The impact of non profit health insurance on treatment seeking behavior the case of vietnam(vhlss 2006

Introduction

In recent years, Vietnam has emphasized the vital role of health insurance in its healthcare system to meet the Millennium Development Goals by improving social care services Introduced in 1992, the health insurance coverage began as a compulsory scheme but later expanded to include voluntary options and free health cards for the underprivileged The Compulsory Health Insurance (CHI) scheme covers current and retired civil servants, employees of state and large private enterprises, and foreign-owned organizations, facilitating inpatient and outpatient treatment, albeit with certain limits The Voluntary Health Insurance (VHI) scheme is available to those not covered by CHI, including the self-employed and employees of small businesses, provided community participation thresholds are met Despite its potential, the adoption of voluntary insurance has faced challenges, including high costs and competition from informal risk-sharing networks, while a dedicated health insurance scheme for the poor has been in place since 2002.

The master's thesis on Economic Management focuses on residents of economically disadvantaged communes and ethnic minorities in Vietnam, supported by various charity organizations and government poverty alleviation programs The initiative has been enhanced under a national program that mandates the establishment of Health Care Funds for the Poor The study explores how health insurance influences healthcare utilization and treatment-seeking behaviors It posits that health insurance reduces healthcare costs at the point of service, thereby increasing access to healthcare services Additionally, it examines how health insurance aids in lowering overall healthcare expenditures through risk-sharing and cost-pooling, particularly benefiting the poor who face potential healthcare catastrophes due to high costs The thesis also investigates the correlation between socio-economic factors, such as education, and treatment-seeking behaviors, highlighting the importance of awareness regarding health status in influencing insured individuals' healthcare choices.

Luận văn thạc sĩ Quản lý Kinh tế

Numerous studies, including those by Jowett (2004), Tridevi (2002), and Giang (2006), have explored the impact of health insurance on healthcare utilization; however, these studies face limitations due to insufficient data and overly strong assumptions, potentially leading to biases in the current health insurance landscape This thesis aims to bridge the knowledge gap by investigating the effects of Vietnamese health insurance on treatment-seeking behaviors, particularly among participants in the health insurance for the poor scheme, which holds significant practical relevance Utilizing the comprehensive VHLSS 2006 dataset, the research will assess the influence of health insurance on various healthcare service utilizations, differentiate between insurance types, and evaluate treatment-seeking probabilities Additionally, the VHLSS 2006 dataset provides extensive information on individual health, household status, and the types of healthcare providers accessed across all provinces.

This study estimates the impact of health insurance on healthcare utilization among the poor over a 12-month period, specifically focusing on outpatient contacts to better capture seasonal effects and other time-related aspects of health treatment behaviors The findings will be valuable for researchers and policymakers seeking solutions to the challenges associated with the Vietnamese Government's goal of achieving universal health coverage for the entire population by 2015.

Research questions

* Central question : What is the impact of health insurance on the treatment- seeking behavior.

+ How does health insurance (and its separate components) affect the usage of public health care services by the insured?

+ How does health insurance (and its separate components) affect the usage of private health care services by the insured?

+ How does health insurance (and its separate components) affect the usage of outpatient health care services by the insured?

+ How does health insurance (and its separate components) affect the usage of inpatient health care services by the insured?

+ Insured individuals tend to use more public health care services than private health care services when feeling ill

+ Health insurance increases the probability of using public health care services, especially those with low income status.

+ Being insured under Health Care Fund for the Poor increases the probability of insured individuals seeking health care services at public providers.

3 Objectives and scope of the study:

This study aims to achieve three key objectives: first, it offers background information on health insurance alongside a descriptive data analysis; second, it conducts an empirical analysis of how health insurance schemes, particularly those aimed at the poor, influence treatment-seeking behaviors over a 12-month period, accounting for seasonal health variations and related factors; third, the thesis concludes with policy recommendations to enhance health insurance effectiveness.

This thesis analyzes the latest Vietnam Households and Living Standards Survey (VHLSS 2006) dataset to evaluate the effects of various health insurance schemes over a 12-month period It first investigates the likelihood of outpatient contracts and inpatient admissions, followed by an examination of health-seeking behaviors across different types of healthcare facilities, including public health facilities, government polyclinics/hospitals, and private clinics/hospitals.

The study utilizes the Vietnam Household Living Standards Surveys 2006 (VHLSS 2006), a comprehensive dataset funded by the World Bank and managed by the Vietnam General Statistics Office (GSO) This dataset provides extensive information on various types of insurance, healthcare expenditures by insured individuals, the types of healthcare services accessed, and the healthcare providers chosen when individuals fall ill Additionally, it includes socio-economic factors related to the insured, such as gender, age, health status, proximity to healthcare providers, and marital status.

In addition, the study also uses other data from the GSO and the Ministry of Health as references to enrich the statistical analysis of the sector. b Model:

In this study, we carefully select appropriate models to address our research questions The logit model is employed to analyze the binary variable representing the probability of contact or admission, while count regression models are utilized to examine the density of contacts or admissions A detailed justification for our model selection will be provided in Chapter IV, which covers the methodology and empirical results.

The thesis is structured as follows: Chapter I outlines the problem statement, methodology, data, research questions, and the study's relevance Chapter II reviews relevant literature and summarizes recent developments in Vietnam's health care and health insurance sectors Chapter III introduces the health care system and health utilization in Vietnam Chapter IV presents the methodology and empirical results of the estimation models, along with a brief description of the data and variables Chapter V discusses the findings and their implications, while Chapter VI concludes the thesis.

Structure of the thesis

This thesis is organized into six chapters: Chapter I outlines the problem statement, methodology, data, research questions, and the study's relevance Chapter II reviews relevant literature and summarizes recent developments in Vietnam's health care and health insurance sectors Chapter III introduces the health care system and health utilization in Vietnam Chapter IV details the methodology and empirical results of the estimation models, along with a brief description of the data and variable information Chapter V presents the findings and their implications, while Chapter VI concludes the thesis.

