By 2016, health insurance (HI) coverage had reached 81.7% of the Vietnamese population.1 Vietnam had committed itself to achieving universal health insurance coverage (UHIC) in 2014 as a means to achieving universal health coverage (UHC),2–4 advocated by the World Health Organization (WHO) to provide access to essential quality health services without financial hardship for all populations.5,6 The proposal for universal HI predates this WHO advocacy, being introduced in the late 1980s when the country was experiencing the various challenges of a low-income country in transition from a socialist economy under the influence of the Soviet Union to “a more market-based economy.”7 The most critical issues facing the health system were the disintegration of health facilities at the primary care level and the lack of financial resources for salaries and medications. A directive to collect partial user fees was issued in April 19898; however, this mechanism lacked sustainability for health system development and had become a direct financial burden for vulnerable patients.9–11 Following a visit to Germany, where the Düsseldorf governor argued for urgent implementation of HI despite Vietnam's economic constraints, Pham Song, Minister of Health (1989-1992), introduced the concept of social HI at the beginning of June 1989 in the People News, the Voice of the Communist Party of Vietnam, with the aim to advocate for implementing HI in Vietnam.11,12 He stated,
...government employees will receive a HI card and can access health care service with better quality without any further payment. Any other person can buy a HI card, and they will get the same benefits as government employees. The only distinction between people is whether you have HI scheme or not. People with higher income will pay a higher premium; this is social equity....11(p1)
By the end of June 1989, the Hai Phong Department of Health (Hai Phong DOH) had been selected to pilot compulsory and voluntary HI. In response, the Hai Phong DOH formed a pilot team leading to write up an HI proposal and later established the Hai Phong Health Insurance Center (HHIC) for the implementation of the piloting process. Socioeconomic and cultural factors had been taken into account in the proposed HI premium and service package. The service package provided was unlimited, which meant that HI would cover any care and treatment provided by contracted health facilities (except workplace injuries, transportation injuries, and fighting injuries).
For more than 2 years from 1989, the pilot accumulated evidence that would persuade the government to scale up HI to nationwide application through the Ordinance on HI.13 However, the National Assembly Standing Committee did not pass this Ordinance in May 1992 and it was subsequently downgraded to the Decree on Health Insurance that was approved by August 1992. This was seen as a major setback to HI implementation. Advocates felt that it was a result of a series of challenges and arguments, arising from misunderstandings of the aim of HI, and a miscalculation of the extent of political support for it. Despite this setback, the political report at the Seventh Communist Congress of the Communist Party noted that unquestioning commitment to the policy of free health care for the whole population had led to policy paralysis. The quality of service was compromised and access effectively limited, and the health system faced many challenges in the period from 1986 to 1992. The report conceded that there were no appropriate policy solutions proposed to resolve this critical situation.14 Universal health care was seen as a right of citizenship,15 and the political and health systems themselves had come under strong pressure because of formulating a prepaid mechanism for health care services16,17 under the poor socioeconomic development.18,19 For example, the 1990's GDP per capita was $98 and about 58% of the population was living below the poverty line.20
In the intervening 25 years, there has been substantial change. The insured coverage level is now more than 80% of the population, and Vietnam has reached this milestone earlier than planned despite facing many challenges associated with extending the population coverage, providing qualified health care services, and reducing out-of-pocket payments.21 Stakeholders' support for the recent acceleration of UHIC in the HI policy process needs to be explored to provide a comprehensive picture of policy development on HI from the early stages of the 1990s to the 2010s. In this case study of UHIC in Vietnam, we examine stakeholders' understanding of the policy and what stakeholders perceive as its impact on their interests. The research casts light on the way stakeholders' own interests have influenced their positions on the policy, subsequently shaping the policy based on the perceived change in these positions, as they draw on the available political and other power they may possess.18
