Removing barriers for people living with HIV in accessing and utilizing social health insurance in vietnam

VIETNAM NATIONAL UNIVERSITY, HANOI

VIETNAM JAPAN UNIVERSITY

NGUYEN KIEU AN

REMOVING BARRIERS FOR PEOPLE
LIVING WITH HIV IN ACCESSING AND
UTILIZING SOCIAL HEALTH INSURANCE
IN VIETNAM

MASTER’S THESIS

Hanoi, 2019


VIETNAM NATIONAL UNIVERSITY, HANOI

VIETNAM JAPAN UNIVERSITY

NGUYEN KIEU AN

REMOVING BARRIERS FOR PEOPLE
LIVING WITH HIV IN ACCESSING AND
UTILIZING SOCIAL HEALTH INSURANCE
IN VIETNAM

MAJOR: PUBLIC POLICY
CODE: 17110073

RESEARCH SUPERVISOR:

Prof. Dr. BUI THE CUONG

Hanoi, 2019


Table of contents
Abbreviations ................................................................................................................
List of tables ..................................................................................................................
CHAPTER 1: INTRODUCTION AND BACKGROUND INFORMATION...........1
1.1 Introduction.................................................................................................... 1
1.2 Country background – Vietnam.................................................................... 2
1.3 HIV situation and financing in Vietnam....................................................... 3
1.3.1 Overview of HIV/AIDS epidemic and PLHIV............................................ 3
1.3.2 HIV policies and financing........................................................................ 5
1.3.3 Social Health Insurance in relation to HIV treatment................................ 7
1.4 Literature review............................................................................................ 9
1.5 Research rationale and objectives............................................................... 10
1.6 Research questions....................................................................................... 11
1.7 Research significance................................................................................... 11
CHAPTER 2: METHODOLOGY........................................................................... 12
2.1 Research methods........................................................................................ 12
2.2 Research setting........................................................................................... 12
2.3 Data collection measures............................................................................. 13
2.4 Data analysis................................................................................................. 14
CHAPTER 3: RESEARCH FINDINGS................................................................. 15
3.1 General information.................................................................................... 15
3.2 Reasons PLHIV not buying SHI................................................................. 17
3.3 Barriers in accessing SHI............................................................................ 20
3.4 Ability and willingness to buy SHI.............................................................. 21
3.3 PLHIV’s use of SHI..................................................................................... 22

3.5 Barriers in utilizing SHI.............................................................................. 23
CHAPTER 4: DISCUSSION.................................................................................. 25
4.1 Key findings.................................................................................................. 25
4.2 Discussion..................................................................................................... 25
4.3 Recommendations........................................................................................ 27
CHAPTER 5: CONCLUSION................................................................................ 29
5.1 Summary...................................................................................................... 29
5.2 Limitations of the study............................................................................... 29
References............................................................................................................... 30
Appendixes............................................................................................................. 33
Appendix 1. Questionnaire for PLHIV............................................................ 33


Abbreviations
AIDS

Acquired Immunodeficiency Syndrome

ART

Antiretroviral Therapy

ARV

Antiretroviral

HIV

Human Immunodeficiency Virus

MOH

Ministry of Health

PLHIV

People living with HIV

SHI

Social Health Insurance

UNAIDS

Joint United Nations Program on HIV/AIDS

UNDP

United Nations Development Program

VAAC

Vietnam Administration on HIV/AIDS Control

VND

Vietnamese Dong

WHO

World Health Organization


List of tables
Table 1: PLHIV by gender and possession of SHI
Table 2: PLHIV by age and possession of SHI
Table 3: PLHIV by location and possession of SHI
Table 4: Means to access SHI
Table 5: Reasons PLHIV do not buy SHI
Table 6: Barriers for PLHIV to access SHI
Table 7: Ability of PLHIV to buy SHI
Table 8: Willingness of PLHIV to buy SHI
Table 9: Most recent use of SHI
Table 10: Most recent service to use SHI
Table 11: Barriers for PLHIV to utilize SHI
Table 12: PLHIV’s wanted services not covered by SHI


