How public health insurance expansion affects healthcare utilizations in middle and low-income households: an observational study from national cross-section surveys in Vietnam.

Public health insurance (PHI) has been implemented with different levels of participation in many countries, from voluntary to mandatory. In Vietnam, a law amendment made PHI compulsory nationwide in 2015 with a tolerance phase allowing people a flexible time to enroll. This study aims to examine mechanisms under which the amendment affected the enrollment, healthcare utilization, and out-of-pocket (OOP) expenditures by middle- and low-income households in this transitioning process.Using the biennial Vietnam Household Living Standard Surveys, the study applied the doubly robust difference-in-differences approach to compare outcomes in the post-amendment period from the 2016 survey with those in the pre-amendment period from the 2014 survey. The approach inheriting advantages from its predecessors, i.e., the difference-in-differences and the augmented inverse-probability weighting methods, can mitigate possible biases in policy evaluations due to the changes within the group and between groups over time in the cross-section observational study.The results showed health insurance expansion with extensive subsidies in premiums and medical coverage for persons other than the full-time employed, young children or elderly members in the family, significantly increased enrollments in the middle- and low-income groups by 9% and 8%, respectively. The number of visits for PHI-eligible services also increased, approximately 0.5 more visit per person in the middle-income and 1 more visit per person in the low-income. The amendment, however, so far did not show any significant effect on reducing OOP payments, neither for the low nor the middle-income groups. To further expand PHI coverage and financial protections, policymakers should focus on improving public health facilities, contracting PHI to more accredited private health providers, and motivating the high-income group's enrollments.

Dominant Factors Affecting Regional Inequality of Infant Mortality in Vietnam: A Structural Equation Modelling Analysis.

BACKGROUND: Despite Vietnam's acclaiming achievements of reducing overall infant mortality rate (IMR), the IMR decline does not occur equally in all regions in Vietnam. This study aims to investigate dominant factors that affect the inequality of infant mortality across regions in Vietnam during the period 2005-2015. METHODS: We use nationally representative data to construct a panel data of 6 economic regions in Vietnam from 2005 to 2015. We employ the structural equation modelling (SEM) approach to quantify the causal effect of socio-economic status (SES), accessing to skilled birth attendance (SBA) and other relevant factors on the disparity of IMR across regions. RESULTS: SES, which is measured by 3 indicators - illiteracy rate (IR), poverty rate (PR) and income per capita - is the dominant factor causing regional inequalities of infant mortality, followed by the use of SBA. Among these indicators, the PR is the most important one causing the regional disparity of IMR and accessing to SBA. The total effect of SES on infant mortality disparity is 2.6 times as high as that of accessing skilled healthcare personnel. CONCLUSION: Bridging the regional gap of using skilled health personnel would contribute to improving the infant mortality inequality in Vietnam. This inequality, however, is not significantly improved only with medical interventions but also with broader and more comprehensive socio-economic interventions at both national and regional levels. Our findings confirm that poverty reduction and growth strategies should be the main focus to boost medical interventions and improve IMR all over the country.

The roles of social economic status and undernutrition in regional disparities of the under-five mortality rate in Vietnam.

OBJECTIVES: From 2005 to 2017, the prevalence of mortality in Vietnamese children under five years old showed large regional disparities. In 2017, mortality in the wealthiest region was 12.6‰, whereas the most disadvantaged region it was three times as high, at 36‰. This study aims to identify factors affecting regional disparities of the under-five mortality rate (U5MR) in Vietnam. METHODS: We applied Structural Equation Modelling to estimate the degree and the pathway through which undernutrition and socio-economic status (SES) contributed to the under-five mortality disparities. RESULTS: SES is estimated as a common latent factor of three socio-economic measures, that is, education, poverty and income. The direct effect of SES on U5MR is at 2.16 through the underweight pathway, which is 5 times higher than the effect of underweight on U5MR. Through the stunting channel, this direct impact is 1.43, nearly twice as high as the impact of the stunting rate. SES also has an indirect effect on U5MR through these undernutrition pathways. In total, we estimate that an increase in SES index will make the U5MR increase by 2.73‰. Among the three indicators of SES, poverty conveys the strongest signal of a considerable change in SES, thus to a subsequent change in U5MR. Among two types of undernutrition, the effect of stunting on U5MR is dominant, more than 3 times as high as that of underweight. CONCLUSION: These findings have important implications for socio-economic and health interventions: those that strongly focus on the reduction of regional poverty and stunting rates would be effective in bridging the regional gap in the U5MR in Vietnam.

OBJECTIFS: De 2005 à 2017, la prévalence de la mortalité chez les enfants vietnamiens de moins de cinq ans a montré de grandes disparités régionales. En 2017, la mortalité dans la région la plus riche était de 12,6 ‰, alors que dans la région la plus défavorisée elle était trois fois plus élevée, à 36 ‰. Cette étude vise à identifier les facteurs affectant les disparités régionales du taux de mortalité des moins de cinq ans (U5MR) au Vietnam. MÉTHODES: Nous avons appliqué la modélisation par équations structurelles pour estimer le degré et la voie par lesquels la sous-nutrition et le statut socioéconomique (SSE) contribuaient aux disparités de mortalité des moins de cinq ans. RÉSULTATS: Le SSE est estimé comme un facteur latent commun à trois mesures socioéconomiques, à savoir l'éducation, la pauvreté et le revenu. L'effet direct du SSE sur l'U5MR est de 2,16 dans la voie de l'insuffisance pondérale, ce qui est 5 fois plus élevé que l'effet de l'insuffisance pondérale sur l'U5MR. A travers la voie du retard de croissance, cet impact direct est de 1,43, soit près de deux fois plus élevé que l'impact du taux de retard de croissance. Le SSE a également un effet indirect sur l'U5MR à travers ces voies de sous-nutrition. Au total, nous estimons qu'une augmentation de l'indice de SSE fera augmenter l'U5MR de 2,73 ‰. Parmi les trois indicateurs du SSE, la pauvreté est le signal le plus fort d'un changement considérable du SSE, donc d'un changement ultérieur de l'U5MR. Parmi deux types de sous-nutrition, l'effet du retard de croissance sur l'U5MR est dominant, plus de 3 fois plus élevé que celui de l'insuffisance pondérale. CONCLUSION: Ces résultats ont des implications importantes pour les interventions socioéconomiques et de santé: celles qui se concentrent fortement sur la réduction de la pauvreté régionale et des taux de retard de croissance seraient efficaces pour combler l'écart régional dans l'U5MR au Vietnam.