The stakeholder analysis was used to identify stakeholders and map their policy positions.22 The qualitative methods included policy and documentary analysis and 34 in-depth interviews (IDIs) and 5 focus group discussions (FGDs) that were conducted between January and April 2014 (Table 1). The study sites were selected purposively, with 1 province from each of 3 main regions: Hai Duong (the North), Da Nang (the Central), and Vinh Long (the South). Da Nang was selected because it had the highest HI coverage (94.0%) among provinces without government subsidy. To provide some contrast to this high level of implementation, Hai Duong and Vinh Long were selected with respective HI coverage rates close to (61.0%) and below (55.0%) the national coverage rate (63.7%).3
All key informants were selected purposively because of their position and the contribution they have made to the implementation policy. The identification of stakeholder agencies in the 1989-1992 phase is based on the prescriptive listings found in the 1992 Decree on Health Insurance and in the 2012-2014 phase is based on the listing designated in the Master Plan for Implementation of UHIC. However, current representatives were not in power in 1989-1992; therefore, the reconstruction of stakeholder positions from the 1989-1992 period was based on an interview with 1 key informant, the director of HHIC, and the team leader of the pilot HI program in the 1989-1992 phase. Because of the single source available for this initial period, the interview evidence was triangulated with other government documents (issued by the Ministry of Health [MOH] and Ministry of Finance [MOF] to deal with the HI introduction), published speeches by the former Minister of Health, and reports of HHIC during this phase. Other interviews with all key informants focused on their experience in the 2012-2015 phase (Table 1).
The IDIs and FGDs were conducted by the first author (Chi K. Hoang) on the basis of semistructured guidelines in Vietnamese and digitally recorded and then transcribed. The average length of interview was 60 minutes, with the topics related to UHIC such as understanding of UHIC and UHC; UHIC as a priority; the Master Plan elements required to influence UHIC progress; and relationship with other stakeholders, etc.
NVivo 10 was used to assist the process of content analysis.23 To generate the initial codes, we started with a list of themes based on the research objectives. In the “searching for themes” phase, free codes were collated into potential additional themes such as contextual factors and internal areas of health system in moving toward UHIC goals. Once the transcripts had undergone a primary analysis, the themes were reviewed and refined. Results then were extracted and linked to relevant codes and themes.
For the stakeholder analysis, we used Kurt Lewin's force field model to explore stakeholders' support and opposition and then determined and compared driving forces and restraining forces that affect a problem.24 The stakeholder analysis first determined the main focus of stakeholders' activity, along with their understanding of UHIC in the context of UHC. Following this, their interest, influence, and positions were described.
Ethical approval was obtained from the School of Population Health Research Ethics Committee of the University of Queensland, and the study was conducted in accordance with the Ethics Committee of Hanoi School of Public Health. Permission was sought from the Hai Phong, Da Nang, and Vinh Long People's Committee before commencing the field work.
For the purposes of this research, we have defined stakeholders as all agencies specified in the state law and regulations documentation around the development, piloting, and implementation of HI in Vietnam. In practice, the relative power of these stakeholders varied enormously and their responsibilities changed over the life of the policy. In Vietnam, these stakeholders' understanding, interest, influence, and positions have changed radically in the last 20 years since the HI policy was initially proposed in 1989. The differences vary according to the stakeholder: positive and sweeping change is evident in the public sector ministries, administrative agencies, and labor representatives, while the potential beneficiaries of HI still retain their negative concerns and opposition to the HI policy.
Stakeholders: Who are they?
The transition period between the HI policy proposal (in 1992) and the Master Plan for UHIC (2013) stretched over 21 years, with multiple stakeholders involved in the HI progress. At the beginning, there were limited stakeholders who were involved in the early stage of the HI process at national and provincial levels. Three core ministries (Health, Finance, and Labor), the General Office of the Council of Ministers, the Council of Ministers, the General Confederation of Labor, and the National Assembly were the key agencies involved in the process of formulation and implementation of the first HI regulation. In the period between 1989 and 1992, 3 provinces (Hai Phong, Vinh Phu, and Quang Tri) participated in the HI pilots. However, Hai Phong was the first and only province to start the pilot and comprehensively implement the HI program across the whole province with the support of its Provincial People Committee, the cabinet, and ministries.
