (and potentially hospital
workers) has a higher incentive to sell their services at a higher price. Because many hospitals
now have more technologically advanced medical equipment due to joint ventures with the17private sector, they can provide more technologically advanced medical treatment that brings
about greater profit to the hospitals and recovers the installation cost of such equipment. In
practice, unnecessary highly technological treatments are frequently reported as in Ha (2011),
and Liberman and Wagstaff (2009). This is a typical problem of supplier-induced demand,
which has already been discussed in the context of the evaluation of the Vietnamese healthinsurance.
Additionally,

hospitals

preferfee-for-service(FFS)

payment

tocapitationorDiagnostic-Related Group (DRG) payment for the health insurance because they are allowed to
set the prices for their services.7 Even if it is regulated as “within a band”, it leads to higher
prices especially in areas where the public can afford the payment or where there is nocompetition. Consequently, the poor suffers more. Liberman and Wagstaff (2009) point out that
the VSS only plays a passive role as payers of bills, and does not represent the insured.
Moreover, neither the VSS nor the state plays a supervisory role in the quality assurance of thehospital even though there are reports such as Long (2008) that patients have to pay indirect
costs such as underhanded payments in order to obtain quicker treatment. Hence, the patientsare left alone in a vulnerable position and normally ignorant regarding medical treatment.
Therefore, as an organizational practice, both the insurance administration and service
deliveries have serious problems. In particular, both supplier-induced demand and FFS pose afurther challenge to the financial sustainability of Vietnam’s health insurance system in coming
years.
6. Financial Sustainability
In many countries with universal health insurance coverage, financial sustainability is an
issue. Although the economic development of Vietnam continues to create higher tax revenue,
deficit of the health insurance fund has continued (Ha 2011). In 2009, according to Ha (2011),
the balance between contribution income and benefit payment was VND 2,415 billion, which isa significantly larger deficit than that of 2008. To our knowledge, the government has not yet
proposed how it will sustain the health insurance system financially. Nevertheless, as thecountry heads towards achievement of universal coverage, the financial situation is expected to
become worse. People who are now enrolled in the voluntary health scheme do not receive any
subsidies. However, when they become included in a compulsory group within 2 years, part of7

The FFS is applicable to both outpatients and inpatients, and the regulation is relatively weak. Fee is determined foreach service by relevant state agencies taking into account the capacity of the hospital in terms of their techniques andability of residents to pay for the treatment. Capitation is paid by the health insurance fund every month per enrolled
patient regardless of the number of treatments and treatment types. The calculation for the capitation is based on the
expenditure of the previous year. The DRG is applied to patients with acute pneumonia for adults or children,
appendix operation, and normal delivery. There are only two hospitals piloting this system, and Tran et al. (2011)
reports that there are no plans for further expansion of this payment system.

18

their premiums will be covered by the government or social security agency. Indeed, the publichealth-related expenditure has already started increasing, especially, in recent years. Figure 4
shows the time series of public health expenditure in terms of percentage of GDP and the total
government expenditure, respectively. Clearly, the public health expenditure is already on an
increasing trend. In particular, the public health expenditure increased about 1 percentage pointin terms of GDP during the past decade. The government’s health related expenditure relative tothe total government expenditure increased greatly in the past few years, implying otherexpenditures are being squeezed out. Containing public health expenditure while keeping OOP
low is apparently a major challenge for Vietnam.

1412

percentage(%)

10

8
6
4
2
0
2000

2001

2002

2003

2004

Health expenditure, public (% of GDP)

2005
year

2006

2007

2008

2009

2010

Health expenditure, public (% of government expenditure)

Figure4. Public health expenditure in Vietnam
Source: World Development Indicators (World Bank, Database)
7. Conclusion and suggestions for further research
The purpose of this paper is to review official documents, existing reports, and related
literature to study Vietnam’s attempt at universal coverage of public health insurance by 2014.
To this end, we reviewed the current system and its plan toward 2014 and identified the issues tobe addressed in order to provide a better public health insurance system. We found, broadly
speaking, complexity and ambiguity, hidden distorted incentives, and financial stability are themain challenges in the current public health insurance system. If these problems are notaddressed at the early stage of designing the insurance system, the challenges will continue incoming years because an institution, such as a health insurance system, could be permanent andthe hysteresis effect could come into play.
19

Although our work is figurative, it does provide some guidance to empirical researches on
the utilization of formal public health insurance, behaviour of health facilities (and theirworkers), and financial sustainability.
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