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 Loan

259 JOURNAL OF SCIENCE, Hue University, N0 61, 2010 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 College of Medicine and Pharmacy, Hue University Nguyen Mau Duyen Health services of Thua Thien Hue Province SUMMARY This study was carried out in a rural commune of Thua Thien Hue province with the objectives to survey the access to health care services amongst households and to assess health financial burden from the perspective of the household. Methods: 200 representatives of households who had a member with an illness in 2008 were interviewed directly. A prepared questionnaire was used during the interview. Results: 39.3% of households used outpatient services in commune health centres. 72% of inpatient services were at Hue central hospital. The ratio of health care expenditure to total income of the poor households was higher than that of the rich group (119.3% vs 0.6%). The highest health expenditure of the households was for pharmaceuticals. Conclusion: There are evidences of the increase in the use of public health care services, especially basic health levels and a rise in out of pocket expenses in households for inpatient services. Consequently, illness within the poor families incurred excessive financial burden, exceeding their ability to pay. Key words: health expenditure, health insurance, inpatient, outpatient, basis health level, inequity, hospital fee, out of pocket, ability to pay. 1. Introduction Vietnam is classified as a low income country. 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, which ranked the third among countries in Asia, after Cambodia and India. 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. 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 260 public health care services for the poor, such as increasing investment in the health sector focusing on difficult areas and ethnic minorities, increasing budgets to develop a basic health network, exempting the poor from health service fees, and expanding the cover of health insurance. 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. The aim was to survey access to health care services and health expenditure of the households. The results of the study will contribute evidence for use in policies for improving equity and effectiveness in health care. Objectives of the study are to survey the access to health care services amongst households in Thuy Van commune, Huong Thuy district and assess health financial burden from the perspective of the household. 2. Methodology 2.1. Study subject Households who had a member with illness in 2007-2008 in Thuy Van commune, Huong Thuy district, Thua Thien Hue province 2.2. Study design A quantitative, descriptive study with a cross sectional survey was conducted. Health expenditure from the household perspective was of interest. Both direct costs and indirect costs were collected. In term of direct costs, both medical costs and non medical costs that were incurred by households were included. However, only income lost by illness was considered as an indirect cost in the study. Data was collected by directly interviewing households using a designed questionnaire. - Cases who experienced illness within 4 weeks before the investigation were interviewed. - Cases who used inpatient services within 12 months before investigation were also interviewed. Annual income per person of each household was estimated by dividing the sum of the annual income of the household by the number of members of that household. The income included salary, and revenue or monetary value of farm products. A P value = 0.05 was used to test statistically significant level. 2.3. Selection of study sample - A list of the households that had members with illness within 1 year before the investigation was reported by village health workers. - The total of 210 households was listed. About 10 households were excluded 261 from the study because they were not available during the time period of the study. The 200 households were included in the study. They located all villages of the commune. - Representatives of the selected households were interviewed. Participants were adults who knew clearly their family situations in terms of finance and health. 3. Results 3.1. Situation of the use of health care services of people in Thuy Van commune 3.1.1. Choosing health care services for acute illness Table 1. The percentage of households choosing the place of treatment Types of health care services Health facility Total Commune health centre (CHC) Transport hospital Hue city hospital Hue Central hospital Private health Self- treatment 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) Table 1 showed that most of households used outpatient services at the CHC to treat diseases occurring within 4 weeks before the time of investigation (39.3%). Self- treatment and private services were also utilised considerably (30.5% and 21.5% respectively). Only 4 cases used inpatient services at the hospital for acute illness. It was reported that 50% of participants used the transport hospital and 50 % used Hue central hospital. Table 2. Reasons for choosing public health facility for outpatient services Unit: % Reason CHC Transport hospital Hue city hospital Hue Central hospital Health insurance registration 81.8 80 100 100 Near their home 13.7 20 0 0 262 Time saving 0 0 0 0 Good quality 0 0 0 0 Others 4.5 0 0 0 Total 100 100 100 100 (p=0,806) Table 2 illustrates that public health facilities were chosen for outpatient services because they are the registered address of health insurance. Close proximity to their home was also an important reason. Quality of health services and saving time were not considered for these selections. However the differences among reasons were not statistical significant (p>0.05) 3.1.2. Choosing health facility for inpatient services within 12 months before the investigation Table 3. Choosing public health facility for inpatient services CHC Area clinics Transport hospital City hospital Hue Central hospital No treatment Total No of households 5 2 37 11 144 1 200 % 2.5 1 18.5 5.5 72 0.5 100 The results of table 3 showed that hospitals were a common selection for inpatient treatment within 12 months before the investigation. 72% of households came to Hue central hospital, 18.5% of households chose the Transport hospital and 5.5% of households were interested in the city hospital. Only 2.5% of them were treated at the CHC. Specially, 0.5% of them reported that they did not access any health facility. Table 4. Reasons of choosing public health facilities for inpatient services Unit: % Reasons Health facility CHC Area clinics Transport hospital City hospital Central hospital Health insurance registration 80 100 81.1 63.6 5.6 Referred by low level 0 0 18.9 27.3 6.3 Serious disease 0 0 0 0 40.6 263 Self-selection 0 0 0 9.1 19.6 Other 20 0 0 0 28 Total 100 100 100 100 100 (p= 0,000) Table 4 showed reasons for selection of health facilities for inpatient services. Besides the central hospital, the main reason reported was the health insurance registration address in all health facilities. City hospital, transport hospital and central hospital received patients referred from lower levels with 27.3%, 18.9% and 6.3% respectively. In the case of severe diseases, selections were Hue central hospital (40.6%). Self-selection of households for inpatient services only occurred at Hue central hospital and Hue city hospital (19.6% & 9.1% respectively). 