La leminhtuyen sum

1 FOREWORD Introduction To implement universal health insurance is determined by our Party and State The plan to implement the roadmap for universal health insurance for the period of 2012-2015 and 2020 approved by the Prime Minister with the target that by 2020 more than 80% of the population participating in health insurance (the Prime Minister 2013) For the last years, Hanoi has had many policies and measures to promote the participation in health insurance in the area However, the rate of health insurance in the area is low, especially in rural areas, with a population of nearly 3.7 million people According to the report by Hanoi Social Insurance, although the number of people participating in health insurance increases annually, from 2011 to 2015 increased by 12.8% By June 2016, Hanoi City had 5,549,227 people participating in health insurance (Pham Chinh, 2016); compared with the preliminary population of Ha Noi by the end of 2015 was 7,216,000 people (General Statistics Office 2016), the coverage rate reached 76.9% In which the groups participating in voluntary health insurance, household health insurance were very low, currently only 334,454 people Expanding the coverage of health insurance in Hanoi city to achieve the Government's goal of universal coverage of health insurance strongly depends on influencing the population participating in voluntary health insurance, especially the farmers Therefore, researching the factors affecting the farmers’ participation in health insurance in Hanoi is an urgent matter in both theoretical and practical terms Research objectives and tasks 2.1 Objectives The thesis proposes the direction and solution to improve the factors in order to promote the farmers’ participation in health insurance in Hanoi city ahead until 2020 and orientation to 2025 2.2 Tasks - To clarify roles and contents of health insurance for the farmers; To develop a theoretical framework for the relationship between (1) the health insurance policies of the Government (ii) the quality of health care services when using health insurance cards (iii) the farmers' income and awareness about the benefits of participating in health insurance (iv) organizations and their management capacity with the involvement of farmers in the health insurance system; To study national and international experiences in creating factors to expand participation in health insurance - On the basis of the general socio-economic characteristics and the situation of participating in health insurance in the area of Hanoi, the thesis analyzes and assesses the factors affecting the farmers’ participation in health insurance and their impact in Hanoi, showing the achievements, limitations and causes of these factors - To recommend major directions and solutions to improve the factors affecting health insurance participation in order to promote the farmers’ participation in health insurance system in the suburban areas of Hanoi until 2020 and orientation towards 2025 Research subject, scope and method 3.1 Research subjects: Factors affecting the farmers’ health insurance participation 3.2 Research scope Scope of content: The impact factors mentioned are composed of factors: (i) Government policies (ii) quality of health care services when using health insurance cards and (iii) people's awareness of the benefits of participating in health insurance (iv) capacity of management organizations and staff involved in health insurance (v) farmers' income Participating in health insurance is reflected in the coverage of health insurance for the farmers Scope of space Research topic is done in Hanoi, directly select some suburban districts Scope of time: Research data of the topic is primary and secondary data related to the status of health insurance participation of farmer households in Hanoi in the period of 2009-2014, proposed to be completed by 2020 Major contributions of the thesis In theoretical term: The thesis has contributed to systematize and develop the basic theoretical issues on factors affecting the farmers’ participation in health insurance on the basis of studying the research works related to the topic In practical term, the thesis has researched the situation of the farmers’ health insurance participation in Hanoi, the thesis has shown the limitations of factors affecting the farmers’ participation in health insurance including i) Government policies for the farmers' health insurance participation promulgated and supplemented but still lower than required and the implementation is not effective; ii) quality of health care services using health insurance cards is not high, the satisfaction of the farmers participating in health insurance is very low; iii) Organizational management and capacity of staff and coordination in health insurance management in the city have not been complied with; iv) Farmers' income is low; and v) Awareness, understanding of health insurance policy is low To have 37.59% of farmers in 2020 and 64.59% of farmers in 2025 participate in the health insurance program, the thesis recommends that the Hanoi i) raise the level of support for health insurance participation for the propoor and medium households; reform health insurance policies towards equity and consistency; increase the mobilization of financial resources to support difficult farmers to participate in health insurance; ii) Improve the quality of health care services provided by health facilities, firstly to eliminate the discrimination between health insurance card holders and non-health insurance card holders; change the form of State budget allocations from service-providing establishments to directly allocate them to health insurance beneficiaries through the form of health insurance; overcome the discrimination of private and public health care facilities in implementing the health insurance policies; iii) Improve the capacity of the management organizations; strengthen the quality of health insurance assessment; improve the quality, responsibility and professionalism of health insurance staff; strengthen the coordination between health insurance with units in the inspection to check the implementation of health insurance policies; apply information technology to management; iv) Improve economic conditions for the farmers; and v) promote communication and education to raise awareness of people about health insurance CHAPTER OVERVIEW AND RESEARCH METHODOLOGY OF FACTORS AFFECTING FARMERS' PARTICIPATION IN HEALTH INSURANCE 1.1 Overview of the research works Based on the overview of the domestic and foreign research works related to the research topic, the thesis has shown that the domestic and foreign research works have outlined the basic ideas and contents of health insurance on the aspects of the target, the calculation method of participation fee, mechanisms to encourage participation, conditions for implementation of universal health insurance; parties involved in providing health insurance; barriers to implement the health insurance; difficulties from the subjects outside of informal sector when actively participating in this form of insurance However, the relationship between the factors and the participation in the health insurance of the people has not been clarified In the other words, the factors of (i) Government policies (ii) quality of health care services when using health insurance cards and (iii) capacity of management organizations and staff related to the health insurance (iv) economic conditions and (v) people’s awareness of the beneficiaries when participating in the health insurance coverage have not been assessed specifically In particular, as of January 1st, 2015, under the new health insurance law, with new policies and regulations such as the health insurance coverage is mandatory for all people and regulation on encouraging to participate in health insurance as the household will be available, how does it affect the farmers’ participation in health insurance? This is the space that the author will perform in the course of the research The research questions that need to be addressed are: Firstly, what are the characteristics of health insurance for the farmers and what are the factors influencing the participation in health insurance of the farmers? Secondly, how does the impact of factors on the participation in health insurance of the farmers today? Which factors have positive impact? which factors restrict the participation in the health insurance system of the farmers? Thirdly, how to increase the level of impact of factors to promote the participation in health insurance of the farmers in the upcoming years? 