LITERATURE REVIEW

Literature review in general

Extensive research highlights the significant influence of health insurance on health service utilization globally In developed nations, studies demonstrate that health insurance positively affects the use of health services For instance, Cameron et al (1987) analyzed data from the Australian Health Survey (1977-1978) using econometric models to identify factors influencing health care utilization Their findings reveal that utilization patterns differ notably across various insurance types, with health status emerging as a more critical factor than insurance choice Additionally, the study indicates the presence of self-selection and moral hazard associated with certain types of health care services.

Ekman (2007) conducted a comprehensive study on the influence of health insurance on outpatient care utilization and expenditure in middle-income countries, specifically focusing on Jordan Utilizing rigorous quantitative methods and household-level data, the research analyzed how the availability of multiple health insurance options affects outpatient care utilization, the intensity of use, and individual out-of-pocket (OOP) spending The study aimed to determine whether different insurance programs have varying impacts on healthcare utilization and expenditures, as well as how these effects differ across income levels.

The master's thesis on Economic Management utilized data from the 2000 Jordan Healthcare Utilization and Expenditure Survey (JHUES), which included a sample of 8,800 households The survey gathered comprehensive information on each household member, focusing on health care utilization and expenditure for a randomly selected individual Employing econometric techniques and a two-part model approach, the study revealed that approximately 60 percent of the population has some form of insurance, though coverage varies significantly across income groups The findings indicated that insurance enhances the intensity of health care utilization and decreases out-of-pocket expenses, yet no overall effect of insurance on the likelihood of seeking care was identified (Ekman, 2007).

In their 2001 study, Sapelli and Vial examined Self Selection and Moral Hazard in Chilean Health Insurance using data from the 1996 National Socioeconomic Survey Their findings revealed that 60% of the population opted for the public insurance National Health Fund (FONASA), while 25% chose private health insurance through ISAPRE, and 11% remained uninsured Additionally, 3% of individuals were affiliated with the Armed Forces and law enforcement, along with others in special coverage schemes The authors developed a theoretical model that captures the interdependence of individual demand for health insurance and healthcare services, framed within intertemporal utility maximization under uncertainty Their empirical analysis highlighted the need to detect self-selection bias, ultimately linking health insurance choices to healthcare consumption.

The master's thesis on Economic Management analyzes the consumption of care services, revealing that families with higher income, young children, larger household sizes, and more education are more likely to purchase health insurance Additionally, the likelihood of opting for private insurance increases with higher income, younger age, fewer dependents, urban residency, and employment in larger companies Conversely, older age and more dependents correlate with a preference for public insurance The study highlights the moral hazard effect, indicating that insured workers, particularly those in public insurance, consume over twice as many physician visits as their uninsured counterparts, largely due to nearly complete coverage in public insurance compared to the cost-sharing typically found in private insurance.

Studies of utilization on healthcare in Vietnam

Recent studies in Vietnam have increasingly focused on the impact of health insurance on healthcare utilization Jowett (2004) investigated how voluntary health insurance affects treatment-seeking behavior, utilizing data from the Institute of Sociology in Hanoi, which was limited to three provinces: Hai Phong, Ninh Binh, and Dong Thap Employing a two-stage multinomial logit model to address endogeneity, the study produced significant empirical findings regarding the types of healthcare providers sought and the nature of care received However, due to data limitations in 2004, the research primarily examined the relationship between voluntary health insurance and treatment-seeking behavior.

The master's thesis on Economic Management examines health insurance as both an endogenous and exogenous variable, revealing that compulsory health insurance schemes have led to a crowding out effect Utilizing comprehensive data from the 1997-1998 Vietnam Living Standards Survey (VLSS), Trivedi (2002) analyzes healthcare utilization patterns, highlighting that insured individuals typically seek treatment at commune health centers and government hospitals, while uninsured individuals prefer private facilities and pharmacies The study finds a statistically significant difference in government hospital usage, with insured individuals utilizing these services approximately 2.5 times more than their uninsured counterparts Conversely, uninsured individuals show a significantly higher usage of private health facilities and drug vendors However, the inability to distinguish between voluntary and compulsory insurance enrollment may result in biased estimates regarding the impact of health insurance on healthcare utilization, particularly for households anticipating higher health expenditures.

Similar to Tridevi (2002) and Jowett (2004), Giang (2006) studied on the health insurance and pattern of health care utilization in the case of Vietnam.

Using data from the Vietnam National Health Survey (VNHS 2001/2002), this study empirically evaluates the impact of three types of health insurance The findings indicate that individuals with public health insurance are more likely to utilize inpatient care and do so more frequently compared to those without insurance Additionally, the results suggest that voluntary health insurance does not influence the frequency of outpatient visits to public healthcare providers (Giang 2002).

As for private providers, the findings gives out that the health insurance diverts the use of health care services from private health providers to public

The master's thesis on Economic Management highlights that both compulsory insurance and health insurance for the poor negatively affect the likelihood and frequency of outpatient visits, while voluntary health insurance shows no significant impact on visits to private providers Due to data limitations, the study could not fully analyze the effects of health insurance for the poor or address potential adverse selection and provider moral hazard Wagstaff (2007) utilized the 2004 VHLSS data to assess the initial effects of the Health Care Fund for the Poor (HCFP), analyzing 9,000 households and over 40,000 individuals The study estimated HCFP's impact by comparing out-of-pocket payments and healthcare utilization between those covered by HCFP and similar individuals not covered, employing propensity score matching to evaluate the similarities between treated and untreated individuals.

A 2007 study by Wagstaff reveals mixed outcomes from the program aimed at improving healthcare access On the positive side, the program has significantly increased service utilization and reduced the risk of catastrophic out-of-pocket spending However, there are notable drawbacks: first, average out-of-pocket expenses remain unchanged, leaving poor households burdened by high health costs despite having HCFP coverage Second, the increase in service utilization is primarily observed in inpatient care rather than outpatient care, which may not be the most cost-effective approach for enhancing health among impoverished Vietnamese families, as they still face additional costs such as transportation and informal payments Lastly, the benefits of increased utilization are disproportionately experienced by wealthier households, with minimal impact on the poorest deciles.

