In our series of articles assessing progress towards UHC implementation, we hear activists from Indonesia, Kenya, South Africa, Ukraine and Vietnam on the challenges facing marginalised groups affected by HIV and the actions they are taking in the battle to ensure UHC truly leaves no one behind.

Vietnam began introducing universal health coverage (UHC) in 2010. The biggest component is social health insurance, which the government uses to fund an essential package of services for all those registered.

HIV treatment was not included in the package until concerted advocacy efforts with the engagement of communities most affected by HIV convinced the government to change track in 2014. Although this signalled a huge step forward and is reflective of a government that is broadly receptive to the issues faced by marginalised populations, some issues remain – not least the need to ensure people living with, and affected by, HIV can access health insurance in the first place. 

“If you don’t have an ID paper here it’s difficult,” says Khuất Thị Hải Oanh, Executive Director at the Centre for Supporting Community Development Initiatives (SCDI).

Without an ID paper you can’t use a health insurance card and this means you won’t be able to access services provided under the package.

“If you don’t have a birth certificate you can’t get an ID paper. So from the very beginning you are excluded,” she explains. “People also simply lose their ID papers – particularly people who do not have stable accommodation or housing, such as sex workers, newly released prisoners or people who use drugs.

“Some women who are selling sex find the owner of the establishment they are in will keep their papers so they cannot escape. Other people will pawn their ID, for say $5 when they desperately need money, then don’t have the money to buy it back.

Those who don’t have a health insurance card have just two options – either they suffer or they pay out of pocket. Often the latter means borrowing money at extremely high interest, so people are spending money they should be using for food or for education for their children.

The impact of advocacy

The need to increase access to the social health insurance scheme is something sympathetic government agencies and activists in Vietnam have been working on since the scheme was first introduced. Now Oanh says the presence of the Partnership to Inspire, Transform and Connect the HIV response (PITCH) has enabled them to build a “critical mass”, which has led to some important advocacy wins.

In 2016, the Prime Minister ordered local governments to ensure that every person living with HIV has a social health insurance card. Then in 2018, a government decree instructed that pictured health insurance cards be made available for people who don’t have ID papers.

“Before, many government officials or even policy-makers did not believe that some people did not have ID cards; they now recognise and accept that these people exist,” she says.

We created this understanding by inviting government officers and National Assembly members to dialogues. People just told their stories about why they don’t have ID – these are real people, with a face and a body and a story and a history.

Addressing new challenges

Although all people living with HIV are now entitled to social health insurance, a number of issues have arisen that need addressing for this to work in practice. The first is to ensure local authorities implement the new government policy so people do not have to experience risky interruptions to their treatment. There is also an issue with confidentiality as the way free health insurance cards have been distributed to people living with HIV in some places has led to information about people’s HIV status being leaked. A community system is now in place to capture timely information on such issues so they can be relayed to those responsible.

Mobility has also been an issue. Although people living with HIV in Vietnam tend to be highly mobile, previously people could only access treatment from the primary-care clinic where they first registered for health insurance. PITCH’s advocacy work is helping to change this – health insurance policy now allows people to use their health card in the same level facility anywhere in their province, and from next year people will be able to use it in the same level facility anywhere in the country.

Closing the gaps

Vietnam’s social health insurance scheme is predominately paid for by monthly contributions from employee salary schemes. Other people, such as those living with disabilities and people living with HIV who cannot afford insurance, are covered by the government. But HIV-negative people from marginalised groups who are unemployed are expected to pay for themselves. Yet many people cannot afford this, so end up going without cover. 

One of PITCH’s key advocacy goals is to rectify this.

A significant step forward came in 2018 and 2019 when a number of provinces used funding from programmes relating to Vietnam’s National Action Plan on Prostitution to buy social insurance cards for sex workers. 

This was done on the basis that having health insurance increases sex workers’ access to health services and facilitates their community integration.

A similar approach is being taken with programmes that support the recovery and social re-integration of people who use drugs. For example, in Ho Chi Minh City some local teams are supporting those enrolled in the drug recovery programme to get a health insurance card. The hope is that this progressive approach will now be replicated in other places and for other key population groups.

Other work has taken place to ensure that prisoners – a group currently explicitly excluded from social health insurance – can still access treatment if they are HIV positive. Vietnam’s National Aids Program is now working with prison authorities to ensure antiretroviral coverage for prisoners with a known HIV status.

HIV prevention

The inclusion of HIV treatment within UHC is significantly helping to ensure people living with HIV are not left behind. Now Oanh says activists are turning their attention to other HIV services.

“Another key advocacy focus is to have harm reduction, addiction treatment and other HIV prevention included in the UHC package,” she says. “That’s the next step.”

Currently harm reduction is supported by another government financing mechanism, while needle and syringe programmes and condoms are covered by the government’s HIV prevention programme and the Global Fund. As the Global Fund withdraws and Vietnam enters transition, the need to ensure these vital services are covered has become more pressing.

“The social health insurance law is due to be revised in 2021,” explains Oanh. “So we are starting to raise awareness among policy makers now –

The government has to make the choice: either they fully pay for HIV prevention from the government budget or they have to include it as part of the social health insurance scheme. We are confident that our allies within the government will listen to our arguments on this as they have listened to our arguments in the past.

Learning lessons from the HIV movement

Various challenges relating to UHC lie ahead, and Oanh says the way they are addressed will reflect lessons learnt from the HIV response – the most important of which is the need for community engagement.

We have to identify people that are being left behind by UHC but also ensure that these people can help to find the solutions and advocate for those solutions. At the UHC High Level Meeting, I want to tell the story of the HIV response. How we managed to reach people who are hidden, who are ignored, who are invisible and engage them – not in a charitable manner but for them to be agents for change.

“I also want delegates to realise that there are people who are left behind, beyond the statistics. Because if you have people who don’t have ID papers they are not counted in the first place. These are the people who are most difficult to reach, who have suffered the most. I want to bring the face and the story of these people to the HLM so they can be recognised.”