The most conspicuous change has been the increase in stakeholders designated in the regulations as participants in policy development and implementation processes. Following the issuance of the Law on HI 2014, the number of stakeholders involved in the HI progress has increased significantly; stakeholders now included 8 ministries (Health, Finance, Labor, Invalids and Social Affairs, Planning and Investment, Education and Training, Information and Communications, and Vietnam Social Security) and 7 mass organizations (General Confederation of Labor, Fatherland Front, Farmers' Union, Women's Union, Medical Association, Chamber of Commerce and Industry, and Youth Union) at the central and provincial levels.25 The other increase has been in the levels at which participants are active. Currently, the roles and responsibilities of the diverse stakeholders maintain a balance between the central and provincial governments as well as between ministries and provincial departments in the vertical management system for UHIC, ensuring structures at each level in the implementation arrangements nationwide.
The differences among stakeholders' understanding of UHIC policy development
In addition to the increase in numbers of stakeholders and the levels at which they are active, evidence from our interviews suggests that their understanding of UHIC has undergone substantial change from 1989-1992 to implementation in 2015. In 1989-1992, the concepts of HI as understood among public authorities and communities were vague, as illustrated in Figure 1. The documentary reviews and the interview showed that health actors centrally and in Hai Phong were more aware of the proposed HI policy than other nonhealth actors. In the first public statement about HI, the Minister of Health (1989-1992) wrote: “Switching quickly from user fee to health insurance would ensure social equality in health care.”11(p1) For other nonhealth actors, there was a lot of confusion in their understanding of the proposed HI policy. This confusion was more intense among nonhealth stakeholders such as the MOF. The MOF was described as believing that HI was similar to other types of insurance that should be under the control of the MOF and Bao Viet Insurance—a state enterprise of the MOF, which covered the health expenses of employees of the government. An MOF's document sent to the MOH stated, “It should be noticed that implementing and leading insurance policy is the MOF's accountability. Therefore, every insurance activity needs to have our consensus.”26
However, by 2012-2015, this understanding not only has developed substantially but also varies according to different stakeholders. The public sector ministries, administrative agencies, and labor representatives have recently demonstrated remarkable awareness and understanding of the UHIC. HI is no longer considered narrowly as a type of insurance or as merely additional financing resources for health: it is now “perceived as a social security policy,” as illustrated in Figure 2.
The increasingly complex understandings of UHIC concepts evident in the interviews with government officials at the central and provincial levels, however, do not extend to people at the community, who maintain a limited understanding of HI. Both the insured and noninsured people in our FGDs have had experience of using an HI card at health facilities—an experience that is associated with discrimination, being offered poorer quality care because they were perceived as being poor. Some of that sense of prejudice has extended to the card: rather than being a symbol of equity in health for all, it is increasingly associated with “nonwealthy people” and as a marker for discrimination.
I see the wealthy purchase HI but never use it. They said that they buy it for “peace of mind” or as an assurance. I also saw one near-poor man who was ill, borrowing money from his relatives to buy a HI card.
We don't use it; we often go to the private clinic. I think that families with illness should buy HI (Laughing).
The differences among the stakeholders' interest and position on HI policy development
With this change of awareness and understanding of HI over time has come a change in the stakeholders' interest and potential positions in terms of implementation. From their initial doubt and uncertainty about HI to recognizing HI as an essential social security policy, the stakeholders' interest has developed in a more positive direction, as illustrated in Table 2.
