Health care utilization, cost burden and coping strategies by disability status: an analysis of the...

Health care utilization, cost burden andcoping strategies by disability status: ananalysis of the Viet Nam National HealthSurvey

Michael Palmer1*, Thuy Nguyen2, Teresa Neeman3, Helen Berry1,Terence Hull1 and David Harley1

1National Centre for Epidemiology and Population Health, The Australian NationalUniversity, Canberra, Australian Capital Territory, Australia2Department of Community-Based Rehabilitation, Hanoi School of Public Health, Hanoi,Viet Nam3Statistical Consulting Unit, The Australian National University, Canberra, Australia

SUMMARY

There is a need for nationally representative information on the affordability of health care bydisability status to assist in the design of equitable health systems in developing countries.Using the Viet Nam National Health Survey (2001–2002), this paper analyses health careutilization, cost burden and coping strategies for people with disabilities versus the populationat large. The results clearly show that the disabled population are more prone to hospital-ization, and spend more on inpatient stays and pharmaceuticals. Households with disabledmembers are at greater risk of catastrophic health expenditures and debt financing, posing aserious threat to economic welfare. Copyright # 2010 John Wiley & Sons, Ltd.

key words: Viet Nam; persons with disabilities; health care disparities; catastrophic health

expenditures; health care financing

INTRODUCTION

People with disabilities (PWDs) disproportionately suffer ill health and poverty.

However, little is known about the utilization and cost burden of health care for this

vulnerable subpopulation relative to the population at large, particularly in

developing countries and countries in transition. There is a crucial need for

representative analysis of inequalities in health care utilization and affordability by

disability status to assist in the design of equitable health systems. We present health

international journal of health planning and management

Int J Health Plann Mgmt 2011; 26: e151–e168.

Published online 28 June 2010 in Wiley Online Library

(wileyonlinelibrary.com) DOI: 10.1002/hpm.1052

*Correspondence to: M. G. Palmer, National Centre for Epidemiology and Population Health, Building62, Cnr Eggleston and Mills Roads, The Australian National University, Acton, Canberra, AustralianCapital Territory, Australia. E-mail: [email protected]

Copyright # 2010 John Wiley & Sons, Ltd.

care access and payments, cost burdens and coping strategies for the disabled and

non-disabled population in Vietnam.

Vietnam has a large population of PWDs due to prolonged periods of war, as well

as the country’s low-middle income status. Disability has implications for a

significant proportion of the Vietnamese population. According to the Vietnam

National Health Survey 2001–2002, approximately 3% of the population are

disabled and 13% of Vietnamese households have at least one member with

disabilities (Ministry of Health, 2004). This equates to 2.1 million PWDs and 7.1

million persons that live with a PWD.1 These estimates, however, are conservative.

Other measures of disability estimate 6 and 15% of the Vietnamese population as

disabled (MOLISA, 2006; General Statistics Office, 2008).

Consistent with the experience of many other countries, in 1989, the Vietnamese

government embarked on a series of health sector reforms as part of a wider economic

reform programme (Segall et al., 2002). In essence, the reforms included the

introduction of user fees at public facilities and the privatization of medical practice

and pharmaceutical trade. Over a decade, the reforms changed health care financing

from a system of near universal public funding to one in which households accounted

for the majority of total health expenditure (World Bank et al., 2001). Despite an

extensive system of commune health centres and district hospitals, the bulk of health

care spending has been at private pharmacies (Chang and Trivedi, 2003). In an effort

to improve formal health care access and use, the Vietnamese government introduced

a national insurance programme for formal sector employees, and later, voluntary

members (Ekman et al., 2008). In response to increasing reports of unaffordable

health charges, fee waivers and free health insurance cards were issued to provide

disadvantaged groups free access to health services at public facilities (Knowles et al.,

2004; Nguyen et al., 2009).

Following these changes, a number of studies have examined the health seeking and

cost burden of the general Vietnamese population and some disadvantaged groups

(Ensor and Pham, 1996; Nguyen et al., 2002; Wagstaff and van-Doorslaer, 2003;

Trivedi, 2004; Chaudhuri and Roy, 2008; Sepehri et al., 2008; Axelson et al., 2009).

Similar research is needed for PWDs and their families relative to the wider

population. This is a significant knowledge gap since PWDs are characterized by both

high health care needs and low ability to pay. In a US population study, PWDs had

consistently higher total health expenditures and higher share of health expenditures

as a proportion of income, than persons without disabilities (Mitra et al., 2008).

Evidence from developing countries is anecdotal or regional. Among adult PWDs in

five villages in southern India, direct costs of treatment and rehabilitation varied

according to the severity and type of disability; major surgery being the most

expensive type of available treatment, equating to almost twice the annual income in

an average two-income landless household, and annual outpatient visits amounting to

roughly a quarter of annual household income (Erb and Harriss-White, 2002). For

relatively minor medical costs, households used private savings or borrowed from

friends and relatives, whereas households with major medical spending undertook

loans from money lenders or sold household assets including jewellery and land.

