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INSTITUTE OF SOCIAL STUDIES NATIONAL UNIVERSITY OF HCM UNIVERSITY OF ECONOMICS THE HAGUE THE NETHERLANDS VIETNAM VIETNAM-THE NETHERLANDS PROJECT FOR M.A ON DEVELOPMENT ECONOMICS DETERMINANTS OF COMMUNE HEALTH CENTER (CHC) USAGE IN LONG AN PROVINCE A thesis submitted in partial fulfillment of the requirements for the degree of MASTER OF ARTS IN DEVELOPMENT ECONOMICS BY HUYNH DANG BICH VY Academic Supervisor: DR NGUYEN VAN PHUC BQ GIAO DVC VA 8AO -;-; ; TRVdNG E>H KINH TE TP.I·ic;~ THUVIEN j; ( ~c HO CHI MINH CITY, AUGUST 2007 }f- ACKNOWLEDGEMENTS Firstly, I would like to express my deep gratitude to all professors and teaching staff in Vietnam-Netherlands programme on Development Economics for their lectures, instructions and the best teaching conditions during my study period from 2004 to present The author would like to give a special thanks to Dr Nguyen Van Phuc, the author's supervisor, for his scientific instructions and his valuable comments on this study In addition, the author owes special gratitude to Mr Truong Dang Thuy and Mr Luong Vinh Quoc Duy for their enthusiastic help and criticism This research would have been completed difficultly were it not for the kind and warm welcome of individuals from over 100 households in Can Duoc and Can Giuoc district during the survey Thanks are due to many friends that I could not fully list here for their strong supports of the survey and their invaluable encouragements and nice wishes And last but not least, all my love is devoted to my parents and brother who always help and encourage me during my learning and doing this study Again, the author is really grateful to all people for their help Any errors in this research are my responsibility alone CERTIFICATION I certify that the substance of this thesis has not already been submitted for any degree and is not being current submitted for any other degree I certify that to the best of my knowledge any help received in preparing this thesis, and all sources used, have been acknowledged in this thesis HUYNH DANG BICH VY ABSTRACT Many studies of the utilization of health care system have been done in different countries over the world In most developing countries like Vietnam, people mainly live in rural area; hence rural health care sector plays an important role One of health care providers is commune health center that provides basic health care Therefore, this study's purpose is to investigate determinants of commune health center usage; specifically it aims at examining the effects of individual income Binary logit model was used to find out the answers for the questions of what determinants of using health care services from CHC are and whether with higher income people tend to use more CHC services or not The author has applied the method of multi-staged sampling to collect data in Can Duoc and Can Giuoc districts, Long An province The object of this research is individuals aged 15 and older that are the adult population and have enough civil capacity to make their own decisions The results show that income is a relatively important determinant of CHC -cnoice -in.-can Duoc and-Catlviuo-c-districts:-Furthermore;-other-factors-such-associo-demography, severity of illness and characteristics of the CHC provider are significantly important These results are useful to give several recommendations to improve the quality of CHC services in order to satisfy particular income group TABLE OF CONTENTS CHAPTER 1: INTRODUCTION I 1.1.PROBLEM STATEMENT 1.2 RESEARCH OBJECTIVES 1.3 RESEARCH QUESTIONS 1.4 METHODOLOGY 1.5 HYPOTHESIS 1.6 RESEARCH SCOPE 1.7 THESIS STRUCTURE CHAPTER 2: LITERATURE REVIEW 2.1.DEFINITIONS 2.2 THEORY OF CONSUMER BEHAVIOR 2.3 THEORIES OF FACTORS AFFECTING HEALTH CARE DEMAND 2.4.MODEL 2.5.SUGGESTED RESEARCH VARIABLES 12 CHAPTER 3: AN OVERVIEW OF HEALTH CARE PROVIDER IN VIETNAM 19 3.1.BACKGROUND ON VIETNAMESE HEALTH CARE SYSTEM 19 3.1.1.Achievements 19 3.12 Shortcomings 21 3.2.COMMUNE HEALTH CENTER 22 CHAPTER 4: RESEARCH METHODOLOGY, ESTIMATION AND RESULS •••••.