For the 1989-1992 phase, the evidence offered comes from triangulating interviews with officials engaged closely in these processes and from documentary sources. The introduction of the HI program had been linked—often unrealistically—to the promise of additional funding that would support the renovation of poorly equipped and staffed health facilities and then promote access to health services. While health policy makers at the central and provincial levels were supporting for the development of HI as the “one and only mechanism” or “unique solution” to develop the health system and they have shown their strong positive interest and very high support, nonhealth stakeholders tended to have slightly negative or uncertain interest and their oppositions ranged from opponent, nonmobilized to very high opponent. What nonhealth stakeholders had doubts about was how it would be financed, how the quality of health care service would improve to meet the need, and whether people would accept prepayment for health care services.27
For the 2012-2014 phase, stakeholders tended to have similar interests, concerns, and positions on the acceleration of the UHIC progress despite their concerns about the quality of health care services and discrimination by health care staff members toward the insured. All stakeholders who represent government agencies emphasized that the support for UHIC had become stronger and “more active” after the issuance of the Master Plan. However, the interviewers, who are hospital managers, reported their concern about the challenge of balancing quality of services and low health expenses covered by HI or balancing the bureaucratic reimbursement mechanism between health care facilities and social security agencies. Their concern partially reflects their moderate interest and support for the implementation of UHIC program.
The service users' reported perceived interest has changed little—from negative to slightly negative. As well, their potential position has moved little—from opponent to moderate opponent. However, the reason behind their change is completely different. In the past they opposed the proposed HI policy due to their feeling that the prepayment concept for health care service was strange and counterintuitive—why pay for health care if you do not need it? Their current opposition toward the UHIC derives from the poor quality of service for the insured, the active discrimination against subsidized HI card holders by service providers who receive much lower reimbursement for their services than full fee-paying patients, and a sense of stigma, with inclusion within the current HI provisions commonly interpreted as designed for the poor.
The differences in stakeholder interest could be largely explained by the change in the political and constitutional legitimacy of the UHIC policy in Vietnam. Earlier attempts at the Ordinance on HI had been unsuccessful, with the MOH proceeding on the strength of a Prime Ministerial decree, and a Ministry's regulation. Now the support of the Law on HI and the high-level endorsement of Master Plan has led to the formal recognition of UHIC as a key state social security measure, which has brought about positive changes to stakeholders' interest and their potential position on the development of UHIC.
The differences about stakeholders' influence and power on UHIC policy development
The power and political influence of stakeholders reflect their ability to affect or block the implementation of the policy.28 Now that the UHIC policy has gained recognition through political and constitutional legitimacy, the accountability and responsibility of stakeholders have been prescribed in the Law on HI and the Master Plan. Compared with the early proposal around HI policies in 1989-1992, the difference in legitimacy has accentuated differences among some stakeholders, resulting in higher influence and higher power status.
Almost all stakeholders' influence on and power over HI policy development have gradually changed in a positive direction, with the exception of service users' influence, which has lessened from high to low as a result of the government's commitment to the development of UHIC. When HI was first introduced and had not been regulated formally, the influence of service users on the proposed HI policy was high despite their low level of power in the system. Key informants suggest that the compulsory participation in the HI program as defined by the Law on HI, and service users' failure to secure better benefits from public authorities, reflects this deterioration in influence.
The government cabinet (named Council of Ministers before 1992) continues to maintain its very high influence and power over the formulation and implementation of the HI policy. The cabinet's decisive role in approving the HI policies and providing resources provides it with power to shape the pathway toward UHIC and its success.
With its leading role in the formulation and implementation of the HI policy, the MOH's influence and power has risen from medium-high to high status. Despite its designated leadership on HI, the exhausted health budget and the lack of a legal framework and experience on HI limited the MOH's power and influence to mobilize the formulation of the proposed HI policy, with only medium-high power at the early stage of the HI (1989-1992).