1Calculation by authors.

Copyright # 2010 John Wiley & Sons, Ltd. Int J Health Plann Mgmt 2011; 26: e151–e168.

DOI: 10.1002/hpm

e152 M. G. PALMER ET AL.

Using national health survey data in Vietnam, this paper addresses questions

relating to disability and equity in health care in a low-middle income country. First,

are there differences in health care use and payments for people with and without

disabilities? Second, are there relative differences in the extent to which these

payments are catastrophic and in the mechanisms used by households to finance

them? Third, how are health care utilization, cost burden and coping strategies

affected by the degree and type of disability, and the number of PWDs in the

household?

In addressing these questions, the research improves current understanding and

contributes to the literature on the impact of direct payment systems upon

disadvantaged groups, providing empirical evidence with which to inform the

conceptual debate about health financing. Such information is also important for

Vietnam and other countries that are formulating policies and programmes of

financial risk protection for PWDs.

DATA AND METHODS

Data

The study uses data from the Viet Nam National Health Survey 2001–2002 (VNHS).

The VNHS was the first nationwide household survey of health and socioeconomic

information conducted by the Vietnamese Ministry of Health and supported by

Swedish Statistical International Consulting (Ministry of Health, 2004). The survey

comprised a three-stage random stratified cluster sample of 158 000 individuals from

36 000 households in 61 provinces. Whilst survey information was collected for

persons of all ages, we limited the sample to persons above 5 years of age because

insurance data was unavailable below this age. For analysis, the sample was divided

among the disabled (n¼ 4905 individuals; 4441 households) and non-disabled

(n¼ 138 845 individuals; 31 559 households) population. The survey collected

information on health status (including disability), health service utilization, health

expenditure and socioeconomic indicators.

PWDs were identified by an impairment screen: ‘Does anyone in the household

have any disabilities?’ according to disability types; mobility, deafness, speaking,

slow mental development, mental illness and vision. People could report more than

one disability, and disabilities were measured without the use of assistive devices

such as eye glasses and hearing aids. Other disability related information included

whether human assistance was needed in self-care (eating and toileting); whether an

assistive device was needed and whether people had access to assistive devices and

rehabilitation services.

Information on health care utilization included the frequency of contacts and

expenditures for inpatient services in the past 12 months, and outpatient services and

self-medication services in the past month. Service information was collected from a

range of publicly and privately owned facilities and expenditures included all the

costs associated with each contact: consultation, medication, ‘gift’, transport and

supplementary expenses (special dietary, clothing or instrument requirements).

Insurance mechanisms were effective only at public health care facilities. For each


DOI: 10.1002/hpm

HEALTH CARE BY DISABILITY STATUSHEALTH CARE BY DISABILITY STATUSe153

inpatient and outpatient contact, information was collected on whether insurance or

fee waiver paid part/all of consultation and treatment fees. Patients were asked

how they financed inpatient and outpatient expenditures (savings or income;

borrowing; sold assets; sold produce or earned more income; reduced expenditures;

paid by someone outside of the household). For those that undertook loans,

information was recorded on whether interest was paid and how patients intended to

service the loan.

In addition, the survey collected socioeconomic data including age, sex, marital

status, ethnicity, highest education level completed and household consumption

expenditure. Real household consumption expenditure (hereafter referred to as

income) was calculated in a post-enumeration of the survey with expenditures for 13

regular household food items and some assets from the VNHS modelled upon total

household expenditures collected in the Vietnam Living Standards Survey 1997–

1998 (Bales, 2003). The survey also collected social beneficiary information

including whether a person was living within a poor household registered by the

commune committee. The lowest 20th percentile of household consumption

expenditure per capita is applied as an alternative poverty-line measure.

Classification of disability

In the survey people could report more than one disability so we coded any person

with >1 disability as having multiple disabilities with separate categories for people

with one disability by categorized type. Seventeen per cent of people with multiple

disabilities were found to have hearing and speech disabilities and hence were

combined into a single category. Because of small numbers, people with psychiatric

disabilities and those with learning disabilities were combined into a single category

(mental disabilities). Disability severity was classified by whether human assistance

was required in eating or toileting (Yes¼ PWD severe/No¼ PWD other). Ninety-one

per cent of households with PWDs surveyed had only one member with disabilities

hence we classified households containing a PWDs (by degree and type) and included

a separate category for households with more than one PWDs.

Methods

Linear regression was used to measure inequalities in health care utilization and

economic burden by disability status. Health care utilization was measured by the

frequency of health care contacts and expenditures; whereas, economic burden was

measured by the prevalence of catastrophic health expenditures and health care

financing mechanisms. For the analysis of health care utilization, we used a two-part

model where the first part was a logistic regression model of contact with health care

providers; the second part a linear regression model of the natural log of health

expenditures for people with at least one contact with a health care provider

(Heckman, 1979; Trivedi, 2004).2 Analysis is provided by health care category ((i)

inpatient, (ii) outpatient, (iii) self-medication).

