Impact of health insurance in Vietnam on healthcare utilization, selfreported health, and financial choices.

Impact of health insurance in Vietnam on healthcare utilization, selfreported health, and financial choices.Impact of health insurance in Vietnam on healthcare utilization, selfreported health, and financial choices.Impact of health insurance in Vietnam on healthcare utilization, selfreported health, and financial choices.Impact of health insurance in Vietnam on healthcare utilization, selfreported health, and financial choices.Impact of health insurance in Vietnam on healthcare utilization, selfreported health, and financial choices.Impact of health insurance in Vietnam on healthcare utilization, selfreported health, and financial choices.Impact of health insurance in Vietnam on healthcare utilization, selfreported health, and financial choices.Impact of health insurance in Vietnam on healthcare utilization, selfreported health, and financial choices.Impact of health insurance in Vietnam on healthcare utilization, selfreported health, and financial choices.Impact of health insurance in Vietnam on healthcare utilization, selfreported health, and financial choices.

MINISTRY OF EDUCATION AND TRAINING UNIVERSITY OF ECONOMICS HO CHI MINH CITY IMPACTS OF HEALTH INSURANCE IN VIETNAM ON HEALTHCARE UTILIZATION, SELF-REPORTED HEALTH, AND FINANCIAL CHOICES DOCTORAL THESIS IN ECONOMICS Ho Chi Minh City, 2022 MINISTRY OF EDUCATION AND TRAINING UNIVERSITY OF ECONOMICS HO CHI MINH CITY IMPACTS OF HEALTH INSURANCE IN VIETNAM ON HEALTHCARE UTILIZATION, SELF-REPORTED HEALTH, AND FINANCIAL CHOICES DOCTORAL THESIS IN ECONOMICS Major: Economic development Code: 9310105 Academic advisors: Dr Le Thanh Loan Assoc Prof Dr Pham Khanh Nam Ho Chi Minh City, 2022 i Declaration I hereby declare that this thesis is entirely my own work, with the exception of quotations and citations, which have been appropriately acknowledged This thesis has not been submitted to any other academic or non-academic institution for any degree or certification Ho Chi Minh City, December 2022 Truong Anh Tuan ii Table of Contents DECLARATION I TABLE OF CONTENTS .II ABBREVIATIONS .VI LIST OF TABLES .VII LIST OF FIGURES VIII CHAPTER 1: INTRODUCTION BACKGROUND HEALTH INSURANCE AND HEALTHCARE SCHEME IN VIETNAM 1.2.1 Development of health insurance in Vietnam .4 1.2.2 Healthcare scheme in Vietnam OBJECTIVES OF THESIS .11 RESEARCH QUESTIONS .12 SCOPE OF THE THESIS 12 STRUCTURE OF THE THESIS .13 CHAPTER 2: THEORY AND LITERATURE REVIEW 16 THEORETICAL BACKGROUNDS 16 2.1.1 Model of demand for health 16 2.1.2 The behavioral model of health services utilization 19 2.1.3 Moral hazard 21 2.1.4 Moral hazard and Cost-sharing 22 2.1.5 Literature relevant to the heterogeneous impact of health insurance coverage on healthcare utilization 24 2.1.6 Theory of precautionary savings 26 CONCEPTUAL FRAMEWORK 28 PROGRAM EVALUATIONS 30 2.3.1 Program impact measures 30 iii 2.3.2 Program impact evaluation methods 31 EMPIRICAL LITERATURE REVIEW AND RESEARCH GAPS 39 2.4.1 Review of key findings 40 2.4.2 Review of methodologies 46 JUSTIFICATION OF ANALYTICAL METHODOLOGIES 50 CHAPTER 3: IMPACTS OF HEALTH INSURANCE ON HEALTHCARE UTILIZATION AND OUT-OF-POCKET EXPENDITURES 53 INTRODUCTION 53 CONCEPTUAL FRAMEWORK 56 METHODS 57 3.3.1 Model specification 57 3.3.2 Data and variables .60 RESULTS 64 3.4.1 Impacts of the health insurance program for the elderly on the probability of being insured 64 3.4.2 Impacts of health insurance on healthcare utilization outcomes .67 MODEL SIGNIFICANCE TESTING 68 3.5.1 Validity of RDD 68 3.5.2 Robustness checks 72 DISCUSSION 74 CONCLUSION 76 CHAPTER 4: IMPACTS OF HEALTH INSURANCE ON HOUSEHOLDS’ FINANCIAL CHOICES: EVIDENCE FROM VIETNAM .78 INTRODUCTION 78 DATA AND VARIABLES 82 4.2.1 Data source 82 4.2.2 Variable definitions and descriptive statistics 83 CONCEPTUAL FRAMEWORK 89 iv RESEARCH HYPOTHESES AND METHODS 90 4.4.1 Research hypotheses 90 4.4.2 Research methods 92 RESULTS 96 4.5.1 Impacts of covariates 96 4.5.2 Impact of health insurance on financial choices 98 4.5.3 Correlations between the error terms 102 ROBUSTNESS CHECKS .103 CONCLUSION .106 CHAPTER 5: IMPACTS OF CO-PAYMENTS ON SELF-REPORTED HEALTH AMONG THE HEALTH INSURANCE INSURED IN RURAL VIETNAM 108 INTRODUCTION 108 CONCEPTUAL FRAMEWORK AND HYPOTHESIS 112 METHODS 113 DATA AND VARIABLES 117 5.4.1 Data source 117 5.4.2 Treatment and outcome variables 117 5.4.3 Covariates 118 RESULTS 120 5.5.1 Propensity score estimation .120 5.5.2 Covariate balance check 121 5.5.3 The impact of co-payment exemption on self-reported health 125 5.5.4 Heterogeneous