The 2 nd Workshop on Equity Indicator Analysis EQUITAP Project 27-31 July 2009 International Health...

The 2nd Workshop on Equity Indicator Analysis

EQUITAP Project

27-31 July 2009

International Health Policy Programme, Ministry of Public Health, Thailand

Background of Lao PDR

• Lao People's Democratic Republic (Lao PDR) is a small, land-locked country in the heart of South-East Asia

• Encompassing 236,800 Square kilometers

• Sharing borders with Thailand to the west, Viet Nam to the east, China and Myanmar to the north and Cambodia to the south

• Source: NSC, Lao Census, 2005

Background of Lao PDR• According to the 2005 Population and

Housing Census, In March 2005, Lao PDR had a total population of 5.62 million

• Growth rate of 2.5 % per year• The population comprises 49 ethnic groups• The population density is 24 persons per

square kilometre• 73 % of the population lives in rural area


•


• The adult literacy rate is 73 percent• Life expectancy at birth is 59 years for

males and 63 years for females• The average household size was 5.9

persons• The major cities are Vientiane Capital,

Savannakhet, Champasack and Luangphrabang



• Buddhism is the dominant religion with more than 65 % of the population as believers

• The official language is Lao

• The administrative system of the country includes about 11,000 villages in 142 districts in 16 provinces, 1 city (Vientiane) and 1 Special region (Xaisomboun)


Health care system of Lao• In Lao PDR, there are two categories of health

care providers– formal health care– non-formal / informal health care.

• The system of formal health care:– (1) services/cares, provided by hospital (hospital

system)– (2) services/cares, provided by primary health

care (PHC system)– (3) services/cares, provided by vertical

programme (vertical programmes)

– Source: NIOPH, Lao Health Survey as apart of WHS, 2006

Health care system of Lao

• The system of non formal/informal health care provision includes:– traditional healers– traditional herbalists– traditional birth attendants– registered pharmacies (including informal

advisers), drug sellers– village health volunteers

– Source: NIOPH, Lao Health Survey as apart of WHS, 2006

Health Facilities in Laos

• 4 central hospitals (Mahosot, Mittaphab, Sethathirath, and Mother & child health)

• 9 specialized centers (Ophthalmology, Tuberculosis, Dermatology, Orthopaedic and Rehabilitation, Mother & Child Health, Malaria-parasitology and entomology, Traditional Medicine Research, Laboratory and epidemiology, HIV/AIDS centers)

• 16 provincial hospitals• 126 district hospitals• 734 health centers

• Source: NIOPH, Lao Health Survey as apart of WHS, 2006

Health Facilities in Laos

• 308 private clinics• 2,132 private pharmacies• 6 pharmaceutical factories• no private hospital


10

Health insurance schemes in Lao

• Civil Servant Scheme (CSS)

• Social Health Insurance (SHI or Social Security Office)

• Community-based health insurance schemes (CBHI)

• Health Equity Fund

• Private health insurance

• Source: NIOPH, Lao Health Survey as apart of WHS, 2006

Objectives

• To explore the incidence of catastrophic health expenditure of Lao

• To assess the magnitude of impoverishment from health care expenditure

• To compute Benefit Incidence Analysis (BIA)

• To compute Financial Incidence Analysis (FIA)

Catastrophic health expenditure

• A situation where household out-of-pocket payments for health are higher than 10% of household resources (income or expenditure)

• This study uses HH expenditure due to the limitation of reported HH income that tend to underreported

FIA and BIA

• BIA– An approach to examine who benefits from

public spending (on health),

– It indicates how well government health resources are targeted and gained by different socio-economic groups, especially the poor and the disadvantaged

• FIA– Who pays for health care among different

socio-economic groups

RESEARCH METHODOLOGYSources of data

1. Lao Expenditure and Consumption Survey (LECS3), 2002-2003 that has already officially permitted to use data from the Department of Statistics, Ministry of Planning and Investment