1.2 Analytical framework and research methodology 1.2.1 Analytical framework of the thesis of Labor, War Invalids and Social Affairs Based on the presentation of the research process, the thesis has developed the following research framework: Impact factors Kinh nghiệm hoàn thiện cá Support policies of the Government Quality of health care services using the health insurance cards Organizing activities of health insurance; Capacity of staff; Coordination among agencies, departments and branches Farmers' income Farmers’ awareness Experience in completing the factors affecting the participation in health insurance of the farmers in foreign countries and in the country Criteria for assessing farmers' participation in health insurance - Coverage Participation structure - The growth rate of The status of factors affecting the participation in health insurance of the farmers in Hanoi city Directions and solutions to complete the factors affecting the participation in health insurance of the farmers Figure Research framework of the thesis 1.2.2 Research methodology Qualitative research The topic used traditional research methods such as dialectical materialism, historical materialism, comparative approach in combination with modern models in analysis such as SWOT, Decision tree, expert method to clarify the relationship between the factors of (i) Government support policies (ii) quality of health care services when using health insurance cards (iii) capacity of health staff and the policies encouraging the farmers’ participation and (iv) economic conditions and awareness of farmers with their participation in the health insurance system Analysis used to find out the advantages and disadvantages of implementing the policies to extend the coverage of health insurance, or to assess opportunities and challenges for achieving the targets set in the next period Quantitative research Firstly, collecting secondary data from the Hanoi socio-economic development report, from Hanoi Statistical Yearbook, Ha Noi City Health Insurance, Hanoi Department of Health, from data statistical surveys on employment, income, living standard and poverty of Hanoi Statistical Office, from the reports of Hanoi Department Secondly, collecting primary data: through surveying and interviewing 330 subjects including farmers and managers 1.2.3 Data processing methods The topic is based on the data and surveys conducted to encode interview questions in qualitative and quantitative manner into quantitative variables and used Excel software to perform statistical descriptions to compare i) participation in the health insurance system of the target groups surveyed according to the criteria of income, occupation and region; (ii) identifying these groups for the government policies on health insurance; (iii) identifying the groups surveyed on barriers to participate in the health insurance system being implemented in the area CHAPTER THEORETICAL AND PRACTICAL ISSUES ON FACTORS AFFECTING PARTICIPATION IN HEAL INSURANCE OF THE FARMERS 2.1 Health insurance and its importance for the farmers 2.1.1 Farmers and farmer groups The farmers are rural laborers who work in the agricultural sector in the broad meaning (including agriculture, forestry and fisheries) with their main means of production are land and surface water The thesis groups the farmers by income, sector and region to analyze and compare the participation of different target groups in the health insurance 2.1.2 Health insurance and its characteristics for the farmers 2.1.2.1 Health insurance and its nature for the farmers The health insurance may be understood as a part of the social security system, which guarantees partial replacement or compensation of income for insured persons when they experience a decline in health on the basis of forming and using a unified monetary fund based on the compulsory regulations of the Government, not for profit purposes The health insurance for the farmers is a form of insurance applied to the farmers for health care, not for profit purposes For the farmers, the health insurance is essentially the same as conventional health insurance, detailed as follows: Firstly, it is voluntary health insurance; Secondly, the insurance applied to the farmers is for health care, not for profit purposes; Thirdly, risk sharing between health insurance participants, between highincome and low-income people, between those who are not at risk and those who are at risk of financial loss; Fourthly, it is economical 2.1.2.2 Characteristics of health insurance for the farmers Firstly, the characteristics of the target subjects and the contribution rate The health insurance for the farmers with the subjects participating in health insurance are the farmers The farmers are those who have unstable and relatively low income As a result, the contribution of health insurance to the farmers is often low and is regulated by specific contribution rates Secondly, the characteristics of risk covered by the health insurance for the farmers The risks covered by health insurance for the farmers are the risks associated with illness and diseases, resulting in the need for medical care by the covered farmers Thirdly, the characteristics of the participants in the health insurance for the farmers In the health insurance for the farmers, there are relationship between the three parties: the insurer, the insured party and the medical examination and treatment establishment The insurer is usually an insurance organization, which is assigned the right to implement health insurance uniformly in the country Participants in the health insurance are the farmers 2.1.3 Importance of the health insurance for the farmers and society 2.1.3.1 For the farmers Firstly, for the farmers, the health insurance plays a very important role in ensuring that part of loss to be covered when the risk occurs Secondly, the health insurance also contributes to improving the quality and social justice in health care services for the farmers 2.1.3.2 For society Firstly, the health insurance for the farmers contributes to reducing the burden on the state budget in ensuring social security Secondly, the health insurance for the farmers contributes to improving the quality of the rural population Thirdly, the health insurance for the farmers contributes to the social justice 2.2 Concept and content of factors affecting the farmers’ participation in the health insurance 2.2.1 The concept of factors affecting the farmers’ participation in the health insurance The factors affecting the participation in health insurance are the category of aspects, contents and measures used to influence the farmers to participate in the health insurance 2.2.2 The content of factors affecting the farmers’ participation in the health insurance 2.2.2.1 Support policies of the Government The policy supporting the farmers to participate in the health insurance is a system of specific views, guidelines, measures and plans of the Government to encourage and create favorable conditions for the groups of farmers to participate in the health insurance 2.2.2.2 The quality of health care services using the health insurance cards The quality of health care services using the health insurance cards is the relation between the demand and the ability to meet the demand for the health care services when using the health insurance cards The quality of health care services when using the health insurance cards is composed of a number of factors related to administrative procedures of health care services; qualifications of doctors and