DFC REPORT

ACCESS TO PRIMARY HEALTH CARE SERVICES
BY OLDER PEOPLE IN RURAL AREAS
OF VIETNAM

Project
Task
Award
E

: WPVNM1207061
: 3.8
: 58363 (AC)
: 511-DFC


LIST OF CONTENTS
LIST OF TABLES.......................................................................................................................i
LIST OF FIGURES....................................................................................................................ii
LIST OF ABBREVIATIONS...................................................................................................iii
ABSTRACT................................................................................................................................iv
1...................................................................................BACKGROUND AND RATIONALE
.......................................................................................................................................................1
2.........................................................................................................................OBJECTIVES
.......................................................................................................................................................3
2.1..............................................................................................................General objectives
...............................................................................................................................................3
2.2..............................................................................................................Specific objectives
...............................................................................................................................................3
3..............................................................................................................................METHODS


Health insurance status of older people..........................................................17

4.4.3.

The utilization of available PHC services by older people.............................17

4.5...........................................................Factors associated with the access to PHC services
.............................................................................................................................................19
5..........................................................................................................................DISCUSSION
.....................................................................................................................................................24
5.1..............................................................................................Characteristics of the sample
.............................................................................................................................................24
5.2...........................................................Factors associated with the access to PHC services
.............................................................................................................................................24
5.3......................................................................................................Limitations of the study
.............................................................................................................................................26
6....................................................................CONCLUSION AND RECOMMENDATION
.....................................................................................................................................................28
6.1..........................................................................................................................Conclusion
.............................................................................................................................................28
6.2................................................................................................................Recommendation
.............................................................................................................................................29
REFERENCE............................................................................................................................30
APPENDIX................................................................................................................................33


LIST OF TABLES

Table 1. Description of dependent and independent variables................................................5

Figure 2. Self-evaluated health status by older people..........................................................10
Figure 3. Percentage distribution of health care utilization by types of health facilities.......18
Figure 4. Map of Giong Trom district, Ben Tre province, Vietnam.......................................33

ii


LIST OF ABBREVIATIONS

CD

Chronic Disease

CHS
IFA

Commune Health Station
International Federation of Aging

IHPH
MOH
PHC
UN
VEA
WHO

Institute of Hygiene and Public Health
Ministry of Health (Vietnam)
Primary Health Care
United Nations

KEY WORDS: access, primary health care, older people, rural areas, Vietnam

iv


1. BACKGROUND AND RATIONALE
The older population in Vietnam is projected to rapidly increase in the next decades
as a result of lower mortality and higher life expectancy. The proportion of older
people (aged 60 and above) was 7.3 percent in 1990, slightly increased to 8.4 percent
in 2010 and will be suddenly reached to 18.3 percent by the year 2030 (UN, 2010).
More than two third of the older people are living in rural areas (IFA, 2008). The
strong flows of laborers from rural to urban areas have increased the proportion of
older people in rural areas and the number of older people living alone or with their
old spouse (who are also older) or with their grandchildren. Moreover, older people
living in rural areas have poorer education level, lifestyles, living conditions (Ninh et
al., 2010) and less access to health care (Hoi, Chuc & Lindholm, 2010) compared to
those living in urban areas. These gaps make older people in rural areas more
vulnerable than others.
Although life expectancy of Vietnamese people has improved, the average healthy
life expectancy has been quite low. It was only 58 years, ranked 116 among 174
countries in the world (MOH, 2008). This also means that older people are living
longer with more illnesses and disability. According to the WHO (2012), chronic
health conditions are the main challenges for older people. In fact, the majority of
older people in Vietnam were suffering from chronic illnesses such as hypertension,
cardiovascular disease, cataracts, joint and born disorders and chronic lung diseases
(Brook, 2008; Hanh et al., 2008). Besides, most of the older people were born, grew
up and experienced long colonial and war periods that caused many difficulties and
unfavourable healthcare conditions for them. In fact, 70 percent of those people “did
not have material accumulation” (IFA, 2008, p. 2). Therefore, burdens of chronic
health illnesses will become heavier and affect not only older people and their

2. OBJECTIVES
2.1. General objectives
To measure the access to PHC services by older people and associated factors in
rural areas of Vietnam
2.2. Specific objectives
1. To describe socio-demographic characteristics, health status and knowledge
on health care of older people in rural areas of Vietnam
2. To measure the access to PHC services by older people in rural areas of
Vietnam in three dimensions: availability, affordability and acceptability
3. To identify factors associated with the access to PHC services by older people
in rural areas of Vietnam

3. METHODS
3.1. Study setting

The study was conducted in Giong Trom district of Ben Tre province in 2012. Giong
Trom is a rural district, located in Mekong Delta region of Vietnam, 120 km far from
Ho Chi Minh city. This district covers an area of 311.4 km 2 and divided into Giong
Trom town and 21 other communes. The total population is around 182,400. The
main economic sector in the district is agriculture with the development of fruittrees, sugar-cane, rice, cattle, poultry, and aquaculture. The cottage industry
professions like locally special cakes, products made of coconut fiber and shell are
also developed.
Giong Trom district has the highest proportion of older people compared to other
districts of Ben Tre province. The number of people aged 60 and above in the district
is 19,075, accounting for over 10 per cent of the total population. Most of the older
people live with their children or other relations while others live alone, without any
pensions, with disability or with poverty.