CHAPTER 1: INTRODUCTION AND BACKGROUND
INFORMATION
1.1 Introduction
Human Immunodeficiency Virus and Acquired Immunodeficiency Syndrome
(HIV/AIDS) is one of the major public health problems in the world
(UNAIDS, 2018). In 2017, the Joint United Nations Program on HIV/AIDS
(UNAIDS) estimated that there were 36.9 million people living with HIV
(PLHIV) worldwide. Vietnam, with a population of 95.5 million people and a
Gross Domestic Product (GDP) per capita of USD 2,389 (World Bank), has a
number of PLHIV reportedly to be 208,371 according to the Vietnam
Administration on HIV/AIDS Control.
Even though a cure is yet to be found for the disease, accessing to

antiretroviral therapy (ART) – a combination of drugs that suppresses and
stops the progression of HIV - can help improve the life expectancy of PLHIV
and help them to lead a healthy and productive life (Oguntibeju, 2012;
Nakagawa F, 2013). That said the treatment requires lifelong commitment and
often is out-of-reach financially for PLHIV, especially those in low and
middle-income countries (Clayden, 2013). In the last decades, ART in
Vietnam was provided free-of-charge mainly through international funding
and programs (Downie, 2017). However, as Vietnam became a lower-middle
income country, external funding for HIV programs, including procurement of
ART medicines has been withdrawn dramatically (MOH, 2014). The
Government of Vietnam, thus, deems transitioning from foreign funded
programs to a more sustainably financing mechanism, in which HIV care and
treatment is covered by Social Health Insurance (SHI) as a priority. It is
reflected in the Law on Health Insurance in 2008 and 2014, and the recent

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Circular No.27/2018 of the Minister of Health on guiding the implementation
of health insurance for HIV treatment. Various decrees and circulars also
support this strategy.
Nevertheless, Nguyen and Wilson (2017) point out that cost of insurance
premiums is a barrier for the near-poor to access to SHI. More specifically,
Nguyen et al. (2017) find that a high proportion of PLHIV was not covered by
SHI for which financial difficulty and lack of information are the underlying
reasons. It is noted that previous studies and researches mostly focus on
access to SHI while to be able to utilize SHI in practice poses other challenges
for PLHIV. This study, therefore, attempts to provide additional data and a
better insight of existing barriers for PLHIV in accessing and utilizing SHI in
Vietnam. It is also hoped to generate feasible recommendations to remove

such barriers to contribute toward improving the quality of life of PLHIV and
social equality in the country.
1.2 Country background – Vietnam
The Socialist Republic of Vietnam is located in Southeast Asia. It is bordered
by China, Laos and Cambodia, with a long coastline that connects to the East
Sea. The country covers approximately 331,212 km 2 and has a population of
95.5 million from 54 different ethnic groups (World Bank).
Since its political and economic reform in 1986, the country has made a
remarkable transformation with a GDP growth rate ranked among the fastest
globally (ICAEW, 2018). The renovation allowed the country to open its
previously isolated market to welcome favorable bilateral and multilateral
trade agreements as well as expand its diplomatic relations, namely joining
ASEAN in 1995, APEC in 1998. Subsequently, in 2011, Vietnam was
categorized as a lower middle-income country, having reduced its poverty

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headcount from 58% in the early 1990s to 14.5% in 2008 (UNDP). At the
moment, Vietnam’s GDP per capita is around USD 2,389 (World Bank).
The social and human aspects of Vietnam have also experienced positive
progress over the years. The country’s Human Development Index value was
0.694 in 2017, which is 46.1% higher than the value of 0.475 in 1990. This
puts the country in the medium human development category – positioning at
116/189 countries in the world (UNDP, 2018). Vietnamese are expected to
live longer with life expectancy at birth at 76.5 years for 2017 (UNDP, 2018).
Child health also gets better with under-5 mortality, infant mortality and
malnutrition rates all drop significantly (WHO).
Despite such improvements, inequality grows larger and quicker in several
dimensions. Taylor (2004) states that wealth gaps exist between geographical

