Primary health concept revisited: where do people seek health care in a rural area of Vietnam?

The government of Vietnam is committed to promote and secure equity in access to health care for all citizens. The current rapid changes towards a market economy may challenge the government's wish for maintaining equity, especially for low income and vulnerable groups. The aim of this study was to investigate aspects of access and utilisation of health care of rural people. The study included a random sample of 1075 out of the 11,547 households in the Field Laboratory in Bavi district, northern Vietnam and a structured questionnaire was used. The results indicate that self-treatment is common practice and private providers are an important source of health services not only for those who are better off but also for poor households. The costs for health care are substantial for households, and lower income groups spent a significantly higher proportion of their income on health care than the rich did. The poor are deterred from seeking health care more often than the rich and for financial reason. As regards sources for payments, the poor relied much more on borrowing money to pay for their health care needs, while those who are better off relied mostly on household savings. A burden of high cost for treatment implies high risks for families to fall into a 'medical poverty trap'. Our findings suggest a need for developing risk-sharing schemes (co-payment, pre-payment and insurance), and appropriate allocation of scarce public resources. We suggest that the private health care sector needs both support and regulations to improve the quality and access to health care by the poor.

Public health services use in a mountainous area, Vietnam: implications for health for policy.

AIMS: The aim of this study is to describe the use of public health services in different social and ethnic groups and to explore the implementation of user fee exemption in a mountainous area in Vietnam. METHODS: A cross-sectional household survey with a structured questionnaire and a four-week diary were used to collect information on illnesses, health seeking behaviour and socioeconomic factors. Three communes in a mountainous district in Northern Vietnam were selected and a random sample of 1,452 individuals in 300 households was drawn. RESULTS: Self-medication was most common (57%) while 30% used public health services when suffering from a health problem. Persons living far from health services attended public health services less frequently than the others (adjusted OR = 0.28; 95% CI 0.15-0.51). This was especially the case for ethnic minorities who were less likely to use public health services than the others were (adjusted OR = 0.47; 95% CI 0.25-0.87). Persons with mild conditions tended to use public health services less than those with more severe conditions (OR = 0.19; 95% CI 0.10-0.37). Health services use was similar among women and men, but the total expenditure per visit was higher for men. Almost no patients supposed to get free attendance had been exempted from user fees. CONCLUSIONS: It was found that there was a geographical inequity in use of public health services while there was relatively equal use of these services between social, gender, and ethnic groups. Long distance in combination with failure of the fee exemption may increase inequity in use of health services in remote and isolated areas. These observations contribute to the basis for implementation of the Vietnamese health policy, emphasizing efficiency and equity.

Expenditure and payment sources for treating acute respiratory infections in rural Vietnam.

This paper highlights important effects of the health sector reform in rural Vietnam, such as the expenditure for treatment, payment sources among patients and provision of private services. Using a cross-sectional design with a structured questionnaire, the occurrence of illnesses and utilization of health care for 4,769 members in randomly selected households were investigated, with a focus on acute respiratory infections (ARI). Three hundred and seventy people were reported to have suffered from an ARI in the four weeks prior to interview. In 96% of the cases some action had been taken, most often self-medication. The average expenditure for the first treatment was high, 25,000 Dong (US$ 1.7), which is appropriately equal to one third of the monthly per capita in the district. The majority of the expenditure was for drug purchasing in the private or public services. Expenditure for treatment of acute respiratory infections was highest in the hospitals, lower in commune health stations and private clinics, and lowest in the case of self-medication. There was no consultation fee at the commune health stations and private clinics. About half of the patients had borrowed money or sold agricultural products to pay for treatment. Only 2% of the patients benefited from health insurance. High burden of ARI, high cost of treatment and poor coverage of health insurance may create severe economic problems in poor families. Our findings indicate a need to develop pre-payment schemes and the appropriate allocation of resources in order to establish an efficient and equitable health care system.

Child spacing and two child policy in practice in rural Vietnam: cross sectional survey.

OBJECTIVE: To explore the reproductive pattern of women in rural Vietnam in relation to the existing family planning policies and laws. DESIGN: Cross sectional survey with question-naires on reproductive history. SETTING: Tien Hai, a district in Red River Delta area, where the population density is one of the highest in Vietnam. SUBJECTS: 1132 women who had at least one child under 5 years of age in April 1992. MAIN OUTCOME MEASURES: Birth spacing and probability of having a third child. RESULTS: The mean age at first birth was 22.2 years. The average spacing between the first and the second child was 2.6 years. Mothers with a lower educational level, farmers, and women belonging to the Catholic religion 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 lost a previous child were more likely to have a third child. CONCLUSION: Most families do not adhere to the official family planning policy, which was introduced in 1988, stipulating that each couple should have a maximum of two children with 3-5 years' spacing in between. More consideration should be given to family planning needs and perceptions of the population, supporting the woman to be in control of her fertility. This may imply improved contraceptive services and better consideration of sex issues and cultural differences as well as improved social support for elderly people.

