Health Care Seeking by the Poor in Transitional Economies: The Case of Vietnam

Abstract

In the last twenty years a number of countries have been undergoing a transition from a socialist planned economy to a market economy. These countries are spread across the globe and vary enormously in their levels of development from the relatively advanced industrialised countries of central Europe through the former Soviet Union to the mainly rural countries of east and south east Asia. The economic transition in Europe and the former Soviet Union has been associated with political change - glasnost as well as perestroika- while political continuity has been more the case in east Asia. In socialist countries during the period of the planned economy health services were financed and provided mainly by the public sector. The services were not well resourced and quality and efficiency were often low. But basic services were widespread and accessible to most people at little or no cost. Preventive care was well developed especially for the control of communicable diseases. Developing socialist countries like China and Cuba had health systems that were internationally commended and came to influence the formulation of the primary health care approach. Basic education services were similarly widespread and employment levels were high. Although incomes were low the income distribution was compressed and basic social protection programmes were in place. Absolute poverty and marginalisation were rare. As a result of all these factors while the level of economic development was still low socialist countries made impressive health gains relative to most market economies at corresponding economic levels. There are two broad categories of transitional experience. In the industrialised economies of Europe and Russia and the related central Asian countries of the former Soviet Union and Mongolia transition resulted in economic contraction and crisis. In most of these countries the living standards of the majority of people fell and large numbers were thrown into poverty. Health status declined dramatically while public health services needed by the poor deteriorated. Health care has become more costly to households and is less accessible to the poor as a consequence. By contrast reform in east Asian transitional economies has brought with it strong economic growth and most people have enjoyed rising incomes. But still a sizeable minority of the population has been left behind in the living standards stakes. The public health systems have been destabilised and the poor find health care less accessible and affordable. Thus whatever the advantages are of liberalisation over socialist planning the health of large sections of the population is not among them. From a situation of only slowly rising income but guarantees of stable livelihood and access to essential social services a new poor has arisen in the transitional economies with much less social sector support. Reform of planned economies needs to come with a health warning. A comparable situation can be seen in developing market economies where a more impoverished poor face higher public sector user fees under policies of macro-economic adjustment and health sector reform. In situations of economic and health sector change it is necessary to know how poor households are responding to alterations in the public health system and the increased availability of other health care options and how the poor are generally coping with the higher cost of health care. This was the subject of our research in Vietnam. Relatively few health care seeking studies have been carried out in transitional economy countries and even fewer have included qualitative methods. None we believe has evaluated the quality of the care to which households have access. In our research we conducted baseline and intervention studies in four rural communes of Vietnam between 1992 and 1998. We studied both the demand and supply sides of health care using complementary quantitative and qualitative methods and observed change over time. Two research reports have been published. In this third report we rework some of our baseline findings in the light of the poverty focus of the intervention research and consolidate our policy conclusions. The main research objectives were: to evaluate the quality of primary health care services; to study household health care decisions and their determinants; to assess the affordability of health care for poor households on the basis of two criteria: whether cost requires the poor to reduce their utilisation of health care and/or whether health care spending inflicts; damage on household economy and welfare; to appraise the adequacy of fee exemption systems for the poor propose ways to improve them and facilitate the introduction of exemption reforms; to improve the accessibility quality and responsiveness of public primary health care services especially for poor households; to study the feasibility of and facilitate collaboration between public health services and local private practitioners in order to increase access of the population especially the poor to affordable primary health care of adequate quality and responsiveness. (excerpt)

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