What was the problem?
In many PEPFAR countries, most funding for the national HIV program comes from the host country. Nevertheless, programs for communities and key populations (KP) remain largely dependent on external donor financing through the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, Tuberculosis, and Malaria (Global Fund). Local public resources to support the KP response have remained underused due to a shortage of social contracting systems, limited social health insurance capacity, and undefined policy frameworks.
What is the solution?
Social health insurance (SHI) is a mechanism for raising funds to finance health services. SHI collects relatively small financial contributions from clients, then pools and manages those resources to pay for a specific list of health services. Because donors have historically paid for HIV services, these services are typically not included as part of SHI covered benefits. In both Vietnam and Thailand, U.S. Agency for International Development (USAID) mission teams developed work plans with their partners to build the capacity for SHI programs to cover HIV services.
What was the impact?
PEPFAR worked to integrate HIV services into the existing SHI basket of services. This has been accomplished primarily through technical assistance to the Vietnam Administration of HIV/AIDS Control (VAAC) and Vietnam Social Security (VSS) and advocacy with the Ministry of Health (MOH). As a result:
- Antiretroviral therapy (ART) can be reimbursed under the SHI scheme.
- 73 percent of facilities in PEPFAR-supported provinces have SHI contracts as of the final quarter of fiscal year 2017 (FY2017). The PEPFAR-funded Health Finance and Governance (HFG) project has been critical to the success of this effort.
- An estimated 14,000 patients received SHI reimbursement for consultations and basic tests at eligible facilities.
- SHI coverage increased from an estimated 40 percent to over 77 percent in PEPFAR-supported provinces by working with provincial authorities and health facilities. This exceeds that national target of 60 percent.
- In support of financial protection for people living with HIV (PLHIV), provincial authorities of 13 provinces committed local funding to subsidize SHI premiums for PLHIV who do not have an eligible SHI card. The VAAC is also in advanced discussions for providing co-payment subsidies to PLHIV in the near future.
With technical assistance from PEPFAR, the Thai National Health Security Office (NHSO) disbursed its first payments to community-based organizations contributing to the achievement of “reach, recruit, test, treat, and retain” outcomes from Thailand’s national “Ending AIDS” strategy. Although these payments have been small, they reflect a watershed moment. Previously, almost none of the nearly $6 million in NHSO resources set aside each year to support the community response went to community partners. NHSO has now committed to approximately $1 million in domestic financing in fiscal year 2018 to community partners receiving LINKAGES technical assistance in Bangkok, and three other high HIV-burden provinces.
How does it work?
Define target populations
In Vietnam, the target populations include PLHIV already on treatment. Many of these people were identified through PEPFAR and Global Fund outreach to key populations. Some provinces committed to subsidize the SHI premium for PLHIV, to remove the barriers for accessing the coverage among vulnerable populations.
In Thailand, the target populations are key populations with who do not know their HIV status and PLHIV on care and treatment who could benefit from community support systems. Expanding the coverage to community-based services also meant clients who were difficult to find through facility-based testing could be easier to identify through community-based means.
Map available resources
The first step in conducting this type of activity involves conducting an analysis of the political and economic factors that affect the transition of financing to SHI. Select a partner with capabilities in health system strengthening, policy analysis and advocacy, economic analysis and modeling, and contracting. Avoid selecting partners that may stray too far away from the political nature of this process. The government will need to trust the partner in a role as unbiased facilitator and source of analytical capabilities. If the political-economic analysis proves feasible, develop a long-term roadmap for the policy, operational, organizational, and budgetary changes required. Leverage the opportunity for creating the roadmap to engage PLHIV, civil society, ministries of health, ministries of finance, administrators of the SHI, and providers of HIV services in meaningful dialog.
PEPFAR technical assistance teams mapped human, financial, and organizational resources available to support the provincial or area-based response to HIV. Local leaders and stakeholders mobilized domestic resources and facilitated the financial sustainability of HIV service providers. This included leaders of civil society organizations representing KPs, representatives from MOH planning divisions, and leaders in SHI scheme administration.
In Vietnam, the advocacy effort reached the Prime Minister who issued a critical Decision (# 2188) to require full enrollment of PLHIV in SHI and their financial protection). The Vietnam program focused on PEPFAR-supported provinces, but the government of Vietnam has committed to dedicating resources to subsidize premiums for PLHIV on SHI, procuring ARV drugs, and ensuring national coverage. In Thailand, PIF support contributed to unblocking domestic funding in six USAID-supported provinces and five USAID-supported NGOs. This domestic funding is expected to increase and diversify in future years.
Bringing an innovation to scale that includes active participation of key populations (SHI enrollment or access to subsidies) requires their active involvement and feedback. Changes that affect large financing mechanisms, such as SHI, require a constant advocacy pressure on decision makers to show potential solutions as the challenges and problems crop up.
Country teams should consider the potential for community-based service provision, private sector contracting, and capitation payment models. Using such models to reduce costs may increase the likelihood of an SHI sustainably financing those services.
Assess health and economic benefits of SHI
PEFAR assessed and documented the potential health and economic benefits of SHI reimbursements for providing HIV services or meeting accreditation standards to provide a basic HIV services package.
SHIs offer opportunities for transferring the financing of HIV services to host country sources. SHI are typically aligned with health system goals to promote equity and universal access to health. They should be inclusive of health conditions that disproportionately affect vulnerable populations. Countries must have the political will to cover the cost of HIV services before shifting financing to SHIs.
One way to bolster political will is to generate evidence around how much HIV treatment should cost the SHI scheme and show its affordability. Governments often worry HIV treatment costs will be too high to cover from premium revenues. However, the cost of including small populations tends to be much lower than expected after the risk has been spread across a large and healthier covered population.
Build local capacity
PEPFAR built capacity of the in-country SHI mechanism to cover, reimburse, and administer coverage for HIV services within their country scheme.
In Vietnam, recipients of technical assistance include the Ministry of Health, the Vietnam Social Security administration, the Vietnam Administration of HIV/AIDS Control, and service delivery providers. The goal was to eliminate future barriers before the transition had taken place. The intervention was expected to maintain access to care without negatively impacting effectiveness, quality or safety of the services. At the system level, the increased number of patients would represent a challenge, but other activities were put in place to overcome this.
Initial costs of the solution in Vietnam were derived including activities for procurement of ARVs through SHI, including HIV in the SHI benefit package and providing financial protection for PLHIV.
The variance in 2016 is due to slow uptake of the ARV procurement solutions and a false start on the MOH side for designing a Centralized Procurement Unit. In 2017 the work got more traction with the GVN and the variance is due to a slowed progress in the approval process of the new SHI benefit package.
Building capacity for SHI to cover HIV in Vietnam
In Thailand, recipients of technical assistance include the National Health Security Office and community-based service delivery providers. Costs for this initial year of support to NHSO in Thailand totaled approximately $150,000 in technical assistance to help local NGOs prepare for funding from NHSO and to discuss and offer guidance on documentation strategies for NHSO to accept as proof of service provision.