2012年-世界发展银行全球_Health_Equity_and_Financial_Protection_in_Vietnam_45页_1mb

Summary of the Health Equity and Financial Protection Report – Vietnam

Core Content

The Health Equity and Financial Protection Report – Vietnam provides an in-depth analysis of health equity and financial protection in Vietnam, focusing on disparities in health outcomes, behaviors, and service utilization, as well as the distribution of government health spending and the progressivity of health financing.

Main Topics and Key Findings

1. Health Equity and Financial Protection as Policy Goals

Vietnam's government has made significant efforts to improve health equity and financial protection through policies such as expanding health insurance coverage and targeting vulnerable populations. The goal of universal health insurance (UHI) is in place, though the program has not yet achieved full coverage.

2. Health Financing System

• Health Expenditure (2009):

  • Vietnam spends 7.2% of GDP on health.
  • Government health expenditure accounts for 8.9% of total government spending, which is significantly less than the 31.3% of GDP.
  • Government health spending per capita is US$31 (current) and US$82 (PPP-adjusted).
  • Out-of-pocket (OOP) spending constitutes 55.3% of total health expenditure, making it the largest source of health funding.

• Funding Sources:

  • General taxation contributes 27% to domestic health spending.
  • Social health insurance (SHI) accounts for 12%, with mandatory enrollment for formal-sector workers.
  • Private insurance contributes only 2%.
  • The majority of health spending is from OOP payments, which remain high despite government efforts.

• Decentralization and Centralization:

  • Vietnam has a high degree of fiscal decentralization, with most health spending funded at the provincial level.
  • The central government supports poverty-alleviation programs, including health facility upgrades.

• Risk-Pooling:

  • User fees were introduced in 1989, but they do not fully cover service costs.
  • Free health cards were provided to the poor and vulnerable to improve access.
  • SHI coverage is around 50% of the population as of 2008, with subsidies for near-poor and selected groups.

3. Health Care Delivery System

• Provider Organization:

  • The public sector operates a pyramid structure, including commune health centers (CHCs), polyclinics, district hospitals, provincial hospitals, and national hospitals.
  • CHCs serve 7,000 people on average and are underused, with users disproportionately from poorer households.
  • Hospitals are heavily used, especially by wealthier individuals.

• Payment Mechanisms:

  • Public providers use a mix of budget allocations (based on bed norms) and fee-for-service (FFS).
  • Provider autonomy has increased since the early 2000s, raising concerns about equity and financial protection.
  • There is limited experimentation with prospective payments.

• Resource Availability:

  • Vietnam has 6.3 public physicians per 10,000 people, lower than the EAP average of 9.41.
  • It has more hospital beds per 10,000 people than other low-income countries and a ratio similar to upper middle-income countries.
  • Inpatient admission rates are comparable to developed countries due to shorter lengths of stay and higher bed-occupancy rates.
  • Outpatient visit rates are much lower, suggesting a health system biased toward inpatient care.

4. Inequalities in Health Outcomes

• Child Health:

  • Infant mortality rate and under-five mortality rate are higher among the poor.
  • Diarrhea and fever are more prevalent among the poor.
  • Malaria is also worse among poor children, though the result is statistically significant.

• Adult Health:

  • Tuberculosis, difficulty with work and household activities, and poor self-assessed health are more common among the poor.
  • Arthritis is more prevalent among the wealthy.
  • Obesity, road traffic accidents, and non-road traffic accidents show no significant inequality.
  • Angina, asthma, depression, and diabetes are not statistically significant in terms of inequality.

5. Inequalities in Health Care Utilization

• Maternal and Child Health (MCH) Interventions:

  • Child immunization, antenatal care, and skilled birth attendance are more common among the better-off.
  • Contraception use is slightly higher among the poor.

• Adult Preventive Care:

  • The wealthy are more likely to use HIV voluntary counseling and testing (VCT), mammograms, and pap smears.

• Adult Curative Care:

  • Outpatient and inpatient services are more utilized by the wealthy.
  • The poor are more likely to use public health centers, though this is not always statistically significant.

6. Benefit Incidence of Government Spending

• Government spending on health is significantly pro-rich, particularly in hospital services and outpatient polyclinics.
• Out-of-pocket spending is concentrated among the wealthy when using total household expenditure measures.
• Non-food discretionary spending shows higher concentration of OOP payments among the poor.
• Subsidies to CHCs are pro-poor, but they account for a small fraction of total government health expenditure.

7. Financial Protection in Health

• Out-of-pocket payments remain the largest source of health funding.
• Catastrophic out-of-pocket payments have increased slightly since the 1990s, especially in the 2000s.
• These payments are highly concentrated among the poor when using discretionary spending thresholds.
• Out-of-pocket payments contribute to impoverishment, with the poverty gap increasing by 15% and 24% at the US$2.00 and US$1.25 poverty lines, respectively.

8. Progressivity of Health Finance

• Health care financing in Vietnam is mildly progressive in 2006.
• General taxation and out-of-pocket payments are the main contributors to progressivity.
• Social health insurance (SHI) is the most progressive source, though it accounts for only 13% of total health spending.
• Voluntary insurance is mildly regressive, but it contributes to a smaller share of health spending.

Key Information

• Data Sources: The report uses data from the Vietnam Living Standards Survey (VLSS), Vietnam Household and Living Standards Survey (VHLSS), Demographic and Health Survey (DHS), Multiple Indicator Cluster Survey (MICS), and World Health Survey (WHS).
• Analytical Tools: The analysis uses the ADePT software and concentration indices to assess inequality.
• Financial Protection: OOP payments have a moderate effect on household financial well-being, with catastrophic payments being a major concern.
• Insurance Coverage: Despite expansion, less than half of the population is covered by health insurance, and coverage remains low among the non-student population.

Conclusion

Vietnam's health system is characterized by significant inequalities in health outcomes and care utilization, with poor households bearing a larger burden of disease and financial costs. While government spending is pro-rich, subsidies to CHCs are pro-poor. The majority of health spending comes from out-of-pocket payments, which are concentrated among the poor and contribute to impoverishment. The progressivity of health financing is mild, with SHI being the most progressive source, but voluntary insurance remains regressive. The report underscores the need for policy reforms to enhance financial protection and equity in health care.