HEALTH CARE SYSTEM AND HEALTH UTILIZATION

Introduction of healthcare system in Vietnam

Vietnam's healthcare system is structured by administrative levels, with the Ministry of Health (MOH) overseeing overall responsibilities at the central level The MOH directly manages 70 subordinate institutions across three primary sectors: hospitals, preventive medicine, and professional institutes, including pharmaceutical universities and schools.

Every province operates a Provincial Health Department (PHD), which is a professional agency overseen by the Provincial People’s Committee (PPC) The PHD advises the PPC on managing local healthcare, protection, and promotion It fulfills tasks assigned by the PPC while adhering to established regulations According to USAID, the PHD is managed by the PPC regarding organizational and operational aspects, but it also receives technical guidance and oversight from the Ministry of Health (MOH) Additionally, the PHD supervises provincial general hospitals, specialty hospitals, and preventive health centers.

At the district level, each district has the District Health Office (DHO), a professional agency under the management of the District People’s

The District People’s Committee (DPC) advises on the management of local health care, focusing on protection and promotion of public health Each district is equipped with a district hospital, a preventive center, and several intercommunal polyclinics These facilities primarily provide inpatient services, emergency care, and basic treatment for common illnesses.

The Commune Health Station (CHS) serves as the primary point of contact for health care within the government system, offering essential primary health care services such as early epidemic detection, treatment for common illnesses, maternal care, and health promotion It plays a vital role in mobilizing community members for birth control and preventive hygiene practices while being accountable to the District Health Office (DHO) and the Commune People’s Committee for local health care initiatives Additionally, the CHS receives technical support from district hospitals, contributing to a comprehensive grassroots health care network that encompasses all 671 districts and 10,876 communes and wards in Vietnam as of 2006 (USAID, 2009).

The private health care system of Vietnam only officially started from

In 1989, the government legalized the establishment of multiple entities in healthcare services, leading to significant growth by the end of 2006 The country boasted 30,000 private clinics, 5 semi-public hospitals, 300 private regional general clinics, and 87 maternity wards, marking a nearly 20 percent increase compared to 1996, when there were 25,698 private practitioners Additionally, there are 49 private hospitals, including 36 general and 13 specialized hospitals, equipped with 4,050 sick beds.

The role of private health clinics in providing health services, particularly inpatient treatment, remains minimal, with only 4 percent of inpatient services delivered by this sector in 2003 While private clinics accounted for 60 percent of outpatient services, public health facilities dominated the market, offering 96 percent of inpatient services and 90 percent of preventive health care services This highlights the significant reliance on public health institutions for comprehensive healthcare delivery.

The private health sector is currently divided into two tiers: a limited number of private hospitals primarily found in major cities and a larger network of private clinics operating in both urban and rural areas However, there is a significant imbalance in the distribution of private practitioners, with a high concentration in urban regions that have better living standards Alarmingly, many private clinics are run by doctors who also manage public health facilities, and up to 70 percent lack proper licenses According to USAID, only 26 percent of private clinics engage in primary health care activities when mobilized Furthermore, many private consulting rooms breach regulations by selling drugs on-site, leading to concerns about the overuse and inappropriate application of medications and advanced technologies, often driven by financial motives.

Despite existing challenges, private health providers have made notable contributions to healthcare by offering flexible hours, improved access, increased medication availability, and more respectful client interactions Additionally, the overall cost of treatment in private healthcare can be lower than in public services, partly due to the common practice of informal "envelope" payments in Vietnam (Giang 2006).

Health care utilization

This section reviews healthcare utilization in Vietnam based on prior studies, focusing on the types of services accessed, including inpatient and outpatient care, as well as instances of no treatment and self-medication Additionally, it examines the usage of healthcare services across various schemes.

2.1 No treatment and self-medication

According to the Vietnam National Health Survey (VNHS) 2002, among 66,795 reported illness cases over a four-week period, only 4% did not seek treatment Self-medication emerged as the predominant choice, utilized by 75% of those who reported illness Both the Vietnam Living Standards Survey (VLSS) 1998 and VNHS 2002 reveal a consistently high rate of self-medication across various age groups and educational levels Notably, a significant disparity exists among ethnic groups, with the Kinh and Chinese populations exhibiting the highest self-medication rates of 73-74%, while ethnic minorities in the Central region and Central Highlands show the lowest rate at 49%.

Over the years, there has been a notable increase in the rate of self-medication, as evidenced by comparisons with previous surveys such as the VLSS conducted in 1993 and 1998 According to Nguyen Thi Hong Ha (2002), the self-medication rate rose from approximately 70% in 1998 to 75% in 2001-2002, as reported by the VNHS Additionally, the average annual contacts with drug vendors per capita increased significantly from 2.1 in 1993 to 6.8 by 1998, with these contacts representing two-thirds of all health-related interactions (World Bank, 2001).

Self-medication is influenced by various factors such as economic hardship, limited access to healthcare, reliance on outdated prescriptions, and the presence of minor illnesses A study by VNHS reveals that only 1% of the population resorts to self-medication due to challenges in accessing health services Notably, economic difficulties are reported as the primary reason for self-medication by just 1% of individuals in the wealthiest quintile, contrasting sharply with 17% among those in the poorest quintile.

The rise in self-medication can be attributed to inadequate healthcare quality for lower-income populations (Litvack, 1998) Additionally, the increased accessibility of pharmaceuticals and the deregulation of over-the-counter sales have further promoted self-medication practices (Trivedi, 2002) This trend raises significant concerns regarding the emergence of antibiotic-resistant bacteria linked to self-medication behaviors.

Firgue 1: Distribution of inpaatient contacts across healthfacilities by rural and urban population

Firgue 1: Distribution of inpatient contacts across health facilities by rural and urban population

District Hospital Provincial Hospital Central Hospital Other public health facility

Source: Vietnam National Health Survey 2002 ( Giang 2006)

Inpatient services are predominantly offered by government hospitals, with a VNHS survey indicating that only 5.4% of individuals sought these services in the 12 months leading up to the survey As illustrated in Figure 1 from the VNHS 2002 survey, private facilities accounted for a mere 4% of inpatient care visits, highlighting the limited use of private healthcare options for inpatient services.