health care managers; morale, attitudes and ethics of doctors and health care staff; and physical conditions to ensure the quality of services and satisfaction of patients with the health insurance cards in both public and private health care facilities 2.2.2.3 Capacity of management and organization, and health insurance staff and coordination between agencies, departments, local authorities and health insurance organizations Capacity to organize and manage health insurance and health insurance staff plays an important role in developing the health insurance system for the people To ensure the sustainable development of health insurance, the most important thing is to help people become aware and trust the benefits of participating in the health insurance Therefore, the implementation of health insurance policy for the farmers needs very close attention of the party committee, the local authorities and the inter-sectoral cooperation between the relevant agencies: Social Insurance, Health Insurance, Education and Training from the propaganda stage to improving the quality of health care services 2.2.2.4 Farmers' income Income is the most important factor affecting the people’s participation in the health insurance In general, in the condition of market economy, the farmers’ income is from two basic sources: (i) the source of income from which people use their labor force to earn from the labor market and (ii) the source of income does not come from exchange of labor force in the labor market 2.2.2.5 The farmers' awareness of the meaning of health insurance The farmer's awareness of importance includes: Firstly, the farmer should know about the health insurance Secondly, the farmers should understand the regimes and obligations when participating in health insurance for the farmers In particular, it is necessary to emphasize the understanding of government support policies towards the people on health insurance premiums, the participation method and the benefits The greater the level of understanding, the higher the level of voluntary willingness to participate in health insurance 2.2.3 Criteria for assessing farmers' participation in health insurance Firstly, health insurance coverage of the farmers Secondly, the participation structure in health insurance of the farmers Thirdly, the growth rate of participating in health insurance of the farmers 2.3 Experience in enhancing the impact of factors affecting farmers' health insurance participation 10 The thesis has mentioned the experiences of some countries such as France, Japan, Korea and other localities such as Ho Chi Minh City, Hai Phong, Bac Ninh, Phu Tho and Thai Binh on the factors affecting the farmers' health insurance participation On this basis, four lessons learned on improving the impact of factors affecting the farmers' health insurance participation, including: Firstly, the local authorities should have support policies; Secondly, to improve the quality of health care services; Thirdly, it is necessary to strengthen the operation of local authorities and coordinate with local authorities in attracting the farmers to participate in the health insurance; Fourthly, to strengthen the propaganda on health insurance for the farmers In general, the voluntary health insurance participation rate of the farmers is very low The report by Hanoi Social Insurance Agency showed that up to 2015, only 18.45% of farmers participated in health insurance This is a challenge for the implementation of universal health insurance in Hanoi Table 1: Rate of health insurance coverage of the farmers in Hanoi CHAPTER SITUATION OF FACTORS AFFECTING THE FARMERS' PARTICIPATION IN HEALTH INSURANCE IN HANOI CITY 3.1 Overview of the natural, socio-economic characteristics and farmers’ health insurance participation in Hanoi city 3.1.1 Socio-economic characteristics of Hanoi city related to the participation in health insurance The thesis has presented the socio-economic characteristics of Hanoi city related to the farmers’ participation in health insurance According to the thesis, Hanoi has been one of the largest and the most important health centers of the country, where a large number of multi-tier hospitals with a team of qualified medical and pharmaceutical personnel, with modern facilities However, the system is showing an imbalance in service availability due to population growth and the increasing need for quality health care 3.1.2 Overview of the farmers’ participation in health insurance in Hanoi city 3.1.2.1 Introduction of Hanoi Social Insurance To present the process of establishment and development of Hanoi social insurance, the thesis shows that the organizational structure of Hanoi social insurance has been strengthened with the structure of 11 professional sections, 30 district and town social insurance with the total number of 1,356 civil servants and employees (376 men and 980 women), of which: 88.65% with graduate and postgraduate degrees, most of civil servants and managers have medium and high level political theoretical background; over 54% of civil servants and officials in the whole system are party members 3.1.2.2 Participation situation in health insurance in Hanoi The thesis indicates that the number of people participating in health insurance was over 4.2 million people in 2010, and by 2015, the number of people participating in health insurance was 7,505,804, reached 90% 3.1.2.3 Participation situation in health insurance of the farmers in Hanoi Target 2010 2011 2012 2013 2014 2015 The number of farmers covered by health insurance 1,055,865 1,058,684 1,095,621 1,093,148 1,052,690 1,051,683 The number of farmers participating in health insurance People 84,976 99,129 111,901 123,789 158,761 193,993 Rate of health insurance coverage for the farmers % 8.05% 9.36% 10.21% 11.32% 15.08% 18.45% 3.2 Analyzing the factors affecting the farmers' participation in health insurance in Hanoi through inspections and surveys 3.2.1 Situation of government health insurance policy 3.2.1.1.Situation of general health insurance policy In recent years, the Government has had many support policies to health insurance participation of the people in general and the farmers in particular, continue to improve the system of legal documents on the mechanism, medical examination and treatment in order to enhance the effectiveness and efficiency of State management over the medical examination and treatment through schemes, decrees and circulars, and best manifested through the Health Insurance Law No 46/2014/QH13 The Government has issued many Decrees to supplement and amend the health insurance law in order to expand the number of beneficiaries of health insurance by the state budget, such as determining some subjects may by health insurance by state budget; to encourage people to participate in household health insurance with the mechanism of gradually reducing the premium paid from the second member; to encourage people to continue participating in health insurance; regulation of payment for the pro-poor; to organize management and declaration to participate in health insurance, etc 3.2.1.3 Status of implementation of policies to support the farmers to participate in the voluntary health insurance of the City Since 2000s, Hanoi health insurance has implemented to expand voluntary health insurance for the farmers in the area In 2001, the Hanoi Social Insurance submitted a plan to implement the next farmer health insurance program in the outskirts of Hanoi Hanoi social insurance also approved a scheme to develop voluntary health insurance in Hanoi until 2005, including the development of voluntary health insurance for the farmers in the area 11 12 Hanoi social insurance has strengthened the propaganda for the farmers to understand this policy Hanoi social insurance, together with the Department of Labor, Invalids and Social Affairs, Department of Finance advised the City People's Committee to raise the rate of health insurance contributions for pro-poor households from 70% to 100% of health insurance premiums as of January 1st, 2014; advised the City People's Committee to