Trends in out-of-pocket expenditure on facility-based delivery and financial protection of health insurance: findings from Vietnam's Household Living Standard Survey 2006-2018.

Much of the existing empirical literature on the association between health insurance and out-of-pocket (OOP) expenditures on facility-based delivery in low- and middle-income countries is cross sectional in nature. Comparatively little is known about the dynamic shifts in OOP expenditures and the health insurance nexus. Using seven biennial waves of Vietnam's Household Living Standard Survey covering the period 2006-2018 and a generalized linear model this study examines trends in OOP expenditures on facility-based delivery and financial protection afforded by Vietnam's social health insurance system. Over the period under consideration, the pattern of health facility utilization among the insured shifted steadily from commune health centers towards higher-level government hospitals. Real OOP for delivery was 52.7% higher in 2018 than in 2006-2008 and insurance reduced OOP expenditures by 28.5%. Compared to district hospitals, giving birth at higher-level government hospitals increased OOP expenditures by 72.3% while giving birth at commune health centers reduced OOP expenditures by 55.7%. Additional analysis involving interactions between insurance status, types of public health facility and year dummies suggested a drop in financial protection of insurance, from 48% to 26.9% among women delivering at district hospitals and from 31.2 to 18.7% among those delivering at higher-level government hospitals. The modest financial protection of health insurance and its declining trend calls for policy measures that would strengthen the quality of maternal care at primary care institutions, strengthen financial protection and curb the provision of two-tiered clinical services and charges.

Institutional setting and wealth gradients in cesarean delivery rates: Evidence from six developing countries.

BACKGROUND: The influence of the type of institutional setting on cesarean delivery is well documented. However, the traditional boundaries between public and private providers have become increasingly blurred with the commercialization of the state health sector that allows providers to tailor the quantity and quality of care according to patients' ability to pay. This study examined wealth-related variations in cesarean rates in six lower- and upper-middle income countries: the Dominican Republic, Egypt, Guatemala, Jordan, Pakistan, and the Philippines. METHODS: Demographic and Health Survey data and a hierarchical regression model were used to assess wealth-related variations in cesarean rates in government and private hospitals while controlling for a wide range of women's socioeconomic and risk profiles. RESULTS: The odds of undergoing a cesarean delivery were greater in private facilities than government hospitals by 58% in Jordan, 129% in Guatemala, and 262% and 279% in the Dominican Republic and Egypt, respectively. Additional analysis involving interactions between the type of facility and wealth quintiles indicated that wealthier women were more likely to undergo a cesarean birth in government hospitals than poorer women in all countries but the Dominican Republic and Guatemala. Moreover, in both Egypt and Jordan, differences in cesarean rates between government and private hospitals were smaller for the wealthier strata than for the nonwealthy. CONCLUSIONS: Large wealth-related variations in the mode of delivery across government and private hospitals suggest the need for well-developed guidelines and standards to achieve a more appropriate selection of cases for cesarean delivery.

Regional Gradients in Institutional Cesarean Delivery Rates: Evidence from Five Countries in Asia.

BACKGROUND: Although the influence of the type of institutional setting on the risk of cesarean birth is well documented, less is known about the regional variations in institution-specific cesarean rates within countries. Our purpose was to examine regional variations in cesarean rates across public and private facilities in five Asian countries with a sizeable private sector: Bangladesh, India, Indonesia, Pakistan, and the Philippines. METHODS: Demographic Health Survey data and a hierarchical model were used to assess regional variations in the mode of delivery while controlling for a wide range of socioeconomic, demographic, and maternal risk factors. RESULTS: The risk of cesarean birth was greater in a private facility than in a government hospital by 36-48 percent in India and Indonesia and by 130 percent in Bangladesh. Regional gradients in cesarean birth were found to be steeper for deliveries in private facilities than in government hospitals in India, Indonesia, and the Philippines. The residents of India's high-use states were 55 percent more likely to undergo a cesarean delivery in a government hospital and 83 percent more likely in a private facility than their counterparts in the medium-use states. Similarly, compared to the residents of the Philippines's medium-use provinces, giving birth in a government facility increased the likelihood of a cesarean delivery by 84 percent and by 173 percent in a private facility. CONCLUSIONS: Large regional variations in cesarean rates suggest the need for more informed clinical decision making with respect to the selection of cases for cesarean delivery and the establishment of well-developed guidelines and standards at the provincial or state levels.