regions, Hanoi and Ho Chi Minh city, for instance, have income per capita
two to five times more than some remote and rural provinces. He also
mentions the discrepancies between women and men, where in women are
less likely to attend secondary school and university, hence less likely to be in
salaried employment, and even when they are, their hourly wage tends to be
lesser. These issues are reaffirmed in a more recent report by Oxfam (2017).
The same report also emphasizes inequalities in economic as well as standard
of living between different ethnic groups and disadvantaged populations.
Similarly, inequality of opportunity due to discrimination based on disability
and HIV status is most severe, according to the 2015 Justice Index by UNDP.
1.3 HIV situation and financing in Vietnam
1.3.1 Overview of HIV/AIDS epidemic and PLHIV
Having the first HIV case detected in December 1990, by the 3 rd quarter of
2017, it was estimated that there were 208,371 people living with HIV in the
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country (VAAC, 2017). Among those, 22% was female and 78% was male.
Although the number of new HIV cases has been reduced over the years, it
has been persistently staying around 12,000 to 14,000 people become infected
every year, and AIDS-related deaths is around 12,000, according to the Joint
United Nations Programme on HIV/AIDS.
HIV in Viet Nam is considered a concentrated epidemic – meaning while
transmission rate among the general population is relatively low (below 0.4%
among adults), the rate is much higher among high-risk populations, typified
by people who use drugs, men who have sex with men and sex workers
(UNAIDS). UNAIDS reports that most of PLHIV in Vietnam lives in large
cities and mountainous provinces. It is noted by Nguyen et al. (2008) that
despite being increasingly at risk of HIV transmission, women in Vietnam are
often under-protected due to lack of awareness, not getting tested and lack of

preventive measures.
In a report published by Vietnam Network of People Living with HIV (2015),
20% of HIV-positive respondents reported being unemployed; households of
PLHIV have monthly income of above VND 5 million (~ USD 216) are 54%,
38% between VND 2 -5 million (~ USD 86 - 216) and 8% under VND 2
million (~ USD 86)1.
Accessing to antiretroviral therapy (ART) – a combination of drugs that
suppresses and stops the progression of HIV - can help improve the life
expectancy of PLHIV and help them to lead a healthy and productive life
(Oguntibeju, 2012; Nakagawa F, 2013). The treatment requires life-long
commitment meaning patients need to take the medication regularly as well as
being adherence to appointed check-ups and testing. Not taking ARV puts
1 The survey was conducted among 1625 participants from Hanoi, Haiphong, Dien Bien, Can
Tho and Ho Chi Minh city.

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PLHIV at risk of opportunistic infections and progression to AIDS. However,
only half of the people who need treatment has access to ART in the country
(VAAC, 2017; UNAIDS; WHO).
Furthermore, even though the 2006 Law on HIV/AIDS Prevention and
Control forbid stigma and discrimination against PLHIV, it is reported that
many still face problems in getting a job, being treated unfairly in the
workplace as well as experience discrimination in healthcare setting (Doan et
al, 2008; Khuat, Nguyen, & Ogden, 2004; Lim et al, 2013).
1.3.2 HIV policies and financing
National programs to control HIV were set up in the early 1990s. Since then,
huge efforts have been made to control the rate of infection, reduce mortality
and improve the livelihood of those affected.

In 1995, an Ordinance on HIV/AIDS prevention and control was adopted by
the National Assembly – it acted as the first legal framework for HIV
intervention efforts in the country. This early period of the HIV response
relied heavily on compulsory testing, coerced rehabilitation of and
stigmatized propaganda about HIV high-risk groups. In 2004, a National
Strategy on HIV/AIDS for 2004 – 2010 with a vision to 2020 was put in
place, which adopted international best practices and recommendations on
HIV prevention, care, support and treatment. This strategy embraced the
concept of harm reduction, encouraged information campaigns and voluntary
testing and counseling instead of mandatory HIV testing. Then, the 2006 Law
on HIV/AIDS Prevention and Control emphasized the principle of no stigma
and discrimination against PLHIV. These changes have shown the country’s
“gradual shift from a punitive approach to a more human rights-based
approach” (as commented by the Inter-Parliamentary Union Advisory Group,