promulgate a series of plans on the implementation of the Law amending and supplementing a number of articles of the Health Insurance Law, assigning targets for implementing health insurance, strengthening the implementation of social insurance and health insurance policies The city has put the target of the proportion of people participating in health insurance into the socio-economic targets, so the People's Committees at all levels must take part in the campaign to improve the coverage of health insurance, especially the groups of farmers 3.2.2 The quality of health care services when using the health insurance cards 3.2.2.1 The policies and measures of the Government to ensure the quality of medical health care services when using the health insurance cards period of 2016-2020, 2016) In addition, the Hanoi Department of Health has continuously improved the quality of health care at health facilities through many positive measures Over the years, the City has also allocated a large amount of state budget for investment in the medical facilities In 2015, Hanoi health insurance signed medical insurance contracts with 205 units with a total of 713 health insurance centers, 15 central health facilities (accounting for 7.3%); 54 health insurance facilities were under the City and equivalent (26.3%); 72 health insurance facilities were at district level and equivalent (accounting for 35.1%) There were 31.2% of health care facilities were medical agencies During 20 years of health care under the health insurance laws and regulations, there have been more than 63 million people with health insurance cards with total paid medical insurance of VND 21,600 billion In fact, the current group of health insurance subjects is often concentrated in rural districts and towns of Hanoi As a result, the farmers may use their health insurance cards at district hospitals 3.2.3 Current status of organization and management capacity on health insurance staff and coordinated implementation Along with the development of the sector, the social insurance has not stopped growing and developing in both the apparatus and staff for the last 20 years To meet the requirements on the staff in the new situation, Hanoi Social Insurance always pays much attention to training, retraining, professional trainings and political theory for its employees Along with the training, improving labor discipline, administrative discipline, sense of responsibility to serve are also interested Collecting the voluntary health insurance premium for the farmer households is carried out by the following modes: health insurance premiums paid by voluntary participants may be paid every or 12 months; the payment time is the time of registration to participate in health insurance in accordance with the current regulations of the Government; Collecting the health insurance premiums from the farmers when they voluntarily participate in social insurance is assigned by the Hanoi social insurance to the districts and towns to directly collect and issue the health insurance cards for participants through voluntary health insurance premium collection agents The voluntary health insurance premium agents collect the premium from the farmers on the monthly basis and submit to the district and town health insurance agencies Procedures related to the settlement of social insurance and health insurance policies and regulations are publicly posted at all headquarter offices i) The Government shall promulgate a maximum level of price frame for a number of medical examination and treatment services in the public medical examination and treatment establishments; to concentrate and enhance the efficiency of the use of state budget and revenue sources in order to raise the quality of medical examination and treatment services, to have solutions to efficiently use the medical equipment and facilities of specialized medical establishments, especially the district hospitals and regional hospitals having been invested in the past time ii) To resolve hospital overcrowding: iii) To propose the solutions to improve the quality of human resources for lower levels and manage the quality of services at the medical examination and treatment establishments: 3.2.2.2 The quality of health care for the health insurance card holders in Hanoi In recent years, the medical human resources in the City has been increasing As of December 31st, 2015, the total number of human resources in the sector reached 17,849 people, of which: - Associate Professors: 05 - Graduates: 3,565 persons; persons; - College: 755 persons; - Doctors: 67 persons; - Intermediate: 10,280 persons; - Speciality 2: 171 persons; - Primary: 129 persons; - Speciality 1: 920 persons; - Others: 1,228 persons - Masters: 734 persons; (Hanoi Department of Health, Project on socialization of health in the 13 of Hanoi Social Insurance, district and town social insurance agencies; Procedures for receiving, circulating, processing dossiers and returning results are in accordance with the "one-door" mechanism promulgated Hanoi social insurance has paid special attention to the application of information technology in professional operations, which is considered as an important factor in the management and implementation of tasks such as collecting, issuing cards, accounting and settling the policies From 1996 up to now, Hanoi Social Insurance has researched and implemented themes and topics on health insurance to promote health insurance management in the area The coordination between the social insurance and the Association of farmers, local departments such as citizen groups, committees of wards and communes to mobilize farmers to participate in health insurance is maintained regularly and closely 3.2.4 Status of the farmers' income and life Over the past years, the rural areas of Hanoi city have been invested, the programs of the City on suburban socio-economic development have been implemented seriously and effectively As a result, the farmers' income also increased, creating opportunities for the farmers, especially rich households, to actively participate in voluntary health insurance 3.2.5 The farmers' awareness of benefits of the health insurance The farmers' awareness of the importance of health insurance has been increasingly improved 3.3 Assessing the factors affecting the farmers' participation in health insurance in Hanoi through inspections and surveys 3.3.1 Impact of factors on variation in coverage of health insurance for the farmers According to the author's survey, there were 461 farmers participating in health insurance in 2012, there were 507 farmers with health insurance cards in 2014, an average increase of 17 people each year, the growth rate of 3.52% This made the proportion of farmers participating in health insurance compared to the total number of farmers surveyed increase If the total number of farmers covered by health insurance was only 52.93% in 2012, by 2013 the proportion increased to 54.63% and by 2014 to 57.26% 14 Chart 1: The proportion of people participating in health insurance in the total number of farmers in the survey (2012 – 2014) 3.3.2 The impact of factors on changes in the coverage of health insurance for the target groups of farmers by income, occupation and region Firstly, by the farmers' income It can be seen that the higher the income, the higher coverage (participation) of health insurance In 2014, 68% of the health insurance participants were rich households, 62% were good income households, 57% were middle income households and 44% were pro-poor households The pro-poor households are low-income households and the number of family members who buy health insurance is very low 15 16 Table The impact of factors on changes in the coverage of health insurance for the target groups of farmers by income, occupation and region Target 2012 2013 2014 By income 28 28 28 Proportion of wealthy people who bought health 68 68 64 insurance % Proportion of people with good income who bought 57 57 62 health insurance % Proportion of people with medium income who bought 54 55 57 health insurance Proportion of