NATIONAL ECONOMICS UNIVERSITY HANOI INSTITUTE OF SOCIAL STUDIES THE HAGUE VIETNAM-NEITHERLANDS CENTER FOR DEVELOPMENT ECONOMICS AND PUBLIC POLICY The impact of non-profit health insurance on treatment seeking behavior: The case of vietnam (VHLSS 2006) A thesis presented by In partial Fulfillment of the Requirement for Obtaining the Degree of Master of Arts in Development Economics Supervisor: Prof HANOI DECLARATION I hereby certify that this thesis has used materials that has been accepted or with out copied of any other degrees or diplomas at any other academic institutions By learning and my knowledge, the thesis contains no sources and materials previously published or written by other persons, except the references listed Hanoi, June 2011 ACKNOWLEDGEMENT By completing the thesis, I would like to express my gratitude to people who gave me a great support and assistance to complete this thesis First of all, I would sincerely express to thanks my suppervisor, Prof Dr … Finally, I would sincerely express to thanks my family and specially from my wife who gave me an encouragement and a contritbution of finance during my study … ABSTRACT In Vietnam, there are some studies on health care services and it gives out some significant ruslts of influence on policy makers However, these studies still have some limitations due to data as well as information updates By using very rich date set from the Vietnam Household Living Standards Surveys 2006 (VHLSS 2006), the thesis has explicitly estimated the effect of health insurance on utilization of all types of health care services and providing detailed information on both of individual health and household status and the type of provider sought covering all provinces Beside, the thesis also estimated the impact of health insurance on health care utilization by the poor In addtion, by the stusdy period covered 12 months, the thesis is better capture seasonal effects as well as other time- related dimensions of health treatment behaviors within a year Findings of the thesis has been suggested that individuals are propensity to visiting or admission to health facilitaties, specially for public health facilitation and the insured is no effect on the frequency of outpatient visit to public providers Deeply, the result of thesis showed that the groups of health insurance/free health card for the poor and children under YOs is commune clinics and the group of compulsory health insurance mainly visited public polyclinics, district hospital or higher level of public health facilities TABLE OF CONTENTS DECLARATION ACKNOWLEDGEMENT ABSTRACT LIST OF ABBREVIATIONS .7 LIST OF TABLES LIST OF FIGURES CHAPTER I 10 Introduction: 10 Research questions 13 Objectives and scope of the study: 13 Data and Methodology: 14 Structure of the thesis 15 CHAPTER II: LITERATURE REVIEW 16 Literature review in general 16 Studies of utilization on healthcare in Vietnam .18 CHAPTER III: HEALTH CARE SYSTEM AND HEALTH UTILIZATION IN VIETNAM .21 Introduction of healthcare system in Vietnam .21 1.1 Public health care system 21 1.2 Private health care system 22 Health care utilization 24 2.1 No treatment and self-medication 24 2.2 Inpatient services 25 2.3 Outpatient services utilization 26 2.4 The schemes of health insurance in Vietnam 27 2.5 Heath care for the poor 28 CHAPTER IV: METHODOLOGY AND EMPIRICAL RESULT 30 Methodology and data 30 1.1 Methodology 30 1.1.1 Logit model 30 1.1.2 Count regression models 31 1.2 Model selection .33 1.3 Data 33 Variable description .34 Descriptive analysis .72 Econometric results .76 CHAPTER V: FINDINGS AND POLICY IMPLICATIONS 83 CHAPTER VI: CONCLUSION 84 REFERENCES 87 LIST OF ABBREVIATIONS CHI : Compulsory Health Insurance CHS : Commune Health Station DHO : District Health Office DPC : District People’s Committee GSO : General Statistics Office HCFP : Health Care Fund for the Poor JHUES : Healthcare Utilization and Expenditure Survey JHUES : Jordan Healthcare Utilization and Expenditure Survey MOH : Ministry of Heath OOP : out-of-pocket PHD : Provincial Health Department PPC : Provincial People’s Committee VHI : Voluntary Health Insurance VHLSS : Vietnam Household Living Standards Surveys LIST OF TABLES Table 1: Health insurance coverage by expenditure quintiles 35 Table 2: The use of outpatient care across providers by the insurance status and the type of insurance .36 Table 3: Decomposition of utilization by health facilities, inpatients 37 Table 4: Number of outpatient contacts per person 38 Table 5: Number of inpatient contacts per person 39 Table 6: Probability of health facilities contacts in general Odd ratio 40 Table 7: The results for contacts and frequency of outpatient contacts at the commune health centres .48 Table 8: Probability of out-patient contacts and Frequencies of contacts: public polyclinics/hospitals 56 Table 9: Probability of out-patient contacts and Frequency of contacts: Private clinics/hospitals 61 Table 10: Probability of in-patient contacts and frequency of contacts: public polyclinics/hospitals .66 LIST OF FIGURES Firgue 1: Distribution of inpaatient contacts across healthfacilities by rural and urban population 25 Figure 2: Health insurance coverage by expenditure quintiles 72 Figure3: Percentage of health contacts of different groups of health insurances .73 10 CHAPTER I Introduction: In recent years, Vietnam has been encouraging and strengthening the explicit role of insurance in health system To achieve the “Millennium Development Goals”, the social care services need to be extended and improved Health insurance is a kind of socialized project which helps share the financial burden of illness between the Government and the population The insurance coverage was introduced in 1992 in Vietnam, the scheme was initially compulsory, then later extended to include a voluntary scheme and a free health-card scheme for the poor was also initiated afterwards The Compulsory Health Insurance (CHI) scheme includes current and retired civil servants and the employees of state enterprises as well as those in large private enterprises with more than ten employees, employees of foreign owned enterprises and organization, the scheme covers the cost of inpatient and outpatient treatment at hospitals, subject to some ceilings The Voluntary Health Insurance (VHI) scheme is in principle open to all those not eligible for coverage under the CHI scheme, including the self-employed, employees of small enterprises, family members of the insured and government employees at or below the district level Currently, the VHI scheme is open to all community groups provided that minimum community thresholds are met, including 20 percent of households in a commune or ward and 30 percent of students in a given school (Nguyen & Akal, 2003) Although, Giang (2006) gave an evidence that many provinces of Vietnam have been reluctant to encourage voluntary insurance scheme, partly due to high cost resulting from adverse selection and Jowett (2004) reviewed that Vietnamese Governmentorganized voluntary schemes may also be crowded by informal risk-sharing networks Besides, ever since 2002 there has been a health insurance scheme implemented for the poor in Vietnam which covers residents of communes 67 insurance coverage, this fact is caused by a significant decrease in health insurance/free health card for the poor is not sufficiently substituted by other types of health insurance Incidences of compulsory health insurance and vulnerary health insurance increase with increase in welfare (expenditure) with a considerable increase by the richest Figure3: Percentage of health contacts of different groups of health insurances Probabilities of having health care contacts are given in Figure Again, free health card for children is only applicable for children under years old and health care utilization of this group is quite different from other groups in the population and we focus on other groups of health insurance Having health insurance seems to increase probabilities of contact with health facilities in general Having heath insurance appear to have a stronger 68 positive association with inpatient admission Explain the differences in terms of % of the insured and uninsured who were admitted to hospitalsIndividuals with compulsory health insurance coverage are more likely other enrollees to seek care, enrollees especially inpatient care The CHI are twice more likely to have a hospital admission than the uninsured Table provides utilization of health care services across the providers The uninsured are 50% more likely to contact the private providers than the insured e By contrast, the insured are more likely to contact public health facilities where insurance benefits can be accessed The group with compulsory health insurance tends to use public polyclinics/district hospital and higher level of public health facilities Behaviors of the group of vulnerary health insurance is somewhat the same as the group with compulsory health insurance in term of utilize public health facilities Private clinics/hospital is still a relatively frequent choice of the groups of free health card for children and vulnerary health insurance; this raises a question of conveniences of these types of health insurances in term of getting health treatments In Table 3, total times of inpatient contacts are decomposed by different types of health facilities Due to different in functionalities of health facilities, the above table may not have much meaning but there are some features should be noted - There are unneglectiable proportions of the first three groups have admission to commune clinics This result raise a question for investment in this level of public health facilities as this type of health facilities is normally regarded as the place for initial health care only 69 Higher ratio of inpatient admissions for groups of health insurance insurance/free health card for the poor and children under years old in village/commune clinics and general clinics/district hospital In the Table 4, average numbers of outpatient contacts by groups of different health insurances schemes over different types of health facilities are presented All insured groups have higher frequencies of outpatient contacts than that of the group without health insurance Beside the group of free health card for children under years old, the group of compulsory health insurance has the highest frequencies of the outpatient contacts The frequency of the group is about 40 per cent higher than that of the group without health insurance As seen in table 2, the most frequent type of outpatient contact for group of free health card for children and the group of heath insurance/free health card for the poor is the commune clinics These groups also relatively less frequently contact to provincial/central hospitals for outpatient treatment, even less than that of the group without health insurance Among four types of health facilities, the group of compulsory health insurance has most frequencies contact to the public polyclinics, district or provincial/central hospital Their frequencies of outpatient consultations in these types of health facilities dominate that of other groups The group of vulnerary health insurance also has low frequency contact in general but has relatively more frequent contact to the private clinics/hospital to those of other types of health insured groups This may indicate that the health insurance status may have little impacts on the behavior of the group The same as Table 4, Table is for average numbers of inpatient contacts by groups of health insurances over different types of health facilities Due to 70 their functionalities, public polyclinics and hospitals are main place of inpatient admission Trends in Table are accelerated in Table that all health insured groups have significantly higher in term