Key issues in operationalizing Deci

Key issues in operationalizing Decision 139 include:
• Informing the public. A public awareness effort is needed to inform beneficiaries of their
right to acquire a health insurance card if classified as poor, what the benefit package
includes, and how to access and use the card. Service providers need to know about the
benefit package, the mechanics of providing services and referrals to succeeding levels of
care, and the need to provide the same quality of service to the beneficiaries.
• Targeting and Eligibility. Decision 139 offers an opportunity to better target assistance
for health care costs. The MOLISA poverty line used in Decision 139 is an extreme
standard based on food requirements. The resulting poverty rate of around 13% is well
short of the 37% headcount for 1998 obtained using the poverty cut-off developed jointly
by GSO and the World Bank (VND 1,790,000 per person per year, based on a 2000-
calorie diet adjusted to include an allowance for non-food consumption).
• Impoverishing health expenses. Adverse circumstances including health problems can
easily push Vietnam’s many near-poor into poverty. Decision 139 stipulates that the fund
be used not only to help the poor and other target groups, but also to provide partial fee
exemption for non-beneficiaries experiencing “unforeseen financial difficulties due to
serious diseases which require high costs for treatment at public hospitals”.
Operationalizing this is left to the management board of the fund. The possible
budgetary implications of such a commitment are appreciable, with the burden higher in
provinces with a large number of near-poor people. For example, it is estimated that
partial reimbursement of the expenses of the non-poor equal to an amount sufficient to
push them back to the poverty line would add VND 193,280 million (25%) to the budget
requirements of the Decision 139 scheme.
• Strengthening readiness. Decision 139 will result in increased demand for health services,
especially hospital care. This would likely lead to building more physical capacity in
provinces where hospitals are overstretched and large demand increases are expected.
• Sustainability. Decision 139 requires that HCFP operate on a sustainable basis but the
proposed arrangements seem unlikely to produce this outcome. All provinces,
irrespective of per capita income, are eligible for a 75% (VND 52,500 per beneficiary)
subsidy from the central government. But for poorer provinces, finding the remaining
25% (VND 17,500) is proving hard. New approaches to sustainability need to be
introduced. One would be to look for cost savings through more efficient use of existing
resources. Another is to explore new ways of transferring funds to the provinces.
• The role of VSS. Province-level purchase of VSS coverage for each beneficiary is seen as
the scheme’s primary modality. This leads to a number of issues, starting with whether
VSS would be able to scale up its operations sufficiently quickly. If all 14.6m
beneficiaries become enrolled with VSS, the total number nationally would double. A
related concern was financial integrity—would Decision 139 undermine VSS’s viability?