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

Reviewer No.1:
Reviewer No.2:
Reviewer No.3:

The thesis is defended before the thesis appraisal board of the
Academy at the Graduate Academy of Social Sciences at:
......hours, date ......... month...... 2019.

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
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grassroots level and factors influencing access (case study in Hai
Duong and Binh Dinh) '' is carried out to answer the following research
questions:
• What is the situation of access to medical examination and treatment
services for the health insurance at the grassroots level in the study area?
• How do the policy/ institutional, service delivery and user factors
influence access to medical examination and treatment services for the
health insurance card holders at the grassroots level?
2. Research objectives and tasks
2.1. Research objectives

3.2. Research scope
The study area was in Tuy Phuoc and Hoai Nhon districts of Binh
Dinh province and Gia Loc and Kim Thanh districts, Hai Duong
province. The study duration: 2014 to 2018. Field survey was
conducted in 2014. The study focused on understanding the access to
medical examination and treatment services at the grassroots level of
people with HI. Those who did not have HI were also investigated to
find out if there were any difference with regard to HI status.
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
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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

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.
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CHAPTER 1
RESEARCH OVERVIEW ON ACCESS TO HEALTH
SERVICES
1.1. Views and policies to increase access to health services

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.

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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.

general dominance of the policy environment.
2.3. Analytical framework and research hypothesis
Analytical framework of the study

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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
Research design
Cross-sectional survey combining quantitative, qualitative methods
and literature review.
Quantitative sample
The study deliberately selected Binh Dinh and Hai Duong provinces
according to the following criteria: (i) a rural plain province; (ii) one in the
North and one in the Central region (to ensure financial feasibility); (iii)
Having 100% of CHSs implementing HI examination and treatment. In
each province, 2 districts were selected. The criteria for district selection
include: (i) average socio-economic conditions; (ii) engaging with HI

 Where to go for medical service if not using services at grassroots
level: 1. Other public health facilities; 2. Private health facilities; 3. Selfpurchase medication.
Independent variables
From demand perspective, variables include gender, age, education
level, occupation, household economic status and variables related to
community factors, which are living locations.

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From supply perspective, variables include: (i) Availability of services
(health facilities providing HI services; types of services); (ii) Quality of
service, including professional quality (capacity and qualifications of
health workers, infrastructure, equipment, medicine) and service quality
(health workers’attitude, examination procedures); (iii) Geographical
factors (distance, travel time); and (iv) Financial factors (including method
of payment and settlement of HI reimbursement).
Processing and analyzing data
Information from the quantitative survey will be entered into the
computer by Epi-Data software and analyzed by social science statistics
software. Quantitative data and information are encoded and analyzed by
SPSS 17.0 software according to basic statistics (frequency, correlation).
Qualitative data is collected through available documents,
observations, in-depth interviews and group discussions, recorded or hand
noted, processed and analyzed using open coding method Information
obtained from qualitative research is processed by the open coding method
according to each subject group. Qualitative results help to better explain
quantitative results and reflect the views and consensus or disagreement of
people on health insurance and help identify issues that people concern.
2.6. Research limitations

in the informal sector was only about 50%, particulary the HI rate of the
self-employed group is less than 30%. The HI enrolment rate in rural areas
(68.4%) was lower than in urban areas (74.2%).
Illness situation in the surveyed areas
Data from the household survey showed that there were more illness
cases among women than men, the age group under 6 years old and those
aged 60 and older were the most ill. The group of 50 - 59 years old also
recorded a high rate of illness. The rate of illness among people with HI
was much higher than those without health insurance.
Health service seeking behavior of surveyed households

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The most preveiling health service seeking behavior of households in
Binh Dinh if acquiring illness was to look for services from pharmacies
(54.2%), followed by private clinics (20.7%) and district hospitals (14.3%),
only a few chose to come to CHSs (6.5%). The model of Hai Duong is
different, though pharmacies still ranked the first (33.6%), CHSs came next
at 26.9% followed by private clinics (21.7%), the number of households
seeking services from district hospital was quite modest (6.3%).
3.3. Current situation of medical examination and treatment in the
surveyed areas
The level of access to health services
The level of access to health services in the surveyed areas were
considered very high (92% of the sick used health services). The most
popular health service consumption model in Binh Dinh was to go to
pharmacies (35.1%), to private clinics (30.3%), to district hospitals
(21.3%) while coming to CHSs ( 5.3%) was the lowest and this model
matches the pattern of health service seeking behavior. Meanwhile, Hai

older used the most health insurance curative services. Comparing the two
provinces, the rate of medical examination and treatment with health
insurance for each of all age groups of Hai Duong was higher than that of
Binh Dinh. Regarding the place of using the service, the sick in Binh Dinh
had the highest level of HI curative service consumption at district
hospitals, while in Hai Duong, more consumption were at CHSs.
According to the type of card, in Hai Duong those who consumed HI
curative service the most were the poor, followed by the retiree, the elderly
and people with meritorious services to the Revolution. The group
registered at CHSs for initial HI examination and treatment consumed the
highest level of HI examination and treatment services. Most services used
was outpatient while inpatient services accounted for only 26% in Binh
Dinh and 18.6% in Hai Duong.