PIP: A 1988 decree on population and family planning issued by Viet Nam's Council of Ministers stipulated a maximum of 2 children per couple, with a spacing of 3-5 years. To assess adherence to this policy and changes in reproductive behavior associated with the transition to a market economy, a cross sectional survey was conducted in Tien Hai, a district in Red River Delta with one of the highest population densities in the country. Five communes representing different modes of production were randomly selected. The sample was comprised of 1120 households and 1132 mothers who were interviewed in their homes in 1992. 1662 pregnancies were reported between April 1987 and April 1992, 91% of which resulted in a live birth. The median age at marriage was 20.9 years, while median age at first birth was 22.2 years. The median spacing between first and second children was 2.6 years. The duration of birth spacing was significantly shorter among women whose first child died, Catholics, and younger women; it was significantly longer among women with a secondary or higher education. The sex of the first child exerted no effect on the spacing duration. 46% of the mothers interviewed had at least 3 children. Factors identified through multivariate analysis as predictive of having a third child were the death of a previous child, lack of a son, no formal maternal education, Catholicism, and involvement in farming. The widespread deviations recorded in this survey from official family policy suggest a need for greater consideration of the perceived needs of Vietnamese families. This may result in improved and more diverse contraceptive options, attention to gender issues in Vietnamese households, and social support for the elderly.

Utilisation of reproductive health services in rural Vietnam; are there equal opportunities to plan and protect pregnancies?

STUDY OBJECTIVES: To describe the utilisation of reproductive health services (family planning, antenatal care, and delivery services) and the socioeconomic determinants for utilisation of health services. DESIGN: This was a cross sectional survey, using a multistage sampling technique. SETTING: Tien Hai district, Thai Binh Province, Vietnam. Altogether 1132 mothers with children under 5 years of age were interviewed about antenatal, delivery, and family planning services utilisation during a five year period (1987-92). MAIN RESULTS: Seventy per cent of the women used contraceptive methods, with the intrauterine device being the most common. The use of the intrauterine device was positively associated with the number of children alive but not with other sociodemographic factors in the mothers. Thirty per cent of the women had attended an antenatal clinic for check ups during their last pregnancy. It was found that mothers with fewer deliveries, higher education, and who were Buddhist or of no religion had utilised antenatal services more frequently than the others. Seventy five per cent of the mothers in this study had been assisted by health professionals at their last delivery. Those mothers with fewer deliveries, higher education, who were Buddhist or had no religion, and had sufficient to eat were more likely to have their births attended by health professionals. CONCLUSIONS: In spite of a relatively high education level in the population and services which are generally available, there was an under utilisation of antenatal and delivery care and there was no equal opportunity for different groups of mothers to use these services. Family planning services were, however, frequently used and were used to the same extent by different groups of mothers. Except for abortion, alternatives to the intrauterine device method were rarely available. If pregnancies are to be protected in an efficient way in rural Vietnam, reproductive health care must be strengthened and efforts should be made to reach the women who are not using these services at present.

Utilization of reproductive health services in a mountainous area in Vietnam.

This study uses data from two surveys performed in 1991 and 1994 in a mountainous district of northern Vietnam. The aim was to describe the utilization of family planning, antenatal care, delivery and immunization services during a period of rapid structural change in the health services in general and implementation of a primary health care project in the study area. This project was aimed at increasing access to health services and improving the quality of primary health care services. Factors influencing the utilization of reproductive health services were analyzed. The contraceptive prevalence among women aged 15-49 increased significantly from 48% in 1991 to 60% in 1994. The most commonly used contraceptive method was intra-uterine devices. The BCG coverage among children under five years of age increased from 36 to 70%. The proportion of pregnant women receiving three antenatal check-ups, as recommended by the health authorities was low and increased slightly from 15% in 1991 to 20% in 1994. About one third of the pregnant women were delivered in health care institutions during this period. The utilization of family planning, antenatal care and delivery services varied with ethnicity and was positively related to the mother's educational level both in 1991 and 1994. There is a need to strengthen the reproductive health services, especially antenatal care and delivery services, in terms of improving the quality of care and accessibility to women. Efforts should be made to reach women with a low education level as well as those belonging to ethnic minorities.