HEA L T HC A R E S EEK I NG B EHA V I OUR I N A S I A N

T R A NS I T I ONA L EC ONOMI ES :
A L I T ER A T UR E R EV I EW A ND A NNOT A T ED
B I B L I OGR A P HY

De v e l o p me n t B i b l i o g r a p h y 1 7
Gi l l Ti ppi ng
J a nu a r y 2 0 0 0
INSTITUTL OF DLVLLOPMLNT STUDILS
Brighton, Susscx BN1 9RL
LNGLAND
Thc work was iundcd hy a rcscarch grant irom thc Lconomic and Social Rcscarch Managcmcnt Unit,
Dcpartmcnt ior Intcrnational Dcclopmcnt (R29,.
2
topyright Institutc oi Dcclopmcnt Studics, 2000
ISBN 1 8586+ 0 9

CONTENTS
Pagc
AtRON\MS AND INITIALS +
INTRODUtTION 5
LITLRATURL RLVIL\ 5
Lconomic transition, incomcs and cquity oi acccss to hcalthcarc
Lconomic transition, thc pricc oi hcalthcarc and aiiordahility 8
Thc aluc oi thc hour and thc importancc oi concnicncc 10
Puhlic hcalth cxpcnditurc and quality oi carc 11
Thc hurgconing priatc scctor 12
Rural hcalth insurancc 12
Iniormal paymcnts 1
tONtLUSION 1+
RLFLRLNtLS 15
ANNOTATLD LNTRILS 16
AUTlOR INDLX 5
AUTlOR INDLX B\ RLGION AND TRANSITIONAL LtONOM\ tOUNTR\
+
ACRONYMS AND INITIALS
BI Bamako Initiatic
tlt coopcratic hcalthcarc
tlS communc hcalth station
tMS toopcratic Mcdical Systcm
ltSB hcalthcarc sccking hchaiour
lI hcalth insurancc
lIL hcalth insurancc lcigislation
LSIS Lao Social Indicator Surcy
MoPl Ministry oi Puhlic lcalth
OTt ocr thc countcr
PDR Pcoplc`s Dcmocratic Rcpuhlic
Plt primary hcalthcarc
PlS priatc hcalth scctor
PPA participatory pocrty asscssmcnt
VLSS Victnam Liing Standards Surcy
5
INTRODUCTION
Thc iocus oi this litcraturc rcicw and hihliography is houschold hcalthcarc sccking hchaiour (ltSB, in
poor rural communitics oi Asian transitional cconomics in gcncral and Victnam in particular. Ninc countrics
classiiy as Asian transitional cconomics (Glcwwc and Litack 1998,. iour in Last or Southcast Asia - thina,
Victnam, Laos, tamhodia; and iic in tcntral Asia - thc iormcr Soict Union countrics oi Uzhckistan, thc
lyrgyz Rcpuhlic, Turkmcnistan and lazakhstan; and Mongolia. Thc litcraturc scarch iound that houschold
hcalthcarc sccking studics arc icw and iar hctwccn in thcsc countrics, particularly thosc oi thc iormcr Soict
Union. As a rcsult, a icw pcrtincnt articlcs arc includcd irom rcscarch carricd out in othcr non-Asian
transitional cconomics, whcrc thc iindings rclatc to thc impact oi cconomic rciorm on thc potcntial uscrs oi
hcalth systcms.
Thc hihliography incorporatcs litcraturc gcncratcd irom thc timc oi cconomic rciorm to thc prcscnt
day. ior thina irom thc carly 1980s; ior Victnam sincc GRLPRL was launchcd in 1986; sincc 1985-86 ior thc
Ncw Lconomics Mcchanism oi Laos Pcoplc`s Dcmocratic Rrcpuhlic (PDR,; sincc 1989 in tamhodia; and
irom thc 1990s ior thc iic tcntral Asian rcpuhlics.
Thc hihliography gics thc ohjcctics; study typc (i.c. rcicw articlc, rcscarch rcport, cmpirical study,;
data sourcc and mcthodology cmploycd; study iindings; policy implications; and conclusions ior thc
litcraturc rcicwcd. Litcraturc has hccn cullcd irom appropriatc journals, sccondary rcicrcnccs and datahascs
such as Mcdlinc. Thcrc arc incitahly othcr sourccs oi litcraturc undcr-rcprcscntcd in this rcicw, onc hcing
thc grcy` litcraturc produccd hy non-gocrnmcntal organisations. Such studics arc oitcn diiiicult to locatc
unlcss rcicrrcd to hy largcr institutions. Timc has prccludcd sccking acccss to this litcraturc.
LITERATURE REVIEW
Thc Asian transitional cconomy countrics icaturcd in this litcraturc rcicw diiicr markcdly. Thcy arc in
diiicrcnt stagcs oi cconomic transition, hac diiicrcnt political and cconomic structurcs and diiicr in thc
structurc, iinancc and organisation oi thcir hcalth scriccs. In countrics whcrc thc proccss oi cconomic
rciorm is morc cstahlishcd (i.c. thina and morc rcccntly Victnam, rcscarch has addrcsscd thc impact oi
cconomic and hcalth scctor rciorm on houschold hcalthcarc sccking, pcrhaps hccausc thc rcpcrcussions ior
poorcr houscholds hac hccomc a morc cidcnt political and policy issuc. In othcr transiorming countrics
(c.g. oi thc iormcr Soict Union,, litcraturc iocuscs undcrstandahly on how to rcstructurc and iinancc thc
hcalth scctor. Littlc attcntion has hccn paid, until rcccntly, to thc impact on uscrs oi, or thc inilucncc oi
uscrs on, thc rciorm proccss (Mclcc, Figucras and thcnct, 1998; \orld Bank 1999a, 1999h,. In tamhodia,
long standing political instahility has mcant that littlc rcscarch oi this kind is currcntly aailahlc, cxisting
hcalth data arc unrcliahlc and thc ciicct oi any cconomic policy on houschold hcalth hchaiour is cxtrcmcly
diiiicult to disccrn. lowccr, at lcast two studics oi hcalthcarc sccking in tamhodia arc currcntly undcr
rcicw hy thc Ministry oi lcalth, so it may hc possihlc in thc ncar iuturc to glcan somcthing oi houscholds`
rcsponscs to illncss in that country (\ilkinson 1999,.
6
ltSB is dciincd as dccision making ior hcalthcarc at thc houschold lccl whcrcin thc dccisions madc
cncompass all aailahlc options. puhlic and priatc, modcrn and traditional. ltSB studics also
accommodatc thc dccision not to takc up aailahlc hcalth scriccs, whcrcin thc usc oi homc rcmcdics or thc
dccision to utilisc no hcalthcarc option at all may hc cxcrciscd. Studics oi ltSB incorporatc, hut arc widcr
than, rcscarch on hcalth scricc utilisation. Utilisation studics iocus on thc cnd point oi thc dccision-making
proccss - thc action ultimatcly takcn - and oitcn rcprcscnt onc typc oi hcalthcarc proision (gcncrally thc
puhlic scctor, and onc scctor oi thc uscr population (usually thosc who can aiiord to acccss puhlic hcalth
scriccs,.
Thc ohjcctic oi ltSB studics is to undcrstand thc proccss oi dccision making ior hcalth and how it is
inilucnccd hy houschold, indiidual, illncss and proidcr charactcristics. In thc contcxt oi cconomic rciorm,
whcrc incomcs may risc or iall and thus inilucncc thc ahility oi houscholds to aiiord social scriccs, cost and
aiiordahility arc particularly important ariahlcs. Most oi thc rcscarch on ltSB currcntly aailahlc uscs
quantitatic mcthods and thcsc placc signiiicant limitations on thc study oi multi-iacctcd issucs such as
aiiordahility, quality oi carc and dccision-making ior hcalth. Qualitatic approachcs arc still rclaticly rarc, as
arc studics that usc a complcmcntary mix oi quantitatic and qualitatic mcthodologics (Tipping and Scgall
1996,. lowccr, rcccnt qualitatic work hy thc \orld Bank (1999a, 1999h, 1999c,, using participatory
mcthods to asscss and undcrstand pocrty, and hy Scgall, Tipping, Dao and Dao (1999,, using a
comhination oi mcthods to cxplorc cquity in acccss to hcalthcarc in Victnam, is a moc in thc dircction oi
rcscarch aimcd at hcttcr rcprcscnting thc dccision-making proccsscs oi poor houscholds.
An carlicr DFID iundcd rcicw and hihliography on ltSB in dccloping countrics idcntiiicd a widc
rangc oi rcscarch, thc hulk oi which pcrtaincd to ccntral and suh-Saharan Airica (Tipping and Scgall 1995,.
Thc 1995 rcicw discusscd a numhcr oi mcthodological issucs that compromisc thc comparison oi ltSB
studics. Thcsc issucs arc summariscd hclow sincc thcy arc similarly pcrtincnt whcn rcicwing transition
cconomy country studics. Thc issucs arc (i, how to comparc thc rcsults oi longitudinal studics, which rccord
thc proccss oi ltSB (Tipping, Truong, Nguycn and Scgall 199+; Vinard 199+; Mhugua 199,, with cross-
scctional studics, which proidc a snapshot oi hcalthcarc hchaiour and can hc compromiscd hy thc
prohlcm oi rcspondcnt rccall (Bcrman, Ormond and Gani 198; lcndcrson, Akin, Zhiming, Shuigao,
laijiang andlcyou199+; Swcnson, Thang, Nhan and Ticu 199,; (ii, how to comparc thc iindings oi cxit-
hascd (usually puhlic scctor, iacility studics (c.g. Ministry oi lcalth 1991a, 1991h, with thc morc
comprchcnsic hcalthcarc sccking data that can hc iound in houschold hascd rcscarch (Bcrman HWDO 198;
Tipping HW DO 199+,; and (iii, how to rcconcilc thc cry diiicrcnt intcrprctations oi ltSB iound in small-
scalc primarily qualitatic studics (c.g. luntc and Sultana 1992; Tunyaanich 1992, crsus largcr scalc
quantitatic rcscarch (c.g. Bcckcr, Pctcrs, Gray, Gultiano and Black 199; lcndcrson HWDO199+,.
In addition to thcsc mcthodological issucs that may compromisc thc study oi ltSB, rcscarch may hc
iurthcr complicatcd hy thc massic and rapid political and macro-cconomic changcs inhcrcnt in thc proccss
oi cconomic transition with all thcir rcpcrcussions at thc lccl oi thc houschold. Thc shiit irom a ccntrally
planncd cconomy, in which thc statc historically organiscs, iinanccs and dclicrs primary hcalthcarc (Plt,

scriccs (as in thina and Victnam,, to a markct cconomy in which othcr non-statc proidcr options arc
allowcd to ilourish or colc passicly (Scgall 2000, incrcascs thc complcxity oi dccision making ior hcalth.
It is this proccss oi changc irom irtually monopolistic statc proision to a markct placc oi hcalthcarc
options that makcs dccision making ior houschold hcalth oi aluc to study. ltSB is thc rcsult oi a complcx
wcighing oi proidcr, paticnt, illncss, and houschold charactcristics (Tipping HW DO 1995,. Ii wc can
undcrstand what undcrlics an indiidual`s dccision to act in rcsponsc to illncss, thcn it may hc possihlc to
asscss thc cxtcnt to which hcalthcarc nccds (in particular thosc oi thc poor, arc hcing mct hy puhlic (and
priatc, hcalth scctors. Scriccs may thcn hc adaptcd appropriatcly. It is also worth stating that whilc hcalth
scctor rciorm may widcn thc options aailahlc to thc hcalthcarc consumcr and parc down inciiicicnt or
ocr-staiicd puhlic scctor scriccs, it also usually hands ocr part oi thc iinancc oi hcalthcarc to houscholds
and thcrciorc raiscs issucs oi aiiordahility and cquity oi acccss. Vulncrahlc groups oi thc population, such as
thc poor, thc cldcrly, womcn and childrcn, arc cspccially compromiscd during cconomic transition. Social
saicty ncts may dctcrioratc, ii thcy cxistcd at all, and mcchanisms to hold thc priatc scctor accountahlc ior
aiiordahility and quality oi carc may hc rudimcntary or non-cxistcnt. low ulncrahlc houscholds copc with
thc ramiiications oi illncss cpisodcs is thcrciorc a particularly salicnt issuc during cconomic transition.
Dcspitc its intrinsic aluc, thcrc is littlc rcscarch on how pcoplc cxcrcisc thc noclty oi proidcr choicc
in transitional cconomy countrics and lcss on thc spcciiic naturc oi hcalthcarc sccking amongst cconomically
ulncrahlc houscholds. Typically, thc iocus oi much rcscarch in this arca is thc impact oi hcalth scctor
rciorm on proidcr, rathcr than uscr hchaiour (Bloom 199; Guldncr 1995; Smithson 199,.
low thcn do houschold consumcrs dccidc what to do in rcsponsc to illncss cpisodcs, gicn this statc
oi ilux in transition cconomy hcalthcarc scctors A summary oi thc main issucs is gicn hclow. As statcd
ahoc, thc primary iocus is on rcscarch and studics conductcd in Victnam, with iindings irom othcr Asian
transitional cconomics includcd whcrc rclcant and aailahlc.
Economi c transi ti on, i ncomes and equi ty oI access to heal thcare
Thc proccss oi cconomic rciorm aiiccts houschold incomcs which in turn aiicct acccss to hcalth scriccs,
particularly whcn scriccs arc no longcr proidcd ircc oi chargc or hac (incrcascd, associatcd costs
(c.g. transportation, drug iccs and iniormal paymcnts,. In tcntral Asian cconomics, acragc incomcs hac
dcclincd suhstantially, whcrcas acragc incomcs hac, on thc wholc, riscn in Last Asian cconomics (Glcwwc
HWDO 1998,. In Victnam, rapid cconomic growth (an acragc annual growth ratc oi 8 pcr ccnt in thc 10 ycars
sincc thc markct rciorms wcrc adoptcd in 1986, has raiscd houschold incomcs across thc country`s sccn
rcgions and across hoth urhan and rural arcas, cnahling pcoplc to huy what wcrc prciously statc suhsidiscd
hcalthcarc scriccs (Glcwwc HWDO1998,. lowccr, not all houscholds arc cnjoying this incrcasc in incomc.
\hilc it cannot hc said that thc rciorm proccss in Victnam has cnahlcd thc rich to gct richcr and thc poor
morc poor`, rcccnt pocrty analysis suggcsts that thc poor arc not hccoming lcss impocrishcd as quickly as
thc rich arc hccoming wcalthicr (\orld Bank 1995; Glcwwc HWDO1998; Scgall HWDO 1999,.
lowccr, thc impact oi this upward trcnd in houschold incomc on cquity oi acccss is lcss clcar, as
thcrc rcmain cconomically ulncrahlc houscholds ior whom thc hcnciits oi cconomic rciorm arc limitcd
8
(Glcwwc HWDO1998,. Rcccnt rcscarch hy Scgall HWDO (1999, in Victnam has idcntiiicd that poor houscholds
hac diiiiculty acccssing social and hcalth scriccs, thc cost oi which rcprcscnts a disproportionatcly high
proportion oi houschold incomc. In particular thc rcscarch iound that thc oiiicial and unoiiicial cost oi
highcr lccl hospital scriccs prccnts thc poor irom acccssing scriccs. Prcliminary analysis oi thc sccond
Victnam Liing Standards Surcy (Gcncral Statistical Oiiicc 199+, conductcd in 1998 also suggcsts that
acccss to hospital carc is incquitahlc. Thc poor, with thcir disproportionatcly low sharc oi hcalth insurancc
(lI, cocr, iind acccssing hospital scriccs, cspccially inpaticnt carc, cry diiiicult, whcrcas thc non-poor, hy
haing thc lion`s sharc oi lI cocragc, makc grcatcr usc oi highcr lccl hospital scriccs and so hcnciit morc
irom statc suhsidics ior hcalthcarc (Dcolalikar 1999,.
Mcanwhilc oi grcatcr conccrn may hc that ccn thc cost oi commune lccl hcalthcarc can proc
prohihitic ior poor houscholds (Scgall HWDO 1999,.
In thina, rcscarch has shown that incrcasing incomc diiicrcntials ncgaticly aiiccts cquity oi acccss. A
cross-scctional study oi cquity and usc oi mcdical carc hy \u, tao and Lucas (199, iound littlc diiicrcncc in
thc utilisation oi outpaticnt scriccs hy incomc group, hut grcatcr diiicrcnccs at highcr lccls oi carc. Thc
poorcst group was morc likcly not to usc any scriccs and to aoid hospital inpaticnt carc duc to an inahility
to pay. This crosion oi thina`s prc-rciorm cquality oi acccss to hcalth with thc incrcasc in incomc
incqualitics is also rcportcd hy Tang, Bloom, Fcng, Lucas, Gong and Scgall(199+,.
Economi c transi ti on, the pri ce oI heal thcare and aIIordabi l i ty
In countrics whcrc cconomics arc contracting, thc pricc oi puhlic hcalthcarc undcr cconomic rciorm is likcly
to risc sincc gocrnmcnts hac icwcr rcsourccs with which to suhsidisc scriccs. \hcrc transition has lcad
to cconomic growth, such as in Victnam and thina, thc prcssurc to incrcasc priccs may hc lcss. But as
Glcwwc HW DO (1998, suggcst, thc moc to a markct cconomy usually inolcs shiiting at lcast part oi thc
costs oi hcalthcarc proision to uscrs oi scriccs. Thc introduction or incrcasc oi uscr iccs in thc puhlic
hcalth systcm may crcatc incqualitics in acccss to scriccs, particularly whcrc compcnsatory cxcmption
systcms do not cxist or proidc inadcquatc saicty ncts ior thc poor and ulncrahlc (Scgall HWDO1999; Lnsor
and Pham 1996h; \ilkinson 1999; \orld Bank 1999c,. \hcrc cxcmption mcchanisms arc in opcration,
incquitics may hc cxaccrhatcd hy inciicctic targcting, as wcll as signiiicant administratic, cconomic and
iniormational harricrs to thcir implcmcntation (Russcll and Gilson 199,.
Analysis oi Victnam Liing Standards Surcy (VLSS, data showcd that thc cost oi scriccs aiiccts
dccision-making ior hcalth. Sccnty pcr ccnt oi thc poorcst quintilc was iound to usc thc chcapcr option oi
scli-mcdication as opposcd to 5+ pcr ccnt oi thc wcalthy (Gcrtlcr and Litack 1998,. Similarly, rcscarch in
Victnam in 1992-9 (Tipping HWDO199+, iound an incrsc rclationship hctwccn thc acragc cost oi a rangc
oi hcalthcarc acts and thc ircqucncy with which thcy wcrc uscd; ocr-thc-countcr (OTt, drug outlcts wcrc
thc chcapcst and most oitcn uscd hcalthcarc option and hospital carc thc most cxpcnsic and largcly
aoidcd option, cspccially hy thc poor. Rcscarch in Laos hy Vinard (199+, and hy lolland, Phimphachanh,
tonn and Scgall (1995, also rcports grcatcr rcliancc on thc chcapcr option oi scli-mcdication hy thc poor.
Similar coping stratcgics hy thc poor arc rcportcd in tamhodia (\ilkinson 1999,.
9
Drug costs in Victnam (iormcrly gocrnmcnt suhsidiscd, rcprcscnt thc largcst proportion oi houschold
hcalth cxpcnditurcs at 80 pcr ccnt (Glcwwc HWDO1998,. That this is so ccn ior poor houscholds (Gcncral
Statistical Oiiicc 199+, suggcsts a willingncss on thc part oi Victnamcsc houscholds to pay thc iull cost oi
drugs (Glcwwc HWDO1998,. Rcscarch in thc luha district oi Azcrhaijan (Guscynoa, thakoury and Lcrcns
1996, similarly rcports a high proportion (62 pcr ccnt, oi houschold hcalth cxpcnditurc spcnt on drugs.
\hilc part oi this cxpcnditurc may hc attrihutcd to thc cost oi prcscrihcd mcdicinc, a signiiicant portion
rcilccts houscholds` purchasc oi OTt mcdicincs. A comhination oi polypharmacy and thc commonly hcld
puhlic hclici that sccral kinds oi drug cnahlc a quickcr, morc ciicctic trcatmcnt than onc drug, mcans that
houschold cxpcnditurc on mcdicincs may wcll hc unncccssarily high. This rcliancc on OTt mcdicincs,
cspccially hy thc poor, has implications ior trcatmcnt ciiicicncy and drug saicty (lcacr 1995; \oliicrs
1995,. It also holds hroadcr ramiiications sincc thc moc away irom curatic carc scriccs at thc primary
lccl and toward OTt mcdicincs mcans loss oi acccss to thosc scriccs that can proidc hoth prccntic
carc and iniormation (Gcrtlcr HWDO 1998,.
lcalthcarc cxpcnditurc as a proportion oi houschold incomc is a usciul indicator oi ahility to pay and
thcrciorc oi cquity oi acccss. Analysis oi thc VLSS data oi 1992-9 shows that a trip to a communc hcalth
station (tlS, costs thc poorcst group 8 pcr ccnt oi thcir annual non-iood consumption and a hospital
outpaticnt isit costs 26 pcr ccnt, in comparison with pcr ccnt and 5 pcr ccnt rcspccticly ior thc wcalthy
(\orld Bank 1995,. A disproportionatcly high cxpcnditurc on hcalth hy thc poor was also iound in Victnam
hy hoth Lnsor and Pham (1996h,. Thc poor spcnd ocr 19 pcr ccnt oi annual pcr capita incomc on
hcalthcarc in comparison with lcss than + pcr ccnt hy thc wcalthy. Scgall, Tipping, Lucas, Truong, Nguycn,
Dao and Dao (2000, iound cxpcnditurc hy thc poor ior amhulatory carc was 1.+ pcr ccnt oi annual
houschold incomc as opposcd to .2 pcr ccnt ior thc non-poor. In thina, \u HWDO. (199, iound that 1 pcr
ccnt oi annual pcr capita nct incomc is spcnt on hcalth hy thosc in low incomc groups crsus pcr ccnt ior
thc high incomc group, and an carlicr study hy \u (1992, also rcports a highcr pcrccntagc cxpcnditurc on
hcalthcarc ior thina`s rural poor. Guscynoa HW DO`s (1996, study in luha district, Azcrhaijan, rcports
cxpcnditurc on hcalth hy thc poorcst group to hc 25 pcr ccnt oi total houschold cxpcnditurcs against 1.5
pcr ccnt ior thc wcalthicst, and in tamhodia, \ilkinson (1999, statcs that thc urhan poor spcnd a high
pcrccntagc oi annual incomc (28 pcr ccnt, on what is gcncrally pcrccicd to hc poor quality hcalthcarc.
Although studics ary in tcrms oi thcir paramctcrs oi analysis (i.c. incomc pcr capita or pcr houschold;
cxpcnditurc ior thc wholc study samplc or thosc rcporting sick; cxpcnditurc ior all hcalthcarc sccking acts or
pcr singlc hcalthcarc act,, similar iindings oi a grcatcr proportion oi annual incomc spcnt on hcalthcarc
costs hy thc poor than thc non-poor arc rcportcd (Lnsor HWDO 1996h; \u HWDO. 199; Fahricant, lamara, and
Mills 1999,.
Thc poor copc with this unaiiordahlc cxpcnditurc hy horrowing, rcducing thcir consumption oi
csscntial goods or sclling asscts (Lnsor and Pham 1996a; Scgall HWDO1999; \ilkcs, \u, Bloom and Gu199,.
A rcccnt participatory pocrty asscssmcnt (PPA, in Victnam hy thc \orld Bank (1999c, iinds thc cconomic
shock oi ill hcalth to hc a causc oi pocrty in all study sitcs. This was particularly thc casc whcn illncss
rcsultcd in thc dcath oi a iamily mcmhcr who had hccn a lahourcr, or whcn thc houschold had to huy highcr
10
lccl hcalth scriccs. Salc oi asscts, horrowing moncy or iood and withdrawing childrcn irom school to
work wcrc somc oi thc coping stratcgics cmploycd to dcal with thc cconomic shock to thc houschold.
lowccr, in thc highland study sitc oi Lao tai and in lo thi Minh tity, many oi thc poor rcportcd liing
with chronic ill hcalth hccausc thc costs oi sccking trcatmcnt wcrc simply unaiiordahlc (\orld Bank 1999c,.