2. Socio-economic profile and satisfaction of insured and un-insured people in Lao P.D.R. with contracted health care providers, 2007, NIOPH-IHPP

Plausible Data sources using for health equity analysis

Survey Year

Institution conducting

surveyNationally

Representative? Sample Size Unit of Analysis

Socio-economic profile and satisfaction of insured and un-insured people in Lao P.D.R. with contracted health care providers 2006/2007

National Institute of

Public Health (NIOPH) NO 1,350

Individual and Household

Lao Expenditure and Consumption Survey

(LECS III) 2002/2003

National Statistical

Department Yes 8,092Individual and

Household

Poverty and Illness Survey (POVILL) 2007 NIOPH NO 3,000

Individual and Household

World Health Survey 2003 NIOPH, NSC Yes 5,000Individual and

Household

MICS 2006NSC, MOH Yes 6,000

Individual (Mother-

Children)and Household

Findings Catastrophic analysis

Impoverishment analysis

Financial incidence analysis (FIA)

Benefit incidence analysis (BIA)

Catastrophic incidence

Monthly out of pocket payment for health per

household, LECS3

5387.858

10929.02

18153.35

27355.86

32734.45

0

5000

10000

15000

20000

25000

30000

35000

Quintile1 Quintile2 Quintile3 Quintile4 Quintile5

Me

an

ou

t o

f p

oc

ke

t p

aym

en

t

Average out of pocket payment by quintile

Series1

Catastrophic health expenditure 2003

Catastrophic incidence by region (LECS3)

1.82

2.58

3.66

2.52

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

Northern Central Southern National

LECS3

Catastrophic health expenditure 2007, Health Insurance Survey, NIOPH/IHPP

Catastrophic incidence by selected provinces (NIOPH)

9.508.30

12.00

9.00

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

Luangprabang Vientiane andCapital

Champhasack Overall

NIOPH


Catastrophic incidence by quintile 2003

1.52.0

3.8 4.0

1.4

0.0

1.0

2.0

3.0

4.0

5.0


LECS3


Catastrophic incidence by quintile 2003

9.411.0

11.9

6.6

11.0

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0


NIOPH


Catastrophic incidence of helth payment in 2003 (LECS3)

1.1

2.4 2.62.22.0

2.7

3.9

2.7

0

1

2

3

4

5

Northern Central Southern National

cata

stro

phic

inci

denc

e

urban

rural

Impoverishment

Impoverishment incidenceLECS3

Pre - oop Post-oopQuintile1 18.96 19.27Quintile2 0.46Quintile3 0.05Quintile4Quintile5Total 18.96 19.78

The effect of health payment on per capital consumption

0

50000

100000

150000

200000

250000

1 2457 4913 7369 9825 12281 14737 17193 19649 22105 24561 27017 29473 31929

Pre OOP HH Expenditure Post OOP HH Expenditure Poverty line

The effect of health payment on poverty headcount by region in Lao

PDR

Poverty headcount by regoin 2007 (NIOPH)

11.0

22.0

14.2

21.523.0

11.9

24.0

15.3

0.0

5.0

10.0

15.0

20.0

25.0

30.0

Luangprabang Vientiane andCapital

Champhasack Overall

Pre-oop

Post-oop

Financial incidence analysis (FIA)

Gini coefficient 0

.2.4

.6.8

1

L(p

)

0 .2 .4 .6 .8 1Percentiles (p)

45° line pce

Lorenz Curve

Gini = 0.74

Concentration and Kakwani index

0.2

.4.6

.81

L(p

) &

C(p

)


45° line C(p): oop

L(p): pce

Lorenz and Concentration Curves

CI = 0.31 Kakwani index = - 0.43

Benefit incidence analysis (BIA)

