Utilisation of health services in a transitional society : Studies in Vietnam 1991-1999

Abstract: General objective: The general objective is to assess the utilisation of public health services among different social groups in a period of rapid policy and society changes in Vietnam. Methods: Studies on the utilisation of reproductive health services were based on one household survey conducted in a lowland district in 1992 and two other surveys performed in 1991 and 1994 in a highland district. 1132, 1756 and 2106 women were interviewed. Studies on utilisation of outpatient services were based on a 1999 household survey of 4769 individuals in a lowland district and another household diary survey of 1452 individuals in a highland district, conducted in 1998. Main findings: Less than one fifth of the pregnant women had attended the recommended three antenatal visits in the 1991-1994 studies. One third of the highland and two thirds of the lowland women had given birth at a health facility. Less educated women, Catholics and women with three or more children were less prone to utilise these services. Modern contraceptives, almost exclusively intrauterine devices, were used by 63% of the couples (1992) in the lowland area where implementation of the population policy had been strong. In the highland areas the corresponding figure was 34-45% during the same period. In the 1992 survey, 46% of the couples had more than two children, and more than half of them had shorter spacing (three years) between the first and the second child than had been recommended and finally stipulated in the 1988 population policy. Less educated women, farmers and Catholics had shorter spacing between the first and second child and also a higher probability of having a third child. In addition, women who had no sons or who had previously lost a child were more likely to have a third child. About half of the people (1998 and 1999 survey) reporting some kind of illness used some kind of self-medication, usually buying drugs, while less than 30% attended the public health facilities. In the lowland area 18 % sought private services. Patients with severe and moderate illnesses were more likely to attend public health services. Patients, who had a long distance to the health services, were less prone to use them. The poor were more prone to deter from public health services than others. For those who sought care in the lowland area, mean expenditure on outpatient care was 7% of the mean household monthly income and 4% for those who practised self-medication. For health facility users, the poorest households spent 17% of their income, while the richest quintile spent only 4%. Fifty- eight per cent had been obliged to sell assets or to borrow money for paying the fees. Only 18% of the study population were covered by health insurance schemes. In the studied highland area, where all people should have been exempted from fees and have free drugs, only 2% of the patients had got exemption from user fees. Conclusions: Utilisation of antenatal care, delivery and outpatient services was low in Vietnam. Inequity in utilisation of antenatal care and delivery services was found with lower attendance among less educated, Catholics, farmers and women with three children or more. The majority of couples did not adhere to the population policy. Inequity in utilisation of outpatient services was also found among patients living far from health services. The heavy burden of payment for health care was due to high cost of treatment, low coverage of health insurance and uncommon exemption from user fees. These studies identify a need for increased utilisation of antenatal and delivery services among the mentioned disadvantaged groups of women. There is also a need for developing appropriate co- payment schemes for vulnerable groups in rural Vietnam.