Các nhân tố ảnh hưởng đến mức độ hài lòng của người tham gia bảo hiểm y tế về chất lượng dịch vụ bảo hiểm y tế ở việt nam TT TIENG ANH

1 INTRODUCTION quality of health insurance services and achieve the universal health insurance that was set by the Prime Minister, the author decides to choose the research topic: "Factors affecting the satisfaction level of health insurance participants about the quality of health insurance services in Vietnam” Rationale According to the Health Sector Overview Report, 3.9% of households (3.5 million citizens) face financial difficulties due to medical expenses In addition, the increasing cost of medical examination and treatment becomes a Research objectives, research subject and scope of research burden on the budget of numerous households, especially families with people suffering from serious and chronic diseases that require long-term treatment 2.1 Research objectives Therefore, in order to reduce people's out-of-pocket medical expenses, it is necessary to increase the coverage of health insurance Successfully implementing universal health insurance would ensure the sustainability of the health insurance fund and reduces out-of-pocket medical expenses According to Vietnamese Social Security, by the end of December 2019, the coverage rate of health insurance reached nearly 90% (nearly 87 million people) Although the current rate of participation in health insurance is high, at approximately 90%, the coverage rates of easily-convinced participants are close to 100% The coverage rates of other groups are significantly low and it is difficult to convince these people because they have to pay the premiums for health insurance by themselves satisfaction level of health insurance participants about the quality of health In order to increase the coverage of health insurance, it is extremely important to study the factors affecting the satisfaction of health insurance today, the author proposes solutions to improve the organization and the service quality The satisfaction of health insurance participants about the quality of health insurance services is their satisfaction with health insurance services on the basis of comparison between results and their own expectations If people are satisfied with the quality of health insurance services, even if participating in health insurance is not compulsory, almost all citizens will still participate in health insurance Determining which factors affect satisfaction with the quality of health insurance services is not only essential for improving the quality of health insurance services, but also is the key for giving specific solutions to increase the coverage rate for different groups of people, especially those that are partly supported by the State and those that pay the premiums by themselves With the desire to study the factors affecting the satisfaction of the quality of health insurance services, thereby proposing solutions to improve the The overall objective of the thesis is to study the factors affecting the insurance services Specific goals are: + Systematize basic theoretical issues about health insurance and factors affecting the satisfaction of health insurance participants about the quality of health insurance services + Analyze the influence of factors on the satisfaction of health insurance participants on the quality of health insurance services in Vietnam + By analyzing the influence of factors on the satisfaction of health insurance participants on the quality of health insurance services in Vietnam implementation of health insurance policy in Vietnam 2.2 Scope of research + The research focuses on clarifying the factors affecting the satisfaction of health insurance participants about the quality of health insurance services through the organization and the implementation of health insurance policy in Vietnam + Time: secondary data was collected from 2015 to 2019, primary data was collected from May 2019 to July 2019 + Location: Hanoi city, Hue city and Ho Chi Minh city 3 2.3 Research subject The research object of the thesis is the theories and empirical analysis of the factors affecting the satisfaction level of health insurance participants about the quality of health insurance services in Vietnam Methodology CHAPTER 1: RESEARCH OVERVIEW AND METHODOLOGY 1.1 Research overview 1.1.1 Overview of foreign studies According to the author's research, there are numerous research studies and papers related to this topic: 3.1 Research design + Qualitative research: through the synthesis and analysis of theoretical + From 1985, the SERVQUAL model developed by Parasuraman et al has been widely used by scholars and researchers to assess customer satisfaction about models of satisfaction, the author builds research model and research hypotheses + Quantitative research: conducting surveys with large samples (N=1500) Based on the collected data, the author analyzes the significance and influence of the factors, analyze the correlation among variables, conduct model testing and research hypotheses 3.2 Reseach model and research hypotheses There are there independent variables and one dependent variable: services in different sectors in many different markets SERVQUAL is a multiobjective scale built to assess customers' perception of service quality There are five factors affecting service quality: Tangibles; Reliability; Responsiveness; Empathy; Assurance + In the field of health services, there are several studies applying SERVQUAL model to assess patient satisfaction such as Yogesh and Satyanarayana (2012); Lee (2016); Toni Lupo (2016) + In the field of insurance, there are several studies on satisfaction and quality of insurance services such as the study of Siddiqui and Sharma (2010); Ramamoorthy et al (2018) on life insurance; research by Borda and Jedrzychowska (2012) and Przybytniowski (2015) on vehicle insurance Studies on satisfaction and quality of insurance services often apply the SERVQUAL model However, the factors affecting the level of satisfaction might be different Responsiveness Assurance the satisfaction level about the quality of health insurance services Reliability Control variables Figure 1: Research model Table 1: Research hypotheses Research hypotheses H1 Responsiveness has a positive effect on satisfaction with health insurance service quality H2 Assurance has a positive