A landscape analysis of health technology assessment capacity in the Association of South-East Asian Nations region.

BACKGROUND: Progress towards achieving Universal Health Coverage and institutionalizing healthcare priority setting through health technology assessment (HTA) in the Association of South-East Asian Nations (ASEAN) region varies considerably across countries because of differences in healthcare expenditure, political support, access to health information and technology infrastructure. To explore the status and capacity of HTA in the region, the ASEAN Secretariat requested for member countries to be surveyed to identify existing gaps and to propose solutions to help countries develop and streamline their priority-setting processes for improved healthcare decision-making. METHODS: A mixed survey questionnaire with open- and closed-ended questions relating to HTA governance, HTA infrastructure, supply and demand of HTA and global HTA networking opportunities in each country was administered electronically to representatives of HTA nodal agencies of all ASEAN members. In-person meetings or email correspondence were used to clarify or validate any unclear responses. Results were collated and presented quantitatively. RESULTS: Responses from eight out of ten member countries were analysed. The results illustrate that countries in the ASEAN region are at different stages of HTA institutionalization. While Malaysia, Singapore and Thailand have well-established processes and methods for priority setting through HTA, other countries, such as Cambodia, Indonesia, Lao PDR, Myanmar, the Philippines and Vietnam, have begun to develop HTA systems in their countries by establishing nodal agencies or conducting ad-hoc activities. DISCUSSION AND CONCLUSION: The study provides a general overview of the HTA landscape in ASEAN countries. Systematic efforts to mitigate the gaps between the demand and supply of HTA in each country are required while ensuring adequate participation from stakeholders so that decisions for resource allocation are made in a fair, legitimate and transparent manner and are relevant to each local context.

Cost-Utility Analysis of Direct-Acting Antivirals for Treatment of Chronic Hepatitis C Genotype 1 and 6 in Vietnam.

OBJECTIVE: Very few cost-utility analyses have either evaluated direct-acting antivirals (DAAs) on hepatitis C virus (HCV) genotype 6 patients or undertaken societal perspective. Recently, DAAs have been introduced into the Vietnamese health insurance drug list for chronic hepatitis C (CHC) treatment without empirical cost-effectiveness evidence. This study was conducted to generate these data on DAAs among CHC patients with genotypes 1 and 6 in Vietnam. METHODS: A hybrid decision-tree and Markov model was employed to compare costs and quality-adjusted life-years (QALYs) of available DAAs, including (1) sofosbuvir/ledipasvir, (2) sofosbuvir/velpatasvir, and (3) sofosbuvir plus daclatasvir, with pegylated-interferon plus ribavirin (PR). Primary data collection was conducted in Vietnam to identify costs and utility values. Incremental cost-effectiveness ratios were estimated from societal and payer perspectives. Uncertainty and scenario analyses and value of information analyses were performed. RESULTS: All DAAs were cost-saving as compared with PR in CHC patients with genotypes 1 and 6 in Vietnam, and sofosbuvir/velpatasvir was the most cost-saving regimen, from both societal and payer perspectives. From the societal perspective, DAAs were associated with the increment of quality-adjusted life-years by 1.33 to 1.35 and decrement of costs by $6519 to $7246. Uncertainty and scenario analyses confirmed the robustness of base-case results, whereas the value of information analyses suggested the need for further research on relative treatment efficacies among DAA regimens. CONCLUSIONS: Allocating resources for DAA treatment for HCV genotype 1 and 6 is surely a rewarding public health investment in Vietnam. It is recommended that the government rapidly scale up treatment and enable financial accessibility for HCV patients.

Can rural health insurance improve equity in health care utilization? A comparison between China and Vietnam.

INTRODUCTION: Health care financing reforms in both China and Vietnam have resulted in greater financial difficulties in accessing health care, especially for the rural poor. Both countries have been developing rural health insurance for decades. This study aims to evaluate and compare equity in access to health care in rural health insurance system in the two countries. METHODS: Household survey and qualitative study were conducted in 6 counties in China and 4 districts in Vietnam. Health insurance policy and its impact on utilization of outpatient and inpatient service were analyzed and compared to measure equity in access to health care. RESULTS: In China, Health insurance membership had no significant impact on outpatient service utilization, while was associated with higher utilization of inpatient services, especially for the higher income group. Health insurance members in Vietnam had higher utilization rates of both outpatient and inpatient services than the non-members, with higher use among the lower than higher income groups. Qualitative results show that bureaucratic obstacles, low reimbursement rates, and poor service quality were the main barriers for members to use health insurance. CONCLUSIONS: China has achieved high population coverage rate over a short time period, starting with a limited benefit package. However, poor people have less benefit from NCMS in terms of health service utilization. Compared to China, Vietnam health insurance system is doing better in equity in health service utilization within the health insurance members. However with low population coverage, a large proportion of population cannot enjoy the health insurance benefit. Mutual learning would help China and Vietnam address these challenges, and improve their policy design to promote equitable and sustainable health insurance.

Economic evaluation of population-based type 2 diabetes mellitus screening at different healthcare settings in Vietnam.

