Health insurance and public health care utilization in vietnam

LISTOFFIGURES...iii LISTOFTABLES...iii CHAPTER1:INTRODUCTION...1 1.1 Problemstatement...1 1.2 Researchobjectives...4 1.3 Researchquestion...4 1.4 Researchscopeanddata...4 1.5 Thestructur

HO CHIMINHCITY,DECEMBER2014

MASTEROFARTSINDEVELOPMENTECONOMICS

UNIVERSITYOFECONOMICS INSTITUTEOFSOCIAL

NETHERLANDSPROGRAMMEFOR

VIETNAM-M.AINDEVELOPMENTECONOMICS

HEALTHINSURANCEANDPUBLICHEALTHCA

REUTILIZATIONINVIETNAM

Athesissubmitted inpartialfulfilmentoftherequirementsforthedegreeofM A S T E R

O F ARTSINDEVELOPMENTECONOMICS

By

TRANTHEHUNG

AcademicSupervisor:

Dr TRUONGDANGTHUY

Vietnamisintheprocessofimprovinghealthsystem.Toachievethisgoal,theVietn am G o v e r n m e n t a t t e m p t s t o e x p e n d t h e c o v e r a g e o f p u b l i c

h e a l t h i n s u r a n c e wh ich isaneffectivetoolinlowandmiddleincomecountriestofinancehealthcarep r o v i s i o n (WHO,2000).Althoughtheinsurancecoverageincreasessignificantlyovert h e lasttenyears,theprivateexpenditureon health isstillhigh.Itonlyreduces6%,particularlyfrom6 9 1 % o f t o t a l e x p e n d i t u r e o n h

e a l t h i n 2 0 0 0 to6 2 9 % i n 2 0 1 0 (WHO,2013).Thiscomesupwithaquestionthatwhetherhealthinsuranceimprovesaccesstoc a r e ?

T o a n s w e r t h i s q u e s t i o n , t h i s s t u d y w i l l a s s e s s theimpacto f h e a l t h insuranceonhealthc a r e utilization,particularlypublichealthservicesthrought w o p u r p o s e s : medicalexaminationandtreatment.Abinaryprobitmodelisusedtoestimatet h e impactofh e a

l t h insuranceonpublichealthcareutilization.T h e n weinvestigatedeterminantsofinsuranceenrollmenttoincreasethenumberofinsurancep a r t i c i p a t o r s i f i n s u r a n c e a f f e c t s

p o s i t i v e l y s i g n i f i c a n t o n h e a l t h c a r e u s e D a t a a r e o b t a i n e d f r o m V i e t

na m H o u s e h o l d L i v i n g S t a n d a r d S u r v e y s ( V H L S S ) i n 2 0 1 0 T h e empirical

r e s u l t s i n d i c a t e t h a t i n s u r a n c e h a s a p o s i t i v e l y sig ni fi ca nt e f f e c t o n p u b l i c

he a l t h careutilization.Inotherwords,wecanconcludethathealthinsuranceactuallyimprovea c c e s s t o c a r e M o r e o v e r , t h e r e s u l t s o f i n s u r a n c e p a r t i c i

p a t i o n showt h a t insuranceenrollmentisaffectedstronglybyincome

andinteractiontermsoffrequencyo f i l l n e s s I t i s a l s o r e m a r k e d t h a t d e m a n d

f o r i n s u r a n c e i s differentb e t w e e n f i v e incomequintiles.Finally,household’scharacteristicsincludinghousehold’ssize,incomeandillnessratioaffectsignificantlytoinsuranceenrollment

LISTOFFIGURES iii

LISTOFTABLES iii

CHAPTER1:INTRODUCTION 1

1.1 Problemstatement 1

1.2 Researchobjectives 4

1.3 Researchquestion 4

1.4 Researchscopeanddata 4

1.5 Thestructureofthisstudy 4

CHAPTER2:LITERATUREREVIEW 6

2.1 Relationshipbetweenhealthutilizationand insurance 6

2.1.1 Healthcareusagetheory 6

2.1.2 Theoryofrelationshipbetweenhealthinsuranceandhealthutilization

1 1 2.3 EmpiricalreviewsofrelationshipbetweenhealthinsuranceandHealthu t i l i z at i o n : 14 2.4 Theoryofinsuranceparticipation: 23

