Primary health concept revisited: Where do people seek health care in a rural area of Vietnam?
Introduction
Vietnam was one of the first countries in the world to introduce policy of primary health care—Health for All—with its health care system reaching out to the people in almost all villages of the country. This extended network of health services was one of the most important factors that contributed to improved health status of the population by providing prevention and primary care [1]. However, by late 1980s, the health sector faced challenges in the form of dramatic decrease in utilisation of public health facilities, a shift towards self-medication and private medical practice by public health care employees. The role of the state as the only provider of health services has been challenged, and financial constraints have restricted activities of the sector. There is some evidence that economic reform has affected the health care system making it less accessible and less affordable, especially for the poor [2]. Since 1989, the government has implemented a number of measures designed to liberate new resources for the health care sector including introduction of ‘user fees’. At the same time, measures are introduced to protect the access to health care by handicapped and families and individuals who are able to present certificate of indigence. The health sector reform also includes legalisation of private practice, e.g. sale of drugs in open market. Recently, a health insurance system has been introduced with primary focus on state employees. With introduction of hospital user fees and recent health insurance schemes, it has been hoped that these cost-recovery measures would contribute with a ‘big’ share of the government health expenditure and to some extent increase health service efficiency. However, it is known from experience in other countries that these measures may also restrict access to health care unless appropriate and effective measures are introduced to protect the most vulnerable groups in the population.
In the transition to market economy, with changes in health financing, the government has put great emphasis on partial payment by individuals. There is no doubt that any additional funding for the health sector is of great importance but the danger is that many people who are unable to pay even small amounts could be deterred or excluded from obtaining health care. Fabricant et al. [3] describe two kinds of negative effects of user charges: (i) the likelihood of decreased utilisation of good quality services by the poor, with a resulting increase in ineffective or dangerous self-care, and (ii) the effect on the household budgets of the poor of the cumulative costs of health care, especially for those already close to subsistence level.
Health care can be financed from a mixture of sources such as taxes, collective group/ individual insurance premiums, local community contributions and direct user fees. These sources are likely to be different in terms of degree of progressiveness. Direct taxes are usually progressive and indirect taxes (e.g. sale taxes) and social insurance are more regressive. However, different kinds of social insurance and some times also private insurance are found to be less regressive than out-of-pocket payment [4]. In 1998, the Vietnamese public health care system was financed from four main sources: taxes (government budget—58%); compulsory health insurance (16%); hospital fees (13%) and foreign aid (13%) [5]. In 1997 the state budget for health was 4328 billion VND—about US$ 47 million, of which 62% was spent on curative care [6]. According to the 1992/1993 Vietnam Living Standard Survey (VNLSS) data [7], household expenditures on health care were approximately 5850 billion VND, compared to only 1404 billion VND of health expenditure in the 1993 state budget and by far the largest care expenditure was for drugs—97% [8].
In recent years, attention paid to the socio-economic inequities in health has increased globally. Number of publications on socio-economic inequities in health has increased over years leading to better information on health inequities and reasons for them [9]. While relationship between socio-economic status (SES) and health status have been well documented in international research literature [10], findings on the relationships between SES and health care utilisation are more scarce and less clear. There is generally little reliable quantitative evaluation of the inequalities that exist in developing countries in terms of either health status or access to and payments for health care [11]. In Vietnam, there are only few studies on utilisation of health services and expenditures for health care at population level and little information is available on different income groups. The Vietnamese government is committed to improve access to health care by poor groups in the society. However, in the light of the macro-economic changes, which also affect the health sector, the government is looking for evidence and direction for policy development. The aims of this study were to: (i) explore the relationship between income groups and utilisation of various health services; (ii) describe level and distribution of household expenditures on outpatient care; (iii) investigate how households mobilise resources for payments for health care; (iv) examine whether the fee levels charged deter patients from using health services.
Section snippets
The setting
The study was conducted in the context of an Epidemiological Field Laboratory (FilaBavi) in a northern rural district of Vietnam—Bavi—hereafter called FilaBavi. Bavi district is located 60 km northwest of Hanoi. It is a combination of flat land and mountainous areas. Total population of this district is 232,400 people with domination of Kinh ethnic sub-group (91%). Agricultural production and livestock breeding are the main income sources and economic activities. The average annual income in
Utilisation of health care
Table 1 shows the pattern of first choice of health care by income quintiles. Overall, self-treatment is the most common practice followed by private practitioners, Communal Health Centres (CHCs) and hospitals. There are tendencies that the poor used CHCs and private practitioners, but not hospitals, more often than the rich did. The frequency of self-treatment was significantly higher in the two richest quintiles than in the poorest quintile (P<0.05).
Even in severe cases, self-treatment was
Discussion
This study describes health-seeking behaviour and expenditure on health in a rural area in the northern part of Vietnam. The questionnaire was designed in a way that allowed calculation of consecutive contacts with health care providers during one month before the interview. However, the findings reported here only refer to the first contact with different health care providers.
The economic status indicator chosen in this study is income. The justification for using income is that it allows for
Conclusions
Our findings, similar to the findings in recent studies in utilisation of health care of TB patients in Vietnam [27] indicate the importance of private sector in providing health services. The poorer section of the population relied more than the richer on using communal health centres and private practitioners. The costs for health care are substantial for households, and lower income groups spent a significantly higher proportion of their income on health care than the rich did. These results
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