The impact of the global economic crisis on HIV and AIDS programmes directed at women and children in Zambia.

This investigation sought to ascertain the extent to which the global economic crisis of 2008-2009 affected the delivery of HIV/AIDS-related services directed at pregnant and lactating mothers, children living with HIV and children orphaned through HIV in Zambia. Using a combined macroeconomic analysis and a multiple case study approach, the authors found that from mid-2008 to mid-2009 the Zambian economy was indeed buffeted by the global economic crisis. During that period the case study subjects experienced challenges with respect to the funding, delivery and effectiveness of services that were clearly attributable, directly or indirectly, to the global economic crisis. The source of funding most often compromised was external private flows. The services most often compromised were non-medical services (such as the delivery of assistance to orphans and counselling to HIV-positive mothers) while the more strictly medical services (such as antiretroviral therapy) were protected from funding cuts and service interruptions. Impairments to service effectiveness were experienced relatively equally by (HIV-positive) pregnant women and lactating mothers and children orphaned through HIV. Children living with AIDS were least affected because of the primacy of ARV therapy in their care.

A Critique of Grossman's Canonical Model of Health Capital.

In the health economics literature, the demand for health and market health inputs is dominated by adaptations of Grossman's health capital model. The model has been widely used to explore a wide range of issues related to health, socioeconomic inequalities in health, demand for medical care, health preventions, occupational choice, and retirement decisions. The commodity of health is viewed as a durable capital stock that yields a flow of healthy time or illness-free time, that depreciates with age, and that can be augmented with the help of market health inputs and own time. The purpose of this article is to provide a comprehensive critical review of the model. Underlying Grossman's model are a faulty conceptual framework and assumptions that tend to exaggerate the degree of control consumers/patients may have over their state of health and survival. The assumption of full information about one's state of health and the efficacy of various health inputs abstracts away from the problems posed by the agency relationship under uncertainty and informational asymmetry. Grossman's individualistic and mechanistic view of health strips health capital and its production of much of their biological/physiological content and their interactions with the individual's social and physical environment.

Socioeconomic status and children's health: evidence from a low-income country.

There has been a growing empirical literature on the relationship between household socioeconomic status (SES) and children's health, and in particular, whether this SES gradient is constant or varies in strength across different life stages. Much of this literature focuses on the developed countries and less evidence has been presented for developing countries. Using Vietnam's rich National Health Survey (2001-02) and appropriate multilevel modeling this study empirically assesses the SES gradient in health and whether it varies in strength across different life stages of children aged 15 and younger (N = 45,448). The results for the interaction terms between the natural logarithm of household consumption and age groups indicate no evidence of a steeper health gradient for older children. However, health-consumption gradients are found to be sensitive to the functional form of the regression model as well as the model specification. The results for the interaction terms between consumption expenditure quintiles and age groups indicate that gradients vary in strength across ages. Not only are children from the poorest households worse off, compared to those from the richest households, but this relative disadvantage is greater among the 0-3 year olds. The inclusion of parental health status in the regression model weakens the gradients for all age groups as does the inclusion of household sources of drinking water. However, poorer children are still relatively worse off, specially the 0-3 year olds. This suggests that absolute deprivation may help explain the relative health disadvantage of younger children. Better measures of poverty alleviation are hence needed to improve children's health in a low-income country such as Vietnam.

Income and regional gradients in being without a regular doctor: does the slope of gradients decrease for those with greater health needs?

OBJECTIVE: Income and regional gradients in being without a regular family doctor have been reported. The study objective was to assess the extent to which the slopes of both income and regional gradients vary by individuals' health needs. METHOD: Using the Canadian Community Health Survey and multivariate regression analyses, the study examined the income and interprovincial variations in potential access among the healthy and less healthy populations. RESULTS: The presence of chronic conditions was associated with lower variations in income-related potential access, with the income gradient flattening at the second-lowest income category. Similarly, the presence of two or more chronic conditions flattened interprovincial variations in potential access. CONCLUSIONS: The results suggest a greater equity in having a regular doctor on the basis of need. Systemic changes might be needed to enhance potential access among the vulnerable segment of the population.