2.5 Empiricalreviewsof insuranceparticipation 24

CHAPTER3:RESEARCHMETHODOLOGY 30

3.1 Anoverviewof Vietnamhealthsystemandhealthcareuse 30

3.1.1 Providernetwork 30

3.1.2 Accessandutilizationofmedicalexaminationandtreatmentservices

3 2 3.2 Overviewofhealthinsurance 34

3.3 Methodologyanddata 36

3.3.1 Methodology 36

3.3.2 Data 38

3.4 Measurementof variablesandexpectedsign 39

CHAPTER4:RESULTS 45

4.1 Descriptive statistic 45

4.2 Empiricalresults 50

4.2.1 Impactof healthinsuranceonpublichealth careuse 50

4.2.1.1 Medicalexamination 50

4.2.1.2 Treatment 52

4.2.2 Determinantsof insuranceparticipation 54

CHAPTER5:CONCLUSIONSANDPOLICYIMPLICATIONS 63

5.1 Conclusionremarksandpolicyimplication 63

5.2 Limitationandfurtherresearch 67

REFERENCES 69

APPENDIX 75

LIST OFFIGURES

Figure2.1:Initialbehavioralmodelofhealthservicesutilization 8

Figure2.2:Modelingtheeffectofinsuranceprogrammeontheuseofhealthservices.21Figure3.1: Proportionofseekingcarein2010 33

Figure3.2:Timelineandroadmapofuniversalhealthinsurancecoverage 34

Figure3.3:Trendinhealthinsurancecoveragefrom1993-2010 36

LIST OFTABLES Table3.1:M e a s u r e m e n t ofvariables 40

Table4.1:Descriptivestatisticsofusingpublichealthcareservicesbypurpose 45

Table4.2:Descriptivestatisticsofinsuranceparticipation 45

Table4.3:Descriptivestatisticsofcontinuousindependentvariables 46

Table4.4:Publichealthcareuseandinsuranceenrollmentbygender 47

Table4.5:Publichealthcareuseandinsuranceenrollmentbyemploymentstatus 47

Table4.6:Publichealthcareuseandinsuranceenrollmentbyarea(rural) 48

Table4.7:Publichealthcareuseandinsuranceenrollmentbyminorethnicpeople 49

Table4.8:Resultsofimpactofhealthinsuranceonmedicalexamination 50

Table4.9:Resultsofimpactofhealthinsuranceonmedicaltreatment 52

Table4.10:Resultsofinsuranceparticipation(householdlevel) 54

Table4.11:Resultsofinsuranceparticipation(individuallevel) 58

Table4.12:Resultsofinsuranceparticipationbydifferentincomequintile 61

iii

VNP19-2014 Master’sThesis

TranTheHung

CHAPTER1:INTRODUCTION

1.1 Problemstatement

After“DoiMoi”programin1986,VietnamhasexperiencedrapidandcontinuouseconomicgrowthwithGDPpercapitaincreasesfrom140USDin1992to1,168USDi n 2010.Moreov

thepastt w en ty years(WorkBank,2013).Whenpeoplebecomemoreaffluent,theywillhaveh i g h e r demandforcare(McPakeetal.2002;Follandetal.2004).Therefore,therateofh e

al t hcar e u sag e incr eases significantlyfrom2002toin2010.Typically,percentageofp e o p l e havinghealthtreatmentin2002is18.9%,andthentheyriseto40.9%oftota

lp o p u lat io n in2010

Overthe period of2 0 0 2

-2 0 1 0, healthcare u ti li zat io n i n Vietnam increases dramatically.Itsuggeststhatpeoplepaymoreattentiontotheirhealth.Asfor2010,thep e r c e n t a g e ofpe op le having healthtreatment isabout40 9% Ofwhich,the ratesof inpatientandoutpatientare8.1%and37.1%respectively.Therearetwomainkindsofh e a l t h c a r e s e r v i c e s t h a t p e o p l e

u s e i n Vietnam,i n c l u d i n g p u b l i c a n d p r i v a t e h e a l t h c a r e s e r v i c e s T h e p e r c

e n t a g e o f p e o p l e u s i n g p u b l i c h e a l t h c a r e s e r v i c e s i s nearlys ev e n t y percent;particularly,theratioofinpatienthospitalizedinpublichealthservicesis a r o u n d 9 0 1 % o f t

o t a l i n p a t i e n t a n d 5 7 2 % i s t h e p e r c e n t a g e ofo u t p a t i e n t u s i n g publichealthcareservicesin2010

Inthelasttenyears,Vietnamhouseholdsstillhavetoconcernwithaburdenofheal th careexpenditure.Theamountofmoneythat peoplehavetospendinhealthcarei s muchmorethanGovernmentspending;privateexpenditureonhealthaccountsfora r o u n d