effect on satisfaction with health insurance service quality H3 Reliability has a positive effect on satisfaction with health insurance service quality to the original SERVQUAL + According to Abd and Izham (2016), health insurance is a special service with unique characteristics Therefore, the factors affecting the satisfaction of health insurance service quality are different from other business services Hence, in the research on health insurance service quality, the SERVQUAL might be adapted + In the US, Fitzgerald and Bias (2016) show that Responsiveness has a positive impact on satisfaction with health insurance service quality Saad et al (2012) analyze the satisfaction of households with public health insurance in Turkey Only 53.3% of households are satisfied with the public health insurance service, most of them are not satisfied with the Assurance Using the original SERVQUAL model, Stanisław et al (2016) analyze the factors affecting the satisfaction of patients covered by health insurance in the Netherlands 5 According to the exploratory factor analysis, the Tangibility factor is not statistically significant The remaining four factors are statistically significant and the Assurance and Empathy have the highest average satisfaction + In Africa, satisfaction with health insurance services has been studied in several countries Shafiu et al (2011) investigate factors affecting the level of + Several studies analyze the satisfaction of health services and health insurance services, but they not run exploratory factor analysis For example, Vu Hong Thai et al (2006) examine the satisfaction of people who come for medical examination at Ho Chi Minh City dermatology hospital Research carried by Pham Thi Tan My et al (2011) on the satisfaction of patients and their customer satisfaction with health insurance services in Nigeria They find that Assurance has the greatest impact on the satisfaction level of customers family members at Van Ninh hospital, Khanh Hoa Research carried by Phan Thi Thuy Vien et al (2011) on patient satisfaction at Tu Du hospital, Ho Chi participating in health insurance Kindie and Sharew (2019) use a regression model to analyze the factors affecting household satisfaction with community health insurance services in Sheko district, Ethiopia The benefit packages have the greatest impact on satisfaction with health insurance services with a standardized beta value of 0.92 Nsiah-Boateng et al (2017) evaluate customer satisfaction with health insurance service quality at district hospitals in Ghana The authors point out factors that affect customer satisfaction about health insurance services In which, Assurance the highest impact, with a beta coefficient of 0.874 Based on survey data from 152 national health insurance participants in Tanzania, Kiyoya (2019) reveal that Reliability and Assurance have the greatest impact on participant satisfaction + In Asia, there are several studies on satisfaction in the field of health insurance, especially in some countries with many similarities in socio- Minh City + Some studies use descriptive statistical methods to measure satisfaction with different factors Hong Ha and Thu Hien (2012) assess customer satisfaction using medical services at hospitals in Vietnam - Cuba, Dong Hoi Quang Binh A study carried by Nguyen Thi Nhu Quynh and Neera Dhar (2014) on the satisfaction of the poor with health care services covered by public health insurance in Vietnam A study carried by Pham Van Hung et al (2016) on an early survey serving the development of a package of basic health services paid for health insurance + Several studies analyze the factors affecting patient satisfaction These studies use the exploratory factor analysis and multivariate regression models Truong Ngoc Hai et al (2011) investigate the satisfaction of patients treated at the general internal medicine department of Cho Ray hospital Multivariable economic and cultural aspects to Vietnam such as Indonesia, Taiwan According to Devadasan et al (2011); Vijay and Krishnaveni (2018), Responsiveness is the regression analysis identifies factors related to patient satisfaction score: (1) Duration of treatment, (2) Self-assessment of their health after treatment, (3) most important factor affecting satisfaction with health insurance service quality in India Liu (2014) shows that Reliability is an important factor affecting the satisfaction of national health insurance participants in Taiwan Astiena and Adila (2017) investigate patient satisfaction with national health insurance in some medical centers in Padang, Indonesia There are four factors affecting patient satisfaction: Reliability, Assurance, Responsiveness and Empathy 1.1.2 Overview of domestic studies There are several paper of satisfaction in the field of health services and health insurance in Vietnam: + Theoretical studies on health insurance and factors affecting participation in health insurance: Tran Quang Lam (2016) and Le Minh Tuyen (2017) Patient's age, (4) Treatment outcome and (5) Patient's quality of life before admission Tang Thi Luu (2012) apply the SERVQUAL to assess the factors affecting patient satisfaction with Da Nang General Hospital After testing the reliability of the scale and analyzing EFA factors, the author proposes factors affecting patient satisfaction including: (1) Impression and reputation of the hospital, (2) Suitability, (3) Responsiveness, (4) Care and attention, (5) Assurance All explanatory variables are statistically significant at the significance level of 5% Le Thi Kim Ngan and Le Thi Thu Trang (2014) examine satisfaction of inpatients about service quality at Can Tho central general hospital There are four statistically significant factors including: Tangibility, Responsiveness, Quality of examination and treatment, Quality of care and services 1.1.3 Research gap + Most of the studies on satisfaction in health and health insurance fields use the SERVQUAL model as a theoretical basis to build the model To study Completely dissatisfied, Unsatisfied, Satisfied, Relatively satisfied and Very satisfied The population is all insureds who have experience of medical examination and treatment with health insurance However, due to the limitation of time and resources, the sample is collected in three cities: Hanoi, Hue and Ho the satisfaction level of health insurance service quality