Tiếp cận của người dân với dịch vụ khám, chữa bệnh bảo hiểm y tế ở tuyến cơ sở và các yếu tố ảnh hưởng (nghiên cứu trường hợp tại hải dương và bình định) tt tiếng anh

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.

This thesis can be found at:
- Library of Graduate Academy of Social Sciences
- National Library of Vietnam


LIST OF PUBLISHED ARTICLES AND WORKS
RELATED TO THE THESIS
1. Nguyen Thi Minh Chau (2014). Concepts of access to health
services and measurement: Review of International Researches.
Practical Medicine Journal, No. 11 (940) 2014, pages 24-27.
2. Nguyen Thi Minh Chau (2015). Access to medical examination
and treatment covered by health insurance in Vietnam: Analytical
review from the policy implication and policy implementation
perspective. Journal of family and gender studies No. 2 (25) 2015,
pages 23-34.
3. Nguyen Thi Minh Chau (2016). Access to medical examination
and treatment covered by health insurance in Vietnam: Critical
review from demand and supply perspectives. Journal of family and
gender studies No. 4 (26) 2016, pages 26-38.


PREAMBLE
1. The necessity of the study:
Health is a fundamental factor and also a goal in the socio-economic
development process of each country. Access to health services is
basically a basic human right (Alma Ata, 1978). But it is not always
guaranteed in everywhere. There is a difference in access to health
services between regions, communities and individuals with different
demographic characteristics, perceptions, awareness and understanding of

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

The purposes of this study are (i) to understand people’s access to
medical examination and treatment with health insurance at the grassroots
level, (ii) to analyze relevant factors from a policy perspective and that of
service provider, service users to make policy suggestions to enhance the
level of access in the study area in particular and for the grassroots level in
general.
2.2. Research tasks
• Develop a theoretical basis to learn about the status of access to
medical examination and treatment services for the health insure at the
grassroots level based on clarifying key concepts related to the research.
• Apply basic theoretical approaches, including structural-functional
theory, theory of rational choice and selectively apply appropriate
elements of common analytical models used in health policy and service
research in the study of access to medical examination and treatment
services for the health insurance card holders at the grassroots level
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• Carry out sociological survey using quantitative and qualitative
methods to analyze and evaluate the status of access to medical
examination and treatment services for the HI participants at the grassroots
level and social differences in access as well as explains the factors
affecting the access of people in Binh Dinh and Hai Duong provinces
• Propose feasible solutions to increase access to medical examination
and treatment services for people with health insurance at the grassroots
level.
3. Research objects and scope
3.1. Research objects
Access to medical examination and treatment services for the HI
participants at the grassroots level and influencing factors.

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
3


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

interviews, group discussions).
5. New scientific contributions of the thesis
The study uses a holistic approach to analyze people’s access to
health insurance (HI) medical services at the grassroots level, both
from the supply and demand perspectives in the context of the policy
environment that governs them. The findings show that the rate of HI
coverage was relatively high but there were differences in
demographic characteristics, economic conditions and resident
locations. People had a tendency of using private services more than
public ones. The high HI rate did not transform into effective
coverage when the rate of people using HI cards for medical services
was not high. For those who came to public health facilities, mostly
to commune health stations and district hospitals, the majority of
them used HI medical services. The level of satisfaction among those
people was very high. The study uses a holistic approach, which is to
consider people’s access to HI medical services at the grassroots
level, both from the supply and demand perspectives and the policy
environment that governs them. The analysis, explanation and
findings of the research contribute to a common understanding of this
research area, providing a basis for policy planning and adjustment to
help remove access barriers.