VNP19-2014 Master’sThesis

TranTheHung

6 2 9 % oftotalexpenditureonhealthwhilegeneralGovernmentexpenditureonhealthisaround37.1in2010comparedtoThailandwith25%ofprivateexpenditure

and75%ofGovernmentexpenditureonhealth(WorldHealthOrganization2013).Themajorelementthatm a k es t he largeproportionof p r i v a t e expenditureishouseholds’ o u

t - o f - p o c k e t payment Out-of-pocketexpenditureisabout93%ofprivateexpenditureo nhealth i n V iet na m2 01 0( WH O, 2 01 3) Anin cre ase i n o ut -

of

-poc ke tpa ym en to n healthm a y leadh o u s e h o l d s t o s e l l t h e i r a s s e t s t o b e a b l e t

o paythe treatmentf e e s M o s t ofhouseholds,especiallypoorhouseholds,havetopaysuchasubstantialshareoftheirincomeforhealthservice.Astheresult,theyarepushedintopoverty(WorldH e a l t h Organization,2004)

Healthriskisprobablythegreatestthreattopeople’livesbecauseitimpactsontheir directexpenditure anditalsoreducestheirhealth affectingtolaborsupplyandp r o d u c t i v i t y leadingtoincomepoverty(Asfaw,2003)

Thisauthorsuggeststhathealthinsuranceisaneffectivetooltodealwithhealthriskforthepoor.Inaddition,healthinsuranceisasa p a r t ofincomep r o t e c t i o n b e c a u s e i t r e d u c e s f

i n a n c i a l b u r d e n o f treatmentatlowincomelevels(Jutting,2003).Healthinsuranceisalsoatoolinordert o c r e a t e a n e q u i t a b l e a c c e s s t o h e a l t h s e r v i c e s t h r

03).Healthi n s u r a n c e d o e s n o t o n l y r i s e h e a l t h c a r e u t i l i z a t i o n , b u t i t a l s o

i n c r e a s e s t h e

usageofphysicianservicesandpreventiveservicesandsoitimproveshealth(Freemanet al,2008).

Healthutilizationisaffectedbymanydeterminantsincludingdemographicfactors;socialstructures,characteristics offamilyandcommunity(Anderson, 1995).T h e authorarguesthatdemographicvariablessuchasage,gender,educationhavelowmutability,sotheycannotbealteredtochange utilization; andc u l t u r a l backgrounds( i e , ethnicity,r eg io n) a r e n ot cha nge ab le topromotehe al thc ar eusa ge ( A n d e

r s o n &Newman,2005)whilepersonal/

familyandcommunity’scharacteristicswhichincludea n importantfactor: he al th insuranceare q u i t e mutablea n d s t r o n g l y a s s o c i a t e d wi th h e a l t h utilization.Forexample,theimpactofhealthinsuranceonhealthcareusehasb e e n d e m o n s t r a t

e d d r a m a t i c a l l y byT h e R a n d H e a l t h I n s u r a n c e S t u d y s u c h a s t h e studiesofManningetal(1987)andJutting(2003).Asaresult,wecanconcludethatincreasinginsuranceparticipationisagoodchoicetoacceleratehealthutilization;anditisnecessaryforpolicymakerstoadopthowtheimpactofinsuranceonhealthcareu t i l i z a t i o n isandthenassesswhataredeterminantsofinsuranceparticipationsoastocreatefavorableconditionsforpeopletojoinhealthinsurancescheme,specially,forthepoorwhodonothaveenoughresourcestousehealthservices

Inthissituation, thestudywillexamine theeffect ofhealth insurancetohealthcar e utilizationatpublichealthcareserviceswithdifferentpurposesincludinghealthtestandtreatment.Inotherword,wewillhypothesizewhetherhealthinsuranceimpro

careutilizationasaproxyf o r accesssuchasFox(1972);Aday&Anderson(1974;1995).Aftermeasuringthei m p a c t ofhealthinsuranceonhealthcareusage,iftheeffectispositivelysignificantmeaningthathealthinsuranceactuallyimprovesaccesstohealthcare,wetheninvestigatedeterminantsaffectingtoinsuranceenrollment.Then,theres

ultsareusedtorecommendpolicyimplicationstoimproveinsuranceparticipationincluding:

administratingstringentlytheinsuranceparticipationofemployeesandfinancialintervention suchassubsidiesfordifferentincomequintiles,especiallyforlowincomeh o u s e h o l d s withhighillnessratio.