of average numbers of inpatient admission that the group of compulsory health insurance have about 2.5 times of inpatient admission to the group without health insurance The group of heath insurance/free health card for the poor also has about a factor of higher in frequencies of inpatient admission to that of the group without health insurance, this trend in conjunction with the different in functionalities of health facilities The former group has significant higher number of inpatient admission to that of the group without health insurance or group of vulnerary health insurance This fact is different from that of outpatient contact For outpatient contacts, main health facilities receiving outpatient contacts of the group of heath insurance/free health card for the poor is the commune clinics and the group has the same or even lower number of outpatient contact to that of the groups without health insurance or vulnerary health insurance Econometric results Table presents the econometric results for the use of health care services About demographic characteristics, coefficients of age, being male are significant at 1% level The odds ratio of age is smaller than one implying that increase in age would result in decrease both out-patient and in-patient contacts, however, the impacts are marginal Being male also reduces probability of out-patient contact by a factor of 23% (100%-77%) and 17% (100%-83%) for in-patient contacts If we study urban and rural areas separately, urban men have lower probability of contact Indeed, men tend to 71 have lower level of utilization in general as also indicated by result of Trevedi (2002) but the smaller disparity in the rural areas may imply that rural female may face some inequality in term of utilizing health services Household level factors which have significant association with probability of contacts are household size and education of household head education Directions of impacts of these variables are as expected Interestingly, living in urban areas would reduce probability of having contacts- both out-patient and in-patient This result is somewhat counterintuitive as urban people often have higher awareness of health problem and they are expected to have higher demand of health services However, higher awareness may increase their utilization of preventive health service and it in turn results in better health of the urban population Turning to impacts of types of health insurance, all coefficients of the types of health insurance are significant at 1% level The significance of the coefficients is also observed when we decompose the whole population into urban and rural areas Only coefficient of free health card for children under 6YOs in the urban area is significant at 10% level, all other coefficients are significant at 1% in both areas These results indicate a strong positive association between having health insurances of any kinds and probability of contacts to health facilities, both out-patient and in-patient For out-patient treatment, the impact is most pronounced for the free heath card for the children under YOs that likelihood of having outpatient consultation is 2.39 times higher for a child having free health card The second largest effect is the health insurance/free health card for the poor These facts demonstrate large impacts of the free health insurance scheme have offered disadvantage groups with great opportunities of approaching formal health services The follower in term of impact is compulsory health 72 insurance, and the smallest impact is vulnerary health insurance scheme Indeed, the modest impact of the vulnerary health insurance is due to its unclear ‘comparing’ group All students are eligible for the vulnerary health insurance and a significant proportion of the objective has participated in this health insurance scheme This group also account for majority of people under the vulnerary health insurance Given high school enrolment rate in Viet Nam, a large number of children in Viet Nam have involved in this scheme, and when we control for other factors, involvement in this health insurance scheme could have the modest impact Impacts of all types of health insurances are higher in the urban areas, especially for the two free health insurance schemes This result indicates that the poor group in rural areas has faced harder disadvantages in term of getting health services to their counterparts in the rural areas where the informal insurance network has been somewhat more effective The order in term of impact magnitudes of the health insurance schemes changes when we look at the result for in-patient treatment For this type of treatment, the compulsory scheme has the largest impact, free health insurance for children under 6YOs and the free health card/health insurance for the poor have the same impacts on probability of having inpatient treatment With above arguments, the modest impact of the vulnerary health insurance is not surprising One again, the larger impacts of all types of heath insurance are observed in the urban areas Interpretation of econometric result: Indicated in the Table 8, the odd ratio of four types of health insurance are more than and statistically significant in logit model, indicating the positive effect of health insurance on the probability of having outpatient contact at 73 public health facilities The positive influence of insurance on the use of outpatient care is more pronounced for group of compulsory health insurance than groups of other three heath insurance schemes Compared with the group without health insurance, group with compulsory heath insurance, voluntary heath insurance, free health card for children under years old and health insurance/free heath card for the poor are more likely to use outpatient care at the public health facilities by 2.42, 2.16, 2.17 and 2.11 respectively Howerver, if we examine the impact of the heath insurance