Distribution of ambulatory service utilization in Lao PDR by quintiles and types

of health facilities, 2003

0.01 0.000.05 0.06

0.110.06 0.09

0.150.17

0.16

0.030.02

0.04

0.06

0.04

0.02

0.07

0.09

0.150.12

0.01

0.01

0.02

0.03 0.02

0.03

0.02

0.03

0.040.02

0.00

0.10

0.20

0.30

0.40

0.50

0.60

Q1 Q2 Q3 Q4 Q5

Am

bu

lato

ry v

isit

s p

er

ca

p p

er

ye

ar

Distribution of ambulatory service by quintiles and health facilities

other Abroad Private clinique HC Provincial/district Hs Central hs

Distribution of hospitalization in Lao PDR by quintiles and types of health facilities, 2003

0.000 0.001

0.0040.005

0.0100.011

0.016

0.019

0.022

0.026

0.003

0.004

0.002

0.002

0.001

0.002

0.003

0.003

0.003

0.001

0.001

0.002

0.002

0.002

0.002

0.0008

0.0057

0.0006

0.0018

0.0013

0.000

0.005

0.010

0.015

0.020

0.025

0.030

0.035

0.040

0.045

Q1 Q2 Q3 Q4 Q5

Ho

sp

ita

l ad

mis

sio

n p

er

ca

p p

er

yea

r

Distribution of hospitalization by quintiles and health facilities

Central hs Provincial/district Hs HC Private clinique Abroad other

Concentration curve of ambulatory service use by types of health facilities, 2003

0.2

.4.6

.81

C(p

)


45° line Central Hospital

Provincial/District hospital Health centers

Private health clinic Hospital/clinic abroad

Other

Concentration Curves of ambulatory service use by health facilities

Concentration curve of hospitalization by types of health facilities, 2003

0.2

.4.6

.81

C(p

)


45° line Central Hospital

Provincial/District hospital Health centers

Private health clinic Other

Hospital/clinic abroad

Concentration Curves

Concentration indices of ambulatory service use and hospitalization by

health facilities

Type of health facilities Concentration indices of ambulatory service

Concentration indices of hospitalization

Central Hospital 0.452 0.459

Provincial/District hospital 0.214 0.153

Health centers 0.158 - 0.1

Private health clinic 0.270 0.028

Hospital/clinic abroad 0.295 0.210

Other - 0.045 - 0.156

Mean Unit cost for hospitalization by type of health facilities in Lao PDR

IPD case 2002 2004

Central hosp - 517,140

Provincal hosp 214,610 378,328

District hosp 157,686 -

Health center 188, 531 -

Percent distribution of net government health subsidies among different health facilities in

2003

Percent distribution of net government health subsidy by quintile and IP health facility

0%

4%8% 8%

13%

7%

12%

15%13%

10%

3%

2%

2%

2%

2%

0%

5%

10%

15%

20%

25%

30%

Q1 Q2 Q3 Q4 Q5

Pe

rce

nt

Central Hs Provincial/district Hs Health center

Limitation of the study

• LECS3– Combination of Provincial

and district hospitals

– No data on OP expenditure

– Use expenditure replaced income

– Sequence of questionnaire

– Unspecified other health facilities

• Health Insurance (NIOPH/IHPP)– Not country

Representativeness– Utilization of health

services focused on urban areas

– Use expenditure replaced income

– Cannot compute BIA and FIA

Limitation of the study

• Lack of unit cost• Update of data• New knowledge of participants • Lack of experiences of participants

Discussion

• Low catastrophic:– Poor people tend to spend on food

consumption more than health care– Time period of data collection

• Access to central hospital and PH and DH

• Improving quality of care both public and private sectors and medical ethic of health care provider

Recommendation for further studies

• Improving instrument of health related national survey that can apply to equity in health

• Unit cost study at different levels

• Knowledge Transfer to Lao Health Staff

Thank you

The 2 nd Workshop on Equity Indicator Analysis EQUITAP Project 27-31 July 2009 International Health...

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