1.2 Researchobjectives

Thiss t u d y aimst o i d e n t i f y r e l a t i o n s h i p b e t w e e n i n s u r a n c e a n d

p u b l i c h e a l t h u t i l i z a t i o n o f p e o p l e inV i e t n a m A f t e r t h a t , d e t e r m i n a n

t s a f f e c t i n g h e a l t h i n s u r a n c e enrolmentaremeasuredinordertoimproveinsuranceenrollment.Assuch,therearet w o mainobjectivesinthisstudy:

- Impactofhealthinsuranceonhealthcareutilizationatpublichealthservicesusingd at afromVietnamHouseholdLivingStandardSurveyin2010

1.4 Researchscopeanddata

Thestudyexaminestheimpactofinsuranceonhealthcareusageofindividualsand

determinants affectinginsuranceparticipationofhouseholdsandindividualsusingc r o s

s sectiondataofVietnamHouseholdLivingStandardSurveys(VHLSS)in2010

1.5 Thestructureofthisstudy

Therearefivechaptersinthisstudywhichareorganizedasfollow:

Chapter2:l it er at ur er ev iew inc lu des theoryaswellasem pi ri cal li te ra tu rea bo u

tt he relationshipbetweeninsuranceandutilization,alsothedeterminantsofinsurance

Chapter3:researchm e t h o d o l o g y whichpresents regression techniqueused anddatacollection

Chapter4:empiricalresults.Thestatisticdescriptionispresentedfirst,andthenexplainingtheempiricalresults.Thecoefficientsofallfactorswillbeinterpretedandd i s c u s s e d Chapter5:summarizesthemainresultsandsomepolicyimplications

r e c o g n i t i o n o f symptomsa n d t h e r e s p o n s e s tothem.

Fort h e s o c i o

-d e m o g r a p h i c a p p r o a c h , v a r i a t i o n s o f u t i l i z a t i o n b e h a v i o r c a n b e relatedtoage,sex,education,occupation,ethnicity,socioeconomicstatus,andincome.AsthetheoryofMoore(1969),theutilizationofhealthcarecanbeviewasatypeofindividualbehaviorwhichisafunctionofindividualcharacteristics,characteristicsofe n v i r o n m e n twheretheyliveandmaybetheinteractionoftheseindividual andsocietalforces.Theauthoremphasizedtheindividualcharacteristicsandlesspaidatte

ntiontot h e societalimpacts.Thismeansthathealthutilizationaffectedmostlybycharacteristico findividualthemselvessuchasage,education,gender,healthstatusandincome,and

soon.Moreover, utilizationamongvariousgroupswithina

populationisalsodifferente v e n whencostbarriersareeliminated(Nolanetal,1969)

FortheSocial-PsychologicalApproach,Stoeckleetal(1963)reviewmuchoftheanalyticliteratureontheseekingofmedicalcareandoutlinethreemajorfactorsinthep a t i e n t ’ s decisionofseekingcareincludingindividuals’knowledgeandattitudesc o n c e r n in g s y m p t o m s ; attitude

sa n d e x p e c t a t i o n s r e g a r d i n g t o h e a l t h s e r v i c e s ; a n d individuals’definitionofillness.Similarly,instudyingillnessbehavior,Mechanic( 1 9 7 8 ) i d e n t i f i e d t h e theoryo f h e a l t h s e e k i n g a n d f o u n d o u t v a r i o u s c i r c u m s t a n c e s affectingtothedecisionofseekingcare.Thefirstoneisthesalienceofdeviantsignsand symptoms.Individuals’perceptionandtoleranceofsymptomsisthesecondandthird.Forth,disruptioncausedbyillnessaffectstoindividual’slife.Fifthisthef r e q u en c y ofillnessanditspersistence.Andthefinalcircumstanceistheindividual’sk n o w l e d g e andculturalassumptionsoftheillness

Fortheorganizationalapproach,thestructureofhealthcaresystemisexaminedt

o accountfordifferencesofhealthcarebehavior.RegardingtoAnderson’sstudyofcomparinghealthservicesintheUnitedState,SwedenandEngland(1972),thed i f f e r

e n c e s i n t h e s u p p l y o f p h y s i c i a n s a n d h o s p i t a l s ’ b e d s l e a d s t o t h e c h a n g

e s o f v ari a ti o n intheus e of hos pi ta l T yp ic al ly, ift he supplyofph ysi cia ns and

h os p i t a l s ’ bedsisdeficientmarkedly,theuseofhealthcareserviceswillbediminished.Moreover,w he n theadmissionsincrease,t h e averagelengthofstayswilldrop.Thea u t

h o r a l s o p o i n t e d o u t t h a t e a c h c o u n t r y h a s e v o l v e d a p a t t e r n o f f i

n a n c i n g a n d o rg an izatio n thatisconsistentwiththeuniquecharacteristicsofitssocialandpoliticalsystems.Hence,interventionstrategiesarenecessary

