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JOURNAL OF SCIENCE, Hue University, N
0
61, 2010 HEALTH FINANCIAL BURDEN AND THE ABILITY TO ACCESS HEALTH
CARE SERVICES OF HOUSEHOLDS IN THUY VAN COMMUNE, HUONG
THUY DISTRICT, THUA THIEN HUE PROVINCE
Nguyen Hoang Lan
College of Medicine and Pharmacy, Hue University
Nguyen Mau Duyen
Health services of Thua Thien Hue Province

SUMMARY
This study was carried out in a rural commune of Thua Thien Hue province with the
objectives to survey the access to health care services amongst households and to assess health
financial burden from the perspective of the household. Methods: 200 representatives of
households who had a member with an illness in 2008 were interviewed directly. A prepared
questionnaire was used during the interview. Results: 39.3% of households used outpatient
services in commune health centres. 72% of inpatient services were at Hue central hospital. The
ratio of health care expenditure to total income of the poor households was higher than that of
the rich group (119.3% vs 0.6%). The highest health expenditure of the households was for
pharmaceuticals. Conclusion: There are evidences of the increase in the use of public health
care services, especially basic health levels and a rise in out of pocket expenses in households
for inpatient services. Consequently, illness within the poor families incurred excessive financial
burden, exceeding their ability to pay.
Key words: health expenditure, health insurance, inpatient, outpatient, basis health
level, inequity, hospital fee, out of pocket, ability to pay.

Huong Thuy district, Thua Thien Hue province
2.2. Study design
A quantitative, descriptive study with a cross sectional survey was conducted.
Health expenditure from the household perspective was of interest. Both direct costs
and indirect costs were collected. In term of direct costs, both medical costs and non
medical costs that were incurred by households were included. However, only income
lost by illness was considered as an indirect cost in the study. Data was collected by
directly interviewing households using a designed questionnaire.
- Cases who experienced illness within 4 weeks before the investigation were
interviewed.
- Cases who used inpatient services within 12 months before investigation were
also interviewed.
Annual income per person of each household was estimated by dividing the sum
of the annual income of the household by the number of members of that household.
The income included salary, and revenue or monetary value of farm products.
A P value = 0.05 was used to test statistically significant level.
2.3. Selection of study sample
- A list of the households that had members with illness within 1 year before the
investigation was reported by village health workers.
- The total of 210 households was listed. About 10 households were excluded 261
from the study because they were not available during the time period of the study. The
200 households were included in the study. They located all villages of the commune.
- Representatives of the selected households were interviewed. Participants were
adults who knew clearly their family situations in terms of finance and health.
3. Results
3.1. Situation of the use of health care services of people in Thuy Van
commune

(p= 0,000)
Table 1 showed that most of households used outpatient services at the CHC to
treat diseases occurring within 4 weeks before the time of investigation (39.3%). Self-
treatment and private services were also utilised considerably (30.5% and 21.5%
respectively). Only 4 cases used inpatient services at the hospital for acute illness. It
was reported that 50% of participants used the transport hospital and 50 % used Hue
central hospital.
Table 2. Reasons for choosing public health facility for outpatient services
Unit: %
Reason CHC
Transport
hospital
Hue city
hospital
Hue Central
hospital
Health insurance
registration
81.8 80 100 100
Near their home 13.7 20 0 0 262
Time saving 0 0 0 0
Good quality 0 0 0 0
Others 4.5 0 0 0
Total 100 100 100 100
(p=0,806)
Table 2 illustrates that public health facilities were chosen for outpatient services
because they are the registered address of health insurance. Close proximity to their

Table 4. Reasons of choosing public health facilities for inpatient services
Unit: %
Reasons
Health facility
CHC
Area
clinics
Transport
hospital
City
hospital
Central
hospital
Health insurance
registration
80 100 81.1 63.6 5.6
Referred by low level

