Tiếp cận và sử dụng dịch vụ y tế của nhóm người nhập cư từ nông thôn vào thành phố (qua khảo sát tại thành phố hà nội) tt tiếng anh

VIETNAM ACADEMY OF SOCIAL SCIENCES GRADUATE ACADEMY OF SOCIAL SCIENCES ***** NGUYEN NHU TRANG ACCESS TO AND USE OF HEALTH SERVICES BY RURAL-URBAN MIGRANTS (SURVEYED IN HANOI) THESIS SUMMARIZATION Major: Sociology Code: 31 03 01 Hanoi, 2019 The research work was completed in the Graduate Academy of Social Sciences Scientific supervisor: Professor-Doctor To Duy Hop Comment 1: Assoc Prof Nguyen Thi To Quyen Comment 2: Assoc Prof Mai Van Hai Comment 3: Assoc Prof Duong Chi Dung The thesis will be defended against the Academy-level Thesis Panel at the Graduate Academy of Social Sciences At … (time),… (date)… (month)……(year) The thesis is available at the National Library LIST OF STUDENT’S PUBLISHED THESIS-RELATED ARTICLES Nguyen Nhu Trang & Nguyen Thi Minh Phuong, 2015: “Rural Highlands - A qualitative analysis on social transition (case-studied in IaNhin and IaKa communes, ChuPah district, Gia Lai province)” Social Science Information Review, No 2/2015 Nguyen Nhu Trang & Le Thuy Nga, 2015: "Social security in the health sector for unofficial migrant workers Suggestions on the role of social workers." Summary record of the international scientific conference on "Challenges on professionalism applicable to Vietnam’s social works in the demand of integration and development" Labor Publishing House, 2015 Nguyen Nhu Trang, Do Thi Le Hang & Nguyen Thi Minh Phuong, 2018: "Developing high-quality human resources serving sustainable development of the Southwest region" Asia-Pacific Economic Review, No 519, June 2018 Nguyen Nhu Trang, 2018: “Access to and use of health services and health insurance by migrants in Hanoi” Sociology Journal, No 2/2018 INTRODUCTION The urgency of the topic As health is one of the fundamental factors affecting the development of each individual and the whole society, it is the goal of countries during its course of development to ensure that their whole citizenry get access to basic health services According to the 1978 Alma-Ata Declaration, access to basic health services is the right to take care of personal health and maintain good physical and mental conditions It is witnessed that the mechanical population in such urban cities of Vietnam as Hanoi and Ho Chi Minh City has increased rapidly in recent years because of the flow of migrants from provinces and rural areas who seek employment or residence opportunities in big cities It is estimated that the ruralurban migration will reach million people by 2019, 1.4 million more than the urban-to-rural migration (General Statistics Office of Vietnam, 2010) Those who migrate from rural to urban areas in search of jobs may face potential risks in their destinations, including health problems and access to healthcare services However, this issue has not yet received sufficient attention from employees and authorities Up to date, most of the major studies on migration often review migrants' health and access to health services in a series of common issues, including livelihoods, income, employment, education or difficulties that migrants may encounter while living in urban areas (according to Le Bach Duong and Nguyen Thanh Liem, 2011, Department of Employment - Ministry of Labor, Invalids and Social Affairs, 2013) In fact, many rural-urban migrants have met health challenges and diseases after living and working in the cities When returning to the countryside, migrants will be not only a burden to their families and localities, but also negatively affect the productivity and labor quality of the entire economy and society once they are not taken care of This is obviously a huge social problem, with multi-dimensional and multi-level effects to individuals and the society In order to properly understand the nature and extent of this problem, more focused research is needed to review the issue in a more comprehensive way in terms of both scientific and practical aspects Because of the above-mentioned reasons, I select the topic of “Access to and use of health services by rural-urban migrants (surveyed in Hanoi)” as the topic of my PhD thesis Purposes, questions and theories of the research 2.1 Purposes of the research  To clarify the situation of access to and use of health services of ruralurban migrants  To analyze the factors affecting the access to and use of health services of rural-urban migrants  To suggest a number of recommendations on ensuring social security for migrants in accessing and using health services 2.2 Research questions  How rural-urban migrants access and use health services for medical examination and treatment?  Which factors affect the access to and use of medical services in medical examination and treatment by rural-urban migrants? 2.3 Research theories  Migrants from rural areas to Hanoi have greater opportunities to access health services and medical examination and treatment services as the availability of health services in the city is higher than that in rural areas  However, they are struggled accessing and using health services in the city due to their limited ability to pay for medical examination and treatment services, health insurance at inappropriate levels, and living characteristics of migrants  Institutional factors, health insurance policies and the habit of selftreatment affect the access to and use of health services of rural-urban migrants Subjects and scope of the research 3.1 Subjects of the research Rural-urban migrants’ access to and use of health services 3.2 Scope of the research Scope of space: the research was conducted in Hanoi Time range: the survey was conducted in 2016 Scope of content: the thesis focuses on clarifying the actual situation and the factors affecting the access to