2Health expenditures were right-skewed with a kurtosis value greater than three hence the OLS log-normalmodel is preferable to the GLM log-normal model (Manning, 1998).


DOI: 10.1002/hpm


For the analysis of economic burden (stage two), we used logistic regression

models to estimate the incidence of catastrophic health expenditure for households

with PWDs that sought care and the incidence of health care financing mechanisms

other than income or savings for households with PWDs that sought care.

Catastrophic health expenditures were defined as exceeding 10% of total household

consumption expenditure. This threshold was thought an approximate level at which

the household is forced to resort to other financing mechanisms or else become

impoverished (van-Doorslaer et al., 2007). Financing mechanisms other than savings

or income imply higher risk to future economic welfare (Russell, 1996; Sauerborn

et al., 1996). These include borrowing, selling assets, selling produce, earning more

income or someone outside of the household paying. Analysis of catastrophic health

expenditures is provided for all health care categories whereas information on

financing mechanisms was collected for inpatient and outpatient expenditures only.

Analysis was performed using STATAVersion 9.2. All estimates are population

based, appropriately weighted to reflect the survey design. To account for

subpopulations we used Stata’s subpop command and standard errors were adjusted

so that they were robust to clustering among household members (Cameron and

Trivedi, 2005). Variation of health expenditure was found to be higher among PWDs

than other Vietnamese persons. Stata’s svy commands automatically produce robust

variance estimators (Stata Corporation, 2003). By transforming to the natural log of

health expenditures we further reduce heteroskedasticity. Adjustments to

consumption expenditure were made for monthly and regional price changes

according to data provided by the General Statistics Office of Vietnam (Bales,

2003).3

RESULTS

Disability prevalence was 3.2% (Table 1). Mobility impairment was the most

common disability representing one-quarter of people with a disability, followed by

visual, hearing and speaking, mental (psychiatric illness and learning disability) and

multiple disabilities. Around 13% of PWDs required someone to help with eating or

toileting, 30% needed an assistive device yet only 7% owned one, and 16% of PWDs

had received rehabilitation assistance from a trained practitioner.

Disabled and non-disabled populations differ significantly across socioeconomic

indicators (Table 2). Relative to persons without disabilities, PWDs were more likely

to be male, unmarried, older, illiterate, less educated, not participating in production

related activities, have lower average income, be poor and live in a rural area. Thirty-

nine per cent of PWDs above the age of 5 were illiterate and only five per cent had

completed upper secondary school; this compared with 8 and 13% for other citizens,

respectively. Approximately two-thirds of PWDs of working age (18–60 years) were

participating in agricultural or non-agricultural production activities compared with

93 per cent of persons without disabilities. PWDs had lower average incomes than

3Regional price information was not available for medical prices and inflation was recorded at only 0.5%for the period of the survey, hence no adjustments were made for medication purchases.


DOI: 10.1002/hpm


other Vietnamese persons and by both measures were more likely to be living below

the poverty line. PWDs were slightly disproportionately over-represented in the Red

River and Mekong Delta regions, with 48% of PWDs coming from these regions

compared with 44% in the non-disabled population.

Across subpopulations, the pharmacy was the most frequently contacted care

provider, followed by outpatient and inpatient service providers (Figure 1). Thirty-

two per cent of PWDs visited a pharmacy, 16% visited an outpatient facility and 9%

had an inpatient admission in the periods surveyed. Relative to the non-disabled

population, PWDs reported a higher contact rate across all service categories with

greatest relative difference at inpatient facilities, followed by pharmacies and

outpatient facilities. Almost all inpatient contacts were at public providers with

PWDs reporting a higher rate of provincial hospital admission and lower rate of

commune health clinic admission than other inpatients (Table 3). Outpatient contacts

were fairly evenly divided between public and private providers; PWDs were less

likely to visit public outpatient facilities and more likely to visit a private clinic than

other persons. The vast majority of self-medication visits were at private providers

with no statistically significant difference across subpopulations.

Insurance cards and fee waivers were effective only at public facilities. At public

inpatient facilities, the majority (58%) of PWDs were uninsured with the remainder

evenly divided between the two insurance mechanisms (Figure 2). However, a lower

proportion of PWDs were uninsured than other inpatients (58% vs. 67%) due to a

higher proportion of fee waivers (19% vs. 9%). At public outpatient facilities, the

proportion of uninsured PWDs was almost half that at inpatient facilities (32% vs.

58%) due to a greater incidence of fee waivers. Relative to other public outpatients,

PWDs were more likely to use an insurance card (28% vs. 15%).

