Nguyen Thi Quyen lives in rural Viet Nam where she spends her time taking care of her grandchildren, cooking for her family and running the household. Quyen used to work as a farm labourer, but since her health deteriorated three years ago, this is no longer an option.

After months of feeling increasingly light headed and drained of energy, Quyen was eventually diagnosed with diabetes. Soon after, she visited a hospital in Hanoi where she had to pay almost 10 million Vietnamese Dong (around US$430) for a month’s worth of examinations, inpatient treatment and medication. This amounts to roughly double that of her husband’s monthly earnings combined with the couple’s income from a small household shop. “We are just farmers, we can’t afford this”, she emphasizes.

Fortunately, with support from Quyen’s two grown children who supplement their parent’s income with their service job salaries, they were able to cover the bill. However, maintaining treatment for Quyen’s chronic illness at such a high monthly cost would be impossible.

Out-of-pocket healthcare spending too often pushes families into poverty and undermines the right to access essential treatment. To protect vulnerable households from the financial burden of ill health, the International Labour Organization (ILO) is working to strengthen social health protection systems around the world to ensure that every person is able to access the health services they need, without financial hardship.

In Viet Nam, the social health protection landscape has advanced considerably over the last three decades alongside sweeping political and economic restructuring and rapid economic development. To address rising levels of out of pocket health spending that accompanied the introduction of user fees, the Government established a Social Health Insurance (SHI) scheme in 1992, which is now the primary vehicle for public health care financing in Viet Nam.

Implemented under the leadership of the Ministry of Health (MoH) and administered by Viet Nam Social Security (VSS), the scheme was originally developed as a pilot. Following successive reforms of the landmark National Health Insurance law, which came into effect in 2009, SHI is now compulsory and covers 90 per cent of the population. The scheme’s success is largely due to the allocation of substantial Government funding, which ensures full subsidies for men and women over 80 and children under six, as well as ethnic minority households and those identified by the Ministry of Labour Invalids and Social Affairs (MoLISA) as poor. For other disadvantaged groups, such as the near poor and students, partial subsidies are available.

In Quyen’s case, she was not enrolled in SHI at the time of her diagnosis and had to pay out of pocket for three months’ worth of costly treatment. “Until I fell ill I didn’t realize I needed to have health insurance […] to be honest, I was too busy working so never thought about it”, the diabetes patient admits.

Fortunately, she was eventually connected with a local health advisor and has since enrolled herself and her family in the scheme. The diabetes patient now only has to pay 90,000 Vietnamese Dong (around US$3.90) when she goes for her monthly tests and 40,000 Vietnamese Dong (around US$1.70) for her medications. Enrollment for the whole family costs less than four million Dong (around US$173) a year. This significant saving makes the cost of enrollment viable for the family, who pool their resources to pay for the coverage costs.

Now that she is able to afford regular treatment and carefully follows her doctor’s dietary guidance, the grandmother’s health has vastly improved and her condition has stabilized. Although Quyen’s health will never be what it was and she is still unable to return to work, having the financial weight of her illness off her shoulders makes all the difference to her peace of mind. “Since we got the insurance, things have been so much easier”, she says. “We are very grateful to the authorities to have this insurance accessible all over the country, because otherwise [treatment] would be too expensive”, she stresses.

To enhance the equitability, efficiency and sustainability of SHI, the ILO is working alongside VSS, MoH and employers’ and workers’ organisations in Viet Nam through the Government of Luxembourg-funded project, Support to the Extension of Social Health Protection in South East Asia.

The regional project supports capacity building for key social health protection stakeholders and practitioners, promotes evidence based policy reforms and assists the development of strategies and activities to ensure people are aware of their rights. The goal is to promote equitable access to health care for all, in line with the guiding principles of the ILO Convention 102 on Social Security, Convention 130 on Sickness and Health Benefits and Convention 183 on Maternity Protection.

In Viet Nam, this objective is enshrined in the country’s pro poor Health Insurance Law, which has significantly advanced the country’s progress towards Universal Health Coverage. This is furthered by the Government’s strategic Health Sector Plan 2016-20, which outlines plans to increase public spending on health insurance, expand population coverage and facilitate strategic purchasing for primary health care.

With a strong legal framework in place and a high level of political commitment to Sustainable Development Goal targets on health, the middle-income country aims to reach a coverage rate of 90.7 per cent of the population this year and ensure 100 per cent coverage for vulnerable groups. A crucial next step for Viet Nam will be to guarantee effective coverage for those who fall between high-income and poor groups, otherwise known “missing middle” including the near poor, informal workers and self- paying households.

With technical support from ILO, the Government is working to ensure that patients like Quyen, who are not eligible for full subsidies or in formal employment, are not left behind. In light of the rapid progress of Viet Nam’s social health protection system over the last three decades, achieving this goal is within reach.