3.2. Health financial burden of households 3.2.1. Outpatient expenditure as proportion of household income Percentage of health expenditure for outpatient service among the total income 0 0.05 0.1 0.15 0.2 0.25 0.3 0.35 Poor Near poor Average Near rich Rich Income group % (p=0.384) Figure 1. Average ratio of outpatient costs to household income Figure 1 showed expenditure for outpatient services within the 4 weeks before investigation compared with the total income of households. The households of the poor, the near poor and the average groups incurred a ratio of health expense to the total income higher than that of the rich and near rich groups (0.28%; 0.29% and 28% compared to 0.1% and 0.02%). However, the difference was not statistically significant (p>0.384) 264 3.2.2. Inpatient expenditure as proportion of household income Table 5. Average ratio of inpatient costs to household income within 12 months Level 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) Table 5 showed that the poor households spent 119.3% of the total income on inpatient services whereas the rich households spent only 0.6%. 3.2.3. Items the households must paid for using health services Table 6. Items the households must paid for using health services Items Payment (VND) Outpatient Inpatient 1. Travel 2700 15,725 2. Medicines 44.935 322,025 3. Hospital Fee 1250 42,750 4. Private consultant fee 1475 5. Laboratory test 150 6. Food related to treatment 7600 7. Food 48,050 8. Accommodation (not including food) 2500 9. Others 4800 10500 Table 6 describes average expenditure for items the households must paid for using health care services. The highest expenditure of the households for health services was medicines. The average expense of medicines for outpatient services was 44,935 VND/household and for inpatient services was 322,025 VND/household. Food and hospital fees were considerable expenses for inpatient services, with 48,050 VND and 42,750 VND respectively. 265 4. Discussion 4.1. Situation of using health services of households in Thuy Van commune 4.1.1. Choosing outpatient services Interviewing household representatives with cases of illness within 4 weeks before the survey showed that outpatient services were used the most for acute illness (56/60 cases). 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%). Self-treatment and private clinics were also chosen, with 30.5% and 21.5% respectively. 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. However, criteria such as good service quality and time saving were not of interest to respondents in this study. 4.1.2. Choosing inpatient services Hospitals were a common selection for inpatient services. The registration address of health insurance was an explanation for using health care services at second level hospitals. The distribution is relevant because it reduced overloading at high level hospitals1. However, 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. Hue central hospital is the highest health care level in Thua Thien Hue province. The availability of modern equipment and techniques, and good health staff has attracted a large number of patients to the 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. The distance of health care allocation and economic problems can affect the poor’s access to health care services. Health financial burden of households in Thuy Van commune Low income households incur higher health financial burden than the rich group for health care services. 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, the study only surveyed expenses for outpatient services within 4 weeks. This ratio for inpatient services 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 households7. 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 266 duration of illness in the poor and including indirect costs in our study are possible explanations for the difference. 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. Among the health care expenditure, highest amount was spent on drugs. Studies showed that out of pocket expenses were generally spent on drugs, 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. Hospital fees also increased health financial burden of households, even in the cases covered by the health insurance scheme. The use of health care services at levels outside of distribution of health insurance scheme resulted in this problem. The hospital fee is considered a reason for the delay in seeking care because of financial constraints among poor people. There is evidence that 0.5% of households in the study did not use any health care services, or they might treat themselves at home. The negative effects of user fees have been linked to poorer health and higher medical expenditure. 5. Conclusion and Recommendation 5.1. 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. However, 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 and hospital fees. Consequently, 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. More efforts for equity and efficiency in the health care system are needed from a household perspective. 5.2. Recommendation On the basis of results from the study, we would like to suggest some recommendations (1) The health insurance system should include community-based health 267 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. (2) Strengthening government regulations concerning the management of the medicine market and development and implementation of an essential drug programme could ensure the highest possible value for money spent on health services and drugs. (3) 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. These solutions hope to contribute to the improvement of health and reduce inequity in health care. REFERENCES 1. Ministry of Health. Evaluating the effectiveness of using health services. National health investigation 2001-2002. Medicine Publisher, 2003. 2. Ministry of Health. Support policy of Government in health care- perspective of beneficiary. National health investigation 2001-2002. Medicine Publisher, 2003. 3. Vietnam – Sweden collaboration program. Health financial solutions for the poor. Medicine Publisher, 2007. 4. WHO, index of health development, 2006. 5. Margaret Whitehead et al. Equity and health sector reforms: can low-income countries escape the medical poverty trap? Lancet 2001; 358:833-36. 6. The World Bank group, Financing health systems in the 21st century, World Bank 2006. 7. Malcolm Segall et al. 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