3




Table 1. Description of dependent and independent variables
Research variables
Independent variables
Age

Description
The age of older people at that time of the
year 2012 and divided into three groups

Categories




Sex

The sex of older people




Educational level

The highest level of education that older
people completed





Total amount of money per month that
older people get; and classified into 5
groups







Self-evaluated household
income by older people

Classified into different levels based on
the comparison with other households in
the commune by older people







Knowledge on health care
Self-evaluated health status
by older people

Knowing at least one way of disease
prevention or health improvement


Going to a health facility for general
health examination by older people
Going to a health facility for CD followup examination by older people with CD
Using CD follow-up examination
according to doctor’s appointment or
periodically by older people with CD
Going to a health facility for health trouble
examination by older people with health
troubles within the last four weeks
















60-69
70-79
80+
Male

Poor
Very poor
Mild
Average
Severe
Yes
No
Used
Not used
Used
Not used
Used
Not used
Used
Not used

5


3.5. Variable measurement and data collection
- Quantitative data: Face-to-face interviews using a structured questionnaire were
implemented with all older people, who were ability and willing to participate in the
interview, at every of selected households. The questionnaire included the questions
on socio-demographic characteristics of older people such as age, sex, education,
religion, ethnicity, marital status, working status, household size, living arrangement,
and household income; on their health status like chronic illnesses, functional
limitations and health troubles within the last four weeks; on their use of health care
services and on some other factors related to access to health care services like health
insurance and travel time.
Trained interviewers from the Institute of Hygiene and Public Health at Ho Chi Minh

was at the age of 60-69 years old accounting for 42.3% (Table 2). Two third of older
people were women. Education level of older people was low. Over haft of older
people had no education including illiteracy and literacy (only read and write); and
17% of them got secondary or higher.
Table 2. Percentage distribution of Age, Sex and Education of older people
Findings
Characteristics
n

%

60-69

46.2

42.3

70-79

34.1

30.7

80+

19.7

27.0

Male


Sex

Educational level

Table 3 shows that almost all older people were Kinh, the majority ethnicity of
Vietnam. Over 50 per cent of older people followed religion; and Buddhism was
their main religion. About marital status, 48% of older people were widower or
widowed; 46.7% were married; 4.7% were single and only 0.6% were divorced.
Although most of older people lived with their children and other members like their
spouse and grandchildren, there were 14.7% of older people living alone, 13.3%
living with only the spouse and 3.5% living with only their grand children.

7


Table 3. Percentage distribution of Ethnicity, Religion, Marital status and
Living arrangement of older people
Percentages
Characteristics

n

%

510

99

6


4.7

Married

241

46.7

Divorced

3

0.6

248

48.0

Alone

76

14.7

With only spouse

69

13.3

persons also living based on social allowance in poor households; the older people
aged 80 and above who do not have retirement or social insurance pension. Besides,
other social policies were also considered in the study such as pension for the older
women whose husbands or sons were martyr in Vietnam war.

8


Table 4. Percentage distribution of Working status and Income of older
people
Findings
Characteristics

n

%

No works

257

49.6

Housework

62

12.0

Farming


5.6

Work income

148

39.7

Allowance from relatives

96

25.7

Social allowance

166

44.5

1

0.2

Lowest - < 500,000 VND

113

31.2

Income/Pension sources (N=373)

Interest from savings account
Total amount of income/pension per
month (N=362)

Apart from the income source from social allowance, other income sources were also
mentioned including retirement pension (5.6%); income from present work (39.7%);
monthly allowance from children or other relatives (25.7%); and interest from
savings account (0.2%). Total amount of income per month were classified into five
groups and presented in Table 4. The first income group (less than 500,000 VND per
month) mainly contained the older people who received social allowance as defined
in Article 17 with the two income levels: 180,000 VND and 270,000 VND per
month.

9


Comparing to other household income in the same commune, 62.7% of older people
evaluated by themselves that their household income was moderate; 27.4% was
under moderate or poorest; and only 1.7% was richest (Figure 1).

Figure 1. Self-evaluated household income by older people

4.2.