The provision of inpatient care by private clinics and hospitals, while still low, has experienced significant growth in recent years, as highlighted by data from the Vietnam Living Standards Survey (VLSS) 1993.

1998 show that utilization of inpatient services in private providers were neglectible (World Bank et al 2001).

Provincial and district hospitals serve the majority of patients seeking inpatient care, while regional policlinics and commune health centers contribute to approximately 4% of these contacts This distribution varies significantly between rural and urban areas In contrast, central hospitals experience a lower share of inpatient services, likely due to their limited accessibility and fewer facilities compared to other healthcare providers.

Outpatient care utilization varies across groups Children under tend to use more outpatient services in private health facilities (Nguyen Thi Hong

Healthcare utilization in Vietnam is marked by significant inequality, with wealthier households predominantly accessing higher-quality hospital services Between 1996 and 1998, affluent urban populations benefited from 76% of the state recurrent budget allocated to hospitals, exacerbating disparities as private hospitals are primarily located in cities This urban bias extends to the medical workforce, as physicians tend to practice in urban areas, leaving rural and remote regions with a shortage of qualified healthcare professionals despite their greater healthcare needs Although the 1989 user fee policy aimed to enhance hospital revenues and improve service quality, the burden of user fees and informal charges remains disproportionately heavy on poorer populations.

As a consequence, the poor who are usually the sicker receive less healthcare (Seperhi, 2003) In 2003 the Government established the Healthcare Fund for

Luận văn thạc sĩ Quản lý Kinh tế the Poor to improve access to healthcare services by the poor and reduce the financial burden of illness on the poor.

2.4 The schemes of health insurance in Vietnam

There are 3 schemes under Vietnam Health Insurance: Compulsory schemes, Voluntary schemes and Schemes for the poor under Healthcare Fund for the Poor.

In August 1992, the Government of Vietnam enacted decree No 299, leading to the introduction of a non-profit public health insurance scheme in 1993 Initially compulsory, this program covered current and retired civil servants, employees of state enterprises, and those with contracts of three months or longer in large private companies with over ten employees It also included employees of foreign-owned enterprises, individuals with disabilities, and people of merit, such as mothers, widows, and orphans of veterans, army invalids, dependents of military personnel (since 2002), and the elderly.

The compulsory health insurance scheme in Vietnam does not extend coverage to family members, while the voluntary scheme is theoretically available to all citizens However, many provinces have hesitated to promote this voluntary insurance due to the high costs associated with adverse selection Notable initiatives include health insurance for school children and a voluntary scheme for farmers, where farmers pay 30% of the premium and the provincial government covers the remaining 70%.

The Health Insurance Program (HIP) provides coverage for impoverished residents in socio-economically challenging communes and ethnic minorities in disadvantaged provinces This initiative is supported by various charitable organizations and government funding through poverty alleviation efforts Recently, the program has been restructured and better funded under a national initiative, directing provinces and centrally-run cities to implement the scheme effectively.

The healthcare program for the poor offers beneficiaries free health insurance cards valued at 50,000 dong or covers their medical expenses at public hospitals, subject to specific limits Notably, there is no co-payment required for these services (Sepehri et al, 2005).

2.5 Heath care for the poor

The Decision 139 mandated all provincial governments to provide free health care to three groups:

Households classified as poor under government standards established in November 2000 include all families in areas supported by the Decision 135 program from 1998, which aids particularly disadvantaged communes, as well as ethnic minorities in Thai Nguyen province and six other mountainous regions identified by Decision 186 as facing significant challenges The central government allocates VND 52,500 (approximately $3) annually per beneficiary to the province's health care fund for the poor (HCFP), with a requirement for provinces to contribute an additional VND 17,500, although compliance has been limited.

Provinces initially had the autonomy to choose between utilizing the VND 70,000 to enroll beneficiaries of the Health Care Fund for the Poor (HCFP) in the government's Social Health Insurance (SHI) program or managing the risk independently by directly reimbursing healthcare providers Although the latter option was initially favored by many provinces, it is now being phased out following a 2005 government directive that updated the existing decision.

METHODOLOGY AND EMPIRICAL RESULT

Methodology and data

This article examines two main dependent variables: whether individuals sought care and the type of health facility utilized, along with the frequency of use This distinction allows for a detailed analysis of how different health insurance types impact service-seeking behavior across various health facilities The study focuses on inpatient admissions, specifically investigating government polyclinics and hospitals, as these are the primary providers of inpatient care Additionally, the models are analyzed for the overall sample and separately for urban and rural areas to highlight differences in health-seeking behaviors between these regions.

The dependent variable in this study is a binary variable that equals 1 if an individual sought medical care (either inpatient or outpatient) within the 12 months leading up to the interview, and 0 if they did not The analysis employs a logit model as described by Gujarati (2004).

Dividing (2) by (3) yields (4), which represents the odds ratio indicating the likelihood of utilizing healthcare services compared to the likelihood of not using them in the 12 months leading up to the interview The right side of equation (1) illustrates the cumulative logistic distribution function.

In the interpretation of the logit model, the exponential of the slope is commonly utilized to assess the change in the odds ratio with a unit change in the variable X This metric indicates how the likelihood of utilizing healthcare services fluctuates as X increases by one unit.

X is a dummy variable, for example, health insurance status, taking values of

1 and O, then measures how much the odds in favor of using healthcare services changes if X takes value of 1 if having health insurance and 0 if not

For analyzing the number of admissions or visits, which are non-negative integer values, count regression models are suitable due to the discrete nature of the dependent variable The Poisson regression model is commonly employed for this type of data, as highlighted by Green (2003).