Bcing ahlc to acccss aiiordahlc hcalthcarc scriccs was ccntral to thc prohlcms prioritiscd hy thc poor in this
study. In thc lyrgyz Rcpuhlic and in Uzhckistan, PPAs (\orld Bank 1999a; 1999h, showcd that hcalthcarc
had hccomc incrcasingly diiiicult to aiiord sincc thc timc oi cconomic rciorm, with ill hcalth pcrccicd as a
major contrihutor to houschold pocrty.
Thc poor arc thus grcatly disadantagcd in tcrms oi thc impact oi hcalth costs on thc houschold
cconomy. Thc conscqucnccs arc a prcicrcncc ior lowcr cost, paymcnt ilcxihlc options at primary lccl oi
scricc. Priatc practitioncrs may hc morc cxpcnsic than puhlic scctor proidcrs, hut thcy oitcn oiicr
grcatcr ilcxihility ocr how and whcn paymcnts can hc madc (Prcscott 199; Scgall HWDO 1999,. lighcr lccl
carc options, with thcir iormal and iniormal costs (such as iood, loss oi carnings and undcr-thc-tahlc
paymcnts,, arc oitcn unaiiordahlc or liahlc to chronically hurdcn thc houschold with dcht (Scgall HWDO1999;
Lnsor HW DO. 1996h; \u HW DO 199,. lowccr, ccn primary lccl proision can incur a high proportion oi
cxpcnditurc hy thc poor (Scgall HW DO 2000,, a iinding which is lcss rcadily apparcnt sincc studics tcnd to
analysc houschold cxpcnditurc ior an aspcct oi primary carc, such as iccs (McPakc 199,, or ior thc morc
cxpcnsic costs associatcd with hospital admission (\u HWDO 199,. That primary lccl carc is an cconomic
hurdcn ior poor houscholds is cidcncc in support oi thc iact that though thc poor may hc willing to pay
ior hcalthcarc, thcy may iind it an cconomic hurdcn on scant houschold rcsourccs (Russcll 1996,.
The val ue oI the hour and the i mportance oI conveni ence
toncnicncc is a dctcrminant oi choicc and has a numhcr oi intcrprctations. A proidcr may hc choscn not
only hccausc it is concnicntly locatcd ncar thc houschold, hut hccausc it proidcs out oi hours carc or
homc isits and thus rcduccs thc opportunity cost oi timc lost irom work. In markct cconomics thc aluc oi
thc hour incrcascs as incomc riscs. In Victnam, houscholds arc now agriculturally scli-cmploycd and
thcrciorc timc spcnt sccking hcalthcarc must hc paid ior hy thc houscholds, unlikc prc GRL PRL whcn thc
coopcratic structurcs suhsidiscd this ncccssity. In Victnam whcrc 9+ pcr ccnt oi rural rcsidcnts hac a tlS
in thcir communc (Prcscott 199,, thc issuc oi thc opportunity cost oi timc spcnt gctting to a communc
puhlic proidcr is prohahly minimal, ccn ior thc poor (although acccss in highland arcas is much morc
diiiicult |\orld Bank 1999c,.
Thc issuc is morc pcrtincnt ior acccss to highcr lccl hospital scriccs. VLSS data show that only 6 pcr
ccnt oi thc poorcst quintilc oi houscholds lic in communcs with a hospital ncarhy (whcrc thc distancc to
thc hospital is still, on acragc, morc than 11 km, as comparcd with 12 pcr ccnt oi thc wcalthicst houscholds
(Prcscott 199,. lowccr, dcspitc thc hroad aailahility oi communc lccl carc, timc spcnt sccking
hcalthcarc still cntails loss oi incomc and so usc oi ncarhy priatc drug scllcrs and OTt drug outlcts may hc
morc concnicnt options ior uscrs than hcalth stations or morc distant highcr lccl iacilitics (Scgall HW DO
11
2000,. \hcrc drugs arc rctailcd in markct placcs, thc opportunity cost ior womcn`s timc, in particular,
rcprcscnts an important rcason ior choicc (Tipping HWDO199+,.
Publ i c heal th expendi ture and qual i ty oI care
thangcs in thc lccl oi puhlic hcalth cxpcnditurc arc likcly to aiicct thc quality oi scriccs and thcrciorc thc
cxtcnt to which thcy arc uscd. tountrics with ncgatic cconomic growth (c.g. thosc oi tcntral Asia, and
which implcmcnt hudgctary rcstraint may iind signiiicant dcclinc in thc quality oi scriccs, whcrcas
cconomic growth may lcad to improcmcnts in scricc quality with positic impact on utilisation. lowccr,
much dcpcnds on how iinancial rcsourccs arc allocatcd across thc social scctors. Thc incrcasing drain oi
scant rcsourccs away irom rural hcalthcarc scriccs to urhan, hospital-hascd carc, and thc mocmcnt oi
qualiiicd hcalth staii to urhan arcas or thc priatc scctor lcads to a dc-skilling oi rural Plt scriccs. In
thina, studics show that this has had an impact on scricc quality as wcll as acccss and aiiordahility (Gong
and \ilkcs 199; Tang 199,.
Rcscarch in Laos indicatcs a mistrust oi, and dissatisiaction with, puhlic scctor iacilitics, suggcstcd hy
thc grcatcr usc oi OTt drug outlcts and priatc scriccs and thc low lccl usc oi puhlic scctor iacilitics
(Ministry oi Puhlic lcalth 199; Laos Social Indicator Surcy 199+,. This is attrihutcd to poor quality carc,
cquipmcnt and drug shortagcs, and low paid, unmotiatcd staii (scc lolland HW DO 1995; Vinard 199+,. In
Victnam, communc lccl carc, upon which thc ast majority oi rural rcsidcnts dcpcnd (Prcscott 199,, is
also pcrccicd to hc oi lowcr quality than highcr lccl hospital scriccs (Gcrtlcr HW DO 1998; Tipping HW DO
199+, hccausc drugs may hc in short supply, cquipmcnt lacking or suh-standard, and hcalth staii rclaticly
undcr-skillcd and poorly qualiiicd. lowccr rcccnt rcscarch suggcsts that quality oi carc in somc hcalth
stations in Victnam may hc improing in thc post rciorm pcriod and thus rc-attracting uscrs (tarlson, Than,
Lc and Grady 1996; Scgall HWDO1999,.
Thc high dcpcndcncc on OTt mcdicincs, cspccially hy thc poor, has major implications ior quality,
gicn thc poor sclling practiccs oi many drug outlcts and thc uniniormcd homc consumption oi such
mcdicincs (Stcnson, Tomson and Syhakhang 199; Zhan, Tang and Guo 199,. Quality oi carc as rcgards
drug sclling and prcscrihing also rcquircs appropriatc iormal scctor prcscrihing, which itscli rcsts on an
appropriatc csscntial drugs policy, training and supcrision oi mcdical staii, and thc ciicctic rcgulation oi
priatc scctor scriccs.
lowccr, quality is not only a rcilcction oi tcchnical skills in diagnosis and trcatmcnt, hut oi thc
proidcr`s hcd-sidc` manncr, ior which thc dcgrcc oi cmpathy and paticnt considcration shown is most
important (Tipping HW DO 1995; tarlson HW DO 1996,. Thus quality oi carc is a kcy dctcrminant oi proidcr
choicc and will ocr-ridc pricc considcrations in somc cascs. For cxamplc in Azcrhaijan, Guscynoa HW DO
(1996, iound that pcoplc wcrc willing to pay towards thc cost oi hcalthcarc proiding thc quality improcd
and morc drugs wcrc aailahlc.
12
The burgeoning pri vate sector
During cconomic transition and contraction oi puhlic scctor scriccs, thc priatc scctor can takc up a
dominant rolc in thc iinancc and dclicry oi hcalthcarc. A comhination oi puhlic scctor downsizing,
dcmohilisation oi army mcdical staii (as in Victnam,, moonlighting hy puhlic scctor cmployccs in ordcr to
supplcmcnt low salarics as wcll as a hurgconing oi iniormal drug scllcrs and rctail drug outlcts can lcad to a
hroad cadrc oi hcalth pcrsonncl proiding scriccs, many oi which arc unliccnscd, illcgal and largcly
unrcgulatcd` (Scgall 2000,. This passic proccss oi priatisation is cidcnt in Victnam whcrc lcss than a third
oi all proidcr contacts arc in thc puhlic scctor and morc than 80 pcr ccnt oi hcalth cxpcnditurcs arc out-oi-
pockct (Glcwwc HWDO. 1998,. lowccr, thc incrcascd utilisation oi priatc scctor scriccs is not matchcd hy
dcclopmcnts in thc monitoring and rcgulation oi thcir scriccs, with gocrnmcnts unclcar ahout what rolc
thc priatc scctor should, and could, hac (Pham 1996,.
Thc lack oi rcgulatory iramcworks mcans that thc quality oi priatc scctor carc is diiiicult to monitor.
Thc hcay rcliancc oi houscholds on scli-mcdication and thc incrcasing rcliancc oi houscholds on priatc
pharmacics and drug cndors magniiics thc risk oi inappropriatc drug consumption pattcrns (Gcrtlcr HWDO
1998,. Acccss to proicssional prcscrihing is hcing ocrshadowcd hy thc widcr sclcction oi drugs aailahlc in
thc priatc scctor and thc rclatic casc with which thcy can hc hought and sold.
In tcrms oi hcalthcarc sccking, howccr, thc priatc scctor can oiicr a morc rcsponsic scricc to uscrs
hy proiding morc ilcxihility ocr how paymcnts arc madc and a morc acccssihlc scricc in tcrms oi out-oi-
hours carc and homc isits (Scgall HWDO1999; Aljunid 1995; lcacr 1995,. As notcd ahoc, a rcccnt \orld
Bank study (1999c, also showcd that poor houscholds oitcn prcicrrcd thc priatc scctor hccausc priatc
practitioncrs would makc housc calls and proidc trcatmcnt on crcdit. Thc tradc-oii ior grcatcr concnicncc
and ilcxihility oi paymcnt may hc thc risk oi suh-standard lccls oi carc and highcr priccs (Gcrtlcr HWDO 1998;
Scgall HWDO1999,.
Rural heal th i nsurance
Attcmpts arc hcing madc in many Asian transitional countrics to introducc lI mcchanisms as a way oi
making hcalth scriccs morc acccssihlc and aiiordahlc. \ct lI systcms arc oitcn diiiicult to implcmcnt ior a
aricty oi rcasons, at lcast somc oi which rclatc to houschold dccision-making ior hcalth. In sparscly
populatcd or rcmotc arcas lI may hc oi littlc hcnciit to houscholds ii acccss to hospital iacilitics is
prohihitic duc to thc timc costs oi tracl and thc cost oi transport, accommodation and iood. lI may also
hc oi littlc hcnciit ii quality oi carc, oncc scriccs arc rcachcd, is unsatisiactory.
\hcrc lI mcchanisms arc in opcration (whcthcr statc run or local,, thc pcoplc insurcd arc oitcn not
thosc most in nccd oi assistcd paymcnts. Thc Gocrnmcnt oi Victnam cstahlishcd a compulsory lI schcmc
ior statc workcrs and cmployccs oi statc and priatc cntcrpriscs in 199 (Lnsor 1995,. Thc insurancc cocrs
inpaticnt and outpaticnt trcatmcnt costs at gocrnmcnt iacilitics, although in rcality insurcd paticnts may still
hac to pay somc oi thc iormal (and iniormal, costs. Prcliminary analysis oi thc VLSS data ior thc pcriod
199-98 show that thc poor hac a disproportionatcly small sharc oi lI cocr. Analysis indicatcs that ocr
thc iic-ycar pcriod thc pcrccntagc oi thc poor with lI (oi all kinds, incrcascd irom 6 pcr ccnt to 8 pcr ccnt,
1
whilc that oi thc non-poor rosc irom 29 pcr ccnt to pcr ccnt (Dcolalikar 1999,. In iact lI in Victnam
appcars to hac incrcascd incquality in hcalth scriccs utilisation hy hcnciiting thc richcst scgmcnt oi thc
population, sincc contrihutions arc disproportionatcly spcnt on iinancing urhan hospital scriccs to thc
ncglcct oi thc rural hcalth systcm (Lnsor 1995,.
It is also diiiicult to collcct suhscriptions in rcmotc, rural scttings and potcntial insurccs, cspccially thc
poor, may douht thc rcturn on thc incstmcnts. Imposing compulsory contrihutions on houscholds may hc
icwcd as yct anothcr tax, proiding littlc hcnciit, and cadcd or paid in part (Lnsor and Rittman 199,.
Voluntary paymcnts may hc icwcd with similar sccpticism. In Victnam qualitatic rcscarch showcd that
pcoplc had littlc intcrcst in thc oluntary lI schcmc, mainly hccausc thc nccd ior hospital trcatmcnt was
rarc, thc insurancc prcmium was high and paticnts with lI could still iacc hospital chargcs (Scgall HW DO
2000,. (A similar lack oi cnthusiasm ior oluntary insurancc is rcportcd in lazakhstan hy Lnsor HW DO
(199,,. In addition, most hcalth cxpcnditurc hy thc poor is at communc lccl (Scgall HW DO. 2000, whcrc
oluntary lI schcmcs do not, hy and largc, proidc cocr.
In thina thcrc is a long tradition oi coopcratic hcalthcarc (tlt, schcmcs (Tang HW DO 199+; Bogg,
lcngjin, lcli, \cnwci and Diwan 1996, dcsigncd to proidc thc rural poor with aiiordahlc and acccssihlc
hcalthcarc. Thc tlt schcmcs collapscd aitcr cconomic rciorm in thc 1980s. Rcccnt ciiorts to rcinstatc
thcm arc iaccd with prohlcms oi cquity. thc uninsurcd rcccic lcss hcalthcarc and yct, duc to thc incrcasc in
icc paymcnts, usc a grcatcr sharc oi thcir incomcs ior hcalthcarc than thc insurcd (lutzin and Barnum
1992,. \hilst thc tlt prcpaymcnts arc dccmcd aiiordahlc ior most rural houscholds, thc small sums
inolcd may nccrthclcss hc a iinancial hurdcn ior thc 10 pcr ccnt oi thina`s rural population liing in
pocrty and ior whom cxcmption irom prcpaymcnts is no longcr rcliahly aailahlc (Tang HW DO 199+,.
Achicing cquitahlc acccss to scriccs ior thc uninsurcd poor is thcrciorc a kcy issuc in transitional cconomy
countrics (Bloom, Lucas, tao, Gao, \ao and Gu 1995; thcrnichosky and Potapchik 199; Nguycn, Lc,
Riikin and \right 1995; Lnsor 1995; Lnsor HWDO. 199; \u 1992,.
InIormal payments
Undcr thc tahlc` paymcnts ior hcalthcarc arc an incrcasingly cndcmic icaturc oi scricc proision in
transitional cconomy countrics, as in dccloping countrics gcncrally. Thcsc arc a prc-rcquisitc ior uscrs to
rcccic prompt, quality carc and a mcans hy which hcalth staii can hoost low salarics. Thc cxtra cxpcnditurc
to houscholds can makc scriccs unaiiordahlc, particularly ior thc poor, hut thc hurdcn oi thcsc paymcnts is
oitcn diiiicult to asscss (Lnsor and Saclyca 1998,. In thc priatc scctor, iniormal paymcnts may hc hiddcn
in thc total trcatmcnt costs or paticnts may choosc, or ncgotiatc, to makc paymcnts in kind, making thc
monctary aluc oi thc iniormal paymcnt opaquc. Similarly, in thc puhlic scctor, iniormal paymcnts can hc
disguiscd hy a highcr mark-up on drug salcs through which hcalth staii dcric a portion oi incomc (Tipping
HW DO 1995,. On thc othcr hand, iniormal paymcnts may hc ocrtly dcmandcd, as rcportcd in lazakhstan,
Uzhckistan and othcr countrics oi thc iormcr Soict Union, ccn ior gocrnmcnt suhsidiscd scriccs
(\orld Bank 1999h; Lnsor HWDO1998; \ilkinson 1999,.
1+
Paymcnts to hcalthcarc proidcrs at highcr lccls oi carc can hc cspccially prohihitic, as thcy may hc
cxpcctcd or dcmandcd hciorc trcatmcnt is dclicrcd. This has scrious implications ior acccss to highcr lccl
scriccs, cspccially ior thc poor (Scgall HW DO 1999; Lnsor HW DO 1996h,. Thc iniormal paymcnt systcm has
implications hoth ior national cxpcnditurc on hcalth, on attcmpts to rciorm hcalth scctors and ior thc
acccss to, and aiiordahility oi, scriccs hy uscrs (scc Lnsor HW DO.`s (1998, work on thc iniormal paymcnt
systcm in lazakhstan,.
CONCLUSION
Thcrc is littlc rcscarch on ltSB in Asian transition cconomy countrics and littlc oi a qualitatic kind. Much
oi thc aailahlc iniormation is dcricd irom quantitatic studics in which issucs oi aiiordahility, quality oi
carc and dccision-making ior hcalth arc diiiicult to mcasurc. Thc PPA studics implcmcntcd hy thc \orld
Bank (1999a, 1999h, 1999c, arc a positic stcp towards rcprcscnting thc oicc oi thc poor using morc
appropriatc mcthods. Thc acccptancc oi participatory and qualitatic mcthods hy thc \orld Bank ior
studying pocrty may mcan that morc rcscarch oi this kind will hc iinanccd and pursucd in thc iuturc. In thc
mcantimc, icw othcr qualitatic studics on ltSB cxist (Scgall HWDO1999,.
It is cidcnt that cconomic rciorm can hac a ncgatic impact on poor and ulncrahlc houscholds and
makc acccss to hcalth scriccs prohlcmatic. Somc pattcrns arc clcar, such as thc hcay dcpcndcncc hy thc
poor on thc usc oi scli-mcdication and thcir inahility to aiiord hospital scriccs. lowccr, it is not only
cxisting cconomically ulncrahlc houscholds that arc at risk. Ill hcalth in a iamily that is cconomically stahlc
can rcducc thc houschold to pocrty. hy loss oi asscts, loss oi lahour powcr and indchtcdncss. Acccss to
csscntial hcalthcarc is a human right which gocrnmcnts oi transition cconomics nccd to accommodatc with
appropriatc policics. Poor houscholds may rcquirc targctcd assistancc ii cquity oi acccss is to hc achiccd.
Thc conclusion to datc may hc that whilc cconomic rciorm can oiicr cconomic hcnciits to many, thcsc
hcnciits arc not ccnly sprcad. Unlcss puhlic scctor hcalth proision is iinancially saic-guardcd and,or
intcrwocn with thc capacity oi thc priatc scctor to oiicr aiiordahlc and adcquatc hcalthcarc, thc cconomic
hcnciits oi rciorm will not hc matchcd hy improcmcnts in thc hcalth status oi thc poor. Ii thc proision oi
hcalthcarc is such that thc poor cannot aiiord to usc scriccs whcn nccdcd, thcn cquity oi acccss will
continuc to hc an unrcsolcd social and political issuc.
In summary, littlc is known ahout how acccss to hcalthcarc is ncgotiatcd hy thc poor and ahout thc
dccision-making proccsscs that takc placc hoth within houscholds and hctwccn uscrs and proidcrs. Lqually,
thc rclatic adantagcs and disadantagcs oi thc rangc oi proidcrs aailahlc, issucs oi aiiordahility and
mcthods oi paymcnt, particularly ior ulncrahlc houscholds, arc rclaticly uncxplorcd arcas. Much oi this
iniormation is outstanding hccausc mcthodologics cmploycd arc not dcsigncd to capturc such iniormation.
tomplcmcnting ltSB studics with qualitatic rcscarch mcthods and longitudinal approachcs would allow
thcsc issucs to hc hcttcr addrcsscd.
15
REFERENCES
Bcckcr, S., Pctcrs, D.l., Gray, R.l., Gultiano, t. and Black, R.L., 199, Thc dctcrminants oi usc oi
matcrnal and child hcalth scriccs in Mctro tchu, thc Philippincs`, Health Transition Review, Vol
No 1. -89
Bcrman, P., Ormond, B. and Gani, A., 198, Trcatmcnt, usc and cxpcnditurc on curatic carc in rural
Indoncsia`, Health Policy and Planning, Vol 2 No +. 289-00
Dcolalikar, A.B., 1999, thangcs in hcalth status and in thc utilisation oi hcalth scriccs in Victnam 199-98.
Major prcliminary iindings irom thc Victnam hcalth scctor rcicw`, mimco, \orld Bank, lanoi
Fahricant, S.J., lamara, t.\. and Mills, A., 1999, \hy thc poor pay morc. houschold curatic cxpcnditurcs
in rural Sicrra Lconc`, International Journal oI Health Planning and Management, Vol 1+ No .
19-99
lcacr, R., 1995, Managing primary hcalth carc. implications oi thc hcalth transition`, World Bank
Discussion Papers No 26, \ashington, D.t.. \orld Bank
luntc, P.A. and Sultana, F., 1992, lcalth-sccking hchaiour and thc mcaning oi mcdications in
Balochistan, Pakistan`, Social Science and Medicine Vol + No 12. 1,85-9
lutzin, J. and Barnum, l., 1992, Institutional icaturcs oi hcalth insurancc programs and thcir ciiccts on
dccloping country hcalth systcms`, International Journal oI Health Planning and Management,
Vol . -6
Mhugua, l.M., 199, Impact oi uscr chargcs on hcalth carc utilisation pattcrns in rural lcnya. thc casc oi
lihwczi Diision`, DPhil thcsis, Unicrsity oi Susscx
McPakc, B., 199, Uscr chargcs ior hcalth scriccs in dccloping countrics. a rcicw oi thc cconomic
litcraturc`, Social Science and Medicine, Vol 6 No 11. 1,9-1,+05
Russcll, S., 1996, Ahility to pay ior hcalth carc. conccpts and cidcncc`, Health Policy and Planning,
Vol 11 No . 219-
Russcll, S. and Gilson, L., 199, Uscr iccs to promotc hcalth scriccs acccss ior thc poor. a woli in shccp`s
clothing`, International Journal oI Health Services, Vol 2 No 2. 59-9
Scgall, M.M., 2000, From coopcration to compctition in national hcalth systcms - and hack. impact on
proicssional cthics and quality oi carc`, International Journal oI Health Planning and Management,
Vol 15 No 1. 61-9
16
ANNOTATED ENTRIES
Author(s,
Titlc
Aljunid, A.
Thc rolc oi priatc mcdical practitioncrs and thcir intcractions with puhlic hcalth scriccs
in Asian countrics
Sourcc 1995, Health Policy and Planning, Vol 10 No +. -+9
Ohjcctics To cxaminc cidcncc on thc rolc oi priatc (allopathic, practitioncrs and thcir
intcractions with puhlic hcalth proidcrs in dccloping countrics, iocusing primarily on
Asia.
Study typc
Data sourcc
& mcthods
Rcicw articlc.
Not applicahlc.
Findings Lidcncc on thc distrihution oi hcalthcarc iacilitics, manpowcr, hcalth cxpcnditurcs and
utilisation ratcs shows that priatc practitioncrs arc signiiicant hcalthcarc proidcrs in
many Asian countrics. Thc papcr rcicws iactors inilucncing ltSB, including
charactcristics oi thc paticnt, thc illncss and thc proidcr. Thc author statcs that limitcd
iniormation has hccn puhlishcd on intcractions hctwccn puhlic and priatc proidcrs
dcspitc thcir cocxistcncc. Issucs rclatcd to cniorccmcnt oi rcgulations, human rcsourccs,
paticnt rcicrrals and discasc notiiications arc cxamincd.
Policy
implications
Rcicwcr`s commcnt. Thc ast majority oi studics rcicwcd in this papcr arc not irom
Asian transitional cconomics. lowccr, thc issucs raiscd arc nccrthclcss rclcant sincc
any priatc hcalth scctor (PlS, that hccomcs a strong altcrnatic choicc ior puhlic scctor
hcalthcarc sccking raiscs issucs oi quality control, monitoring and rcgulation, issucs
which arc ccntral to hcalth scctor rciorm programmcs. Thc papcr also contrihutcs to an
undcrstanding oi thc harricrs to hcalthcarc sccking iaccd hy scricc uscrs with policy
implications ior cquity in acccss to hcalthcarc scriccs.
tonclusions Thc author statcs that morc rcscarch is rcquircd to documcnt and analysc thc cxisting
intcractions hctwccn puhlic and PlSs ii policics arc to hc dcclopcd which idcntiiy thc
appropriatc rolc oi priatc practitioncrs and cncouragc good quality, cost-ciicctic carc in
thc priatc scctor.