on the use of public health care servie for outpatient between urban and rural, the children of free health card for children under year olds and people of the health insurance/ free health card for the poor are accessing more outpatient contacts in the urban than people in the rural by 3.53 and 3.49 respectively Those show that the groups of free health card for children under year olds and the poor have been cared and accessed with public health care service in the urban Men are less likely to have outpatient visit to public health facilities but have higher frequency of visits than women The likelihood of having outpatient contacts to public health facilities decreases with age As for education effect, the odd ratio of technical/university is statistically significant, it is indicating the higher education will be high awareness to take care their health and the educated individuals are less likely to use outpatient care than those with no education, but when they so they are more likely to use it more frequently For the odd ratio of education including primary school and high school are not significant, indicating that these education have no influence on the probability of visit The coefficients of all education categories are not significant in truncated Poisson model, meaning that there is no education effect on frequency of use of outpatient treatment to public health facilities 74 For income effect are is statistically significant, indicating that the income has lower probability of having outpatient visit to public providers than the rich In truncated Poisson model, coefficient of income is 0.15 significant, suggesting that the more income the more spending in health services Interesting that residents of the central Vietnam are more likely to use outpatient care than their counterparts in the South and the North The odd ratio and coefficient of are significant Being married increases likelihood of having outpatient visit by factor of 1.45 but it has no influence on the frequency of visit The ethnic majority Kinh are more likely to use outpatient treatment and use more often than the ethnic minorities with significant at 1% and odd ratio is 0.72 Urban people has higher probability of visit than the rural population The likelihood of having outpatient visit to public health facilities increases with household size Interpretation of econometric result: As the table showed, the odd ratio of four types of health insurance are less than and significant in logit model, indicating the negative effect of health insurance on probability of utilization These results suggest that insurance diverts the pattern of utilization from private to public health facilities where the insured can be accessed Beside, The effect is more pronounced for the free health card for children under years olds, in particular, having free health card for children under years old decreases the likelihood of having outpatient contact to private providers at high 0.77 while having health insurance/free health card for the poor decreases the likelihood of having outpatient contact by 0.66 The estimation of zero truncated negative binomial model represents that only the coefficient of compulsory and vulnerary health insurance are statistically significant and negative The coefficient of free health card for 75 children under years old and heath insurance/free health card for the poor are not significant Health insurance decreases the frequency of use of those with compulsory and vulnerary health insurance by 0.20 and 0.15 respectively Men have lower probability of use but higher frequency of use than women To education explanation, the odd ratio of the probability of education is less than and good significant, indicating that outpatient contact to private health care providers less than public providers In contrast, the coefficient of all educated in truncated negative model is negative and significant, except the coefficient of university educated, showing that the lower frequency of use than the reference group As for income effect, the higher the income, the higher the probability of having contact and high frequency of utilization and coefficient has significant too, this is in contract with Giang (2006), Giang concluded that the higher income, the lower of probability of having contact to private providers Interesting of regional effects, the differenct trend in two groups, the North and Central have lower likelihood of having outpatient contact less than while higher probability of outpatient contact than people in the South and all group has statatically significant However, the coefficients of regional categories are not significant in truncated Poisson model, meaning that there is no regional effect on frequency of use of outpatient service to private health care providers For in marriage, we could not see the significant in both of probability and frequency Ethnic minorities have less likelihood of having contact and less frequency of contact than ethnic minorities (reference group) Urban citizens have lower probability of having contact than rural ones ((reference group), 76 however, living in urban or rural areas has no influence on the frequency of contact Interpretation of econometric result: By estimated coefficients of four types of health insurance are positive and significant inpatient both count regression (zero-truncated poisson) and logit model, indicating that health insurance increases both probability of having hospital inpatient admission and frequency of admission The effect is largest for the group of compulsory health insurance in both models The effect is lowest for voluntary health insurance scheme in term of probability of admission and lowest for the free health card for children under YOs in term of frequency of admission In particular, having insurance increase a hospital admission by 2.17 for those with compulsory health insurance, by a