Measuring financial protection for older persons in Viet Nam

Globally, studies on the impact of out-of-pocket spending on health care tend to be based on country-level data detailing household health expenditures, which gloss over variations in health care utilization and expenditures by population subgroups such as older people. Older people generally have higher rates of chronic conditions and multi-morbidities which may require greater use of health care and putting them at risk of high out-of-pocket payments.

The population in Viet Nam is rapidly ageing. Studies suggest that households with older members are more likely to suffer catastrophic health spending. However, data are lacking to determine the breakdown of spending to understand spending on care and financial coping strategies.

To study the breakdown of health care spending among households with older members and to identify possible gaps in existing financial protection policies related to health care of older people.

1. A desktop review and analysis of existing financial protection policies.
2. Twenty in-depth interviews and 28 focus group discussions with policymakers, health managers, health care providers and older people to deepen understanding of current financial protection policies that apply to older people and identify possible gaps in those policies and potential policy solutions.
3. A household survey of 1,536 people 60 years and older with good cognitive function to collect data on their health expenditures and related factors using a multi-stage cluster sampling design in three provinces representing the north, central and south regions of the country.
4. Statistical analysis to describe patterns of health and long-term care utilization by the older person, breakdown of out-of-pocket (OOP) spending for the older person’s care, the financial burden of OOP health expenditure and financial coping strategies.
5. Qualitative data analysis using a grounded theory approach.

• Several limitations in existing financial protection policies were identified through a literature review and focus group discussions with policy makers. These include inadequate level of social assistance benefits; lack of coverage for social care services; and gaps in health insurance coverage among self-employed and low-income older people.
• Of the 1,536 older people interviewed, 82.4% reported having health problems in the preceding 4 weeks, including acute illnesses, injuries, and chronic conditions. The total number of illness episodes reported from the survey sample was 2,355 cases. Nearly all (95%) of older people sampled are covered with health insurance, and this is higher than the reported figure for the total national population (88.1% in 2019). Nonetheless, care was not sought in over 30% of all reported episodes of ill health. These cases resulted in OOP spending for self-medication (mean of 26.7 USD per person per month among those with health care needs). Among the 70% of cases in which care was sought, 93% received outpatient care. Of these, 60.4% resulted in OOP payment (mean of 35.6 USD per month). The majority of OOP spending for outpatient care was related to medicines.
• Among the 70% of cases in which care was sought, 7% (n=115) received inpatient care. Most of these cases (79.6%) resulted in OOP payment amounting to a mean of 188.7 USD per person per month among those with health care needs, which exceeded the average monthly income of 144.6 USD for households with older persons [1]. The OOP payments for inpatient care were mostly for co-payments, buying medicines beyond the health insurance benefit package and indirect costs (travel, meals, etc.) with some regional variation.
• Only 3.5% of older people (n=55) reported using long-term health or social care services at home or in a facility in the previous 12 months, with most (60%)  paying out of pocket (mean of 95.2 USD per person per month). 
• Some 8.6% of the sampled households with older people spent 40% or more of their non-food expenditure on OOP spending for health care including long-term care. Most of this spending was related to the care of the older member(s) of the household. The proportion of households spending 40% or more of their non-food expenditure on OOP health spending was three times as high in households with older members suffering from noncommunicable diseases compared to those with only self-reported healthy older people.
• Some 12.2% of the sampled households had to employ financial coping strategies to pay for the OOP cost of care for older persons. Households borrowed money from relatives/friends (31%), got a loan from individuals/agents (25%) or sold their properties (4%), while the rest (39%) dipped into their savings.

[1] Note that the analysis of distribution of OOP excluded cases of cancer and surgery which were outliers due to excessively high costs of treatment compared to the health spending of the rest of the older population.

Disaggregation of health care utilization and expenditure data by vulnerable sub-populations (e.g., by older age groups, chronic health conditions) enables a nuanced understanding of the drivers of OOP health spending in a population, which can inform financial protection policies. Globally, analysis of policies and their health benefits for households with older people or with people with chronic care needs may be a priority for research on financial protection in health, especially in contexts undergoing rapid population ageing. This type of research may help to develop appropriate health policies and intervention programs to achieve fairness in financial protection.  

Prefectural or municipality-level data on health and long-term care expenditures do not provide the information necessary to determine whether households with older persons are experiencing financial hardship due to OOP spending. Special surveys may be required to obtain these data. This kind of data may help to evaluate the effectiveness of policies in reducing financial hardship due to health care utilization or in reducing foregone care among the local population of older people. In the absence of such data, WKC is conducting analysis of existing national household surveys and collecting information from medical social workers in Kansai to better understand the challenges of ensuring financial protection in health for older people in Kansai.

Giang, N.H., Vinh, N.T., Phuong, H.T. et al. Household financial burden associated with healthcare for older people in Viet Nam: a cross-sectional survey. Health Res Policy Sys 20 (Suppl 1), 112 (2022). https://doi.org/10.1186/s12961-022-00913-3

Preliminary results were described in the Global Monitoring Report on Financial Protection in Health 2021 (Box 11, p49)

Technical Report (PDF download available below)