and use of health services of migrants in comparison with local residents Methodology and research methods of the thesis 4.1 Methodology This thesis applies sociological theories such as the rational choice theory and the capital and social network theory to explain the situation of access to and use of health services of migrants from rural areas into the city, and explain their decisions in selecting different medical facilities in medical examination and treatment The research is based on migrant workers’ rights to health care and access to high-quality medical services for illness prevention or treatment To concurrently resolve the methodologies of individualistic approach and/or collectivistic approach by criticizing the limitations of extreme views such as individualism or collectivism only; recognizing the relative rationality of counterbalance viewpoints such as the viewpoint that thinks high of individualism than collectivism and vice versa; aiming to select a reconciliation viewpoint or combine two methodological approaches: Individualistic and Collectivistic methodologies 4.2 Research methods of the thesis This is a cross-sectional study, of which its research objects only provide onetime information with required contents at a certain time The research combines main methods to answer research questions, including secondary document analysis, observation, qualitative research and quantitative research 4.2.1 Secondary document analysis method 4.2.2 Observation method 4.2.3 Qualitative research method In-depth interview and group discussion were maintained continuously during the fieldwork and before, during and after the quantitative survey The indepth interview has taken into account the group of local residents, who were born in Hanoi and are permanent residents, as the control group 4.2.4 Quantitative research method The student uses the World Bank’s data set on "The situation of residence in Vietnam" During the analysis process, the student uses the information of 648 cases of migrants who moved to Hanoi years prior to the time of the survey The analysis has made comparison on the access to and use of health services between migrants and local residents who have registered permanent residence in Hanoi New scientific contributions of the thesis The research on “Access to and use of health services by rural-urban migrants” contributes to the general theoretical knowledge of the sociology major in the study of access to social services for particular population groups Urban migrants’ access to healthcare services in cities helps ensuring health security in their new places of residence and stabilizing their lives to make plans for the new life The research shows the ability to apply modern sociological theories about rational choice, social capital and social networks Besides, the thesis also confirms that the topic has researched not only from a public medical or health perspective but also from a sociological perspective in terms of health, which comes out with the finding and explanation of social factors affecting human health in the process of integrating into new lives On the other hand, the research shows that the combination of qualitative and quantitative research methods is appropriate and support each other in explaining the raised issues The qualitative research method is conducted both before and after the quantitative research method to better understand the causes and effects and explain the problems by quantitative research results Theoretical and practical significance of the thesis 6.1 Theoretical significance  The thesis contributes to the enriching of definition system in researching the access to and use of health services  The application of theory in the research helps explaining and verifying the appropriateness and correctness of the rational choice theory and capital theory, and the social network in the practice of Vietnam (Hanoi case study)  To provide new theoretical knowledge for specialized research areas, and access to Health Sociology, Urban Sociology, Rural Sociology and Policy Sociology researches 6.2 Practical significance The study on “Access to and use of health services by rural-urban migrants” helps identifying factors affecting the process of accessing and using health services at new residence places for those migrating to urban areas by analyzing their practical access to and use of health services The study also contributes practical evidence on limited factors which are the bottlenecks causing difficulties in accessing health services On the other hand, the study provides evidence on the appropriateness of healthcare policies, specifically health insurance for urban migrants Information obtained from in-depth interviews and group discussion shall act as a profound database for reference of relevant studies The research results of the thesis may lay the foundation for making recommendations to adjust policies in a timely manner to meet the needs in accessing and using health services to take care of urban migrants The thesis’s structure Apart from the introduction, conclusion, recommendations, the list of references, lists of abbreviations, tables, figures and appendices, the thesis is divided into chapters Chapter An overview of research situation on issues related to the thesis topic Chapter Theoretical foundations of topic research Chapter Socio-demographic characteristics and health situation of rural-urban migrants Chapter The practical situation on access to and use of health services by ruralurban migrants Chapter Factors affecting the access to and use of health services by rural-urban migrants CHAPTER AN OVERVIEW OF RESEARCH SITUATION ON ISSUES RELATED TO THESIS TOPIC 1.1 The situation of rural-urban migrants The migration trend between regions has witnessed dramatic