INTRODUCTION: Few economic evaluations have assessed the cost-effectiveness of screening type-2 diabetes mellitus (T2DM) in different healthcare settings. This study aims to evaluate the value for money of various T2DM screening strategies in Vietnam. METHODS: A decision analytical model was constructed to compare costs and quality-adjusted life years (QALYs) of T2DM screening in different health care settings, including (1) screening at commune health station (CHS) and (2) screening at district health center (DHC), with no screening as the current practice. We further explored the costs and QALYs of different initial screening ages and different screening intervals. Cost and utility data were obtained by primary data collection in Vietnam. Incremental cost-effectiveness ratios were calculated from societal and payer perspectives, while uncertainty analysis was performed to explore parameter uncertainties. RESULTS: Annual T2DM screening at either CHS or DHC was cost-effective in Vietnam, from both societal and payer perspectives. Annual screening at CHS was found as the best screening strategy in terms of value for money. From a societal perspective, annual screening at CHS from initial age of 40 years was associated with 0.40 QALYs gained while saving US$ 186.21. Meanwhile, one-off screening was not cost-effective when screening for people younger than 35 years old at both CHS and DHC. CONCLUSIONS: T2DM screening should be included in the Vietnamese health benefits package, and annual screening at either CHS or DHC is recommended.

Rural health care in Vietnam and China: conflict between market reforms and social need.

China and Vietnam have adopted market reforms in the health sector in the context of market economic reforms. Vietnam has developed a large private health sector, while in China commercialization has occurred mainly in the formal public sector, where user fees are now the main source of facility finance. As a result, the integrity of China's planned health service has been disrupted, especially in poor rural areas. In Vietnam the government has been an important financer of public health facilities and the pre-reform health service is largely intact, although user fees finance an increasing share of facility expenditure. Over-servicing of patients to generate revenue occurs in both countries, but more seriously in China. In both countries government health expenditure has declined as a share of total health expenditure and total government expenditure, while out-of-pocket health spending has become the main form of health finance. This has particularly affected the rural poor, deterring them from accessing health care. Assistance for the poor to meet public-sector user fees is more beneficial and widespread in Vietnam than China. China is now criticizing the degree of commercialization of its health system and considers its health reforms "basically unsuccessful." Market reforms that stimulate growth in the economy are not appropriate to reform of social sectors such as health.

Costing of commune health station visits for provider payment reform in Vietnam.

Expanding effective coverage in Vietnam will require better use of available resources and placing higher priority on primary care. The way providers are currently paid does not give priority to primary care and does not reflect the costs of delivering services. This paper aims to estimate the unit costs of primary care visits at commune health stations (CHS) in selected areas in Vietnam. Seventy-six CHS from two provinces in northern Vietnam were studied. Costs were calculated from the perspective of the CHS using the top-down costing using the step-down cost accounting technique in order to estimate the full cost of delivering services. On average, the cost of one outpatient visit in mountainous, rural and urban CHSs was VND 49,521 (US$2.40), VND 41,375 (US$2.01) and VND 39,794 (US$1.93), respectively. Personnel costs accounted for the highest share of total costs followed by medicines. The share of operating costs was minimal. On average, CHSs recover 18.9% of their total cost for an outpatient visit from social insurance payments or fees that can be charged patients. The results provide valuable information for policy-makers as they revise the provider payment methods to better reflect the costs of services and give greater priority to primary care.

Assessment of systems for paying health care providers in Vietnam: implications for equity, efficiency and expanding effective health coverage.

Provider payment arrangements are currently a core concern for Vietnam's health sector and a key lever for expanding effective coverage and improving the efficiency and equity of the health system. This study describes how different provider payment systems are designed and implemented in practice across a sample of provinces and districts in Vietnam. Key informant interviews were conducted with over 100 health policy-makers, purchasers and providers using a structured interview guide. The results of the different payment methods were scored by respondents and assessed against a set of health system performance criteria. Overall, the public health insurance agency, Vietnam Social Security (VSS), is focused on managing expenditures through a complicated set of reimbursement policies and caps, but the incentives for providers are unclear and do not consistently support Vietnam's health system objectives. The results of this study are being used by the Ministry of Health and VSS to reform the provider payment systems to be more consistent with international definitions and good practices and to better support Vietnam's health system objectives.

A simple simulation model as a tool to assess alternative health care provider payment reform options in Vietnam.

Vietnam is currently considering a revision of its 2008 Health Insurance Law, including the regulation of provider payment methods. This study uses a simple spreadsheet-based, micro-simulation model to analyse the potential impacts of different provider payment reform scenarios on resource allocation across health care providers in three provinces in Vietnam, as well as on the total expenditure of the provincial branches of the public health insurance agency (Provincial Social Security [PSS]). The results show that currently more than 50% of PSS spending is concentrated at the provincial level with less than half at the district level. There is also a high degree of financial risk on district hospitals with the current fund-holding arrangement. Results of the simulation model show that several alternative scenarios for provider payment reform could improve the current payment system by reducing the high financial risk currently borne by district hospitals without dramatically shifting the current level and distribution of PSS expenditure. The results of the simulation analysis provided an empirical basis for health policy-makers in Vietnam to assess different provider payment reform options and make decisions about new models to support health system objectives.