1
Author(s,
Titlc
Bloom, G.
Primary hcalth carc mccts thc markct. Lcssons irom thina and Victnam
Sourcc 199, Working Paper No 5, Brighton. IDS
Ohjcctics To rcicw hcalth scctor rciorm in thina and Victnam and to outlinc thc kcy points that
may hcnciit policy makcrs and rcscarchcrs in othcr low and middlc incomc countrics
which arc considcring radical hcalth scctor rciorms.
Study typc
Data sourcc
& mcthods
\orking papcr.
Not applicahlc.
Findings Both Victnam and thina dcclopcd low cost rural hcalth scriccs during thc carly 1950s
and mid-190s and hoth hac strongly inilucnccd intcrnational hcalth policy on Plt. A
proccss oi cconomic lihcralisation has hccn undcrway in hoth countrics ior sccral ycars
and this has ciicctcd thcir hcalth scriccs in diiicrcnt ways. Thosc who can aiiord to pay
hac a widcr choicc oi hcalth scriccs hut costs hac riscn and thcrc arc grcatcr
diiicrcnccs in acccss to mcdical carc. Thc thincsc and Victnamcsc gocrnmcnts arc
sccking stratcgics to makc thcir hcalth scriccs morc cost ciicctic and cquitahlc.
Thc author dcscrihcs ior thina and Victnam. (i, thc impact oi cconomic rciorms on thc
hcalth systcm; (ii, changcs in hcalth systcm pcriormancc, including incrcascd incquality in
acccss, rising costs and thc impact on prccntic carc scriccs; and (iii, thc rcstructuring
oi thc hcalth scctor, which suhsumcs issucs oi cquity, cost-ciiccticncss, ciiicicncy and
rcsponsicncss to uscrs nccds.
Policy
implications
Rciorm options should hc addrcsscd in tcrms oi thcir likcly impact on thc achiccmcnt
oi policy ohjcctics. Spccial attcntion should hc paid to thc inilucnccs on proidcr
hchaiour, such as iinancial inccntics, gocrnmcnt supcrision and rcgulation, and
mcchanisms to makc proidcrs accountahlc to uscrs.
tonclusions Thc conclusion is that onc oi thc most important dctcrminants oi thc kind oi hcalth
scctor that cmcrgcs during thc transition to a markct cconomy will hc a gocrnmcnt`s
prcparcdncss to crcatc a scricc that mccts priority nccds and its capacity to dcclop
stratcgics in ordcr to iuliil this.
18
Author(s,
Titlc
Bloom, G., Lucas, l., tao, S., Gao, J., \ao, J. and Gu, X.
Financing hcalth scriccs in poor rural arcas. adapting to cconomic and institutional
rciorm in thina
Sourcc 1995, Research Report No 0, Brighton. IDS
Ohjcctics To improc undcrstanding oi thc impact oi cconomic and institutional changc on hcalth
scriccs in poor rural arcas oi thina and to idcntiiy possihlc stratcgics ior adapting rural
hcalth scriccs to thc ncw situation.
Study typc
Data sourcc
& mcthods
Rcscarch rcport.
Litcraturc rcicw. Routinc rcports and data irom thc statistical hurcaux, gocrnmcnts and
hcalth iacilitics oi thrcc poor rural countics. Donglan, Shihing and Xunyi. Intcricws with
county and township hcalth and political authoritics. Focus group discussions with hcalth
workcrs and scricc uscrs.
Findings Thc rcport prcscnts thc iindings oi studics oi hcalth cxpcnditurc and iinancc in thc thrcc
countics. It rcicws thc gocrnmcnt`s attcmpts to cncouragc local gocrnmcnts to
cstahlish hcalth prcpaymcnt schcmcs. It concludcs hy drawing lcssons irom thina`s
cxpcricncc with hcalth scctor rciorm ior policy makcrs in othcr countrics.
Thc situation diiicrcd grcatly in thc thrcc countics, rcilccting thc cnormous ariation
hctwccn study rcgions. thangcs in thc systcm oi hcalth iinancc hac altcrcd thc
cnironmcnt within which hcalth scricc proidcrs iunction. Thcsc proidcrs carn morc
moncy hy iaouring curatic carc and sclling largc quantitics oi drugs. this has
contrihutcd to a rapid risc in thc cost oi hcalthcarc.
Thc papcr concludcs that in thc ciiort to cncouragc local gocrnmcnts to cstahlish
prcpaymcnt schcmcs, thc Ministry oi Puhlic lcalth (MoPl, has iocuscd hcaily on
gcncrating additional rccnuc irom oluntary` houschold contrihutions to thc dctrimcnt
oi othcr hcalth scctor iunctions. Strcngthcning inccntic structurcs ior thc proision oi
priority scriccs and monitoring and rcgulation systcms arc rcquircd.
Policy
implications
Thc policy implications oi thc rcscarch rcport arc dircctcd to policy makcrs in othcr
transitional cconomy countrics as lcssons to hc lcarncd`. Thcsc lcssons dcric irom
thina`s ciiorts to adapt rural hcalth scriccs to cconomic and institutional changc and
thc impact such changcs hac had on hcalth and hcalth scriccs, and irom thina`s ciiorts
to iormulatc rciorm stratcgics.
tonclusions Stratcgics ior structural changc in thc hcalth scctor should hc iormulatcd on thc hasis oi
a stratcgic analysis which. (i, rccogniscs thc complcxity oi thc hcalth scctor; (ii, asscsscs
policy options on thc hasis oi thcir likcly impact on thc achiccmcnt oi hcalth scctor
prioritics; (iii, dcclops stratcgics that rccognisc thc link hctwccn thc hcalth scctor and
othcr cconomic and institutional iactors; and (i, rccogniscs thc political naturc oi hcalth
scctor rciorm.
19
Author(s,
Titlc
Bogg, L., lcngjin, D., lcli, \., \cnwci, t. and Diwan, V.
Thc cost oi cocragc. rural hcalth insurancc in thina
Sourcc 1996, Health Policy and Planning, Vol 11 No . 28-52
Ohjcctics Thc long-tcrm ohjcctic (ocr iour ycars, is to study thc impact on cquity oi thc changcs
in hcalthcarc iinancing in thina. Thc currcnt papcr aims to study thc allocatic ciiicicncy
oi coopcratic lI, with implications ior cquity in hcalthcarc utilisation and hcalth
outcomc.
Study typc
Data sourcc
& mcthods
Lmpirical study.
A controllcd natural cxpcrimcntal dcsign to analysc hcalth cxpcnditurc trcnds in two
twin` countics oi Jiangso proincc, thina, onc oi which has a hcalth iinancing systcm
hascd on uscr iccs, thc othcr on lI. Study pcriod 1986-9+. Thc study uscs accounts data
and intcricws.
Findings Thc authors assumc that diiicrcnt iinancing systcms yicld diiicrcnt hcalthcarc
cxpcnditurc proiilcs and will diiicr in thcir impact on cquity in tcrms oi who hcars thc
cost oi, and who cnjoys acccss to, hcalthcarc. A iundamcntal issuc is thcrciorc to
undcrstand which paramctcrs in thc iinancing systcm arc thc cxplanatory ariahlcs. thc
rclatic mix oi uscr iccs, hudgcts and insurancc; paymcnt modcs and lccls; or thc
rclatic pricc oi diiicrcnt scriccs. Thc prcscnt study analyscs coopcratic lI crsus uscr
iccs as cxplanatory ariahlcs, with inilation adjustcd pcr capita hcalthcarc cxpcnditurc,
curatic cxpcnditurc, prccntic cxpcnditurc and highcr lccl curatic cxpcnditurc as
dcpcndcnt ariahlcs. Thc hypothcsis is that a systcm hascd on oluntary lI will
contrihutc to a highcr lccl oi hcalthcarc cxpcnditurc and incrcasing sharc oi hoth
curatic carc and tcrtiary carc cxpcnditurc.
Findings show that coopcratic lI will inducc highcr growth in hcalthcarc cxpcnditurc
and lcad to a shiit irom prccntic mcdicinc to curatic mcdicinc. A highcr (county, lccl
oi tcrtiary curatic carc cxpcnditurc (thc lattcr consuming most oi thc puhlic iunding hut
uscd mainly hy highcr incomc lccl paticnts, is also indicatcd.
Policy
implications
\orld Bank hcalth iinancing policics that proposc that uscr iccs, priatisation,
dcccntralisation and lI togcthcr will improc allocatic ciiicicncy and rcducc incquitics
in acccss to hcalthcarc arc contradictcd hy thc prcscnt study.
tonclusions toopcratic lI lcads to an cscalation oi hcalthcarc cxpcnditurc and a shiit away irom
prccntic mcdicinc to curatic carc at highcr lccls oi scricc.
20
Author(s,
Titlc
tarlson, J., Than, T.T.l., Lc, l.D. and Grady, l.
Rcport on thc iinancing and dclicry oi hasic scriccs at thc communc lccl in ly Anh,
la Tinh, Victnam
Sourcc 1996, Oxiam Ul,I, Victnam Programmc, lanoi, Victnam
Ohjcctics To study trcnds in local liclihoods, hasic scriccs dclicry, and thc ciiccts oi rapid
cconomic growth in two communcs. Thc iocus is on changcs in thc hcalth and cducation
scctors.
Study typc
Data sourcc
& mcthods
Rcscarch study using quantitatic and qualitatic mcthods.
Scmi-structurcd intcricws with houschold mcmhcrs and local hcalth and political
authoritics, conductcd in 1996. Fic days` iicldwork.
Findings For currcnt purposcs, only iniormation on thc hcalth scctor is rcicwcd hclow. Thc
rcport summariscs thc iacilitics, organisation and staiiing oi district and communc lccl
puhlic hcalthcarc scriccs. Thc hudgct ior hcalthcarc at district lccl and hclow as wcll as
icc collcction is rcicwcd. Thc implcmcntation oi national hcalth programmcs is
dcscrihcd. Data on thc utilisation ratcs oi district and communc hcalth scriccs show a
stcady incrcasc sincc 199 whcn gocrnmcnt nationaliscd hcalth workcr salarics.
Qualitatic data on thc puhlic`s pcrccptions oi hcalthcarc scriccs sincc thc cconomic
rciorms suggcst that communc lccl scriccs hac improcd, with staii and drugs morc
rcadily aailahlc, hut that thc attitudc oi somc doctors is still wanting and thc poor iccl
cspccially disparagcd. lospital costs arc prohihitic, cspccially ior thc poor. Thc papcr
prcscnts usciul data on district and communc rccnuc and cxpcnditurcs, including data
on rccnuc irom local contrihutions`.
Policy
implications
Thc authors statc that thc administration oi thc gocrnmcnt`s pocrty allciation
programmc nccds addrcssing in ordcr to improc thc rcimhurscmcnt oi hcalthcarc
proidcrs ior ircc hcalthcarc scriccs proidcd to thc poor. Policics on thc proision and
iinancing oi hasic scriccs nccd rciining in ordcr to rcducc thc ocr-rcliancc on drugs as
a sourcc oi incomc ior tlSs and to addrcss thc inahility oi thc cry poor to aiiord uscr
iccs ior hcalthcarc. Thc rcgrcssic naturc oi houschold contrihutions` ior thc poor also
rcquircs attcntion.
tonclusions Local and national oiiicials must look hcyond crcating programmcs that targct and
amclioratc thc situation oi thc poor, to making puhlic incstmcnt dccisions that arc pro-
poor in thcir conccption.
21
Author(s,
Titlc
thcrnichosky, D. and Potapchik, L.
lcalth systcm rciorm undcr thc Russian hcalth insurancc lcgislation
Sourcc 199, International Journal oI Health Planning and Management, Vol 12. 29-95
Study typc
Data sourcc
& mcthods
Discussion papcr.
Not applicahlc.
Ohjcctics To discuss thc rciorm iramcwork ior hcalth insurancc lcgislation (lIL, in Russia and to
put iorward a comprchcnsic sct oi potcntial solutions to thc prohlcms and issucs
surrounding implcmcntation oi thc lIL.
Findings Thc Russian lIL, amcndcd in 199, initiatcd iar-rcaching rciorm in thc iinancing,
organisation and managcmcnt oi thc Russian hcalth systcm. lowccr, thc
implcmcntation oi thc lcgislation has hccn slow and unstructurcd duc to a lack oi
appropriatc administratic and iinancial mcchanisms. thcsc conccrn cntitlcmcnt to carc,
priatc-puhlic mix, iinancial rcsponsihilitics oi gocrnmcnt at all lccls, incstmcnt
instrumcnts, rcimhurscmcnt and compcnsation systcms, and a wcll dciincd rolc oi
gocrnmcnt. Thc authors discuss thcsc issucs in thc contcxt oi thc Russian cconomy, thc
statc oi thc hcalth systcm and thc ciiort to rciorm thc lIL. \hilc thc papcr`s main iocus
is on thc rciorm iramcwork, thc implications ior hcalth systcm uscrs - ior cxamplc, as
rcgards quality oi carc, hcalth costs, cquity oi acccss and protcction ior thc oluntarily
insurcd - can hc sccn.
Policy
implications
Many oi thc wcakncsscs in thc Soict hcalth systcm can hc attrihutcd historically to thc
wcak and amhiguous rolc oi thc statc in thc hcalth systcm. As thc Russian Fcdcration
mocs irom a highly ccntraliscd to a dcccntraliscd icdcral systcm, thcrc is an ccn grcatcr
nccd to rcdciinc thc rolc oi gocrnmcnt in thc hcalth systcm.
tonclusions Rcdciining thc rolc oi thc statc may hc a highly prohlcmatic issuc ior Russia gicn thc
innatc icar and distrust oi thc (Soict, Statc`, hut onc that has critical rcpcrcussions ior
progrcss in hcalth scctor rciorm.
22
Author(s,
Titlc
tommunity lcalth Rcscarch Unit, lanoi
Asscssmcnt oi primary hcalth carc projccts in Victnam
Sourcc 199, Rcd tross oi Victnam and Danish Rcd tross
Ohjcctics To rcport on thc implcmcntation oi Plt actiitics in thrcc pilot communcs oi Thai
Binh Proincc, Victnam, and thc currcnt and potcntial rolc oi thc Rcd tross in thcsc
actiitics. Thc study aims to idcntiiy. (i, human and matcrial rcsourccs ior Plt
proision; (ii, constraints and prohlcms to Plt implcmcntation; (iii, priority nccds oi
thc community, cspccially womcn and childrcn; and (i, kcy indiiduals and organisations
ior iacilitating Plt implcmcntation.
Study typc
Data sourcc
& mcthods
Rcscarch study using participatory mcthods.
Data dcrics irom houscholds (i.c. thosc with prcgnant or postnatal womcn, childrcn
undcr iic, sick, disahlcd or cry poor,, local hcalth, social and political authoritics.
Twclc days` iicldwork
Findings Thc rcport proidcs a hroad rcicw oi thc pilot communcs, including dcmographic and
socio-cconomic structurc; structurc and proision oi hcalth scriccs (puhlic and priatc,;
morhidity data; communc social and political structurcs and thcir rolc in Plt actiitics;
community participation in hcalth; and utilisation oi hcalth scriccs.
Policy
implications
No policy implications drawn.
tonclusions tommunc spcciiic rccommcndations arc madc ior improing communc hcalth status,
ior implcmcnting Plt actiitics, and ior augmcnting thc rolc oi thc Rcd tross in Plt
actiitics.
2
Author(s,
Titlc
Lnsor, T.
Introducing hcalth insurancc in Victnam
Sourcc 1995, Health Policy and Planning, Vol 10 No 2. 15+-6
Ohjcctics To dcscrihc thc ocrall dcsign oi lI in Victnam and to discuss issucs rclating to
implcmcntation that must hc addrcsscd hy indiidual proinccs.
Study typc
Data sourcc
& mcthods
Discussion papcr.
Not applicahlc.
Findings Victnam has introduccd social insurancc as part oi its rciorm oi thc hcalthcarc systcm.
Lnsor dcscrihcs thc currcnt status oi lI. Thc scopc ior compulsory payroll insurancc is
limitcd duc to thc small sizc oi thc iormal scctor. Proinccs arc hcginning to cxpcrimcnt
with pilot modcls oi oluntary insurancc. Lnsor discusscs issucs rclating to cxtcnsion oi
hoth compulsory and oluntary lI schcmcs and raiscs prohlcms associatcd with
maintaining cquitahlc acccss to good quality carc ior thc poor. turrcnt systcms oi
rcimhurscmcnt oi proidcrs arc discusscd. Thc dcclopmcnt oi contracts hctwccn
hospitals and insurancc ccntrcs and thc nccd to account ior hcalthcarc scriccs is a major
changc in thc hcalth systcm and is challcngcd hy thc inadcquacy oi hasic cquipmcnt, and
low wagcs and inccntics ior hcalth staii. Lnsor discusscs thrcc ways in which thcsc
diiiicultics can hc allciatcd.
Policy
implications
Thc way in which thc lI systcm is dcclopcd in Victnam will critically shapc thc way
hcalthcarc is dclicrcd to thc population in thc iuturc. Policy makcrs must considcr.
(i, how to maintain control oi insurancc cxpcnditurcs to aoid ocr hurdcning thc
cconomy; (ii, how to hcst iinancc lI through taxation whilst taking into account thc
strcngth oi thc cconomy and thc nccd to rcdistrihutc rccnuc to aoid rcgional
incqualitics; and (iii, how to maintain cquitahlc acccss to scriccs ior thc uninsurcd poor.
tonclusions Victnam can hcnciit irom thc crrors oi othcr countrics and shapc a social insurancc
systcm that maintains a high lccl oi acccss to hasic hcalthcarc, allows ior national
rcdistrihution oi iunding and pcrmits control ocr national cxpcnditurc.
2+
Author(s,
Titlc
Lnsor, T. and Pham, B.S.
Acccss and paymcnt ior hcalthcarc. thc poor oi northcrn Victnam
Sourcc 1996a, International Journal oI Health Planning and Management, Vol 11 No 1.
69-8
Ohjcctics To cxaminc thc impact oi uscr iccs on thc rural poor.
Study typc
Data sourcc
& mcthods
Rcscarch study using quantitatic mcthods.
A 1995 surcy oi 1,02+ houscholds in northcrn Victnam on hcalth chargcs, cxcmptions
and thc utilisation oi scriccs. Thc surcy uscd qucstionnaircs and scmi-structurcd
intcricws.
Findings Findings suggcst that thc poor gcncrally dclay trcatmcnt, makc lcss usc oi gocrnmcnt
hcalth iacilitics and pay morc ior cach cpisodc oi illncss at communc hcalth ccntrcs than
thc rich. It appcars that thc poor may hc discriminatcd against cithcr in thc amount thcy
pay ior trcatmcnt or in thc typc and quantity oi trcatmcnt that is prcscrihcd. Thc study
shows that a signiiicant proportion oi thc poor (and non-poor, iind chargcs a hurdcn
and hac to horrow to mcct costs, rcducc consumption oi csscntial goods such as iood
or iucl, or scll asscts. A signiiicant minority is dctcrrcd irom using iacilitics altogcthcr
hccausc oi cost. Lxcmption irom hcalth iccs is largcly indcpcndcnt oi incomc and many
oi thc poor do not qualiiy ior assistancc.
Policy
implications
Thc currcnt systcm oi cxcmption iails to proidc adcquatc protcction to thc poor; a
rcision oi thc systcm oi cxcmptions is rcquircd. Sincc it is thc poor in poorcr
communcs that arc most ciicctcd hy high uscr iccs, a policy that targctcd 50 pcr ccnt oi
thc poorcr communcs would capturc ocr 80 pcr ccnt oi thosc in diiiiculty and it is to
thcsc arcas that any assistancc irom gocrnmcnt or donors should hc targctcd.
tonclusions \ith thc adoption oi uscr chargcs as part oi hcalth scctor rciorm policy, thc importancc
oi adcquatc cxcmption mcchanisms is impcratic ii thc poor arc to hc ahlc to acccss
hasic hcalthcarc scriccs.
25
Author(s,
Titlc
Lnsor, T. and Pham, B.S.
lcalth chargcs and cxcmptions in Victnam
Sourcc 1996h, Bamako Initiatic Opcrations Rcscarch Programmc, Research Paper No 1, Ncw
\ork. UNItLF
Ohjcctics Thc main ohjcctics wcrc. (i, to asscss thc way in which hcalth scriccs at communc and
district lccls makcs proision ior thosc not ahlc to pay chargcs ior mcdical carc; (ii, to
cxaminc how much houscholds pay ior hoth puhlic and priatc hcalthcarc scriccs, and
to cxaminc thc rolc oi pricc and incomc as harricrs to consuming hcalthcarc rclatic to
othcr iactors such as distancc to iacilitics and houschold charactcristics; (iii, to asscss thc
impact oi cconomic and non-cconomic iactors on thc utilisation oi scriccs; and (i, to
tcst thc icasihility oi dccloping an improcd instrumcnt ior idcntiiying thosc unahlc to
pay uscr chargcs. \hilc thc iocus oi thc rcscarch programmc is on thc Bamako Initiatic
(BI,, thc projcct also studicd non-Bamako arcas.
Study typc
Data sourcc
& mcthods
Rcscarch study using quantitatic mcthods.
Full dctails oi a houschold surcy in northcrn Victnam conductcd in 1995 with 1,02+
houscholds oi hcalth chargcs, cxcmptions and thc utilisation oi hcalth scriccs, thc main
rcsults oi which arc summariscd in Lnsor and Pham (1996a,.
Findings For iull dctails oi iindings, scc rcport. Thc main points arc that in comparison with thc
wcalthy, thc poor spcnd a grcatcr proportion oi incomc on hcalthcarc; pay morc ior cach
isit to hospital or hcalth ccntrc ior trcatmcnt; arc morc likcly to hc ill; arc lcss likcly to
scck carly trcatmcnt; arc lcss likcly to scck trcatmcnt at hospital or a hcalth ccntrc; and
hac a lowcr lccl oi scli-rcportcd hcalth. turrcnt cxcmption mcchanisms appcar
inadcquatc in cnsuring cquitahlc acccss to hcalthcarc. No clcar hcnciit oi thc BI
programmc could hc iound; rcasons ior this arc proidcd. Sincc houscholds put moncy
asidc to pay ior iuturc hcalthcarc, thc nccd ior ciicctic and local prcpaymcnt schcmcs is
supportcd.
Policy
implications
An cxcmption systcm that cncouragcs thc poor to scck carly trcatmcnt is nccdcd. Thc
systcm should hc hascd on acragc communc incomc comhincd with thc usc oi
communc rccords and statistical tools to idcntiiy thc poor and monitor thc systcm.
Thc currcnt hurdcn oi hcalth iccs ior thc poor suggcsts that thc BI should hc hroadcncd
to put morc cmphasis on ciicctic hcalthcarc as wcll as targcting it at arcas most in nccd.
Thc cxisting oluntary lI schcmc could hc cncouragcd with somc suhsidy ior thc poor
and crcation oi a systcm ior idcntiiying thosc rcquiring assistancc.
tonclusions Thc authors concludc that thcrc arc adantagcs to comhining a systcm oi prcpaymcnts
with cxcmptions and thc managcrial and motiational ciiccts, on hoth staii and
houscholds, oi a propcrly monitorcd BI programmc. Sincc dircct paymcnt is now an
csscntial icaturc oi hcalthcarc in Victnam, it is important that stcps hc takcn to cnsurc
that acccss to quality scriccs ior thc poor is maintaincd and ccn incrcascd.
26
Author(s,
Titlc
Lnsor, T. and Rittman, J.
Rciorming hcalth carc in thc Rcpuhlic oi lazakstan
Sourcc 199, International Journal oI Health Planning and Management, Vol 12. 219-+
Ohjcctics To dcscrihc thc hackground and introduction oi mcdical insurancc in lazakstan and
discuss two major issucs in thc rciorm proccss. (i, cocragc oi rural arcas; and (ii, thc
rolc oi thc insurancc systcm in contrihuting to morc iundamcntal hcalth systcm rciorm.
Study typc
Data sourcc
& mcthods
Rcicw papcr.
Not applicahlc.