changes in recent years, with the rural-urban migration phenomenon replacing rural-rural migration The increase of population in Hanoi due to migration accounted for 30-39 percent (http://www.gopfp.gov.vn/so6-111) In particular, the number of migrants to the inner city accounts for about 70-80 percent of the total migrants in the city The main cause of migration for economic purposes accounts for 63 percent while the irregular and seasonal rates of migration are 42 and 90 percent, respectively Migrant workers in urban areas mainly work in the private, unofficial, low-income and unstable sector Currently, the number of migrant women has increasingly developed and occupied a large proportion amongst rural-urban migrants 1.2 Life of migrants in the city Most of migrants work in the unofficial sector with high working time, unsecured labor safety conditions, low income and instability and are forced to rent houses in the context of high urban living costs Therefore, many have chosen minimum spending solution, including medical expenses This has increased the risk of illness accumulation that they may suffer in the future 1.3 Access to and use of social security services by migrants Situation of access to social security services by rural-urban migrants One may assume that migrants who are poor must have encountered certain barriers to access social security services According to the latest study conducted by Action Aid, 63.3 percent of unofficial migrant workers in Hai Phong City have no access to social security service, while that number in Ho Chi Minh City is 90 percent (Action Aid, 2014) “The proportion of migrant workers participating in different types of voluntary insurance remains low due to the following main reasons: 1/Freelance migrant workers has unstable income while the voluntary insurance premiums are extremely high; 2/- Migrant workers not have access to information on insurance types, therefore are not aware of the benefits of these insurances; 3/- Supportive policies from local authorities to promote migrant workers’ participation in insurance are insufficient” (Pham Van Quyet, 2014) Access to and use of health services by rural-urban migrants Different migrant groups have different levels of access to health services This depends on their residence registration, social positions and economic conditions as well as the awareness on healthcare of the migrants themselves In addition, the State's policies towards migrants and permanent residents are different while there also remains discrimination between the insured and non-insured in the healthcare system (Le Bach Duong and Nguyen Thanh Liem, 2011) Access to healthcare services is mainly taken by family themselves or by selecting medical establishments suitable to their pockets There remain several shortcomings in the migrants’ receiving of healthcare services at their destinations (Nguyen Huu Minh et al., 2005) The research results also reveal that there are differences in health care between different groups of migrants and between different regions Female migrant workers tend to choose state facilities for medical examination and treatment rather than male laborers Migrants to Hanoi use health insurance cards more than those who migrate to other regions (General Statistics Office of Vietnam, 2006: 97) Before migration, the proportion of migrants using contraception is similar to that of non-migrants This rate increased significantly after they moved to new places (Institute of Sociology, 1998) Migrants' health insurance accessibility varies between residence groups The rate of nonregistered migrants having health insurance cards is remarkably low (Dang Nguyen Anh et al., 2007) 1.4 A number of comments and direction of the topic Studies have shown policy gaps in the migrants’ ability to access and use basic social services in urban areas Healthcare service is one of the five fundamental social services that the Government is paying attention to, especially for urban migrants Besides, one should take into account whether migrants should Represented by Pierre Bourdieu, James Coleman and Robert Putnam, the theory highlights the dimensions: faith (confiance), network (réseau) and reciprocity (réciprocité) The social network theory also helps us to clarify social space, links and capital Social network is a collection of links between individuals or population groups The characteristics and nature of the social network structure are studied from different directions, which is the structure of social relations, social interaction and social relations among individuals and between individuals and collectives On the sociological level, the concept of social networks is based on social interaction system theory (Vu Quang Ha, 2001) CHAPTER SOCIO-DEMOGRAPHIC CHARACTERISTICS AND HEALTH SITUATION OF RURAL-URBAN MIGRANTS 3.1 Socio-demographic characteristics of migrants to Hanoi 3.1.1 Gender The proportion of men and women in the survey sample is different, with the percentage of women is about percent higher than men: 47.8 percent of respondents are male and 52.2 percent of respondents are female 3.1.2 Age groups The majority of migrants to Hanoi are in the working age (76.8 percent) The under-18-year-old group accounts for 22.2 percent, mostly are children accompanying their families or living with their parents in migrant families or are the babies who were born during the time their parents live in urban areas The group of over-60-year-old migrants makes up only percent These are the people who are working or are grandparents looking after their grandchildren With a small percentage of only percent of the total number of migrants, there will not be much value to analyze the process of accessing and using urban health services by this group Therefore, the analysis focuses