Tài liệu Health insurance and public health care utilization in vietnam

UNIVERSITY OF ECONOMICS INSTITUTE OF SOCIAL STUDIES HO CHI MINH CITY THE HAGUE VIETNAM THE NETHERLANDS VIETNAM - NETHERLANDS PROGRAMME FOR M.A IN DEVELOPMENT ECONOMICS HEALTH INSURANCE AND PUBLIC HEALTH CARE UTILIZATION IN VIETNAM BY TRAN THE HUNG MASTER OF ARTS IN DEVELOPMENT ECONOMICS HO CHI MINH CITY, DECEMBER 2014 UNIVERSITY OF ECONOMICS INSTITUTE OF SOCIAL STUDIES HO CHI MINH CITY THE HAGUE VIETNAM THE NETHERLANDS VIETNAM - NETHERLANDS PROGRAMME FOR M.A IN DEVELOPMENT ECONOMICS HEALTH INSURANCE AND PUBLIC HEALTH CARE UTILIZATION IN VIETNAM A thesis submitted in partial fulfilment of the requirements for the degree of MASTER OF ARTS IN DEVELOPMENT ECONOMICS By TRAN THE HUNG Academic Supervisor: Dr. TRUONG DANG THUY HO CHI MINH CITY, DECEMBER 2014 ABSTRACT Vietnam is in the process of improving health system. To achieve this goal, the Vietnam Government attempts to expend the coverage of public health insurance which is an effective tool in low and middle income countries to finance health care provision (WHO, 2000). Although the insurance coverage increases significantly over the last ten years, the private expenditure on health is still high. It only reduces 6%, particularly from 69.1% of total expenditure on health in 2000 to 62.9% in 2010 (WHO, 2013). This comes up with a question that whether health insurance improves access to care? To answer this question, this study will assess the impact of health insurance on health care utilization, particularly public health services through two purposes: medical examination and treatment. A binary probit model is used to estimate the impact of health insurance on public health care utilization. Then we investigate determinants of insurance enrollment to increase the number of insurance participators if insurance affects positively significant on health care use. Data are obtained from Vietnam Household Living Standard Surveys (VHLSS) in 2010. The empirical results indicate that insurance has a positively significant effect on public health care utilization. In other words, we can conclude that health insurance actually improve access to care. Moreover, the results of insurance participation show that insurance enrollment is affected strongly by income and interaction terms of frequency of illness. It is also remarked that demand for insurance is different between five income quintiles. Finally, household’s characteristics including household’s size, income and illness ratio affect significantly to insurance enrollment. ACKNOWLEDGEMENT This thesis is not only the result of my own effort, it also consists direct and indirect supports of other individuals and organizations. I would like to express my deep gratitude to them. My academic supervisor, Dr. Truong Dang Thuy, is the person that I would like to thank firstly. Without his comments and supports, I would not finish my thesis in time and as good as this. Furthermore, I would also like to acknowledge the Scientific Committee, the lecturers and staffs of Vietnam-Netherlands Programme for the knowledge and guidance during the period of studying and writing thesis. Last but not least, I am grateful to my family for create favorable conditions to help me learn better. Finally, I would like to thank my friends, especially “HLNTTV Group” for their supports in the whole time of studying. HCMC, December 2014 Trần Thế Hùng TABLE OF CONTENTS LIST OF FIGURES ....................................................................................................... LIST OF TABLES ......................................................................................................... CHAPTER 1: INTRODUCTION .................................................................................... 1.1 Problem statement .............................................. 1.2 Research objectives ............................................ 1.3 Research question ............................................... 1.4 Research scope and data ..................................... 1.5 The structure of this study .................................. CHAPTER 2: LITERATURE REVIEW ......................................................................... 2.1 Relationship between health utilization and insu 2.1.1 Health care usage theory ............................................................................. 2.1.2 Theory of relationship between health insurance and health utilization ...... .............................. 2.3 Empirical reviews of relationship between healt utilization: ................................................................................................................... 2.4 Theory of insurance participation: ..................... 2.5 Empirical reviews of insurance participation: ... CHAPTER 3: RESEARCH METHODOLOGY ........................................................... 3.1. An overview of Vietnam health system and hea 3.1.1. Provider network.. 3.1.2. Access and utiliza .............................. 3.2. Overview of health insurance ............................ 3.3. Methodology and data ....................................... 3.3.1. Methodology ....... 3.3.2. 3.4. Data ...... Measurement of variables and expected sign .... CHAPTER 4: RESULTS ............................................................................................... 