2.2 Research questions How do rural-urban migrants access and use health services for medical examination and treatment?. Which factors affect the access to and use of medical servi
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VIETNAM ACADEMY OF SOCIAL SCIENCES
GRADUATE ACADEMY OF SOCIAL SCIENCES
*****
NGUYEN NHU TRANG
ACCESS TO AND USE OF HEALTH SERVICES BY
RURAL-URBAN MIGRANTS (SURVEYED IN HANOI)
THESIS SUMMARIZATION
Major: Sociology Code: 9 31 03 01
Hanoi, 2019
Trang 2The research work was completed in the Graduate Academy of Social Sciences
Scientific supervisor: Professor-Doctor To Duy Hop
Comment 1: Assoc Prof Nguyen Thi To Quyen
Comment 2: Assoc Prof Mai Van Hai
Comment 3: Assoc Prof Duong Chi Dung
The thesis will be defended against the Academy-level Thesis Panel at the Graduate Academy of Social Sciences
At … (time),… (date)… (month)……(year)
The thesis is available at the National Library
Trang 3LIST OF STUDENT’S PUBLISHED THESIS-RELATED
ARTICLES
1 Nguyen Nhu Trang & Nguyen Thi Minh Phuong, 2015:
“Rural Highlands - A qualitative analysis on social transition (case-studied in IaNhin and IaKa communes, ChuPah district, Gia Lai province)” Social Science Information Review, No
2/2015
2 Nguyen Nhu Trang & Le Thuy Nga, 2015: "Social security
in the health sector for unofficial migrant workers - Suggestions on the role of social workers." Summary record of
the international scientific conference on "Challenges on professionalism applicable to Vietnam’s social works in the demand of integration and development" Labor Publishing
House, 2015
3 Nguyen Nhu Trang, Do Thi Le Hang & Nguyen Thi Minh
Phuong, 2018: "Developing high-quality human resources
serving sustainable development of the Southwest region"
Asia-Pacific Economic Review, No 519, June 2018
4 Nguyen Nhu Trang, 2018: “Access to and use of health
services and health insurance by migrants in Hanoi”
Sociology Journal, No 2/2018
Trang 4INTRODUCTION
1 The urgency of the topic
As health is one of the fundamental factors affecting the development of each individual and the whole society, it is the goal of countries during its course of development to ensure that their whole citizenry get access to basic health services According to the 1978 Alma-Ata Declaration, access to basic health services is the right to take care of personal health and maintain good physical and mental conditions
It is witnessed that the mechanical population in such urban cities of Vietnam as Hanoi and Ho Chi Minh City has increased rapidly in recent years because of the flow of migrants from provinces and rural areas who seek employment or residence opportunities in big cities It is estimated that the rural-urban migration will reach 5 million people by 2019, 1.4 million more than the urban-to-rural migration (General Statistics Office of Vietnam, 2010) Those who migrate from rural to urban areas in search of jobs may face potential risks in their destinations, including health problems and access to healthcare services
However, this issue has not yet received sufficient attention from employees and authorities Up to date, most of the major studies on migration often review migrants' health and access to health services in a series of common issues, including livelihoods, income, employment, education or difficulties that migrants may encounter while living in urban areas (according to Le Bach Duong and Nguyen Thanh Liem, 2011, Department of Employment - Ministry of Labor, Invalids and Social Affairs, 2013) In fact, many rural-urban migrants have met health challenges and diseases after living and working in the cities When returning
to the countryside, migrants will be not only a burden to their families and localities, but also negatively affect the productivity and labor quality of the entire economy and society once they are not taken care of This is obviously a huge social problem,
Trang 5with multi-dimensional and multi-level effects to individuals and the society In order to properly understand the nature and extent of this problem, more focused research is needed to review the issue in a more comprehensive way in terms of both scientific and practical aspects
Because of the above-mentioned reasons, I select the topic of “Access to and use of health services by rural-urban migrants (surveyed in Hanoi)” as the topic of
my PhD thesis
2 Purposes, questions and theories of the research
2.1 Purposes of the research
To clarify the situation of access to and use of health services of urban migrants
rural- To analyze the factors affecting the access to and use of health services
of rural-urban migrants
To suggest a number of recommendations on ensuring social security for migrants in accessing and using health services
2.2 Research questions
How do rural-urban migrants access and use health services for
medical examination and treatment?