Does autonomization of public hospitals and exposure to market pressure complement or debilitate social health insurance systems? Evidence from a low-income country.

Granting public hospitals greater autonomy and creating organizational arrangements that mimic the private sector and encourage competition is often promoted as a way to increase efficiency and public accountability and to improve quality of care at these facilities. The existence of good-quality health infrastructure, in turn, encourages the population to join and support the social health insurance system and achieve universal coverage. This article provides a critical review of hospital autonomization, using Vietnam's experience to assess the influence of hospital autonomy on the sustainability of Vietnam's social health insurance. The evidence suggests that a reform process based on greater autonomy of resource mobilization and on the retention and use of own-source revenues can create perverse incentives among managers and health care providers, leading to the development of a two-tiered provision of clinical care, provider-induced supply of an inefficient service mix, a high degree of duplication, wasteful investment, and cost escalation. Rather than complementing social health insurance and helping the country to achieve universal coverage, granting public hospitals greater autonomy that mimics the private sector may indeed undermine the legitimacy and sustainability of social health insurance as health care costs escalate and higher quality of care remains elusive.

How much do I save if I use my health insurance card when seeking outpatient care? Evidence from a low-income country.

Much of the existing literature on the financial protection of health insurance focuses on the impact of insurance status on total out-of-pocket expenditure on all sorts of care sought, regardless of whether the insured patients use their health insurance cards. Using Vietnam's 2006 Household Living Standard Survey data and an appropriate multivariate regression model, this article assesses the influence of Vietnam's three health insurance schemes on out-of-pocket expenditures with and without controlling for the actual use of the health insurance card when seeking outpatient care. Vietnam's experience suggests that insurance provides some financial protection, provided that insurance benefits are actually accessed. Compared with private fee-paying patients, the use of the insurance card reduces out-of-pocket expenditures, on average, by as much as 50-56%. In contrast, failure to control for the use of the health insurance card reduces the financial protection of insurance to 26-37%. However, the financial protection benefits afforded by Vietnam's insurance schemes are distributed rather inequitably. Insurance reduces out-of-pocket expenditures by as much as 71-75% for contacts at the major state hospitals, as compared with 26-38% for contacts at the community health centres. The overall financial protection provided by insurance is also found to be larger for the higher-income individuals than the middle- and low-income individuals. Efforts to ensure that all enrollees receive equitable and good-quality health services according to the benefits package appear warranted. Improving the quality of care provided by the community health centres-the main access point for medical care for many enrollees with health insurance for the poor coverage-and a more effective referral system may also be a cost-effective way of channelling outpatient service contact to the lower-level health facilities, away from the overcrowded higher-level health facilities.

Determinants of prenatal care use: evidence from 32 low-income countries across Asia, Sub-Saharan Africa and Latin America.

While much has been written on the determinants of prenatal care attendance in low-income countries, comparatively little is known about the determinants of the frequency of prenatal visits in general and whether there are separate processes generating the decisions to use prenatal care and the frequency of use. Using the Demographic and Health Surveys data for 32 low-income countries (across Asia, Sub-Saharan Africa and Latin America) and appropriate two-part and multilevel models, this article empirically assesses the influence of a wide array of observed individual-, household- and community-level characteristics on a woman's decision to use prenatal care and the frequency of that use, while controlling for unobserved community level factors. The results suggest that, though both the decision to use care and the number of prenatal visits are influenced by a range of observed individual-, household- and community-level characteristics, the influence of these determinants vary in magnitude for prenatal care attendance and the frequency of prenatal visits. Despite remarkable consistency among regions in the association of individual, household and community indicators with prenatal care utilization, the estimated coefficients of the risk factors vary greatly across the three world regions. The strong influence of household wealth, education and regional poverty on the use of prenatal care suggests that safe motherhood programmes should be linked with the objectives of social development programmes such as poverty reduction, enhancing the status of women and increasing primary and secondary school enrolment rate among girls. Finally, the finding that teenage mothers and unmarried women and those with unintended pregnancies are less likely to use prenatal care and have fewer visits suggests that safe mother programmes need to pay particular attention to the disadvantaged and vulnerable subgroups of population whose reproductive health issues are often fraught with controversy.