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2014; Pham et al, 2010). Later, the 2008 Law on Health Insurance removed
the diagnosis and treatment of HIV from the list of exceptions for health
insurance coverage. The Law was again amended in 2014 to further adapt to
the changing strategy and needs for HIV treatment.
In addition, Vietnam is also committed to several international documents and
strategies related to HIV/AIDS prevention and PLHIV, namely the 2001
UNGASS Declaration on HIV/AIDS which recognizes the fundamental rights
of PLHIV and the importance of “access to medicines”; and the “90-90-90”
target which aims for 90% of PLHIV to know their status, among those 90%
will receive ART and among those 90% will have viral suppression by 2020.
Financially, the Government of Vietnam has been increasing budget for HIV
interventions and programs over the years. However, it is still heavily

dependent on international donor contributions – with more than 70% of the
overall financing coming from external sources (MOH cited by PEPFAR,
2018). More importantly, almost 90% of ART medicines in the country come
from two big international donors – PEPFAR and the Global Fund, both of
whom have plan to either discontinue or uncertain about future aid
commitments (vietnamnews.vn).
In response to the reality that ART in Vietnam will no longer be provided freeof-charge through international funding and programs, the Government has
strategized to secure the medicine procurement through funds from the
national Social Health Insurance (Downie, 2017). It is estimated that SHI
coverage needs to increase to 80% by 2020 to potentially cover 52% of HIV
treatment payment needs (USAID, 2015).

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1.3.3 Social Health Insurance in relation to HIV treatment
It is proven that health insurance plays a crucial role in reducing financial
burden and acts as a protective measure for people against unexpected health
costs. Several high-income and middle-income countries such as Brazil,
Mexico, Thailand and Taiwan have had health insurance scheme in place to
cover for HIV services (UNAIDS, 2012).
As for Vietnam, the concept of health insurance was first mentioned in the
country’s Constitution in 1992. It was the most important basis for the
formation of health insurance system and the implementation of health
insurance policies in the country. In the same year, the Health Insurance
Regulation was promulgated with coverage limited to government officials
and formal workers. At the time, voluntary participation was not clearly
regulated.
After 15 years of implementation, policies and regulations surrounding SHI
have been revised and/or amended several times in order to expand the

coverage and to better cope with the country’s development stages. The
number of people participating in health insurance had increased over the
years. Nevertheless, by 2008, the number of people participating in health
insurance was only 37.7 million, accounting for 43.76% of the population
(MOH, 2012).
In response, the approval of the abovementioned 2008 and 2014 Law on
Health Insurance marks the government’s aim toward universal health
coverage. With the established policy and system, a number of amendments
was added, regulating the compulsoriness of social health insurance. Its
compulsory membership has been expanded to include formal workers, the
poor, the near-poor, elderly, and children under 6 years old. Government

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budget covers partially or fully for more beneficiaries, specifically 100%
health insurance premium cost for the poor, ethnic minorities and children
under 6 years old; up to 95% for the near-poor and retired people, and up to
80% for others (Nguyen, et al., 2017). This has resulted in a reduction of
household’s out-of-pocket money for medical expenses from 62.9% in 1998
to 48.5% in 2012 and to 44.3% in 2013 (MOH, 2016); and an increase in the
number of persons participated in social health insurance of over 75.9 million,
accounting for 81% of the population (General statistics office, 2017)
As of 2017, the concept of “voluntary health insurance” is replaced by the
regulation of “health insurance by household” meaning any individual that is
not under the compulsory and/or special categories (the employed, those in
military/police force, the poor, the near-poor, students, children under 6 years
old etc.) will be required to join under this category. The health insurance
premium for this “household” category is set at VND 702,000/ person/ year,
and is reduced for each family member joining after. This is an effort of the

government to increase health insurance coverage.
Regarding HIV treatment, the 2008 Law on Health Insurance adds more
benefits on preventive medicines including HIV screening and testing. The
2014 Law on Health Insurance, along with following Circular No.27/2018 of
the Minister of Health provide detailed guidance on the implementation of
SHI for HIV treatment. As a result, the Ministry of Health now aims to
provide ARV treatment through SHI for 40,000 PLHIV by the end of 2019
(MOH, 2019). This target, by itself, is a challenge since an earlier
countrywide survey shows that only around 30% of PLHIV has access to SHI
(VAAC, 2014).