poor people who bought health 40 44 39 insurance % By occupation +/% +/% 1.Total of households 196 196 196 2.Total of persons 871 875 882 0.5 0.8 3.Total of health insurance card 461 478 505 17 3.7 27 5.6 holders (Persons) 3.1 Number of laborers in the households with health insurance 248 266 283 18 7.3 17 6.4 (Persons) 3.2.Number of student health 213 212 222 -1 -0.5 10 4.7 insurance card holders (Persons) Number of persons without health 410 397 377 -13 -3.2 -20 -5.0 insurance cards (Persons) Proportion of people with 53 55 57 3.7 5.6 health insurance % 5.1 Proportion of laborers in the households with health insurance 28 30 32 6.8 5.5 % 5.2 Proportion of student health 24 25 25 -0.9 3.9 insurance card holders % Proportion of persons without 47 45 43 -2 -3.6 -3 -5.8 health insurance cards % 3.4 Key achievements and limitations on the factors affecting the farmers' participation in the health insurance 3.4.1 Key achievements: Firstly, the Government has issued and amended many policies to encourage the farmers' participation in the health insurance Secondly, relevant ministries, departments and sectors have actively worked out measures to improve the quality of health care services when using the health insurance cards Thirdly, to strengthen the organization, management and improvement of the quality for the health insurance staff Fourthly, to actively implement measures to improve knowledge and ability to participate in health insurance for the farmers Fifthly, the coverage of health insurance of the farmers increased over the years; the structure of health insurance participation has changed well; the growth rate of health insurance participation of the farmer households has increased markedly 3.4.2 Limitations of factors affecting the farmers’ participation in health insurance in Hanoi Firstly, the Government’s support policies for participation in health insurance of the farmers were promulgated and supplemented but the Proportion of people in mixed households who bought health insurance % 57 59 61 Proportion of people in the pure-farming households 47 49 51 who bought health insurance % By region Proportion of people living in delta areas bought 55 57 54 health insurance Proportion of people living in the mountainous areas 50 54 57 bought health insurance Secondly, by the nature of occupation Currently, the proportion of mixed households participating in health insurance is higher than that of the purefarming households Thirdly, by region Basically, the proportion of the farmers’ health insurance participation in the delta and mountainous areas is quite equal 3.3.3 Impact of factors on changes in the growth rate of health insurance for the farmers In 2012, the total number of health insurance card holders was 461 people, accounting for 53% of 871 persons in 196 households; In 2013, 478 holders, accounting for 55%, increasing 17 persons, or 3.7% compared to that of 2012; in 2014, 505 holders, accounting for 57%, increased 27 persons, or 5.6% compared to that of 2013 It can be seen that in the period of 2012 - 2014, the size and growth of health insurance participation of the surveyed farmer households increased slightly Table Growth of the farmers’ health insurance participation through surveys Target 2012 2013 2014 2013/2012 2014/2013 17 18 implementation has not been effective For the pro-poor households, their incomes are too low, not enough to cover and pay for basic daily living expenses, spending an amount on health insurance even if supported is still a burden for them.The Fourthly, the farmers’ income is low Living expenses are not enough, so the premium is a difficult problem for the farmer households, especially propoor ones Table Average income of the farmer households in 2014 Unit Million VND General Pro-poor households changes in regulations on payment for health care costs for the health insurance card holders increases the burden on the farmers, especially for low-income people Secondly, the quality of health care services covered by the health insurance is not very high, long waiting time for medical examination and treatment, cumbersome procedures for medical examination and treatment, transfer for the health insurance card is complicated, discrimination between medical examination and treatment using health insurance cards and without health insurance cards The morale and attitudes of the health insurance staff are poor, which not meet the farmers’ satisfaction Thirdly, management organizations and health insurance staff in the city not meet the requirements Administrative procedures for purchasing the health insurance is complicated, from photocopying the family register, completing the forms to asking for certification of the local authorities causing difficulties for the farmers when participating in the health insurance The network of health insurance agents has been diversified with 601 agents collecting health insurance premiums (including Commune People's Committees, organizations, post offices) and 1,203 agent members have been trained, guidance on solving problems of implementing health insurance for the households by the ministries and branches is not timely and not specific, leading to reactions from the participants In Hanoi, there are 197 registered health insurance facilities, but the payment of health insurance still has many obstacles, which make many people still have to pay from their own pockets According to the law, people's committees of communes and wards have a clear responsibility in the health insurance system, but there are no specific guidelines and no budget to support the implementation The propaganda has not been implemented well, most of the people who not participate in health insurance say that they not know the policies, guidelines of the Government Health insurance officials not clearly communicate the preferential levels and benefits of health insurance to the farmers, especially those with difficult circumstances Besides, health insurance officials not guide perfectly the health insurance participation, so it is difficult for the farmers to access to the health insurance Although the qualifications of the social insurance officials of the City has been constantly improved, the fact that the staff working in health insurance agencies in communes, wards and towns is unprofessional, most of staff is working in war invalids and social affairs, women's union cadres Total of farmer households with information Households 196 39 29.46 12,094 Average expenditure/year 16.40 9,482 Variance for savings and other expenditures 13.06 2,612 Fifthly, awareness and understanding about the pre-eminence of the health insurance policy are low, which also create the coverage of the health insurance of the farmers in Hanoi Average income/year Million/person/year 19 20 Chapter SOLUTIONS TO IMPROVE THE FACTORS AFFECTING THE FARMERS’ PARTICIPATION IN HEALTH INSURANCE IN HANOI CITY 4.1 Development objectives and direction to improve the factors affecting the farmers’ participation in health insurance in Hanoi 4.1.1 The basis for determining development objectives and direction to improve the factors affecting the farmers’ participation in health insurance in Hanoi 4.1.1.1 The development objectives of health insurance to 2020 of the country On November 22nd, 2012, the Politburo, the 11th Party Central Executive Committee promulgated the Resolution No 21-NQ/TW defining the objectives of universal health insurance coverage until 2020, with the target of achieving the coverage of health insurance to 80% of the population Health insurance is one of the two main pillars of the country's important social security policy, ensuring social progress and equality, ensuring sociopolitical stability and socio-economic development In addition, the management of health insurance must also aim to "manage, use effectively and ensure the balance of health insurance fund” To build modern and professional social insurance and health insurance systems with high efficiency, meeting the requirements of industrialization, modernization and international integration” (Party Central Executive