Regression estimates confirm that the effects of disability on access and payment

to health facilities are considerable (Table 4). PWDs experienced approximately

70% greater odds of hospitalization and spent 70% more during hospital stays

compared with other Vietnamese persons. Among PWDs, those that required help

with eating or toileting (PWDs severe) experienced approximately twice the odds of

hospitalization (3.19/1.54) and spent approximately twice (3.29/1.46) as much

Table 1. Profile of disability, Viet Nam National Health Survey 2001–2002

Prevalence (%) Proportion of PWDs (%)

People with disabilities (PWDs) 3.2Disability types:

Mobility 0.8 25.0Mental 0.6 18.8Visual 0.7 21.9Hearing and Speaking 0.7 21.9Multiple 0.5 15.6

Need indicators:Needs help with eating or toileting 0.4 12.5Owns necessary assist device 0.2 7.2Needs an assist device 1.0 30.0Received rehabilitation assistance 0.5 16.3


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during hospital stays compared with other disabled inpatients. Among disability

types, PWDs with a mental disability had the highest inpatient admission rate and

PWDs with a mobility disability experienced the highest inpatient expenditures.

PWDs of all disability types except for those with a hearing and speaking disability

had significantly higher inpatient admission rates compared with non-disabled

persons. For outpatient contacts and spending, no significant differences between

subpopulations were observed with the exception of persons with severe disabilities

who spent 54% more than other outpatients. Overall, PWDs were no more likely to

Table 2. Descriptive statistics by disability status, Viet Nam National Health Survey 2001–2002

Non-disabled PWDs

Mean S.E. Mean S.E.

Male 48.0 0.1 56.1� 0.6Married (>18 years) 71.9 0.2 51.2� 0.9Age (years) 29.3 0.1 44.3� 0.4Age groups (%)5–19 years 37.2 0.2 20.2� 0.720–39 years 37.5 0.2 27.0� 0.840–59 years 17.0 0.1 20.5� 0.6> 60 years 18.3 0.1 32.4� 0.7

EducationIlliterate 8.4 0.2 39.2� 0.8<Primary 25.4 0.2 23.0� 0.7Primary 29.6 0.2 19.3� 0.7Lower secondary 23.2 0.2 13.6� 0.6Upper secondary 13.4 0.2 5.0� 0.4

Employeda (18–60 years) 93.3 0.1 67.1� 0.1Income (’000 dong) 3258.9 22.7 2919.4� 29.1Income quintilesPoor 18.7 0.5 23.4� 0.9Below average 21.2 0.3 24.3� 0.8Average 20.7 0.3 20.8 0.7Above average 19.3 0.3 18.6 0.7Rich 20.1 0.4 12.8� 0.6

Registered poor household 11.6 0.4 19.8� 0.7Ethnic minority 14.4 0.7 11.8� 0.8Rural resident 76.7 0.2 79.3� 0.8RegionRed River Delta 22.2 0.2 24.7� 0.9Northeast 11.6 0.1 8.8� 0.5Northwest 3.0 0.08 2.3� 0.2North central coast 12.6 0.2 13.1 0.7South central coast 8.3 0.1 9.6� 0.5Central highlands 5.4 0.1 4.2� 0.3Southeast 15.2 0.2 13.8 0.8Mekong delta 21.7 0.2 23.4� 0.7

aSelf-employed in agriculture or non-agricultural activities in the previous twelve months.�p� 0.05.


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self-medicate than the general population, though people with severe disabilities and

those with visual disabilities were (OR 1.4 and 1.3, respectively). However,

significant differences between subpopulations existed for pharmaceutical spending:

PWDs spent 24% more than the non-disabled population; people with severe

disabilities spent 64% (1.92/1.17) more than other disabled persons and mental

disabilities were associated with highest pharmaceutical spending among disability

types (41% greater than the reference category of persons without disabilities).

Households containing PWDs devoted a higher proportion of income to health

care than other households (21% vs. 15%) (Table 5). Inpatient contacts consumed the

highest income share (11%) for households with disabled members, followed by

outpatient visits (9%) and pharmaceuticals (5%). Relative to other households,

households with disabled members allocated a higher proportion of household

resources across all service types with the greatest difference observed for inpatient

care, followed by pharmaceuticals and outpatient care. Households with disabled

members were more likely to incur catastrophic health expenditures than other

households (38% vs. 30%). Approximately one-quarter of households with PWDs

experienced catastrophic inpatient and outpatient expenditures, and 10 per cent

experienced catastrophic pharmaceutical expenditures; at rates greater than other

households. Among those with catastrophic spending, a higher proportion of

households with disabled members were poor compared with other households (30%

vs. 23%). Regarding health care financing mechanisms, income or savings were most

commonly used to finance inpatient and outpatient expenditures by all households.

Figure 1. Proportion of people with one or more contacts at health facilities, by disabilitystatus and health care type. Source: Viet Nam National Health Survey 2001–2002. Error barsdisplay robust standard errors


DOI: 10.1002/hpm


However, households with PWDs used other mechanisms including borrowing, sale

of home produce or earning more income, or someone outside the household paying,

more frequently than other Vietnamese households. In particular, 42 per cent of

households with disabled members took out a loan in order to finance inpatient

expenditures, compared with one-third of other households. A higher fraction of

inpatient- than outpatient-related loans were interest-bearing (1/5 vs. 1/4) with no

statistical difference across subpopulations.