Findings In thc contcxt oi dcclining hcalth status and dctcriorating puhlic iinanccs, thc
gocrnmcnt oi lazakstan in 1995 introduccd a systcm oi compulsory lI. Thc papcr
discusscs thc impact oi thc iinancial crisis on paticnts as shown hy thc incrcasc in
iniormal contrihutions to hcalth staii hy paticnts, as wcll as scmi-oiiicial contrihutions hy
paticnts oi mcdical supplics, iccs ior hospital scriccs and a dccloping priatc scctor.
Thc papcr thcn discusscs in dctail thc hackground to, and introduction oi, mcdical
insurancc in lazakstan and discusscs how thc rciorms will aiicct mcdical carc in rural
arcas. Industrial-stylc insurancc schcmcs arc inappropriatc ior rural arcas.
Altcrnatic options such as partial insurancc cocragc, a morc ciicctic contrihution
asscssmcnt and collcction or oluntary community schcmcs arc possihlc. Thc potcntial
impact oi thc insurancc iund on widcr hcalth scctor rciorm will hc grcatcst ii thc
iollowing prohlcms arc addrcsscd. uncqual acccss to hcalthcarc, poor and inappropriatc
quality oi carc, tcchnical inciiicicncy and limitcd paticnt choicc.
Policy
implications
lcalth scctor rciorm is changing thc rolc rcquircd oi statc institutions and rcquircs a
diiicrcnt rcgulatory and stratcgic rolc than currcntly cxists. Futurc planning dcpcnds on a
dciinition oi thc rclatic rolcs oi thcsc statc hodics.
tonclusions Altcrnatic solutions ior cstahlishing rural lI schcmcs arc rcquircd to thosc dcsigncd ior
urhan arcas. tommunity participation in thc iunding and organisation oi hcalthcarc, and
a systcm that draws on a aricty oi iunding mcthods whilst cnsuring acccss to thc
population majority, may hc thc kcy.
2
Author(s,
Titlc
Lnsor, T. and Saclyca, L.
Iniormal paymcnts ior hcalth carc in thc Formcr Soict Union. somc cidcncc irom
lazakstan
Sourcc 1998, Health Policy and Planning, Vol 1 No 1. +1-+9
Ohjcctics Thc papcr addrcsscs thc issuc oi iniormal, undcr-thc-tahlc, paymcnts ior hcalthcarc,
which arc a kcy icaturc oi hcalthcarc systcms oi thc iormcr Soict Union and tcntral and
Lastcrn Luropc.
Study typc
Data sourcc
& mcthods
Rcscarch papcr.
Not applicahlc.
Findings In lazakstan, iniormal paymcnts hac cscalatcd sincc thc start oi thc transition pcriod
and can signiiicantly hoost thc incomc oi mcdical staii. Thc papcr rcicws somc oi thc
causcs oi thc growth oi this iniormal paymcnt systcm and looks at thc typcs oi iniormal
paymcnts (i.c. cash or kind, to practitioncr or hcalth iacility,. It rcicws thc scant
cmpirical cidcncc on how widcsprcad thc iniormal mcdical cconomy is and discusscs
thc diiicrcnt approachcs to, and diiiicultics oi, rcscarching this linc oi cnquiry.
Policy
implications
Thc issuc has potcntially signiiicant policy implications. Iniormal paymcnts may lcad to
grcatcr incquitics in acccss to hcalthcarc, ior thc poor, ior womcn and ior rural arcas, hut
thc rcality is highly complcx and littlc cmpirical data cxists as yct to clariiy thc situation.
Thc iniormal paymcnt systcm may also lcad to inciiicicnt and inappropriatc scricc
proision and could also cloud attcmpts to dcisc ncw inccntics within thc iormal
paymcnt systcm. It also rcduccs thc impcratic ior gocrnmcnts to prioritisc dccisions
ahout scricc proision.
tonclusions Thc impact oi attcmpts to rciorm systcms using \cstcrn modcls could hc rcduccd
unlcss thc ciicct and sizc oi thc iniormal paymcnt systcm is takcn into account. In
conclusion, a scrics oi rcscarch qucstions to addrcss this uncxplorcd issuc is gicn.
28
Author(s,
Titlc
Gcncral Statistical Oiiicc
Victnam Liing Standards Surcy. 1992-199
Sourcc 199+, lanoi. Statc Planning tommittcc - Gcncral Statistical Oiiicc
Ohjcctics To asscss thc ciiccts oi cconomic rciorm on houschold wcliarc.
Study typc
Data sourcc
& mcthods
Quantitatic rcscarch.
First nationally rcprcscntatic surcy oi +,800 urhan and rural houscholds using
qucstionnaircs ior houscholds, ior communitics and ior rccording markct priccs.
louscholds arc diidcd into iic incomc quintilcs.
Findings For iull dctails scc rcport. Only thc summary oi ltSB is rcportcd hcrc (scc Tahlcs .1.1
to .10.2,. Oi thc 2.6 pcr ccnt oi pcoplc rcporting illncss in thc iour wccks prior to
intcricw, 5+ pcr ccnt sought a consultation with a doctor, pcr ccnt with an assistant
doctor and 10 pcr ccnt with a nursc. Thcrc is a hcay rcliancc on scli-mcdication ( pcr
ccnt oi thc poorcst scli-trcat comparcd with 55 pcr ccnt oi thc wcalthy,. Thc
consultation ratc rangcs irom 2.9 ior thc poorcst quintilc to .+ ior thc wcalthicst
quintilc. Thc poorcst quintilc usc priatc proidcrs (16 pcr ccnt, morc than puhlic scctor
scriccs (12 pcr ccnt,, in contrast with thc wcalthicst quintilc (26 pcr ccnt and 18 pcr ccnt
rcspccticly,. As incomcs risc pcoplc opt ior highcr quality hospital carc rathcr than
puhlic clinics and shiit away irom thc usc oi paramcdics to highcr quality priatc doctors.
Acragc annual pcr capita hcalth cxpcnditurc is 82,500 VND, which is ocr 6 pcr ccnt oi
consumption cxpcnditurc. lcalth cxpcnditurc in thc top incomc hand is almost six timcs
highcr than thc lowcst incomc hand. Acragc pcr capita incomc is +.+ timcs grcatcr in thc
top incomc quintilc than in thc hottom (scc Tahlcs .1.1-.6.+,.
Policy
implications
Thc surcy was dcsigncd spcciiically to iniorm policy and rcscarch ahout socio-cconomic
conditions oi houscholds in Victnam.
tonclusions A hroad summary is gicn ior cach scction oi data. Scc rcport to cxtrapolatc iindings
irom tahlcs. Spcciiic to thc ahoc iindings it can hc concludcd that. (i, thc poor hac lcss
acccss to high quality proidcrs (puhlic hospitals and priatc doctors, than thc wcalthy;
(ii, thc prohahility oi sccing a high quality proidcr arics irom lcss than 10 pcr ccnt in
thc poorcst quintilc to ocr a third in thc wcalthicst; and (iii, thc priatc scctor is a morc
important scricc proidcr ior thc poor than is thc puhlic, with implications ior acccss to
prccntic carc scriccs and curatic carc oi monitorcd quality.
29
Author(s,
Titlc
Gcrtlcr, P. and Litack, J.
Acccss to hcalth carc during transition. thc rolc oi thc priatc scctor
Sourcc 1998, in D. Dollar, P. Glcwwc, and J. Litack. (cds,, Household WelIare and
Vietnam's Transition, \ashington, D.t.. \orld Bank Rcgional and Scctoral Studics.
25-55.
Ohjcctics Thc chaptcr cxamincs thc cxtcnt to which priatc hcalth proidcrs in Victnam arc iilling
thc gaps lcit hy thc contraction oi thc puhlic scctor in thc mid-1980s, iollowing
gocrnmcnt policics to opcn up thc PlS and incrcasc thc rcal hudgct ior thc puhlic
scctor hcalth systcm. Arcas whcrc gocrnmcnt policics could improc acccss to, and
hcnciits irom, mcdical carc arc idcntiiicd.
Study typc
Data sourcc
& mcthods
An cmpirical rcicw and sccondary analysis oi hcalth data that draws largcly on thc VLSS
data oi 1992-9.
Not applicahlc.
Findings Thc chaptcr notcs thc largc incrcasc in out-oi-pockct cxpcnditurcs hy houscholds on
hcalthcarc during thc transition pcriod, oi which priatc sourccs makc up thc grcatcr
sharc. Also notcd is thc pcrccntagc oi hcalth cxpcnditurc spcnt on drugs, all out-oi-
pockct, and again primarily irom thc priatc scctor. Findings irom thc VLSS surcy on
acccss to hcalth scriccs arc rcportcd, which includc thc dominant usc oi scli-mcdication,
cspccially hy thc poor; thc grcatcr usc oi priatc, rathcr than puhlic, proidcrs hy all, hut
cspccially thc wcalthy; and thc shiit in thc usc oi puhlic scctor scriccs with incrcasing
incomc whcrchy thc poor rcly morc on tlSs and thc wcalthy on hcttcr quality hospital
carc.
Policy
implications
Thc allocation oi puhlic rcsourccs to curatic and prccntic carc nccds rcising in ordcr
to mcct thc nccds oi thc poor and to hcttcr complcmcnt what thc priatc scctor can
oiicr. Thc lack oi rcgulation and monitoring in thc priatc scctor is causing signiiicant
hcalth and iinancial prohlcms ior houscholds. Improing quality in thc puhlic scctor
rcquircs major incstmcnts. \ays to improc acccss to proicssionally prcscrihcd drugs
arc nccdcd.
tonclusions Thc priatc scctor has hccomc dominant in hoth thc iinancc and dclicry oi hcalthcarc
during thc transition pcriod hut thc lack oi rcgulatory mcchanisms rcquircs attcntion.
Thc pattcrn oi puhlic spcnding hcnciits thc poor thc lcast. Rcallocation oi puhlic
suhsidics away irom hospitals to hcalth stations would hcnciit thc poor and improc
scricc quality. Thc priatc scctor is, to somc cxtcnt, iilling thc gaps, hut lcss so ior thc
poor who arc rclying on scli-prcscription and scli-diagnosis with thcir attcndant dangcrs.
0
Author(s,
Titlc
Glcwwc, P. and Litack. J.
Proision oi hcalth carc and cducation in transitional Asia. kcy issucs and lcssons irom
Victnam
Sourcc April 1998, Working Paper No 1+, UNU,\IDLR, lclsinki, Finland. Thc \orld
Bank
Ohjcctics Lxamincs thc impact oi thc transition to a markct cconomy on hcalth and cducation
outcomcs in transitional Asia with particular iocus on thc casc oi Victnam.
Study typc
Data sourcc
& mcthods
Lmpirical rcicw.
Not applicahlc.
Findings From a rcicw oi thc cmpirical cidcncc, thc authors concludc that hcalthcarc scriccs
appcar to hc gcncrally hcttcr than thcy wcrc prior to thc introduction oi GRLPRL policics
and that incrcascs in incomc cnahlc most pcoplc to pay ior hcalth scriccs dcspitc pricc
incrcascs. Thc authors dcducc that quality has prohahly improcd although thcrc is no
hard data ior this. Thc iact that incomc mortality has stcadily dcclincd suggcsts that thc
ciicct oi GRLPRL has not hccn ncgatic as rcgards thc hcalth status oi thc population.
Policy
implications
Liiorts to cnsurc acccss to hcalthcarc ior pcoplc with such low incomcs that thcy cannot
aiiord to pay thc priatc costs associatcd with acccss, cspccially to hospital carc, arc
nccdcd. Thc authors suggcst that Victnam should takc notc oi thc hcalthcarc issucs that
conirontcd thina during its transition to a markct cconomy such as. hospitals taking up
thc lion`s sharc oi spcnding; ncglcct oi thc implication oi cquipmcnt purchasc and ncw
construction on iuturc rccurrcnt costs; and thc high proportion oi hcalth cxpcnditurcs
that arc duc to drug consumption, with implications ior staii salarics and drug pricing.
tonclusions In rclation to hcalth. protccting and improing hcalth outcomcs dcpcnds on thc succcss
oi cconomic rciorms in gcncrating incomc growth; strong cconomic growth gcncrally
incrcascs outcomcs. Thc naturc oi thc cconomy hciorc thc rciorms has an important rolc
in dctcrmining thcir ocrall impact. Small-scalc cxpcrimcntation oi spcciiic policics
should hc donc hciorc implcmcnting thcm on a largcr scalc. Gocrnmcnts nccd to
dcclop mcdium- to long-tcrm plans ior hlcnding puhlic and priatc proision oi hcalth
scriccs. Bccausc somc groups will incitahly iacc scrious prohlcms, idcntiiying and
protccting ulncrahlc groups is an important task oi thc gocrnmcnt post rciorms.
1
Author(s,
Titlc
Gong, \. and \ilkcs, A.
lcalth human rcsourccs in rural thina
Sourcc 199, IDS Bulletin, Vol 28 No 1. 1-9
Ohjcctics To analysc and rcicw thc major prohlcms rcgarding human hcalth rcsourccs in poor
rural arcas oi thina.
Study typc
Data sourcc
& mcthods
Rcscarch articlc.
Draws on data irom a 199 National lcalth Scriccs Surcy hy thc MoPl, thina.
Findings Thc aailahility oi hcalth workcrs in rural thina is high in comparison with othcr
countrics as a rcsult oi gocrnmcnt policy to cnsurc that thc rural population has acccss
to hasic hcalthcarc scriccs. lowccr, data irom a national surcy show that many arc
poorly traincd, poorly cducatcd and hac low workloads. A growing lahour markct ior
skillcd pcrsonncl in thc last 15 ycars has mcant that ocr 80 pcr ccnt oi qualiiicd doctors
hac lcit rural arcas ior county or urhan hospital posts. Lcss qualiiicd or untraincd
pcrsonncl arc allowcd to proidc scriccs without supcrision and hac hccn promotcd
hy rural hcalth iacilitics to compcnsatc ior staiiing losscs. But this has ncithcr stoppcd
thc outilow oi hcttcr qualiiicd pcrsonncl, nor improcd thc quality oi carc amongst thosc
rcmaining.
Policy
implications
To cnsurc that hcalth pcrsonncl oi adcquatc quality arc aailahlc in rural hcalth iacilitics,
thc iollowing policics arc discusscd. adopting a rural oricntation policy ior training;
prccnting loss oi wcll traincd pcrsonncl hy an inccntics systcm; implcmcnting lcgal
rcgulation oi promotion and cmploymcnt; and raising quality and productiity oi staii
through a systcm oi suhsidics that rclatcs staiiing nccds to workloads. Liicctic
pcrsonncl managcmcnt policics arc rcquircd.
tonclusions In ordcr to hring thc cxisting pcrsonncl up to a lccl oi cxpcrtisc that matchcs thcir
position, a massic national in-scricc training schcmc is rcquircd, thc succcss oi which
will dcpcnd on thc allocation oi suhstantial iinancial rcsourccs and thc intcgration oi
training stratcgics with widcr hcalth planning actiitics.
2
Author(s,
Titlc
Guldncr, M.
lcalth carc in transition in Victnam. cquity and sustainahility
Sourcc 1995, Health Policy and Planning,Vol10 (supplcmcnt,. +9-62
Ohjcctics To suggcst ways to saicguard thc sustainahility oi thc Victnamcsc hcalth scctor in thc
contcxt oi cconomic and political rciorm.
Study typc
Data sourcc
& mcthods
Rcicw articlc.
Thc papcr is hascd on a 1992 casc study oi sustainahility in thc Victnamcsc hcalth scctor,
prcparcd ior Sac thc thildrcn Fund (Ul,. Scc Guldncr, M. and Riikin, S., 199,
Sustainahility in thc hcalth scctor, part 1. Victnam casc study`, London. Thc Sac thc
thildrcn Fund, ior iull dctails.
Findings A critiquc oi thc rciorm proccss in Victnam and its impact on thc hcalth scricc. \hilc
thcrc is no iniormation on thc impact oi rciorm on thc uscrs oi hcalth scriccs, thc
articlc oiicrs a pcrspcctic on thc hcalth scctor rciorm proccss itscli. Sccn issucs rclatcd
to sustainahility in thc hcalth scctor arc raiscd and discusscd. lack oi appropriatc
iniormation; undcr-iunding; nccd ior policy iramcworks; nccd ior rcgulatory iramcworks
and institution huilding; coordination and intcgration; community inolcmcnt; and thc
appropriatcncss oi donor incstmcnt.
Policy
implications
Scc conclusions.
tonclusions Thrcc thcmcs arc uscd to illustratc thc prohlcm oi sustainahility in Victnam. (i,
iragmcntation oi thc hcalth systcm, which is undcrmining thc dcclopmcnt oi
iramcworks to guidc thc transition proccss in thc hcalth systcm; (ii, an intcrnal capacity
to managc thc proccss oi changc which rcquircs hoth an asscssmcnt oi thc impact oi
changc and thc institutional capacity to dircct changc; and (iii, a rcdciinition oi rolcs and
rcsponsihilitics within thc hcalth systcm to aoid thc diminution oi puhlic hcalth scriccs
and to cnsurc thcir sustainahility. Rcad in rclation to Smithson, P. (199,.

Author(s,
Titlc
Guscynoa, Z., thakoury, S. and Lcrcns, P.
Study oi hcalth carc dcmand and hcalthcarc cxpcnditurc in luha district, Azcrhaijan
Sourcc 1996, Bamako Initiative Technical Report Series No 5, Ncw \ork. UNItLF
Ohjcctics To conduct a study oi houschold ltSB and hcalth cxpcnditurcs prior to dcsign and
implcmcntation oi a UNItLF assistcd hcalth scctor rciorm plan.
Study typc
Data sourcc
& mcthods
Rcscarch study using quantitatic mcthods.
A houschold surcy (n~6, in luha district, Azcrhaijan conductcd in 199+ using
qucstionnaircs.
Findings Thc acragc hcalthcarc cxpcnditurc pcr pcrson pcr ycar is USS10.+, oi which 61 pcr ccnt
is spcnt on drugs, 16 pcr ccnt on unoiiicial consultation iccs, 11 pcr ccnt on transport
and 12 pcr ccnt on diagnostic tcsts, iood and othcr costs. Findings show that + pcr ccnt
oi sick paticnts hac to horrow moncy and 1 pcr ccnt hac to scll asscts to pay ior
hcalthcarc. Oi paticnts rcicrrcd to hospital, lcss than hali arc admittcd hccausc oi thc
diiiiculty thcy hac aiiording hospital costs. Many houscholds (6+ pcr ccnt, cxprcss a
willingncss to contrihutc to hcalth costs, proiding quality oi carc is improcd and thc
aailahility oi drugs cnsurcd. A prcpaymcnt schcmc, with cxcmptions ior thc poor and
disahlcd, is thc prcicrrcd mcthod oi contrihution. In thc contcxt oi thc proposcd
rciorms, thc cost oi a hasic packagc oi hcalth scriccs cocring morc than 80 pcr ccnt oi
hcalth prohlcms at thc hcalth ccntrc lccl is cstimatcd at USS pcr pcrson pcr ycar. Ii
houscholds wcrc to pay this cost in iull, thc rcport statcs that this would rcprcscnt
saings oi ahout 0 pcr ccnt oi actual houschold hcalth cxpcnditurcs; saings could hc
highcr with thc gocrnmcnt hudgct takcn into considcration.
Policy
implications
A policy and stratcgy ior thc rational usc oi drugs is rcquircd to rcducc thc high drug
cxpcnditurc. Policy on thc introduction oi uscr iccs nccds to considcr how much
houscholds can aiiord to spcnd on hcalthcarc and to promotc thc systcm as a iirst stcp
towards a prcpaymcnt schcmc. Appropriatc cxcmption mcchanisms nccd to hc
cstahlishcd ior thc poor, with communitics inolcd in idcntiiying houscholds that
rcquirc support.
tonclusions Thc quality and rcsponsicncss oi scriccs and thc rcgulation oi hcalth workcr actiitics
nccd improing. tommunitics arc prcparcd to contrihutc towards hcalthcarc proiding
quality oi carc and drug supplics arc cnsurcd. lowccr, thcrc is cidcncc to suggcst that
somc houscholds hac diiiiculty acccssing or aiiording hcalthcarc. appropriatc saicty ncts
arc rcquircd.
+
Author(s,
Titlc
lcndcrson, G., Akin, J., Zhiming, L., Shuigao, J., laijiang, M. and lcyou, G.
Lquity and thc utilisation oi hcalth scriccs. rcport oi an cight-proincc surcy in thina
Sourcc 199+, Social Science and Medicine, Vol 9 No 5. 68-99
Ohjcctics To look at cquity with rcspcct to thc proision and usc oi hcalth scriccs in thina.
Study typc
Data sourcc
& mcthods
Rcscarch study using quantitatic mcthods.
A 1989 thina lcalth and Nutrition Surcy oi ,800 houscholds in cight proinccs.
Analysis oi a suh-samplc oi 6,51 pcoplc, agcd 20-+5, on any illncss or accidcnt in thc
iour wccks prior to hcing intcricwcd.
Findings Multiariatc analyscs wcrc pcriormcd on data irom 669 adults, 85 pcr ccnt oi whom
sought carc ior thcir illncss,accidcnt. Utilisation oi scriccs was classiiicd as inpaticnt,
outpaticnt and othcr`. Bcyond thc lccl oi illncss sccrity, only a icw indiidual-lccl
iactors wcrc rclatcd to scricc usc. gcndcr (icmalc, and cmploymcnt in statc-run
cntcrpriscs wcrc associatcd with highcr pattcrns oi usc. Agc, cducation, pcr capita
houschold incomc, insurancc cocragc and distancc all appcarcd unrclatcd to sccking
carc.
Thc authors suggcst that thina has achiccd a widc distrihution oi hcalth scriccs at thc
local lccl, which arc widcly uscd hy thosc who nccd thcm and which arc acccssihlc and
rcasonahly incxpcnsic. lowccr, analysis oi working agc adults only may idcntiiy
ariahlcs that diiicr irom thosc inilucncing thc rcsponsc to illncss oi youngcr or oldcr
agc groups. Thcrc was also much ariation in thc quality oi iacilitics. across iacilitics as
wcll as amongst thosc oi thc samc typc. But thc potcntial inilucncc oi quality on
utilisation was not analyscd. No data on thc naturc oi thc illncss,accidcnt rcportcd or on
thc rcstriction it imposcd on normal daily actiitics was rccordcd. Nor was timc spcnt
traclling to thc scricc(s, actually uscd ior thc illncss cpisodc analyscd, rathcr thc timc to
thc most commonly uscd iacility. Thcsc issucs arc rcctiiicd in latcr surcy instrumcnts.
Policy
implications
No policy implications drawn
tonclusions Thc authors` conclusion is that, in contrast to rcccnt rcports oi dcclining acccssihility to
scriccs, thcrc appcars to hc rclaticly cqual acccss to hcalthcarc, a iinding which is in
contrast to othcr comparahlc studics and may hc duc to mcthodological iactors oi thc
prcscnt study.
5
Author(s,
Titlc
lolland, S., Phimphachanh, t., tonn, t. and Scgall, M.
Impact oi cconomic and institutional rciorms on thc hcalth scctor in Laos. implications
ior hcalth managcmcnt
Sourcc 1995, Research Report No 28, Brighton. Institutc oi Dcclopmcnt Studics
Ohjcctics To study thc impact oi cconomic and institutional rciorms on thc hcalth scctor in Laos
and makc rccommcndations ior dccloping a sustainahlc and intcgratcd puhlic hcalth
systcm.
Study typc
Data sourcc
& mcthods
Rcscarch study.
Thc currcnt study is part oi a largcr projcct on thc hcalth scctor rciorm in Laos PDR.
Data dcrics irom casc studics oi two hcalth programmcs in iour sitcs in 199-9+ and
irom intcricws with and iniormation irom hcalth and political authoritics.
Findings Thc packagc oi rciorms dcsigncd to stimulatc cconomic dcclopmcnt, and puhlic scctor
managcmcnt and scricc proision arc discusscd. Thc icaturcs and impact oi thc Ncw
Lconomic Mcchanisms arc prcscntcd. Institutional rciorm is dcscrihcd and
administratic rciorm in thc scnsc oi a ciil scricc rcstructuring and scqucntial mocs
irom a ccntraliscd systcm oi administration to dcccntraliscd gocrnmcnt and thcn hack
to iiscal ccntralisation arc cxamincd. Thc impact oi thc cconomic crisis and rciorm
programmc on thc hcalth scctor is dcscrihcd. Thcrc is spccial iocus on puhlic hcalth
scctor cxpcnditurc, including cost rccocry schcmcs and houschold hcalthcarc spcnding.