on the group of people in the working age (76.8 percent) 3.1.3 Educational level Migrants graduated from high schools accounted for the highest proportion of 47.3 percent The group holding higher education degrees ranks second with 11.6 percent and is equivalent to the group without degrees (11.2 percent) The group of which migrants are graduated from colleges and secondary schools are nearly the same: 9.7 percent and 10.3 percent The remaining groups, including primary and intermediate vocational schools and professional high school; primary schools; and postgraduate level, account for 6.7 percent, 2.7 percent and 0.5 percent, respectively 3.1.4 Marriage status The number of single migrants accounts for 65 percent of the total number of migrants, doubling the rate of married migrants (33.7 percent) Legally separated/divorced and widowed migrants account for a very small percentage, only 0.4 percent and 0.8 percent, respectively 3.1.5 Ethnic composition Kinh people account for the majority of 95 percent, while other ethnic groups such as Thai, Tay or Hoa only make up a total of 4.5 percent Migrants from rural areas to Hanoi are mainly from lowland provinces, only a few are coming from mountainous provinces Migrants from ethnic minorities often face the barrier of language, education, skills, geographical distance and other soft skills It may be the cause of limiting the migration process of ethnic minorities to the city 3.1.6 Employment and occupational status Migrants work in different occupational groups, with the highest rate being those working in the service/sales group (29.5 percent) These jobs are personal service staff, sales staff, personal care workers and securities The simple labor group ranks second with 21.5 percent, while middle-level and handicrafted workers are nearly equal with 14.3 percent and 13 percent The group of machinery assemblers and operators ranks fifth with 11 percent The rest are office staff (6.5 percent) and the group working in the high-level professional sector (4.2 percent) The average income of migrants at the time of the 2015 survey was VND 3,753,000 per month (2015/2016 HRS data analysis) 3.1.7 Time of migration to Hanoi This study only analyzes those who migrated to Hanoi years before the time of the survey, which is from 2010 During 2010-2015 alone, the total number of migrants to Hanoi accounted for 56,2 percent of the total number of migrants to the city in the survey sample 3.1.8 Household characteristics Household size of migrants to Hanoi is smaller than that of permanent residents The household size of immigrants is 2.7, much lower than the household size of permanent residents of 4.1 18 percent of migration households have single person, while only percent of households of permanent residents have one person While the percentage of households with children in permanently resided families is 60 percent, this rate in migrant families is only 33 percent The average age of migrant household owners is 34 years old, much younger than the average age of permanently residing families, which is 47 The marriage rate of owners of permanently resided families is 91 percent while that of migrant households is 75 percent CHAPTER THE PRACTICAL SITUATION ON ACCESS TO AND USE OF HEALTH SERVICES BY RURAL-URBAN MIGRANTS 4.1 Access to health services by rural-urban migrants 4.1.1 Availability and accessibility of medical services Healthcare service is one of the basic social services necessary for the life process of human Hanoi is the city with diversed and high-quality medical service system, including medical stations in wards/communes, district-level medical centers, general clinics, general hospitals at district-, provincial- and central-level, specialized hospitals, sectoral hospitals, international hospitals, and private hospitals, among others There is also a system of high-quality private clinics to serve the healthcare demand of the people Healthcare facilities are always available to serve medical examination and treatment demand the whole citizens in general and urban immigrants in particular Health facilities in Hanoi are usually located in positions whereas convenient for everyone to reach and access easily for medical examination and treatment The distance from households to health facilities in Hanoi is relatively convenient with the system of health facilities covered in almost every urban and suburban district The availability of medicines and medical human resources are the factors that create the convenience and readiness for access to health services by the citizens in general and urban migrants in Hanoi in particular 4.1.2 Access to health services with health insurance Health insurance coverage rate The rate of citizens covered by health insurance, especially health insurance at their places of residence, is one of the criteria to assess the access to and use of health services of rural-urban migrants The current health insurance coverage rate for rural migrants to Hanoi is 77 percent while this rate is 76.1 percent for local residents (2015/2016 HRS data analysis), higher than the health insurance coverage rate of migrants nationwide Thus, it can be seen that the rate of migrants covered by health insurance in Hanoi is relatively high, ensuring their access to health services and medical examination and treatment with health insurance Access to health services with health insurance at inappropriate levels However, among migrants who are covered by health insurance, the number of health insurance of inappropriate levels is quite high, accounting for 28 percent, mainly concentrated in the group of over-40-year-old persons who are main laborers This is also the group whose health conditions show signs of decreasing due to ageing problem Thus, migrants covered by health insurance