of health insurance participants, the author decides to use SERVQUAL model as the theoretical Chi Minh with geographical locations in both the North, the Central and the South The sample consists of 1500 insureds who have experience of medical basis Although there are some disadvantages, this model is widely applied in both domestic and foreign studies to analyze the factors affecting the satisfaction of service users Health insurance is a public service with special characteristics, moreover, the policy as well as the implement of health insurance is very different among countries Therefore, it is impossible to build a common model to assess satisfaction with the quality of health insurance for all nations Based on studies on service satisfaction and quality in the health service sector and the characteristics of the health insurance policy in Vietnam, the author would make adjustments in the SERVQUAL + According to the author's knowledge, the number of studies on satisfaction in health insurance in Vietnam is very limited Most of these few studies only focus on a certain health facility, which does not represent the Vietnamese population Moreover, these studies only analyze and assess examination and treatment with health insurance in Hanoi, Hue and Ho Chi Minh City 1.2.2.4 Analyzing data The author converts questionnaires into quantitative variables and uses Excel software for descriptive statistics Then, the author uses SPSS software to test the reliability of the scale and build a linear regression model with the dependent variable being Satisfaction of the health insurance participants about the quality of health insurance services Then, the author examines the impact of factors on the satisfaction of health insurance participants about the quality of health insurance services as well as the correlation among factors satisfaction with health services and hospitals The quality of health insurance services includes not only medical and hospital services but also some aspects of HEALTH INSURANCE SERVICES 2.1 Overview of health insurance health insurance payment, coverage of drugs and medical supplies covered, access to health insurance, complaints about health insurance, etc It is the research gap 1.2 Methodology 1.2.1 Analyzing secondary data 1.2.2 Analyzing primary data 1.2.2.1 Research model and hypotheses 1.2.2.2 Measure of variables 1.2.2.3 Data collection Primary data is collected in the form of questionnaires Variables are measured using the Likert scale (1932) with a rating scale from to including: 2.1.1 The definition and types of health insurance Health insurance includes two types: social health insurance and private health insurance Social health insurance is organized by the State in accordance with the provisions of law, while private health insurance is organized and implemented by insurance companies The thesis focuses on social health insurance, because in Vietnam by the end of 2019, the coverage rate of social health insurance has reached about 90% of the population Although the private health insurance has developed rapidly, it only covers a small part of the population with high incomes Health insurance is defined as a social security policy implemented by the State, based on the contributions of participants and support from the State CHAPTER 2: THEORIES OF HEALTH INSURANCE AND FACTORS EFFECTING ON SATISFACTION ABOUT THE QUALITY OF 10 Budget, in order to pay for medical examination and treatment costs for participants when they encounter health risks 2.1.2 Nature of health insurance - Health insurance is an objective demand of citizens, especially in the market economy 2.2 Definition of quality of health insurance service 2.2.1 Service quality 2.2.1.1 Definition of service Service is a non-tangible and purposeful activity of a supplier to meet some human demand Health insurance service is a special type of service In essence, health insurance services include activities carried out by health facilities and agencies implementing health insurance policies 2.2.1.2 Definition of service quality Quality and service quality are complex concepts that are difficult to define In order to evaluate service quality, it is necessary to consider both the service system of the provider (the supply) and the perceptions, expectations and psychology of service users (the demand) 2.2.2 Quality of health insurance service Health insurance service is a special public service, because both health insurance agencies and health facilities jointly provide health insurance services Therefore, the quality of health insurance services depends not only on the quality of health services, but also on the health insurance policy and the implementation of this policy by the health insurance agency Factors such as the list of drugs and medical supplies, covered medical expenses or settlement of complaints, etc all have an impact on the quality of health insurance services The thesis does not focus on the quality of medical professionals Instead, it focuses on the factors of functional quality of health services, health insurance policies and the implementation of health insurance policy of the social insurance agency To sum up, quality of health insurance services is the ability of health insurance services to meet the needs of health insurance participants, which is the result of a comparison between the expectations of the insured and their perceptions of using health insurance services 2.2.3 Improving the quality of health insurance services is an objective demand of participants as well as social insurance agencies and medical facilities Most participants only use health insurance services when they are sick Therefore, the quality of health insurance services has a great impact on the medical examination and treatment process and their health status A highquality service helps patients reduce time, effort and money in medical - Health insurance is always considered as a pillar policy in the system of social security, along with social insurance and social assistance - Health insurance contributes to the redistribution of income among participants - The relationship in health insurance is a complex, multi-party relationship - Health insurance is not only a social security policy, but also a public insurance service organized by the State - The goal of health insurance is to improve health