Tóm tắt tiếng anh: Impact of health insurance in Vietnam on healthcare utilization, selfreported health, and financial choices.

Impact of health insurance in Vietnam on healthcare utilization, selfreported health, and financial choices.Impact of health insurance in Vietnam on healthcare utilization, selfreported health, and financial choices.Impact of health insurance in Vietnam on healthcare utilization, selfreported health, and financial choices.Impact of health insurance in Vietnam on healthcare utilization, selfreported health, and financial choices.Impact of health insurance in Vietnam on healthcare utilization, selfreported health, and financial choices.Impact of health insurance in Vietnam on healthcare utilization, selfreported health, and financial choices.Impact of health insurance in Vietnam on healthcare utilization, selfreported health, and financial choices.Impact of health insurance in Vietnam on healthcare utilization, selfreported health, and financial choices.Impact of health insurance in Vietnam on healthcare utilization, selfreported health, and financial choices.Impact of health insurance in Vietnam on healthcare utilization, selfreported health, and financial choices.Impact of health insurance in Vietnam on healthcare utilization, selfreported health, and financial choices.Impact of health insurance in Vietnam on healthcare utilization, selfreported health, and financial choices.Impact of health insurance in Vietnam on healthcare utilization, selfreported health, and financial choices.

MINISTRY OF EDUCATION AND TRAINING

UNIVERSITY OF ECONOMICS HO CHI MINH CITY

-

TRUONG ANH TUAN

IMPACTS OF HEALTH INSURANCE IN

VIETNAM ON HEALTHCARE

UTILIZATION, SELF-REPORTED HEALTH, AND FINANCIAL CHOICES

SUMMARY OF DOCTORAL THESIS

MINISTRY OF EDUCATION AND TRAINING

UNIVERSITY OF ECONOMICS HO CHI MINH CITY

-

TRUONG ANH TUAN

IMPACTS OF HEALTH INSURANCE IN

VIETNAM ON HEALTHCARE

UTILIZATION, SELF-REPORTED

HEALTH, AND FINANCIAL CHOICES

Major: Economic development Code: 9310105

Academic advisors:

1 Dr Le Thanh Loan

2 Assoc Prof Dr Pham Khanh Nam

The research was conducted and completed at University of

Economics Ho Chi Minh City:

Academic advisors:

1 Dr Le Thanh Loan 2 Assoc Prof Dr Pham Khanh Nam Reviewer 1:

Reviewer 2:

Reviewer 3: :

The thesis will be defended at University of Economics Ho Chi Minh City At hour day month year The thesis can be found at the following library: ……….………

Chapter 1: INTRODUCTION Background

As health insurance coverage is being extended in Vietnam, research into the policy's effects has become a high concern In reality, there have been a number of studies on the impact of health insurance on vulnerable groups However, most of the research has only focused on children and the poor The free health insurance program for the Vietnamese elderly generates a natural experiment that may be utilized to evaluate the effects and supplement existing empirical findings on moral hazard

In Vietnam, co-payments were first introduced in 1998, but the effect

of pharmaceutical cost-sharing policies on health outcomes in the Vietnamese healthcare setting has not been studied yet The question

of whether or not co-payments reduce healthcare utilization and therefore affect individuals' health status remains unanswered Enrolling in health insurance is assumed to have an impact on other financial services such as savings, borrowing, investing, and other insurance in a household However, there is little empirical evidence

to support the link between health insurance and financial services for families in Low- and middle-income countries (LMICs) No research has been conducted on the impact of health insurance on other financial services in Vietnamese households

Health insurance and healthcare scheme in Vietnam

1.2.1 Development of health insurance in Vietnam

Vietnamese health insurance has been in place for almost 29 years It had been piloted in some provinces before 1992, including Hai Phong,

Quang Tri, and Vinh Phu The government issued Decree 299/HBT

on August 15, 1992, and it was in force from 1992 to 1998

1.2.2 Healthcare scheme in Vietnam

Payments in health insurance in Vietnam are basically made on a tripartite basis The insured pay The Vietnam Social Security Agency (VSS) premiums, but they also pay co-payments when they visit a healthcare facility for a medical examination and treatment The contracted providers are responsible for delivering services to insured individuals and claiming reimbursement from the VSS (Ha et al., 2021)

Objectives of thesis

This thesis’s objectives are as follows:

1 To assess the degree to which the health insurance program for the elderly facilitates healthcare utilization and provides financial protection to covered individuals

2 To explore the impacts of having health insurance on households' choices of financial services such as private insurance, savings, investments, and credit

3 To examine the impacts of health insurance co-payments in Vietnam on the self-reported health of those covered by the plan