Regression results confirm that households containing PWDs experienced higher

odds of catastrophic health expenditures than other Vietnamese households that

sought care (Table 6). Increased odds of catastrophic expenditure were greatest for

pharmaceutical purchases (43%), followed by inpatient (27%) and outpatient (15%)

expenditures. Households with a single member with severe disability experienced

76% (2.02/1.15) and 51% (1.98/1.31) greater odds of catastrophic inpatient and

pharmaceutical expenditures, respectively, than households with a member with non-

severe disability. Households with a vision impaired member were at high risk of

catastrophic health expenditure across all service types; households with a member

Table 3. Proportion of peoplewith one or more contacts at health facilities, by disability statusand health care provider

Non-disabled PWDs

Mean S.E. Mean S.E.

InpatientCommune clinic 13.2 0.7 6.6� 1.3District hospital 34.3 1.0 34.8 2.6Provincial hospital 35.1 0.9 48.5� 2.6Central hospital 12.5 0.7 14.8 1.9Other public facility 5.2 0.4 6.4 1.2Private hospital/clinic 4.8 0.3 3.4 1.0Others 0.5 0.1 0.4 0.3

OutpatientCommune clinic 29.6 1.0 26.3 2.0District hospital 10.6 0.5 10.9 1.5Provincial hospital 8.0 0.4 8.8 1.2Central hospital 4.6 0.3 4.5 0.8Private clinic 33.4 0.7 39.3� 2.1Private traditional practitioner 3.6 0.1 4.3 0.8Others 7.8 0.4 3.6� 0.8

Self-medicationCommune clinic 9.8 0.5 9.0 0.9Private clinic 10.5 0.4 12.2 1.1Private pharmacy, drug vendor 75.6 0.7 73.1 1.5Private traditional practitioner 2.9 0.1 3.5 0.5Others 1.0 0.2 1.8� 0.4

Source: Viet Nam National Health Survey 2001–2002.Notes: Percentages do not add to 100 because respondents could report contact at more thanone provider.�p� .05.


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with a mobility disability were at high risk of catastrophic inpatient and

pharmaceutical expenditures; and those with a member with a mental disability

or more than one PWD were at high risk of catastrophic pharmaceutical

expenditures. Households with PWDs experienced a higher likelihood of using

coping strategies other than income or savings to finance inpatient and outpatient

expenditures, relative to other Vietnamese households (Table 6). The odds were

slightly higher for inpatient than outpatient expenditures (37% vs. 33%). Households

with a member with severe disability were most likely to resort to high-risk financing

mechanisms for outpatient expenditures (OR 1.94), whereas those with a member

with a visual or mobility disability were vulnerable for both inpatient and outpatient

expenditures. Households with more than one disabled member were most likely to

seek alternative financing mechanisms for inpatient expenditures; a rate over

twice that of non-disabled households and 64% higher than single PWD households

(2.15/1.31).

DISCUSSION

Vietnamese persons with disabilities are more prone to hospitalization, and spend

more on inpatient stays and pharmaceuticals than do the general population. Higher

use of hospital services by PWDs infers higher health care needs. This finding is

reinforced by a greater proportion of PWD inpatients using higher-level hospital

services where the availability, quality and cost of treatments are higher. The result

that PWDs incur greater inpatient expenditures infers higher treatment needs than

Figure 2. Insurance status of people with one or more contacts at public health facilities, bydisabilty status and health care type. Source: Viet Nam National Health Survey 2001–2002


DOI: 10.1002/hpm


Table

4.Logisticmodeloftheprobabilityofseekingcareandlinearregressionmodelofexpenditureforpersons(>

5years)thatseek

care,bydisability

statusandtypeofhealthcare

Inpatient(12months)

Outpatient(1

month)

Self-medication(1

month)

Care-seeking

oddsratio

Expenditure

ratio

Care-seeking

oddsratio

Expenditure

ratio

Care-seeking

oddsratio

Expenditure

ratio

Personswith

disabilities(PWDs)

1.69��

�(0.11)

1.70��

�(0.15)

1.09(0.06)

0.98(0.07)

1.06(0.04)

1.24��

�(0.05)

Bydegree

Severe(n¼672)

3.19��

�(0.49)

3.29��

�(0.51)

0.90(0.14)

1.54��

(0.32)

1.40��

�(0.17)

1.92��

�(0.26)

Non-severe(n¼4233)

1.54��

�(0.11)

1.46

� ��

(0.14)

1.11�(0.06)

0.94(0.07)

1.03(0.05)

1.17��

��(0.05)

Bytype

Mobility(n¼1216)

1.70��

�(0.19)

2.03��

�(0.28)

1.03(0.10)

0.81(0.11)

1.12(0.08)

1.32��

�(0.10)

Mental(n¼825)

2.21��

�(0.34)