Altcrnatics to puhlic scctor scriccs arc dcscrihcd, as wcll as pattcrns oi houschold
hcalthcarc sccking. It appcars that scli mcdication or a priatc consultation arc thc iirst
options ior choicc; usc oi puhlic scctor scriccs arc sccondary and this pattcrn prcails
rcgardlcss, largcly, oi illncss sccrity. Thc low-lccl utilisation oi puhlic hcalth posts
rcilccts poor quality carc, in addition to a lack oi drugs and cquipmcnt, inacccssihility oi
iacilitics and cultural and linguistic harricrs to usc ior cthnic minority pcoplcs. lcalth
workcrs arc low paid and dcmotiatcd. Thc continuing low lccl oi gocrnmcnt
cxpcnditurc on hcalth, thc maldistrihution oi aailahlc rcsourccs to urhan ocr rural arcas
and thc iocus on prccntic ocr curatic carc scriccs compound thc situation.
Rcscarch iindings irom casc studics oi thc hcalth programmcs arc rcicwcd.
Policy
implications
A rangc oi policy implications is cidcnt. Spcciiic to thc impact oi rciorms on thc hcalth
scctor and thcrciorc on uscrs oi puhlic and priatc hcalth scriccs, thcrc nccds to hc
considcrahlc strcngthcning in national capahilitics in hcalth policy iormulation, donor
managcmcnt, hcalth scricc planning and managcmcnt, and PlS rcgulation.
tonclusions \hilc Laos clcarly nccds morc rcsourccs, thc authors suggcst that hcttcr usc could hc
madc oi thc rcsourccs alrcady aailahlc. Thc authors proposc rciorms to thc systcms oi
hcalth policy iormulation, hcalth planning and rcsourcc allocation, and hcalth systcm
managcmcnt, in ordcr to cmpowcr proincial and district hcalth structurcs to plan and
cxccutc hcalth scriccs appropriatc to local conditions and which utilisc community
inolcmcnt.
6
Author(s,
Titlc
lsiao, \.
Markctisation - thc illusory magic pill
Sourcc 199+, Health Economics, Vol . 51-6
Ohjcctics To cxaminc thc cmpirical rcsults oi a numhcr oi countrics that cmhraccd a ircc markct
approach to thc iinancc and proision oi hcalth scriccs.
Study typc
Data sourcc
& mcthods
Gucst cditorial.
Not applicahlc.
Findings Thc papcr rcicws iour countrics that hac cmhraccd markct principlcs in rciorming
thcir hcalth systcms. thilc, thc Philippincs, Singaporc and South lorca. \hilc thcsc
countrics arc not thc iocus oi thc prcscnt hihliographic rcicw, thc papcr is includcd as it
highlights critical issucs ior hcalth scctors that arc run according to markct principlcs.
Thc author rcicws thc hcalth systcm oi cach country and contrasts ccntrally planncd
hcalth systcms with ircc-markct hcalth systcms. lsiao concludcs that a complcx mixcd
systcm may hc thc hcst solution.
Policy
implications
Markctisation is a complcx systcm oi rcgulatcd markcts. Thc principlcs and practiccs
cidcnt irom countrics haing undcrgonc markctisation illustratc how statcs can structurc
a systcm to hring out thc positic markct iorccs.
tonclusions Liiicicnt markctisation is a challcngc ior thosc dccloping nations that lack thc iinancial
and human rcsourccs to iund hasic hcalthcarc, dcsign thc rcgulatory mcchanisms and
managc markct compctition. But markctisation could hc pilotcd in arcas in ordcr to
asccrtain what comhination oi statc and markct rolcs may work hcst within that nation`s
culturc, socio-cconomic and political structurc, all thc timc taking into account thc
adcrsc ciiccts oi markctisation.

Author(s,
Titlc
Lao Social Indicator Surcy, 199+
\omcn and childrcn in thc Lao PDR. rcsults irom thc Lao Social Indicator Surcy
Sourcc Vicntianc. National Statistical tcntrc, tommittcc ior Planning and toopcration
Ohjcctics To hcttcr undcrstand thc hcalth and dcmographic status oi thc Lao population.
Study typc
Data sourcc
& mcthods
Rcscarch study using quantitatic mcthods.
Thc Lao Social Indicator Surcy (LSIS,, undcrtakcn in 199, was part oi thc Lao
Lxpcnditurc and tonsumption Surcy, a rcprcscntatic houschold surcy intcricwing
illagc hcads, houschold hcads and icmalc houschold mcmhcrs oi rcproductic agc in
urhan and rural arcas hy pocrty group.
Findings Thc rcport dcscrihcs thc hcalthcarc proidcrs aailahlc and thc acragc distancc to thcm.
Nurscs arc thc most acccssihlc proidcrs and hospitals thc lcast. \ithin two kilomctrcs,
69 pcr ccnt oi illagcs hac a mcdical practitioncr, +9 pcr ccnt a pharmacy and 8 pcr
ccnt a hospital. Utilisation oi scriccs hy prcgnant womcn and hy childrcn ior common
illncsscs is rcportcd. Thcrc is a much grcatcr utilisation oi priatc scriccs hy womcn in
urhan arcas and grcatcr rcliancc on gocrnmcnt hospitals hy rural womcn. Rural womcn
arc morc likcly to do nothing, or to scli-trcat, than womcn in urhan arcas. A high rcliancc
on pharmacics ior thc trcatmcnt oi childrcn in hoth urhan and rural arcas is notcd.
Policy
implications
Nonc drawn.
tonclusions Nonc cxtrapolatcd. Surcy rcsults arc prcscntcd ior rclcant gocrnmcnt dcpartmcnts to
intcrprct.
8
Author(s,
Titlc
Li, J., tao, S. and Lucas, l.
Utilisation oi hcalth scriccs in poor rural thina. an analysis using a logistic rcgrcssion
modcl
Sourcc 199, IDS Bulletin, Vol 28 No 1. 2+-1
Ohjcctics To cxplorc thc dctcrminants oi hcalth scriccs utilisation in poor rural arcas oi thina in
ordcr to iniorm policy makcrs on ciicctic targcting oi scriccs to thosc in most nccd
and on thc dcsign oi risk-sharing schcmcs to protcct thc poor irom hcalth cxpcnditurc
shocks.
Study typc
Data sourcc
& mcthods
Rcscarch study using quantitatic mcthods.
Analysis oi houschold incomc data irom 2,69+ houscholds (12,509 pcoplc, in thrcc
countics. Study uscd 1+ day illncss rccall.
Findings Thc study analyscs scli-rcportcd morhidity and usc oi hcalth scriccs hy mcans oi a
logistic rcgrcssion modcl using a comhination oi indicators to rcilcct prcdisposing
charactcristics (agc, scx and cducation,, cnahling charactcristics (houschold incomc and
distancc to thc ncarcst proidcr, and pcrccicd sccrity oi illncss (thc numhcr oi days
spcnt hcd-hound,. Thc rcsults indicatc grcat ariation in thc utilisation oi hcalth scriccs
hctwccn thc thrcc study countics, ccn whcn controlling ior a numhcr oi iactors which
may hc assumcd to inilucncc dcmand which, thc papcr suggcsts, may rcilcct diiicrcnccs
in scricc proision across thc thrcc countics. Oi thc prcdisposing charactcristics, agc
appcars to hc thc most powcriul prcdictor oi scricc usc, with illncss among thc
youngcst iamily mcmhcrs prccipitating a dccision to scck carc, in contrast with illncss in
thc cldcrly who arc lcss likcly to scck carc.
Policy
implications
Nonc drawn.
tonclusions Incomc appcars to pay a signiiicant rolc in thc dccision to usc hcalth scriccs, which
appcars contrary to thc authors` cxpcctations, sincc thcy assumc that thc majority oi thc
samplc hac acccss to local, low cost illagc doctors. It is diiiicult to cxtrapolatc irom
thcsc iindings hccausc thc kind oi hcalthcarc proidcr sought and cxpcnditurc on sccking
carc is not includcd in thc analysis. Thc authors suggcst that thc iinding may hc cxplaincd
hy a rclationship hctwccn incomc and supply-sidc iactors that is not capturcd in thc
rcgrcssion modcl. Thcy statc that thcrc is likcly to hc a strong corrclation hctwccn
acragc houschold incomcs in a county and thc iinancc aailahlc ior hcalth scriccs in
that county.
9
Author(s,
Titlc
Mclcc, M., Figucras, J. and thcnct, L.
lcalth scctor rciorm in thc iormcr Soict Rcpuhlics oi tcntral Asia
Sourcc 1998, International Journal oI Health Planning and Management, Vol 1. 11-+
Ohjcctics To discuss thc kcy clcmcnts oi thc proposals ior hcalth scctor rciorm dcclopcd in thc
iormcr Soict Rcpuhlics oi tcntral Asia.
Study typc
Data sourcc
& mcthods
Rcicw articlc.
\lO data and thc \lO lcalth Systcms in Transition proiilcs ior 1995 and 1996.
Findings \hilc thc six rcpuhlics rcicwcd hac many aspccts in common, such as iinancing hascd
on social insurancc, thcrc arc also many diiicrcnccs, rcilccting national political,
cconomic and historical circumstanccs. Most attcntion to datc has iocuscd on thc dcsign
oi thc proposcd rciorm systcm and lcss on thc potcntial harricrs to implcmcnting rciorm
packagcs. Thcsc harricrs, such as thc numcrous adcrsc iactors in thc contcxt in which
rciorm is taking placc, wcakncsscs in thc proccss oi rciorm itscli, or iailurc to inolc
groups (uscrs, proidcrs, policy makcrs and intcrcst groups, on whom thc succcss oi
rciorms may dcpcnd, arc discusscd.
Policy
implications
Thc contcxt oi policics must hc cxamincd alongsidc thc contcxt within which policy is
hcing implcmcntcd as wcll as thc kcy actors inolcd in thc proccss.
tonclusions Thc authors suggcst that gocrnmcnts and adisors togcthcr takc hcttcr account oi thc
ohstaclcs to implcmcntation and hc morc cognisant oi thc national contcxt - cconomic,
political and cultural - within which rciorm is to takc placc.
+0
Author(s,
Titlc
Ministry oi lcalth, S.R. oi Victnam
Final rcport on hcalth surcy in Bac Thai and \cn Bai Proinccs
Sourcc 1991a, Rcport 10-1991, Dcpartmcnt oi Planning, Ministry oi lcalth, lanoi, Victnam
Ohjcctics To cxaminc. (i, thc utilisation oi hcalth iacilitics; (ii, uscrs` willingncss to pay ior scriccs;
(iii, thc currcnt quality oi hcalth scriccs as pcrccicd hy hoth uscrs and proidcrs; and
(i, thc main prohlcms iacing hcalth scricc proidcrs. Thc rcsults arc tahulatcd.
Study typc
Data sourcc
& mcthods
Rcscarch study using quantitatic mcthods.
\orld Bank commissioncd surcy oi 1+ hcalth proidcrs in 106 communcs oi two
mountainous proinccs in Victnam. A uscr cxit surcy was conductcd; intcricwcrs wcrc
puhlic scctor mcdical doctors.
Findings Main iindings. (i, communc hcalth ccntrcs and polyclinics wcrc iaourcd hy low incomc
houscholds whcrcas high incomc groups optcd ior a traditional mcdical consultation;
(ii, 0 pcr ccnt oi hcalth scricc uscrs wcrc adults; (iii, thc majority (80 pcr ccnt, camc
ior curatic carc, primarily ior symptoms oi iccr, cough, hcadachc and dcprcssion;
(i, hcalth workcrs had low ratcs oi daily contact with paticnts, no timc was allocatcd to
prccntic carc, hcalth cducation or outrcach actiitics, and thc quality oi diagnostic and
trcatmcnt skills was poor; (, hcalth workcrs idcntiiicd thcir kcy prohlcms to hc low
salarics, a lack oi instrumcnts and drugs, and diiiicult working conditions. An incrcasc in
thc usc oi priatc physicians and a dccrcasc in thc usc oi puhlic iacilitics wcrc notcd.
Policy
implications
Nonc statcd.
tonclusions Fcw diiicrcnccs in scricc proision and scricc utilisation wcrc iound hctwccn thc
mountainous study arcas oi thc currcnt rcport and thc plains oi thc Ministry oi lcalth
study, 1991h. Thc rcport suggcsts that paticnt satisiaction is high and that scriccs mcct
thc nccds oi thc mountainous population. But quality oi carc is also rcportcd as poor,
scriccs arc inciiicicnt and drug supplics and instrumcnts inadcquatc. Liing conditions
ior hcalth workcrs arc poor and many rcsort to priatc practicc. Thc trcnd oi pcoplc
towards usc oi thc priatc scctor grows, whilst usc oi thc puhlic scctor shrinks.
+1
Author(s,
Titlc
Ministry oi lcalth, S.R. oi Victnam
Final Rcport on hcalth surcy in Quang Nam - Da Nang, tuu Long and lai lung
Proinccs
Sourcc 1991h, Rcport 5-1991, Dcpartmcnt oi Planning, Ministry oi lcalth, Victnam
Ohjcctics To cxaminc. (i, thc utilisation oi Plt scriccs; (ii, uscrs` willingncss to pay ior Plt
scriccs; (iii, thc currcnt quality oi Plt scriccs as pcrccicd hy hoth uscrs and
proidcrs; and (i, thc main prohlcms iacing hcalth scricc proidcrs. Thc rcsults arc
tahulatcd hy proincc, urhan,rural arca, scx, agc, and typc oi proidcr.
Study typc
Data sourcc
& mcthods
Lmpirical study using quantitatic mcthods.
A \orld Bank commissioncd surcy oi 86 hcalth proidcrs in an urhan and a rural
district oi thrcc proinccs in thc plains arca oi Victnam. A uscr cxit surcy was
conductcd. Intcricwcrs wcrc puhlic scctor mcdical doctors.
Findings Main iindings. (i, 0 pcr ccnt oi hcalth scricc uscrs wcrc adults, thc ast majority (90
pcr ccnt, opting ior curatic carc scriccs ior thc trcatmcnt oi, primarily, iccr, cough,
achcs and pains and dizzincss; (ii, rclatic to pcr capita incomc hcalth costs wcrc
pcrccicd to hc cxpcnsic; (iii, dcspitc high lccls oi uscr satisiaction with scricc quality
(95 pcr ccnt,, diagnostic skills and prccntic carc scriccs wcrc wcak; and (i, hcalth
workcrs idcntiiicd thcir kcy prohlcms to hc low salarics, inadcquatc supply oi drugs and
cquipmcnt and poor iacilitics. lcalth workcrs idcntiiicd a nccd to intcgratc priatc hcalth
workcrs into thc puhlic hcalth arcna.
Policy
implications
Nonc drawn.
tonclusions Thrcc main issucs nccd addrcssing. (i, staii salarics; (ii, drugs, cquipmcnt and iacilitics;
and (iii, thc intcgration oi traditional mcdicinc into Plt scricc dclicry. Morc
iniormation ahout priatc scctor scriccs is nccdcd as wcll as a morc thorough caluation
oi thc quality oi carc oi hcalth scricc proidcrs.
+2
Author(s,
Titlc
Ministry oi Puhlic lcalth
Toward a national drug policy. rcport irom thc national drug scminar Towards a NDP`
in Lao PDR, 1992
Sourcc 199, Vicntianc, Stockholm and Bangkok. Lao MoPl, larolinska Institutc, and thc
National Lpidcmiological Board oi Thailand
Ohjcctics To usc thc National Drug Scminar to iormulatc a national drug policy.
Study typc
Data sourcc
& mcthods
tonicrcncc procccdings.
Not applicahlc.
Findings A situational analysis oi thc rational usc oi drugs is gicn. Thc majority oi thc study
samplc rcicrrcd to (60 pcr ccnt, huy drugs without prcscription irom pharmacy shops
staiicd largcly hy untraincd dispcnscrs. Poor prcscrihing practiccs and polypharmacy
wcrc ircqucntly iound. Thc prohlcms associatcd with thc shiit to a markct cconomy ior
drug distrihution and procurcmcnt arc notcd. A nccd ior policy rcgarding thc rcgulation,
utilisation and monitoring oi traditional mcdicincs was also rcportcd.
Policy
implications
Findings point to thc nccd ior comprchcnsic national drugs policy and a clcar plan oi
implcmcntation.
tonclusions A rciscd drait oi a national drug policy ior Laos PDR.
+
Author(s,
Titlc
Nguycn, l.T., Lc, l.l.T., Riikin S.B. and \right, L.P.
Thc pursuit oi cquity. a hcalth scctor casc study irom Victnam
Sourcc 1995, Health Policy, Vol . 191-20+
Study typc
Data sourcc
& mcthods
Rcicw papcr.
Not applicahlc.
Ohjcctics To rcicw thc issuc oi cquity within thc contcxt oi hcalth scctor rciorm in Victnam and
to discuss thc ciicct oi policy, lcgislation and human rcsourccs on thc pursuit oi cquity in
acccss to hcalthcarc.
Findings Thc papcr rcicws thc Victnamcsc hcalth systcm and thc ciicct oi thc currcnt political
and cconomic contcxt on cquity in acccss to hcalthcarc. Thc impact oi iccs ior scricc on
cquity and thc inahility oi thc gocrnmcnt`s cxcmption systcm to support thc poor arc
discusscd. Rcccnt policy dcclopmcnts, including that oi lI arc critiqucd and thc lack oi
ciicctic coordination hctwccn and within gocrnmcnt and donor actiitics ior thc hcalth
scctor arc notcd. Lcgislation ior thc rcgulation oi iccs and drugs costs is oi particular
importancc, cspccially as rcgards thc pharmaccutical scctor. Thc impact oi human
rcsourcc dcclopmcnt on cquity is discusscd, such as thc ciicct oi low salarics and poorly
motiatcd hcalth staii on thc quality oi scricc dclicry.
Policy
implications
Liiorts to rcdrcss thc growing incqualitics oi acccss dcpcnd upon. (i, thc iormulation and
implcmcntation oi policy (in particular policy on lI and policy on coopcration hctwccn
donors and gocrnmcnt in hcalth assistancc,; (ii, lcgislatic powcr to cniorcc policy (ior
taxation oi priatc practicc and rcgulation oi thc pharmaccutical scctor,; and (iii, human
rcsourcc dcclopmcnt.
tonclusions Thc pursuit oi cquity is not only a mattcr oi morc moncy hut oi addrcssing a rangc oi
rclatcd issucs that impact upon achicing cquity.
++
Author(s,
Titlc
Pham, l.D.
Thc political proccss and thc priatc hcalth scctor`s rolc in Victnam
Sourcc 1996, International Journal oI Health Planning and Management, Vol 11. 21-0
Ohjcctics To rcicw thc currcnt situation oi thc PlS in Victnam.
Study typc
Data sourcc
& mcthods
Rcicw articlc.
A 1992 study oi thc PlS in cight proinccs; casc study oi PlS growth in lo thi Minh
city 1992-95 and a rapid appraisal on PlS growth in 5 proinccs in 1995. Intcricws
with policy makcrs.
Findings Thc papcr dcscrihcs. (i, thc lcgal hasis ior dcclopmcnt oi thc PlS; (ii, thc growth oi thc
PlS; and (iii, policy-makcrs` pcrccptions oi PlS dcclopmcnt. Mixcd icws ahout thc
PlS prcail amongst policy makcrs, which thc author suggcsts arc rootcd in idcological
conilicts as wcll as issucs oi ciiicicncy and cquity. Rccommcndations arc madc ior
appropriatc support to priatc practitioncrs and improcmcnts in thc hcalth systcm.
Policy
implications
Dcclopmcnt oi thc PlS could scrc to rclcasc puhlic iunds to hclp rcdrcss growing
prohlcms oi cquity in acccss to scriccs and should accompany thc nccd ior gocrnmcnt
to iocus on thc hcalth prioritics oi thc poor.
tonclusions Lcgislation to dcclop thc iniormal priatc scctor has hccn slow to matcrialisc ior a
aricty oi rcasons. Futurc dcclopmcnts must hc carricd out within thc contcxt oi an
intcgratcd puhlic and priatc national hcalth systcm.
+5
Author(s,
Titlc
Prcscott, N.
Pocrty, social scriccs and saicty ncts in Victnam
Sourcc 199, World Bank Discussion Paper No 6, \ashington, D.t.. \orld Bank
Ohjcctics To cxaminc thc changing rolc oi thc puhlic scctor in iinancing and proision oi social
scriccs and saicty ncts in Victnam and to asscss its ciiicicncy in targcting puhlic
rcsourccs to thc poor in thc contcxt oi Victnam`s cconomic rciorms.
Study typc
Data sourcc
& mcthods
Discussion papcr.
Rcport draws upon data irom thc VLSS oi 1992-9.
Findings As rcgards hcalth, thc papcr outlincs thc dcclining utilisation oi hcalth iacilitics and thc
incquitahlc acccss to quality scriccs hy thc poor. Thc hcay rcliancc on scli-mcdication,
particularly hy thc poor, is notcd as wcll as thc dcpcndcncc oi thc cry poor on priatc,
morc than puhlic, proidcrs. As rcgards puhlic scctor proision, thc cry poor makc
grcatcr usc oi communc hcalth ccntrcs than thc non-poor. A shiit in thc choicc oi
proidcr irom communc hcalth ccntrcs to hospital scriccs and irom priatc paramcdics
to quality priatc practitioncrs with incrcasing incomc is notcd.
Policy
implications
Bcttcr targcting oi puhlic cxpcnditurc to priority arcas and priority hcalth programmcs is
nccdcd ii thc incquitahlc acccss to scriccs hy thc poor is to hc addrcsscd. This inolcs
rcducing thc harricrs to utilisation oi distancc, scricc costs and quality oi carc.
tonclusions Thcrc is a thrcciold quality gap` hctwccn thc poor and non-poor in thc prohahility oi
sccing a high quality (hospital or priatc, proidcr. Thc poor iacc lowcr quality and
highcr priccs ior hasic hcalthcarc at puhlic iacilitics. Bcttcr targcting oi puhlic suhsidics is
nccdcd.
+6
Author(s,
Titlc
Scgall, M.M., Tipping, G., Dao, X.V. and Dao, L.l.
Lconomic rciorm, pocrty and cquity in acccss to hcalth carc. casc studics in Victnam
Sourcc 1999, Research Report No +, Brighton. Institutc oi Dcclopmcnt Studics
Ohjcctics To incstigatc and pilot diiicrcnt ways oi incrcasing thc acccss oi poor houscholds to
Plt scriccs. (i, hy looking at thc acccss oi thc rural poor to csscntial hcalthcarc and thc
adcquacy oi cxisting icc cxcmption systcms; (ii, hy tcsting thc icasihility oi dccloping
collahoration hctwccn puhlic and priatc hcalth practitioncrs at thc communc lccl; and
(iii, to pilot thc dcclopmcnt oi a iinancially sustainahlc and locally owncd illagc hcalth
workcr systcm in rcmotc mountainous illagcs.
Study typc
Data sourcc
& mcthods
Rcscarch rcport.
Action rcscarch in six communcs oi northcrn Victnam using quantitatic, qualitatic and
participatory mcthods (scc also Tipping, Truong, Nguycn and Scgall 199+,.
Findings lospital costs arc a rccogniscd hurdcn ior poor houscholds hut thc rcscarch rcports that
poor houscholds hac diiiiculty acccssing ccn communc hcalth scriccs; dcht and
disincstmcnt arc common coping rcsponscs and no clcar cxcmption policy cxists at
communc lccl to assist thc poor. A hcnchmark cost oi a possihlc policy to suhsidisc thc
poor ior thc cost oi drugs at hcalth stations was calculatcd and icasihlc sourccs oi
iinancc proposcd.
Thc pilotcd collahoration hctwccn thc puhlic hcalth scctor and rctircd priatc
practitioncrs showcd that thc priatc hcalth workcrs wcrc willing to hc inolcd as post-
rciorm illagc hcalth workcrs and to hclp proidc a morc intcgratcd nctwork oi Plt
scriccs, cspccially to thc poor. Issucs iacilitating thc collahoration arc discusscd.