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6. The theoretical and practical signification of the thesis
Applying the structural-functional theory to indentify and
analyze the grassroots health structure’s components and their
interaction, the findings show that not many private health facilities
providing HI medical services resulted in users’ limited choice of

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

Global trend
There is a qualitative transition from the right of access under the Alma
Ata Declaration on primary health care to equity in access in the global
move for universal health coverage to ensure access to health services and
financial protection against risks from health service consumption.
Viewpoints and orientations of Vietnam
The Constitution stipulates the right to health care of all citizens. The
view of equity in health care is reflected in the Politburo Resolution No.
46 on the protection, care and improvement of people's health in the new
situation. Resolution No. 20 of the 12th Central Committee of the Party on
strengthening the protection, care and improvement of people's health in
the new situation emphasizes "grassroots health is the foundation" to build
a medical system towards equity, quality, efficiency and integration.
Health insurance policy (HI) has been implemented since 1992, Health
Insurance Law issued in 2008, amended and supplemented in 2014.
Regulations, guidelines on HI, grassroots health as well as policies to
support specific groups are in place, relatively comprehensive and always
adjusted and supplemented to ensure access to medical examination and
treatment for all people at the grassroots level. However, there are still
inadequacies in policy implications, policy enforcement and adverse
impact.
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1.2. Overview of Vietnam's health system
Organization of the health system
The health system is divided into 3 levels: central, provincial and
grassroots (district and commune). The current service delivery system is
a public-private mix with the public sector playing a leading role.
Service delivery capacity

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.

From a demand perspective, demographic characteristics, health status,
financial affordability, awareness and habits ... affect access. These factors
are directly interlinked and are subject to the general dominance of the
policy environment, conditions of socio-economic development of the
country, region and locality.
CHAPTER 2
THEORETICAL BASIS AND RESEARCH METHOD
2.1. Key concepts related to the research theme
Key concepts: (i) Access; (ii) Health services / medical examination
and treatment services (iii) Health insurance, HI examination and
treatment; (iv) Grassroots / grassroots health; (v) Influence factor. Access,
in this study, is viewed both ways: accessibility and actual access.
2.2. The main theories applied in research
The theory of rational choice is used to help find out what factors
influencing individual decisions in consideration of advantages and
disadvantages of HI benefits of a specific service before making a decision
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that he/she perceives as the most profitable, most reasonable choice. The
structural-functional theory helps assess the components of the grassroots
health, clarifying the relationship between the role, function and capacity
of grassroots health and the needs and actual access of the people.
The health service seeking behavior, the 5A model, measurement
framework of access from supply and demand sides and access barriers
provide good reference and direction for the study. There are many
similarities in these models, but generally, the models recognize that the
interaction between supply and demand can bring about different results in
terms of accessibility and in fact, supply and demand issues are not easily
separated and directly related to each other and both are subject to the

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

9


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

examination and treatment: (iii) local government paying attention to
health activities. At each district, randomly selected 4 communes, each
commune randomly selected 02 villages. At each village, 50 households
were selected by systematic random method.
The sample size surveyed in the descriptive study was calculated using
1,398 households. The total number of households surveyed was 1,600 to
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ensure the sample size in case a household does not agree to participate or
data missing due to insufficient response from some household. In fact,
the study has investigated 1,588 households.
Qualitative samples
Qualitative research using in-depth interview (IDI) and focus group
discussion (FGD): 04 IDIs of HI patients at district hospitals (one per
district hospital); 04 FGDs for HI patients at district hospitals (8-10 HI
patients per one FGD); 08 FGDs with HI people (one per commune, each
of 8-10 people with health insurance); 08 FGDs for people without health
insurance (one per commune); 02 FGDs with provincial department of
health; 04 FGDs with district hospitals; 04 FGDs of management agencies
at district level (district health unit, Social Insurance); 08 IDIs with heads
of commune health stations selected for the study and 04 FGDs with all
heads of commune health stations in the study district.
2.5. Variable analysis system and data processing techniques
Dependent variable
 Participation in health insurance: 1: yes; 0: no
 Having consumed any form of examination and treatment services
when falling sick: 1: yes; 0: no
 Use of HI cards for examination and treatment: 1: yes; 0: no.
 Having satisficed with HI examination & treatment: 1: yes; 0: no

 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.