1.79��

(0.39)

1.23(0.16)

1.11(0.21)

0.87(0.10)

1.41��

�(0.15)

Visual

(n¼1107)

1.81��

�(0.22)

1.58��

�(0.21)

1.17(0.11)

1.09(0.13)

1.29��

�(0.10)

1.10(0.07)

Hearingand

Speaking(n¼1020)

1.10(0.17)

1.35(0.35)

1.05(0.12)

0.90(0.12)

0.94(0.08)

1.21��

(0.10)

Multiple

(n¼737)

1.84��

�(0.35)

1.54��

(0.45)

0.86(0.15)

1.27(0.27)

0.97(0.13)

1.21�(0.15)

N134629

7107

134629

15464

134629

35603

R2

0.187

0.148

0.093

Source:

VietNam

National

HealthSurvey

2001–2002.

Notes:

Thedependentvariable

forprobabilitymodelsis

abinaryindicatorofcontact

athealthcare

facilities

(yes

¼1)andnaturallogofhealth

expendituresforlinearregressionmodels.

Separatemodelswererunfordisabilitysubpopulationsagainst

thereference

category

ofpersonswithoutdisabilitiescontrollingforarangeof

independentvariables:age2,percapitalconsumptionexpenditure,anddummyvariablescapturinginsurance,exem

ption,sex,ethnicity,educationlevel,

urban

andregion.

Robuststandarderrors

arein

brackets.

� p�.10.

��p�.05.

�� p

�.01.


DOI: 10.1002/hpm


patients without disabilities. Despite faring better than other inpatients, over half of

PWDs received no financial protection from inpatient fees at public facilities

(accounting for almost all inpatient contacts). Little difference between

subpopulations in access rates and spending exists at outpatient facilities. The

former may reflect similar primary health care needs, although the higher proportion

of PWD contacts at private providers relative to other Vietnamese persons might

indicate otherwise. Jowett et al. (2004) also find that disability was associated with

higher private outpatient usage, but no significant association with public outpatient

providers, in three Vietnamese provinces. Lower physical accessibility and treatment

quality, particularly towards poor patients, at public health services may explain this

phenomena (Axelson, 2005). Nonetheless, the majority (56%) of PWDs outpatient

contacts are at public facilities, and approximately two-thirds are covered by some

form of insurance at a rate higher than other outpatients. It is likely for this reason,

and not equivalent treatment needs, that little difference in outpatient expenditures is

observed between disabled and non-disabled outpatients. While there is no

difference in the likelihood of accessing drug vendors by disability status, PWDs

have greater medication needs. Though the spending difference is smaller than

Table 5. Descriptive statistics of household economic burden, by disability status

Households—noPWD

Households—PWDs

Mean S.E. Mean S.E.

Health expenditure to income ratio 15.0 0.4 21.0� 1.2Inpatient services 7.3 0.3 10.6� 0.9Outpatient services 7.7 0.2 8.9� 0.5Self-medication 3.2 0.1 4.5� 0.2

Catastrophic health expenditurea 30.1 0.7 38.3� 1.5Inpatient services 17.0 0.5 22.7� 1.2Outpatient services 21.3 0.4 24.0� 1.1Self-medication 6.0 0.2 9.6� 0.6

Catastrophic health expenditure inlowest income quintile

23.3 0.7 30.4� 1.8

Inpatient financing mechanismsSavings/income 77.8 0.7 70.8� 1.4Borrowing 34.2 0.7 42.3� 1.6Sold produce or earned more income 8.8 0.5 11.3� 1.0Someone outside household paid 11.5 0.5 17.5� 1.1

Outpatient financing mechanismsSavings/income 73.2 0.6 73.1 1.2Borrowing 6.6 0.3 8.3� 0.6Sold produce or earned more income 5.0 0.3 6.9� 0.6Someone outside household paid 2.2 0.1 4.8� 0.6

Interest bearing inpatient loan 26.7 1.4 27.7 2.7Interest bearing outpatient loan 18.3 2.2 19.9 5.5

Source: Viet Nam National Health Survey 2001–2002.a� 10% of total household consumption expenditure.�p� 0.05.


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Table

6.Logisticmodelsoftheprobabilityofcatastrophichealthexpendituresanduse

ofhealthcarefinancingmechanismotherthan

incomeorsavingfor

householdsthat

soughtcare,bydisabilitystatusandtypeofhealthcare

Catastrophic

Expenditures—

OddsRatios

Financingother

than

income/sav-

ings—

OddsRatios

Inpatient

Outpatient

Self-medication

Inpatient

Outpatient

HouseholdswithPWDs

1.27��

�(0.11)

1.15��

(0.08)

1.43��

�(0.13)

1.37��

�(0.11)

1.33��

�(0.10)

HouseholdswithPWD¼1(n¼4033)

1.28��

�(0.12)

1.11(0.08)

1.42��

�(0.13)

1.31��

(0.10)

1.33��

�(0.10)