The model indicates that the discrete dependent variable Y follows a Poisson distribution, with its parameter linked to According to the Poisson assumption, the probability of observing specific counts of Y, such as y=0, 1, 2, 3, and so on, is defined by a function of

Normally, there are 3 assumptions under Poisson regression:

(i) Parameter is specified as the log linear function of x and that

(ii) Conditional variance of Yi is equal to conditional mean:

(iii)/ Yi, xi are independently and identically distributed (maximum likelihood method).

The Poisson model often fails to meet its second assumption, leading to a significant limitation known as overdispersion, where the conditional variance exceeds the conditional mean While Poisson regression estimations remain consistent under these conditions, they lack efficiency (Long, 1997, cited in Giang, 2006) A widely accepted alternative to address this issue is the negative binomial model.

The negative binomial regression model imposes a less restrictive assumption on the equi-dispersion Negative binomial distribution is a compound Poisson with probability distribution as follows:

Where: is the gamma function and , the parameter measures degree of dispersion

In the Poisson regression model, the observed heterogeneity influences both the conditional mean and variation Conversely, the negative binomial model incorporates an additional random variable into its conditional mean, with its variation stemming from unobserved heterogeneity (Long, 1997, cited in Giang, 2006) While the expected value of Y in the negative binomial distribution aligns with that of the Poisson distribution, the conditional variance of the negative binomial distribution is greater, surpassing the conditional mean.

(7) C/ Problem of truncation and models for truncated counts:

In our study, we encountered an excessive number of zeros in the sample, which is not an issue with the binary model but rather a problem of truncation in count models Standard count regression methods like Poisson or negative binomial models can result in inconsistent estimations due to this truncation To address this issue, we employ truncated count models, such as truncated Poisson and truncated negative binomial models, which include only individuals who have reported at least one instance of outpatient contact or inpatient admission.

The truncated Poisson and truncated negative binomial models are the most suitable for analyzing health utilization frequencies A crucial step in model selection is testing for overdispersion, as it ensures the consistency and efficiency of empirical estimations Since the Poisson regression model is a special case of the negative binomial model, the hypothesis test (Ho) is conducted to evaluate overdispersion This test can be performed using the likelihood ratio method, applicable when estimating the negative binomial model under standard conditions, without weight or standard error adjustments.

The analysis utilizes data from the VHLSS 2006, a comprehensive survey that examines various household aspects, including demographics, education, income, expenditure, and assets Notably, the health section of this survey offers extensive insights into individual health, surpassing the information provided in the VHLSS 2002 and VHLSS 2004 Specifically, section 3 covers health status over the preceding four weeks and twelve months, health insurance involvement, and general health treatment utilization Additionally, subsequent sub-sections focus on disability and chronic health conditions.

The master's thesis on Economic Management examines the impact of reproductive health and behaviors on overall health, utilizing interviews to gather data It includes an analysis of health insurance history and its utilization, concluding with a detailed look at health treatment usage Data was collected over two time spans: 4 weeks for outpatient contacts and 12 months for inpatient admissions The survey encompassed 64 provinces, capturing information from 9,190 households and 39,071 individuals across 3,063 communes and wards This research adopts a 12-month reference period for both outpatient and inpatient data, in contrast to Giang's (2006) study, which focused solely on outpatient contacts over a 4-week period due to the unavailability of 12-month data.

Variable description

The thesis employs two classes of models: a logit model to assess the probability of individuals seeking care from health facilities and count models to analyze the frequency of such contacts or admissions In the logit model, the dependent variable is binary, indicating whether an individual has sought care (1) or not (0), while the count model focuses on the number of contacts or admissions Both models utilize a common set of independent variables prevalent in health services utilization literature, including individual-level factors such as age, gender, education, income (proxied by expenditure), marital status, and health status Additionally, household-level variables like the education and ethnicity of the household head, along with household income, are considered, as these factors can significantly influence health treatment decisions for children The analysis also incorporates living areas (urban or rural) and regional distinctions, which are essential for understanding individual and household behaviors in Vietnam, particularly in the context of Living Standard Surveys.

Table 1: Health insurance coverage by expenditure quintiles

Free health card for children 5.16 3.39 3.09 2.36 1.87 3.17

Health insurance / Free health card for the poor 48.05 19.85 10.96 7.88 4.75 18.3

Table 2: The use of outpatient care across providers by the insurance status and the type of insurance

Free health card for children

Health insurance /Free health card for the poor

Table 3: Decomposition of utilization by health facilities, inpatients

Free health card for children 14.52 48.39 37.10 0.00

Health insurance /Free health card for the poor 17.05 46.56 35.52 0.87

Table 4: Number of outpatient contacts per person

Free health card for children 0.721 0.243 0.103 0.546 1.613

Health insurance /Free health card for the poor 0.617 0.295 0.127 0.313 1.354

Table 5: Number of inpatient contacts per person

Free health card for children 0.016 0.049 0.037 0.000 0.101

Health insurance /Free health card for the poor 0.022 0.058 0.046 0.001 0.128

Table 6: Probability of health facilities contacts in general Odd ratio

Number of days in bed due to illness/injuried 0.999 0.999 0.999 1.013 *** 1.011 *** 1.015 ***

Free health card for children under 6 Yos 2.389 *** 3.979 *** 2.067 *** 1.667 *** 1.902 * 1.550 ***

Health insurance/ Free health card for the poor 1.865 *** 2.401 *** 1.752 *** 1.667 *** 1.917 *** 1.624 ***

Standard Errors are given below the Odd ratios

*: significance at 10%; **: significance at 5%; ***: significance at 1%

Table 7: The results for contacts and frequency of outpatient contacts at the commune health centres

Probability of contact Frequencies of contacts

Number of days in bed due to illness/injuries 0.998 * 1.001 0.997 ** 0.002 * 0 0.003 **

Free health card for children under 6 Yos 2.954

Free health card for the poor * * * * * *

Likelihood ratio test statistics for overdispersion 2472.58

Probability is estimated with logit model Standard Errors are given below the Odd ratios/Coefficients

Density is estimated with zero truncated negative binomial model *: significance at 10%;

Table 8: Probability of out-patient contacts and Frequencies of contacts: public polyclinics/hospitals