impacts 126 5.5.5 Sensitive test for hidden bias 128 DISCUSSION 129 CONCLUSION .132 CHAPTER 6: CONCLUSIONS .133 v KEY FINDINGS .133 6.1.1 The impacts of health insurance on healthcare utilization and out-ofpocket expenditures 133 6.1.2 The impact of health insurance on households’ financial choices 134 6.1.3 The impacts of co-payments on self-reported health 134 CONTRIBUTIONS OF THE THESIS 134 POLICY IMPLICATIONS OF THE THESIS FINDINGS 136 LIMITATIONS AND AREAS FOR FUTURE RESEARCH 138 LIST OF THE AUTHOR'S PUBLICATIONS 141 REFERENCES 142 APPENDICES 163 vi Abbreviations ATE: Average Treatment Effect ATT: Average Treatment Effect of the Treated BMI: Body Mass Index DID: Difference–in–Differences ITT: Intention-to-treat effect IV: Instrumental variable LATE: Local average treatment effect LMICs: Low- and middle-income countries OLS: Ordinary least squares PSM: Propensity score matching RCTs: Randomized controlled trials RD: Regression discontinuity RDD: Regression discontinuity design TVSEP: Thailand-Vietnam Socioeconomic Panel UHC: Universal health coverage US: United States VHLSS: Vietnam Household Living Standard Survey VSS: Vietnam Social Security Agency 2SLS: Two-stage least squares vii List of tables Table 1.1: Health insurance reform in Vietnam .6 Table 2.1: Overview of econometric methods for program impact evaluation 38 Table 3.1: Descriptive statistics of control variables 61 Table 3.2: Descriptive statistics of outcome variables 63 Table 3.3: Impact of the health insurance program for the elderly on the probability of being insured .65 Table 3.4: Regression model for the probability of being insured when reaching 80 years old, using pre-policy data .67 Table 3.5: Impacts of health insurance on healthcare utilization outcomes 68 Table 3.6: RD estimates of covariates 72 Table 3.7: Robustness checks with different bandwidths .73 Table 3.8: Intention-to-treat effects 74 Table 4.1: Definitions of dependent variables 85 Table 4.2: Definitions of control variables .86 Table 4.3: Descriptive statistics of variables (mean, standard deviation) .88 Table 4.4: Pairwise tetrachoric correlations between dependent variables 89 Table 4.5: Univariate probit coefficients 99 Table 4.6: Multivariate probit coefficients 100 Table 4.7: Correlation between error terms in multivariate probit regressions 103 Table 4.8: IV random-effects two-stage least-squares regressions .104 Table 4.9: Bivariate probit models .105 Table 5.1: Variable definitions and descriptive statistics 119 Table 5.2: Covariate balance check and bias reduction 123 Table 5.3: Statistical tests pre-matching and post-matching 125 Table 5.4: Impact of co-payment exemption on self-reported health 126 Table 5.5: Heterogeneous effects of co-payment exemption on self-reported health 127 Table 5.6: Mantel-Haenszel test 129 viii List of figures Figure 1.1 Organisational chart of the Vietnamese healthcare system .9 Figure 1.2: Payment mechanism in health insurance .10 Figure 2.1: Andersen’s Behavioral Model of Healthcare Utilization .20 Figure 2.2 Conventional ex-post moral hazard effect 23 Figure 2.3: Conceptual framework for the thesis 29 Figure 3.1: Conceptual framework for the impacts of health insurance on healthcare utilization and out-of-pocket expenditures 57 Figure 3.2 Insurance coverage, aged 70 – 89 years old 65 Figure 3.3 Histogram of age around the cutoff point (960 months) .70 Figure 3.4 Estimated density of age around the cutoff point (960 months) 70 Figure 3.5 RD plots of covariates 71 Figure 4.1 Map of Vietnam's surveyed provinces 84 Figure 4.2: Conceptual framework for the impacts of health insurance on financial choices 90 Figure 5.1: Conceptual framework for the impact of co-payment on self-reported health 113 Figure 5.2: Histogram of propensity score distribution for treated and control individuals 121 Figure 5.3: Standardised percent bias of covariates prior and post matching 122 Figure 5.4: The density distribution of propensity scores before and after the PSM for treated and control groups 125 ... of health insurance on other financial services in Vietnamese households Health insurance and healthcare scheme in Vietnam 1.2.1 Development of health insurance in Vietnam Vietnamese health insurance. ..MINISTRY OF EDUCATION AND TRAINING UNIVERSITY OF ECONOMICS HO CHI MINH CITY IMPACTS OF HEALTH INSURANCE IN VIETNAM ON HEALTHCARE UTILIZATION, SELF-REPORTED HEALTH, AND FINANCIAL CHOICES.. . beneficiaries'' healthcare behaviors This thesis examines the impacts of health insurance in Vietnam on a range of healthcare behaviors, including healthcare usage, out -of- pocket spending, financial decisions,