4.1. Descriptive statistic............................................. 4.2. Empirical results ................................................ 4.2.1. Impact o 4.2.1.1. Medical 4.2.1.2. Treatmen 4.2.2. Determin CHAPTER 5: CONCLUSIONS AND POLICY IMPLICATIONS .............................. 5.1 Conclusion remarks and policy implication ...... 5.2 Limitation and further research ......................... REFERENCES .............................................................................................................. APPENDIX .............. LIST OF FIGURES Figure 2. 1: Initial behavioral model of health services utilization.................................................8 Figure 2. 2: Modeling the effect of insurance programme on the use of health services . 21 Figure 3. 1: Proportion of seeking care in 2010....................................................................................33 Figure 3. 2: Timeline and roadmap of universal health insurance coverage...........................34 Figure 3. 3: Trend in health insurance coverage from 1993-2010...............................................36 LIST OF TABLES Table 3. 1: Measurement of variables......................................................................................................40 Table 4. 1: Descriptive statistics of using public health care services by purpose................45 Table 4. 2: Descriptive statistics of insurance participation............................................................45 Table 4. 3: Descriptive statistics of continuous independent variables......................................46 Table 4. 4: Public health care use and insurance enrollment by gender....................................47 Table 4. 5: Public health care use and insurance enrollment by employment status...........47 Table 4. 6: Public health care use and insurance enrollment by area (rural)...........................48 Table 4. 7: Public health care use and insurance enrollment by minor ethnic people.........49 Table 4. 8: Results of impact of health insurance on medical examination.............................50 Table 4. 9: Results of impact of health insurance on medical treatment...................................52 Table 4. 10: Results of insurance participation (household level)................................................54 Table 4. 11: Results of insurance participation (individual level)................................................58 Table 4. 12: Results of insurance participation by different income quintile..........................61 iii Tran The Hung Master’s Thesis VNP19-2014 CHAPTER 1: INTRODUCTION 1.1 Problem statement After “Doi Moi” program in 1986, Vietnam has experienced rapid and continuous economic growth with GDP per capita increases from 140 USD in 1992 to 1,168 USD in 2010. Moreover, Vietnam’s poverty headcount drops from 60% to 20.7% in the past twenty years (Work Bank, 2013). When people become more affluent, they will have higher demand for care (McPake et al. 2002; Folland et al. 2004). Therefore, the rate of healthcare usage increases significantly from 2002 to in 2010. Typically, percentage of people having health treatment in 2002 is 18.9%, and then they rise to 40.9% of total population in 2010. Over the period of 2002-2010, healthcare utilization in Vietnam increases dramatically. It suggests that people pay more attention to their health. As for 2010, the percentage of people having health treatment is about 40.9%. Of which, the rates of inpatient and outpatient are 8.1% and 37.1% respectively. There are two main kinds of health care services that people use in Vietnam, including public and private health care services. The percentage of people using public health care services is nearly seventy percent; particularly, the ratio of inpatient hospitalized in public health services is around 90.1% of total inpatient and 57.2% is the percentage of outpatient using public health care services in 2010. In the last ten years, Vietnam households still have to concern with a burden of health care expenditure. The amount of money that people have to spend in health care is much more than Government spending; private expenditure on health accounts for around 62.9% of total expenditure on health while general Government expenditure on health is around 37.1 in 2010 compared to Thailand with 25% of private expenditure 1 Tran The Hung Master’s Thesis VNP19-2014 and 75% of Government expenditure on health (World Health Organization 2013). The major element that makes the large proportion of private expenditure is households’ out-of-pocket payment. Out-of-pocket expenditure is about 93% of private expenditure on health in Vietnam 2010 (WHO, 2013). An increase in out-of-pocket payment on health may lead households to sell their assets to be able to pay the treatment fees. Most of households, especially poor households, have to pay such a substantial share of their income for health service. As the result, they are pushed into poverty (World Health Organization, 2004). Health risk is probably the greatest threat to people’ lives because it impacts on their direct expenditure and it also reduces their health affecting to labor supply and productivity leading to income poverty (Asfaw, 2003). This author suggests that health insurance is an effective tool to deal with