Forthesocialsystemsapproach,ithasemergedasawayofunderstandinghealthutilization.Onthebasisofsocialsystems,in1960’s,Andersondevelopedtheinitial

characteristi Enabling resources Need Use of health services

Personal/

familycommunity

PerceivedEvaluated

Demographic

Social structure

behaviormodellookingatthreecategoriesofdeterminantssuchaspredisposingc h a r a c t e

r i s t i c s , enablingresourcesincludingfactors w h i c h e n a b l e o r i m p e d e use,andpeople’sneedfor care thataffects topeople’suseof h e a l t h services(Anders

on, 1995)

Figure2.1:Initialbehavioralmodelofhealthservicesutilization

Source:Anderson(1995)

In1972,Andersonexpendedandrefinedtheinitialbehavioralmodelinordertopredicttheeffectofchangesinsocialstructureofpopulationandofsupplyofhealthservicesincludingt h e s u p p l y o f h o s p i t a l b e d s , a g g r e g a t e l e v e l o f e d u c a t

i o n , e m p l o y m en t ,

incomeandsocio-demographiccharacteristicssuchasage,ethnicityande c o l o g i c a l featuresonhealthutilization

Inaddition,theupdatedutilizationmodelcanbecharacterizedbypurpose,typ

ea n d unitofanalysis.Inthecaseofpurpose,healthcareutilizationisasprimarycarewith stopping illnessbeforeitbeginsorsecondarycarewithreferringtotheprocessoftreatmentortertiarycarewithprovidingstabilization forlong-

termirreversibleillnessessuchasheartdiseaseordiabetes.Fortypecharacteristic, healthcar e u t i l i z a t i o n i s asa c h o i c e o f h e a l t h s e r v i c e s s u c h a s H o s p i t a l , P h y

s i c i a n , D r u g s a n d Medications,Dentist,NursingHome,andOther.A finalcharacterdesc

ribingtheu t i l i z a t i o n istheunitofanalysiswhichincludesthecontactwithaphysicianduringthe

periodof t i m e o r t h e u s i n g v o l u m e o f s e r v i c e s A l t h o u g h h e a l t h c a r e u t i l i z a t i

o n h a s differentcharacteristics,determinantsaffectingtouseofhealthservicesarebasedonc h a r a c t e r i s t i c s ofpopulationandhealthservices(Anderson,1995;AndersenandNewman,2005)

Ingeneral,theextentofhealthcareistoimprovehealthwhichshouldbeprimitiveinthedescriptionofconsumers’preferences.Healthcareserviceswouldthenb e demandedonlyasaninputintotheproductionofhealth,andthelevelofdemandfor serviceswouldbedeterminedbytheextenttowhichtheysatisfiedtheindividual’sunderlyingpreferenceforhealth.Individualsuse theiravailableresourcesto achieveh e a l t h , sotheirpreferencesforhealtharerepresentedwithinastandardutility-

maximizingf r a m e w o r k A l l o f a l t e r n a t i v e u s e s t h a t i n d i v i d u a l s m u s t h

a v e f o r t h e i r resourcest o a d m i t a c h o i c e a r e b u n d l e d i n t o a g e n e r i c g o o d d

e n o t e d c T h e u t i l i t y f u n c t i o n ofhealthcareuseis:

�=�(�,ℎ)Whereh i s l e v e l o f h e a l t h t h a t i n d i v i d u a l s e n j o y rathert h a n q u a n t i t y o f h e a l

t h

careservicesconsumed

Thedemandformedicalcareis notconstrainedto achoiceofhowmuch,butalsoo f whatkindmeaningthatindividualcandecidehowoftentovisit,aswellaschoosevisitingv a r i o u s p r o v i d e r s s u c h a s h o s p i t a l , c l i n i c , h e a l e r A f t e r h a v

i n g madet h e s e choices,consumersmayalsofacethechoiceofwhatkindsoftreatmentstheywishtoa d o p t i n c l u d i n g t h e u s e o f d r u g s a n d o t h e r r e m e d i e s W

h i l e m a n y o f t h e s e i n p u t decisionswillbebasedonrecommendationsmadebytheprovider,suchr e c o m m e n d a t i o n s maybealteredwithvariationsinpricesandi

ncomes.Foranindividualwithincomem,thepricevectordefinesaconsumptionvectoras

�=�(ℎ,�,�)Wherempresentsincomeandpisthepriceofmedicalservices

Theexistenceofsuchdiscretechoicesrequiresmoreelaborateeconometrictechniquestoestimatethedemandcurves.Thediscretechoicecanbemodeledinanintegratedfashionusingamultilevelapproach

�̂(��)=�̂�[𝜋̂1��̂1�+𝜋̂2��̂2�+⋯+𝜋̂𝑛�̂𝑛]