Does the type of provider and the place of residence matter in the utilization of prenatal ultrasonography? Evidence from Canada.

BACKGROUND: There has been a proliferation of repeat prenatal ultrasound examinations per pregnancy in many developed countries over the past 20 years, yet few studies have examined the main determinants of the utilization of prenatal ultrasonography. OBJECTIVE: The objective of this study was to examine the influence of the type of provider, place of residence and a wide range of socioeconomic and demographic factors on the frequency of prenatal ultrasounds in Canada, while controlling for maternal risk profiles. METHODS: The study utilized the data set of the Maternity Experience Survey (MES) conducted by Statistics Canada in 2006. Using an appropriate count data regression model, the study assessed the influence of a wide range of socioeconomic, demographic, maternal risk factors and types of provider on the number of prenatal ultrasounds. The regression model was further extended by interacting providers with provinces to assess the differential influence of types of provider on the number of ultrasounds both across and within provinces. RESULTS: The results suggested that, in addition to maternal risk factors, the number of ultrasounds was also influenced by the type of healthcare provider and geographic regions. Obstetricians/gynaecologists were likely to recommend more ultrasounds than family physicians, midwives and nurse practitioners. Similarly, birthing women who received their care in Ontario were likely to have more ultrasounds than women who received their prenatal care in other provinces/territories. Additional analysis involving interactions between providers and provinces suggested that the inter-provincial variations were particularly more pronounced for family physicians/general practitioners than for obstetricians/gynaecologists. Similarly, the results for intra-provincial variations suggested that compared with obstetricians/gynaecologists, family physicians/GPs ordered fewer ultrasound examinations in Prince Edward Island, British Columbia, Nova Scotia, Alberta and Newfoundland. CONCLUSION: After controlling for a number of socioeconomic and demographic factors, as well as maternal risk factors, it was found that the type of provider and the province of prenatal care were statistically significant determinants of the frequency of use of ultrasounds. Additional analysis involving interactions between providers and provinces indicated wide intra- and inter-provincial variations in the use of prenatal ultrasounds. New policy measures are needed at the provincial and federal government levels to achieve more appropriate use of prenatal ultrasonography.

What impact does contact with the prenatal care system have on women's use of facility delivery? Evidence from low-income countries.

Prenatal and delivery care are critical both for maternal and newborn health. Using the Demographic and Health Surveys (DHS) data for thirty-two low-income countries across Asia, sub-Saharan Africa and Latin America, and employing a two-level random-intercept model, this paper empirically assesses the influence of prenatal attendance and a wide array of observed individual-, household- and community-level characteristics on a woman's decision to give birth at a health facility or at home. The results show that prenatal attendance does appreciably influence the use of facility delivery in all three geographical regions, with women having four visits being 7.3 times more likely than those with no prenatal care to deliver at a health facility. These variations are more pronounced for Sub-Saharan Africa. The influence of the number of prenatal visits, maternal age and education, parity level, and economic status of the birthing women on the place of delivery is found to vary across the three geographical regions. The results also indicate that obstetrics care is geographically and economically more accessible to urban and rural women from the non-poor households than those from the poor households. The strong influence of number of visits, household wealth, education and regional poverty on the site of delivery setting suggests that policies aimed at increasing the use of obstetric care programs should be linked with the objectives of social development programs such as poverty reduction, enhancing the status of women, and increasing primary and secondary school enrollment rate among girls.

Does the financial protection of health insurance vary across providers? Vietnam's experience.

