Introduction

^*Setting and Context

By the end of 2018, international funds would be phased out and it meant that patients must pay ART fee if they did not have health insurance. The Circular No.15/2015/TT-BYT was the best solution in assuring the ART continuity for HIV patients when they only paid about 20-30% of the treatment fee [1].

^*The Circular No.15 key contents:

The brief benefits for patients were stated in Circular No.15 as in 3 articles:

1. HIV-positive people having health insurance who received medical examination and treatment and people having health insurance who used HIV/AIDS related medical services should have the benefits of health insurance policy holders within the limits prescribed by regulations of law on health insurance [2];

2. HIV-positive people having health insurance that were treated with ARV at a medical facility might continue receiving the HIV/AIDS examination and treatment at the same facility according to the regulations in the Circular No. 32/2013/TTBYT dated October 17, 2013 by the Minister of Health in order to ensure convenient treatment, maintaining the stability and effectiveness in HIV/AIDS treatment and prevention;

3. The payment of cost of medical examination and treatment between the medical facilities and social insurance organization should comply with the legislations in health insurance. The health insurance fund did not cover the examination and treatment for people covered by health insurance that had been covered by the state budget (according to national medical target program, ODA projects, etc.) or other lawful capitals” [3,4].

^*The Implementation Barriers

The most challenge in implementing Circular No.15 at national level was the average rate of HIV patients having health insurance was about 30%, and the plan was to increase this portion up to 60% in 2020. The lowest ART fee with 1^st line regimens was about 4 million VND/month, but this fee [5] would be increased 7-8 times with 2^nd line. If patients could not afford ART fee, they would drop out of treatment. Without ART, it harmed not only to patients’ health, but also increased the risk of HIV transmission in community [6]. A survey from 8 Vietnamese hospitals and health centers in 2013, less than 50% patients reported having SHI. There were 93% patients who were willing to pay for SHI if ART was covered by SHI in future [1]. Implementation SHI policy for HIV patients might face many challenges, the most difficult one was the low SHI coverage proportion in Vietnamese HIV-positive people, on the average just 30%, ranging from 15% to 55 % depending on regions and on the awareness of SHI benefits [6], and 72% at Bach Mai OPC-reported in August 2016.

^*The System Failure

MoH requested Department of Health (DoH) of all provinces to implement this Circular at all hospitals. Difficulties that arose during the implementation of this Circular should be reported to MoH for consideration and solution. Each hospital must find its own way of implementing this Circular and following the general guidance. The brief guidance of implementation Circular No.15 for health settings as in 3 articles:

1. Health insurance-covered medical facilities should add the provisions about HIV/AIDS diagnosis and treatment to the annual contract for health insurance-covered examination and treatment according to the regulation in this Circular with the social insurance organization [7];

2. Any medical facility treating people with ARV that was affiliated to medical centers of districts, HIV/AIDS prevention centers, preventive medical centers of provinces and other medical facilities eligible for providing medical services according to the legislations should sign a contract with a social insurance organization for the provision and payment for medical examination and treatment service for HIV/AIDS infected people;

3. Polyclinic hospital of districts or medical centers of districts, agencies, units being under a contract with the social insurance organization for providing health insurance-covered medical service at local medical facilities should add the provisions about HIV/AIDS examination and treatment to the contract for health insurance-covered medical examination and treatment at local medical facilities.”

Aims: This study aimed to improve the readiness of Circular No.15 implementation at Bach Mai hospital to assess the stakeholders’ acceptability, appropriateness, feasibility and sustainability of the intervention.

Methods: Qualitative study (March 2017-April 2017)

^*The survey with stakeholders using in-depth interviews with topic questions related to Circular No.15 awareness, and implementation barriers. (topic questions, Appendix 1)

^*Interviews with stakeholders on the project activities for project assessment (05 managerial staffs, 05 OPC staffs and 20 HIV patients) (topic questions, Appendix 2 and 3)

Results

^*Acceptability

Hospital managers agreed that this Circular should be implemented since it was good for patients and for hospital in having budget from SHI to maintain OPC. “With our key function was to provide healthcare service for people, Bach Mai hospital always did its best. Therefore, the implementation Circular 15 was the priority task to ensure HIV patients continuing their treatment, and avoid the treatment failure due to treatment interruption. Our board of director supported OPC in doing MoH guidelines” (Board of Director representative) [8].

OPC staff thought that Circular No.15 implementation a good chance for them to have short-term or long-term labor contracts with Bach Mai hospital. “We had been working here for many years, more than ten years. Our salary had not changed since the beginning, but we still loved working here. We hoped that we would be employed as hospital staff in future when this Circular was implemented.” (OPC staff)

HIV/AIDS treatment costed much monthly. Now patients could follow treatment without paying. They could not afford the full fee in a lifetime treatment. Co-payment mechanism with SHI might help them to keep on treatment. Some patients, now, thought that they could pay for treatment fee without using SHI. Perhaps, they might change their mind when treatment fee was too much to handle by their own.

“I ran my own business. I could buy ARV drugs in future if they were not free like now. I did not want to use SHI because it was time-consuming.” (One patient from Bac Ninh province).