status, share losses among participants, reduce out-of-pocket medical expenses, and contribute to ensuring social security 2.1.3 Principles of health insurance The health insurance has five basic principles: (1) Risk pooling (2) Principles of self-responsibility for their own health (3) Coverage and participation of health insurance must be prescribed by law (4) Several groups of citizens is supported by the State (5) Each citizen at a time only participates in health insurance according to a certain group 2.1.4 Roles of health insurance There are three main roles of health insurance: + Provide basic and comprehensive medical services for prevention, treatment, rehabilitation and health promotion for people + Protect people from financial risks due to sickness + Ensure equity in accessing health services, Ensure that all citizens can access basic health services, regardless of their financial status 11 12 examination and treatment Conversely, a poor quality service makes their medical examination and treatment more difficult, more expensive, and even dangerous to their lives If citizens are satisfied with the quality of health insurance services, even if participating in health insurance is not mandatory, most of them would participate in health insurance One of the reasons why citizens not buy health insurance is that they not really believe in the quality of health insurance services Therefore, it is necessary to constantly improve the quality of health insurance services 2.3 The satisfaction of participants with the quality of health insurance services 2.3.1 The concept and classification of the satisfaction of participants with the quality of health insurance services Satisfaction of health insurance participants is an overall attitude or an emotional response to the difference between their expectations about the quality of health insurance services and what they receive and experience when using the health insurance service From the above concept, the satisfaction of participants with the quality of health insurance services is classified into five levels: Very Unsatisfied, Unsatisfied, Relatively Satisfied, Satisfied, Very Satisfied 2.3.2 Factors affecting the satisfaction level of participants with the quality of health insurance services 2.3.2.1 Responsivenesss Responsiveness is the first factor affecting the satisfaction level of participants with the quality of health insurance services According to Parasuraman et al (1985), responsiveness represents the desire and willingness of service staff to provide timely service to customers For health insurance services, responsiveness is reflected in the easy access of participants to health insurance and administrative procedures when providing medical care with health insurance (Fitzgerald and Bias, 2016) 2.3.2.2 Assurance Assurance is the ability to reliably and accurately deliver the promised service According to Emel (2014), assurance is the consistent and reliable provision of services, accurate payment and complete record keeping It includes the consistency, the stability in the first time providing services Ensuring service commitments is one of the expectations of customers In the field of health insurance, many studies have shown that Assurance has a positive effect on the satisfaction level of participants with the quality of health insurance services such as the study of Shafiu et al (2011), Yogesh et al Satyanarayana (2012), Nsiah-Boateng et al (2017), Astiena and Adila (2017), Kindie and Sharew (2019) 2.3.2.3 Reliability Reliability is the provision of services with a polite and respectful attitude to customers, which is demonstrated through expertise, and effective customer service Parasuraman et al (1988) argue that Reliability is reflected in the professional level, behavior and communication of employees The combination of attitude and ability creates a sense of trust for customers Customers will feel more satisfied with the service when the reliability of suppliers meets their expectation In the field of health insurance, many studies have shown that Reliability is an important factor affecting the satisfaction of health insurance participants: Liu (2014), Lee (2016), Astiena and Adila (2016) 2017), Sarker et al (2018), Kiyoya (2019) 2.4 Health insurance in several nations and lessons for Vietnam 2.4.1 Health insurance in several nations 2.4.2 Lessons for Vietnam + The health insurance policy depends on the socio-economic conditions, culture and awareness of people in each country + The State always plays an essential role in promulgating and implementing health insurance policy + The design of health insurance policy should be done in a long-term perspective + The level of contribution of each group of participants, the scope of benefits covered by health insurance, the method of co-payment and the method of payment between health insurance agency and medical facilities should be calculated precisely At the same time, all these factors must be managed in order to balance and stabilize the financial health insurance fund 13 14 CHAPTER 3: ANALYSIS OF FACTORS INFLUENCING QUALITY SATISFACTION OF HEALTH INSURANCE SERVICES IN VIETNAM 3.1 Overview of health insurance in Vietnam 3.1.1 Foudation and development 3.1.2 Management organization 3.1.3 The implementation of health insurance services in Vietnam 3.1.3.1 The number of participants The number of participants in health insurance increases sharply in recent years In 2019 it reaches 85.6 million people, which equals nearly 22 times the number in 1993 when the health insurance is introduced The proportion of the population covered by health insurance in 2019 is about 90% Several groups such as officials, public employees have the proportions of approximately 100% 3.1.3.2 Health insurance fund management The revenues and expenditures of health insurance increase continuously during 1993-2019 The health insurance fund is a stable and sustainable financial source, serving the people's medical examination and treatment, contributing to reduce the financial burden on health care for the State budget In 2019, the amount of the health insurance fund increases by nearly 900 times compared to 1993, with revenues and expenditures of VND 104,538 billion and VND 104,443 billion, respectively 3.1.3.3 The organization of medical treatment and ensuring the benefits of medical