0 0 18.9 27.3 6.3
Serious disease 0 0 0 0 40.6 263
Self-selection 0 0 0 9.1 19.6
Other 20 0 0 0 28
Total 100 100 100 100 100
(p= 0,000)
Table 4 showed reasons for selection of health facilities for inpatient services.
Besides the central hospital, the main reason reported was the health insurance
registration address in all health facilities. City hospital, transport hospital and central

264
3.2.2. Inpatient expenditure as proportion of household income
Table 5. Average ratio of inpatient costs to household income within 12 months
Level Poor
Near
Poor
Average
Near
rich
Rich
Percentage of health
expenditure among the
total income
119.3% 1.3% 1.2% 3.7% 0.6%
(p=0.419)
Table 5 showed that the poor households spent 119.3% of the total income on
inpatient services whereas the rich households spent only 0.6%.
3.2.3. Items the households must paid for using health services
Table 6. Items the households must paid for using health services
Items
Payment (VND)
Outpatient Inpatient
1. Travel 2700 15,725
2. Medicines 44.935 322,025
3. Hospital Fee 1250 42,750
4. Private consultant fee 1475
5. Laboratory test 150
6. Food related to treatment 7600
7. Food 48,050
8. Accommodation (not including food) 2500

services in the study, whereas it was the registration address of health insurance for only
5.6% of households. Hue central hospital is the highest health care level in Thua Thien
Hue province. The availability of modern equipment and techniques, and good health
staff has attracted a large number of patients to the hospital. The use of health care
services at the high level by bypassing regulated health levels has increased the health
expenditure of households. It was of concern that 0.5% of households did not use any
formal health care services for their illness. The distance of health care allocation and
economic problems can affect the poor’s access to health care services.
Health financial burden of households in Thuy Van commune
Low income households incur higher health financial burden than the rich group
for health care services. For outpatient services, the ratio of health expenses to
household income is affordable based on the benchmark proposed for developing
countries by World Bank (1-2%) (1987) and Russell (5%) (1996). However, the study
only surveyed expenses for outpatient services within 4 weeks. This ratio for inpatient
services in our study is greatly exceeds these affordability benchmarks, up to 119.3%.
The result is much higher than the study results of Margaret et al (2001), which found
that only 20% of income was used for total health care expenditures in the rural poor
households
7
. The health cost gap between the poor and the rich in our study is also
higher (119.3% vs 0.6% compared to 20% vs 8% in the study of Margaret). Longer 266
duration of illness in the poor and including indirect costs in our study are possible
explanations for the difference. It is clear that the poor households could not afford to
health costs, even though they were actually incurred. Debt and poverty result from
illness within poor households in Vietnam, “especially when illness or death strikes a
bread winner or require households to use expensive hospital services”. Similar patterns
of debt occur in some settings in Africa, China and Cambodia.

(1) The health insurance system should include community-based health 267
insurance subsidized by public funds, which covers costs for essential drugs. The tax
policies based on income should be implemented to ensure effective pooling of risks
across the whole population.
(2) Strengthening government regulations concerning the management of the
medicine market and development and implementation of an essential drug programme
could ensure the highest possible value for money spent on health services and drugs.
(3) Comprehensive investment should pay attention to basic health levels in
order to increase access to care among poor people and reduce overload on central
hospitals.
These solutions hope to contribute to the improvement of health and reduce
inequity in health care.

REFERENCES
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2. Ministry of Health. Support policy of Government in health care- perspective of
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3. Vietnam – Sweden collaboration program. Health financial solutions for the poor.
Medicine Publisher, 2007.
4. WHO, index of health development, 2006.
5. Margaret Whitehead et al. Equity and health sector reforms: can low-income countries
escape the medical poverty trap? Lancet 2001; 358:833-36.
6. The World Bank group, Financing health systems in the 21
st
century, World Bank 2006.
7. Malcolm Segall et al. Research report: Health care seeking by the poor in transitional