registering for medical examination and treatment in other provinces/cities but have not yet transfered health insurance to their new places of residence will face several difficulties for enjoying health insurance regimes Access to health services according to registered places for medical examination and treatment under health insurance cards The analysis results also show that access to health services by migrants is significantly related to their registered places for medical examination and treatment under health insurance In both migrant and local groups where the health insurance is registered in residing districts, the rate of citizens choosing district-level hospitals is relatively high (23.8 percent and 24.1 percent, respectively) while the rate of migrant and local patients visiting hospitals in the city is lower (15.9 percent and 17.2 percent, respectively) However, the proportion of people who come to central hospitals of the group where medical examination and treatment is registered in districts/rural districts is currently lower and at the lowest level compared to the groups registering medical services in other districts and provinces The highest proportion of people who come to central hospitals lays in the migrant group who register for health insurance treatment in other provinces/cities (42.5 percent) Those who are not covered by health insurance also topped at choosing medical examination and treatment at central hospitals (39.1 percent for migrants and 42 percent for local residents) This has further affirmed the quality of health services at central-level hospitals, which are highly appreciated and selected by a majority of citizens It is noteworthy that the rate of using health insurance for outpatient medical examination and treatment by the migrant group having registered for medical examination and treatment in Hanoi is 38.4 percent, while this rate in the group having registered for health insurance treatment in other provinces and cities is only 20 percent Thus, the fact that migrants having successfully registered healthcare facilities in Hanoi has helped improving their rate of using health insurance for inpatient medical examination and treatment, of which the costs will be high for not using health insurance However, the proportion of migrants using health insurance for inpatient medical examination and treatment in the group registered for medical examination and treatment covered by health insurance in Hanoi is lower than that of those who have registered for health insurance-covered medical examination and treatment in other provinces and cities (15.2 percent compared with 27.5 percent) The reason is that the use of health insurance for outpatient medical care in Hanoi is not really convenient and effective compared with the use of health insurance in their provinces or cities of residence or compared with not using health insurance 4.1.3 Access to health services by migration time There are two factors that one cannot skip when conducting research on emigrants and migrants, which are space and time Space is the places wherever the migrants go and stay In this study, their living space is in Hanoi The time is understood to be the period of time they have lived in the migration areas since they arrived and began to live continuously The analysis focuses on groups: the group of newly migrated ones within recent years, the group of migrants who have moved to Hanoi for more than years and the group of local residents The research analyzes the accessibility of health services of those who are sick (who need medical treatment) The highest rate of accessing health services belongs to the migrant group of less than years (65 percent) while the lowest is the over-5-year migrant group (60.3 percent), and the rate of access to health services in the local group is 63 percent It is drawn that about two-thirds of the people in the three groups have accessed health services when being sick, and there are insignificant disparities between groups, fluctuating within percent 4.2 Use of health services by rural-urban migrants Using health services is the process of interaction between human being and health services in healthcare activities, and is the process of implementing steps or methods to achieve health in the best way The use of medical services benefits users’ health and users have the right to choose how to use the service or claim the quality of the service Within the scope of the thesis, the author will describe and analyze the main contents of using health services, including selection of treatment methods and selection of places for medical examination and treatment Besides, the thesis will analyze the use of health services according to the migration time of the group compared with the local residents 4.2.1 Selection of treatment methods In the last sickness, 62.4 percent of migrants in Hanoi went to health facilities to use healthcare services About one-third of the surveyed people go with self-treatment by buying medicines in pharmacies according to the seller's instructions, or by purchasing the medicines that were previously taken if they felt like having the same symptoms Explaining their decisions to buy medicine at pharmacies without going to health facilities or seeing doctors for treatment, migrants all said that it is convenient, fast, inexpensive and they have recovered by doing so before Migrants tend to take it simple to treat common diseases that way Long working time, instability and difficult life give these workers less attention to healthcare Low income and the pressure to make money and send money to their hometowns have contributed significantly to this non-encouraged behavior The lack of benefits of the public health system because they are "off-line" may also be one