Out of pocket payment for health care in vietnam: An example from the case of appendectomy treatment at sonla general provincial hospital in 2012–2013 – Nguyen Duc Toan

Journal of military pharmaco-medicine n 0 8-2018 124 OUT OF POCKET PAYMENT FOR HEALTH CARE IN VIETNAM: AN EXAMPLE FROM THE CASE OF APPENDECTOMY TREATMENT AT SONLA GENERAL PROVINCIAL HOSPITAL IN 2012 - 2013 Nguyen Duc Toan1; Pham Le Tuan2; Quach Thi Can3 SUMMARY Objectives: To calculate the out of pocket payment for the case of appendectomy treatment at Sonla General Provincial Hospital in 2012 - 2013. Subjects and methods: All of 322 appendicitis patients who were treated at Sonla General Provincial Hospital from Jan 2012 to Dec 2013 were interviewed by using a structured questionnaire. The direct cost for treatment of patients was also collected using payment receipts from the hospital. Data were analyzed using the STATA version 14.0. Results and conclusion: The study found the out of pocket payment for appendectomy treatment was 2.228 million VND and accounted for 43.8% of the total direct cost. The corresponding figure for patients with health insurance was 1.822 million VND and 34.4%. The better health insurance coverage will reduce the out of pocket. * Keywords: Appendectomy treatment; Out of pocket payment; General provincial hospital. INTRODUCTION Out-of-pocket payments (OOPs) are defined as direct payments made by individuals to health care providers at the time of service use. This excludes any prepayment for health services, for example in the form of taxes or specific insurance premiums or contributions and, where possible, net of any reimbursements to the individual who made the payments [8]. Reducing the OOP for health care is a trying of any government in developing countries in order to get equity in health care. In Vietnam, National health insurance was introduced in 1992. Time by time, the health insurance (HI) coverage has increased and it’s an important factor effecting to reduce the OOP. There are some studies in Vietnam to look at the OOP and/or financial burden of household in general [5, 6] or a group of diseases, like non comunicable disease [4] but it’s limitation of OOP for Sonla province specially and for the whole of Vietnam in generally. So that, this study was conducted with aim: To calculate the out of pocket payment for the case of appendectomy treatment at Sonla General Provincial Hospital in 2012 - 2013. SUBJECTS AND METHODS 1. Subjects. 322 patients who were hospitalized for appendectomy treatment during the period from Jan 2012 to December 2013. 1. ENT Hospital, Hochiminh City 2. Medicine and Pharmacy University 3. Medicine and Pharmacy University Corresponding author: Nguyen Duc Toan (@gmail.com) Date received: 01/08/20181 Date accepted: 24/09/2018 Journal of military pharmaco-medicine n 0 8-2018 125 SUBJECTS AND METHODS 1. Subjects. 322 patients who were hospitalized for appendectomy treatment during the period from Jan 2012 to December 2013. 2. Methods. * Study design and setting: It was a cross sectional study during the time from Jan 2012 to Dec 2013 at the Sonla General Provincial Hospital. * Data collection: Face-to-face interview using a structured questionnaire was conducted with either patients themselves or their close relatives. The interview was conducted immediately after hospitalization at patients’room. The longest interval was 3 months. Interviewers included 15 medical doctors who worked at the general provincial hospital. However, some expenditure also got from the Finance Department of the Hospital. * Data analysis: STATA program version 14.0 was used for data analysis. The costs were calculated by using mean (SD) and median (25 - 75%). The non- parameter Mann-Whitney test was used for testing the difference in the cost between different groups. RESULTS AND DISCUSSION * Characteristics of patients: Among 322 patients studied, more than 80% were from 18 to 60 years old and up. The mean of age was 41.7 ± 18.2 years. The proportion of male and female was 53.1% and 46.9%, respectively. The main occupation was farmer (35.4%), following public servants (19.9%). Unemployment was accounted for 13.7%. The patients had HI was 265 patients (82.3%), among them only 10 patients covered 100% by HI. Average duration time for appendectomy treatment was about 5 days. These figures were similar to the information from 103 Military Hospital [3]. The number of appendectomy cases at Sonla General Provincial Hospital in 2012 and 2013 were about almost the same as number of that at 103 Military Hospital in 1995 [3]. Table 1: Direct cost for one case of appendectomy treatment. Unit: Million VND Cost Median (25 - 75%) p* With HI (n = 265) Without HI (n = 57) Direct medical cost 4,400 (2,698 - 5,271) 3,200 (2,494 - 4,471) < 0,05 Paid by HI 3,436 (1,669 - 4,466) 0 < 0,05 Paid by patients 0,474 (0,277 - 1,050) 3,200 (2,494 - 4,471) < 0,05 Direct non-medical cost 0,650 (0,430 - 1,030) 0,620 (0,410 - 0,900) > 0,05 Indirect cost 0,420 (0 - 0,900) 0,500 (0 - 1,000) > 0,05 Total cost 5,504 (3,766 - 6,985) 4,478 (3,400 - 5,902) < 0,05 (* Mann-Whitney test) Journal of military pharmaco-medicine n 0 8-2018 126 There was about 18% of studied patients having no HI. The difference between group with and without HI was statistically significant for some comparison except the direct non-medical cost and indirect cost. (*: Direct cost and OOP were significantly different between different groups). Figure 1: Average OOP and HI payment for direct cost (Unit: thousand VND). For the patients without IH, they had to pay 100%, while the patients with HI had to pay 34.4% for direct cost of appendectomy treatment. The OOP percentage was different from year 2012 and 2013 and from open surgery and laparoscopy. In general, the OOP was 2,228 million VND and accounted for almost 44.0% of total direct cost. The direct cost and OOP were statistically significant difference by years, surgery methods and between those with and without HI (p < 0.05). So far, we have not found the timing relevant figures to compare with the result of our study. But in Pakistan in 2004 - 2004, OOP on health care was 67% [6]. Hoang Van Minh and others showed OOP in Vietnam at some points of time was much lower than that from our study: in 2002; 2004; 2006; 2008 and 2010 was VND 67,300; VND 126,400; VND 114,000; VND 201,300; and VND 243,000, respectively [5]. The difference between OOP absolute figures in Hoang Van Minh,s study and our study can be explained by the methodology. We just calculated OOP for a specific acute case at one province while Hoang Van Minh analyzed data from a sery of National surveys. Journal of military pharmaco-medicine n 0 8-2018 127 Table 2: Detail direct cost for appendectomy treatment. Unit: Million VND Cost item Paid by HI Paid by patients (OOP) Median (25 - 75%) Mean ± SD % Median (25 - 75%) Mean ± SD % Laboratory test 0.268 (0 - 0.473) 0.296 ± 0.262 62.4 0.081 (0.028 - 0.322) 0.178 ± 0.200 37.6 Medicines 0.925 (0 - 1.509) 1.324 ± 1.979 70.1 0.245 (0.090 - 0.104) 0.564 ± 0.636 29.9 Operation 0.978 (0 - 1.794) 1.045 ± 1.012 63.1 0.210 (0.068 - 0.595) 0.610 ± 0.853 36.9 Consumables 0.045 (0 - 0.076) 0.051 ± 0.059 66.2 0,011 (0.004 - 0.046) 0.026 ± 0.030 33.8 Consultation and bed 0.037 (0 - 0.228) 0.138 ± 0.187 63.0 0.060 (0.008 - 0.108) 0.081 ± 0.095 37.0 Others (Direct non-medical) 0 0 0 0.650 (0.430 - 0.980) 0.768 ± 0.462 100.0 All patients 2.537 (0 - 4.181) 2.856 2.973 56.2 1.564 (1.027 - 2.901) 2.228 ± 1.696 43.8 All direct non-medical payment was covered by 100% patients. Beside as it included transportation fees, food, accommodation for the patients and their relatives. For all patients, the expenditures for medicine was accounted for nearly 30%. These figures came not only from non-insured patients but from all patients together. The result looked like that as there are lists of tests and of medicines that HI will cover. The tests or medicines are not included in the lists patients have to pay regardless with or without IH. For example, the test to detect is not included in the list. Table 3: Expenditure for medicines of appendectomy treatment. Unit: thousand VND Kind of Medicines Paid