Bydegree:

Severe(n¼576)

2.02��

�(0.38)

1.26(0.20)

1.98��

�(0.39)

1.38(0.28)

1.94��

�(0.30)

Non-severe(n

¼3457)

1.15(0.11)

1.12(0.08)

1.31��

�(0.14)

1.30��

�(0.11)

1.24��

�(0.10)

Bytype

Mobility(n¼1040)

1.54��

�(0.25)

1.13(0.14)

1.35�(0.23)

1.35��

(0.21)

1.40��

(0.20)

Mental(n¼633)

1.20(0.26)

0.94(0.15)

1.60��

(0.31)

1.24(0.23)

1.23(0.21)

Visual

(n¼940)

1.43��

(0.23)

1.39��

(0.19)

1.47��

(0.25)

1.43��

(0.23)

1.58��

�(0.23)

HearingandSpeaking(n¼823)

0.85(0.18)

0.97(0.14)

1.29(0.24)

1.15(0.20)

1.06(0.17)

Multiple

(n¼597)

1.45(0.31)

1.34�(0.21)

1.17(0.26)

1.35(0.26)

1.36�(0.24)

HouseholdswithPWD>1(n¼408)

1.26(0.31)

1.37(0.25)

1.83��

(0.41)

2.15��

(0.45)

1.45(0.30)

N7116

14527

20408

7011

13117

Source:

VietNam

National

HealthSurvey

2001–2002.

Notes:Dependentvariablesarecatastrophic

expenditure

(yes

¼1)andfinancingmechanism

other

than

income/savings(yes

¼1)forpersonswithoneor

more

contact/s.

Separatemodelswererunfordisabilitysubpopulationsagainstthereference

category

ofhouseholdswithoutPWDscontrollingforarangeofindependent

variables:

household

size,household

consumptionexpenditure,sexandeducationlevel

ofhousehold

head,ethnicity,

urban/rurallocation,regionand

insurance

status.

� p�.10.

��p�.05.

�� p

�.01.


DOI: 10.1002/hpm


annual inpatient expenditures, monthly medication expenditures can be substantial

over the course of time. This is a considerable risk for PWDs because private

pharmacies are the most commonly contacted care provider. Formal health care

usage by PWDs remains low, despite being higher than that for persons without

disabilities. Around one-fifth of PWDs have received rehabilitation from a trained

practitioner and one-quarter of the total reported need for assistive devices is met.

These results suggest that low affordability and lack of specific services are decisive

factors. A qualitative study of PWDs in five Vietnamese provinces finds high fees as

the greatest barrier to health care access, followed by lack of transportation means,

administration and waiting times, lack of appropriate service, stigma and

discrimination experienced at facilities and poor building access (Le et al., 2008).

Households with PWDs that seek care face a higher chance of catastrophic health

expenditures across all health care types than other Vietnamese households. Whilst

no difference in outpatient spending is recorded between persons with and without

disabilities, this result suggests that incomes among households with PWDs seeking

outpatient services are lower than other households. Furthermore, while spending

differences by disability status are greatest for inpatient treatment, pharmaceutical

expenditures pose the greatest threat to household income. This suggests that low-

income households with PWDs are more likely to access self-medication than

inpatient services, consistent with the wider experience of the poor in Vietnam and

other countries (Whitehead et al., 2001; World Bank et al., 2001; Chang and Trivedi,

2003). Among households with catastrophic health expenditures, a higher proportion

of thosewith disabledmembers are poor. As a result, households with PWDs resort to

borrowing or other mechanisms to pay for medical payments at a rate higher than

other Vietnamese households. This is most evident for inpatient payments. Greater

debt-financing among households with PWDs infers that income and savings are

insufficient to meet treatment costs. Depleted savings and debt can threaten

household living standards in the short-term, as consumption of other goods and

services are sacrificed, and reduced capacity for human or capital investment can

have important consequences for long-term welfare (the so-called ‘medical poverty

trap’) (Whitehead et al., 2001). The majority of households borrow interest-free,

however, some are unable to source loans in the community perceivably because

their medical bills are too big or lack of social capital. Households with interest-

bearing loans, in particular, are at high-risk of impoverishment.

Disability degree is strongly related to the utilization and economic burden of

health care. People that require assistance eating or toileting, representing

approximately 13% of the disabled population, experience consistently high health

care costs and low ability to pay compared with other PWDs. The picture also varies

considerably by disability type. As expected, mobility disabilities are associated with

high use of inpatient care (reporting highest inpatient expenditures) and

pharmaceuticals. This is consistent with the findings of a qualitative study in

southern India (Erb and Harriss-White, 2002). In that study visual disabilities were

the second most frequently treated, through provision of spectacles or cataract

surgery, and aural disabilities were least treated. Our results show similar pattern

with moderately high access rates to inpatient and self-medication services among

people with a visual disability and the lowest utilization rates among people with


