Universal Health Insurance Coverage in Vietnam: A Stakeholder Analysis From Policy Proposal (1989) to Implementation (2014).

CONTEXT: In 1989, health insurance (HI) was introduced in Vietnam and began to be implemented in 1992. There was limited progress until the 2014 Law on HI that was revised with the aim of universal health insurance coverage (UHIC) by 2020. This article explores stakeholder roles and positions from the initial introduction of HI to the implementation of the Master Plan accelerating UHIC. OBJECTIVE: To better understand the influence of stakeholders in accelerating UHIC to achieve equity in health care. DESIGN: Using a qualitative study design, we conducted content analysis of HI-related documents and interviewed social security and health system key informants, government representatives, and community stakeholders to determine their positions and influence on UHIC. RESULTS: Our findings demonstrate different levels of support of stakeholders that influence in the HI formulation and implementation, from opposition when HI was first introduced in 1989 to collaboration of stakeholders from 2013 when the Master Plan for UHIC was implemented. Despite an initial failure to secure the support of the Parliament for a Law on HI, a subsequent series of alternative legislative strategies brought limited increases in HI coverage. With government financial subsidization, the involvement of multiple stakeholders, political commitment, and flexible working mechanisms among stakeholders have remained important, with an increasing recognition that HI is not only a technical aspect of the health system but also a broader socioeconomic and governance issue. The different levels of power and influence among stakeholders, together with their commercial and political interests and their different perceptions of HI, have influenced stakeholders' support or opposition to HI policies. CONCLUSIONS: Despite high-level policy support, stakeholders' positions may vary, depending on their perceptions of the policy implications. A shift in government stakeholder positions, especially at the provincial level, has been necessary to accelerate UHIC progress and build institutional capacity.