Where:�̂��=�̂�(��)istheestimateduseofmedicalcarebyindividualiwhoconsumes

servicej

xiisavectorofregressorsusedtoexplainmedicalcareusesuchasprice,incomeanddemographicvariables

�̂(��)=�̂�𝜋̂1��̂1�= �̂��̂�Thisequationis composedof t h e probability thataclinic visitwill be chosen ( j = 1) ,

timest h e e x p e c t e d quantityofs e r v i c e s p u r c h a s e d , c o n d i t i o n a l o n use.I f t h e r e i

s anassumptionthatthequantityconditionalonuseisfixed,thenoneinterestingthingis

estimatingprobabilityofhealthcareuse,�̂�

Fromtheutilityfunctionabove,itisclearthatutilitygainedfromchoosingvisitofaclinicdependsonhealthstatus,incomeandprice;andutilitycanalsogainfromxi.A c c o r d i

n g t o b e h a v i o r t h e o r y o f

h e a l t h c a r e u t i l i z a t i o n , xishouldb e a v e c t o r o f ch ar act eri sti cs ofindividualsandalsoincludescharacteristicsofhouseholdsandco m m u n i t i e s wheretheylive

Where:��i sa v e c t o r o f c h a r a c t e r i s t i c s o f individuals,h o u s e h o l d s a n d

communities.��i sincomeandℎ�i shealthstatusofindividuali.p1isthepriceof

.Witht h i s incometransfer,peopletendto consumemorehealthcarethantheywouldwithoutinsuranceandtheincometransfercanbedescribedbyutilitytheory.

otherg o o d s Witht h e p r i c e o f medicalc a r e M a n d assumei t i s normalizedby1,demandformedicalcareis

�𝑢=�( ,� �0)=�(1,�0)Whenp e o p l e p u r c h a s e i n s u r a n c e , theyh a v e t o payp r e m i u m R whichc

Y0−𝜋(1−�)��=���+��

or Y0+(1−𝜋)(1−�)��=��+��Comparedtobudgetconstraintwithoutinsurance:

Y0=�𝑢+�𝑢Thespendingwithinsurance(��+��)islargerthanspendingwithouti n s u r a n c e (�

𝑢+�𝑢)by( 1−𝜋)(1−�)��whichi s k n o w n a s incometransfer T h e income

Where�̂� isth ef it te d v a l u e of ��;an dF is m o n o t o n i c a l l y increasing w i t hR

→[0,1].Itmeansthatifthe utilityindexis higher,theprobabilityofvisiting aclinicis

higher

2.3 Empiricalr e v i e w s o f r e l a t i o n s h i p b e t w e e n h e a l t h i n s u r a n c

e a n d H e a l t h u t i l i z a t i o n :

Toassesstheimpactofhealthinsuranceonhealthcareusage,manystudiespayattentiont o b e h a v i o r o f s e e k i n g c a r e w h e n p e o p l e n e e d w h i c h b a s e s o n a

n a l y z i n g determinantsofindividual,householdandcommunitycharacteristics

Tobegin,thestudyof

Manningetal(1987)isoneofempiricalreviewdoneearly.T h e studyreportsonthedemandforhealthservicesandtheroleofhealthinsuranceinT h e UnitedState.Particularly,thestudyfocusesontheuseofmedicalcaremeasuredbydifferentschemes:probabilityofanymedicaluse,probabilityofanyinpatientuse,t h e numberofoutpatientvisitsratherthandentalservicesorpsychotherapy.Althoughth e studyexaminestheimpactofhealthinsuranceonthedemandformedicalcare,thea u t h o r s a l s o employo t h e r c o n t r o l l e d c o v a r

i a t e s s u c h a s s i t e , h e a l t h s t a t u s ,

socio-demo gr aph ic, andeconomicvariables The un it ofanalysisisindividual levelastheauthorsarguedthatmostmajorfactorsbelongtoindividualcharacteristicsratherthanfamily.I n o r d e r t o c o n t r o l f o r o t h e r c o v a r i a t e s , s t u d y a p p l i e s a n a

l y s i s o f v a r i a n c e ( A N O V A ) andmulti-regressionmethod

Typically,theauthorsusedtwo-partmodeltobemorerobustandagainstselectionmodelsalthoughthedataaretrulygeneratedbyaselectionmodel

ayearofanindividual.Thesecondequationislog-linearregressionwhichmeasurestotalmedicalexpenditureofusersduringayear.Moreformally,theprobitandlog-linearmodelsforthedichotomyarebelow:

Theprobabilityprobitmodel: �1�=� �1 �+𝜇1�

(𝜇1�|��)~�( 0 , 1 )Where:medicalexpenseispositiveifI1i>0,and0isotherwise

Xiisavectorofindividualcharacteristicssuchasinsurancestatus,age,gender,healthstatus,etc.Theloglinearmodelforpositiveexpense:

r e s p o n d s s t r o n g l y o n h e a l t h i n s u r a n c e I n g e n e r a l , t h e a u t h o r s

s u g g e s t t h a t demandelasticity formedicalca re r es p o n d s t o cos tsha ri ng In o

th er wo rd s, i nsu re d individualsconsumemoremedicals e r v i c e s t h a n theyw o u l d h

a v e i f t h e y p a i d f u l l p r i c e

Usingalogisticregression,Saksenaetal(2010)measuredtheimpactofinsuranceo n healthutilizationandexpenditureinRwanda.UsingsurveydatafromRwanda,thea u t h o r s contributetheevidencethatmutualhealthinsurance(MHI)inRwandaactuallyimproveaccesstocare byexaminingMHIeffectonhealthcareusageandfinancial

protection.T h e u n i t o f analysisi s i n d i v i d u a l l e v e l w h o r e p o s t e d d e m a n d A l o g i

s t i c regressionisemployedtoruntheutilizationmodelwithabinaryutilization.Theformofutilizationmodelis:

Oneproblemthatt hea ut ho rs ha d is “endogeneity” To dealw i t h th is problem,theyu s e t h e D u r b i n - W u -

H a u s m a n t e s t t o c h e c k i n g t h e e n d o g e n e i t y b e t w e e n h e a l t h insuranceandutilizationandtheresultwasinsignificant.T h e a u t h o r s c o n c l u d e t h a t h e a l t h insuranceincreasessignificantlyhealthcareutilizationwhenpeoplehavedemand.Furthermore,t

purchasedh e a l t h servicesasdoubleasuninsured

Third,empiricalresearchofSekyiandDomanban(2012)studiesther elat ion s

hi p betweentheNationalHealthInsuranceScheme(NHIS)ando u tp at i en t utilizationofmedicalcareandexpenditureinGhanabasedonanalysesofahouseholdsurveycarriedoutwithintheMfantsemanMunicipalitytosolicitc r o s s -

s e c t i o n a l i n f o r m a t i o n o n h o u s e h o l d s T o a s s e s s t h e e f f e c t ofN H I S

me mb er sh i p onoutpatientutilizationandexpenditure,theauthorsemployedthetwo-partm o d e l d e v e l o p e d byM a n n i n g e t a l (1987).T h e firstpartisthebinary

logitmodelw h i c h p r e s e n t s t h e i m p a c t o f i n s u r a n c e o n p r o b a b i l i t y o f a

p e r s o n v i s i t i n g amodernhealthservicessuchashealthcentres/

healthp o s t , d i s t r i c t h o s p i t a l s , andprivatehospitals.Themodeltakestheform:

𝑃���( 𝑖 𝑖� � �>0)=���+𝜇�Where:dependentvariableequals1ifapersonvisitsanymodernprovider;0is

not

Xisasetofcovariatesincludinginsurancestatus,individualandhousehold‘scharacteristics

Thesecondequationislinearmodelestimatingthelevelofoutofpocketexpenditureo n healthatthepointofvisit

(����������������� ���� � � �> 0)=�𝑖 / 𝑖 𝑖 �𝜙+��Dependentvariableistotaloutofpocketexpenditureincludingcostoftreatment,transports,medicaments(drugs),consultationandanyotherexpenditurerelatedtotheuseo f m o d e r n h e a l t h c a r e s e r v i c e s a n d a l s o paymentm a d e t o p r i v a t e p r o v i

Secondly,the residual t e r m s inutilization

andexpenditure-âis testedwithê Ift h e c o e f f i c i e n t êisstatisticallysignificantfromzero,onecanas

sumethatfailuretorejectt h e nullhypothesis:insurance is exogenous The studyalsoincludeshealthstatusto c o n t r o l forself-selection

Thea u t h o r s c o n c l u d e t h a t w h i l e t h e u n i n s u r e d i n d i v i d u a l s r e p o r

t s i g n i f i c a n t l y w o r s e h e a l t h u t i l i z a t i o n , h e a l t h i n s u r a n c e , h o w e

v e r , i s l o w e r b a r r i e r f o r p e o p l e t o access to ca r e , m e a n i n g t h a t t he i nsu

re dw o u l d l i k e t o u se morem e d i c a l se r v i c es a t modernproviders,particularly,outpatientcare

Anotherr e s e a r c h i s t h e impacto f s c h o o l h e a l t h i n s u r a n c e p r o g r a m ( S