Health status of older people

Health status of older people was first evaluated by respondents themselves. Then
information about chronic diseases, functional limitations and health troubles

Neurological diseases
Others
Disease duration (N=380)
Less than 1 year
From 1 to 5 years
Over 5 years
No answer

n

%

380

73.4

194
167
109
55
30
27
95

51.1
43.9
28.7
14.5
7.9
7.1

Types of functional limitations (N=82)
Mobility
75
91.5
Bathing
45
54.9
Going to toilet
35
42.7
Putting on/off clothes
27
32.9
Eating/ Drinking
23
28.0
Levels of functional limitations
(N=81)
Mild
20
24.4
Moderate
51
62.2
Severe
10
12.2

Over 60% of functional limitations among older people were estimated to be
moderate (older people partly requiring supports from other persons); 24.4% was

13.7
Others
98
23.9
Levels of health troubles (N=407)
12


Mild
Moderate
Severe

201
155
52

49.1
37.9
12.7

13


Table 7 indicates that 79% of older people had health troubles that made they feel
uncomfortable or unhealthy or prevented them from doing daily activities. Headache,
backache, dizziness and cough were common symptoms. Among those older people,
49% felt that the troubles did not or insignificantly influence their daily activities
(mild); 38% was moderate; and remaining older people reported that they could not
do anything and had to lie on bed almost all day.
4.3.

Vietnamese government has promulgated the Elderly Law No. 16/2009-L-CTN in
which PHC for older people has been assigned for local authorities, CHSs and
communities. The Law has officially taken effect since the first of July, 2010. Article
13 of the Law has defined responsibilities of CHSs in providing PHC services for
older people including: health education and communication; instruction of health
care and disease prevention skills; medical file supervision and management;
examination and treatment diseases in accordance with CHSs’capacity; periodic
health examination (cooperating with district health center or hospital); health care at
home for older people living alone and not able to go to a health facility. Authorities
are responsible for providing financial supports of transportation for health staff to
14


implement “health care at home” service. Authorities also have responsibility to
support for poor older people with money to travel from a health facility to their
home and vice versa.
In the context of the Law, all CHSs of the four selected communes were surveyed to
identify PHC services available for older people in Giong Trom district. Some other
information related to the availability of PHC services was also collected from older
people. The results show that PHC services for older people of all the CHSs were
very poor. No CHSs had enough PHC services as assigned by the Law.
Examination and treatment diseases in accordance with CHSs’capacity was the main
service that all CHSs had been implementing. However, the service was intended to
all people and there were no special activities for older people. Only one CHS head
mentioned that “older people will get priorities when they went to the CHS for
examination”. Besides, the service quality also had many limitations caused by the
shortage of human and financial resources, work overload and poor infrastructure.
Among CHSs surveyed, two CHSs had no medical doctors. The total number of
health staff was around 6 people including CHS head. “The human resource is too
inadequate and not able to meet the job well” said one CHS head. On average, each

Actually, about half of older people interviewed (52.2%) said that they received
information about disease prevention and health improvement from health staff.
Dietary with salt reduction, fat reduction and sweet reduction were mentioned by
most of those people.
No CHSs provided activities for health care at home for older people living alone
and not able to go to a health facility. The lack of time and the quantity of health staff
at CHSs was the main reason why they could not deploy those activities. Another
reason was that they did not any “fee for transportation”. Some health staff said that
they did examine and treat for older people at home when they were asked and the
older people or their relatives paid for them. Besides, they said that the program on
management and rehabilitation for people with disabilities could partly supports for
older people. However, only two CHSs reported on the number of disabled people
managed at communities and hospitals during last year and some activities such as
visits and guidelines for rehabilitation process.
Similarly, other activities such as medical file supervision and management and
periodic health examination (cooperating with district health center or hospital)
were still not deployed. Heads of CHSs said that they started managing the older
people’s health through getting the list of older people from the Commune’s Elderly
16


associations or provincial hospitals. One CHS only got the list of older people aged
80 years and above. About periodic health examination, CHSs did not actively
cooperate with district health center or hospital to organize examination phases for
older people. The Commune’s Elderly associations played a crucial role in
implementing the activity. Other organizations like Red Cross association were
sometimes organized “free health examination for older people on the occasion of
27-7, the Vietnamese martyr’s day”. They normally combined health examination to
other activities like visits and gifts for older people at special occasions. CHSs were
only invited to participate in those occasions instead of actively making plans on

living in rural areas, from access to health care services. Table 9 shows that the
percentage of older people having a health insurance card was 84%. Among them,
62.3% were provided free health insurance cards and 37.7% were purchased.
Table 9. Health insurance status of older people
Findings
Variables
n
%
Having health insurance card
435
84
(N=518)
Type of health insurance card
(N=432)
Free health insurance card
269
62.3
Self-purchased health insurance card
163
37.7

4.4.3. The utilization of available PHC services by older people
The results from CHSs survey show that PHC services available for older people
were very poor. Examination and treatment for older people with illnesses were the
main service. Therefore, the percentage of older people used the health care services
represented the actual access to available PHC services by older people and partly
expressed the acceptability of older people to those services.
Table 10. Utilization of health care services among older people
Findings
Variables

18