11


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

Due to selection of the sample intentionally to ensure the feasibility of
the budget, data collected may not be well representative. Some variables
need to be included in the analysis are not available. At the time of the
survey, private sector has not engaged much in HI examination and
treatment activities, this is a limitation but also a suggestion for the next
research direction on the role and attraction of private sector and the
promotion of public-private partnership. Given the evolving changes with
regard to HI examination and treatment, particularly policies, compared to
the time of the survey, this is on the one hand considered as a limitation of
12


the research but on the other hand is an opportunity for the research to
contribute to the verification of the appropriateness and righteousness of
policies and regulations newly promulgated. This also evokes the need for
more policy impact assessments to provide evidence for policy
adjustment.
CHAPTER 3
CURRENT SITUATION OF ACCESS TO HI EXAMINATION
AND TREATMENT SERVICES IN GRASSROOTS FACILITIES
OF BINH DINH AND HAI DUONG
3.1. Situation of health insurance enrolment
Compared to health insurance coverage of the whole country at the
same time of the survey (71.5%), Binh Dinh had a higher rate of health
insurance enrolment (72.9%) and Hai Duong was lower (68.4%). Overall,
in the two provinces, female (73.6%) participated more than male (67.8%),
HI policies were well implemented with regard to children under 6 years of
age, students, the retiree and the poor (over 98%). The groups with the high
educational levels participated the most. The problems of "the middle gap",
the risk of "reverse selection" are of concern when the rate of HI enrolment

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

13


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

Duong shows another picture with the most popular option being to CHSs
(26.9%), followed by private clinics (25.9%), pharmacies (20.6 %) and
district hospitals (17.1%).
The level of access was different among population groups and
between the two provinces. People with minor illnesses often went to the
pharmacy, the level of illness increased, the rate of going to the pharmacy
reduced, and the rate of seeking for examination and treatment from
hospitals increased. People living in urban areas of Binh Dinh had more
access to health services than those living in rural areas.
Health service consumption according to HI status
In Binh Dinh, more than 80% of the sick without HI used private
services compared to just over 50% of the group with HI. Meanwhile HI
group aquired services from grassroots health facilities (including district
14


hospitals - 22.6% and CHSs - 18.5%) tripled times higher than those
without HI. In Hai Duong, more than 75% of the sick without HI looked
for services from private facilities, while more than 50% of those with
HI went to the grassroots health facilities (33.1% in CHSs, 20.1% in
district hospitals).
3.4. Current status of access to and use of HI curative services
Among the sick who are health insured, only 41.9% of their visits was
for HI medical examination and treatment, this rate of Binh Dinh (28.7%)
was much lower than Hai Duong (55.9%) ).
Although the rate of using health insurance card for medical
examination and treatment was generally low, most of those who paid a
visit to a facility eligible for providing HI curative services, chose to
consume services covered by HI (Binh Dinh: 91.8%; Hai Duong: 89.5%).
The group of children under 6 years old and the group of 60 years and

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

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.
However, inadequacies in policy implication, policy implementation
make the capacity of the service delivery system limited, becoming an
access barrier. The reverse of supply-side incentives to stimulate demand
negatively affects people's access to health services covered by HI.
4.2. Factors from service delivery system
Low participation of the private sector in delivery of HI examination
and treatment services narrows down users’ choice. The grassroot health
facilities at the study area have not really done well the function of HI
medical examination and treatment. There are many reasons including
difficulties in organizational structure and human resources, inadequacies
in medical equipment and medicine supplies that limit the capacity and
capability of grassroots health facilities, thus reducing people’s access.
Professional quality is not high due to limited capacity to deliver
16


technical services, procedures are yet troublesome while services are not
enough to meet the diverse needs of the people, payment modes and
reimbursement methods are still problematic. These are access barriers
because they make health facilities not function well, limit the benefits of
HI card holders resulting in increasing bypass and disruption of the
referral system, reducing people's confidence in grassroots health.
There are also optimistic signs that if grassroot health facilities well
identify their competitive edge, they can make a good breakthrough. With
local people placing high importance on geographical accessibility, it is a
right investment for CHS to improve service quality so that they can well
perform the primary health care functions and help reduce overload for the