H I P ) ona c c e s s tocareinEgyptdonebyYip&Berman(2001).Accordingtothem,improveaccessmeansincreasingvisitsrateandreducingfinancialburden.Inotherwords,theya s s e s s t h e i m p a c t o f h e a l t h i n s u r a n c e onh e a l t h u t i l i z a t i o n a n d o u t o f p

o c k e t expenditurebasedonEgyptHouseholdHealthCareUtilizationandExpenditure

S u r v e y i n 1 9 9 4 T h e a u t h o r s d i d n o t s e p a r a t e medicalp r o v i d e r s : p u b l i c a n d

p r i v a t e p r o v i d e r s becausetheywanttesttheeffectofSHIPonoverallaccess.Ifvisitstopublicservicesareonlycounted,theresultswillbemisinterpretationonoverallaccess.Form e t h o

d o l o g y , t h e t w o

-p a r t modeld e v e l o -p e d a s -p a r t o f t h e R a n d H e a l t h I n s u r a n c e Ex-perimentwasemployed.Specially,alogitmodelestimatingtheimpactofSHIPonindividualchild’sprobabilityofvisitingaformalprovider:publicandprivateprovidersispartone.Themodelcanbewrittenasfollow:

𝑃���( 𝑖 𝑖� � �>0)=���+𝜇�Aloglinearmodelestimatingthelevelofoutofpocketexpenditurewithpositive

useofhealthservicesisparttwo.Theequationcanbewrittenas:

��� ����������������� ���� � � �>0)=�𝑖 / 𝑖 𝑖 ��+��

a g e o f c h i l d r e n w i t h healthproblem,theproportionofuninsuredchildrenseekingcareismuchlowerthanc h i l d r e n c o v e r e d byt h e S H I P Ina d d i t i o n , t h e l o w e s t i

n c o m e c h i l d r e n h a v i n g insurancebenefitthemostintermofutilization(probabilityofvisits)

FifthisthestudyofJutting(2003)estimatingwhetherhealthinsuranceimprovesac

Senegal.Theauthormeasurestheeffectofcommunitybasedhealthinsurance onaccessbyassessingthei m p a c t o f h e a l t h i n s u r a n c e o n h e a l t h u t i l i z a t i o n a n d o u

t o f p o c k e t e x p e n d i t u r e T h e

authorusesthetwo-partmodeldevelopedaspartoftheRandHealthInsuranceExperimentintheUnitedState(Manningetal.,1987).Specially,alogitmodela s s e s s e s theprobabilityofvisitingahospital:

𝑃���( 𝑖 𝑖� � �>0)=���+���+𝜇�Where:Prob(visit>0)isprobabilityofusinghealthservices

MstandsforhealthinsurancestatusXisasetofindividual,householdandcommunitycharacteristics

Theloglinearmodelestimatesthelevelofoutofpocketexpenditurewithpositiveuseofhealthservicesisparttwo:

��� ����������������� ���� � � �>0)=�𝑖 / 𝑖 𝑖 ��+��

self-selectionissue,t h e authorincludesaproxyforhealthstatusinthestudy.Moreover,thetotalsampleincludesickandnon-sick,memberandnon-

memberisincludedtocontrolforasampleselectionbias

Theresultsshowthatmembershiphasastrongpositiveeffectonprobabilityofho sp it ali zatio n a n d i t a l s o h a s s i g n i f i c a n t l y negatively affectedt o ex p e n

d i t u r e i n t h e c a s e o f h o s p i t a l i z a t i o n F r o m t h e r e s u l t s , J u t t i n g c o n

f i r m e d t h a t c o m m u n i t y b a s e d healthinsuranceactuallyimproveaccesstocare,particularly,hospitalization

Sixth,Water(1999)assessedthe impactof p u b l i c

-f i n a n c e d health insuranceon h e a l t h u t i l i z a t i o n i n E c u a d o r u s i n g d a t a

f r o m t h e 1 9 9 5 E c u a d o r L i v i n g S t a n d a r d s M e a su r e m e n t Survey.Theauthoremployedbivariate probitestimationtechniques toanalysestheeffectofinsuranceontheuseofhealthcareservices.Inthisstudy,Watere x p e r i e n c e d theendogeneityproblemandgaveasolutiontosolveit;andoneimplicationisthatusingbivariateprobitmodelcanbecorrectionforonlyonee n d o g e n o u s v a r i a b l e ine a c h e q u a t i o n H e f i r s t l y b u i l t u p t h e m o d e l o f h e a l t h c a r e demand(M)whichispositedasafu

nctionofasetofexogenousvariables(X)aswellasthreepotentiallyendogenousvariables:healthinsuranceaffiliation(I),healthstatus( H )