Which factors affect the access to and use of medical services in medical examination and treatment by rural-urban migrants?
2.3 Research theories
Migrants from rural areas to Hanoi have greater opportunities to access health services and medical examination and treatment services as the
availability of health services in the city is higher than that in rural areas
However, they are struggled accessing and using health services in the city due to their limited ability to pay for medical examination and treatment services, health insurance at inappropriate levels, and living characteristics of migrants
Institutional factors, health insurance policies and the habit of treatment affect the access to and use of health services of rural-urban migrants
self-3 Subjects and scope of the research
Trang 63.1 Subjects of the research
Rural-urban migrants’ access to and use of health services
3.2 Scope of the research
Scope of space: the research was conducted in Hanoi
Time range: the survey was conducted in 2016
Scope of content: the thesis focuses on clarifying the actual situation and the
factors affecting the access to and use of health services of migrants in
comparison with local residents
4 Methodology and research methods of the thesis
to high-quality medical services for illness prevention or treatment
To concurrently resolve the methodologies of individualistic approach and/or collectivistic approach by criticizing the limitations of extreme views such as individualism or collectivism only; recognizing the relative rationality of counterbalance viewpoints such as the viewpoint that thinks high of individualism
than collectivism and vice versa; aiming to select a reconciliation viewpoint or
combine two methodological approaches: Individualistic and Collectivistic methodologies
4.2 Research methods of the thesis
This is a cross-sectional study, of which its research objects only provide time information with required contents at a certain time The research combines 4 main methods to answer research questions, including secondary document analysis, observation, qualitative research and quantitative research
Trang 7one-4.2.1 Secondary document analysis method
4.2.2 Observation method
4.2.3 Qualitative research method
In-depth interview and group discussion were maintained continuously during the fieldwork and before, during and after the quantitative survey The in-depth interview has taken into account the group of local residents, who were born
in Hanoi and are permanent residents, as the control group
4.2.4 Quantitative research method
The student uses the World Bank’s data set on "The situation of residence in Vietnam" During the analysis process, the student uses the information of 648 cases
of migrants who moved to Hanoi 5 years prior to the time of the survey The analysis has made comparison on the access to and use of health services between migrants and local residents who have registered permanent residence in Hanoi
5 New scientific contributions of the thesis
The research on “Access to and use of health services by rural-urban migrants” contributes to the general theoretical knowledge of the sociology major in the study of access to social services for particular population groups Urban migrants’ access to healthcare services in cities helps ensuring health security in their new places of residence and stabilizing their lives to make plans for the new life The research shows the ability to apply modern sociological theories about rational choice, social capital and social networks Besides, the thesis also confirms that the topic has researched not only from a public medical or health perspective but also from a sociological perspective in terms of health, which comes out with the finding and explanation of social factors affecting human health in the process of integrating into new lives On the other hand, the research shows that the combination of qualitative and quantitative research methods is appropriate and support each other in explaining the raised issues The qualitative research method is conducted both before and after the quantitative research method to better understand the causes and effects and explain the problems by quantitative research results
6 Theoretical and practical significance of the thesis
6.1 Theoretical significance
Trang 8 The thesis contributes to the enriching of definition system in
researching the access to and use of health services
The application of theory in the research helps explaining and verifying the appropriateness and correctness of the rational choice theory and capital
theory, and the social network in the practice of Vietnam (Hanoi case study)
To provide new theoretical knowledge for specialized research areas, and access to Health Sociology, Urban Sociology, Rural Sociology and Policy
The research results of the thesis may lay the foundation for making recommendations to adjust policies in a timely manner to meet the needs in
accessing and using health services to take care of urban migrants
7 The thesis’s structure
Apart from the introduction, conclusion, recommendations, the list of references, lists of abbreviations, tables, figures and appendices, the thesis is divided into 5
Trang 9CHAPTER 1
AN OVERVIEW OF RESEARCH SITUATION ON ISSUES RELATED
TO THESIS TOPIC 1.1 The situation of rural-urban migrants
The migration trend between regions has witnessed dramatic changes in recent years, with the rural-urban migration phenomenon replacing rural-rural migration The increase of population in Hanoi due to migration accounted for 30-39 percent (http://www.gopfp.gov.vn/so6-111) In particular, the number of migrants to the inner city accounts for about 70-80 percent of the total migrants in the city The main cause of migration for economic purposes accounts for 63 percent while the irregular and seasonal rates of migration are 42 and 90 percent, respectively Migrant workers in urban areas mainly work in the private, unofficial, low-income and unstable sector Currently, the number of migrant women has increasingly developed and occupied a large proportion amongst rural-urban migrants
1.2 Life of migrants in the city
Most of migrants work in the unofficial sector with high working time, unsecured labor safety conditions, low income and instability and are forced to rent houses in the context of high urban living costs Therefore, many have chosen minimum spending solution, including medical expenses This has increased the risk of illness accumulation that they may suffer in the future
