Universal health coverage lessons from Vietnam
Virtually every country worldwide has committed to achieving universal health coverage (UHC) by 2030, as part of the United Nations Sustainable Development Goals. But some countries are progressing much faster than others in delivering equitable access not only to health services, but also to affordable medicines and vaccines. Among those leading the pack is Vietnam.
Today, 87.7% of Vietnam’s population — or 83.6 million people — are covered by health insurance. According to the latest Global Monitoring Report on UHC, published jointly by the World Health Organization and the World Bank, 97% of Vietnamese children now receive standard immunisations, compared to 95% in the United States. Since 1990, the country’s maternal mortality rate has fallen by 75%.
Vietnam has managed to reach such impressive milestones ahead of schedule, despite having an average per capita income of just US$2,342 as of 2017. The key to its success is not the scale of investment in healthcare, which amounts to a modest $142 per person annually (including both public funding and out-of-pocket expenses), but rather how the government uses its resources, including intellectual capital.
Vietnam’s strategic approach can be seen in the Direction of Healthcare Activities programme, which requires health facilities at the central and provincial levels to help build up the capacity of district and community facilities. A key objective is to shift more of the burden of delivering medical services from higher-level hospitals onto lower-level primary healthcare facilities.
Given a long history of deep disparities in health outcomes between urban and rural areas, Vietnamese still often try to bypass their local healthcare centres in favour of major hospitals in urban centres. This creates inefficiencies in the health system and increases out-of-pocket costs for patients and their families, without guaranteeing the best care.
So, beyond ensuring that community health facilities can offer affordable, quality care, there is a need to change public perceptions. Families need to trust that they can get a dependable diagnosis of malaria, chronic obstructive pulmonary disease, or diabetes locally, as well as necessary medications and other treatments.
To this end, health facilities must strengthen their relationships with local communities, above all by routinely providing a level of service that satisfies patients.
Such relationships will help to advance another health-improving, cost-saving imperative: local health workers must be able to educate their communities to maintain health and avoid illness. Success will require good working conditions and access to the ongoing training and management support.
Vietnam’s government recognises that, to implement its healthcare strategy effectively, it needs help. It has established a new Working Group for Primary Healthcare Transformation, with participation from the public, non-profit and private sectors. Its founding partners are the World Economic Forum, Harvard Medical School and Novartis (of which I am chairman of the board).
The working group aims to strengthen existing primary-care demonstration projects in 30 Vietnamese provinces and apply the lessons learned to developing holistic solutions that can be replicated and scaled up. It will also place a high priority on rigorous measurement and evaluation of outputs, from the quality of community-level health services to the cost-effectiveness of primary care.
Each partner is invited to contribute capabilities, resources and knowhow. For example, Harvard Medical School brings world-class expertise in the organisational management of primary healthcare teams. National partners bring, among other things, a deep understanding of the local context.
For its part, Novartis offers an understanding of how to deploy digital technology at large scale, engage rural communities in health education and expand education programmes for healthcare practitioners in rural communities.
In fact, Novartis has already made similar contributions through another successful public-private partnership in Vietnam, entitled Cung Song Khoe (CSK), since 2012. That program has expanded both care for common conditions such as diabetes, hypertension and respiratory conditions, and patient health education and continuing medical education for health professionals. Since 2012, CSK has reached more than 570,000 people, mainly adults, across 16 provinces.
Vietnam has significant challenges ahead. It will need to grapple with behavioural and environmental factors underlying poor health and disease, especially high rates of smoking and alcohol consumption, and air pollution. The country also has one of the world’s most rapidly ageing populations.
Moreover, important healthcare reforms must still be undertaken to improve outcomes. For example, the government should create incentives for doctors to be more selective in referring patients to higher-level hospitals and to send more patients to local primary-care centres.
Nonetheless, Vietnam’s progress has been remarkable, thanks partly to the government’s embrace of strategic public-private partnerships. For countries that have struggled to move forward, this model — and approaches from other high performers in the race for UHC, such as Indonesia, Rwanda and Thailand — may be worth embracing.
Jörg Reinhardt is Chairman of the Board of Directors for Novartis. ©Project Syndicate, 2019, www.project-syndicate.org