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1.4 Literature review
PLHIV’s accessibility to Social Health Insurance
Clayden (2013) says that prices of ARV in some low and middle-income
countries including Vietnam, is actually much higher than that of African
nations. This and the fact that even with free-of-charge ART, PLHIV in
Vietnam still have to face with other out-of-pocket payments that is
“catastrophic” and may hinder their access to treatment (Tran, et al., 2012).
This statement is supported by another study by Nguyen et al. (2014) in
which, given free ART, 10.5% of participants were still unable to access the
treatment due to inability to pay for the associated expenditures (such as
testing and travel costs); and 16.2% could only partially afford these costs.
This raises further importance of PLHIV’s accessibility to SHI in order to
access and/or maintain their ARV treatment in the context of withdrawing
international funding.
Nguyen and Wilson (2017) find that level of enrollment in SHI among the
near-poor was associated with cost of insurance premiums, knowledge of

insurance benefits, and overall affordability. Financial constraints again were
concluded as the reason for majority of opioid-addicted patients in Northern
provinces of Vietnam, many of whom are HIV-positive, to access to SHI
(Tran et al, 2017).
Besides financial difficulty, Nguyen et al. (2017) also find that a high
proportion of PLHIV was not covered by SHI due to lack of information. The
researchers comment that PLHIV might not be willing to buy SHI because
they do not fully understand its benefits and so have the feeling of difficulty
when buying and using it.

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Furthermore, even though stigma and discrimination has not been clearly
pointed out as factors hindering access and utilization of Vietnamese PLHIV
to SHI, previous literature, both in the world and in the context of Vietnam,
has shown that stigma and discrimination are factors that prevent PLHIV to
access to care and treatment (Feyissa et al., 2019; Tran et al., 2019).
1.5 Research rationale and objectives
Vietnam continues to show its strong commitment to both ending the AIDS
epidemic and improving quality of life of PLHIV, which can be achieved by
having a sustainable health financing mechanism. Increasing the rate of health
insurance coverage among PLHIV as well as ensuring they can effectively use
health insurance to engage in treatment are important steps towards this goal.
However, barriers might exist that hinder PLHIV’s accessibility to and
utilization of social health insurance.
Although previous studies and researches have identified a number of
obstacles hindering PLHIV’s ability to access to social health insurance
including financial difficulties, other aspects related to PLHIV’s experience in
buying and using social health insurance are not yet addressed and can be

explored to further the understanding of the actual issues faced by PLHIV.
This study, therefore, aims to:
 Provide an understanding of the situation and urgent needs to support
people living with HIV in Vietnam through social health insurance in
the context of declining international aids;
 Explore current barriers faced by people living with HIV in Vietnam
to accessing and utilizing social health insurance; and
 Provide recommendations to remove such barriers and thus improve
the accessibility to and utilization of social health insurance of people
living with HIV.
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1.6 Research questions
This study seeks to answer the following questions:
 What are the current barriers for PLHIV in accessing SHI in Vietnam?
 What are the current barriers for PLHIV in utilizing HI in Vietnam?
 What are the recommendations to remove such barriers?
1.7 Research significance
Findings from this study will contribute additional data and knowledge on
barriers for PLHIV in accessing and utilizing SHI in Vietnam. It is also hoped
to generate feasible recommendations to remove such barriers to contribute
toward improving the quality of life of PLHIV and social equality in the
country.

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CHAPTER 2: METHODOLOGY
2.1 Research methods

The study was implemented during a larger research conducted by the Center
for Supporting Community Development Initiatives where the author
interned. This Center focuses on working with vulnerable populations,
including those living with and affected by HIV/AIDS. It had helped the
author collect data from more participants from different cities/provinces.
The study was conducted using a mixture of quantitative and qualitative
methods. This enable the author to both extract information from a large
sample of people as well as explore further specific areas of interest.
Quantitative data was collected through a self-reported questionnaire survey
given to 200 HIV-positive people in 13 cities/provinces; while qualitative data
was collected through 5 focus group discussions and observations with 15
participants.
The questionnaire as well as discussions given were in Vietnamese.
Translation from Vietnamese to English was done later for both data collected
through the questionnaire survey as well as answers from focus group
discussions.
2.2 Research setting
The study was conducted in different cities/provinces from different regions
in order to ensure the representativeness of participants, including:
 Large city: Hanoi, Ho Chi Minh city;
 Northern Delta Region: Bac Giang, Bac Ninh, Vinh Phuc, Hai Duong;
 Mountainous and remote area: Dien Bien, Son La, Phu Tho, Thai
Nguyen;

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 Central region: Lam Dong, Khanh Hoa;
 Southern region: Binh Duong.
Survey participants by current place of living

No.

