DOES HEALTH INSURANCE AFFECT HEALTHCARE SERVICES UTILIZATION AND PROTECT CITIZENS FROM CATASTROPHIC HEALTH EXPENDITURE IN VIETNAM? EVIDENCE FROM HOUSEHOLD LIVING STANDARD SURVEY Nguyen Thi Thu Thuong Vietnam 55th Master of Public Health/International Course in Health Development (MPH/ICHD) 18th September 2019 – 7th September 2019 Royal Tropical Institute (KIT) Vrije Universiteit (VU) Amsterdam Amsterdam, The Netherlands DOES HEALTH INSURANCE AFFECT HEALTHCARE SERVICES UTILIZATION AND PROTECT CITIZENS FROM CATASTROPHIC HEALTH EXPENDITURE IN VIETNAM? EVIDENCE FROM HOUSEHOLD LIVING STANDARD SURVEY A thesis submitted in partial fulfilment of the requirement for the degree of Master of Public Health By Nguyen Thi Thu Thuong Vietnam Declaration: Where other people’s work has been used (either from a printed source, internet or any other source), this has been carefully acknowledged and referenced in accordance with departmental requirements. The thesis “Does health insurance affect healthcare services utilization and protect citizens from catastrophic health expenditure in Vietnam? Evidence from Household Living Standard Survey” is my own work. Signature: 55th Master of Public Health/International Course in Health Development (MPH/ICHD) 18th September 2019 – 7th September 2019 Royal Tropical Institute (KIT)/ Vrije Universiteit (VU) Amsterdam Amsterdam, The Netherlands September 2019 Organised by: Royal Tropical Institute (KIT)/ Vrije Universiteit (VU) Amsterdam Amsterdam, The Netherlands In co-operation with: Vrije Universiteit Amsterdam/ Free University of Amsterdam (VU) Amsterdam, The Netherlands TABLE OF CONTENTS LIST OF FIGURES. iii LIST OF TABLES.
iii LIST OF APPENDIXES. v LIST OF ABBREVIATIONS. vi GLOSSARY OF TERMS. BACKGROUND INFORMATION ON VIETNAM.
Geographical, Demographic and socio-economic Context. Health system context. Health service delivery system. Healthcare outcomes and health need.
PROBLEM STATEMENT, JUSTIFICATION, OBJECTIVES AND METHODOLOGY. Problem statement and justification. FINDINGS AND DISCUSSION. Health financing situation and health insurance reform in Vietnam.
Health financing situation in Vietnam. Health insurance reform in Vietnam. Impact of health insurance on healthcare utilization among different groups in Vietnam. Estimated effects of health insurance reform on healthcare utilization outcomes.
Association between health insurance and catastrophic health expenditure in Vietnam. Findings of logistic regression. Health insurance and healthcare utilization. HI and outpatient and inpatient care.
HI and healthcare utilization at different levels of provider. HI and types of provider and types of visit. Catastrophic health expenditure. HI and CHE.
HI and CHE in rural area. HI and CHE toward outpatient and inpatient care utilization. Health system and structural factors and CHE. 38 CHAPTER 5: CONCLUSION AND RECOMMENDATION.
Recommendations on improving HI scheme. Recommendations on strengthening the health system. 56 WORD COUNT: 13,200 ( without tables, figures and its titles) ii LIST OF FIGURES Figure 1. The organization of health system in Vietnam Figure 1.
Health finance flows in Viet Nam Figure 2. Conceptual framework for evaluating impact of UHC on healthcare utilization and financial protection, adapted from Andersen’s behavioral model Figure 3. Structure of health financing resources, 2005-2016 Figure 3. Health insurance coverage expansion, 1992 – 2016 Figure 3.
Trends and structure of health insurance coverage by entitlement group, 2009 – 2014 Figure 3. Health insurance coverage rate by target group in the period 2011 – 2014 Figure 3. Rate of participation or non-participation in HI across different samples by occupation status, 2014, mean Figure 3. Rate of participation or non-participation in HI across different samples by expenditure quintile groups, 2014, mean Figure 3.