Thc succcss oi thc dcclopmcnt oi a nctwork oi illagc hcalth workcrs ior thc rcmotc
illagcs arosc irom cmphasis upon local dccision making and community owncrship oi
thc illagc hcalth workcrs schcmc and upon iinancc irom local political authoritics. \hilc
this was cidcntly sustainahlc a ycar into thc projcct thc long-tcrm iahility nccds to hc
monitorcd. Issucs rclatcd to prohlcms oi sustainahility arc discusscd.
+
Policy
implications
Bcttcr targcting oi cxcmption mcchanisms ior thc poor arc nccdcd, particularly at
communc lccl. A morc ilcxihlc policy to incorporatc priatc hcalth workcrs into puhlic
scctor hcalth actiitics would proidc morc intcgratcd and rcsponsic Plt scriccs,
cspccially to thc poor. For illagc hcalth workcr schcmcs to hc sustainahlc, rcliahlc
sourccs oi local iinancc arc rcquircd as wcll as community support ior illagc hcalth
workcrs scriccs.
tonclusions Markct rciorms hac madc most pcoplc hcttcr oii hut a minority has hcnciitcd only
slightly and arc cxpcricncing diiiiculty acccssing csscntial hcalth scriccs ccn at
communc lccl. Thc cost oi suhsidising thc poor ior communc lccl csscntial drugs is
rclaticly small and could hc mct irom a aricty oi sourccs oi iinancc. Priatc
practitioncrs may hc willing to act as post-rciorm illagc hcalth workcrs and to
collahoratc with thc puhlic hcalth scctor in rcturn ior oiiicial rccognition and thc right to
work lcgally. Thc rcmotc illagc hcalth workcr nctwork succccdcd duc to community
participation and thc willingncss oi local authoritics to iinancc it. Thc sustainahility oi thc
schcmc dcpcnds largcly on how thc communitics pcrccic thc aluc oi illagc hcalth
workcrs` scriccs.
+8
Author(s,
Titlc
Scgall, M., Tipping, G., Lucas, l., Truong, V.D., Nguycn, T.T., Dao, X.V. & Dao, L.l.
lcalth carc sccking hy thc poor in transitional cconomics. thc casc oi Victnam
Sourcc 2000, IDS Research Report 43, Brighton. Institutc oi Dcclopmcnt Studics
Study typc
Data sourcc
& mcthods
Basclinc and intcrcntion studics on ltSB in six rural communcs oi northcrn Victnam
hctwccn 1992 and 1998, using a comhination oi quantitatic, qualitatic and partcipatory
mcthods. Scc Tipping, Truong, Nguycn and Scgall (199+, and Scgall, Tipping, Dao and
Dao (1999, ior mcthodological and study dctails.
Ohjcctics Thc ocrall ohjcctic was to idcntiiy ways oi incrcasing thc acccss oi poor houscholds to
Plt scriccs oi good quality and rcsponsicncss. For thc currcnt rcport, thc ohjcctic
was to carry out sccondary analysis oi rcscarch iindings and to consolidatc conclusions
ior policy iormulation.
Findings Thc rcscarch addrcsscd. (i, thc prohlcm oi aiiordahility oi hcalthcarc ior poor
houscholds in thc contcxt oi cconomic rciorm; and (ii, thc dctcrminants oi houschold
choicc oi hcalthcarc option, with spccial rcicrcncc to poor houscholds.
Thc study rcports that cconomic rciorms hac madc most pcoplc hcttcr oii, hut thcy
hac lcit a minority oi houscholds still in pocrty, ior which thc hcnciits hac hccn only
modcst. Thcsc poor houscholds arc hurdcncd hy dcht and arc cry ulncrahlc to
cconomic shocks oi all kinds.
tomparcd with thc non-poor, poor houscholds uscd lcss iormal hcalthcarc and incurrcd
lcss hcalthcarc cxpcnsc, cspccially at lcan timcs oi thc ycar. But thc diiicrcntial in thcsc
rcspccts was much lcss than that in thc ratio oi hcalthcarc spcnding to houschold
incomc. Thc poor strctch thcir rcsourccs much morc to ohtain hcalthcarc and in thc
proccss put thcir houschold cconomics undcr grcat strain.
A hospital admission is a massic iinancial hurdcn ior thc poor lcading to scrious
disincstmcnt and,or dcht. Trcatmcnt is aoidcd ii possihlc. lowccr, most hcalthcarc
spcnding hy poor houscholds is at thc communc lccl whcrc costs arc mainly ior drugs.
Lcn this cxpcnditurc is a hurdcn ior poor houscholds and disincstmcnt and,or dcht is
common.
Lxcmption oi thc poor irom chargcs is rarc in communc puhlic scriccs and thcrc is no
clcar oiiicial policy on this suhjcct. Thc study calculatcd a hcnchmark cost oi a policy oi
cxcmpting poor houscholds irom paying ior csscntial drug trcatmcnt hy tlSs which
would add ahout 15 pcr ccnt to thc puhlic iunding oi tlS scriccs and could hc
iinanccd hy thc pocrty allciation programmc, local gocrnmcnt gcncral rccnuc,
and,or a communc hcalth tax.
Thc diiicrcntial prcicrcncc ior (amhulatory, hcalthcarc proidcrs hy thc poor and non-
poor arc dcscrihcd and analyscd in rclation to thc main considcrations oi cost,
concnicncc and pcrccicd quality oi scricc. Intcrcntions at thc communc lccl to
(i, incrcasc thc rcsponsicncss and accountahility oi thc tlS to scricc uscrs and (ii, to
crcatc a coordinatcd puhlic,priatc mix oi communc hcalthcarc arc dcscrihcd.
+9
Policy
implications
Thc purposc oi thc rcscarch was to idcntiiy ways oi incrcasing thc acccss oi poor
houscholds to Plt scriccs oi good quality and rcsponsicncss in Victnam. Thc study`s
conclusions, summariscd hclow, hac hroad applicahility to othcr transitional cconomy
countrics, cspccially thc dccloping transitional cconomics oi Asia, and also to many low-
incomc countrics gcncrally.
tonclusions Gcncral conclusions. (i, Thc usc oi complcmcntary mcthods to study dcmand and supply
sidcs togcthcr gac a dcpth oi undcrstanding oi hcalth rclatcd hchaiour impossihlc to
achicc with thc usc oi cithcr mcthodological approach alonc and allows triangulation to
cross-chcck data alidity. (ii, Thc usc oi a longitudinal houschold illncss rccord gac a
complctc and accuratc rccord oi illncss ccnts, proidcd a mcasurc oi illncss incidcncc, as
distinct irom prcalcncc, and cncompasscd scasonal changcs in ltSB. (iii, For primary
as wcll as hospital carc, thcrc is a nccd to cstimatc cost and idcntiiy iundcrs sincc thc
poor grcatly hurdcn thcmsclcs with thc cost oi illncss, cspccially ior hospital carc, hut
ccn ior primary carc. (i, Proposals ior cxcmption policics should hc costcd ior
icasihility and thcir potcntial iunding sourccs idcntiiicd. (, Primary lccl icc cxcmption
policy should hc linkcd to thc promotion oi rational drug usc to aoid thc unncccssary
purchasc (ia polypharmacy, oi drugs hy thc poor. (i, Thc tcchnical quality and,
cspccially, thc uscr iricndlincss oi thc puhlic hcalth systcm nccd to hc improcd. (ii,
Priatc practitioncrs can hc inolcd in thc puhlic hcalth systcm hy cxchanging a lcgal
rccognition to work with agrccmcnt to comply with monitoring and rcgulation actiitics,
as a mcans oi improing quality oi carc.
50
Author(s,
Titlc
Smithson, P.
Sustainahility in thc hcalth scctor, Part 2. lcalth iinancing and sustainahility in Victnam
Sourcc 199, papcr prcparcd ior Sac thc thildrcn Fund (Ul,, London.
Ohjcctics This rcport iorms part oi StF`s programmc oi rcscarch into hcalth scctor sustainahility,
which constitutcs a scrics oi casc studics analysing sustainahility in tcrms oi thc historical
contcxt oi hcalth scctor dcclopmcnt, tcchnical capacity and thc cconomic and political
iramcwork in which dccisions ahout rcsourcc allocation and managcmcnt takc placc.
Study typc
Data sourcc
& mcthods
Rcscarch rcport.
tasc study carricd out in Victnam in 1992.
Findings Thc rcport discusscs thc hcalth scctor in thc contcxt oi thc country`s transition irom a
command to a markct cconomy. It cxplorcs thc distinction hctwccn puhlic and priatc
hcalthcarc proision and thc rclatic scalc and rolc oi cach. Thc iinancing oi puhlic
hcalth scriccs, systcms oi puhlic rccnuc collcction and cxpcnditurc allocation arc
dcscrihcd with cmphasis on thc rclationship hctwccn diiicrcnt lccls oi gocrnmcnt. An
ocricw oi cxpcnditurc on puhlic scctor hcalth scriccs at all lccls is gicn. Possihlc
rcasons ior thc dcclinc in thc utilisation oi puhlic hcalth scriccs arc discusscd; a
dctcrioration in iinancing is rciutcd as thc likcly cxplanation. Thc author suggcsts that
incrcasing cost to paticnts prccipitatcd hy thc introduction oi uscr iccs couplcd with thc
growth oi priatc` work in puhlic iacilitics and thc poor prcscrihing practiccs that oitcn
rcsult, is thc most likcly causc ior thc dcclinc in utilisation. Thc allocation oi rcsourccs in
thc hcalth scctor hctwccn gcographical arcas, lccls oi thc hcalth scricc, and hctwccn
wagc and non-wagc cxpcnditurcs is cxamincd; qualitatic constraints to ciicctic rcsourcc
managcmcnt arc mcntioncd hricily. A rcicw oi thc rolc oi cxtcrnal assistancc is gicn
and iinally cidcncc on thc sccrity oi undcr-iunding iacing thc hcalth scctor is
summariscd.
Policy
implications
Policy implications arc implicit in thc iindings and in thc conclusions hclow.
tonclusions Gicn thc timing oi this study and thc immincnt liiting oi thc cmhargo, a major
conclusion oi thc papcr is thc anticipatcd rapid risc in cxtcrnal assistancc. Thc author
cautions that thc mcagrcncss oi local rccurrcnt rcsourccs will placc limitations on thc
amount oi incstmcnt which can hc ahsorhcd on a sustainahlc hasis and a signiiicant
amount oi donor cxpcnditurc will nccd to hc dcotcd to rccurrcnt support ii iinancially
unsustainahlc incstmcnts arc to hc aoidcd. Liicctic coordination oi donors as rcgards
thc iinancing ior hcalth is csscntial. Lqually, thc powcr halancc ior policy dialoguc, gicn
thc prcdictcd incrcasc in assistancc to hcalth scctor iinancing, puts donors in a cry
inilucntial position, hut onc which may thrcatcn to distort or discmpowcr domcstic
hcalth policy.
51
Author(s,
Titlc
Stcnson, B., Tomson, G. and Syhakhang, L.
Pharmaccutical rcgulation in contcxt. thc casc oi Lao PDR
Sourcc 199, Health Policy and Planning, Vol 12 No +. 29-+0
Ohjcctics To dcscrihc and analysc thc systcm oi drug rcgulation in Lao PDR in rclation to thc
puhlic social goals oi cquity and quality oi carc.
Study typc
Data sourcc
& mcthods
Lmpirical study.
Rcicw oi oiiicial documcnts, 0 intcricws with kcy iniormants and 15 surcys oi
pharmacics in 1996.
Findings Thc massic incrcasc in priatc pharmacics in Lao PDR. Mcans that morc than 80 pcr
ccnt oi all drugs arc distrihutcd through thc priatc scctor, primarily through ior-proiit
priatc pharmacics. Thcrc arc scrious ilaws in thc dispcnsing and usc oi drugs as a rcsult
oi thc low lccl oi cxpcrtisc amongst pharmacy staii, thc work oi unrcgistcrcd priatc
practitioncrs, thc purchasc oi drugs without prcscription, polypharmacy and thc ocr-usc
oi antihiotics and injcctions. Liiorts to rcgulatc this growing priatc markct ior drugs arc
undcrway in ordcr to achicc goals oi cquity and quality oi carc. lowccr, total drug
cxpcnditurc may hc as low as USS1 pcr pcrson pcr ycar making it diiiicult to achicc
rcasonahlc acccss to drugs ior all.
So iar thc rcgulatory systcm has iocuscd on cntry into thc pharmaccutical drug markct
and on issucs oi product quality and conditions oi salc. An cniorccmcnt systcm including
sanctions is hcing dcclopcd; othcr policy instrumcnts such as iniormation and cconomic
mcans arc largcly unuscd.
Policy
implications
Thc gocrnmcnt iaccs a tradc-oii hctwccn achicing thc goals oi quality oi
pharmaccutical scriccs and gcographical cquity oi acccss.
tonclusions Thc likclihood oi moing towards a morc practicc-oricntcd rcgulatory systcm ior drug
control will dcpcnds on thc socio-cconomic dcclopmcnt oi Lao PDR, on thc aailahility
oi rcsourccs, on a thorough undcrstanding oi thc issucs inolcd and on political will.
52
Author(s,
Titlc
Swcnson, I.L., Thang, N.M., Nhan, V.Q. and Ticu, P.X.
Factors rclatcd to thc utilisation oi prcnatal carc in Victnam
Sourcc 199, Journal oI Tropical Medicine and Hygiene, Vol 96. 6-85
Ohjcctics To analysc thc inilucncc oi sclcctcd indiidual and community charactcristics on thc
utilisation oi prcnatal carc.
Study typc
Data sourcc
& mcthods
Rcscarch study using quantitatic mcthods.
Analysis uscd data irom thc 1988 Victnam Dcmographic and lcalth Surcy and 1990
Victnam Acccssihility oi tontraccptics Surcy.
Findings Spcciiic analysis oi thc impact oi hcalth scriccs aailahility and othcr dcclopmcnt
charactcristics oi thc community (c.g. aailahility oi clcctricity and puhlic transport, on
utilisation oi prcnatal carc was donc on a rural suh-samplc.
Thc womcn`s cducational lccl and total numhcr oi liing childrcn wcrc thc most
important prcdictors oi prcnatal carc utilisation. Agc indcpcndcnt oi parity did not
signiiicantly aiicct thc usc oi prcnatal carc. Rural womcn and womcn liing in proinccs
with thc highcst iniant mortality ratcs wcrc signiiicantly lcss likcly to usc prcnatal scriccs
than thcir countcrparts in thc urhan arcas and proinccs with low iniant mortality ratcs.
Non-physician hcalthcarc proidcrs wcrc thc main sourccs oi prcnatal carc ior womcn in
hoth rural and urhan arcas.
Policy
implications
Attcmpts to cncouragc womcn oi limitcd cducation to usc prcnatal scriccs arc callcd
ior. Thc acccssihility and aailahility oi prcnatal scriccs nccd to hc incrcascd.
tonclusions Gicn thc strong association hctwccn womcn`s cducational achiccmcnt and utilisation
oi prcnatal carc scriccs, thc impcratic is to promotc thc cducational achiccmcnts oi
womcn.
5
Author(s,
Titlc
Tang, S.-L.
Thc changing rolc oi township hcalth ccntrcs
Sourcc 199, IDS Bulletin, Vol 28 No 1. 9-+
Ohjcctics Analysc thc impact oi cconomic rciorm on thc pcriormancc oi township hcalth ccntrcs
in thina.
Study typc
Data sourcc
& mcthods
Rcscarch articlc.
Draws on data irom a casc study oi township hcalth ccntrcs in Donglan tounty, thina.
Findings Township hcalth ccntrcs, as proidcrs oi a rangc oi curatic and prccntic hcalthcarc
scriccs as wcll as training and supcrision, hac a kcy position in thina`s rural hcalthcarc
systcm. A casc study oi hcalth ccntrcs in a poor rural county shows that thc pcriormancc
oi many iunctions dcclincd during thc 1980s. Utilisation ratcs hac droppcd as many
hcalth ccntrcs arc unahlc to compctc ior paticnts in thc dccloping markct ior mcdical
carc. Thc aricty and quality oi scriccs has dccrcascd with thc loss oi qualiiicd pcrsonncl
and a lack oi mcdical cquipmcnt. Incrcascd uscr chargcs, poor scricc attitudc and a lcss
rcsponsic scricc rclatic to othcr proidcr options hac rcduccd puhlic coniidcncc in
hcalth ccntrc scriccs. Thc pcriormancc oi othcr important iunctions, such as
immunisation, discasc prccntion and matcrnal and child hcalthcarc programmcs has
hccn undcrmincd hy iinancial constraints, as has training, supcrision and routinc
rcporting. Thc iocus has shiitcd to programmcs that allow incomc gcncration.
Policy
implications
Discussion in thina oi policy options to addrcss this situation iocuscs on whcthcr
incstmcnt in hcalth ccntrcs should hc incrcascd, or whcthcr thc rolc oi hcalth ccntrcs
should changc to rcilcct cxisting constraints.
tonclusions Thc author puts iorward a stratcgy ior strcngthcning hcalth scriccs at thc township
lccl, namcly, to rcorganisc rural hcalth scriccs at thc township lccl hy idcntiiying -5
kcy hcalth ccntrcs to hc gicn priority in thc allocation oi pcrsonncl, iinancial and
physical rcsourccs hy county gocrnmcnts. Such a modcl dcpcnds on political hacking
and tcchnical support; in-scricc training to improc quality oi carc; appropriatc iunding
oi prccntic carc programmcs; and lastly, ciicctic staii managcmcnt to cnsurc quality
staii stay in post.
5+
Author(s,
Titlc
Tang, S.-L., Bloom, G., Fcng, X., Lucas, l., Gong, X. and Scgall, M.
Financing hcalth scriccs in thina. adapting to cconomic rciorm
Sourcc 199+, Research Report No 26, Brighton. Institutc oi Dcclopmcnt Studics
Ohjcctics To discuss and rcicw thina`s adaptation oi its rural hcalth scriccs to thc programmc oi
cconomic rciorms.
Study typc
Data sourcc
& mcthods
Rcscarch rcport.
Rcicw oi cmpirical and policy matcrial. Includcs data irom a 1988 study on hcalth
iinancc conductcd with houscholds, mcdical iacilitics, hcalth authoritics and hcalth cadrcs
(pp 66-10,.
Findings As rcgards scricc utilisation (scc pp 89-10,, thc study uscs thrcc indicators oi acccss to
carc. thc acragc lccl oi utilisation rclatic to rcportcd morhidity; thc proportion oi
pcoplc nccding carc hut not rccciing it; and thc cxtcnt to which non-usc oi scriccs is
attrihutcd to cost. Thcsc indicators arc comparcd ior pcoplc in rich and poor countics
with and without lI cocr. Findings showcd signiiicant non-usc oi scriccs cspccially hy
thc cldcrly oi rich and poor countics and thc young oi poor countics. ligh costs wcrc
oitcn citcd as thc cxplanation though utilisation did not diiicr hy insurancc cocr. Thc
cost oi hospital inpaticnt carc was a signiiicant harricr ior thc poor, and rcprcscntcd ocr
hali thc acragc incomc pcr capita oi a poor houschold.
Policy
implications
In rclation to thc changcs in thc organisation oi rural hcalthcarc scriccs, thc rcsulting
prohlcms oi cquity oi acccss to scriccs ior thc poor and thc loss oi collcctic rcsourccs
to iinancc hcalth scriccs, thc rcport discusscs thc organisation and implcmcntation oi
thc MoPl`s policy ior coopcratic hcalthcarc schcmcs (scc thaptcr 6,.
tonclusions Thc authors arguc that any ciiort to cstahlish a ncw systcm oi rural hcalth iinancc must
hc linkcd to othcr aspccts oi thc rural hcalth systcm, particularly to thc systcm oi
paymcnt oi hcalth proidcrs and thc mcchanisms ior hcalth scctor planning,
coordination and rcgulation.
55
Author(s,
Titlc
Tipping, G. and Scgall, M.M.
lcalth carc sccking hchaiour in dccloping countrics. an annotatcd hihliography and
litcraturc rcicw.
Sourcc 1995, IDS Development Bibliography No 12, Brighton. Institutc oi Dcclopmcnt
Studics
Study typc
Data sourcc
& mcthods
Annotatcd hihliography and litcraturc rcicw.
Litcraturc puhlishcd hctwccn 198+ and 199+ on houschold ltSB rcicwcd ior thc
countrics oi suh-Saharan Airica, South Asia and Southcast Asia.
Ohjcctics To rcicw thc litcraturc on ltSB in dccloping countrics.
Findings Thc rcicw discusscs thc mcthodological approachcs ior studying ltSB and thc issucs
that compromisc comparison oi studics. Dctcrminants oi ltSB arc rcicwcd (c.g. socio-
cconomic ariahlcs, concnicncc, cost, quality oi carc, social status oi womcn, illncss typc
and sccrity, ctc., and thc dctcrminants oi spcciiic hcalthcarc options summariscd.
Studics that addrcss issucs oi quality asscssmcnt and assurancc arc rcicwcd.
Bihliography oi 11+ studics,articlcs.
Policy
implications
Scc studics ior policy implications.
tonclusions A numhcr oi mcthodological iactors compromisc thc comparison oi studics on ltSB,
which arc in thcmsclcs rclaticly icw. ltSB is a multi-iacctcd dccision-making proccss
ior which cost, concnicncc and quality oi carc togcthcr may hc thc most important
issucs. Qualitatic studics, or studics which complcmcnt quantitatic mcthods with a
qualitatic dimcnsion, would iacilitatc an undcrstanding oi thc proccsscs hy which pcoplc
acccss hcalthcarc scriccs.
56
Author(s,
Titlc
Tipping, G. and Scgall, M.M.
Using a longitudinal illncss rccord to study houschold hcalth carc dccision making in
rural communcs oi Victnam
Sourcc 1996, Health Policy and Planning, Vol 11 No 2. 206-11
Ohjcctics Thc papcr aims to dcscrihc onc oi thc rcscarch mcthods uscd to study houschold ltSB
in rural communcs oi Victnam. Thc principal aim oi thc rcscarch was to acquirc a icw
oi Plt scricc dclicry irom hoth uscr and proidcr pcrspcctics. Thc mcthod
dcscrihcd is a longitudinal illncss rccord (IR, dcsigncd to asscss houschold hcalthcarc
dccision-making.
Study typc
Data sourcc
& mcthods
louschold hascd study utilising a comhination oi quantitatic, qualitatic and
participatory mcthods.
Rcscarch was carricd out in iour rural communcs oi northcrn Victnam irom 1992 to
199+ on a samplc oi 66+ houscholds. Thc longitudinal IR mcthod was implcmcntcd ocr
a iour-month pcriod.
Findings Thc papcr rcicws thc mcthodological issucs associatcd with ltSB studics and dcscrihcs
thc dcsign and implcmcntation oi thc IR. Adantagcs and disadantagcs oi thc IR arc
gicn. Thc papcr gics an ocricw oi thc study iindings and discusscs thcm in rclation
to houschold pocrty and thc ahility to pay. It rcports that houscholds choosc hcalthcarc
proidcrs on thc hasis oi pcrccicd quality oi carc, concnicncc oi scricc and
aiiordahility. Poor houscholds (dciincd hy iood shortagc, uscd communc puhlic scriccs
morc oitcn, and highcr lccl scriccs lcss oitcn, than non-poor houscholds and had morc
ircqucnt diiiiculty in mccting hcalthcarc costs (dciincd as thc nccd to takc loans, dcicr
paymcnt or scll asscts,.
Policy
implications
For policy implications oi thc rcscarch scc Tipping, Truong, Nguycn and Scgall (199+,.
tonclusions Thc authors concludc that thc IR was a aluahlc houschold-hascd instrumcnt ior
proiding quality iniormation on houschold illncss cpisodcs and dccision making. It
appcarcd mcthodologically rohust. By monitoring illncss ccnts ocr timc, thc likclihood
oi inaccuratc and incomplctc rccall is minimiscd; dccision-making proccsscs can hc
rccordcd in dctail; and incidcncc, rathcr than prcalcncc ratcs, can hc calculatcd. Its
disadantagcs arc thc organisational logistics and running costs, and thc dcmand ior a
lccl oi local cxpcrtisc and participation. It is hcst uscd in parallcl with qualitatic
soundings oi community opinion.
5
Author(s,
Titlc
Tipping, G. and Truong, V.D.
Rural hcalth scriccs in Victnam. thcir contcmporary rclcancc to othcr Asian transitional
cconomics
Sourcc 199, IDS Bulletin, Vol 28 No 1. 110-15
Ohjcctics To rcicw thc impact oi cconomic rciorm on Plt in Victnam.