of the causes of self-treatment behavior leading to inefficiency and other health risks However, migrants may only so when they face common health problems such as flu, abdominal pain, headache and body aches When having bigger problems such as severe illness that require treatment, scans, screening or testing or diseases that require medical intervention, immigrants have to select other options Compared to local residents who have permanent residence in Hanoi, the proportion of migrants using health services when being sick or having health problems is not too different 4.2.2 Selection of medical examination and treatment establishments The analysis shows that 36 percent of migrants in Hanoi choose health services at their places of residence, mainly in the wards and districts where they reside Meanwhile, 64 percent of migrants had to go to another place to seek medical care, possibly another district or province/city Regarding the group of local residents, the proportion of people using health services for medical examination and treatment at their places of residence is 44.8 percent, while the people using health services for non-resident healthcare accounts for 55.2 percent, mainly health services in other districts in the city Only a few of local residents in the research sample take medical examination and treatment in other provinces or cities, mainly due to their works (their agencies are located in neighboring provinces and they only return to Hanoi on weekends) Medical examination and treatment at the places of residence is convenient in terms of movement, travelling time and costs Meanwhile, migrants are actually having more difficulties than local people in using health services that are not in the same place of residence The number of migrants using health services mainly for medical examination accounts for 64.7 percent, while that for treatment makes up 75 percent In addition, the use of health services for reproductive healthcare - family planning and vaccination account for small proportions of 8.1 percent and 3.7 percent, respectively 4.2.3 Use of health services under migration time Which medical facilities did rural-urban migrants select to use health services for their examination and treatment? Most of them chose central-level hospitals with an equally high rate in all migrant groups of less than years, over years and local residents: 38.8 percent; 37.8 percent and 40.1 percent Obviously, there is no big difference in the use of health services by these population groups The selection of health services at facilities in examination and treatment of diseases among groups are almost the same We continue to analyze in depth the situation on use of health services by these groups based on their status of being covered and not being covered by health insurance, showing that all three groups, including the insured and non-insured, tend to use health services at central-level hospital Among the non-insured migrants, the group of migrants who have migrated to Hanoi for less than years has the lowest rate of using health services at provincial/city hospitals, only 8.3 percent, much lower than the group of migrants who have moved to Hanoi for more than years (30.3 percent) and the local group (19.6 percent) Compared with the insured ones who use health services at provincial/city hospitals, this rate is much higher in the three above-mentioned groups, with 17.1 percent, 33.1 percent and 20.4 percent, respectively It can be seen that health insurance is likely to be more influential to the use of health services compared to the time the migrants reside in Hanoi 4.2.4 Rational selection of health services Within the scope of the thesis, we analyze the behavior of rational selection of the process of accessing-using health services in the health care of migrants in the perspective that selects appropriate health services so that the costs of medical examination and treatment is low but ensures the highest medical examination and treatment efficiency together with the most convenient care for patients The rational selection on healthcare service of a person is considered based on many factors, for example, his/her habits, interests, customs, experience, personal relationships, culture, social standards, or prestige of medical facilities, professional qualifications of doctors, health insurance status, among others Therefore, the way of choosing healthcare services of each person is different that they consider to be the most reasonable for themselves Obviously, to make the most rational and beneficial healthcare decision, one must consider several factors, including internal and external ones Therefore, choosing a treatment method, medical service or medical facility to some extent may be the most rational choice for a person but not for an other That is the reasonableness/unreasonableness of limited rational choice! 4.3 Access to and use of health services on reproductive healthcare and prevention of HIV transmission for rural-urban migrants Young immigrants is the group with active reproductive activities, so the risks associated with reproductive health and sexual health are also higher than other groups of age According to the General Statistics Office, 46.9 percent of non-migrants believe that migrants are more likely to be infected with HIV than non-migrants Although being classified as a population group with high risks of reproductive diseases, none of the surveyed female and male migrant workers have completed periodic checkup It is alledged that they feel "shy" when being examined for reproductive health issues Most people who move to Hanoi have access to and access well to knowledge and ways to prevent sexually transmitted diseases from television or the mass media However, they have limitations in access to