^*Appropriateness

Hospital managers thought that it was very important to implement this Circular at Bach Mai OPC where there were a lot of patients.

“Bach Mai OPC had had many years of HIV/AIDS management with guidelines from VAAC and MoH since 2009. Now we were managing about 1500 patients under ART.” (Bach Mai OPC representative staff).

OPC staff had many year working at OPC so they loved their job and loved their patients too. And they hoped that they would receive more incentives from SHI in future when Circular No.15 is implemented.

“In fact, if we did not love this job, we would stop working here long time ago. Our patients loved us too. You knew, we did not have any extra incentives like hospital staff at special events like Tet holidays” (OPC staff)

All patients understood the importance of keeping on treatment and had enough knowledge of SHI and Circular No.15.

^*Feasibislity

Bach Mai hospital was one of the big hospitals in Northern region of Vietnam with high quality in medical services. “Now, all clinical procedures were available at all departments. The Quality Control department was always ready to support OPC in standardizing its procedures to assure the treatment quality for patients by the time of implementing Circular 15. With good procedures, we could easily do the financial clearance with SHI.” (Quality Control Department representative)

 “Pharmacy department had ARV drug management procedures. In future, if all ARV drugs were still distributed by VAAC, I think, there was no change in our drug management procedures” (Pharmacy Department representative staff).

With the good rapport between health staff and patients, they easily provided the patient education with highest efficacy.

“In fact, if we did not love this job, we would stop working here long time ago. Our patients love us too. You know, we did not have any extra incentives like hospital staff at special events like Tet holidays” (OPC staff)

All patients bought SHI card for future usage (100% SHI coverage). This was a very good condition for Bach Mai OPC implementing Circular No.15 in future. As our final assessment about SHI coverage, at that time 1500 patients already bought SHI cards.

^*Sustainability

Most medical services at Bach Mai hospital were covered by SHI. So in future, HIV/AIDS medical services were considered as chronic diseases and paid like normal financial procedure.

“It was necessary to have guidelines in financial clearance from Social Health Organization, especially HIV/AIDS service price approved by SHI, not by ourselves. Here, we had the financial software to manage the service fees so there was no difficulty in adding HIV/AIDS service price to the program.” (Financial Department representative staff)

Long-term contract with Bach Mai hospital was very difficult to have. So OPC staff would try their best for being employed permanently.

“It was not easy to get a permanent position at Bach Mai hospital since there were many people applying, but the positions were limited” (OPC staff)

Most patients wanted to keep on treatment at Bach Mai OPC with referred or not referred SHI.

“I bought SHI card at my province. In the future, I still wanted to be treated here (Bach Mai OPC) even I must pay higher due to different level SHI. Because the treatment service here was good, doctors were kind and warm to patients. I had been treated here for many years, so I were worried when being moved to other place” (One patient from Bac Giang province).

Discussion

Our main study results were: (1) We made all hospital managers know and understand the importance and the obligatory of implementing Circular No.15 at Bach Mai hospital. At first, the attention of Bach Mai Hospital in HIV/AIDS official letters from MoH, SHI such as Circular No.15, guidance No. 4609 was very low.

These documents were not well circulated to all relevant departments, only transferred to OPC and OPC had not done any response to these documents since all ART fees were still sponsored by International Fund. The relevant departments did not know that they had the key roles in implementing Circular No. s15, they thought that it was OPC’s responsibilities, such as financial department should play the role of the consultant for OPC about medical service price, but it did not do so. And General Plan department should play the role of plan making on implementing Circular No.15, but it did not do so.

The results we obtained after the interventions had been sustainable in some aspects such as recruited one doctor with long term contract, maintained OPC management model and personnel, SHI benefits consultancy content. However, it might not be sustainable in some aspects. SHI coverage of 100% that was just at the time assessment may be lower in the future since the number of patients were not stable (referred patients, new patients, or even died patients), and the patients’ understanding of Circular No 15 was changing over the time. We should pay more attention to unsustainable things in order to keep on intervening them; especially we needed to assure all patients would use SHI in future for their treatment, because some of them expressed the intention of not using it in our study survey. For other health settings, the interventions should be modified according to the real context. However, the step by step of our procedure could be applied for other health settings.

Study Limitations

The Circular had not been taken in effect at any hospitals since it was issued in 2015. So, we could only do intervention as the preparation for the hospital readiness. We did not have the chance to do SHI procedure on HIV/AIDS for patients in the real situations.

Most data in our study were qualitative ones and some data were missing such as the willingness of using SHI card in 1500 patients at post-intervened periods, the health staff’s understanding Circular No.15 assessment after training and patient’s knowledge assessment after consulting.

Lessons Learned

^*Positive factors

• Bach Mai hospital supported us in doing the study activities (hospital staff interviews, patient interviews).
• Bach Mai OPC collaborated in consulting patients on Social Health Insurance, in doing paperwork (HIV/AIDS medical service price estimation, reports) as the supplement contract with Social Health Insurance organization.

