Strengthening Health Systems by Integrating Financing Programs

Integration. It comes up a lot when we talk about strengthening health systems. Often, we associate integration with service delivery: supporting healthcare providers to combine related services—family planning with post-partum care or HIV testing, for example—to make services more patient-centered and efficient.

But integration also inherently involves all parts of the health system, and how it engages with other sectors, like education or employment, that contribute to better health outcomes

Increasingly, maturing health systems must focus on integrating fragmented health financing programs, including those supported by donors, into country-led and financed programs designed to accelerate universal health coverage. The steps towards that, we know, are incremental and often years or decades long. A country must mobilize sufficient resources for health and align functions across its health system to support this transition. In the example above, integrated provision of family planning with post-partum care or HIV testing may be limited, for instance, unless numerous criteria are met, such as:

• National policies are in effect, permitting qualified providers to perform the full range of services
• Funding to pay for services and commodities is sufficient and payments are timely
• Supply chains consistently provide medicines and supplies that healthcare providers need to deliver quality services.

For decades, Abt has led global and bilateral health projects funded by USAID and other donors that support governments, communities and local actors to integrate standalone, donor-financed programs into locally-led programs. One pathway to achieve this is by expanding coverage of people and services in government-led health financing programs, designed to be equitable and responsive to citizens. Many of these pursuits support domestic resource mobilization and promote local ownership and accountability. Their results depend on a host of financial and non-financial factors—politics, pandemics, and people, to name a few—and progress is usually piecemeal.

Learning From Vietnam’s Progress Toward Sustainable Financing

Integration efforts can start small, laying groundwork for bigger steps over time. Governments in Nigeria and Tanzania, for example, with USAID support from the Abt-led Sustaining Health Outcomes through the Private Sector (SHOPS) Plus project are expanding access to health commodities by partnering with private health providers to distribute government-managed commodities for family planning, HIV, tuberculosis, or other essential health care to clients. These early partnerships integrate private providers with publicly-financed commodity procurement. They set the stage for more strategic purchasing arrangements in the future, with more providers.

In Vietnam, the Abt-led Local Health System Sustainability (LHSS) project and earlier USAID programs, including Sustainable Financing for HIV/AIDS (SFA), and Health Finance and Governance have supported country counterparts to undertake more expansive integration activities as the country leads its HIV response. Starting in 2014, the Vietnam Social Security (VSS) program, with USAID support, began to pay for HIV treatment and antiretroviral drugs in the country’s social health insurance (SHI) scheme, which had become mandatory for citizens.

Integrating HIV services into the SHI scheme required making coordinated changes to policies, financing, and operations of the health system. The Agency worked with government counterparts—the Ministry of Health, the Vietnam Authority for AIDS Control, the Office of Government, and the Ministry of Finance—to, for example, modify policies to cover people living with HIV in SHI and promote sustainable premium subsidies at national and provincial levels. It integrated formerly stand-alone HIV clinics into the public health system, and these clinics became part of the SHI scheme’s network. Other efforts:

• Adapted procurement, payment, and dispensing practices for antiretroviral drugs—creating mechanisms to pay for them in advance and enable multi-month dispensing
• Expanded enrollment of people living with HIV in SHI, and
• Improved the SHI scheme’s capacity to monitor its performance. 

A SFA brief reported notable progress in recent years toward achieving sustainable financing for Vietnam’s HIV response. As of 2019, over 90 percent of people living with HIV in Vietnam were enrolled and using services as SHI members. With funding from the central and provincial government budgets and private contributions to the SHI scheme, Vietnam increased domestic financing for HIV from 36 percent in 2016 to an estimated 53% in 2020. Additionally, local governments committed $2.4 million to help fund SHI premiums and antiretroviral drug copayments for patients in need.

Building on these accomplishments, the National Tuberculosis Program, with support from the LHSS project is now working to integrate standalone financing for tuberculosis services into the SHI scheme by 2025. Vietnam reached an important milestone in this effort in December 2021 when the insurance scheme completed its first-ever purchase of first-line tuberculosis medicines.