DOI: 10.1002/hpm


hearing and speaking disabilities. As a proxy of disability severity, multiple

disabilities are associated with reasonably high inpatient and medication

expenditures. The finding that mental disabilities (psychiatric and learning

disabilities) are associated with the highest likelihood of inpatient admission is

surprising given the low availability of mental health services in low- and middle-

income countries (Patel, 2001; Miller, 2006). Mental health services appear

relatively well represented in Vietnam. Presently, there are two central psychiatric

hospitals, one each in the north and south; psychiatric hospitals in approximately

every other province; and a psychiatric unit in district health centres. In addition, for

more than a decade, a national strategy has provided persons living with certain

psychiatric and neurological conditions (schizophrenia, depression and epilepsy)

free treatment and medication at commune health facilities. However, inpatient

expenditures and self-medication expenditures remain high, with mental disabilities

recording the highest self-medication expenditures among disability types. The

probability of catastrophic expenditure is significant only for self-medication

purchases, which suggests that low-income households with a member with mental

disability are not using inpatient services to the same extent as self-medication

services. In contrast, for mobility and visual disabilities, the direction and

significance of economic burden measures are consistent with health care utilization,

suggesting a more equal economic composition across health care services.

Compared to households with a single PWD, we find households with multiple

disabled members are at high risk of catastrophic self-medication expenditures and

risky inpatient financing mechanisms. It is intriguing that there is no significant

association with catastrophic inpatient expenditure. One possible explanation is that

these households with multiple disabled members, whilst poorer, experience higher

insurance coverage at public health facilities.

Study limitations

The above anomalies may be partially explained by selection bias. Because of the

strict definition of disability applied and the low use of formal health services

(particularly inpatient services), certain disability subpopulations access various

health services in small number and are subject to comparatively large standard error.

Other bias may be evident in the self-report of disability and interviewer error. In a

post-enumeration re-survey of 24 communes, a measurement error of 2.4% was

recorded for disability resulting ‘from different understanding of the definition of

disability, or not probing carefully to find out whether a disability existed’ (Bales,

2003: p. 73). Our definition of health care utilization is limited to actual use and does

not take into account the opportunity to use health services or empowerment to make

well-informed decisions about health care use (Thiede et al., 2007); both of which

are pertinent to PWDs. In one aspect—ability to pay—this study suggests PWDs

have less opportunity to use health services than their counterparts without

disabilities. Furthermore, negative perceptions reported among some family

members towards those with a disability and low general access to information

among PWDs in Vietnam implies limits to decision-making power (Le et al., 2008).

In these respects, health care needs reported in this study are conservative. Similarly,


DOI: 10.1002/hpm


poverty estimates do not take into account the extra costs associated with disability,

which are shown here to be considerable for medical treatment. Catastrophic

expenditures are also likely under-estimates. Non-food consumption expenditure is

arguably a better measure of the impact of out-of-pocket expenditures on the living

standards of households that devote a high budget share to subsistence expenses

(van-Doorslaer et al., 2007). There are possible recall errors with inpatient

expenditures recorded in the 12 months prior to survey and insufficient recall may

partly explain the small variation between subpopulations for outpatient and self-

medication estimates. Our results are based on cross-sectional data and do not

capture the economic burden of health care over time. This is a considerable

limitation since disability is typically long-term in nature.

CONCLUSION

Using nationally representative data, individual health seeking and its burden for the

household are examined for the disabled and non-disabled population in a

developing country setting. After controlling for a range of covariates including

insurance, disability is found to be a significant determinant of health care utilization

and catastrophic health expenditures. Furthermore, households containing PWDs

that incurred catastrophic health expenditures are disproportionately poor. This

combination can have far reaching consequences. One finding from this study is that

households with PWDs borrow to finance health care expenditures at a rate higher

than other Vietnamese households. While the long-term implications require further

research, depleted savings and debt-financing pose a serious threat to household

welfare. These results support our view that high fees and out-of-pocket payments

take a particularly heavy toll on households with high medical needs and low

payment ability. Results further suggest that policies of financial risk protection have

not done enough to reduce the burden of health care among PWDs. This research

underlines the importance that adequate provision is made to protect the most

vulnerable in global health-policy reform. Careful consideration should be given to

the protection against catastrophic health expenditures for vulnerable population

groups. Efforts should also be taken to improve rehabilitation services and the

distribution of assist devices for PWDs. In view of the low use of formal health care,

complementary strategies such as community based rehabilitation warrants further

consideration.

ACKNOWLEDGEMENTS

The lead author was supported by an Australian post-graduate award and a

supplementary scholarship from the National Centre for Epidemiology and Popu-

lation Health, the Australian National University. The Hanoi School of Public Health

generously hosted the lead author for one year to collect data and supporting

materials related to this research. The Vietnamese Ministry of Health supplied

the data used in this study as well as supporting legal documentation and interview.


DOI: 10.1002/hpm


An anonymous reviewer provided helpful comments on an earlier version of the

paper. The views expressed in this paper are those of the authors alone.

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