2 What impacts does health insurance have on households' choices of private insurance, savings, investments, and credit?

3 What impact do co-payments in health insurance have on reported health among the insured?

Scope of the thesis

For the research on the effects of health insurance on healthcare use and out-of-pocket expenditures, the current study centers only on the behaviors of elderly adults aged around 80 years in rural regions of 63 provinces and cities in Vietnam The scope of this study on the effects

of health insurance on household financial choices is restricted to rural households living in the provinces of Ha Tinh, Thua Thien Hue, and Dak Lak The boundary of the study on the effect of the co-payment program on health status is limited to rural individuals in the provinces

of Ha Tinh, Thua Thien Hue, and Dak Lak

Structure of the thesis

The thesis is organized in an essay-based format, with three essays addressing different health insurance-related impacts in Vietnam This thesis is divided into six major chapters

Chapter 2: THEORY AND LITERATURE REVIEW Theoretical backgrounds

2.1.1 Model of demand for health

The Grossman model of demand for health has been generally applied

in the health economic field by many researchers (Mwabu, 2007) In Grossman’s model, people are endowed with an initial stock of health, which depreciates over the years, but can be increased by investment Individuals invest in health by consuming healthcare and also combining exercise, diet, and time These investments help to

maintain or improve people’s stocks of health, which in turn provide them with healthy days (Folland et al., 2013)

2.1.2 Behavioral model of health services utilization

This model was originally developed by Ronald M Andersen in the 1960s to explain why families utilize healthcare, then revised by himself, and it has gone through four phases (Andersen, 1995) In this model, Andersen revealed that the utilization of health services is a function of three groups of factors, including predisposing factors, enabling factors, and need factors

2.1.3 Moral hazard

Moral hazard can be divided into two distinct types, which are called ex-ante moral hazard and ex-post moral hazard (Chun-Wei Lin, 2012) Essentially, both types of moral hazard behaviors occur following individuals purchasing insurance Ex-ante moral hazard refers to the phenomena prior to the advent of illness in which insured individuals engage in risky health behaviors, increasing the probability of a loss Ex-post moral hazard is related to the increased consumption of healthcare services once an event of illness has occurred (Jowett et al., 2004)

2.1.4 Moral hazard and Cost-sharing

To reduce the social welfare losses due to moral hazards in healthcare, health economics justifies the use of cost-sharing as a policy tool (e.g., a deductible, co-payment, or co-insurance) to limit the utilization of healthcare services (Folland et al., 2013)

2.1.5 Theory of precautionary savings

The basic implication of the theory is that individuals, in the presence

of uncertain future income, are likely to diminish consumption and save more

Conceptual framework

Figure 2.1: Conceptual framework for the thesis

Program evaluations

2.3.1 Program impact measures

There are a range of program effect measures, and the choice of which measure to employ will depend on the policy topic of interest A few

of the measures include Average Treatment Effect (ATE), Average Treatment Effect of the Treated (ATT), Local Average Treatment Effect (LATE)

2.3.2 Program impact evaluation methods

The program is not assigned randomly but rather based on the needs

of communities and individuals who then self-select the program (Khandker et al., 2009) As a result, participants have different characteristics that make them more likely to join the program than

non-participants and also impact their outcomes Selection bias is the term used to describe this phenomenon (Becker & Caliendo, 2007) The use of experimental and quasi-experimental approaches is motivated by the goal of eliminating selection bias

Empirical literature review and research gaps

2.4.1 Review of key findings

Impacts of health insurance on healthcare utilization and out-of-pocket expenditures

The current understanding of the impacts of health insurance on healthcare utilization and out-of-pocket expenditure of the elderly in LMICs is inadequate at the moment due to a scarcity of literature and inconsistent findings from current studies Mixed and limited findings rationalize the need to further investigate the impacts of health insurance on the elderly In this regard, the present thesis seeks to cover some such gaps by evaluating the effects of health insurance on healthcare utilization and out-of-pocket expenditures of the elderly in Vietnam

1.3.2.3 Impacts of health insurance on households’ financial service choices

In developing countries, households often include several financial services in their risk management strategies; thus, the correlations between these services should be taken into account It emphasizes the importance of more research into the impact of health insurance on concurrent financial services in order to present a more detailed picture of the effects and to account for their correlations

1.3.2.4 The impact of cost-sharing on health

There is a paucity of studies examining the effects of cost-sharing on either overall self-reported health or disease-specific health The

results are mixed, which highlights the need for more research to be conducted Because the vast majority of previous research was carried out in developed countries, the conclusions drawn from those studies may not be applicable to countries that are still in the process of developing This indicates that research is even more urgently needed

in developing countries

2.4.2 Review of methodologies

Methodologies for studies on the impacts of health

insurance on healthcare utilization and out-of-pocket

expenditures

The methodological choices used for each study are mostly driven by the exogenous changes induced by a change in a health policy or the implementation of a new program And because most research uses secondary data, the availability of data in the countries where the authors want to do studies also affects the methods used