Using household panel data from Vietnam, this paper compares out-of-pocket health expenditures on outpatient care at a health facility between insured and uninsured patients as well as across various providers. In the random effects model, the estimated coefficient of the insurance status variable suggests that insurance reduces out-of-pocket spending by 24% for those with the compulsory and voluntary coverage and by about 15% for those with the health insurance for the poor coverage. However, the modest financial protection of the compulsory and voluntary schemes disappears once we control for time-invariant unobserved individual effects using the fixed effects model. Additional analysis of the interaction terms involving the type of insurance and health facility suggests that the overall insignificant reduction in out-of-pocket expenditures as a result of the insurance schemes masks wide variations in the reduction in out-of-pocket sending across various providers. Insurance reduces out-of-pocket expenditures more for those enrollees using district and higher level public health facilities than those using commune health centers. Compared to the uninsured patients using district hospitals, compulsory and voluntary insurance schemes reduce out-of-pocket expenditures by 40 and 32%, respectively. However, for contacts at the commune health centers, both the compulsory health scheme and the voluntary health insurance scheme schemes have little influence on out-of-pocket spending while the health insurance scheme for the poor reduces out-of-pocket spending by about 15%.

Who is giving up the free lunch? The insured patients' decision to access health insurance benefits and its determinants: Evidence from a low-income country.

OBJECTIVES: This paper examines the determinants of the insured's decision to use their health insurance card when seeking outpatient and inpatient health care in Vietnam. METHODS: Uses Vietnam's latest Household Living Standard Survey data and random-intercept logistic regression to assess the influence of the observed individual, household and commune/ward factors on the insured's decision to access health insurance benefits while controlling for the unobserved commune/ward-specific factors. RESULTS: Compared to the compulsory enrollees, the voluntary enrollees and the beneficiaries of the Health Care Fund for the Poor are less likely to use their card when seeking inpatient care. An individual's likelihood of accessing insurance benefits varies inversely with income and the level of education, suggesting that the outpatient care provided to the insured is of inferior quality. CONCLUSIONS: Although health insurance has the potential of increasing access and reducing the financial burden of health care utilization, Vietnam's experience clearly suggests that these benefits may not be fully realized as long as the quality of care remains low and the high opportunity costs of accessing insurance benefits deter the insured from accessing benefits.

Taking account of context: how important are household characteristics in explaining adult health-seeking behaviour? The case of Vietnam.

Understanding the factors affecting the utilization of health services is essential for health planners, especially in low income countries where increasing access to and use of health services is one of the main policy goals of government. While much has been written on adult health-seeking behaviour, there is comparatively little known about the influence of the broader context such as the effects of family and community on individual use of health care services in low income countries. Using Vietnam's latest National Household Survey data, this paper empirically assesses the influence of individual- and household-level factors on the use of health care services, while controlling for the unobserved household-level effects. The estimates obtained from a multilevel logistic regression model suggest that the individual's likelihood of seeking treatment is jointly determined by the observed individual- and household-level characteristics as well as unobserved household-level effects. The chance of seeking medical treatment when ill varies strongly with the observed individual- and household-level covariates, including health insurance status, income, the type and severity of illness, the number of other household members with an ailment and the presence of young children in the household. However, the variability implied by the unobservable household-level effects outweighs the variability implied by the observed covariates, indicating a high degree of homogeneity in health-seeking behaviour among the household members. Failure to take account of homogeneity in health-seeking behaviour among the household members leads not only to biased results but also to inefficient policy targeting. Policies aimed at increasing access to and the use of medical services need to be sympathetic to both individuals and households.

How important are individual, household and commune characteristics in explaining utilization of maternal health services in Vietnam?

Using Vietnam's latest National Household Survey data for 2001-2002 this paper assesses the influence of individual, household and commune-level characteristics on a woman's decision to seek prenatal care, on the number of prenatal visits, and on the choice between giving birth at a health facility or at home. The decision to use any care and the number of prenatal visits is modeled using a two-part model. A random intercept logistic model is used to capture the influence of unobserved commune-specific factors found in the data regarding a woman's decision to give birth at a health facility rather than at home. The results show that access to prenatal care and delivery assistance is limited by observed barriers such as low income, low education, ethnicity, geographical isolation and a high poverty rate in the community. More specifically, more prenatal visits increase the likelihood of giving birth at a health facility. Having compulsory health insurance increases the odds of giving birth at a health facility for middle and high income women. In contrast, health insurance for the poor increases the likelihood of having more prenatal visits but has little effect on the place of delivery. These results suggest that the existing safe motherhood programs should be linked with the objectives of social development programs such as poverty reduction, and that policy makers need to view both the individual and the commune as appropriate units for policy targeting.