Study typc
Data sourcc
& mcthods
Rcicw articlc.
Not applicahlc.
Findings \hilc thc currcnt transitional pcriod has undcrmincd thc iinancial hasc oi Plt in
Victnam and madc thc dclicry and quality oi scriccs ulncrahlc, particularly at thc
communc lccl, thc gocrnmcnt oi Victnam is rcsponding in arious ways to try and
saicguard puhlic hcalth proision. Thc papcr looks at somc oi thc mcasurcs takcn hy thc
gocrnmcnt to prcscrc thc dclicry oi Plt, such as nationalising communc hcalth
workcr salarics and suhsidising hcalth scriccs in rcmotc highland arcas. Thc papcr
discusscs changcs in utilisation oi scriccs, gocrnmcnt policics to saicguard acccss to
csscntial scriccs ior thc poor, thc rolc oi thc priatc scctor in Plt dclicry and thc
impact oi cconomic rciorms on thc iinancing oi hcalthcarc.
Policy
implications
Rcliancc on oluntary` houschold contrihutions to holstcr thc iinancc oi social iunds,
including hcalth, is widcsprcad. This iorm oi community iinancc is only tcnahlc ii thc
majority oi houscholds can aiiord to pay. Sincc much oi thc iinancing oi communc lccl
hcalthcarc currcntly dcpcnds on local political will and thc ahility oi uscrs to aiiord hcalth
iccs, thcrc is a nccd to cncouragc Plt as a political priority in all communcs and to
cnsurc cquitahlc acccss to hcalth scriccs ior all.
tonclusions Thc authors arguc that thc gocrnmcnt oi Victnam`s political commitmcnt to puhlic
hcalth hoth past and prcscnt, and its propcnsity to adapt to changc, may sustain thc
proision oi hasic hcalthcarc scriccs during thc currcnt pcriod oi rapid cconomic
rciorm.
58
Author(s,
Titlc
Tipping, G., Truong, V.D., Nguycn, T.T. and Scgall, M.M.
Quality oi puhlic hcalth scriccs and houschold hcalth carc dccisions in rural communcs
oi Victnam
Sourcc 199+, Research Report No 2, Brighton. Institutc oi Dcclopmcnt Studics
Ohjcctics To dcclop and apply mcthods ior caluating thc quantity and quality oi communc
hcalth scriccs and ior studying houschold hcalthcarc dccisions and thcir dctcrminants.
To incstigatc how thc quality oi Plt could hc improcd and thc scricc madc morc
rcsponsic to uscrs in thc contcxt oi cconomic adjustmcnt and rciorm in Victnam.
Study typc
Data sourcc
& mcthods
Rcscarch study using quantitatic and qualitatic mcthods.
Rcscarch conductcd in 1992-9 in iour rural communcs oi northcrn Victnam. Thc
mcthods includcd a cross scctional houschold surcy (n~66+,, a iour month longitudinal
illncss study, intcricws and iocus group discussions with icmalc houschold mcmhcrs, in-
dcpth study oi iour tlSs and thcir scriccs, and scmi-structurcd intcricws with hcalth
and political authoritics.
Findings Asscssmcnt oi thc quality oi tlS scricc dclicry showcd that thc rank ordcr oi tlS
pcriormancc was not thc samc as that oi communc prospcrity, hut oi thc lccl oi hcalth
workcr salarics and allowanccs. Bcttcr pcriormancc was rclatcd to thc political and
iinancial priority aiiordcd to hcalth hy local political authoritics. Thc suhjcctic
asscssmcnt oi thc tlSs hy houschold rcspondcnts mirrorcd thc clinical caluation oi
tlS scriccs.
Thc ltSB study showcd that illncss cpisodcs wcrc trcatcd hali hy scli-carc and hali hy
hcalthcarc consultation (oi which hali wcrc with communc puhlic scriccs,. Thc main
dctcrminants oi hcalthcarc dccision making wcrc cost, concnicncc, and thc pcrccicd
proicssional skill and pcrsonal attitudc oi hcalth proidcrs. Proidcrs that oiicrcd out oi
hours carc and homc isiting wcrc sought aitcr. tlSs oiicrcd a lcss ilcxihlc scricc than
priatc hcalth workcrs or drug scllcrs. A good standard oi iacilitics, cquipmcnt and drugs
also inilucnccd houschold dccision-making.
Thc main costs in amhulatory carc wcrc ior drugs with thc rank ordcr oi cost thc rccrsc
oi thc ircqucncy with which houscholds chosc to usc thc hcalthcarc options. Poor and
non-poor houscholds rcportcd similar ratcs oi illncss and madc similar hcalthcarc
dccisions, hut poorcr houscholds sought communc puhlic scriccs morc oitcn and
highcr lccl scriccs lcss oitcn than non-poor houscholds. Poor houscholds wcrc morc
likcly than non-poor houscholds to scll asscts, horrow or dcicr paymcnt.
59
\hilc houscholds prcicrrcd to attcnd thc tlS, somc tlSs iarcd poorly on kcy critcria
such as hcalth workcr skill and attitudc and thc standard oi iacilitics. tlSs nccd to
rcarrangc shiits in ordcr to cxtcnd thcir opcning hours and hcalth workcrs should hc
morc prcparcd to makc homc isits.
Policy
implications
Rcstoration oi thc tlS would hac positic implications ior thc quality oi Plt, thc takc
up oi prccntic scriccs and aiiordahility, cspccially ior thc poor.
tonclusions Thrcc iactors would prohahly rcstorc thc tlS to its position as thc most popular
hcalthcarc option at thc primary lccl. (i, a grcatcr political and iinancial commitmcnt hy
thc gocrnmcnt and communc pcoplc`s committccs; (ii, cnhanccd accountahility oi thc
hcalth station to thc community; and (iii, improcd supcrision and in-scricc training oi
communc hcalth workcrs hy thc district hcalth ccntrc.
60
Author(s,
Titlc
Tunyaanich, N.
Victnamcsc iamily hcalth practiccs. an in-dcpth study oi iamily hcalth sccking hchaiour
at thc communc lccl
Sourcc 1992, UNItLF, lcalth Lducation and tommunication Projcct l2, lanoi, Victnam.
Ohjcctics To study hcalth sccking and hcalth practiccs with spccial iocus on curatic and
prccntic hcalthcarc practiccs and thc uptakc oi hcalth cducation iniormation and
actiitics in iamilics with childrcn undcr iic ycars.
Study typc
Data sourcc
& mcthods
Rcscarch study.
A dcscriptic study hascd on a samplc oi + houscholds with childrcn undcr iic ycars
(total population 169 pcoplc, in onc communc oi northcrn Victnam.
Findings A hroad hrush oi iniormation is gicn including thc socio-political structurc oi thc
communc, thc rangc oi aailahlc hcalth proidcrs, hcalth cducation actiitics and a
rcsumc oi thc prccntic hcalth programmcs implcmcntcd hy thc hcalth station.
Rccall oi rccurrcnt illncss, oi illncss in thc iic wccks prcccding thc study and during thc
iour-wcck study pcriod is rcportcd. Oi thc 122 rcportcd illncsscs, 56 pcr ccnt wcrc in
childrcn undcr iic, mainly rcspiratory illncsscs. Thc study docs not rcport thc kind oi
practitioncr sought, hut dctails thc numhcr oi stagcs in thc hcalthcarc sccking proccss
(1--, and summariscs thc typc oi illncss (acutc rcspiratory illncss, diarrhocal discascs,
othcr`, in rclation to thc usc (or othcrwisc, oi antihiotic drugs. To summarisc, thc main
illncss rcsponsc is to huy antihiotics, usually OTt, typically ior a rcspiratory illncss. Thc
rclatic strcngths and adantagcs oi priatc practitioncrs arc summariscd and thc
shortialls in hcalth cducation and communication dctailcd.
Policy
implications
lcalth cducation programmcs and pcrsonncl rcquirc appropriatc training and tcchnical
and matcrial support, with matcrials dcsigncd to suit thc nccds oi thc audicncc, ii thc
lccl oi knowlcdgc oi hcalth uscrs, particularly womcn, is to hc improcd. Iniormation
should hc targctcd to thc audicncc as wcll as to priority hcalth issucs.
tonclusions tonclusions arc madc in rclation to matcrnal child hcalthcarc and thc utilisation oi hcalth
scriccs hy womcn. \omcn`s hcalth knowlcdgc is poor, attrihutcd to inadcquatc or non-
cxistcnt hcalth cducation programmcs. Thc most common trcatmcnt stratcgy oi womcn
is to huy drugs OTt and scli-trcat; opportunitics ior disscminating hcalth cducation
iniormation arc thcrciorc minimal. Thc priatc scctor oiicrs morc skillcd and concnicnt
scriccs hut iocuscs only on curatic carc.
61
Author(s,
Titlc
Vinard, P.
Lnquctcs sur lc rccours aux soins ct lcs dcpcnscs dc santc cn Rcpuhliquc Dcmocratiquc
Populairc du Lao. Rcsultats prcliminaircs |Rcscarch on hcalthcarc sccking and hcalthcarc
costs in thc Dcmocratic Pcoplc`s Rcpuhlic oi Lao. Prcliminary iindings
Sourcc 199+, BI Technical Report Series No 2, \orld Bank,UNItLF, Vicntianc
Ohjcctics To incstigatc hcalthcarc sccking and hcalthcarc costs.
Study typc
Data sourcc
& mcthods
Rcscarch rcport.
A houschold hascd hcalthcarc sccking study oi 85 houscholds in iic districts oi Lao
PDR, carricd out hy UNItLF in collahoration with thc Laos Ministry oi lcalth.
Findings Using a thrcc-month illncss rccall pcriod, 8 pcr ccnt oi houscholds rcportcd at lcast onc
illncss. Thc charactcristics oi thc illncss cpisodcs arc dcscrihcd. lomc rcmcdics wcrc
oitcn uscd hut as an adjunct to othcr sourccs oi hclp. Scli-mcdication, thc iirst sourcc oi
trcatmcnt in 51 pcr ccnt oi cascs, was prcicrrcd hy thc young and uscd ior non-scrious
illncsscs. Twcnty ninc pcrccnt oi illncss cpisodcs had a sccond act`, primarily a priatc
consultation ii aiiordahlc, a spiritual hcalcr ior thc poor, or a hospital consultation ior
thc morc scrious illncsscs and ior thosc ior whom hospital carc was acccssihlc. Thc
poorcst houscholds wcrc lcss likcly to usc a sccond option. Third acts wcrc rarc.
Dctcrminants oi choicc, and thc adantagcs and disadantagcs oi cach typc oi hcalthcarc
option, as pcrccicd hy uscrs, arc discusscd. Thc importancc oi thc cost oi hcalthcarc,
ahility to pay, mcthod oi paymcnt and thc rclation to houschold wcalth is discusscd
Policy
implications
Implications ior thc apparcntly wcll rcgardcd, hut minimally uscd, puhlic scctor hcalth
stations and ior monitoring thc priatc scctor, arc discusscd.
tonclusions Thc usc oi scli-mcdication and priatc scctor proidcrs as Plt sccking options is
strcsscd. louschold cxpcnditurc on hcalthcarc is an important issuc cspccially ior thc
poor. Thcrc is a dcmand ior hcttcr quality puhlic scctor scriccs. As thc principlc oi icc
paymcnt appcars to hc acccptahlc to houscholds, thcrc cxists a ncw sourcc oi rccnuc ior
puhlic scctor carc to iinancc such improcmcnts. Thcrc is a nccd to promotc thc puhlic
scctor as wcll as rcgulatc thc priatc scctor, in ordcr to control houschold cxpcnditurc on
hcalthcarc.
62
Author(s,
Titlc
\hitc, J.
Oi Spirits and Scriccs. lcalth and hcaling amongst thc hill trihcs oi Rattanakiri
proincc, tamhodia
Sourcc July 1995, mimco, lcalth Unlimitcd Rattanakiri Intcgratcd lcalth Programmc, London
Study typc
Data sourcc
& mcthods
Anthropological study oi onc hill trihc (a lrcung illagc, Sruk lrch, in O thum district,
ocr pcriod oi a ycar and hrici comparatic studics in illagcs oi two othcr hill trihcs.
Scc ahoc.
Ohjcctics To incrcasc thc lcalth Unlimitcd projcct`s undcrstanding oi thc liicstylc oi thc cthnic
minority groups with cmphasis on hcalth rclatcd issucs, oi which ltSB is onc
componcnt.
Findings Thc study dcscrihcs thc common hcalth prohlcms, hclicis ahout illncss causation and
ltSB oi thc lrcung. Thc diiicrcnt indigcnous trcatmcnts which thc lrcung usc as a
primary rcsponsc to illncss arc dcscrihcd. \cstcrn mcdicinc, sought irom SKHW NKXPV,
markct pharmacics and district hospitals, is popular and oitcn icwcd as chcapcr and
strongcr` than somc traditional thcrapics. Thc usc oi multiplc thcrapics is a common
pragmatic coping stratcgy ior illncss, hut spiritual hclicis still strongly inilucncc
hchaiour. Gocrnmcnt hcalth scriccs arc undcr-utiliscd not only hccausc oi thc
strcngth oi indigcnous hclici systcms hut hccausc oi acccss prohlcms. \cstcrn mcdicinc
tcnds not to hc sought irom thc hcalth proidcrs supportcd hy lcalth Unlimitcd (thc
SKHW NKXPV and district hospitals,. This is primarily duc to a lack oi awarcncss oi thc
hcalth proidcrs` actiitics and drug supplics; a lack oi iaith in thc hcalth workcrs`
ahilitics and rolc; low cxpcctations on thc part oi hoth proidcrs and uscrs; and poor
quality carc.
Policy
implications
Nonc idcntiiicd.
tonclusions Lxtrapolating irom thc study, somc oi thc conclusions arc that all scctors oi illagc
socicty nccd to hc inolcd in any proccss oi hcalth cducation and that, hccausc oi thc
naturc oi thc indigcnous hclici systcm ior illncss, good communication and a mutual
undcrstanding hctwccn thc iormal hcalth scctor and thc indigcnous hcalth systcm is
nccdcd, as wcll as a community hascd hcalth workcr who is trustcd cnough to hridgc
hoth hcalth systcms.
6
Author(s,
Titlc
\ilkcs, A., \u, l., Bloom, G. and Gu, X.
toping with thc costs oi sccrc illncss in rural thina
Sourcc 199, Working Paper No 58, Brighton. Institutc oi Dcclopmcnt Studics
Ohjcctics To study houscholds that had spcnt a largc proportion oi thcir 199 annual incomc on
mcdical iccs in ordcr to incstigatc, in 1996, how thcy had mohiliscd rcsourccs to copc
with costs and whcthcr costs had impocrishcd thcm. (Thc poorcst houscholds arc
cxcludcd irom thc study on thc grounds oi cxisting pocrty.,
Study typc
Data sourcc
& mcthods
Rcscarch study.
A iollow-up study in 1996 oi a 199 surcy on hcalth scriccs utilisation and cxpcnditurc
in rural thina (scc \u, l., tao, S. and Lucas, l., 199, Lquity in thc utilisation oi
mcdical scriccs. a surcy in poor rural thina,` IDS Bulletin, Vol 28 No 1. 16-2,.
turrcnt study samplc is 2+ houscholds.
Findings Thc mcthodological prohlcms associatcd with using an illncss ccnt rccall pcriod oi thrcc
or morc ycars arc discusscd. Thc study rcports that most houscholds could iinancc thc
high mcdical costs without drastic opportunity costs and wcrc ahlc to maintain
production and incomc. Outsidc iamily rcsourccs, cspccially thosc acccsscd through
social nctworks, wcrc important sourccs oi lahour and iinancial support. Many
houscholds wcrc ahlc to iinancc suhscqucnt unanticipatcd cxpcnditurcs. Thc usc oi
iormal and iniormal loans, usc oi saings, dclaycd rcpaymcnt oi dcht, rcduccd
consumption or incstmcnt, and incrcascd dcmands on houschold mcmhcrs (oitcn
childrcn, to compcnsatc ior thc lost lahour powcr oi thc sick arc somc oi thc coping
stratcgics rcportcd. A small numhcr oi houscholds with icwcr options aailahlc wcrc lcss
ahlc to copc; thosc which lost cithcr corc asscts or lackcd social conncctions wcrc thc
most ulncrahlc to thc impact oi suhscqucnt iinancial shocks. It is thcsc and thc poorcst
houscholds that rcquirc a morc ciiicicnt systcm oi saicty ncts.
Policy
implications
Thcrc is a nccd ior improcd iunding oi hospital scriccs ior thc cry poor; possihilitics
includc highcr gocrnmcnt suhsidics ior hcalth iacilitics or grcatcr iunding ior currcnt
systcms oi iinancing scriccs ior thc poor, such as social rclici or mcdical icc cxcmption.
tonclusions It is thc poorcst houscholds, such as thosc which arc ulncrahlc to loss oi corc asscts,
which hac limitcd acccss to social nctworks, in which thcrc is chronic or rcpcatcd
illncss, or in which thcrc is a solc carncr or low initial incomc, that rcquirc a morc
ciiicicnt systcm oi saicty ncts in ordcr to copc with thc impact oi suhscqucnt iinancial
shocks.
6+
Author(s,
Titlc
\ilkinson, S.
Thc right to hasic hcalth carc - tackling urhan pocrty in tamhodia
Sourcc Dcccmhcr 1999, Options News, Ncwslcttcr No +.
Study typc
Data sourcc
& mcthods
tomprchcnsic ltSB study oi thc urhan population oi Phnom Pcnh conductcd in April
1999 as part oi thc Phnom Pcnh Urhan lcalth Projcct, onc componcnt oi tamhodia`s
national lcalth Scctor Rciorm III programmc.
Full projcct dctails and iindings iorthcoming.
Ohjcctics To improc thc quality oi aiiordahlc carc in Phnom Pcnh particularly ior poor
communitics.
Findings Prcliminary iindings suggcst that thc urhan poor pay almost 28 pcr ccnt oi annual
incomc ior what is gcncrally pcrccicd to hc poor quality hcalthcarc. To mcct hcalth
costs pcoplc arc iorccd to takc out loans that grcatly cxaccrhatc cxisting iinancial
hardship. Acccss to scriccs is poor; pcoplc cannot aiiord to spcnd thc timc nccdcd to
qucuc ior trcatmcnt at hospitals, whcrc thcy arc chargcd oiiicial and unoiiicial iccs.
Acccssing thc gocrnmcnt`s cxcmption systcm is diiiicult and only a small pcrccntagc oi
thosc liing hclow thc pocrty linc rcccic suhsidiscd carc. Pcoplc rcsort to untraincd
drug scllcrs and traditional mcdicinc. Priatc practitioncrs practicc polypharmacy to
incrcasc iccs and thc quality oi thcir carc is poor.
Policy
implications
Succcss oi thc urhan hcalth projcct`s initiatics will iniorm ocrall hcalth policy
dcclopmcnt ior tamhodia in tcrms oi a comprchcnsic urhan hcalth stratcgy ior thc
country and thc scopc ior puhlic,priatc partncrships.
tonclusions Thc iindings oi thc study on ltSB arc shaping initiatics to improc thc quality oi
aiiordahlc hcalthcarc, cspccially ior thc urhan poor.
65
Author(s,
Titlc
\ittcr, S.
Doi Moi` and hcalth. thc ciicct oi cconomic rciorms on thc hcalth systcm in Victnam
Sourcc 1996, International Journal oI Health Planning and Management, Vol 11. 159-2
Ohjcctics To analysc thc changcs that hac takcn placc in thc hcalth systcm in Victnam sincc thc
cconomic rciorm proccss hcgan in thc latc 1980s.
Study typc
Data sourcc
& mcthods
Rcicw articlc.
Not applicahlc.
Findings \ittcr statcs that whilc cconomic lihcralisation has lcad to growth and incrcascd choiccs
ior many, it has also incrcascd incomc and rcgional disparitics and madc acccss to social
scriccs prohlcmatic ior thc cconomically ulncrahlc. Thc rcality is onc oi incrcasing
hcalth costs ior paticnts in thc iorm oi oiiicial and unoiiicial paymcnts to staii and
paymcnts ior drugs. Thc puhlic scctor is iaccd with dramatic dccrcascs in thc utilisation
oi puhlic iacilitics, a shiit towards scli-prcscription, incrcascd priatc practicc hy puhlic
cmployccs, and incrcasing rcliancc on iorcign donors to support prccntic programmcs.
Policy
implications
Gocrnmcnt policy strcsscs cquity and ircc acccss to hcalthcarc ior thc poor yct thc
cidcncc points to rising costs and dccrcascd usc oi puhlic scctor iacilitics, which
challcngc currcnt policy and planning in thc hcalth scctor.
tonclusions Thc author concludcs hy mcasuring thc changcs that hac takcn placc in thc hcalth scctor
against iour kcy critcria. (i, \hcrc costs hac riscn and utilisation dccrcascd, thc poor arc
prohihitcd irom acccssing scriccs. \ith incrcasing incomc incqualitics, acccss is a critical
issuc. (ii, \hilc iunding lccls arc inadcquatc to mcct thc hcalth nccds oi thc population,
priatc spcnding on hcalth has incrcascd, as has cxtcrnal aid. Thc kcy issuc is thc ciicctic
usc oi rcsourccs. (iii, Somc improcmcnts in ciiicicncy arc cidcnt such as thc shiit
towards thc usc oi population norms ior rcsourcc allocation, hut improcd training and
supcrision, incrcascd pay, rcgulation oi thc priatc scctor and a strongcr iocus on
communc lccl scriccs arc also nccdcd. (i, Improcmcnts in hcalth outcomcs arc hard
to asscss in rclation to thc impact oi cconomic rciorm, hut hcalth indicators do not
appcar to hac changcd much ocr thc pcriod. Ratcs oi malnutrition rcmain unacccptahly
high, howccr. Lxpcrtisc in hcalth iinancing, managcmcnt, training, supcrision and
communications arc paramount to dcal with thc changcs imposcd hy thc rciorm proccss.
66
Author(s,
Titlc
\oliicrs, I.
Thc rolc oi pharmaccuticals in thc priatisation proccss in Victnam`s hcalth carc systcm
Sourcc 1995, Social Science and Medicine, Vol +1 No 9. 1,25-2
Ohjcctics To discuss thc rolc oi pharmaccuticals in thc priatisation proccss in Victnam`s
hcalthcarc systcm.
Study typc
Data sourcc
& mcthods
Rcicw articlc.
Not applicahlc.
Findings Thc papcr dcscrihcs thc changcs in thc Victnamcsc hcalthcarc systcm and in thc supply
and dcmand ior drugs hciorc and aitcr thc cconomic rciorm proccss was launchcd in
1989. \oliicrs argucs that in thc transaction hctwccn uscrs and priatc proidcrs, drugs
arc thc tangihlc goods cxchangcd and around which a pricc can hc ncgotiatcd, in contrast
to adicc (which is diiiicult to cost, or mcdical tcsts (ior which cquipmcnt and skill may
hc lacking,. Thc author discusscs pharmaccuticals in thc contcxt oi thc history and
dcclopmcnt oi Victnam`s hcalth systcm and as a markcr ior social and political changc.
Policy
implications
Nonc drawn.
tonclusions Thc author argucs that thc attitudc oi hoth purchascrs and proidcrs oi hcalth scriccs
toward pharmaccuticals is a mctaphor ior thc changing hcalthcarc systcm oi Victnam, an
undcrstanding oi which is critical to hcttcr planning oi csscntial drugs programmcs.
6
Author(s,
Titlc
\orld Bank
lyrgyz Rcpuhlic. tonsultations with thc Poor
Sourcc 1999a, prcparcd ior thc Glohal Synthcsis \orkshop, Pocrty Group, PRLM, \orld
Bank
Ohjcctics PPA study undcrtakcn to iniorm thc \orld Dcclopmcnt Rcport 2000,1 on Pocrty
and Dcclopmcnt.
Study typc
Data sourcc
& mcthods
PPA to proidc iniormation on wcll-hcing and trcnds in wcll-hcing ocr timc; on
prioritiscd prohlcms oi thc poor; on coping stratcgics; institutional rclations and
rcsponsihilitics; and changcs in gcndcr rclations at houschold and community lccls.
A rangc oi group discussions and intcricws wcrc conductcd in ninc sitcs in thc thrcc
poorcst REODVWV oi thc lyrgyz Rcpuhlic and thc capital city.