treatment for participants a, The number of medical treatments and the medical expenses covered by health insurance The number of medical treatments increases rapidly, reaching 184 million times in 2019, an increase of nearly 90 times compared to 1993 The frequency of medical examination and treatment with health insurance also increases from 1.84 times/person/year in 2009 to 2.11 times /person/year in 2019 Health insurance benefits are expanded Thousands of new medical services, including hundreds of high-tech, high-cost services and a number of new disease groups are covered by the health insurance By the end of 2019, there are nearly 15,000 health care facilities covered by health insurance throughout the country, including remote islands and mountainous areas After nearly 30 years of implementing the health insurance policy, more than 350 million turns of medical examination and treatment people are paid by health insurance with a total payment of nearly 460,000 billion VND Tens of millions of patients participating in health insurance with incurable diseases and serious diseases requiring long-term treatment are indemnified b) The professional qualifications of the medical staff Out of nearly 180,000 medical staff, the percentage of medical staff with degrees and professional qualifications accounts for a very small percentage The proportions of medical specialists II Medicine and Master of Medicine are very low, at 2.92% and 1.81%, respectively The percentage of doctors with a PhD degree or higher is only 0.19% Thus, the number of treating doctors and specialists with high professional qualifications is still small, which does not meet the demand of citizens c) Equipment of medical facilities covered by health insurance Health care facilities in Vietnam still have many limitations in terms of physical conditions and infrastructure Even level hospitals still not meet the needs of patients Most central hospitals face overcrowding, many patients share the same hospital bed, the toilet area is still dirty and does not meet medical hygiene conditions District hospitals and commune health care facilities not face overcrowding of patients, however, the facilities are still poor and outdated They are unable to perform surgeries, procedures, and subclinical tests requiring complex and intensive techniques 3.1.4 General assessment of the implementation of health insurance services in Vietnam 3.1.4.1 Achievements - In 2012, the health insurance coverage rate is below 65% of the population By the end of 2019, this firgure reaches nearly 90% of the population, which is equivalent to 85 million people Thus, Vietnam basically completes the goal of universal health insurance - The benefits of are expanded, funding sources for medical care at health facilities are guaranteed - Renovate the financial mechanism in the direction of correct and adequate calculation of health service prices in order to gradually reduce the payment from state budget Health facilities improve the quality of medical 15 16 examination and treatment Ensure fairness in evaluating the performance of medical facilities across the country, ensure the benefits of participants - The assessment of costs of medical care and treatment with health insurance focuses on improving and renovating management quality, the ability to monitor and control In line with the direction of administrative reform and application of information technology in the field of health insurance, contributing to improving the responsibility and initiative of the social insurance agency, medical examination and treatment facilities as well as enhancing the effectiveness of supervision 3.1.4.2 Limiatations - Several party committees not extensively disseminate the health insurance policy to the beneficiaries of the health insurance regime, especially in remote and isolated areas - Communication on the health insurance policy has not achieved high efficiency: the implementation organization is not strategic; sometimes still passive and unprofessional - The proportion of citizens participating in the health insurance accounts for over 90% of the total population, and still nearly 10% of the population has not yet joined health insurance (equivalent to about 10 million people) The majority of them live in rural areas and come from households working in agriculture, forestry, fishery and salt production; individual business households, etc It is difficult to convince them because they have to pay out of pocket to participate in health insurance - The provisions of the Law on Health Insurance and its guiding documents are not consistent - Administrative procedures for health insurance are still inadequate - Health insurance costs tend to increase, leading to an overspending of the health insurance fund from 2016 to 2019 - Regulations on the list of drugs and medical supplies covered by the health insurance fund are still inadequate - The physical facilities of health care facilities covered by health insurance at the district level are poor and outdated, unable to perform complicated surgeries, procedures and tests Medical qualifications at these facilities are also limited People are still not satisfied with the procedures in medical examination, treatment, health insurance payment such as: complicated paperwork, time consuming procedure, etc 3.2 Analysis of factors affecting the level of satisfaction with the quality of health insurance services in Vietnam 3.2.1 Testing the scales 3.2.1.1 Testing the reliability of measurement scales Cronbach's Alpha coefficients show that all three scale components have reliability greater than 0.7 Thus, the designed scale is statistically significant 3.2.1.2 Exploratory Factor Analysis KMO and Bartlett's values show that there is a correlation between the variables; p-value (Sig) of 0.000 is less than the significance level α = 0.05 At the same time, the KMO value = 0.866 is in the statistically significant range (from 0.5 to 1), implying that factor analysis for grouping these variables together is appropriate The Factor loading coefficient (multiplier loading) of the observed variables must be greater than 0.5 (Amir and Omidi, 2016) The analysis results show that the multiplier loading of all 12 observed variables is greater than 0.5 Thus, the 12 components of the questionnaire were preserved and extracted into 03 