A robust health system to achieve universal health coverage in Vietnam

In the Nikkei Forum 28th Future of Asia held on May 25–26, 2023, Deputy Prime Minister Tran Luu Quang said Vietnam will stick to the 6.5% GDP growth target despite the slowdown of global economic growth.¹ Vietnam has experienced a rapid economic growth since the economic reform in 1986. Along with the economic growth, the health of the Vietnamese people has significantly improved between 1990 and 2020, whereby the life expectancy grew from 69 to 75 years, and the under-five child mortality rate decreased from 30 to 21 per 1000 live births.^2,3 Both new and old health challenges are posing pressures to the country's healthcare system despite the significant progress it has achieved: Vietnam is one of the Asian countries with the fastest growing ageing populations; non-communicable diseases have surpassed infectious diseases to become the major causes of premature mortality; the country ranks as the sixth most vulnerable country affected by climate change has experienced extreme weather events between 1999 and 2018,⁴ and is currently suffering from a record-breaking heatwave.⁵

The public healthcare system in Vietnam is divided into central, provincial, district, and commune levels, with the current health services heavily reliant on hospital-based care models, as around 73% of total health spending occurs in hospitals.⁶ Quality of health service is one of the reasons patients bypass the primary health facilities to visit central or provincial hospitals, as high-quality healthcare facilities and medical staff are mainly located in municipal cities like Hanoi and Ho Chi Minh City. Hospital autonomy policy requires each institution to manage their own operating costs and revenues, including incomes from user fees or health insurance. This policy encourages profit-driven competition with primary healthcare centers to attract and retain patients. However, a crowded public hospital is not an efficient way for healthcare service delivery, which leads to fragmentation of care that could ultimately harm the quality and efficiency of the system. Out-of-pocket expense in Vietnam is around 39.6% of total health expenditure in 2020 while the world average is 16.32%.⁷ Under the current healthcare delivery system, patients will need to pay more for better-quality service, a higher copayment rate if they bypass the referral system, and non-medical costs such as travel and accommodation to receive treatment in big cities, all of which pose further financial burden to patients.

Ongoing investment in health is needed to maintain a sustainable healthcare system to address both current and future health challenges. However, the public financial outlook is rife with uncertainty in the short term. Despite increases in economic growth, The future of health financing in Vietnam report, published by the World Bank in 2019, forecasted that the public health budget will not be significantly increased due to fiscal consolidation and the comparable or even higher spending than countries of a similar income level.⁶ Health financing policy has been changed towards a fee-for-service model for curative health services and reimbursed by social health insurance. According to the country's Minister of Health, 90.85% of Vietnamese were covered by social health insurance in 2020. External aid takes up a small amount of total health spending but still counts as the major financial source for diseases like tuberculosis and HIV. The Global Fund to Fight AIDS, TB and Malaria will continue to support the country in ending the three epidemics, pledging over US$130 million between 2024 and 2026.⁸ However, external aids have already significantly decreased and eventually will be phased out, when domestic funds like social health insurance will be required to fill the gap for the control of diseases and thus of great public health importance.

The control of healthcare cost escalation in Vietnam has not been effective over the past decades, due largely to the use of fee-for-service as the main provider payment methods, increased autonomy of public hospitals, and increased demands for high-quality services, many of which are not covered by its social health insurance. There are concerns that health insurance funds will soon be in deficit, mainly driven by the rising prices of medical examination and treatments. While the Vietnamese social health insurance provides a generous benefits package, it is not evidence-based. The decisions are mainly generated by health professionals’ recommendations and include diagnoses and treatments for medical care services at all levels, even expensive modalities. From July 1, 2023, household health insurance contributions will increase with the base salary rise.⁹ Increasing premium is one of the options to make health insurance funds in a balanced state, but critically more important is that Vietnamese health insurance should provide an evidence-based benefit package, along with a more efficient healthcare service delivery system, including more spending on preventative care.

Louise Freijser and colleagues summarise four innovative roles hospitals can play to strengthen primary health care in different contexts in the Western Pacific region.¹⁰ For Vietnam, the technical transfer from higher-level hospitals to primary healthcare centers could help to enhance healthcare services quality and ameliorate referral systems, which could contribute towards “improving the supply and demand for frontline primary care services”. Primary care providers like commune and village healthcare workers can play an essential role in reducing infectious diseases burdens in the country, but they are not well prepared for the change towards an ageing society and the resulting health burdens shift to noncommunicable diseases. As an example, the last barrier for Vietnam to become a malaria-free country is to eliminate malaria cases in remote areas and ethnic minorities living in the high-risk areas. The impression of my last month's trip to a commune health station in Chau Hoi, about 300 km to the south of the capital city Hanoi, is the strong connections of the local primary healthcare workers with communities and patients. The close bond and mutual trust help commune and village healthcare workers to efficiently spot suspected malaria cases and provide prevention and healthcare services for communities they service. The doctor-patient connection can be transformed towards providing continuous care for noncommunicable diseases and the ageing population. However, in order to maximize their potential, they need to be well trained and equipped with medical resources and funds.

Despite facing the challenge of balancing public financial spending on health and providing high-quality health service to every Vietnamese, achieving universal health coverage by 2030 is one of the major policy targets set by the Vietnam government. A strong and robust healthcare system characterised by integrative and collaborative primary and tertiary cares is key to achieving this not-so-far-away goal.

Declaration of interests

JC is Editor-in-Chief of The Lancet Regional Health—Western Pacific.