health risk for the poor. In addition, health insurance is as a part of income protection because it reduces financial burden of treatment at low income levels (Jutting, 2003). Health insurance is also a tool in order to create an equitable access to health services throughout the population at lowincome countries (WHO, 2000). Ensor (1995) discusses that voluntary health insurance plays an important role in reforming overall health care system by making health service provision more efficient. Recognizing the important role of health insurance, many authors study the relationship between health insurance and financial risk protection or health, especially, impact of health insurance on health utilization. Saksena et al (2010) state that health insurance has statistically significant positive impact on health care utilization of health services when people are needed. For the poor, health insurance is an effective tool which increases health care usage when they are sick (Jutting, 2003). Health insurance does not only rise health care utilization, but it also increases the 2 Tran The Hung Master’s Thesis VNP19-2014 usage of physician services and preventive services and so it improves health (Freeman et al, 2008). Health utilization is affected by many determinants including demographic factors; social structures, characteristics of family and community (Anderson, 1995). The author argues that demographic variables such as age, gender, education have low mutability, so they cannot be altered to change utilization; and cultural backgrounds (ie, ethnicity, region) are not changeable to promote health care usage (Anderson & Newman, 2005) while personal/family and community’s characteristics which include an important factor: health insurance are quite mutable and strongly associated with health utilization. For example, the impact of health insurance on health care use has been demonstrated dramatically by The Rand Health Insurance Study such as the studies of Manning et al (1987) and Jutting (2003). As a result, we can conclude that increasing insurance participation is a good choice to accelerate health utilization; and it is necessary for policy makers to adopt how the impact of insurance on health care utilization is and then assess what are determinants of insurance participation so as to create favorable conditions for people to join health insurance scheme, specially, for the poor who do not have enough resources to use health services. In this situation, the study will examine the effect of health insurance to health care utilization at public health care services with different purposes including health test and treatment. In other word, we will hypothesize whether health insurance improves access to health care since many studies use health care utilization as a proxy for access such as Fox (1972); Aday & Anderson (1974; 1995). After measuring the impact of health insurance on health care usage, if the effect is positively significant meaning that health insurance actually improves access to health care, we then investigate determinants affecting to insurance enrollment. Then, the results are used to recommend policy implications to improve insurance participation including: 3 Tran The Hung Master’s Thesis VNP19-2014 administrating stringently the insurance participation of employees and financial intervention such as subsidies for different income quintiles, especially for low income households with high illness ratio. 1.2 Research objectives This study aims to identify relationship between insurance and public health utilization of people in Vietnam. After that, determinants affecting health insurance enrolment are measured in order to improve insurance enrollment. As such, there are two main objectives in this study: - Impact of health insurance on health care utilization at public health services using data from Vietnam Household Living Standard Survey in 2010. - Investigating determinants which impact to join the insurance scheme of people. Then, policy implications are recommended to increase the number of insurance participators. 1.3 Research question This research aims to handle the question: Does health insurance actually improve access to care at public services? If yes, how to improve insurance participation? 1.4 Research scope and data The study examines the impact of insurance on health care usage of individuals and determinants affecting insurance participation of households and individuals using cross section data of Vietnam Household Living Standard Surveys (VHLSS) in 2010. 1.5 The structure of this study There are five chapters in this study which are organized as follow: 4 Tran The Hung Master’s Thesis VNP19-2014 Chapter 2: literature review includes theory as well as empirical literature about the relationship between insurance and utilization, also the determinants of insurance. Chapter 3: research methodology which presents regression technique used and data collection. Chapter 4: empirical results. The statistic description is presented first, and then explaining the empirical results. The coefficients of all factors will be interpreted and discussed. Chapter 5: summarizes the main results and some policy implications. 