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.
17


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

participate in health insurance. The illness level not only affects the level
of service use but also governs decisions about where to use the service.
CONCLUSION AND RECOMMENDATIONS
1. Conclusion
Situation of health insurance participation
The HI rate is relatively high in the study area, equivalent to the
national level at the same period, although there are differences between
different groups, i.e. women are more participated, groups of 50 years and
older participate more, so is group with higher educational levels. The
health insurance policy is well implemented with children under 6,
students, the retiree and the poor. But many of the problems that other
studies have shown are found in the study area, i.e. low level of law
compliance in the salaried group, a problem of "middle space" and the risk
of "reverse selection" in the informal sector and the near poor group, low
participation in rural areas compared to urban areas. This result confirms
the first hypothesis of the thesis: "The proportion of people participating in
health insurance in the study area is relatively high but there are many
differences in demographic characteristics, economic conditions and
living areas".
Access to health services and HI examination and treatment
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The rate of using HI benefits when seeking for health care among the
ill is very modest in all groups, including pensioners and policy
beneficiaries, even though HI fully pays them for examination &
treatment. The most popular model of using health services in Binh Dinh
is to look for services from pharmacies, followed by from private clinics
and district hospitals, very few people come to CHSs. Hai Duong again
shows another picture, the most popular option is to CHSs, followed by

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,
19


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

From the perspective of structural-functional theory that consider the
grassroot health structure is basically the structure reflecting the linkage of
and interation among actors involved and the functioning rightly of each
actor in harmany with that of other actors and the whole system, i.e. the
grassroot health structre, make it functioning effectively. Analysing the
research results from that angle and with reference to other relevant
research, the study may provide the following statements that test the fifth
hypothesis:
Not many private health facilities provding HI examination and
treatment services results in users’ limited choice and less access.
Meanwhile, the grassroots health care system has not yet performed well
the HI examination and treatment function due to its limited capacity,
weak system management and inadequate health financing solutions.
Easily accessible location can be an advantage but not enough, it is the
quality of the service that makes the difference, especially when removal
of technical routes implemented. Improvement in professional quality
requires investment in time and resources but improving the quality of
service is something that can be done right away.
These findings contribute to confirming the necessity and the
rightousness of recently promulgated policies and regulations as well as
efforts to strengthen capacity, improve quality of medical services and
satisfaction of people that have been being deployed over the years.
Individual and household characteristics

20


With the sixth hypothesis related to service users - factors of personal
characteristics and household status have an impact on the decision to
participate and use health insurance when going to health care services of

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

specific elements of age, gender, health status, health care needs.
2. Recommendation
Fine tuning the policy/ institutional mechanism
Examining the model of health insurance with differentiative rates of
premium and benefits are compatible with the rates that many countries
have applied to raise attractiveness, increase risk sharing and sustainability
of the health insurance funds.
The results of the study also help affirm of the appropriateness and
righteousness of policies currently being implemented and indicate that
assessment and studies on policy impacts need to be conducted more in
the context of many new policies and regulations currently in place. They
will provide evidence to help adjust and supplement policies and design
appropriate interventions. The study also suggests for more researches on
social dimensions of high concerns relevant to access to HI medical
examination and treatment, such as equity in access, quality of care,
satisfaction and the like.
Strengthening the systems of service delivery and health financing
Increasing the share of HI fund for CHSs and promoting the
implementation of electronic medical records is the right direction for
grassroots health to take on the role of “gate keeper”, to be the focal point
to coordinate medical care for common diseases and continuous
comprehensive health care according to family medicine principles. This
will help to best promote the grassroots health capacity, contributing to
reducing the workload for the higher levels, ensuring the role, function and
operational efficiency of each level and the whole system.
Considering the application of international experiences on provision
of good outpatient benefit packages is an important strategy to increase
access to health services by health insurance participants. Service
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