HEALTH FINANCIAL BURDEN AND THE ABILITY TO ACCESS HEALTH CARE

SERVICES OF HOUSEHOLDS IN THUY VAN COMMUNE, HUONG THUY

DISTRICT, THUA THIEN HUE PROVINCE

NGUYEN HOANG LAN. MD, MHEPublic Health Faculty, Hue college of medicine &

pharmacy; PhD student in KKU.

INTRODUCTION

In Vietnam, the resources of the government for public expenses in general, and for the health sector in particular, have been limited.

Health expenses of households amounted to 72% of the total health expenditure of the country

The health expenses of households have risen not only due to an increase in the use of private health services, but also due to expenses such as hospital fees and pharmaceuticals at public health facilities.

As a result, most of the poor who do not receive any support will incur a financial burden through illness

INTRODUCTION

To achieve equity in health care, the Vietnamese government is always interested in providing health care services for the poor

There have been many policies and solutions to improve access to public health care services for the poor

However, it is reported that poor households in Vietnam have limited use of public health services, especially in rural areas.

This research was implemented in a rural commune in Thua Thien Hue province with the objectives: To survey the access to health care services amongst

households in Thuy Van commune, Huong Thuy district. To assess health financial burden from the perspective of the

household.

STUDY METHODOLOGY

Study subjects Representatives of 200 households who had at least one

member with illness in 2007-2008 in Thuy Van commune Study design

A quantitative, descriptive study with a cross sectional survey was conducted.

Data was collected by directly interviewing households using a designed questionnaire, including:

• Cases who experienced illness within 4 weeks before the investigation.

• Cases who used inpatient services within 12 months before investigation

• Health expenditure of the household on both direct costs and indirect costs.

• Annual income per person per household

RESULTS AND DISCUSSION Situation of the use of health care services of people in Thuy Van commune

Choosing health care services for acute illnessTable 1. The percentage of households choosing the place of treatment

Types of health

Health facility

care services

CHC Transport hospital

Hue city hospital

Hue Central

hospital

Private health

Self-treatment

Total

Inpatient 0 2 0 2 0 0 4

% 0 50 0 50 0 0 100

Outpatient 22 3 1 1 12 17 56

% 39.3 5.1 1.8 1.8 21.5 30.5 100

(p=0.000)

RESULTS AND DISCUSSION

0

20

40

60

80

100

CHC Transporthospital

Hue cityhospital

Hue centralhospital

Health Insurance Near their home Time saving

Good quality Others

Figure 1. Reasons for choosing public health facility for outpatient services

(P=0.806)

Unit: %

RESULTS AND DISCUSSION

Almost all of the households received this service at the CHC (33.5%). The explanation for this was the registration address of the health insurance scheme (81.8%)

According to the National health investigation of 2001-2002, this was also a general phenomenon throughout Vietnam. “Convenience, time saving, and saving expenses from consultant fees of medical doctors in self-treatment,” was reasons for these choices.

RESULTS AND DISCUSSION

Choosing health facility for inpatient services within 12 months before the investigation

2.5 1

18.5

5.5

72

0.5

01020304050607080

CHC Areaclinics

Transporthospital

Hue cityhospital

Huecentralhospital

NoTreatment

No of households

Figure 2. Choosing public health facility for inpatient services

Unit: %

RESULTS AND DISCUSSION Reasons of choosing public health facilities for inpatient services

0

20

40

60

80

100

CHC Areaclinics

Transporthospital

Hue cityhospital

Huecentralhospital

Health insurance Referred by lower levelSerious disease Self-selectionOther

Figure 3. Reasons of choosing public health facilities for inpatient services

(P=0.000)

Unit: %

RESULTS AND DISCUSSION

72% of households used Hue central hospital for their inpatient services in the study, whereas it was the registration address of health insurance for only 5.6% of households.

The availability of modern equipment and techniques and good staff has attracted a large number of patients to the Hue central hospital.

The use of health care services at the high level by bypassing regulated health levels has increased the health expenditure of households.

It was of concern that 0.5% of households did not use any formal health care services for their illness that can be explained by distance of health care allocation and economic problems.

RESULTS AND DISCUSSION

Health financial burden of households Outpatient expenditure as proportion of household income

0

0.05

0.1

0.15

0.2

0.25

0.3

Poor Near poor Average Near rich Rich

Income group

Figure 4. Average ratio of outpatient costs to household income

(P=0.384)

Unit: %

RESULTS AND DISCUSSION

Inpatient expenditure as proportion of household income Table 5. Average ratio of inpatient costs to household income within 12 months

Poor Near Poor Average Near rich Rich

Percentage of health expenditure among the total income

119.3 1.3 1.2 3.7 0.6

(P=0.419)

RESULTS AND DISCUSSION

For outpatient services, the ratio of health expenses to household income is affordable based on the benchmark proposed for developing countries by World Bank (1-2%) (1987) and Russell (5%) (1996).

However, this ratio for inpatient services for the poor households in our study is greatly exceeds these affordability benchmarks, up to 119.3%.

The result is much higher than the study results of Margaret et al (2001), which found that only 20% of income was used for total health care expenditures in the rural poor households. The health cost gap between the poor and the rich in our study is also higher (119.3% vs 0.6% compared to 20% vs 8% in the study of Margaret).

Longer duration of illness in the poor and including indirect costs in our study are possible explanations for the difference.

RESULTS AND DISCUSSION

It is clear that the poor households could not afford to health costs, even though they were actually incurred. Debt and poverty result from illness within poor households in Vietnam, “especially when illness or death strikes a bread winner or require households to use expensive hospital services”. Similar patterns of debt occur in some settings in Africa, China and Cambodia.

RESULTS AND DISCUSSION

2700

44935

00 4800

1250

150 7600

1475

Travel MedicinesHospital fee Private consultant feeLaboratory test Food related to treatmentFood AccomodationOthers

Figure 5. Items the households must paid for using outpatient health services

Items the households must paid for using health services

Unit: VN dong

RESULTS AND DISCUSSION

322025

48050 157252500

42750

Travel Medicines Hospital fee Food Accomodation

Figure 6. Items the households must paid for using inpatient health services

Unit: VN dong

RESULTS AND DISCUSSION

Among the health care expenditure, highest amount was spent on medicines even though the patients were receiving health care services at public health services.

Lack of drugs or irrational use of medicines has resulted in this problem. Besides, the preference for expensive imported drugs from both providers and users has also been highlighted.

These problems have not only generated harmful effects on health, but also waste scarce financial resources, especially among poor people

CONCLUSION

The introduction of health insurance schemes in Vietnam has increased the population’s access to public health care services, especially, basic health levels. This has contributed to a reduction in health costs for acute illness among households.

It seems that financial pooling has not been efficient for inpatient services. Rises in out of pocket costs for public health care services is mainly from medicines.

In poor families, sickness incurs a large financial burden, exceeding their ability to pay. The magnitude of this situation is known as “the medical poverty trap”.

The inequity in health care expenditure was shown by the gap in the ratio of health expenses to household income between rich and poor households in this study.

RECOMMENDATION

The health insurance system should include community-based health insurance subsidized by public funds, which covers costs for essential drugs. The tax policies based on income should be implemented to ensure effective pooling of risks across the whole population.

Strengthening government regulations concerning the management of the medicine market and development and implementation of an essential drug programme

Comprehensive investment should pay attention to basic health levels in order to increase access to care among poor people and reduce overload on central hospitals.

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