5 Tran The Hung Master’s Thesis VNP19-2014 CHAPTER 2: LITERATURE REVIEW 2.1 Relationship between health utilization and insurance 2.1.1 Health care usage theory The behavior of health utilization has traditionally explained in five different approaches including the sociocultural approach, the socio-demographic approach, the social-psychological approach, the organizational approach, and the social systems approach (Anderson, 1973). For the sociocultural approach, health care usage is a part of a cultural complex and, as such, related to other social institutions in a society or subculture. One example of Shuval (1970) shows that the utilization of health services depends on the basic latent functions of catharsis, cooperation with social system through contacts with social institution, status achievement through such contacts, and the resolution of conflicts between magic and science. Zborowski (1952) founds that responses to pain among ethnic groups are different when he attempted individual utilization behavior. It means that cultural condition affects to personal recognition of symptoms and the responses to them. For the socio-demographic approach, variations of utilization behavior can be related to age, sex, education, occupation, ethnicity, socioeconomic status, and income. As the theory of Moore (1969), the utilization of health care can be view as a type of individual behavior which is a function of individual characteristics, characteristics of environment where they live and maybe the interaction of these individual and societal forces. The author emphasized the individual characteristics and less paid attention to the societal impacts. This means that health utilization affected mostly by characteristic of individual themselves such as age, education, gender, health status and income, and 6 Tran The Hung Master’s Thesis VNP19-2014 so on. Moreover, utilization among various groups within a population is also different even when cost barriers are eliminated (Nolan et al, 1969). For the Social-Psychological Approach, Stoeckle et al (1963) review much of the analytic literature on the seeking of medical care and outline three major factors in the patient’s decision of seeking care including individuals’ knowledge and attitudes concerning symptoms; attitudes and expectations regarding to health services; and individuals’ definition of illness. Similarly, in studying illness behavior, Mechanic (1978) identified the theory of health seeking and found out various circumstances affecting to the decision of seeking care. The first one is the salience of deviant signs and symptoms. Individuals’ perception and tolerance of symptoms is the second and third. Forth, disruption caused by illness affects to individual’s life. Fifth is the frequency of illness and its persistence. And the final circumstance is the individual’s knowledge and cultural assumptions of the illness. For the organizational approach, the structure of health care system is examined to account for differences of health care behavior. Regarding to Anderson’s study of comparing health services in the United State, Sweden and England (1972), the differences in the supply of physicians and hospitals’ beds leads to the changes of variation in the use of hospital. Typically, if the supply of physicians and hospitals’ beds is deficient markedly, the use of health care services will be diminished. Moreover, when the admissions increase, the average length of stays will drop. The author also pointed out that each country has evolved a pattern of financing and organization that is consistent with the unique characteristics of its social and political systems. Hence, intervention strategies are necessary. For the social systems approach, it has emerged as a way of understanding health utilization. On the basis of social systems, in 1960’s, Anderson developed the initial 7 Tran The Hung Master’s Thesis VNP19-2014 behavior model looking at three categories of determinants such as predisposing characteristics, enabling resources including factors which enable or impede use, and people’s need for care that affects to people’s use of health services (Anderson, 1995). Figure 2.1: Initial behavioral model of health services utilization Predisposing characteristi cs  Demographic  Social structure Source: Anderson (1995) In 1972, Anderson expended and refined the initial behavioral model in order to predict the effect of changes in social structure of population and of supply of health services including the supply of hospital beds, aggregate level of education, employment, income and socio-demographic characteristics such as age, ethnicity and ecological features on health utilization. In addition, the updated utilization model can be characterized by purpose, type and unit of analysis. In the case of purpose, health care utilization is as primary care with stopping illness before it begins or secondary care with referring to the process of treatment or tertiary care with providing stabilization for long-term irreversible illnesses such as heart disease or diabetes. For type characteristic, health care utilization is as a choice of health services such as Hospital, Physician, Drugs and Medications, Dentist, Nursing Home, and Other. A final character describing the utilization is the unit of analysis which includes the contact with a physician during the 8 Tran The Hung Master’s Thesis VNP19-2014 period of time or the using volume of services. Although health