1.3 Access to and use of social security services by migrants
Situation of access to social security services by rural-urban migrants
One may assume that migrants who are poor must have encountered certain barriers to access social security services According to the latest study conducted by Action Aid, 63.3 percent of unofficial migrant workers in Hai Phong City have no access to social security service, while that number in Ho Chi Minh City is 90 percent (Action Aid, 2014)
“The proportion of migrant workers participating in different types of voluntary insurance remains low due to the following main reasons: 1/- Freelance migrant workers has unstable income while the voluntary insurance premiums are extremely high; 2/- Migrant workers do not have access to
Trang 10information on insurance types, therefore are not aware of the benefits of these insurances; 3/- Supportive policies from local authorities to promote migrant workers’ participation in insurance are insufficient” (Pham Van Quyet, 2014)
Access to and use of health services by rural-urban migrants
Different migrant groups have different levels of access to health services This depends on their residence registration, social positions and economic conditions as well as the awareness on healthcare of the migrants themselves In addition, the State's policies towards migrants and permanent residents are different while there also remains discrimination between the insured and non-insured in the healthcare system (Le Bach Duong and Nguyen Thanh Liem, 2011) Access to healthcare services is mainly taken by family themselves or by selecting medical establishments suitable to their pockets There remain several shortcomings in the migrants’ receiving of healthcare services at their destinations (Nguyen Huu Minh et al., 2005)
The research results also reveal that there are differences in health care between different groups of migrants and between different regions Female migrant workers tend to choose state facilities for medical examination and treatment rather than male laborers Migrants to Hanoi use health insurance cards more than those who migrate to other regions (General Statistics Office of Vietnam, 2006: 97) Before migration, the proportion of migrants using contraception is similar to that of non-migrants This rate increased significantly after they moved to new places (Institute of Sociology, 1998) Migrants' health insurance accessibility varies between residence groups The rate of non-registered migrants having health insurance cards is remarkably low (Dang Nguyen Anh et al., 2007)
1.4 A number of comments and direction of the topic
Studies have shown policy gaps in the migrants’ ability to access and use basic social services in urban areas Healthcare service is one of the five fundamental social services that the Government is paying attention to, especially for urban migrants Besides, one should take into account whether migrants should
Trang 11have health insurance cards or not, and whether different migrants in different regions should use their cards for medical examination and treatment In addition, migrants working in offical sectors tend to have better access to health insurance than those in unofficial sectors
The research will continue analyzing the process of access to and use of health services, factors related to the migrants’ access to and use of health services in the cities in the context where related policies and regulations of the government have changed in favor of urban migrants The research also studies the interactions between individuals and groups of migrants in the decision-making process of choosing and using health services We not only focus on the in-depth analysis of access to and use of health services from the perspective of health insurance coverage, but also present in-depth analysis on the issue of health insurance at inappropriate levels, household health insurance, and health insurance payment when migrants approach health services for medical examination and treatment The research approach is taken not only from the perspective of policy analysis or service delivery system but also from service users on the basis of applying the rational choice theory and social capital and social network theory to consider the factors related to their decisions on accessing and using health services
CHAPTER 2 THEORETICAL FOUNDATIONS OF TOPIC RESEARCH 2.1 Tool definitions
2.1.1 The definition of access in health sector
The study of the thesis reviews migrants’ access to health services based
on their ability to reach health facilities upon necessity This means that when there is a need for medical examination and treatment, which maybe a periodic health check, illness or injuries that need to be examined and treated, the migrant may enjoy health services in health facilities
2.1.2 The definition of health service use
Using health services is the process of interaction between patients and health services in healthcare activities, and is the process of implementing steps
or methods to achieve health in the best way The use of medical services
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or claim the quality of the service
2.1.3 The definition of health services
According to the World Health Organization (WHO), "health services include all services of diagnosis, treatment of diseases and healthcare and rehabilitation activities They include personal and community health services.” Health services include outpatient and inpatient medical examination and treatment, meeting the demand on healthcare of the people Health services are
also construed as health programs that take care of and improve people's health
All health services are provided in healthcare facilities, which are construed as places of medical examination and treatment and healthcare, including hospitals from central to local levels (central hospitals, provincial-level hospitals and district-level hospitals), private hospitals, international hospitals, specialized hospitals, sectoral hospitals, regional clinics and
commune/ward health stations
2.1.4 The definition of health insurance
According to the Vietnamese Law on Health Insurance, “health insurance is
a form of insurance applied to the healthcare sector for not-for-profit purposes, the implementation of which is organized by the State.”