••••• 27 4.l.DATA COLLECTION METHODS 27 4.1.1.Sampling technique 27 4.1.2.Sample size 28 4.2.DATA 29 4.2.1.The main contents of the questionnaire 29 4.2.2 Dependent variable 30 4.2.3 IndeJJendent variables ._._._., ._~· _ 30 4.2 3.1 Socio-demographic characteristics ~.-:_=30 4.2.3.2 Individual and household income 32 4.2.3.3 The characteristics of the perceived illness 33 4.2.3.4 Attributes ofhealth care provider and the non-monetary cost 35 4.3.STRENGTH AND WEAKNESS OF COLLECTED DATA 41 4.4.REGRESSION RESULTS 42 CHAPTER 5: CONCLUSIONS AND RECOMMENDATIONS 50 5.l.CONCLUSIONS 50 5.2.RECOMMENDATIONS 51 REFERENCES: 52 APPENDICES: 56 APPENDIX 1: 56 APPENDIX 2: 60 APPENDIX 3: 64 - LIST OF TABLES TABLE 2.1: The expected signs ofdeterminants ofhealth care usage 17 TABLE 3.1: Infrastructure in three levels ofpublic health care system in 2006 in Vietnam 23 TABLE 3.2: The proportion of out-patient health service contacts of each level of income people at each type ofprovide 25 TABLE 4.0: Appropriate sample size 29 TABLE 4.1: The number and the percentage ofobservations for each type ofproviders 30 TABLE 4.2: Basic socio-demographic characteristics ofthe respondents 31 TABLE 4.3: Average income of respondent and average income per capita per month 32 TABLE 4.4: Mean individual income offive groups 33 TABLE 4.5 Choice ofprovider by income quintile 33 TABLE 4.6: Results ofthe survey CHC andnon-CHC respondents in terms oflDAY 34 TABLE 4.7: Results of the survey CHC and non-CHC respondents in terms ofRDAY 35 TABLE 4.8: Availability ofdrugs in the CHC 36 TABLE 4.9: Total expenditure for consultation and drugs 37 TABLE 4.10: The number of observations that people have used specific health care provider 38 TABLE 4.11: Data definitions 39 TABLE 4.12: Logit regression results 43 TABLE 4.13: The changes in the probability of using CHC provider -ageCJrlvofductin;hs=.~,• if having change in ••- ,••,-.-.-.-.-.•••••••• 44 TABLE 4.14: The changes in the probability ofCHC usage of male and female if age increases by one year, given other factors 45 TABLE 4.15: The changes in the probability ofCHC usage of male and female if the ratio ofdistance increase by one unit, given other factors 45 TABLE 4.16: The changes in the probability ofCHC usage ofmale and female if the user fee ofCHC is cheaper, given other factors 46 TABLE 4.17: The changes in the probability of CHC usage if changing severity of illness, given other factors 47 TABLE 4.18: The changes in the probability ofCHC usage as having change in income, given other factors 48 TABLE 4.19: Descriptive statistics of variables ,.56 TABLE 4.20: Correlations among independent variables 58 LIST OF FIGURES FIGURE 2.1: The behavioral model FIGURE 2.2: Choice ofa health care provider FIGURE 3.1: Total expenditure on health (THE) as% ofGDP 20 FIGURE 3.2: Total expenditure on health in million VND for 1996-2005 20 FIGURE 3.3: Inequality in the use ofhealth services 22 FIGURE 3.4: Proportion ofout-patient health care service visits by type ofprovider 24 FIGURE 3.5: Main reasons for choosing outpatient facility used 25 ACRONYMS CHC Commune Health Center GSO General Statistics Office LHS Left Hand Side MOH Ministry of Health MTEF Medium-Term Expenditure Framework RHS Right Hand Side SD Standard Deviation UNDP United Nations Development Programme UNICEF United Nations Children's Fund VDR Vietnam Development Report VLSS Vietnam Living Standards Survey VNHS Vietnam National Health Survey WB World Bank WHO World Health Organization CHAPTER I INTRODUCTION The introduction chapter consists of six parts The problem statement is presented in section 1.1 The following parts such as research objectives, research questions, methodology, and hypothesis are in section 1.2, 1.3, 