Methodologies for studies on the impacts of health

insurance on households’ financial services

While there is empirical evidence of correlations between financial services, previous research examining the impact of health insurance

on financial services using quasi-experimental approaches overlooked the correlations

Methodologies for studies on the impact of cost-sharing

a person cannot self-select to be exempted from cost-sharing However, selection bias may also exist in this case due to omitted variable bias, which occurs when an omitted variable is correlated with both treatment and outcome

Justification of analytical methodologies

Methodology for research on impacts of health insurance on healthcare utilization and expenditures

In the Vietnamese context, randomized controlled trials (RCTs) are infeasible due to the fact that health insurance is a legislated policy for all people; hence we cannot randomly assign health insurance to individuals Given this, I have to settle for the next best possible choice: a quasi-experimental strategy (the regression discontinuity design: RDD)

Methodology for research on impacts of health insurance on households’ financial services

In order to address the interconnected nature of various financial products, I decided to use multivariate probit regression to examine the impact of health insurance on private insurance, savings, investments, and credit choices

Methodology for research on the impact of co-payments on health

After ruling out the possibility of RCTS, I resort to a quasi-experiment, the PSM method, in an attempt to minimize selection bias in the study

Chapter 3: IMPACTS OF HEALTH INSURANCE ON HEALTHCARE UTILIZATION AND OUT-OF-POCKET

EXPENDITURES

Introduction

The current understanding of the health-seeking behaviors of the elderly in LMICs is inadequate at the moment due to a scarcity of

literature and inconsistent findings from current studies This paper bridges this gap by particularly examining the impact of a public health insurance program for the elderly on healthcare use in rural Vietnam

Conceptual framework

The conceptual framework for this research is based on a theory and two models, including moral hazard theory, Grossman's model, and Andersen's behavioral model

Methods

3.3.1 Model specification

As indicated by Lee & Lemieux (2010), the regression model for the

fuzzy RDD basically includes two stages as follows:

First stage: D i =α 0 + α 1 T + f age i + α 2 X i + v i (2)

Second stage: Y i =β 0 + β 1 D i + g age i + 2 X i + e i (3)

Where D i is a binary variable of insurance status for individual i D i is the predicted value of the probability of being insured obtained from

equation (2) T i is a binary variable that indicates whether an

individual belongs to the treatment group (age ≥ 80 years), and serves

as an instrumental variable (IV) for insurance status age i refers to the

age of an individual f(.) is the smooth function of age and health insurance status; g(.) is the smooth function of age and the outcomes

X i ' is a vector of control variables v i and e i are random error terms

3.3.2 Data and variables

In the baseline analysis, the thesis uses four waves of VHLSS data in the years 2012, 2014, 2016, and 2018, which were all fielded after the health insurance program was effective for the elderly In the baseline model, the sample is limited to the elderly aged 70 to 89 years old

living in rural areas In addition, I employ the wave of 2010, a policy dataset, for a placebo check

3.4.2 Impacts of health insurance on healthcare utilization outcomes

The program increases the probability of an inpatient visit, the number

of inpatient visits, and expenditures per inpatient visit; however, the coefficients are not statistically significant The program's impact on the number of outpatient visits loses its statistical significance at any

conventional level It is somewhat surprisingly noted that the program

statistically decreases the probability of an outpatient visit by nearly 63% The study finds a negative impact of the health insurance program on expenditures per outpatient visit

Model significance testing

3.5.1 Validity of RDD

The validity of my analysis hinges on the assumption that individuals are not able to precisely manipulate the running variable in close proximity to the threshold (Lee & Lemieux, 2013) On the whole, I find no evidence of manipulation of individuals at the threshold, thus supporting the validity of RDD

3.5.2 Robustness checks

The robustness of the baseline results will be verified by narrowing down the window size around the cutoff point The findings from the robustness checks are that the impact of the health insurance program

on expenditures per outpatient visit is statistically significant with smaller samples

Discussion

The findings imply that health insurance reform strategies based only

on universal health coverage may be insufficient to expand healthcare access in LMICs This issue was also mentioned by M T Nguyen (2020) when studying the effects of free health insurance for children

in Vietnam

Conclusion

The most remarkable finding to emerge from this research is that the health insurance program for the elderly in Vietnam causes no moral hazard effect This result does not confirm previous research carried out in this area in LMICs However, it serves as evidence that the health-seeking behavior of the middle-old in the presence of insurance may be different from that of other generations

Chapter 4: IMPACTS OF HEALTH INSURANCE ON HOUSEHOLDS’ FINANCIAL CHOICES: EVIDENCE FROM

VIETNAM Introduction

When assessing the impact of health insurance, one important issue that previous research has generally overlooked is the interconnectedness of financial services In practice, households may use a variety of financial services, some of which correlate with one another (Farrell et al., 2016; Giesbert et al., 2011; Viganò &