factors in accordance with the original research intention The percentage of variance explained for all three factors is 69.802%; greater than the 50% criterion Thus, 03 factors explain 69.802% of the variation of 12 observed variables All Initial Eigenvalues (% of Variance) values are greater than 2%, then all 12 variables are statistically significant After analyzing exploratory factors, it could be concluded that the research scale is statistically significant 3.2.2 Testing hypotheses 3.2.2.1 Analyzing correlation among independent variables All correlation coefficients among the independent variables are less than 0.7 Therefore, there is no multicollinearity The relationship between the dependent and any independent variable is significant 3.2.2.2 Regression analysis and testing hypotheses Linear regression equation with dependent variable being the satisfaction level of health insurance participants about the quality of health insurance services is: 17 18 HL = 1.036 + 0.241 * DU + 0.087 * DB + 0.214 * TC Thus, the impact of Responsiveness to the satisfaction level of health insurance participants about the quality of health insurance services is the strongest (DU) The lowest impact belongs to the Assurance (DB) Explain the slope coefficients b: + b1 = 0.241 > indicates that when DU increases by unit, the average satisfaction level of participants about the quality of health insurance services increases by 0.241 units The standard regression value of the variable DU affects 29.7% to the satisfaction level of health insurance service quality Thus, the research hypothesis H1 is accepted, Responsiveness has a positive effect on satisfaction with health insurance service quality + b2 = 0.087 > when DB increases by unit, the average satisfaction level of participants about the quality of health insurance services increases by 0.087 units The standard regression value of the variable DB affects 11.6% to the satisfaction level of health insurance service quality Thus, the research hypothesis H2 is accepted, Assurance has a positive effect on satisfaction with health insurance service quality + b3 = 0.214 > when TC increases by unit, the average satisfaction level of participants about the quality of health insurance services increases by 0.214 units The standard regression value of the variable TC affects 27.8% to the satisfaction level of health insurance service quality Thus, the research hypothesis H3 is accepted, Reliability has a positive effect on satisfaction with health insurance service quality 3.3 Assess the satisfaction level of health insurance participants about health insurance services 3.3.1 General assessment Of the 1364 survey participants, 433 are dissatisfied and very dissatisfied, accounting for 31.74% - a large proportion of survey respondents are not satisfied with the quality of health insurance services There is a difference in satisfaction with the quality of health insurance services in three cities The percentage of survey respondents who are satisfied with the quality of health insurance services in Hue is the highest In contrast, in Ho Chi Minh City, more than 32% of survey respondents are not satisfied with the quality of health insurance services, which is the highest percentage of people dissatisfied with health insurance services The level of satisfaction of survey participants at the three health care levels is very different The number of survey respondents who are dissatisfied and very dissatisfied with the quality of health insurance services at district health care facilities is the highest The cause of this phenomenon is that the facilities and equipment of the district medical facilities are not properly invested and not meet the medical treatment needs Moreover, the professional qualifications of medical staff and doctors at district health facilities are very limited Therefore, the percentage of survey respondents who are satisfied with the quality of health insurance services at central and provincial and city health care facilities is 31.05% and 23.16%, respectively The rate at district health care facilities is only less than 18% 3.3.2 Factors on the Responsiveness of health insurance services The average value of satisfaction of health insurance participants about the Responsiveness is 3.498 Among four factors of Responsiveness, factor Dapung4 (Administrative procedures for medical examination and treatment with health insurance) has the lowest average value of satisfaction (3.376) Many participants say that the medical examination and treatment procedures covered by health insurance are complicated and cumbersome, causing timeconsuming for patients Moreover, the propaganda and awareness raising of the participants of health insurance is still not good, so patients not understand the necessary documents and procedures when performing medical examination and treatment with health insurance It is difficult and time consuming for both the patient and the medical staff Factor Dapung3 (wide network of health care facilities covered by health insurance) has the highest average value of satisfaction (3.663) The satisfaction level of participants about the network of health care facilities is quite high, because it covers a wide range from the central to local levels, including 04 levels: the central level; provincial and city lines; district and ward lines Patients with health insurance cards could receive medical treatment at all central hospitals and major hospitals of other ministries/sectors On average, each province has nearly 20 hospitals that are health care facilities covered by health insurance Numerous district hospitals across the country signed contracts 19 20 for health care and treatment with health insurance Thus, the network of health care facilities covers the whole country, from ward health facilities to central hospitals in big cities 3.3.3 Factors on the Assurance of health insurance services Compared with the Responsiveness and Reliability, the average value of satisfaction of participants about the Assurance is the lowest, at only 3.461 In which, two factors with the lowest average value of satisfaction are the factor Dambao3 (3.289) and Dambao2 (3.317) These two factors measure the satisfaction of participants about the richness in the list of covered health care services and the list of covered drugs and medical supplies