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VIETNAM ACADEMY OF SOCIAL SCIENCES GRADUATE ACADEMY OF SOCIAL SCIENCES NGUYEN THI MINH CHAU PEOPLE'S ACCESS TO MEDICAL EXAMINATION AND TREATMENT SERVICES COVERED BY HEALTH INSURANCE AT

VIETNAM ACADEMY OF SOCIAL SCIENCES

GRADUATE ACADEMY OF SOCIAL SCIENCES

NGUYEN THI MINH CHAU

PEOPLE'S ACCESS TO MEDICAL EXAMINATION AND TREATMENT SERVICES COVERED BY HEALTH INSURANCE AT THE GRASSROOTS LEVEL AND FACTORS INFLUENCING ACCESS (CASE STUDY IN HAI

DUONG AND BINH DINH)

Major: Sociology Code: 91.31.04.01

SUMMARY OF DOCTORAL THESIS

Ha Noi, 2019

THIS WORK IS COMPLETED AT GRADUATE ACADEMY OF SOCIAL SCIENCES

MENTOR: PROF DR NGUYEN HUU MINH

hours, date month 2019

This thesis can be found at:

- Library of Graduate Academy of Social Sciences

- National Library of Vietnam

LIST OF PUBLISHED ARTICLES AND WORKS

RELATED TO THE THESIS

1 Nguyen Thi Minh Chau (2014) Concepts of access to health services and measurement: Review of International Researches Practical Medicine Journal, No 11 (940) 2014, pages 24-27

2 Nguyen Thi Minh Chau (2015) Access to medical examination and treatment covered by health insurance in Vietnam: Analytical review from the policy implication and policy implementation perspective Journal of family and gender studies No 2 (25) 2015, pages 23-34

3 Nguyen Thi Minh Chau (2016) Access to medical examination and treatment covered by health insurance in Vietnam: Critical review from demand and supply perspectives Journal of family and gender studies No 4 (26) 2016, pages 26-38

1 The necessity of the study:

Health is a fundamental factor and also a goal in the socio-economic development process of each country Access to health services is basically a basic human right (Alma Ata, 1978) But it is not always guaranteed in everywhere There is a difference in access to health services between regions, communities and individuals with different demographic characteristics, perceptions, awareness and understanding of health

For studies in Vietnam, recently there have not been many studies using a comprehensive approach to evaluate people’s access to medical examination and treatment services in the context of many new policies in this area

The role of family and individual factors as well as service delivery factors with regard to people's access need to be considered in the overall relationship Moreover, studying the level of access and use of services by

a community is a topic that is of great concern to policy makers, particularly in the context of transition from a centrally planned economic system to a market mechanism that entails profound changes in the health system from having no or only one option to many options while the state continues to invest in public health

In order to use resources effectively, maintain advantages in service delivery, especially to the disadvantaged, medical facilities must adapt to

the new situation Therefore, the research: ''People’s access to medical examination and treatment services with health insurance at the

grassroots level and factors influencing access (case study in Hai Duong and Binh Dinh) '' is carried out to answer the following research

2 Research objectives and tasks

2.1 Research objectives

The purposes of this study are (i) to understand people’s access to medical examination and treatment with health insurance at the grassroots level, (ii) to analyze relevant factors from a policy perspective and that of service provider, service users to make policy suggestions to enhance the level of access in the study area in particular and for the grassroots level in general

2.2 Research tasks

• Develop a theoretical basis to learn about the status of access to medical examination and treatment services for the health insure at the grassroots level based on clarifying key concepts related to the research

• Apply basic theoretical approaches, including structural-functional theory, theory of rational choice and selectively apply appropriate elements of common analytical models used in health policy and service research in the study of access to medical examination and treatment services for the health insurance card holders at the grassroots level

• Carry out sociological survey using quantitative and qualitative methods to analyze and evaluate the status of access to medical examination and treatment services for the HI participants at the grassroots level and social differences in access as well as explains the factors affecting the access of people in Binh Dinh and Hai Duong provinces

• Propose feasible solutions to increase access to medical examination and treatment services for people with health insurance at the grassroots level

3 Research objects and scope

4 Methodology and research methods

4.1 Methodology

The study uses structural-functional theory and rational choice theory

to serve the analysis

4.2 Research Methods

The study uses the commonly used research design, which is a cross-sectional survey, combining methods of quantitative information collection (household survey) and qualitative (in-depth interviews, group discussions)

5 New scientific contributions of the thesis

The study uses a holistic approach to analyze people’s access to health insurance (HI) medical services at the grassroots level, both from the supply and demand perspectives in the context of the policy environment that governs them The findings show that the rate of HI coverage was relatively high but there were differences in demographic characteristics, economic conditions and resident locations People had a tendency of using private services more than public ones The high HI rate did not transform into effective coverage when the rate of people using HI cards for medical services was not high For those who came to public health facilities, mostly

to commune health stations and district hospitals, the majority of them used HI medical services The level of satisfaction among those people was very high The study uses a holistic approach, which is to consider people’s access to HI medical services at the grassroots level, both from the supply and demand perspectives and the policy environment that governs them The analysis, explanation and findings of the research contribute to a common understanding of this research area, providing a basis for policy planning and adjustment to help remove access barriers

6 The theoretical and practical signification of the thesis

Applying the structural-functional theory to indentify and analyze the grassroots health structure’s components and their interaction, the findings show that not many private health facilities providing HI medical services resulted in users’ limited choice of access Meanwhile, the grassroots health had not yet performed well