City/Province
1

Dien Bien

2

Son La

3

Bac Giang

4

Bac Ninh

5

Phu Tho

6

Hanoi

7

Ho Chi Minh city

8

Thai Nguyen

9

Hai Duong

10

Vinh Phuc

11

Lam Dong

12

Nha Trang (Khanh Hoa)

13

Binh Duong
Total

2.3 Data collection measures
Quantitative data
A questionnaire survey was designed with 3 parts:
 Part 1: General information of all participants, including their current

living location, gender and age.
 Part 2: For those who do not have social health insurance, asking
about their experience in accessing SHI – including the reasons they do
not and/or cannot buy SHI, barriers faced when accessing SHI, their
financial ability and willingness to buy SHI;

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 Part 3: For those who have had social health insurance, asking about
how they can access to SHI, their use of SHI, and barriers faced when
utilizing SHI.
Qualitative data
5 focus group discussions were conducted between groups of 3 to 5
participants following a guide. A total of 15 people was interviewed, among
them 9 have had social health insurance and 6 have not. The discussions are
recorded only for the purpose of analyzing data and will be destroyed once
transcribed to ensure the confidentiality of the participants.
2.4 Data analysis
Data collected from the questionnaire survey was converted from the hard
copies into excel spread sheets while answers from the focus group
discussions was transcribed from the records into word file for analysis.

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CHAPTER 3: RESEARCH FINDINGS
3.1 General information
A total of 200 people living with HIV was given the self-reported
questionnaire. They are currently living in 13 cities/provinces of Vietnam.

Among the participants, 163 (82%) are male, 34 (17%) are female and 3 (2%)
identifies themselves as transgender.
Table 1: PLHIV by gender and possession of SHI

Male
Female
Transgender
Total

It is worth noted that more than half of those surveyed (51%) are currently not
having SHI. This result shows that many either are reluctant to buy or do not
have enough information about SHI.
Table 2: PLHIV by age and possession of SHI

Under 24 years old
From 24 to 50
years old
Above 50 years old
Total

As for the age of the participants, majority (91%) of those surveyed are
between 24 to 50 years old, only 6% and 3% are those under the age of 24
and above 50 years old respectively.

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Table 3: PLHIV by location and possession of SHI

Large city

Northern Delta Region
Mountainous and remote area
Central region
Southern region
Total

As can be seen from table 3, the rate of PLHIV having SHI is highest in large
city (Hanoi and Ho Chi Minh city) with the number of PLHIV having SHI
more than double the number of non-SHI PLHIV. Data also shows that among
those currently having SHI in large city, majority (24) bought their own. This
could be attributed to better financial condition of those living in this location.
Table 4: Means to access SHI
Bought their own
Given free-of- charge
Household belong to the poor category
Household has member(s) rendered great merit to the country
Household has member(s) in police/military force
Others (incl. bought by employer)
Total

For those who currently have SHI, the survey seeks to understand how they
accessed to SHI. Among the 98 participants that currently have SHI, 25 (25%)
received SHI card free-of-charge due to mainly their household belongs to the
poor category (18), their household has member(s) rendered great merit to the
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country (2), their household has member(s) in police/military force (1) and
other reasons, including having SHI bought by their employer (4).
Majority of participants had to buy their own SHI (75%).