1.4, and 1.5, respectively Research scope as well as several reasons for choosing Can Duoc and Can Giuoc districts as research places is revealed in section 1.6 The last section is thesis structure 1.1 Problem statement Health sector is one of main concerns of many countries in the world as well as in VietNam During the period since Doi Moi (Renovation) to the present, the government has invested resources and implemented many reforms in this sector The rural heath care system is strengthened as the government's priority because around 72.9% of 84,108 million Vietnamese people live in rural area (UNDP, 2006) It is organized at four levels: national, province, district, and commune (Tran Tuan, 2004) Together with private providers and self-medication, almost all communes have a commune health centre (CHC) According to Nanak Kakwani and Hyun H:-Son -(2U01i)~CH seems to play an-impoftantrole_in - providing basic health services to the poor in Viet Nam In particular, CHC is responsible for primary curative care service in a community, especially in rural area However, the role of the commune health center has declined One of the reasons of this is that a large part of primary curative care service is shared with other providers Another reason is that people tend to seek higher quality health care services because of an improvement of living standard The CHC system only retains its dominant role in preventive care (Tran Tuan, 2004) This study investigates determinants of CHC usage and finds out whether CHC is normal or inferior goods, especially in two districts of Long An province, namely, Can Duoc and Can Giuoc This kind of information would help decision makers develop appropriate plan for CHCs Since, suppliers could provide appropriate health care services and contribute to conduct an accessible and affordable health service to consumers Therefore, this research concentrates on investigating determinants of commune health center usage in Can Duoc and Can Giuoc districts, Long An provmce 1.2 Research objectives General objective is to examine the factors affecting commune health center usage in Can Duoc and Can Giuoc districts, Long An province Specific objectives are to measure the effect of individual income on CHC usage and to propose appreciate plan for CHCs to satisfy the demand for health care services of people living in the two research places 1.3 Research questions A general question is: what are determinants of using health care services fromCHC? And the other is: Are individuals with higher income more likely to use health care service from CHC? 1.4 Methodology Descriptive methods are used to review the background conditions of Vietnamese health care system, especially health care information from survey in Long An province Moreover, an econometric model is formulated to examine the relative effects of various determinants of CHC usage In particular, the author applied binary logit model to find out answers for the above research questions 1.5 Hypothesis The study hypothesis is that there is a negative relationship between individual income and CHC usage in rural area The higher income is, the higher demand for health care facilities with high quality such as public or private hospitals, private clinics is As a result, demand for CHC usage will reduce DUMTK -2.156593 0.895397 -2.408533 0.0160 DIST -0.241918 0.101927 -2.373431 0.0176 IDAY -0.130222 0.073340 -1.775585 0.0758 RDAY -0.242408 0.119049 -2.036203 0.0417 INSURANCE 2.655181 0.687793 3.860438 0.0001 DRUG 0.882526 0.647343 1.363305 0.1728 MARRIED -2.317710 0.847004 -2.736362 0.0062 RPRICE 4.006398 1.194293 3.354618 0.0008 RWTIME -0.297194 0.095241 -3.120450 0.0018 RELIGION -1.193 365 1.000772 -1.192444 0.2331 INCl 0.992605 0.936270 1.060170 0.2891 INC2 -1.202333 0.973284 -1.235337 0.2167 INC4 -1.545579 0.844319 -1.830564 0.0672 AGEGEN 0.111306 0.048761 2.282678 0.0224 GENDER -2.450744 