Probability of contact Frequency of contacts

All sample Urban Rural All sample Urban Rural

Number of days in bed due to illness/injuries 1.000 1.000 1.000 0.003

Free health card for children under 6 Yos 2.171 ** 3.536 ** 1.763 ** 0.235 - 0.543 **

Health insurance/Free health card for the poor 2.115

Probability is estimated with logit model

Density is estimated with zero truncated Poisson model as zero truncated negative binomial models did not converage

Standard errors are given below the Odd ratios/Coefficients

Table 9: Probability of out-patient contacts and Frequency of contacts: Private clinics/hospitals

Number of days in bed due to illness/injuried 0.999 0.999 0.999 0.002 *** 0.001 0.003 ***

Free health card for children under 6 Yos 0.777 ** 0.950 0.754 ** 0.097 0.192 0.082

Health insurance /Free health card for the poor 0.668 *** 0.912 0.621 *** 0.071 0.3 * -0.046

Likelihood ratio test statistics for overdispersion 3195.51 929.62 2150.7

Probability is estimated with logit model Density is estimated with zero truncated negative binomial model Standard errors are given below the Odd ratios/Coefficients

Table 10: Probability of in-patient contacts and frequency of contacts: public polyclinics/hospitals

Number of days in bed due to illness/injuries 1.013 *** 1.011 *** 1.014 *** 0.006 *** 0.006 *** 0.005 ***

Free health card for children under 6 Yos 1.855 *** 1.944 * 1.770 *** 0.125 -2.094 * 0.578

Health insurance/ Free health card for the poor 1.650 *** 1.912 *** 1.632 *** 0.294 * 0.132 0.333 *

All sample Urban Rural All sample Urban Rural insurance

Probability is estimated with logit model

Density is estimated with zero truncated Poisson model as zero truncated negative binomial models did not converage

Standard Errors are given below the Odd ratios/Coefficients

Descriptive analysis

Table 1 illustrates the bivariate relationship between the dependent variables and the type of insurance, as well as the relationship with other significant independent variables For guidance on the elements to include in the descriptive analysis, refer to the descriptive analysis section of my papers or similar studies The analysis will commence with Figure 3.

Figure 2: Health insurance coverage by expenditure quintiles

Generally, just more than a haft of Viet Nam population is covered by at least one type of health insurance Ratio of free health card for children under

6 YO is mainly depended on ratio of children in the quintiles, thus it does not have much meaning and we will not discuss in detail.

The poorest individuals primarily benefit from health insurance, particularly through free health cards designed for low-income populations, while other insurance types are less common In contrast, the three middle income quintiles experience relatively poorer health outcomes.

The decline in health insurance and free health cards for low-income individuals has led to inadequate alternatives in health coverage This significant reduction highlights the urgent need for improved insurance options to ensure that vulnerable populations receive the necessary healthcare support.

Incidences of compulsory health insurance and vulnerary health insurance increase with increase in welfare (expenditure) with a considerable increase by the richest.

Figure3: Percentage of health contacts of different groups of health insurances

Figure 3 illustrates the probabilities of health care contacts, highlighting that the free health card for children is exclusively available for those under 6 years old This age group exhibits distinct health care utilization patterns compared to other demographics, prompting a focus on the health insurance needs of older populations.

Having health insurance seems to increase probabilities of contact with health facilities in general Having heath insurance appear to have a stronger

A master's thesis in Economic Management reveals a positive correlation between health insurance coverage and inpatient hospital admissions Specifically, individuals with compulsory health insurance are significantly more likely to seek care, particularly inpatient services, compared to those without insurance In fact, individuals enrolled in compulsory health insurance are twice as likely to be admitted to hospitals than their uninsured counterparts.

Table 2 provides utilization of health care services across the providers.

Uninsured individuals are 50% more likely to seek care from private providers compared to those with insurance, who tend to utilize public health facilities to access their benefits Those with compulsory health insurance predominantly use public polyclinics and district hospitals, while the behavior of individuals with voluntary health insurance mirrors that of the compulsory group in their reliance on public health services.

Private clinics and hospitals remain a popular option for families utilizing free health cards for children and vulnerable health insurance This trend highlights the need to evaluate the convenience and effectiveness of these health insurance types in accessing necessary medical treatments.

Table 3 breaks down the total number of inpatient contacts by various types of health facilities While the differences in facility functionalities may limit the table's overall significance, certain key features warrant attention.

A significant portion of the first three groups has access to community clinics, prompting a reevaluation of investment in these public health facilities Traditionally viewed as primary healthcare providers, these clinics play a crucial role in the overall health system.

A higher proportion of inpatient admissions is observed among individuals with health insurance or free health cards, particularly for low-income families and children under six years old, in village and commune clinics as well as general clinics and district hospitals.

Table 4 illustrates the average number of outpatient visits across various health insurance groups in different healthcare facilities Notably, all insured groups demonstrate a higher frequency of outpatient contacts compared to those without health insurance.

Children under 6 years old benefit from free health cards, while those with compulsory health insurance exhibit significantly higher outpatient contact rates Specifically, the frequency of outpatient visits among insured individuals is approximately 40 percent greater than that of those without health insurance.

Table 2 reveals that the most common outpatient contact for children with free health cards and for those with health insurance or free health cards for the poor is through commune clinics In contrast, these groups have significantly lower rates of outpatient treatment at provincial or central hospitals compared to individuals without health insurance.

Compulsory health insurance facilities frequently engage with public polyclinics and district or provincial/central hospitals, leading to a higher rate of outpatient consultations compared to other health facility groups.

Vulnerary health insurance groups exhibit low overall contact frequency, yet they tend to utilize private clinics and hospitals more often than other health insurance types This suggests that health insurance status has a minimal influence on their healthcare-seeking behavior Similar to Table 4, Table 5 presents the average number of inpatient contacts across various health insurance groups and types of healthcare facilities.

Luận văn thạc sĩ Quản lý Kinh tế their functionalities, public polyclinics and hospitals are main place of inpatient admission.