intervention programs on reproductive health care and HIV prevention in their residing areas because the time that these programs are broadcasted are often in working hours Meanwhile, the migrant group has few activities at their residing place as they work all day and return home lately and therefore cannot be advised by local authorities CHAPTER FACTORS AFFECTING THE ACCESS TO AND USE OF HEALTH SERVICES BY RURAL-URBAN MIGRANTS In this Chapter, we focus on analyzing the impact of institutional, cultural and economic factors and health insurance policies on the access to and use of health services by rural-urban migrants The groups of factors are as follows: 5.1 The group of institutional and policy factors include health policies and health insurance Up to date, the Vietnamese Government has made several positive changes in completing regulations (institutions) and policies on health care, ensuring equality for all people in accessing and using the health service system when having health problems The Health Insurance Law has been revised to create favorable conditions for population groups to access easily to highquality public health services, while the "policy gaps" have also been gradually narrowed as the conditions for purchase of health insurance and regulations on use health services have been simplified However, in fact, rural-urban migrants still face certain limitations when accessing and using health services in the new places of residence due to their inappropriate-level health insurance Despite the fact that the health insurance coverage is relatively high with 77 percent of the surveyed migrants participating in health insurance, it is more important to help rural-urban migrants actually benefit from the services during the process of accessing and using health services covered by health insurance, making health insurance really a support for migrants in healthcare activities The lack of health insurance, use of health insurance at inappropriate levels or the habit of self- treatment and self-purchase of medicines are all negative factors that affect the quality in accessing and using health services by urban migrants 5.2 The group of cultural factors The patients’ habit of self-treatment and self-purchase of medicines without being consulted by doctors when having health problems, along with the fear and non-awareness of health problems, have affected positive behaviors in terms of healthcare and access to health services Analysis of survey data shows that there remains a high rate of migrants who not access health services and only purchase medicines for self-treatment at home (52.2 percent) This cultural habit exists not only in the group of newly migrated ones but also among those who have lived in the city for a long time They are seen easily putting their trust in the pharmacists instead of following doctors’ prescriptions This habit of self-treatment not only reduces the awareness of accessing the health system for medical care but also leads to other risks, including inaccuracy in self-diagnosis and dose, tardiness in seeking medical consultation upon required or having unusual and serious side effects, unsafe drug interactions, as well as the risk of depending on and abusing drugs, among others Self-treatment may help us less anxiety than waiting for a doctor's visit, but it surely is not a safe method to treat the disease With health being the most precious property of every person and one should rather prevent than treating the disease, it is necessary to give periodic health checks a priority However, many people are assuming that doctoral visits should only be done when their bodies show signs of fatigue This is definitely a wrong and extremely dangerous concept In fact, many people only have their health checked when having clearly seen symptoms, therefore when the disease is at last stages, the treatment will be difficult and expensive In all cases of in-depth interviews, none of the asked migrants have taken periodic health examination, only of them has thought about periodic health checkups but not yet able to so There are differences in health insurance status between men and women:  Among those who are covered by health insurance, women dominating with 80.9 percent of female migrants in Hanoi are covered by health insurance, while this rate in male migrants is 72.4 percent  In the group without health insurance, the proportion of women is lower with 19.1 percent while the proportion of men is 27.6 percent The factor of gender not only creates a difference in access to and use of health services and health insurance but also affects both groups’ decisions on accessing and using services Women are often willing to approach health facilities for health services upon necessity while men are less willing to so because of their reluctance to wait for services or hesitation with administrative procedures 5.3 The group of economic factors Migrants in Hanoi have low and unstable income while urban medical costs are higher than in other areas Therefore, migrants tend to ask for the community’s assistance when they have health problems that need to access and use health services The mobilization for help of migrants with the same situation has driven the process of accessing and using health services in a better manner, reducing medical costs for migrants Income is the factor that not only affects the access to and use of health services of migrants, but also reduces positive healthcare activities such as periodical health check and medical examination and treatment at health facilities for sicknesses and reduces the opportunity to access high-quality medical services in urban areas The expenses for medical examination and treatment, if are not covered by health insurance, will be taken from the expenditure