2.121698 -1.155086 0.2481 DISTGEN 0.183040 0.141454 1.293992 0.1957 RPRICEGEN -1.412581 1.496820 -0.943721 0.3453 Mean dependent var 0.331169 S.D dependent var _S.E._Qf_regressio_n_ _ _ _j)_.)25_795 _ Akaike info criterion 0.472169 0.851188 - - - - - - - - - - - Sum squared resid 14.22308 Schwarz criterion 1.245598 Log likelihood -45.54149 Hannan-Quinn criter 1.011396 Restr log likelihood -97.79051 Avg log likelihood -0.295724 LR statistic (19 dt) 104.4980 McFadden R-squared 0.534295 Probability(LR stat) 8.15E-14 Obs with Dep=O 103 Total obs 154 Obs with Dep=l 51 Following Hamilton test, the author compared the restricted and the unrestricted versions of the model 62 Basing on the likelihood ratio LR/LUR, the author made use of a chi-squared statistic: =-2*(-45.54149-(-45.18569)) = 0.7116 x;os(3) = 7.814727764 While · We see that Xi < X;.os(3) The Chi-square critical value at a 5% significant level is 7.8147 Since the Chi-square critical value is greater than Chi-square calculated value, the hypothesis of keeping three above variables such as INC3, EDUGEN and RCONS is rejected Therefore, we can not reject the null hypothesis that the restricted version of the model can be maintained 63 APPENDIX3: HOUSEHOLD MEMBER INFORMATION DATE: / / DISTRICT: COMMUNE: HOUSEHOLD CODE: How many members are there in your household? people I I Member code Occupation Farming: Employee: Housewife: Business (private business): Others: (specify) Was Marital status member ill/ Married: injured? Unmarried: Gender Age Which grade Religion Race Male: has [name] Yes: Kinh: Female: finished? (record No:O Chinese: ves: Birth No:O year l i 64 ages the highest grade) Cham: Others: HOUSEHOLD MEMBER'S INCOME INFORMATION DATE: / I DISTRICT: COMMUNE: HOUSEHOLD CODE: ! I Note: if interviewer can not ask detail, you should ask the ~verag income of each member A WORKER Member code 10 How ! many 11 How much ~oney you 12 Other ' ' months you work receive per month (}'ND/month) ' I per year? ! • ! 65 mcome (from bonus, subsidy ) per year? 13 Total HOUSEHOLD MEMBER'S INCOME INFORMATION DATE: / / DISTRICT COMMUNE: IIOlJSEIIOI.D CODE: B AGRIClJLTlJRE: 14.Is this income Member Which plants did 15 Area ~der household you cultivate? or code cultivatioJ ! (m2) personal I i I I Personal D Farm products D llousehold D Industrial crops D Others: Personal D Farm products D llousehold D Industrial crops D Others: Personal D Farm products D I llousehold D Industrial crops D Others: ' 66 16 flow many times 17.Average is this crop harvested revenue each year? each crop? 18 Average 19 Total of cost of each income? crop? I HOUSEHOLD MEMBER'S INCOME INFORMATION DATE: / ! •.• DISTRICT I COMMUNE: I HOUSEHOLD CODE: C_BREEDING + AQUICULTURE: I 21 Which animal you feed 22 How Cattle: times is this crop revenue household or Poultry:2 harvested personal? Fish:3 year? 20 Is this Member mcome code Others: Personal D Household D Personal D Household D Personal D Household D Personal D Household D I I ! I I I i 67 many 23 Average 24 Average cost of 25 Total of each each each crop per month? month? crop per income? HOUSEHOLD MEMBER'S INCOME INFORMATION DATE: / ! DISTRICT COMMUNE: HOUSEHOLD CODE: D- SERVICES: Depreciation/year i I I I 26 Is this Member income code 27 Which service 28.How 29.1 30 31 The you do? many Average cost cost of each crop buying Avfrage lenue household or Tilling: months personal? Insect preventing: you of each per month? ~2 of IHow many total years machine you did money use you work cr1p per (materials, Product preliminary: per month? Others: year? rep au i cost ) I I I ? each receive if machine? buying that machine? I ! Personal Household Personal Household 68 Other 35 Total ~ost (tax, income? nterest, will jwage ) ! Irrgation: ~4 33 The INFORMATION OF PERSON'S ILLNESS/ INJURY Household code: _ Ill person code: 37 When did you have illness/ injured in the most recent? days ago The kind of