Committee 2012) Besides, the Government also proposed other measures such as improving the quality of medical examination and treatment with the health insurance, ensuring benefits of participants in health insurance in accordance with the law, meeting the needs of medical examination and treatment of the insured At the same time, step by step reforming the financial mechanism towards direct investment for the beneficiaries of health care services through the form of health insurance, ensuring the balance of revenues and expenditures of the health insurance fund, striving to reduce the out-of-pocket medical expenses to less than 40% by 2020 4.1.1.2 Health insurance and socio-economic development objectives of Hanoi until 2020 Firstly, the socio-economic development objectives of Hanoi until 2020 About the general objectives: To mobilize all resources, to promote comprehensively and synchronously the renewal processes, industrialization and modernization; to build the capital city to be increasingly rich and beautiful, civilized and modern The economy continues to grow, the structure is moving in the right direction: services - industry - agriculture, there are many products with high technological content, value added and competitiveness To promote and improve the quality of planning and management of urban planning; to build socio-economic infrastructure more and more synchronously and modernly, and sustainable environment Socio-culture, education and training, health, science and technology continue to develop; Social security is guaranteed, people's life is improved; national defense and security are firmly strengthened; foreign relations are expanded, raising the prestige and position of the capital city To promote the leading role, the development center of the Red River Delta and the whole country Secondly, the health insurance development objectives of Hanoi until 2020 Resolution No 21 of the Politburo has set the general objectives of Hanoi social insurance, including: To continue implementing the policies and regulations on social insurance and health insurance effectively; to rapidly increase the coverage of the subjects participating in social insurance, especially voluntary social insurance; to implement the objective of universal health insurance By 2020, about 50% of the labor force will participate in social insurance; To effectively use the social insurance fund and ensure the balance of the health insurance fund The Conference of Assessing the current situation and solutions to implement social insurance and health insurance in 2016 to 2020 in Hanoi city determines to adjust the target of implementing health insurance in 2016 reaching 80% and by 2020 to raise this ratio to 90.1%”(Nguyen Duc Hoa, 2016) Hanoi social insurance proposed that the City People's Committee support 20% of health insurance premiums for pupils in the districts of the City, raising the criteria of health insurance coverage ratio from 70% to 80% for the communes meeting new countryside standards 4.1.2 The health insurance development objectives for the farmers in Hanoi until 2020 4.1.2.1 About the growth rate of voluntary health insurance participation of the farmers Based on the survey results of the author and the report by the Hanoi Social Insurance in 2015, the thesis uses the voluntary health insurance rate of 3.57% per year as a basis for the increase of health insurance for the farmers until 2020 and 2025 At the same time, based on the support of the local authorities and the increase of the impact factors, the thesis developed three options for participation rate in health insurance The first option is the basic option to take voluntary health insurance rate of the farmers during the period of 2015-2025, an average annual increase of 3.57%, the farmers’ participation proportion in health insurance will be 36.30% in 2020, and will be 54.15% in 2025 The second option is the medium option; in the three years of 2015-2017, the growth rate was 3.57% per year; 2018-2020 an average increase of 4% per year; 2021- 21 22 2022 an average increase of 5% per year, and 2023-2025 an average increase of 5.5% 2012-2014, the thesis estimates voluntary health insurance participation of the farmers based on the criteria of income, occupation and region As the proportion of voluntary health insurance participation of the farmers surveyed in 2012-2014 was higher than the results of Hanoi social insurance, so the proportion of health insurance participation through the period 2014-2020 and 2021- 2025 is also a little higher The specific results of voluntary health insurance participation rate of the farmers by income, occupation and region until 2020 and 2025 are shown in table 4.2 as follows At that rate, the voluntary health insurance participation rate of the farmers in 2020 will be 37.59%, in 2025 will be 64.09% The third option is the high option, in the years of 2015-2017, the growth rate was 3.57% on average per year; in 2018, the growth rate will be 4%; 2019-2020 increase 0.5% further compared with the previous year, so the growth rate in 2019 will be 4.5% and in 2020 will be 5%; in the next three years 2021-2023, an increase of 1% further compared with that of the previous year, so the growth rate of 2021 will be 6%.in 2021, 7% in 2022 and 8% in 2023; in two years of 2024-2025, each year increase 1.5% further compared with the previous year that is 9.5% in 2024 and 11% in 2025 According to such growth rate, it is expected that by 2020 there will be 39.09% of farmers participating in voluntary health insurance and in 2025 there will be 80.59% of farmers participating in voluntary health insurance in Hanoi Considering the current situation, the topic has chosen the medium option, because under the influence of the government policies and support policies of the City, the basic option is almost low compared to the coverage capacity of voluntary health insurance for the farmers; under the high option, it requires high efforts of both the government and the people to support and contribute Thus, the author thinks that choosing the medium option is more reasonable with the efforts of both sides today Table Options for increasing the participation rate of the farmers in Hanoi by 2025 Unit % Year Basic option Medium option High option 2015 18.45 3.57 18.45 3.57 18.45 2016 22.02 22.02 22.02 2017 25.59 25.59 25.59 2018 29.16 4.00 29.59 4.00 29.59 2019 32.73 33.59 4.50 34.09 2020 36.30 37.59 5.00 39.09 3.57 39.87 2021 5.0 42.59 6.00 45.09 2022 43.44 47.59 7.00 52.09 2023 47.01 5.5 53.09 8.00 60.09 2024 50.50 58.59 9.50 69.59 2025 54.15 64.09 11.00 80.59 The author's calculations are based on data of Hanoi social insurance in 2015 4.1.2.2 Structure of participation in health insurance of the groups of farmers Based on the options and participation rate of the farmers surveyed in 23 24 Table Expected participation structure of health insurance for the farmers based on the medium option Unit % Health insurance 2020 2025 participation rate in 2014 Proportion of farmer participants by income Rich and good income 46.34 69.05 95.55 Average 38.41 61.12 87.62 Pro-poor 15.25 37.96 64.46 Proportion of farmer participants by occupation Mixed 64.95 87.66 100.00 * Pure-farming 35.05 57.78 84.28 Proportion of farmer participants by region Delta 70.29 92.89 100.00** Mountain 29.71 52.42 79.92 Notes: * completed in 2023; ** completed in 2022 Source: The author's calculations are based on the data by Ha Noi social insurance in 2015 and survey results of 196 farmer households; 4.1.3 Direction to improve the factors affecting the farmers’ participation in health insurance in Hanoi City 4.1.3.1 The direction to improve the factors to increase the participation in health insurance for the groups of farmers by income The direction to increase the participation in health insurance of the farmers by good income groups is to continuously improve the quality of medical examination and treatment when using health insurance cards in the upcoming time For middle-income people, it is necessary to focus on mobilizing and propagating to people about the benefits