The influence of health insurance on hospital admission and length of stay--the case of Vietnam.

Few studies analyze the effects of health insurance on inpatient care in low income countries. This paper provides an empirical assessment of the influence of Vietnam's health insurance schemes on both hospital admission and the length of stay (LOS) using the Vietnam National Health Survey 2001-2002 and an appropriate count data regression model. Our findings suggest that the influence of health insurance on hospital admission and the LOS varies across insurance schemes. The compulsory insurance scheme and the insurance scheme for the poor increase the expected LOS by factors of 1.18 and 1.39, respectively, while the voluntary insurance scheme has minimal effect on the expected LOS. Insurance also increases the likelihood of hospital admission far more for compulsory members than for members of the other two insurance schemes. The positive influence of insurance on hospital admission and the LOS also varies across income quintiles, regions and types of health facilities. While the compulsory and voluntary schemes increase the likelihood of hospital admission more for lower and middle income individuals, the influence of the compulsory scheme on the expected LOS is more pronounced for patients in the middle income groups. The influence of insurance on the LOS is also found to be stronger in the North than in the South and stronger for patients admitted to provincial hospitals rather than district hospitals.

Does non-profit health insurance reduce financial burden? Evidence from the Vietnam Living Standards Survey Panel.

Many low-income countries are implementing non-profit medical insurance to increase access to health services, especially among low-income households, and to raise additional revenue for financing public health services. This paper estimates the effect of insurance on out-of-pocket health expenditures using the Vietnam Living Standards Surveys for 1993 and 1998 and appropriate models for panel data. Our findings suggest that health insurance reduces health expenditure when unobserved heterogeneity is accounted for. Failure to capture unobserved heterogeneity produces contrary results that are consistent with previous cross-sectional studies in the literature. Health insurance is found to reduce out-of-pocket expenditure between 16 and 18% and the reduction in expenditure is more pronounced for individuals with lower incomes. At mean income, the effect of health insurance is to reduce health expenditures between 28 and 35%.

Penalizing patients and rewarding providers: user charges and health care utilization in Vietnam.

The introduction of a comprehensive system of user charges in 1995 provided public health facilities in Vietnam, especially hospitals, with a growing source of revenue. By 1998 revenues from user charges accounted for 30% of public hospital revenues. Increasingly, provider incomes have relied on fee revenues and provision-based bonuses, the effect of which is that a poorly regulated fee-for-service system has replaced a salary system based upon a centrally determined global budget. This paper examines the potential influence of providers' on the use of publicly provided health services. Using facility-based data over the period 1996-98, the relative contribution of treatment intensity is compared and contrasted under the two sources of hospital revenues from patients, namely a user charge system and a third party payment system based on fee-for-services. The primary focus of the comparison is on the treatment intensity for all hospital contacts, hospital admissions and the length of hospital stays, decisions normally taken by the providers and over which patients have little or no influence. The results indicate that growth in patient revenues was associated with large increases in intensity. The growth in intensity was more pronounced in the case of inpatient contacts. Moreover, both the admission rate and the length of hospital stay were far higher for better off individuals than for the poor, and greater for the insured than the uninsured. The increase in the intensity of hospital care for both health insurance enrollees and the uninsured can be seen as, among other things, an attempt on the part of providers to increase revenue from health insurance premiums and user charges in the face of a shrinking share of public resources allocated to hospitals, and low wages and salaries.

Is the Canadian health care system fiscally sustainable?

Current concerns over escalating health care costs and the sustainability of the Canadian health care system are based on analytical concepts and models that have their own limitations and deficiencies. Measuring health care costs across subsectors over the long-term period, the authors argue that Canada's health care costs, especially those under the direct control of provincial governments, are relatively stable. Using appropriate measures of sustainability, there is no indication that Canada's public health care expenditure is unsustainable. Nor is there any indication that Canada's public health care expenditures are out of line with those of its main trading competitors, including the United States.