Of the 1364 survey participants, 117 people (accounting for nearly 8.6%) are completely dissatisfied and 111 people (accounting for 8.14%) are not satisfied with the list of covered drugs and medical supplies Similarly, for the list of covered health care services, there are also 120 people (8.8%) being completely dissatisfied and 119 people (8.72%) being not satisfied Many respondents comment that the list of covered drugs, medical supplies as well as health care services is incomplete and does not meet the needs of patients This list also changes frequently, causing patients to feel that the social insurance agency tends to remove "good, highquality, expensive" drugs from the list but only provides drugs " popular, low quality, cheap” Therefore, the level of satisfaction with the list of drugs, medical supplies as well as health care services is relatively low 3.3.4 Factors on the Reliability of health insurance services The average value of satisfaction of participants about the Reliability is relatively high, at 3.593 The average value of satisfaction of the factor Tincay3 (facilities and equipment of health care facilities) is quite low, at only 3.468 Among 1364 survey participants, 221 people (16.2%) choose the degree of being very dissatisfied or dissatisfied with the facilities and equipment of health care facilities Notably, the percentage of survey respondents who are not satisfied with the facilities of the central health facilities; provincial and city lines and district lines are nearly the same District hospitals have poor and outdated equipments that cannot perform complex surgeries, procedures, and paraclinical tests Recently, provincial and city hospitals invest in modern equipments, but the qualification of medical staff is far from those of the central level Therefore, the use of subclinical results in diagnosis and treatment are not really effective The central line is invested, equipped with modern equipments Furthermore, the qualification of medical staff is very high, many of them are leading experts, but all central hospitals have to face overcrowding Several patients must share a hospital bed The toilet area does not meet medical hygiene conditions Therefore, the facilities and equipment of medical facilities in general still not meet the needs of patients The issue of upgrading medical facilities and equipment is not only a problem for lower-level medical facilities but also for large hospitals at the central level CHAPTER 4: PERCEPTION, ORIENTATION, AND SOLUTIONS TO ENHANCE THE QUALITY OF HEALTH INSURANCE SERVICES TO SATISFY THE PARTICIPANTS IN VIETNAM 4.1 Perception, orientation, and objectives to develop health insurance in Vietnam 4.1.1 Perception to develop the health insurance The key perception to develop the health insurance is towards universal health insurance, creating a stable financial source in the direction of fairness and efficiency, gradually improving the quality of health care services, ensuring the responsibilities, and satisfaction of participants, ensuring national social security 4.1.2 Orientation to develop the health insurance Firstly, develop and perfect the health insurance policy Secondly, synchronously implememt solutions to improve the quality of medical examination and treatment covered by health insurance Third, further innovate the financial mechanism in the direction of direct investment for beneficiaries of health insurance Fourth, strengthen the state management of health insurance Fifth, for provinces and cities, the implementation of Resolution 21 must be determined as a political task and a socio-economic target of each locality Sixth, promote propaganda and dissemination of the law on health insurance in the direction of professionalization in both content and method of approaching participants 4.1.3 Objectives to develop the health insurance - Ensure all citizens can access primary health care services 21 22 - Improve the quality of medical examination, treatment and rehabilitation services at all levels; reduce overcrowding in upper-level hospitals - Developing human resources for health in both quantity and quality - Renovate operational and financial mechanisms for the health sector, rapidly increase public investment in health, develop universal health insurance - Improve the management capacity and implementation capacity of health policies, promote administrative reform, develop the health information system to meet the needs of innovation and development of the health sector 4.1.4 Perception to improve the quality of health insurance services in Vietnam - Firstly, it is necessary to improve the capacity and effectiveness of strategic management in the social insurance and health sectors - Secondly, it is necessary to build a competitive market for health insurance services - Third, it is necessary to evaluate and perfect the health insurance policy 4.2 Solutions to enhance the quality of health insurance services to satisfy the participants in Vietnam 4.2.1 Reform the administrative procedures and apply information technology in the field of health insurance It is necessary to systematize and apply information technology in the payment and medical examination of health insurance Building a database to check information of participants in medical examination and treatment This database should be systematized by time, location, list of drugs and medical supplies Health facilities, especially provincial and central health facilities, need to invest in developing management software in the field of medical examination and treatment covered by health insurance 4.2.2 Innovation in communication about health insurance 4.2.2.1 Innovation in the media organization model 4.2.2.2 Innovation in content, form and method of communication 4.2.2.3 Monitor, evaluate and measure communication effectiveness, proactively take measures to prevent and handle incidents and crises in communication 4.2.3 Review and update the list of covered drugs and medical supplies on a regular basis 4.2.4 Innovate and diversity health insurance payment methods There are three payment methods: payment by service price, payment by rate and payment by case of illness However, in Vietnam, payment is mainly based on service prices With the payment-for-service method, it is very difficult to control medical expenses because the nature of the