factor of 1.65 for those covered by the health insurance/free health card for the poor scheme and 1.57 for the vulnerary health insured Interesting that the people are living in the urban tend to untilize their treatment in hospitals larger than people’s utilization in rural for four types of health insurance Men have lower probability of having admission than women in both of urban and rural Regarding to education effect, head household education has negative impacts on probability of admission to commune clinics when they have higher grade to public hospitals, this point is good explanation that the awareness of selection to commune clinics for simple treatments Income effects are not only significants in the contact decision (probability of admission) but also significants in the frequency decision stage 77 CHAPTER V FINDINGS AND POLICY IMPLICATIONS The thesis has used the dataset of Vietnam Households and Living Standards Survey (VHLSS 2006) to estimate the impact of Vietnam’s three health insurance schemes on the pattern of health seeking utilization in a 12month period preceding the household interview Firstly, the thesis examined that all three health insurance schemes have positive impacts on probabilities of health facilities contact, especially for inpatient admission and influences on treatment seeking behaviors toward public health facilitation Secondly, the impacts of insured status of group of volentary health insurance are moderate and this group is closest to behaviors of the group without health insurance among four types of health insurance schemes Thirdly, the main place for groups of health insurance/free health card for the poor and children under YOs in term of outpatient visits is commune clinics The group of compulsory health insurance mainly has outpatient contacts at public polyclinics, district hospital or higher level of public health facilities Fourthly, the impact of all types of health insurances are higher in the urban areas, especially for the two free health insurance schemes Finally, for outpatient treatment, the most impacts is the free heath card for the children under YOs and the health insurance/free health card for the poor is the second largest In summary, because the positive impact on probabilities of health insurance to seeking treatment, the policies should focus on increase coverage of health insurance As group of health insurance/free heath cards for the poor and for the children under YOs mainly have outpatient visits at commune clinics, services of this type of health facilities should be impro 78 CHAPTER VI: CONCLUSION The primary purpose of this study was to assess empirically the influence of Vietnam’s various health insuarnc schemes on pattern of health seeking utilization Based on thesis empirical results, the thesis pointed out some findings and suggestion to researchers and policy makers First results gave out to health care services, it confirmed that individuals are propensity to visiting or admission to health facilitaties, specially for public health facilitation Giang studied on the health insurance and pattern of health care utilization: The case of Vietnam By using the Vietnam National Health Survey data (VNHS 2001/2002), she also showed that the public providers, the insured have higher probability of use and higher frequency of use of inpatient care than the uninsured Beside, there has an evidence of thesis that result of voluntary health insurance is same with Giang’s study and it concluded that the insured is no effect on the frequency of outpatient visit to public providers In addition, in term of treatment seeking to outpatient visits, the result of thesis showed that the groups of health insurance/free health card for the poor and children under YOs is commune clinics and the group of compulsory health insurance mainly visited public polyclinics, district hospital or higher level of public health facilities Tridevi’stdudy also pointed that insured individuals, when ill, tend to seek treatment at commune health centers and governmental hospitals rather than private health facilities and pharmacies Conclusion, by taking the advantage of VHLSS 2006 dataset and rich references, thesis has included and filled in the knowledge gap left by the afore-mentioned studies, some findings have given out The health issurance for the poor has catched up with meaningfull results and the results of thesis confirmed that have a positive impact of free health care for the poor on treatment seeking Although, thesis still has a chance to next studies when it has not cove 79 REFERENCES ¬ - A Sepehri, W Simpsona and S Sarmab (2006) “ The influence of health insurance on hospital admission and length of stay: The case of Vietnam” Department of Economics, University of Manitoba, Winnipeg, Man., Canada, R3T 5V5, Social Science & Medicine 63: 1757–1770 (2006) - A.Sepehri, Chernomas, R., & Akram-Lodhi, H A (2005) Penalizing patients and rewarding health care providers: User charges and health care utilization in Vietnam Health Policy and Planning, 20(2), 90–99 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States AID (USAID) 2009 Assessing Provincial Health Systems in Vietnam: Lessons from two provinces - Ministry of Health (MOH) 2008 Joint Annual Health Review 2008 (JAHR): Health Financing in Vietnam ... questions * Central question: What is the impact of health insurance on the treatmentseeking behavior * Sub-questions: + How does health insurance (and its separate components) affect the usage of. .. afore-mentioned studies, the thesis examines the impact of Vietnamese health insurance on treatment seeking behaviors of the insured, with a further focus on those of the insured under the health insurance. .. information on health insurance and a discriptive analysis of data (ii) It presents empirical analysis of the impact of health insurance schemes, with focus on the health insurance for the poor, on