This study reviews the migrants’ access to and use of health services, which are not only based on their residence status but also on whether they are covered by health insurance or not The study will analyze the differences in accessing and using health insurance among the insured and non-insured participants
2.1.5 The definition of rural-urban migrants
In order to clarify the definition of rural-urban migrants, it is necessary to first define the definition of migrants Migrants are those who move from one territory to another to establish a new place of residence within a certain period
of time This definition is used by the United Nations to affirm the connection
Trang 13between a certain distance movement through an administrative boundary, and a change of residence (Dang Nguyen Anh, 2009)
Within the scope of the thesis topic, rural-urban migrants are defined as those who move from rural areas to cities The thesis focuses on studying migrants from rural areas to Hanoi
2.2 Research theories
2.2.1 Rational choice theory
The theory of rational choice is based on the premise that a person always act deliberately, thinking to select and use resources reasonably in order to achieve maximum results with minimum costs That is, before deciding an action, a person always measure its costs and benefit, only taking action if the cost is equal or smaller than the benefit and not doing so if the cost is higher than the benefit such act may bring
The theory of rational choice is represented by George Homans and Peter Blau The rational rational choice theory helps us to explain migrants’ decisions
in the selection of medical services (medical examination, consultation and treatment, etc.) These choices, apart from such factors as occupation, education level, economic ability, among others, must be made based on their social capital as well as their network of relationships (family and society) Therefore,
we will introduce different perspectives of scholars on social capital as well as the social network theory in the next section
2.2.2 The definition of social capital and the social network theory
The definition of social capital
Although there are different interpretations and definitions, these definitions and explanations have one thing in common: the social capital supports the ability of the acting subject to seek benefits when they have membership in social networks It can be seen that social capital has the following fundamental characteristics: 1)- trust and confidentiality; 2)- reciprocity and mutual benefits; 3)- rules, standards and sanctions; 4)- the ability
of combination into a social network
Trang 14Represented by Pierre Bourdieu, James Coleman and Robert Putnam, the theory highlights the dimensions: faith (confiance), network (réseau) and reciprocity (réciprocité) The social network theory also helps us to clarify social space, links and capital
Social network is a collection of links between individuals or population groups The characteristics and nature of the social network structure are studied from different directions, which is the structure of social relations, social interaction and social relations among individuals and between individuals and collectives On the sociological level, the concept of social networks is based on social interaction system theory (Vu Quang Ha, 2001)
CHAPTER 3 SOCIO-DEMOGRAPHIC CHARACTERISTICS AND HEALTH
SITUATION OF RURAL-URBAN MIGRANTS
3.1 Socio-demographic characteristics of migrants to Hanoi
3.1.1 Gender
The proportion of men and women in the survey sample is different, with the percentage of women is about 5 percent higher than men: 47.8 percent of respondents are male and 52.2 percent of respondents are female
3.1.2 Age groups
The majority of migrants to Hanoi are in the working age (76.8 percent) The under-18-year-old group accounts for 22.2 percent, mostly are children accompanying their families or living with their parents in migrant families or are the babies who were born during the time their parents live in urban areas The group of over-60-year-old migrants makes up only 1 percent These are the people who are working or are grandparents looking after their grandchildren With a small percentage of only 1 percent of the total number of migrants, there will not be much value to analyze the process of accessing and using urban health services by this group Therefore, the analysis focuses on the group of people in the working age (76.8 percent)