Healthcare for the poor in five provinces in the northern uplands and central highlands
Healthcare for the poor in five provinces in the northern uplandsand central highlands
Dam Viet Cuong, Tran Thi Mai Oanh, Duong Huy Luong,
Nguyen Khanh Phuong, Tran Van Tien, Vu Thi Minh Hanh,
Phan Hong Van and colleagues
Supporting the poor and ethnic minorities is always a top priority of the Vietnamese Communist Party and Government. To support the poor in an active, comprehensive, and effective manner, the Prime Minister issued Decision No. 139/2002/QĐ-TTg on healthcare for the poor. Project “Healthcare support to the poor of the northern uplands and central highlands” (HEMA), funded bythe European Commission (EC) from 2006 to 2010, aims to improve healthcare for the poor in 5 provinces of Dien Bien, Lai Chau, Son La, Gia Lai and Kon Tum. The Health Strategy and Policy Institute conducted ahousehold survey (total of 1,575 households)to collect baseline data and necessary information including health status and healthcare services for project design and evaluation. This is a comprehensive survey taking into account not only the health service providers and management agencies’ perspective but also that of the beneficiaries.
Healthcare seeking behavior by poor people
•The most common choice was public health facilities. Self-treatment was also common, occurring among 30% – 40% respondents.
•Most respondents selected commune health station (CHS) for treatment of mild illness (97%). For severe illness, people tended to go to district and provincial hospitals. However, commune health station still had the highest ranking among choices of people for severe illness (81%).
•The most common reason for not seeking care was that people did not perceive their illness as severe enough and had transportation difficulties.
•About 40% of respondents who had used health insurance reported that they utilized more healthcare services after receiving health insurance cards as it was less costly and more convenient.
•About 53% of interviewed women had prenatal check-up visits during their pregnancies. Prenatal care in the Northern uplands was not as good as in the Central Highlands. In general, prenatal care was relatively poor in the studied areas in terms of both quantity and quality. Most of prenatal care (83%) was provided by commune health stations. A very high percentage of delivery took place at home. Safe delivery kits were available for only 30% of cases.
•About 86.3% of households reported that they used either health card or health insurance card for getting healthcare.
•Percentages of health card/health insurance card (HC/HIC) usage were high for both outpatient (OP) and inpatient care (IP).
•Main reasons for not using HC/HIC were that illness was not considered as severe enough or people were not sick. Lack of information on how to use the cards was also a noticeable reason for not using the cards.
•The rate of not seeking care and self-treatment was high among those who did not have HC/HIC.
Outpatient care utilization
•CHSs were a key provider of outpatient care (82%) for the poor in the studied areas. Private practitioners had a minor role in providing healthcare in these disadvantaged provinces.
•People having HC/HIC had higher average number of OP visit per 100 persons per year in comparison withpeople not having HC/HIC.
•Average utilization of OP care in the studied population was one visit per person per year.
Inpatient care utilization
•District hospitals were a key provider for IP care.
•There were little differences in IP utilization between those who had HC/HIC and those who did not.
•The average IP utilization of the studied population was 4 visits per 100 persons per year.
Healthcare expenditure among beneficiaries after introducing Decision 139
•The use of HC/HIC significantly reduced medical costs of OP and IP care. However, people still had to pay a considerable out-of-pocket amount for prescription drug and other indirect costs which were not covered by HI.
•Overall people with HC/HIC paid less for direct and indirect costs.
Implementation of the Healthcare Fund for the Poor (HCFP) in five project provinces
•A fair number of the poor and ethnic minorities did not get their HC/HIC
•There were difficulties in defining and determining “the poor”.
oThe process of determining “the poor” was complex but the list of eligible people was identified and documented in hand-writing.
oThere was no cross-checking mechanism to assess adequacy of this list.
oThere was limited funding for this work.
•There was a delay in printing and issuing the HC/HIC.
•Management capacity of health insurance agencies
oBecause the fund management board (FMB) members held other critical positions, they lacked time to organize regular meetings and perform management functions.
oSupport staff for FMB members was also limited in both number and competency.
oDue to understaffing, social insurance agencies’ monitoring and evaluation of insurance benefits at all levels were inadequate.
oManagement processes and procedures were weak. Payment records were mainly hand-written.
oInadequate health management information systems were observed in all five provinces. There was no consistent forms for data collection. Weak monitoring of the implementation of HCFP and poor data in health facilities at different levels were observed.
oInformation technology (IT) was weak in terms of human resources, software development and application.
•Information, education, and communication (IEC) activities
oTask assignment and responsibility lines for IEC were not clear.
oThere was no strategy for IEC in any of the provinces. Current IEC activities were not well designed. Responsibilities for IEC activities especially at commune level were not clearly identified. In addition, there was no budget allocated for IEC activities. As a result, there was still a large number of beneficiaries who neither fully understood their rights and responsibilities nor knew how to use their HC/HIC.
oThere was no existing official feedback mechanisms for beneficiaries.
oProcess of identifying the poor at the local level was weak with ambiguous criteria.
Impacts of HCFP on beneficiaries
The HCFP had positive impacts on healthcare for the poor in terms of increasing service utilization and reducing financial burden for the target population. However, the survey data found that these HCFP benefits were not enjoyed by all beneficiaries. Apparently, many beneficiaries did not visit health facilities.
Barriers to utilization of health services
•Distance to healthcare facilities, especially in remote areas, was a major barrier to service utilization.
•Difficult transportation, especially to hospitals at higher levels, was another major factor limiting access to care services.
•Low awareness on healthcare among some ethnic minority people in remote areas adversely affected usage of both curative and preventive health services in all five provinces.
•Limited benefits including “treatment ceiling”, availability ofhealthcare services and drugs especially at CHSs were other barriers that influenced health service utilization.
•Some beneficiaries avoided healthcare services because of the extra out-of-pocket payment for medicine and indirect costs such as food, and transportation.
•Complicated administrative procedure was another barrier in accessing healthcare services especially at higher level health facilities.
In conclusion, accessibility to out-patient and inpatient care by the poor and other target groups was improved since the introduction of the HCFP policy. However, effectiveness of the policy with regard to healthcare provision was still limited in all five studied provinces. There was evidence that the current coverage still left out a certain number of the poor and ethnic minorities. Though accessibility to health care services among beneficiaries was improved, the increased benefits were not as expected due to low quality of care at grassroots facilities, high indirect costs, and poor management of the HCFP.