Rate of participation or non-participation in HI across different groups by region, 2014, mean Figure 3. Common support assumption test to assess the distribution of Propensity Scores before and after matching. Rate of participation in different types of HI according to consumption expenditure quintile among households experiencing CHE, Vietnam, 2016, mean. Household HI coverage rate according to consumption expenditure quintile among households experiencing CHE, Vietnam, 2016, mean Figure 3.
Rate of households suffering CHE, living in urban or rural areas participating in different HI programs, Vietnam, 2016, mean LIST OF TABLES Table 2. The number of observations used in this study Table 3. Estimated average treatment effects on treated (ATT) of HI scheme on healthcare utilization across different samples with PSM method Table 3. Statistical tests to evaluate the matching Table 3.
Indicators of household health expenditure among different consumption expenditure quintiles in 2016 Table 3. Multinomial logistic regression of catastrophic health expenditure Table 3. Logistic regression result for interaction terms between place of residence and frequency of outpatient care utilization Table 3. HI participation status and outpatient services utilization among households with or without incurring CHE.
iii LIST OF APPENDIXES Appendix 2. Andersen’ behavioral model Appendix 2. Definition of variables in evaluating impact of HI on healthcare utilization Appendix 2. Definition of variables in multinomial logistic regression Appendix 3.
Health insurance of target groups in Vietnam after adopting revised HI Law Appendix 3. Descriptive statistics for the insured and the non-insured of different health insurance programs in 2014 Appendix 3. Healthcare utilization across different samples in 2014 and 2016, (Mean) Appendix 3. Descriptive statistics across different treatment and control groups before matching Appendix 3.
Logit regression estimates of propensity scores for participation in HI scheme. Tests for selection bias after matching Appendix 3. Descriptive statistics of households according to catastrophic health expenditure status, 2016 Appendix 3. Sensitivity analysis between outpatient and inpatient subsamples Appendix 3.
Sensitivity analysis between urban and rural subsamples iv ACKNOWLEDGEMENT I would like to express my sincere gratitude to the Dutch Government, the OKP Scholarship Fund for giving me the opportunity to study and acquire knowledge in an advanced country with top quality education like the Netherlands. I would like to thank the University of Economics and Business Administration, Thai Nguyen University for enabling me to continue to study and improve my professional qualifications. I would like to thank the KIT Institute, the program director, the staffs, and especially the coordinators of MPH/ICHD program, who have encouraged me. I remember most of Mr….'s saying, "Please consider KIT as a home, you are children, and I am like parents.
We are happy to see you happy, we are worried when you are sad”. That sentence gave me the strength to always try. I would like to express my sincere thanks to thesis supervisor Mr. YVDB and back-stopper Mr.
They always help, follow, care about my thesis progress. They always motivate and ask me critical questions to complete my thesis. They do not manage day or night, work days or holidays to read and edit my thesis. I cannot thank enough.