Findings Thc incidcncc and dcpth oi pocrty has incrcascd in thc last tcn ycars. Incquality has
incrcascd and markct rciorms only hcnciit thc wcalthy. Many pcoplc now cannot aiiord
to pay thc cost oi hcalthcarc (or cducation,, prciously proidcd ircc hy thc statc. This
clcarly diiicrcntiatcs thc rich irom thc poor. Scc rcport ior dctailcd iniormation on
pocrty asscssmcnt.
Policy
implications
No policy implications arc drawn; thc iniormation gathcrcd spcaks ior itscli.
tonclusions Transition has cngcndcrcd many prohlcms cspccially ior thc poor. Factors rclatcd to thc
cconomic crisis, such as uncmploymcnt and high priccs, ctc, hac madc thc poor ccn
morc ulncrahlc. Thcrc is a lack oi gocrnmcntal support ior thc ulncrahlc. Formal
institutions such as hcalth and cducation scriccs arc inadcquatcly iundcd and as a rcsult
cannot iunction ciiccticly; thcy arc poorly rcgardcd. Thc poor turn to thc community
ior support sincc iormal institutions arc iailing to dclicr assistancc.
68
Author(s,
Titlc
\orld Bank
Uzhckistan. tonsultations with thc poor
Sourcc 1999h, prcparcd ior thc Glohal Synthcsis \orkshop, Pocrty Group, PRLM, \orld
Bank
Ohjcctics PPA study undcrtakcn to iniorm thc \orld Dcclopmcnt Rcport 2000,1 on Pocrty
and Dcclopmcnt.
Study typc
Data sourcc
& mcthods
PPA to proidc iniormation on wcll-hcing and trcnds in wcll-hcing ocr timc; on
prioritiscd prohlcms oi thc poor; on coping stratcgics; institutional rclations and
rcsponsihilitics; and changcs in gcndcr rclations at houschold and community lccls.
A rangc oi intcricws and group discussions wcrc conductcd in thrcc sitcs in thrcc
rcgions oi Uzhckistan.
Findings As rcgards hcalthcarc, thc study iinds that pcoplc pcrccic thc quality oi scriccs to hac
dctcrioratcd sincc cconomic rciorm. Unoiiicial paymcnts in cash or kind to hcalth staii
ior scriccs and drugs arc incrcasingly riic. Lcn scriccs suhsidiscd hy gocrnmcnt incur
unoiiicial costs. Lxcmption systcms do not assist thc ulncrahlc hccausc oi hurcaucratic
ohstaclcs. Illncss thcrciorc thrcatcns thc iinancial stahility oi houscholds and thc sick arc
now rcgardcd as a ulncrahlc scgmcnt oi thc population. Thc implication ior childrcn
whosc iamilics cannot aiiord to pay thc unoiiicial costs chargcd ior a rangc oi prccntic
carc scriccs, including inoculations ior prccntahlc discascs, is cspccially scrious.
Policy
implications
No policy implications arc drawn; thc iniormation gathcrcd spcaks ior itscli.
tonclusions Ocrall iindings arc summariscd (pp 6-9,. Rcgarding hcalthcarc scriccs, pcoplc pcrccic
that undcr cconomic rciorm, thc quality oi carc has dctcrioratcd, scriccs arc cxpcnsic
and unaiiordahlc ior many. Lquity is undcr thrcat, cspccially ior childrcn.
69
Author(s,
Titlc
\orld Bank
Victnam. tonsultations with thc poor. A synthcsis oi participatory pocrty asscssmcnts
irom iour sitcs in Victnam. Lao tai, la Tinh, Tra Vinh and lo thi Minh tity
Sourcc 1999c, prcparcd ior thc Glohal Synthcsis \orkshop, Pocrty Group, PRLM, \orld
Bank, hy Victnam-Swcdcn Mountain Rural Dcclopmcnt Programmc, Action Aid, Sac
thc thildrcn Fund (Ul, and Oxiam (GB,
Ohjcctics PPA study undcrtakcn to iniorm thc \orld Dcclopmcnt Rcport 2000,1 on Pocrty
and Dcclopmcnt.
Study typc
Data sourcc
& mcthods
PPA to proidc iniormation on wcll-hcing and trcnds in wcll-hcing ocr timc; on
prioritiscd prohlcms oi thc poor; on coping stratcgics; institutional rclations and
rcsponsihilitics; and changcs in gcndcr rclations at houschold and community lccls.
A rangc oi intcricws and group discussions wcrc conductcd inoling ocr 1,000
houscholds in iour sitcs in Victnam.
Findings As rcgards hcalthcarc sccking. liclihoods and liing conditions hac improcd, in thc
minds oi thc poor, ocr rcccnt ycars. lowccr, ccn hcttcr-oii houscholds icar illncss
cpisodcs which incur high cxpcnditurc and rcducc houschold capacity to carn. Ill hcalth
is thc most commonly citcd rcason ior houschold pocrty in rcccnt ycars, lcading to
disincstmcnt oi asscts and thc nccd to takc out iniormal scctor loans, with thcir long
tcrm impact on houschold liclihoods. Aoidancc oi mcdical trcatmcnt is also a coping
stratcgy ior thc poor. Prioritiscd prohlcms includc thc nccd to improc acccss to
aiiordahlc hcalthcarc, cspccially ior thc cldcrly. A prcicrcncc ior priatc practitioncrs was
oitcn citcd hccausc thcy oiicr homc isits and trcatmcnt on crcdit.
Policy
implications
No policy implications arc drawn; thc iniormation gathcrcd spcaks ior itscli.
tonclusions Thc poor cannot aiiord thc high dircct and indircct costs oi sccking trcatmcnt, arc morc
likcly to hc ill, and suiicr grcatly whcn a iamily mcmhcr ialls sick. As a rcsult,
rccommcndations to makc puhlic hcalth scriccs morc aiiordahlc and acccssihlc to poor
houscholds wcrc madc in all oi thc PPA sitc rcports.
0
Author(s,
Titlc
\orld Bank
Victnam Pocrty Asscssmcnt and Stratcgy
Sourcc January 1995, thc \orld Bank, tountry Opcrations Diision, tountry Dcpartmcnt 1,
Last Asia and Paciiic rcgion, lanoi, Victnam
Ohjcctics To dcclop a consistcnt nation-widc pocrty proiilc using thc VLSS data oi 1992-9 to
strcngthcn thc gocrnmcnt oi Victnam`s dcsign and targcting oi pocrty rcduction
policics. To cxaminc thc changing rolc oi thc puhlic scctor in iinancing and proision oi
social scriccs and saicty ncts in Victnam and to asscss its ciiicicncy in targcting puhlic
rcsourccs to thc poor in thc contcxt oi Victnam`s cconomic rciorms.
Study typc
Data sourcc
& mcthods
Rcport.
Thc rcport is hascd upon data irom thc VLSS oi 1992-9, a nationally rcprcscntatic
houschold surcy oi liing standards hascd on +,500 houscholds and 2,000 pcoplc in
urhan and rural arcas oi Victnam`s sccn gcographic rcgions.
Findings As rcgards thc utilisation oi hcalth scriccs and pocrty (scc pp 95-108,, thc rcport
outlincs thc dcclining utilisation oi hcalth iacilitics and thc incquitahlc acccss to quality
scriccs hy thc poor. Thc hcay rcliancc on scli-mcdication, particularly hy thc poor, is
notcd as wcll as thc dcpcndcncc oi thc cry poor on priatc, morc than puhlic, proidcrs.
As rcgards puhlic scctor proision, thc cry poor makc grcatcr usc oi communc hcalth
ccntrcs than thc non-poor. \ith incrcasing incomc a shiit in thc choicc oi proidcr irom
communc hcalth ccntrcs to hospital scriccs and irom priatc paramcdics to quality
priatc practitioncrs with incrcasing incomc is notcd.
Policy
implications
Bcttcr targcting oi puhlic cxpcnditurc to priority arcas and priority hcalth programmcs is
nccdcd ii thc incquitahlc acccss to scriccs hy thc poor is to hc addrcsscd. This inolcs
rcducing thc harricrs to utilisation oi distancc, scricc costs and quality oi carc.
tonclusions Thcrc is a thrcciold quality gap` hctwccn thc poor and non-poor in thc prohahility oi
sccing a high quality (hospital or priatc, proidcr. Thc poor iacc lowcr quality and
highcr priccs ior hasic hcalthcarc at puhlic iacilitics. Bcttcr targcting oi puhlic suhsidics is
nccdcd.
1
Author(s,
Titlc
\ip, \. t., \ang, l. and Liu, \.
Dctcrminants oi paticnt choicc oi mcdical proidcr a casc study in rural thina
Sourcc 1998, Health Policy and Planning, Vol 1 No . 11-22
Ohjcctics To analysc thc iactors inilucncing paticnt choicc oi mcdical proidcr
Study typc
Data sourcc
& mcthods
Rcscarch study using quantitatic mcthods.
Thc study is hascd in Shunyi county oi Bcijing in 199 and analyscs houschold surcy
data oi 1,8 outpaticnt trcatmcnt cascs.
Findings Thc study is thc iirst attcmpt to idcntiiy and quantiiy thc indiidual iactors dctcrmining
paticnt choicc oi proidcr in rural thina. Proidcr choicc rclatcs to thina`s thrcc ticr
hcalthcarc systcm oi illagc hcalth posts, township hcalth ccntrcs and county (and highcr
lccl, hospitals. It is analyscd in rclation to thrcc iactors hypothcsiscd to aiicct paticnt
dcmand. insurancc status, incomc and discasc pattcrn. Thc study shows that rclatic to
paticnts who pay icc-ior-scricc, thosc with lI (gocrnmcnt or Lahour lcalth Insurancc
hcnciiciarics, arc morc likcly to usc county hospitals, whilc paticnts insurcd undcr thc
rural toopcratic Mcdical Systcm (tMS, arc morc likcly to usc illagc lccl iacilitics.
ligh-incomc paticnts arc morc likcly to usc county hospitals than low-incomc paticnts,
who usc illagc lccl doctors. Discasc pattcrns appcar to hac a signiiicant impact on
proidcr choicc and paticnts with chronic illncss wcrc morc likcly to usc county hospitals
than illagc hcalth posts (thc study docs not control ior illncss sccrity,.
Policy
implications
Good tMS cocragc at thc illagc lccl would cncouragc utilisation at that lccl and
dctcr ocrusc oi highcr lccl proidcrs (ii accompanicd hy rcsourccs dircctcd towards
improing illagc lccl quality oi carc,. tMS cocragc also incrcascs thc likclihood oi
sccking iormal trcatmcnt, which ior thc poor may rcducc thc risk oi scrious illncss that is
associatcd with dclaycd sccking ior hclp. It might thcrciorc rcducc illncss costs.
Thc study shows that paticnts` ltSB must hc takcn into account in scricc planning and
rcsourcc allocation.
tonclusions Thc authors concludc that thina`s pattcrn oi cconomic growth is changing proidcr
choicc dramatically with incrcasing numhcrs oi pcoplc willing to pay highcr out-oi-
pockct costs in ordcr to usc thc highcr quality, county lccl, hospital scriccs. This
couplcd with thc cpidcmiological transition in rural arcas has important implications ior
thc organisation oi hcalthcarc iinancc and dclicry in rural thina.
2
Author(s,
Titlc
\u, D.
thangcs in hcalthcarc iinancing and hcalth status. thc casc oi thina in thc 1980s
Sourcc 1992, Innocenti Occasional Papers, Economic Policy Series No +, Florcncc, Italy.
UNItLF Intcrnational thild Dcclopmcnt tcntrc
Ohjcctics To rcicw dcclopmcnt oi hcalthcarc policy in thina and thc impact oi hcalth scctor
rciorms on hcalthcarc.
Study typc
Data sourcc
& mcthods
Rcicw papcr.
Not applicahlc.
Findings Thc papcr quotcs data on thc utilisation oi hcalth scriccs post-cconomic rciorm in
rclation to thc distrihution oi hcalthcarc rcsourccs and thc incrcascs in thc cost oi
mcdicincs and uscr iccs. Thc author citcs studics to show thc rcliancc oi rural
houscholds on hcalth scriccs at suh-county lccl, scriccs that wcrc rccciing
diminishing iinancial support. Studics oi thc urhan-rural shiit in uscr paymcnts as a sharc
oi total hcalth cxpcnditurc show scricc cocragc in rural arcas to hc impaircd and
scricc utilisation dccrcasing. Mcdical cxpcnscs as a proportion oi acragc annual incomc
arc shown to hc a grcatcr hurdcn ior rural than urhan incomcs. Issucs oi cquity oi acccss
to hcalth scriccs, cspccially ior thc poor in rural arcas, arc highlightcd.
Policy
implications
Thc author suggcsts that thina`s hcalth scctor rciorms wcrc implcmcntcd without
considcration cithcr ior thc naturc oi hcalthcarc scriccs or how hcst to iinancc thcm. hy
thc gocrnmcnt as puhlic goods, irom uscr iccs or a mixturc oi thc two. Thc author
statcs that hcalthcarc in thina has yct to hc rccogniscd as a hasic human right and as an
incstmcnt in pcoplc and in thc dcclopmcnt oi human capital.
tonclusions Thc author summariscs thc ncccssary stcps to hc madc in thc iinancc, organisation and
dclicry oi hcalth scriccs which may thcn lcad to improcmcnts in hcalth status. A
grcatcr iocus on rural hcalthcarc scriccs is rcquircd. Suggcstions to makc thc hcalthcarc
nctwork morc ciiicicnt and cost-ciicctic arc madc. Thc conclusion is that rciorm is an
on-going proccss.

Author(s,
Titlc
\u, l., tao, S. and Lucas, l.
Lquity in thc utilisation oi mcdical scriccs. a surcy in poor rural thina
Sourcc 199, IDS Bulletin, Vol 28 No 1. 16-2
Ohjcctics To cxaminc cquity in thc utilisation oi curatic mcdical carc scriccs in poor rural thina,
iocusing on thc ltSB oi thosc liing hclow thc pocrty linc.
Study typc
Data sourcc
& mcthods
Rcscarch study.
A 199+ houschold surcy oi thrcc study countics oi thina, cocring 2,22 houscholds.
Qucstionnaircs on houschold charactcristics, illncss cpisodcs, usc oi scriccs and mcdical
cxpcnditurcs in 199.
Findings Thc study catcgoriscs houscholds into thrcc incomc groups using pcr capita houschold
incomc and Statc touncil dciinitions oi pocrty. Data on thc usc oi outpaticnt scriccs
(hascd on two-wcck illncss rccall, is analyscd rclatic to thcsc thrcc groups. Limitcd
cidcncc is iound oi a diiicrcntial usc oi scriccs hy thc thrcc incomc groups, hut a much
grcatcr ariation is iound in thc usc oi inpaticnt carc. Poorcr houscholds arc signiiicantly
morc likcly not to scck mcdical carc whcn sick, mainly duc to thc hurdcn oi cost. This,
thc authors concludc, may indicatc that uscr chargcs ior outpaticnt carc arc acting as a
dctcrrcnt, cspccially ior thc poor. Similarly, cost prohihits thc poor irom cntcring
inpaticnt iacilitics. cxpcnditurc pcr hospital admission ior thc low incomc-group cost 18
pcr ccnt oi thc nct incomc pcr capita and 59 pcr ccnt oi thcir nct incomc pcr houschold.
Policy
implications
Sincc thc main iactor inilucncing thc non-usc oi scriccs is thc paticnt`s inahility to pay
ior carc, this indicatcs a nccd ior improcd stratcgics to cnsurc acccss to hasic hcalthcarc
scriccs ior all, cspccially thc poor.
tonclusions Thc papcr concludcs that thc rclaticly cqual acccss to hcalthcarc that cxistcd hciorc thc
cconomic rciorm programmc in thina has hccn crodcd as incquality in houschold
incomcs has incrcascd. In particular thcrc has hccn a considcrahlc impact on acccss to
inpaticnt scriccs hy poor houscholds, ior whom hcalthcarc cxpcnditurc may cxcccd total
annual incomc and lcad to iurthcr impocrishmcnt.
+
Author(s,
Titlc
Zhan, S., Tang, S.-L. and Guo, \.
Drug prcscrihing in rural hcalth iacilitics in thina. implications ior scricc quality and
cost
Sourcc 199, IDS Bulletin, Vol 28 No 1. 66-0
Ohjcctics To rcport thc rcsults oi a surcy oi drug prcscrihing hy iacilitics in thrcc poor rural
countics in thina.
Study typc
Data sourcc
& mcthods
Rcscarch study.
Analysis oi drug usc at county and township lccl hcalth iacilitics in thrcc poor rural
countics in thina. Analysis oi ,182 prcscriptions.
Findings Lxccssic and inappropriatc prcscrihing oi drugs was iound which cxposcd paticnts to
risk oi inciicctic trcatmcnt and adcrsc sidc ciiccts and contrihutcd to unncccssarily
high mcdical costs. Inappropriatc prcscrihing hchaiour hy hcalth proidcrs was also
complicatcd hy thc puhlic`s hclicis ahout thc grcatcr ciiccticncss oi importcd drugs ocr
local drugs, oi injcctions ocr tahlcts, oi cxpcnsic drugs ocr chcapcr oncs, couplcd
with thc inahility oi poor houscholds to aiiord a iull coursc oi prcscrihcd drugs.
Policy
implications
A programmc oi rciorms aimcd at proiding thc population with acccss to ciicctic carc
at rcasonahlc cost must includc mcasurcs to improc drug usc.
tonclusions Thc authors arguc that stratcgics ior improing prcscrihing practicc will hac to includc
changcs in hcalth workcrs` iinancial inccntics, improcd training and supcrision oi
hcalth workcrs` dispcnsing oi drugs, as wcll as rcgulation oi thc right to prcscrihc and scll
ccrtain typcs oi drugs.
5
AUTHOR INDEX
Aljunid, A., 1995
Bloom, G., 199
Bloom, G., Lucas, l., tao, S., Gao, J., \ao, J. and Gu, X., 1995
Bogg, L., lcngjin, D., lcli, \., \cnwci, t. and Diwan, V., 1996
tarlson, J., Than, T.T.l., Lc, l.D. and Grady, l., 1996
thcrnichosky, D. and Potapchik, L., 199
tommunity lcalth Rcscarch Unit, Ministry oi lcalth, 199
Lnsor, T., 1995
Lnsor, T. and Pham, B.S., 1996a
Lnsor, T. and Pham, B.S., 1996h
Lnsor, T. and Rittman, J., 199
Lnsor, T. and Saclyca, L., 1998
Gcncral Statistical Oiiicc, 199+
Gcrtlcr, P. and Litack, J., 1998
Glcwwc, P. and Litack, J., 1998
Gong, \. and \ilkcs, A., 199
Guldncr, M., 1995
Guscynoa, Z., thakoury, S. and Lcrcns, P., 1996
lcndcrson, G., Akin, J., Zhiming, L., Shuigao, J., laijiang, M. and lcyou, G., 199+
lolland, S., Phimphachanh, t., tonn, t. and Scgall, M., 1995
lsiao, \., 199+
Lao Social Indicator Surcy, 199+
Li, J., tao, S. and Lucas, l., 199
Mclcc, M., Figucras, J. and thcnct, L., 1998
Ministry oi lcalth, SR oi Victnam, 1991a
Ministry oi lcalth, SR oi Victnam, 1991h
Ministry oi Puhlic lcalth, 199
Nguycn, l.T., Lc, l.T.T., Riikin, S. and \right, L.P., 1995
Pham, l.D., 1996
Prcscott, N., 199
Scgall, M.M., Tipping, G., Dao, X.V. and Dao, L.l., 1999
Scgall, M., Tipping, G., Lucas, l., Truong, V.D., Nguycn, T.T., Dao, X.V. and Dao, L.l., 2000
Smithson, P., 199
Stcnson, B., Tomson, G. and Syhakhang, L., 199
Swcnson, I. L., Thang, N. M., Nhan, V. Q. and Ticu, P. X., 199
Tang, S.-L., 199
6
Tang, S.-L., Bloom, G., Fcng, X., Lucas, l., Gong, X. and Scgall, M., 199+
Tipping, G. and Scgall, M.M., 1995
Tipping, G. and Scgall, M.M., 1996
Tipping, G. and Truong, V.D., 199
Tipping, G., Truong, V.D., Nguycn, T.T. and Scgall, M., 199+
Tunyaanich, N., 1992
Vinard, P., 199+
\hitc, J., 1995
\ilkcs, A., \u, l., Bloom, G. and Gu, X., 199
\ilkinson, S., 1999
\ittcr, S., 1996
\oliicrs, I., 1995
\orld Bank, 1999a
\orld Bank, 1999h
\orld Bank, 1999c
\orld Bank, 1995
\ip, \.t., \ang, l. and Liu, \., 1998
\u, D., 1992
\u, l., tao, S. and Lucas, l., 199
Zhan, S., Tang, S.-L. and Guo, \., 199

AUTHOR INDEX BY REGION AND TRANSITIONAL ECONOMY COUNTRY

Southeast Asi a
&DPERGL D
\hitc, J., 1995
\ilkinson, S., 1999
&KL QD
Bloom, G., 199
Bloom, G., Lucas, l., tao, S., Gao, J., \ao, J. and Gu, X., 1995
Bogg, L., lcngjin, D., lcli, \., \cnwci, t. and Diwan, V., 1996
Gong, \. and \ilkcs, A., 199
lcndcrson, G., Akin, J., Zhiming, L., Shuigao, J., laijiang, M. and lcyou, G., 199+
Li, J., tao, S. and Lucas, l., 199
Tang, S.-L., 199
Tang, S.-L., Bloom, G., Fcng, X., Lucas, l., Gong, X. and Scgall, M., 199+
\ilkcs, A., \u, l., Bloom, G. and Gu, X., 199
\ip, \. t., \ang, l. and Liu, \., 1998
\u, D., 1992
\u, l., tao, S. and Lucas, l., 199
Zhan, S., Tang, S.-L. and Guo, \., 199
/DRV
lolland, S., Phimphachanh, t., tonn, t. and Scgall, M., 1995
Lao Social Indicator Surcy, 199+
Ministry oi Puhlic lcalth, 199
Stcnson, B., Tomson, G. and Syhakhang, L., 199
Vinard, P., 199+
9L HWQDP
Bloom, G., 199
tarlson, J., Than, T.T.l., Lc, l.D. and Grady, l., 1996
tommunity lcalth Rcscarch Unit, 199
Lnsor, T., 1995
Lnsor, T. and Pham, B.S., 1996a
Lnsor, T. and Pham, B.S., 1996h
Gcncral Statistical Oiiicc, 199+
8
Gcrtlcr, P. and Litack, J., 1998
Glcwwc, P. and Litack, J., 1998
Guldncr, M., 1995
Ministry oi lcalth, SR oi Victnam, 1991a
Ministry oi lcalth, SR oi Victnam, 1991h
Nguycn, l.T., Lc, l.T.T., Riikin, S.B. and \right, L.P., 1995
Pham, l.D., 1996
Prcscott, N., 199
Scgall, M.M., Tipping, G., Dao, X.V. and Dao, L.l., 1999
Scgall, M., Tipping, G., Lucas, l., Truong, V.D., Nguycn, T.T., Dao, X.V. and Dao, L.l., 2000
Smithson, P., 199
Swcnson, I.L., Thang, N.M., Nhan, V.Q. and Ticu, P.X., 199
Tipping, G. and Scgall, M.M., 1996
Tipping, G. and Scgall, M.M., 1995
Tipping, G. and Truong, V.D., 199
Tipping, G., Truong, V.D., Nguycn, T.T and Scgall, M.M., 199+
Tunyaanich, N., 1992
\ittcr, S., 1996
\oliicrs, I., 1995
\orld Bank, 1999c
\orld Bank, 1995
Central Asia
.D]DNKVWDQ
Lnsor, T. and Rittman, J., 199
Lnsor, T. and Saclyca, L., 1998
8]EHNL VWDQ
\orld Bank, 1999h
.\UJ\] 5HSXEO L F
\orld Bank, 1999a
$]HUEDL M DQ
Guscynoa, Z., thakoury, S. and Lcrcns, P., 1996
9
2WKHU UHIHUHQFHV
Aljunid, A., 1995
thcrnichosky, D. and Potapchik, L., 199
lsiao, \., 199+
Mclcc, M., Figucras, J. and thcnct, L., 1998