Health insurance in Viet Nam

20 World Health • 47th Year, No.6, November-December 1994 Health insurance in Viet Nam Bui Due Khonh The notion of health insurance is just scratching the surface so far in Viet Nom, reaching only 5-B% of the popula- tion. Many years of having a subsidized health system have led to a form of habitual complacency. The well-to-do are quite ready to pay for care if they fall sick and are not interested in health insurance, which the poor feel they cannot afford. But the hope is that the insurance scheme will eventually ensure greater access to care, and better quality of care, for all patients. VietNam underwent more than 30 years of terribly destructive warfare followed by many years of an international trade embargo. It is also regularly battered by natural calamities. Most of its people- 85% - are engaged in agriculture; by nature they are dogged and industrious, but most of them have hard lives, beset by poverty and disease. In the past, thanks to the state subsidy system, they could expect examination and treatment free of charge at health facilities if they fell ill. But today the national health budget is barely enough for the deliv- ery of health services, and can only respond to about half of the mini- mum health demands. There are Viet Nom's insurance scheme will eventually ensure better access to health care for all its people. increasing shortages of such items as medical equipment, chemicals, drugs and X-ray films. Since 1989, in an effort to overcome the erosion of the social services, the State has allowed health facilities to collect a portion of the hospital fees. The very poor still receive free treatment, but what is collected from patients who are able to pay represents only a minor proportion of what is spent on them. Throughout the entire health service, hospital fees amount to 8-10% of the total expenditure on hospitals. Still, despite this relatively modest share of charges in total expenditure, many people are worried that if they fall seriously ill, they may have to borrow money in order to pay the hospital charges. In 1993, the Health Ministry passed a decree obliging all civil servants and wage-earners- some 10% of the total population- to con- tribute 3% of their income to health insurance: 2% paid by the employer in the public or private sector, and 1% paid by themselves. One year after the scheme went into action, less than half of those concerned have actually joined the scheme; still uninsured are some employees of private companies and some self- employed persons. Of the people not belonging to the compulsory scheme, the great major- ity are peasant farmers or small traders. The poor and very poor constitute between 15% and 20% of the population; they know that if they make enough money they can join the health insurance scheme and their anxieties will be eased, but they tend to accept their fate with resignation. Pilot scheme Some time ago, the Vietnamese Health Ministry introduced a pilot health insurance scheme in the region of Haiphong which, besides A helping hand to cross the flooded street. Natural catastrophes regularly pose special problems for the health personnel. World Health • 47th Year, No. 6, November-December 1994 21 A calendar helps to promote the messages of good health for all the family. Breastfeeding for a new-born baby in the "rooming in" ward of a provincial health centre. being a major port city, includes rural districts . Thanks to the enthusiasm of the Haiphong people 's committee and of those who actually run the scheme, membership increased rapidly in some districts from 5% to 25% of the residents. With the help of WHO consultants, the scheme is being extended as a policy-oriented research project to other districts, each with a population of nearly a quarter of a million. About 10% of households have a relatively high standard of living, well over half a medium standard, and 20% a low standard. In a matter of months after the pilot scheme was introduced, all the localities concerned have demon- strated initiative and ingenuity. Its leaders include not only adminis- trators, members of workers' and peasants' unions, youth organiza- tions and women's groups, but also schoolteachers who have been encouraging the children to tell their parents about the health insurance scheme, and priests. Women and the elderly constitute two groups who need little persuasion to invest in the scheme, once they realize that it will relieve them of the worry of facing unexpected expenditure on medical or hospital care. Health insurance cards are being offered to parents and grandparents as birthday or anniver- sary cards, and can even be paid for with rice or other farm products. So far, the notion of health insurance is just scratching the surface, reaching only 5-8% of the population. Many years of having a subsidized health system have led to a form of habitual complacency. The well-to-do are quite ready to pay for care if they fall sick and are not interested in health insurance, which the poor feel they cannot afford. The research team hopes that, with the backing of the Health Ministry, the authorities at different levels and WHO, the initial experi- ments in Haiphong and elsewhere can be built upon. The experiences of such countries as France, Germany and Sweden as well as those of neighbouring countries like Thailand are also being studied, and Global commitment needed the hope is that VietNam's health insurance scheme will eventually ensure greater access to care, and better quality of care, for all patients. In particular, the poor will at last have a solid basis for meeting their health needs and will be able to take pride in the fact that they are taking care of their own health. • Dr Bui Due Khanh is Deputy Director of the Vietnamese Department of Planning and Finance, and Chief of Health Insurance under the Viet Nom- Sweden health cooperation scheme. His address is Ministry of Health, Hanoi, Viet Nom I 0000. Before na tional authorities worry about the cost of tackling the manifo ld problems that w ill beset us in the next century, they might well consider what would be the cost of not tackl ing them. Failing to deal adequately w ith rapid popula tion rise, unchecked migration, poverty, inequi ty in hea lth , insani tary conditions and unhealthy lifestyles amounts to a recipe for disaster. The consequences must inevitably include soc ial disruption, greater poli tica l and relig ious extremism and a tendency for local tensions to escalate into national and international conflicts. Therefore, administra tions need to consider the high poli tical cost of inaction. Heads of state and of government must act as cata lysts for a g lobal comm itment to action to improve the quali ty of life of people everywhere. The very stabili ty of those heads of state and of government may depend on this ! The sorry history of the present century offers sufficient proof that social tensions do not stay with in national borders. They travel, transforming themselves into such issues as migration, drug abuse, diseases, poverty and terrorism - in short, issues that do not lend themselves to narrow national solutions but must be resolved at the internationa l leve l. Today, and to mo rrow, w e need to assess whether present development models and current international cooperation are truly responsive to the needs of sustai nable human development and whether they contribute to lowering tensions and improving human wel l-being in our global village. Based on a text by Ambassador juan Somavia, Chairman olthe Preparatory Committee olthe World Summit lor Social Development. Contributed by Dr Habibo Wassel, Division of Interagency Affairs, World Health Organization, 12 1 1 Geneva 27. Switzerland.