of health insurance For the pro-poor farmers, the income is not high, so it is difficult to access the health insurance The future direction of these factors is to increase the support and grant of free health insurance cards to 100% of pro-poor households to ensure that all people are entitled to the health insurance benefits 4.1.3.2 The direction to improve the factors to increase the participation in health insurance for the groups of farmers by occupation health insurance for the groups of farmers by region The direction to improve the factors to promote the participation in health insurance for the groups of farmers is that i) to increase measures to improve the income of the farm households, especially the households in the mountainous areas; ii) to continue implementing the policies to support health insurance participation for vulnerable households For the groups of farmer households in the delta areas, it is necessary to strengthen measures to propagate and strictly manage the participants of health insurance 4.2 Solutions to improve the factors affecting the farmers’ participation in health insurance in Hanoi in the upcoming years 4.2.1 Improving the government support policies Firstly, to expand the level of health insurance support to the groups of farmer households participating in health insurance Despite having the guidelines that the City will support 100% of cost for health insurance cards for the pro-poor and newly-escaped households, currently only 70% is supported Therefore, it is recommended that the City People's Committee continue using the City's fund to support the remaining 30% for the pro-poor households in the next years For the medium households, the city currently supports 30% of cost for health insurance cards In the upcoming years, the city will increase the rate to 45%-50% of cost for the health insurance cards It is recommended that the People's Committee support the agricultural household groups to participate in this type of household health insurance Support rate may range from 5% to 10%, depending on the City's budget For the elderly, the City People's Committee may also: Support 30% of the card's face value for those who are 60 years old or more, and 50% for those who are 79 years old or more Secondly, to reform the health insurance policies towards equity and consistency Towards the goal of equal access to health services and universal health insurance coverage, the Government health insurance policies in the upcoming time are necessary to ensure uniform premium and health insurance coverage for all beneficiaries All people who use their health insurance card in the right line are paid all medical expenses In the upcoming time, the provisions of the policies on household health insurance should be adjusted in a more liberal way Accordingly, the registration place for initial medical care may be flexible to select the health care facilities based on the permanent or temporary residence places It is necessary to propagate for those who wish to participate in household health insurance, living in the houses for rent If the landlord resolutely does not list, those should complain, call for intervention from the local police or the The direction to improve the factors affecting the participation in health insurance for the groups of farmers by occupation in the future is that i) the City should continue to promote economic development to create jobs and increase income for the farmers; ii) on the other hand, to strengthen the management of health insurance 4.1.3.3 The direction to improve the factors to increase the participation in 25 26 People's Committee At the same time, representatives of local authorities need to participate in requesting the landlord to declare temporary residence in accordance with the Residence Law and list the health insurance cards for individuals who have registered for temporary residence Thirdly, to increase the mobilization of financial resources to support difficult households participating in health insurance In order to increase the support rate for disadvantaged people participating in the health insurance, apart from the fund of Hanoi City, there should be measures to mobilize more social resources To mobilize the contribution of domestic and foreign organizations and individuals for charitable activities, provision and support of medical equipment and medical examination and treatment, or support to purchase health insurance cards for the farmers with low income Hanoi Social Insurance can launch many charitable programs, call for the help of individuals and organizations in the area such as “Joint Hands for Public Health”, “Giving health insurance cards - giving peace of mind”, On this basis, Hanoi social insurance based on the list of pro-poor households, middle-income households, , difficult households in the area to ask for support from the organizations such as KIDO, VCB, for the rest to help the households buy health insurance cards Giving free health insurance cards should be held solemnly, with specific coverage on the mass media, etc Hanoi Social Insurance may propose to the Social Insurance of Viet Nam to allow the use of funds to cover the health insurance fund of health insurance in the provinces and cities to provide support according to the groups participating in health insurance 4.2.2 Solutions to improve the quality of medical examination and treatment activities using health insurance cards emergency patients to actively allocate reasonable treatment time, to help the patient reduce the waiting time and allow the unit to actively enhance the medical examination Sixthly, Hanoi Health Department, together with medical facilities needs to build up the staff of the whole system, training to improve the qualifications for the civil servants on political, professional capacity, positively strive to complete the tasks Seventhly, it is necessary to resolve relationship between cost and quality This means that to improve the quality of medical treatment, it should be accompanied by an increase in investment costs In order to increase financial resources for health care, and the quality of health services, the City needs to mobilize from various sources Firstly, removing the status, the psychological discrimination between the people with health insurance cards and those who not use health insurance cards at the examination Secondly, to transfer state funding from the service provider level to the direct beneficiaries of health services through the form of health insurance Thirdly, to overcome the discrimination of private health care facilities in the implementation of health insurance policies Fourthly, other measures to improve the quality of medical examination and treatment of the medical facilities Fifthly, to promote the pilot implementation of quality and patient satisfaction program in some large hospitals in Hanoi such as Bach Mai Hospital, Viet Duc Hospital, K Hospital, National Pediatrics Hospital, National Eye Hospital, National hospital of obstetrics and gynecology, Huu Nghi Hospital (Hanoi) The social insurance agencies should continue supporting these hospitals to quickly develop plans, deploy medical appointments by phone, Internet for non- Eighthly, in order to minimize overcrowding at hospitals, people should be encouraged to register their primary care facilities at their commune and ward health stations 4.2.3 Enhancing capacity of management organization and staff on health insurance and coordinated implementation Firstly, to organize the implementation of health insurance support for the farmer households participating in health insurance Hanoi Social Insurance should direct the district social insurance agencies to coordinate with Statistical agency, Invalids and Social Affairs Department, Finance Department, of the districts to list the agricultural households in the area It is necessary to coordinate with People's Committees at all levels to propagate the support policies to the farmer households To diversify forms of propaganda on policies to support farmers to participate in health insurance