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The level of satisfaction among HI medical service users was very
high (Binh Dinh: 73.9%; Hai Duong: 88.3%) in all types of facilities that
the sick accessed. The main reasons for satisfation were not having to pay
much thanks to HI, good attitude of health workers, adequate medicine,
convenient procedures and health facilities close to home.
CHAPTER 4
FACTORS AFFECTING CCESS TO HI EXAMINATION AND
TREATMENT IN STUDY AREA
4.1. Policy and institutional factors
Health insurance policy provides assurance on access to health
services, especially for disadvantaged groups.
The participation of Party committees, authorities, locally tailored
policies, appropriate propaganda and mobilization methods help expand

higher levels. However, the easily accessible location is not a guaranteed
condition if there are many other options in the same area or nearby,
especially when barrier on technical routes of medical examination and
treatment removed. It is the service quality that makes the
difference.Improving technical quality requires investment of time and
resources, but improving service quality, from a sense of attitude to
information and adequate advice to make patients sastified is something
that can be done right away.
4.3. Factors affecting demand
There are differences in health insurance participation, health insurance
curative service consumption according to personal characteristics,
families and living areas. Verification by logistic regression model on
people aged 18 and over in the study area confirm the results as gender,
age, education, occupation, living standards, living areas are corelation
with the rate of HI participation. Regarding access to HI curative services,
there are also certain differences in age, level of illness, living area, place
of initial health care registration, place of medical examination and
treatment.
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Most of the HI card holders participated in HI because they are
supported for card purchase, whereas many non-participants said the
reason was because there was no money, because of high fees. Even the
group of near poor households, despite having a high rate of participation
in HI, are among groups that use HI curative services the least due to the
limitation of co-payment.
People have knowledge about health insurance but only paying
attention to specific benefits for themselves. Awareness is not high is the
cause of "reverse selection" situation, only the elderly and sick people will

private health facilities and pharmacies, district hospitals were not used
much. People in urban areas of Binh Dinh have access to health services
more than rural people.
Despite the low rate of using HI benefits in search for health services,
most people, who come to public facilities, use HI examination and
treatment services and there are differences in age, where the initial health
care registration is, and where health care services are used.
Such research findings help test the validity of the second hypothesis:
"People have a diversity in using health services with a tendency of using
private services more than public ones" and the third hypothesis: “For
those who come to public health facilities, mostly to commune health
stations and district hospitals, most of them use HI examination and
treatment services though differences in demographic characteristics,
economic conditions and living areas are observed”.
Policy/ institutional influences
From policy reviews, related document and research references to
specific survey results in the study area, it shows that policy and
institutional issues have a great impact on people’s access to HI
examination and treatment services and this is in accordance with the
fourth hypothesis of the thesis, specifically:
HI policy provides assurance on access to health services, especially
for disadvantaged groups. The participation of Party committees,
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authorities, locally tailored policies, appropriate propaganda and
mobilization methods help expand HI coverage to the still less involved
groups that are the near poor and those of the informal sector, entitling
them access to HI examiniation and treatment services when needed.
Effect of service delivery system

different target groups - empirical results help provide evidence that
confirms this hypothesis: gender, age, education, occupation, living
standards, living area have a relationship with the rate of HI participation
and plcae to register for initial medical care, place to use HI services, is
related to the use of HI for medical examination and treatment.
Considering people's choices through the lens of the theory of rational
choice, the following statements are made:
Regarding access to health insurance services, research shows that
there are statistically significant differences in age, illness level, living
area, place of initial medical examination and treatment registration,
place where service is consumed. People aged 60 and over in both
provinces, especially in Hai Duong, uses HI curative care services the
most among all age groups. This is also a group that has high rate of HI
participation, a rational choice from a perspective that the older the age
is the more health problems they might acquire so is the higher
dependance they are on the HI benefits to reduce curative care costs, if
any. Financial barriers can lead to improper health seeking
behaviorstemming primarily from affordability rather than health care
needs. People's awareness of the benefits of HI has not yet been
transformed into using HI cardwhen seeking for services because the use
of health services is dominated by habits, prejudice and subjective
feeling of health status.
The research results and findings also raise the question of equity in
access to health care when HI enrolment and the consumption of HI
medical examination and treatment are affected by favorable factors such

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as income, HI status, residence, awareness, beliefs and habits rather than