This MOH's influence and power promotion has been repeated in social security agencies at the national and local levels. In the past, the HHIC had medium-low influence and power with respect to the proposed HI policy, but its counterparts in Hai Duong, Da Nang, and Vinh Long now have high influence and power in relation to HI development in their provinces.
The MOF continues to retain its high influence and power at the national level. At the local level, Department of Finances (DOF), however, has medium-high influence and power. HI has become compulsory for the whole population, and the central budget accounts for 100% and 70% of the HI premiums for the poor and the near-poor, respectively. The DOF representatives feel less empowered to influence policy but are still responsible for the provincial budget, which constitutes about 20% of the HI premiums for the near-poor, with the rest paid by the insured.
The government offices at the central and provincial levels have retained their high influence and power in the proposed HI policy in the past and in the current implementation of the UHIC policy. They pointed out that, as HI has become one of the provincial socioeconomic development indicators, the political commitment of local governments to accelerate UHIC progress is a prerequisite for their own performance appraisal.
The influence and power of the Ministry of Labor, Invalids and Social Affairs (MOLISA) have increased from medium to medium-high levels. The Departments of Labor at the local level share the same influence and power levels as the MOLISA. The accountability and responsibility of the MOLISA toward the labor force and other vulnerable groups, together with prescribing all citizens to compulsorily participate in the HI program, certainly made the MOH an influence and power in the pathway toward UHIC.
Vietnam's transition to UHIC has included multiple stakeholders over the past 20 years. Stakeholders have played critical roles in the policy process to establish the HI policy and implement the Master Plan for UHIC.29 Findings highlighted main weaknesses in the formulation of HI policy such as poor understanding about HI concept, inadequate resources, and weak capacity of health facilities. Since the involvement of stakeholders is considered a component of the policy process,30 the integration of knowledge on political know-how and scientific and technical analysis with professional experience are the main reasons for the success of policies.31 Findings showed that stakeholders' positions were influenced by their own interests, urgency, and the values and opinions among each stakeholder.32 These influences on policy making contributed to the failure of HI policy in the initial legal codification of HI in 1992.
This case study pointed out not only the importance of the political and constitutional legitimacy of the HI policy in the implementation process but also the need to establish HI as a socioeconomic indicator as well as a formal working mechanism among the stakeholders at the central and provincial levels. It also makes useful suggestions for Vietnam and other countries with similar contexts for strategies to strengthen policy making such as call for political interests, build institutional capacity, and enhance stakeholders' understanding on policy issues.
Strengths and limitations
As for strengths, this study recruited various stakeholders at different sectors and administrative levels as all key informants closely involved in the implementation of the Master Plan. To our knowledge, this study is the first country-based health policy analysis examined HI policy in the 1989-1992 phase in parallel with the HI implementation in the 2012-2014 phase.
The recall bias is one of the limitations. However, it was minimal since most of the official documents on the initial HI policy were obtained. Data retrieved from the interview for the 1989-1992 phase were validated by the document and media review.
Implications for Policy & Practice
- The review of stakeholders' role in the HI policy process over the past 20 years shows that Vietnam has achieved a remarkable milestone in accelerating UHIC to achieve equity in health care with the understanding, interest, influence, and position of key stakeholders toward the proposed HI policy during the agenda-setting process from 1989 to 1992 and mapping out the uneven support landscape for HI in this period. The results show that the lack of stakeholder understanding about UHIC concepts has been the main challenge to ensuring adequate political support for the formulation and implementation of UHIC policy.
- In the 20 years that have followed, however, the HI agenda in Vietnam has made major strides in establishing its priority and addressing HI population coverage. Therefore, the success on the pathway toward UHIC depends on maintaining the stakeholders' supportive positions and influence. As they commit to clear and certain positive positions on the UHIC program, the pathway toward UHIC goals will be shorter. The government and policy drivers need to promote further communication to end users as to what strategies and action plans the UHIC will take to enable the Vietnamese population to engage in an informed implementation of UHIC and ultimately UHC.
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