illness (choose one of them) a) Bronchitis (1) b) Diarrhea (2) c) Gastritis (3) d) Conjunctivitis (4) e) Piss poisoning (5) f) Tonsillitis (6) g) Sinusitis (7) h) Sore throat (8) i) High blood pressure j) Rhinitis 0 (9) (10) (11) k) Injured The first treatment: 39 Being ill/ injured, did you get a cure immediately? Yes o (going on question 41) 40 No o (going on question 40) If you did not have a cure immediately, how many days after did you have treated for your illness/ injury after? days 41 Which facility did you choose for the treatment? a) CHC o b) Private clinic o c) Self-medication o d).Other o 69 42 Did you have re-treatment? Yes D (If Yes, it will be the different observation) NoD 43 If having re-treatment: If not having re-treatment: a/ How many days did you use drugs for 43 b/ How many days did you use treatment ? days drugs b/ How many days did it take to get over days before re-treatment? the illness? days 44 Did the patient have to take days off from your work/study/daily work? Yes 45 D (going to question 45) No o (going to question 46) How many days did the patient have to take days off from your work/ study/ daily work? days In question 41, if the answer is CHC, going on question 7, 48 In question 41, if the answer is not CHC, going on question 46,47 46 How far is it from your house to the chosen facility? (m) 47 How far is it from your house to the CHC? (m) 48-; How-far-is-it-from-your-house-to-the_neare_st facilty1~ 49 How you go to the chosen facility? a) By walking 50 = _ @) D b) Bicycle o c) Motorbike o d) Othero How long des it take on average from your house to the chosen f act'lity ? .mmutes 51 How much was the cost spent for the consultation? VND 52.How much was the cost spent for drugs? .VND for days => VND/per day 70 In question 41, if the answer is CHC, going on question 54, 55 In question 41, if the answer is not CHC, going on question 53, 54 53 How long did it take to wait for consultation and buy drugs at this chosen f ac1.lity ? rmnutes 54 In your opinions, how long does it take to wait for consultation and buy drugs at CHC provider? minutes 55 In your opinions, how long does it take to wait for consultation and buy drugs at N' • prov1"der? mmutes d1uerent 56 Have you ever chosen CHC provider for your treatment? Yes o No 57 Have you ever chosen private clinic for your treatment? Yes o No o 58 Have you ever chosen self-medication for your treatment? Yes o No o D Note: in question 59, 60, interviewers will ask the respondents' subjective opinions 59 Compare the cost of consultation of CHC to other facilities'? a).Cheaper o 60 -62~ c).Similar o d).You not know o Compare the cost of drugs of CHC to other facilities'? a).Cheaper o 61 b).More expensive o b).More expensive o Did you have health insurance? c).Similar o d).You not know o Yes o NoD In-your opinions,-is-there-drugs available in_CHC? _ a).Yes o 63 b) No o c)You not know o Why don't you use CHC provider? (can choose many reasons) a) CHC is not clear o (1) b) Too far from your house o (2) c) The staff are not good o (3) d) The quality of services is not good, even too bad o (4) e) You not trust them o (5) f) It takes long time to wait for consultation o (6) 71 g) Others : (7) 72 Household code: Ill person code: The second treatment: (the same illness of the first treatment) 41 Which facility did you choose for the treatment? a) CHC o b) Private clinic o c) Self-medication o d).Other o 42.Did you have re-treatment? Yes o (If Yes, it will be the different observation) No o If having re-treatment: 43.If not having re-treatment: a/ How many days did you use drugs for 43 b/ How many days did you use treatment ? days drugs b/ How many days did it take to get over days before re-treatment? the illness? days 44 Did the patient have to take days off from your work/study/daily work? Yes o (going to question 45) No o (going to question 46) -·~45Huwmanydsithepvok_}'Lf I fr.mn_yol