^*Negative factors

Although Social Health Insurance issued the guidance no. 4609, the supplement contract on HIV/AIDS medical service price list, on November 17^th, 2015 right after the Circular No.15 of Ministry of Health (July 26^th, 2015), Bach Mai hospital had not done this yet. The main reasons of delaying implementation were: (i) The remain of International Funds on HIV treatment at OPC; (ii) No further guidance from MoH on the standard HIV medical service price for patients and (iii) No Circular 15 implementing activities at Bach Mai hospital since 2015.

References

1. Tran BX, Nguyen QLT, Nguyen AH, Phan HTT, Latkin C (2014) Potential impacts of expanding social health insurance coverage for patients with HIV/AIDS in Vietnam. AIDS 20^th
2. Gaudine A, Gien L, Thuan TT, Dung DV (2010) Perspectives of HIV-related stigma in a community in Vietnam: a qualitative Int J Nurs Stud 47: 38-48.
3. Khan JAM, Ahmed S (2013) Impact of educational intervention on willingness-to-pay for health insurance: A study of informal sector workers in urban Bangladesh. Health Economics Review 3: 12.
4. Pulerwitz J, Oanh KT, Akinwolemiwa D, Ashburn K, Nyblade L (2015) Improving hospital-based quality of care by reducing HIV-related stigma: evaluation results from Vietnam. AIDS Behav 19: 246-256.
5. UNAIDS and The Henry J Kaiser Family Foundation (2016) Financing the Response to HIV in Low- and Middle-Income Countries: International Assistance from Donor Governments in 2015.
6. Vietnam Administration of AIDS Control (2015) Report on Circular No.15 Implementation Conference.
7. Vietnam Social Health Insurance Report, 2014.
8. Up-to-date the decisions, Circular

      (a) 26/06/2015 Circular 15/2015/TT-BYT on SHI and patient’s copayment on ART fee

      (b) 17/11/2015 Guideline 4609/2015/BHXH-CSYT on how to apply Circular 15

      (c) 15/11/2016 Decision 2188/2016/QĐ-TTg on fund for purchasing ARV drugs

      (d) 28/06/2017 Circular 28/2017/TT-BYT on ARV drugs purchasing and management

^*Questions for managerial staff, (Board of Director, General Planning, Finance, Quality Control and Pharmacy) were:

1. “Have you ever heard about circular No.15?” If yes, please brief the circular content;
2. Provide the copy of circular No.15 and explain in detail about the content then ask, “Would you commit to implement this circular? And why?”
3. “Is there any advantages and disadvantages for implementation circular No.15 that you may think of?”
4. “What are your proposed solutions to each barrier?”
5. Stating there are 2 options for OPC management, the first model is the current management that OPC is separated from general health clinic department; the second model is OPC will be merged to general health clinic department. “Which one do you think that is suitable and feasible? And why?”
6. Stating the OPC staff being paid by international funds and not being official hospital staff. When the funds phase out, “Would they be recruited by hospital to maintain OPC personnel and service quality?” and why?”

 ^*Questions for health staff (doctors and nurses) were:

1. “Have you ever heard about circular No.15?” If yes, please brief the circular content;
2. Would you be able to provide consultancy on SHI benefits and circular No.15 content to patients? If yes, please brief the consultancy content.
3. Stating the OPC staff being paid by international funds and not being official hospital staff. When the funds phase out, “Would they accept to work for OPC if being hired by hospital with long or short-term contract? And why?”

^*Questions for HIV patients were:

1. “Do you have SHI card?” If No, why?
2. If yes, “Have you ever used it for health check-up?”
3. Have you ever heard that in the future patients need SHI for co-paying HIV/AIDS treatment fee?
4. Are you willing to use SHI card for future treatment? If No, why?
5. If you are referred to provincial OPC, would you accept? And why?

Appendix 1: Topic Questions for In-Depth Interviews.

Appendix 2: Poster for Patient Education.

^*The brief content of Circular No.15 for patient education was extracted as following:

1. Patients who have SHI card will receive partial coverage by SHI according regulations of law on health insurance; it may be 80% or 70% of the medical fees.
2. Patients may continue receiving the HIV/AIDS examination and treatment at the same facility, as they desire.
3. Patients who are being covered by the state budget (according to national medical target program, ODA projects, etc.) or other lawful capitals” will not receive SHI coverage.

^*The other contents for patient education:

1. Patient’s information is confidential. It means that only health staff are allowed to access the patient’s information but not allow to let other ordinary people to know about it. Confidentiality is different from secret. The secret is limited people to get to know about the information.
2. ART treatment procedure is standardized as national guidelines and all ARV drugs are the same from OPC to OPC. The quality of ART is also standardized. Patients can access any OPC for HIV/AIDS treatment.

^*Updating other lawful documents supporting Circular No.15 over time were as below:

1. Circular No.15 for SHI coverage HIV/AIDS treatment by MoH on 26 June 2015
2. Guidelines No. 4609 for implementing Circular No.15 by SHI organization on 17 November 2015
3. Decision 2188 for using SHI budget to buy ARV drugs by Government on 15 November 2016
4. Circular No.25 for ARV centralized purchase by MoH on 28 June 2017 Appendix 3: Consultancy Content.