of the migrant himself or of his family While the income of rural-to-urban migrants is currently low for them to pay for daily costs, urban medical costs are considered more expensive than in the countryside Apart from such direct costs as consultation fee, money for testing, medicine and other medical supplies, patients also have to pay for meals, travel expenses and other arising expenses Their income is also reduced due to the days of illnesses that they are unable to work In addition, 45.6 percent of migrants access and use health services but are not covered by health insurance It is clearly a large proportion as these people are in the group of people who are not covered by health insurance or cannot use health insurance due to health insurance at inappropriate levels They have to use personal money in the context of high medical costs, low wages and unstable lives Health insurance issues continue to directly impact many aspects of access to health services of urban migrants CONCLUSION AND RECOMMENDATIONS Conclusion From the descriptions and analysis of the actual situation on access to and use of health services of migrants from rural areas into Hanoi and the influencing factors, we pointed out the following main findings of the topic:  Rural-urban migrants have more opportunities to access health services and medical examination and treatment services as the availability of health services in the city is higher than in rural areas  However, migrants face difficulties in accessing and using health services when the registered health examination and treatment establishments are not in the same place of their residence: Although the health insurance coverage of rural-urban migrants is relatively good, equivalent to that of local residents, the rate of migrants accessing and using health services other than their places of residence remains high, giving them more difficults than local residents  Health insurance at inappropriate levels prevents migrants from accessing and using health services: Although the Health Insurance Law has revised the requirements on health insurance participation, from compulsory permanent residence to temporary residence, and that initial registered establishments for medical examination and treatment can be changed according to living and working areas, the situation of health insurance at inappropriate levels of migrants is extremely high in the groups of under 18 and over 40 years old This is one of the reasons that prevent migrants from accessing and using health services  Compared to the factor of migration time, health insurance is the factor that has stronger impacts on access to and use of health services: The analysis research emphasizes the access to and use of health services based on the health insurance status of migrants as health insurance is a bridge for migrants to access and use highquality health services in medical examination and treatment, reduce medical expenses and ensure equality in healthcare services Health insurance is also the criteria that the Ministry of Health uses to assess the accessibility and use of health services by the citizens  Migrants have limited access to health services due to high medical costs: While facing many difficulties in life such as low income and instability, rural-urban migrants still have to pay for health services with high costs This is also the reason why migrants tend to take selftreatment methods instead of accessing and using health services  Migrants have limited access to reproductive healthcare and HIVinfection prevention programs at their places of residence: Although being awared of the importance of reproductive healthcare and HIV infection prevention, most of migrants not have access to these health programs in their places of residence due to their living and working characteristics (the frequency of movement or working over hours while healthcare programs are taking place in their residential areas) Recommendations From the findings of the thesis, we have come out with a number of practical and feasible recommendations to ensure that migrants have access to high-quality health services, ensuring their rights to healthcare and equality in access to health services Firstly, we suggest adding new forms of health insurance such as mobile health insurance, a form of health insurance for emigrants/migrants who are moving for the most of their lives Mobile health insurance should be considered as a form of insurance for emigrants/migrants to access and use high-quality health services at their new places of residence, ensuring equality in healthcare and minimizing personal spending for medical expenses Secondly, migrants should proactively update information and raise awareness in healthcare activities, creating the habit of immediately accessing health services for examination and treatment when having health problems Last but not least, local authorities should well manage migrants in their localities to provide health programs, disseminate policy information and changes of regulations related to their lives to help them access health services and basic services in urban areas to ensure a good life at their new places of residence ... Sociology, Urban Sociology, Rural Sociology and Policy Sociology researches 6.2 Practical significance The study on “Access to and use of health services by rural-urban migrants” helps identifying... and localities, but also negatively affect the productivity and labor quality of the entire economy and society once they are not taken care of This is obviously a huge social problem, with multi-dimensional... and non-insured in the healthcare system (Le Bach Duong and Nguyen Thanh Liem, 2011) Access to healthcare services is mainly taken by family themselves or by selecting medical establishments