Can rural health insurance improve equity in health care utilization? a comparison between China and Vietnam

International Journal for Equity in Health Can rural health insurance improve equity in health care utilization? a comparison between China and Vietnam Xiaoyun Liu 0 2 Shenglan Tang 1 Baorong Yu 6 Nguyen Khanh Phuong 5 Fei Yan 4 Duong Duc Thien 3 Rachel Tolhurst 2 0 China Center for Health Development Studies, Peking University , PO box 505, 38 Xue Yuan Road, Hai Dian District, Beijing 100191 , P. R. China 1 Special Programme for Research and Training in Tropical Diseases (TDR), World Health Organization , Avenue Appia 20, 1211, Geneva 27 , Switzerland 2 Liverpool School of Tropical Medicine , Pembroke Place, Liverpool L3 5QA , UK 3 Health Policy Unit, Ministry of Health , 138A Giang Vo, Hanoi , Vietnam 4 School of Public Health, Fudan University , 138 Yi Xue Yuan Road, Shanghai , China 5 Health Strategy and Policy Institute , 138 Giang Vo, Ha Noi , Viet Nam 6 Shandong University , 44 Wenhua Xi Road, Jinan 250012, Shandong , China Introduction: Health care financing reforms in both China and Vietnam have resulted in greater financial difficulties in accessing health care, especially for the rural poor. Both countries have been developing rural health insurance for decades. This study aims to evaluate and compare equity in access to health care in rural health insurance system in the two countries. Methods: Household survey and qualitative study were conducted in 6 counties in China and 4 districts in Vietnam. Health insurance policy and its impact on utilization of outpatient and inpatient service were analyzed and compared to measure equity in access to health care. Results: In China, Health insurance membership had no significant impact on outpatient service utilization, while was associated with higher utilization of inpatient services, especially for the higher income group. Health insurance members in Vietnam had higher utilization rates of both outpatient and inpatient services than the nonmembers, with higher use among the lower than higher income groups. Qualitative results show that bureaucratic obstacles, low reimbursement rates, and poor service quality were the main barriers for members to use health insurance. Conclusions: China has achieved high population coverage rate over a short time period, starting with a limited benefit package. However, poor people have less benefit from NCMS in terms of health service utilization. Compared to China, Vietnam health insurance system is doing better in equity in health service utilization within the health insurance members. However with low population coverage, a large proportion of population cannot enjoy the health insurance benefit. Mutual learning would help China and Vietnam address these challenges, and improve their policy design to promote equitable and sustainable health insurance. Health insurance; Rural area; Equity; Health services utilization; China; Vietnam - Introduction Many developing countries are trying to find ways to achieve universal healthcare coverage, and reduce the reliance on out-of-pocket payment and provide financial protection against high medical expenses [1,2]. Taxbased health financing and social health insurance are most frequently used mechanisms for achieving the goal. Both China and Vietnam have experienced rapid economic development and dramatic social changes over the past three decades. Health sector reforms in the two countries have led health facilities to rely increasingly on user charges. This has resulted in great financial difficulties in accessing health care, especially for the rural poor [3,4]. The central governments of both countries have promoted the development of social health insurance for many years to address these problems. However, different historical and political trajectories have led to the development of very different rural health insurance policies and systems. Vietnamese health insurance system Vietnams national health insurance system is divided into compulsory health insurance (CHI) and voluntary health insurance (VHI). Both CHI and VHI are designed and managed by the central government, and have been experiencing rapid policy changes in the recent years [5]. The CHI system was initiated in 1992 and now covers mainly employees in the formal sector, civil servants, and some social protection groups. Since 2005, the poor and ethnic minorities have also been covered by the CHI. The eligibility of the poor for CHI is authorized by local government. The premium for the CHI is 3% of employees salary, of which 2% is paid by employers, and 1% by employees. CHI premiums for the poor are paid by central government budget, and have increased from 50,000 VND (about 2.8 USD) per capita in 2005 to 180,000 VND (10 USD) in 2008. CHI has a clearly defined benefit package. Patients needed to co-pay 20% of their medical cost before 2005. This co-payment was cancelled after 2005 with the exception of high technology health services, for which CHI only covered a limited part of the cost. A new health insurance law (being effective on 1st January 2010) again regulated a co-payment level at 5-20%. VHI in Vietnam was originally designed to cover specific occupational and age groups such as school children, farmers, professional groups. A minimum enrollment rate of 10% was set for each group. In 2007, VHI scheme was made available to all citizens and the 10% minimum rate of enrollment was canceled. Premiums for VHI varied across groups and urban/rural residence: 25,000 to 70,000 VND (1.4 to 3.9 US dollars) for school children and 60,000 to 140,000 VND (3.3 to 7.8 US dollars) for other residents. Since 2007, VHI pre mium has increased sharply (from 60,000 to 120,000 VND for school children, and from 120,000 VND to 320,000 VND for all others). Government did not have subsidy for VHI. VHI had a same benefit package as CHI, but co-payment for high technology health services was 40%. The Vietnam Social Security agency (VSS), established in 2003, is the government agency responsible for the administration of social insurance programmes including the CHI and VHI. VSS is responsible for collecting premium, pooling the fund, issuing health insurance cards and reimbursing service providers [5]. Chinese health insurance system China has developed separate health insurance systems for urban and rural areas. Urban residents are covered by an employment-based basic medical insurance scheme and an urban resident scheme [6]. In rural areas, the central government of China launched the New Medical Cooperative Scheme (NCMS) in 2003. This is a voluntary health insurance scheme. All NCMS members pay a flat rate premium of 10 Yuan (1.25 US dollar), which has increased to 20 Yuan since 2008. Central and local governments heavily subsidize NCMS to varying degrees in different regions and provinces. NCMS benefit package focuses on inpatient services, aiming to reduce financial burden due to high medical cost [7]. The responsibility of collecting and managing the NCMS fund are under (...truncated)