Econometric results

Table 6 presents the econometric results for the use of health care services

Demographic characteristics reveal significant coefficients for age and gender at the 1% level Specifically, the odds ratio for age indicates that as age increases, both out-patient and in-patient contacts decrease, although the effects are marginal Additionally, being male reduces the likelihood of out-patient contact by 23% and in-patient contact by 17% When examining urban versus rural areas, urban men exhibit a lower probability of seeking medical contact, highlighting a trend where men generally tend to engage less with healthcare services.

Luận văn thạc sĩ Quản lý Kinh tế have lower level of utilization in general as also indicated by result of Trevedi

In 2002, the smaller disparity in rural areas suggests that rural women may experience some inequality in accessing health services Key household factors significantly influencing the likelihood of seeking healthcare include household size and the education level of the household head, with the effects of these variables aligning with expectations.

Living in urban areas may actually lower the likelihood of seeking both out-patient and in-patient health services, which seems counterintuitive given that urban residents typically possess greater health awareness This heightened awareness often leads to a greater use of preventive health services, ultimately contributing to improved overall health within urban populations.

The analysis of health insurance types reveals that all coefficients are significant at the 1% level, with consistent significance observed across urban and rural populations Notably, the coefficient for free health cards for children under 6 years old in urban areas is significant at the 10% level, while all other coefficients maintain significance at the 1% level in both settings These findings highlight a robust positive correlation between possessing any form of health insurance and the likelihood of accessing health facilities, including both outpatient and inpatient services.

The free health card significantly increases outpatient consultation rates for children under six, with those holding the card being 2.39 times more likely to seek care Additionally, health insurance or free health cards for low-income individuals also show a substantial positive effect These findings highlight the considerable benefits of the free health insurance scheme, which provides disadvantaged groups with improved access to formal health services, followed closely by the impact of compulsory health insurance.

The master's thesis on Economic Management highlights the limited impact of the vulnerary health insurance scheme, primarily due to the lack of a clear comparison group Since all students qualify for this insurance, a significant portion of the target population participates, making them the majority under the scheme With Vietnam's high school enrollment rate, many children are included in this program However, when controlling for other variables, the overall influence of participation in the vulnerary health insurance scheme remains modest.

Health insurance impacts are significantly greater in urban areas, particularly for the two free health insurance schemes This suggests that the impoverished population in rural regions experiences greater challenges in accessing healthcare services compared to their urban counterparts, where informal insurance networks have proven to be more effective.

The impact of health insurance schemes on in-patient treatment varies significantly, with the compulsory scheme demonstrating the greatest influence Both free health insurance for children under six years old and free health cards for the impoverished show equivalent effects on the likelihood of receiving in-patient care Consequently, the limited effect of vulnerary health insurance is to be expected.

One again, the larger impacts of all types of heath insurance are observed in the urban areas

According to Table 8, the odds ratios for four types of health insurance exceed 1 and are statistically significant in the logit model, demonstrating a positive impact of health insurance on the likelihood of outpatient contact.

A master's thesis on the management of economic public health facilities reveals that compulsory health insurance significantly enhances the use of outpatient care compared to other insurance schemes Specifically, individuals with compulsory health insurance are 2.42 times more likely to utilize outpatient services at public health facilities than those without insurance In contrast, voluntary health insurance, free health cards for children under 6, and health insurance or free health cards for the poor show lower likelihoods of 2.16, 2.17, and 2.11, respectively Moreover, an analysis of urban versus rural access indicates that children with free health cards and individuals with health insurance or free health cards for the poor have greater access to outpatient services in urban areas, with rates of 3.53 and 3.49, respectively This highlights that vulnerable groups, such as young children and the impoverished, are receiving better access to public health care services in urban settings.

Men exhibit a lower likelihood of visiting public health facilities for outpatient care compared to women, yet they tend to visit more frequently when they do The probability of outpatient visits decreases with age Higher education levels, particularly technical and university education, significantly correlate with increased health awareness, leading educated individuals to utilize outpatient care less often but more frequently when they do In contrast, primary and high school education levels do not significantly impact the likelihood of outpatient visits Overall, the coefficients for all education categories in the truncated Poisson model suggest that education does not significantly influence the frequency of outpatient treatment usage at public health facilities.

The income effect is statistically significant, revealing that individuals with lower income have a reduced likelihood of utilizing outpatient services from public providers compared to wealthier individuals In the truncated Poisson model, the income coefficient of 0.15 is significant, indicating that higher income levels correlate with increased spending on health services.

Residents of central Vietnam are more inclined to utilize outpatient care compared to those in the South and North, with significant odds ratios and coefficients Being married increases the likelihood of outpatient visits by a factor of 1.45, although it does not affect the frequency of visits The ethnic majority, Kinh, are significantly more likely to seek outpatient treatment than ethnic minorities, with a notable odds ratio of 0.72 Additionally, urban residents have a higher probability of visiting healthcare facilities than their rural counterparts, and the likelihood of outpatient visits to public health facilities rises with larger household sizes.

The logit model analysis reveals that the odds ratios for four types of health insurance are below 1, indicating a significant negative impact on the likelihood of healthcare utilization This suggests that insurance coverage tends to shift usage from private to public health facilities where insured individuals can receive services Notably, the effect is particularly strong for free health cards for children under six, which reduce the probability of outpatient visits to private providers by 0.77 In contrast, health insurance or free health cards for low-income individuals decrease the likelihood of outpatient contact by 0.66.

The estimation of the zero-truncated negative binomial model indicates that only the coefficients for compulsory and vulnerary health insurance are statistically significant and negative In contrast, the coefficient for the free health card does not demonstrate similar significance.

FINDINGS AND POLICY IMPLICATIONS

The thesis analyzes the Vietnam Households and Living Standards Survey (VHLSS 2006) to assess the influence of three health insurance schemes on health-seeking behaviors over the past year It finds that all schemes positively affect the likelihood of using health facilities, particularly for inpatient admissions and public health services Notably, the voluntary health insurance group exhibits moderate impacts, resembling uninsured individuals' behaviors Outpatient visits are primarily made at commune clinics by those with health insurance or free health cards for the poor and children under six, while compulsory health insurance users frequent public polyclinics and district hospitals Additionally, the effectiveness of all insurance types is greater in urban areas, especially for the two free health insurance schemes, with the free health card for children under six having the most significant impact on outpatient treatment, followed by the health insurance/free health card for the poor.