The last but not the least, I would like to thank my husband and family for their support and undying love. I also thank my two little children who have always been docile and independent when I am not around them. v LIST OF ABBREVIATIONS ATT average treatment effect on the treated CDs Communicable diseases CHC Commune health center CHE Catastrophic health expenditure CHE Current health expenditure DOH Department of Health FFS Fee-for-service GDP Gross Domestic Product GSO General Statistics Office of Vietnam HI Health insurance HS Heavily subsidized HSHI heavily subsidized health insurance (he poor, near-poor and policy beneficiaries group) LMIC Low and middle-income countries MoH Ministry of Health NCDs Non-communicable diseases NN Nearest-neighbor matching OOPs Out-of-pocket health expenditures PHB Provincial Health Bureaus PPP Purchasing Power Parity SHI Social health insurance UHC Universal Healthcare Coverage UHI Universal health insurance VHI Voluntary health insurance VHLSS Vietnam Household Living Standards Survey VSS Vietnamese Social Security WB World Bank WHO World Health Organization vi GLOSSARY OF TERMS Adverse selection is a situation when people who are high risk of illness and have a greater need to use health services tend to enroll in health insurance than healthy people.(1) Capitation payment method is a method of quarterly and monthly prepayment for service providers a pre- determined amount of money per capita for a predetermined range of services (usually primary health care services) (2) Case-based or Diagnosis-related-groups is package payment according to pre- payment method determined medical examination and treatment costs for each case based on diagnosis. Catastrophic health expenditure when out-of-pocket expenditure exceeds 40% of the household's capacity to pay Copayment / cost sharing is the regulation that a health insurance participant pays part of the cost of health services, in addition to the amount that the health insurance organization pays for that health service.
(1) Fee-for-service payment method is a payment method including medical examination and treatment costs based on the price of medical examination and treatment services; and expenses for drugs, chemicals, medical supplies, blood etc. and other incurred costs which are applied for patients at medical examination and treatment facilities. Formal sector is a formal economic sector, managed by social institutions, and employees have formal labor relations through labor contracts.(1) Fund pooling is a function of the financial system, a collection of health financing sources, for example, health insurance contributions of individuals and organizations into a fund, with the purpose of share financial risks in a large community, so that large medical expenses are shared among individuals and households. (1) Global budget payment method Health care providers receive a specified amount of money from purchasers to cover the costs of the pre-agreed services that they provide for a specific period of time.
It is calculated based on inputs, outputs or both. This method gives providers more flexibility in making spending decisions (2) Impoverishment occurs when a non-poor household turns to a poor after health payments Informal sector includes employees who do not have a formal labor relations (free labor, or labor without formal labor contracts). (1) Integrated people-centred health services people and communities are at the centre of health system, not disease. People are promoted to be responsible for their health (3) Line item budget The medical service provider receives a specified amount from purchasers to compensate input costs such as labor, drugs, supplies for a specific period of time.
Providers have less flexibility (2). vii Meritorious people include people with meritorious services to the revolution; people directly involved in the resistance against the America to save the country; people participating in war of national defense, undertaking international missions in Cambodia etc. Out-of-pocket expenditure includes costs for check-ups, treatment, medicines, hospital fees and others ( allowances for physicians, travel, expenditures for buying medical instruments/supplies, fees for on- demand services, expenditures for buying additional medicines, traveling, caring) relating to visits for check-up/treatment. OOPs also include expenses for self-treatment.
OOPs are net of reimbursement paid by health insurance. Provider payment mechanism is “the way that health purchasers pay health care providers to deliver services”(2) Universal Health Coverage is to ensure that everyone has the right to access quality health care services anywhere, whenever they need without financial difficulties. It covers all essential services throughout life - from health promotion to prevention, treatment, rehabilitation and palliative care. (1) User fee a direct payment to a healthcare provider when using medical services (1) viii INTRODUCTION As a lecturer working at the Department of Medical Economics, Thai Nguyen University of Economics and Business Administration.
I realize that health financing is very important to my training and research. I hope that I can convey knowledge about this field to my students, or to organize short-term training courses on health financing for managers at district hospitals. Besides, health insurance is one of the pillars of social security system in Vietnam. Health insurance can help vulnerable groups and those living in remote areas fairly access health care services based on their needs.
Although Vietnam's population health insurance coverage has increased over the past years, people's out-of-pocket expenses remain high and tend to increase, making households incur huge medical costs beyond affordability, or catastrophic health expenditure. This makes country difficult to achieve the strategic health financing goals 2016-2020. In 2014, the Vietnamese National Assembly issued a revised Health Insurance law with increased funding from the state budget for purchasing health insurance cards for some groups, changes in copayment rates, and other regulations.