service-price payment method can easily lead to oversupply Furthermore, hospitals are implementing the current autonomy mechanism, which easily leads to the risk of imbalance in revenue and expenditure of the health insurance fund Then, it is difficult to control medical costs Currently, the Ministry of Health, in collaboration with Vietnam Social Security, has piloted both methods of payment for medical examination and treatment costs with health insurance (outpatient fixed fund allocation, and inpatient fund allocation - DRG The payment for medical services according to DRG will contribute to controlling service prices and people's spending very effectively It also allocates resources to paying for each patient for year, without abnormally increasing the price of medical services, and at the same time ensuring that the health insurance revenue is consistent with the service price that the hospital collects through DRG 4.2.5 Renovate the financial mechanism towards correct calculation, full price of medical services, design basic medical service packages and advanced medical service packages 4.2.5 Improve the quality of complaint settlement and health insurance inspection 4.2.6 Solutions for health care facilities 4.2.6.1 Increase the quantity and improve the professional quality and attitude of medical staff 4.2.6.2 Upgrading the physical facilities of health care facilities 4.2.7 Solutions for participants The goal of this solution is to promote the supervisory role of citizens participating in health insurance services Thereby, promote the role of participants and the community in improving the quality of health insurance services Accordingly, (i) Strengthen communication, building and 23 24 implementing the hospital communication model corner, disclose information on the operation capacity and service quality of medical facilities to improve knowledge of participants, create competition among health care facilities covered by insurance; (ii) Develop and issue regulations on ensuring the exercise of rights and obligations of participants; (iii) Develop hospital regulations on the right to monitor and give feedback on the quality of health care services covered by health insurance 4.3 Recommendations 4.3.1 Recommendations for the government - Direct the commercial banks to pay attention to investment preferential credit programs for health care, both for public and non-public health facilities, to build facilities and purchase equipment to improve the quality of medical examination and treatment services - The Government is requested to pay attention to the following contents when submitting to the National Assembly the draft Law on Medical Examination and Treatment: + In order to properly implement the guiding point of Resolution 20NQ/TU, stipulate a basic package of health services for both participants and those not participating in health insurance + The Ministry of Health shall assume the prime responsibility for, and coordinate with the Ministry of Finance and relevant ministries, formulating and announcing the economic and technical norms of medical examination and treatment services + Add regulations on mandatory norms for doctors per hospital bed; nurses per hospital bed; minimum medical examination time per patient + Supplement regulations on payment methods for medical examination and treatment costs other than the current price-based payment method, such as payment by rate or by diagnosis group At the same time, clearly stipulate the roadmap to implement the new payment method 4.3.2 Recommendations for the Ministry of Health and relevant ministries Fully and promptly promulgate documents guiding the drug bidding Organize national centralized bidding for the list of essential drugs to ensure cost-effectiveness and cost-effectiveness in medical examination and treatment covered by health insurance Develop mechanisms and policies for the private healthcare, allow publicprivate cooperation in human resources and brands to promote the participation of the private sector in the health sector Develop projects to mobilize foreign capital (ODA) for health Plan the network of medical facilities, ensure that all communes have medical stations, invest in facilities and equipment to meet the requirements of primary health care Strengthen training to improve professional and management capacity for the medical staff 4.3.3 Recommendations for Vietnamese Social Security Upgrade and complete the social insurance application on the mobile device platform "VssID - Digital Social Insurance", provide functions and utilities to look up payment information, history of health insurance costs Continue to review, reduce and simplify administrative procedures; expande the provision of online public services at level at all stages of the professional process, from the payment of health insurance premiums to Vietnamese Social Security, reception and management of health insurance premiums, payment settlement to improve the service quality of health insurance participants Strengthen discipline, administrative discipline, public service ethics, code of conduct of social insurance employees, create maximum convenience for medical facilities and participants 4.3.4 Recommendations for the local authorities The local authorities at all levels need to strengthen the implementation of the health insurance policy, which should be considered as one of the key tasks of social security Regularly inspect the organization and implementation of the Law on Medical Examination and Treatment, the Law on Health Insurance for the health sector, the local social insurance security, and medical facilities Assign specific and clear responsibilities to each agency in implementing solutions to protect and improve citizens's health  ... diversity health insurance payment methods There are three payment methods: payment by service price, payment by rate and payment by case of illness However, in Vietnam, payment is mainly based... insurance Firstly, develop and perfect the health insurance policy Secondly, synchronously implememt solutions to improve the quality of medical examination and treatment covered by health insurance... satisfy the participants in Vietnam 4.2.1 Reform the administrative procedures and apply information technology in the field of health insurance It is necessary to systematize and apply information