HI medical service delivery function due to its limited capacity, weak system management and inadequate health financing Through the lens of the rational choice theory, empirical results provide evidences that gender, age, education, occupation, living standards, resident locations had a relation with the HI enrolment rate while place registered for HI primary medical care, place the service was consumed had a relation with HI card holders’ decision of using HI medical services This can be considered as one of reference sources for individuals, organizations operating in or paying concerns to policies and practices related to grassroots health

7 Structure of the thesis

In addition to the Introduction and Conclusion, the thesis consists

of four chapters: Chapter 1 Overview of research issues; Chapter 2 Theoretical basis and research methods; Chapter 3 Status of access

to medical examination and treatment services for the health insurance participants at the grassroots level in the study area; Chapter 4 Factors affecting the access to medical examination and treatment services for the health insurance participants at the grassroots level in the study area

CHAPTER 1 RESEARCH OVERVIEW ON ACCESS TO HEALTH

SERVICES 1.1 Views and policies to increase access to health services

Global trend

There is a qualitative transition from the right of access under the Alma Ata Declaration on primary health care to equity in access in the global move for universal health coverage to ensure access to health services and financial protection against risks from health service consumption

Viewpoints and orientations of Vietnam

The Constitution stipulates the right to health care of all citizens The view of equity in health care is reflected in the Politburo Resolution No

46 on the protection, care and improvement of people's health in the new situation Resolution No 20 of the 12th Central Committee of the Party on strengthening the protection, care and improvement of people's health in the new situation emphasizes "grassroots health is the foundation" to build

a medical system towards equity, quality, efficiency and integration Health insurance policy (HI) has been implemented since 1992, Health Insurance Law issued in 2008, amended and supplemented in 2014 Regulations, guidelines on HI, grassroots health as well as policies to support specific groups are in place, relatively comprehensive and always adjusted and supplemented to ensure access to medical examination and treatment for all people at the grassroots level However, there are still inadequacies in policy implications, policy enforcement and adverse impact

1.2 Overview of Vietnam's health system

Organization of the health system

The health system is divided into 3 levels: central, provincial and grassroots (district and commune) The current service delivery system is

a public-private mix with the public sector playing a leading role

Service delivery capacity

The Government has invested resources for the service delivery system, especially for the grassroots health network, implemented many measures to strengthen human resources, improve the quality of medical examination and treatment towards people's satisfaction Capacity of the service delivery system has been improved with more medical services including HI examination and treatment services delivered, service quality improved, examination and treatment procedures reduced However, the capacity of grassroots health has not yet met the changes in disease pattern and the needs of the people

All public and private health facilities must have a certificate and practice license to participate in HI examination and treatment The number of health facilities participating in HI examination and treatment is relatively stable over the years Almost 100% of commune health stations (CHSs) participate in while only one fifth of the private sector join There

is fierce competition between hospitals and those of the grassroots network, between different technical levels instead of coordination, especially when removal of technical routes implemented

1.3 Access to health services and HI examination and treatment

Facing the common challenge of inequity in access as that of many countries, Vietnam has made significant progress in strengthening HI coverage People participating in HI have access to services at all levels, the level of service consumption tends to increase, mostly concentrated at the grassroots level but there are many social differences in access

From a supply perspective, the availability of resources, types of services, geographic location as well as operational organization are systematic factors that attract or hinder people from accessing service From a demand perspective, demographic characteristics, health status, financial affordability, awareness and habits affect access These factors are directly interlinked and are subject to the general dominance of the policy environment, conditions of socio-economic development of the country, region and locality

CHAPTER 2 THEORETICAL BASIS AND RESEARCH METHOD 2.1 Key concepts related to the research theme

Key concepts: (i) Access; (ii) Health services / medical examination and treatment services (iii) Health insurance, HI examination and treatment; (iv) Grassroots / grassroots health; (v) Influence factor Access,

in this study, is viewed both ways: accessibility and actual access

2.2 The main theories applied in research

The theory of rational choice is used to help find out what factors influencing individual decisions in consideration of advantages and disadvantages of HI benefits of a specific service before making a decision

that he/she perceives as the most profitable, most reasonable choice The structural-functional theory helps assess the components of the grassroots health, clarifying the relationship between the role, function and capacity

of grassroots health and the needs and actual access of the people

The health service seeking behavior, the 5A model, measurement framework of access from supply and demand sides and access barriers provide good reference and direction for the study There are many similarities in these models, but generally, the models recognize that the interaction between supply and demand can bring about different results in terms of accessibility and in fact, supply and demand issues are not easily separated and directly related to each other and both are subject to the general dominance of the policy environment

2.3 Analytical framework and research hypothesis

Analytical framework of the study

Research hypothesis

(i) The rate of people participating in HI is relatively high but there are differences among groups according to demographic characteristics, economic conditions, living areas; (ii) People have more diversity in access with the trend of using private sector services than public ones; (iii) Most people go to public health facilities using HI services despite differences in demographic characteristics, economic conditions and living areas; (iv) Social security policies, communication activities have major impacts on access to health services of HI card holders; (v) The service delivery system has a great impact on people's access to HI examination and treatment; (vi) Individual and family factors also influence the decision to use HI examination and treatment services at the grassroots level

2.4 Research methods and research data

The sample size surveyed in the descriptive study was calculated using 1,398 households The total number of households surveyed was 1,600 to