To enhance the positive effects of health insurance on treatment-seeking behavior, policies must prioritize expanding health insurance coverage Specifically, health insurance programs and free health cards aimed at low-income individuals and children under six should improve outpatient services at community clinics, ensuring better access to essential healthcare.

CONCLUSION

This study empirically evaluates the impact of various health insurance schemes in Vietnam on health-seeking behaviors The findings suggest that individuals are more likely to utilize health care services, particularly in public facilities Giang's research on health insurance and health care utilization patterns in Vietnam, utilizing data from the Vietnam National Health Survey (VNHS 2001/2002), indicates that insured individuals have a higher probability and frequency of using inpatient care compared to the uninsured These insights provide valuable recommendations for researchers and policymakers in the health sector.

Evidence from a thesis indicates that the outcomes of voluntary health insurance align with Giang's study, concluding that having insurance does not influence the frequency of outpatient visits to public healthcare providers.

The thesis reveals that individuals with health insurance or free health cards, particularly the poor and children under six, primarily seek treatment at commune clinics, while those with compulsory health insurance tend to visit public polyclinics and district hospitals Tridevi's study highlights that insured individuals are more likely to seek care at government facilities rather than private options Utilizing the VHLSS 2006 dataset and extensive references, this thesis addresses existing knowledge gaps, demonstrating that free health care for the poor significantly enhances treatment-seeking behavior and yields meaningful results in health outcomes.

Although, thesis still has a chance to next studies when it has not cove

A study by Sepehri, Simpson, and Sarma (2006) published in Social Science & Medicine investigates the impact of health insurance on hospital admissions and the duration of patient stays in Vietnam Conducted by researchers from the Department of Economics at the University of Manitoba, the research highlights the significant role that health insurance plays in shaping healthcare access and outcomes in the Vietnamese context The findings suggest that improved health insurance coverage can lead to reduced hospital admissions and shorter lengths of stay, emphasizing the importance of health policy in enhancing healthcare efficiency and patient well-being.

- A.Sepehri, Chernomas, R., & Akram-Lodhi, H A (2005) Penalizing patients and rewarding health care providers: User charges and health care utilization in Vietnam Health Policy and Planning, 20(2), 90–99.

- A Wagstaff (2007) Health Insurance for the Poor: Initial Impacts of Vietnam’s Health Care Fund for the Poor Development Research Group, The World Bank, Washington DC, USA, Working paper: WPS4134 (2007).

-A Wagstaff (2001) Paying for Health Care: Quantifying fairness, catastrophe, and inpoverishment, with application to Vietnam, 1993-1998. Development Research Group, The World Bank, 1818 H St NW, Washington DC, 20433, USA.

A Chaudhuri and Roy (2008) conducted a study analyzing the changes in out-of-pocket healthcare payments in Vietnam from 1992 to 2002, highlighting the implications for equity in healthcare financing The research emphasizes the financial burden on households and its impact on access to healthcare services, providing insights into the economic disparities faced by different segments of the population This work, affiliated with the Department of Economics at San Francisco State University and the Centers for Disease Control and Prevention, underscores the importance of understanding healthcare payment dynamics to inform policy and improve equity in healthcare access.

NE, Mail Stop E94, Atlanta, GA 30333, United States Health policy, Heap:

B Ekman's 2007 study examines the influence of health insurance on outpatient utilization and expenditures in a middle-income country, utilizing data from national household surveys Conducted by the Health Economics Program at Lund University in Sweden, this research highlights the critical role of health insurance in shaping healthcare access and financial implications for individuals.

- B.Vial, C Sapelli (2001) “ Self selection and Moral Hazard in Chilean Health Insurance” Department of Health Sciences, University of Economia, Chile, Documento de Trabajo, No 195 (2001).

- Bloom, G., & Gu, X (1997) Introduction to health sector reform in China IDS Bulletin, 28(1), 1–11.

- Cameron AC, Trivedi PK, Milne F, Piggot J (1987): A Microeconometric Model of the Demand for Health Care and Health Insurance in Australia The Review of Economic Studies 1988, 55(1):85-106.

C Garg and A Karan (2005) analyze the relationship between health expenditures and income poverty in India, highlighting the importance of reducing out-of-pocket costs to achieve Millennium Development Goal 1 Their research, published as a working paper by the World Health Organization and the Institute for Human Development, emphasizes that minimizing healthcare expenses can significantly alleviate financial burdens on low-income households, ultimately contributing to poverty reduction efforts.

- Giang’s Master Thesis (2006) Health insurance and Pattern of health care utilization: The case of Vietnam Vietnam-Netherlands Project for Master in Development Economics, Hanoi, Vietnam.

- M Jowett, P Martinsson (2004) “Health insurance and Treatment seeking behavior: Evidence from a low-income country” Department of Health Sciences, University of York, UK, Health Economics 13: 845 – 857

- M Jowett and R Thompson (1999) Paying for Health Care in Vietnam: Extending voluntary health insurance coverage Centre for health Economics University of York York YO10 5DD ENGLAND Discussion paper 167.

- Nguyen, T K P., & Akal, A (2003) Recent advances in social health insurance in Vietnam: A comprehensive review of recent health insurance regulations Hanoi: Health Financing Master Plan Technical Paper Series-1, World Health Organization.

Tiêu đề	The Impact Of Non-Profit Health Insurance On Treatment Seeking Behavior: The Case Of Vietnam (VHLSS 2006)
Tác giả	Le Tuan Sang
Người hướng dẫn	Prof. Ardeshir Sepehri, PhD
Trường học	National Economics University Hanoi
Chuyên ngành	Development Economics
Thể loại	Thesis
Năm xuất bản	2011
Thành phố	Hanoi

Định dạng
Số trang	96
Dung lượng	1,72 MB