What was the problem?
In many PEPFAR countries, most funding for a national HIV program comes from the host country. Nevertheless, programs for pecific 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, the 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 (TA) to the Vietnam Administration of HIV/AIDS Control (VAAC) and Vietnam Social Security (VSS), and through advocacy with the Ministry of Health (MOH). As a result of these efforts:
- Antiretroviral therapy (ART) can be reimbursed under the SHI scheme.
- 73% 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% to over 77% in PEPFAR-supported provinces by working with provincial authorities and health facilities. This exceeds that national target of 60%.
- In support of financial protection for people living with HIV (PLHIV), the 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 TA 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 TA in Bangkok, and three other high HIV-burden provinces.
How does it work?
Define target populations
In Vietnam, the target population includes 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 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 helped identify clients in the community who were difficult to find through facilities.
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 a SHI model. Select a partner with capabilities in health systems 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 the role of an unbiased facilitator and as a source of analytic capabilities. If the political-economic analysis proves feasible, develop a long-term roadmap for the policy, including the 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 dialogue.
PEPFAR technical assistance teams mapped the human, financial, and organizational resources available to support the provincial or area-based response to HIV. Local leaders and stakeholders mobilized domestic resources. This included leaders civil society organizations' leaders 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), requiring full enrollment of PLHIV in SHI and guaranteeing their financial protection. Vietnam's program focused on PEPFAR-supported provinces, but the country's government has committed resources to subsidize premiums for PLHIV on SHI, procuring ARV drugs, and ensuring national coverage. In Thailand, external support from a Key Populations Innovation Fund contributed to the guarantee of domestic funding in six USAID-supported provinces and for five USAID-supported NGOs. This domestic funding is expected to increase and diversify in the coming years.
Bringing an innovation to scale that includes active participation of KPs requires their active involvement and feedback. Changes that affect large financing mechanisms, such as SHI, require consistent advocacy pressure on decision-makers, especially to provide potential solutions as challenges and problems arise.
Country teams should consider the potential of community-based service provision, private sector contracting, and capitation payment models. Using such models to reduce costs may increase the ability of SHI to sustainably finance those services.
Assess health and economic benefits of SHI
PEFAR assessed and documented the potential health and economic benefits of SHI reimbursements for HIV service provision, as well as the benefits of meeting accreditation standards to provide a basic HIV services package.
SHIs offer opportunities to transfer the financing of HIV services to host country resources. SHI is typically aligned with health system goals to promote equity and universal access to healthcare. 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 the financing structure to SHIs.
One way to bolster political will is to generate evidence around how much HIV treatment should cost the SHI scheme and to show its affordability. Governments often worry that HIV treatment costs will be too high to cover from SHI premium revenues. However, the cost of including small populations tends to be much lower than expected, especially after the risk has been spread across a larger and healthier population.
Build local capacity
PEPFAR built capacity of the SHI mechanism to cover, reimburse, and administer coverage for HIV services within their country scheme.
In Vietnam, recipients of TA include the Ministry of Health, the Vietnam Social Security administration, the Vietnam Administration of HIV/AIDS Control, and service delivery providers. The intervention was expected to maintain access to care without negatively impacting effectiveness, quality or safety of the provided services.
In Vietnam, the initial costs of the solution were included: (1) procurement activities for ARVs, to evaluate HIV’s inclusion in the SHI benefit package (2) cost of providing financial protection for PLHIV. The variance in 2016’s funding (see graph below) is due to slow uptake of ARV procurement solutions and a false start by the MOH in designing a Centralized Procurement Unit. In 2017, the work gained more traction with the Government of Vietnam and the variance is attributed to slowed progress in the approval process for the new SHI benefit package.
Building capacity for SHI to cover HIV in Vietnam
In Thailand, recipients of TA included the National Health Security Office (NHSO) and community-based service delivery providers. Costs for the initial year of support to NHSO in Thailand totaled approximately $150,000 in TA to help local NGOs prepare for funding from NHSO and to discuss and offer guidance on service provision documentation strategies for NHSO.
Revised by the PEPFAR Solutions Team, May 2018