by HI (n = 322) OOP (n = 322) p Mean (25 - 75%) % Median (25 - 75%) % Antibiotics 0.714 ± 0.977 53.9 0.363 ± 0.417 64.4 < 0.05 Painkiller 0.162 ± 0.161 12.2 0.097 ± 0.121 17.2 < 0.05 Infusion 0.318 ± 0.844 24.0 0.080 ± 0.113 14.2 < 0.05 Other medicines 0.131 ± 0.571 9.9 0.024 ± 0.097 4.2 < 0.05 Total 1.324 ± 1.979 100 0.564 ± 0.636 100 < 0.05 The biggest parts of OOP medicines were for antibiotics and painkillers. It’s reasonable because the operated patients are suffering from the pain and have high risk with infection. Journal of military pharmaco-medicine n 0 8-2018 128 The table 4 showed that the higher income patients had the less paid by HI. The patients who paid all by themself had daily income almost three time higher than that of patients who were totally covered by HI. It’s not be sure to say that the better income group had no HI. Appendectomy treatment can be done at district hospitals and the HI will pay for insured patients but for some cases the insured want to take health service at higher level and they are able and happy to pay. The study had some limitation, such as: - Recall bias could be existed in the case of the interviewing was conducted long time after the hospitalization. - It did not include the household income and economical quintile groups, therefore we cannot calculate the economical burden of the household in general and for each quintile group. - It just look at OOP for one acute condition (one episode) at individual level but not for the whole family for longer time period (usually one year). Table 4: OOP payment in comparison with studied patients’ income. Unit: thousand VND Subject OOP Average daily Income Ratio Totally covered by HI (n = 10) 650,0 36.0 18.1 Partly covered by HI (n = 265) 1,959.5 94.4 20.8 Totally covered by OOP (n = 57) 4,478.0 107.7 41.6 All patients 2,270.7 94.9 23.9 Averagely, the patients had to pay 23.9 daily income for appendectomy treatment at the province hospital. The figure for patients with totally covered by HI, partly covered by HI and totally covered by themselves was 18.1; 20.8 and 41.6 daily income, respectively. The more covered by HI the less daily income was. CONCLUSION The average OOP for appendectomy treatment at Sonla General Provincial Hospital in 2012 and 2013 for all patients was 2,228 million VND and accounted for 43.8% of total direct cost. The corresponding figure for patients with HI was 34.4%. The better HI coverage will reduce the OOP. REFERENCES 1. The Sonla provincial ethnic committee. The report N 0 53/BC-BDT on the situation of ethnic minorities and the implementation of policies for small ethnic minority groups. 2018. 2. The Ministry of Labour, Invalids and Social Affairs. Decision 749/QĐ-LDTBXH dated 13 rd May 2013 approving the results of the survey on poor households. 2013. Journal of military pharmaco-medicine n 0 8-2018 129 3. 103 Military Hospital. Acute appendicitis. Internet access, available on 3 rd Sept. 2018. 4. Vu Duy Kien, Hoang Van Minh, Kim Bao Giang, Amy Dao, Le Thanh Tuan and Nawi Ng. Socioeconomic inequalities in catatrophic health expenditure and impoverishment associated with non-communicable disease in urban Hanoi, Vietnam. International Journal for Equity in Health. 2016, 5, 169. DOI 10.1186/s12939-016-0460-3. 5. Hoang Van Minh, Nguyen Thi Kim Phuong, Privanka Saksena Chris D.James, Ke Xu. Financial burden of household out-of pocket health expenditure in Viet Nam: Findings from the National living standard survey 2002 - 2010. Social Science & Medicine. 2012, pp.1-6. 6. Ashar Muhammad, Azam Syed. Socio- economic determinants of household out-of- pocket payments on healthcare in Pakistan. Int J. Equity Health. 2012, pp.11-51. 7. Natascha Wagner, Stella Quimbo, Riti Shimkhada, John Peabody. Does health insurance coverage or improved quality protect better against out-of-pocket payment? Experimental evidence from the Philippines. Social Science & Medicine. 2018, 204, pp.51-58. 8. WHO. Out-of-pocket payments, user fees and catastrophic expenditure www.who.int/health_financing/topics/financial- protection/out...pocket-payments.