care utilization has different characteristics, determinants affecting to use of health services are based on characteristics of population and health services (Anderson, 1995; Andersen and Newman, 2005). In general, the extent of health care is to improve health which should be primitive in the description of consumers’ preferences. Health care services would then be demanded only as an input into the production of health, and the level of demand for services would be determined by the extent to which they satisfied the individual’s underlying preference for health. Individuals use their available resources to achieve health, so their preferences for health are represented within a standard utilitymaximizing framework. All of alternative uses that individuals must have for their resources to admit a choice are bundled into a generic good denoted c. The utility function of health care use is: = ( , ℎ) Where h is level of health that individuals enjoy rather than quantity of health care services consumed. The demand for medical care is not constrained to a choice of how much, but also of what kind meaning that individual can decide how often to visit, as well as choose visiting various providers such as hospital, clinic, healer. After having made these choices, consumers may also face the choice of what kinds of treatments they wish to adopt including the use of drugs and other remedies. While many of these input decisions will be based on recommendations made by the provider, such recommendations may be altered with variations in prices and incomes. For an individual with income m, the price vector defines a consumption vector as 9 Tran The Hung Master’s Thesis ( 0, 1,…, ) = ( − 0, − 1,…, − ) VNP19-2014 The function of health care utility can be rewritten as = (ℎ, , ) Where m presents income and p is the price of medical services. The existence of such discrete choices requires more elaborate econometric techniques to estimate the demand curves. The discrete choice can be modeled in an integrated fashion using a multilevel approach. 1 1 Where: ̂ = ̂( ) is the estimated use of medical care by individual i who consumes ̂( ) = ̂[ ̂ ̂ + ̂ ̂ 2 2 + ⋯+ ̂ ̂] service j. xi is a vector of regressors used to explain medical care use such as price, income and demographic variables. Category j = {1…n} assumed as a various types of medical care services including clinics, public hospitals, traditional healers, and so forth. And ̂ = ̂( ) is the estimated probability that individual i will consume some quantity of medical care; ̂ = ̂ ( ) is the estimated conditional probability that individual i will use medical service j. Formally, probability can be estimated as ̂ = ̂ In the case of dichotomous choice, there are only two alternatives (j=0) and (j=1), for example self-care and clinic. The equation predicting medical care use above collapses to: 10 Tran The Hung Master’s Thesis VNP19-2014 ̂( ) = ̂ ̂ ̂ = ̂ ̂ 1 1 This equation is composed of the probability that a clinic visit will be chosen (j=1), times the expected quantity of services purchased, conditional on use. If there is an assumption that the quantity conditional on use is fixed, then one interesting thing is estimating probability of health care use, ̂. From the utility function above, it is clear that utility gained from choosing visit of a clinic depends on health status, income and price; and utility can also gain from x i. According to behavior theory of health care utilization, x i should be a vector of characteristics of individuals and also includes characteristics of households and communities where they live. Considering the utility index associated with the choice of a clinic visit over selfcare, the utility form can be obtained as 1 = 1( , , ℎ , 1) = + + ℎ+ 1 + 1 (a) Where: is a vector of characteristics of individuals, households and communities. is income and ℎ is health status of individual i. p1 is the price of medical services that individual i consume. 2.1.2 Theory of relationship between health insurance and health utilization Nyman (2001) states that people purchase insurance in order to obtain the income transfer which is the difference between any given payoff if ill and the premium. With this income transfer, people tend to consume more health care than they would without insurance and the income transfer can be described by utility theory. 11 Tran The Hung Master’s Thesis VNP19-2014 0 In the absence of insurance, a consumer with initial income, Y would like to maximize his utility when he is sick: 0 The budget constraint is: Y = max ( , ) + Where M is medical care and Y is residual income available for purchases of other goods. With the price of medical care M and assume it is normalized by 1, demand for medical care is = ( , 0 ) = (1, 0 ) When people purchase insurance, they have to pay premium R which cover expected expenses, and the price of medical care reduce from p=1 to c. The budget constraint now is Y0− = + Where: c is the coinsurance rate. The demand for care with insurance becomes = ( , , 0 ) Assume that premium is not fixed (because it covers expected expenses), so R should be a function of = (1 − ) i Where is the probability of illness and (1-c)M is health care expenses paid by the insurer. It is also known as a payoff. As a result, the ill consumer’s budget constraint after insurance is: Y0−(1−) =+ 12