During the focus group discussions, all interviewed PLHIV reported receiving
information about the prospect of ART medications to be covered by SHI
from the clinics where they are being treated, through community support
groups, and via the Internet etc. The general opinion on this issue is positive;
they are aware of and have the need to buy SHI. Among the interviewees,
however, few fully understand the benefits of health insurance (including
those who have SHI). The reason driving them to buy SHI is a concern of
discontinuing their HIV treatment.
3.2 Reasons PLHIV not buying SHI
Prior to the study, thorough literature review and informal discussions had
taken place in order to generate suggestions for reasons PLHIV not buying
SHI. Several previous literatures have suggested the main reason PLHIV
cannot or do not buy SHI was due to financial constraints, lack of information
about SHI, and fear of stigma and discrimination. However, as the results
show, the barriers are much more diverse:
Table 5: Reasons PLHIV do not buy SHI
Do not have money
Afraid to be stigmatized and discriminated against when
using SHI
Do not care
Do not think it is necessary
Have difficulties buying SHI
Others

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Total

Financial constraints

As can be seen clearly from the data collected, the majority (45%) of non-SHI
respondents in the survey said that the biggest barrier preventing them from
accessing social health insurance is financial issues.
“I have heard many (PLHIV) complained. Many of us have to take care of
every day’s end-needs; having to pay for ART medicines is adding more
burden to us. For others, the money (to buy SHI) may not be much, but for us
(it is)…” said a male interviewee from Bac Giang.
Stigma and discrimination
Stigma and discrimination are also a highlight in the survey results (20%).
When asked about stigma and discrimination, participants reported that
people using health insurance cards for medical examination often did not
receive the same quality of service as those who voluntarily paid and paid
more money. Especially in the case of people living with HIV, the attitude of
health workers towards them is much worse. PLHIV also fear that health
insurance cards with their personal information will make them identifiable to
their village, community. In the past, when PLHIV went for ART, they could
use fake names or go to out-patient clinics that are far from their place of
residence to receive medicines every month. Now, if they use SHI card, they
must take the medicine according to their place of residence and have to
publicize the identity there.
In addition, the interviewed PLHIV also expressed concern that their identity
would be revealed if ART was to be provided through SHI, especially for
those with employment. Because of this, it is possible that PLHIV with SHI

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do not want to use the card. Some even said that their employers purchased
health insurance for them, but they did not use it because they were afraid to
reveal their identity.

“I know that a month's ART medications range from VND 1 to 1.5 million,
but if letting SHI covers for that and I lose my job, I would rather pay for the
medications” said a male interviewee from Ho Chi Minh city.
“A friend of mine said that she would rather stop taking ART medications if it
was paid for by SHI because she was working for a formal agency and they
might find out (about her HIV status)" said a female interviewee from Bac
Giang.
“I am very reluctant to go to big hospitals. When I go to a private hospital, I
do not have to reveal my HIV status. I rarely use SHI card since I am afraid of
being discriminated against, so buying SHI is for naught” said a male
interviewee from Hanoi.
Lack of awareness
Two other reasons PLHIV said they do not buy SHI were that they did not
care and found it unnecessary. Communication on the benefits of health
insurance, despite being implemented by many agencies, still does not seem
to reach the marginalized groups; or the communication messages are not
strong enough, suitable or targeted at these groups. It is important to note that
at the time of the survey, many participants might be on ART provided by
international-funded programs or projects so they might not realize the
importance of having SHI to sustain their treatment.
A similar portion of participants also said that they had difficulties buying
social health insurance.

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3.3 Barriers in accessing SHI
Table 6: Barriers for PLHIV to access SHI
Do not have enough money to buy SHI regularly
Afraid to be stigmatized or discriminated against when

using SHI (compare to non-SHI patients)
Do not live with their family so the regulation of buying
SHI by household make it more difficult
Do not know how to buy SHI / Lack of information
Do not have Identification Card
Do not have family-register book
The place to buy SHI is far from where I live
Do not have a permanent residential registration
SHI officials make it hard for me
Others
Total

When ask to elaborate barriers to accessing SHI, besides the same
abovementioned reasons PLHIV do not buy SHI which are not having enough
money and afraid of stigma and discrimination, other factors also come up:
The regulation of buying SHI by household
The regulation of buying SHI by household seems to make it more difficult
for PLHIV to access SHI.
“I was directly told that I needed to buy SHI by household. I can afford to
buy for myself, I can't buy (SHI) for my whole family. My wife’s family has
12 people. (They said) even if I wanted to buy, I had to encourage my family
(to buy SHI), otherwise I had to pay for all of them” said a male interviewee
from Hanoi.

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