Secondly, to improve health insurance assessment To effectively implement the management of health insurance funds, the social insurance agencies in the country should be more active in coordinating with the health sector and medical facilities across the country to implement the process of receiving the patients, evaluating, assessing, paying for the health insurance premiums closely; To intensify the inspection and examination of medical examination and treatment establishments; to organize the extensive training courses to raise awareness, responsibilities and professional staff for assessment, request to follow closely assigned units, to coordinate with medical staff to test, instruct the patients correctly, enough procedures for medical insurance In the management and use of the health insurance fund, to ensure the progress of payment and settlement of medical examination and treatment expenses, to raise the efficiency of the use of medical examination and treatment funds, to ensure benefits for health insurance participants, and the localities should actively implement the method of inspecting the dossier of the 27 28 centralized health insurance The health insurance management agency should have solutions to improve professional skills for the team of assessors Thirdly, to improve the quality of human resources for health insurance team Fourthly, to strengthen coordination between the health insurance agencies and the units for inspection and examination Fifthly, to apply the information technology in management 4.2.4 Improving the economic conditions for the people insurance; many measures to improve the quality of medical examination and treatment when using health insurance cards have been applied; the management of medical examination and treatment with health insurance cards has been strengthened; the health insurance staff are improved in both professional and medical ethics; many measures to improve knowledge and ability to participate in health insurance for the farmers have also been implemented, so the farmers' participation in health insurance in the City has been increased over the years; The growth rate of health insurance participation of farmers has been increased markedly The participation structure in health insurance has changed very well By 2014, the proportion of farmers participating in health insurance was 57%, of which the rich households accounted for 68%, good income households accounted for 62%, poor households accounted for 57% and 44% of pro-poor households The proportion of households participating in health insurance was higher than that of pure-farming households; the proportion of participation in health insurance for the farmers in the delta and mountainous areas was quite equal 3) In addition to the above mentioned aspects, the factors affecting the farmers' participation in health insurance are still inadequate; i) the Government support policies on farmers' participation in health insurance have been promulgated and supplemented, but the implementation has not been effective; ii) The quality of health insurance services is not high, the satisfaction of farmers participating in health insurance is very low; iii) Management organizations and health insurance staff in the city are still far from fulfilling the requirements; iv) Farmer's income and v) farmers' awareness about health insurance participation are low These factors have been tested through the assessment of barriers affecting health insurance participation Results show that 85.8% of the 152 people who participated in the voluntary health insurance system in 2014 indicated the limitations on procedures, low income and impractical benefits were barriers to their participation in this system In the other words, about the beneficiary policy, management organization and income are the main barriers for farmers' participation in health insurance From that, the thesis showed that in order to carry out the process of universal health insurance in Hanoi, the thesis has developed and selected plans on the proportion of health insurance participation from 2017 to 2025, increasing the proportion of farmers participating in health insurance by 37.59% in 2020 and 64.09% in 2025 In order to this, the thesis proposes the orientation to improve the specific factors for each farmer and the main groups of solutions for implementation Specific groups of solutions: i) To expand the support of health insurance coverage for the target group of insured farmers, namely 100% of health insurance card premium for the pro-poor households, to raise the financial support for the medium-income households from 30% to 45%- Firstly, to improve the level of labor for the farmers to meet the demands for labor Secondly, to promote the diversification of industries to increase labor demands in the districts across the city in the direction of industrialization and modernization Thirdly, to diversify forms of production and business organizations in order to create jobs for the farmers Fourthly, to improve the jobs for the farmers 4.2.5 Raising awareness of people about health insurance participation To continue renovating the contents, organization and form of propaganda, paying attention to characteristics of the objects; it is necessary to intensify the coordination between social insurance and propaganda boards and mass organizations in the propagation of health insurance At the same time, to intensify the inspection and examination of the observance of the law on health insurance; to timely detect and handle violations, minimize the situation of evasion, health insurance debts and negative or fraudulent activities in order to enjoy health insurance benefits and regimes CONCLUSION To develop the health insurance for the farmers is very important, but it is very difficult to reach universal health insurance in the whole country in general, Hanoi in particular In the past years, despite the fact that the City has adopted many measures to implement health insurance for the farmers, the proportion of health insurance is still very low Therefore, the study of the factors affecting the farmers' participation in health insurance in Hanoi is a matter with theoretical and practical meanings Based on the overview of related domestic and foreign studies, the thesis has developed a theoretical framework on factors affecting the farmers' participation in health insurance on the basis of clarifying the concepts, the importance of the health insurance for the farmers; the factors affecting the farmers' participation in health insurance on aspects including i) Government support policies; ii) Quality of health care service when using health insurance cards; iii) Organizing activities of health insurance; iv) Farmer's income and v) Farmer's awareness Based on the secondary and secondary data collected during the survey, the thesis has clearly stated that over the years, the Government has issued and amended many policies to encourage the farmers' participation in health 29 50% To support from 5% - 10% for the other households participating in the health insurance by households; to reform health insurance policies towards equity and consistency; to increase the mobilization of financial resources to support difficult farmers to participate in health insurance; ii) To improve the quality of health care services when using the health insurance cards by removing discrimination between those with health insurance cards and those without health insurance cards; to change the form of State budget allocations from service-providing establishments to directly grant them to health service users through the form of health insurance; to overcome the discrimination of private medical examination and treatment establishments in implementing the health insurance policies; iii) To strengthen capacity of management and to improve the qualification of health insurance staff; iv) To improve economic conditions for the farmers and v) To strengthen the dissemination and education activities to raise awareness among farmers about the benefits of participating in health insurance