Document [original]

Duong Anh Vuong, Steffen Flessa, Paul Marschall, Son Thai Ha, Khue Ngoc

Luong, Reinhard Busse

Determining the impacts of hospital cost-

sharing on the uninsured near-poor

households in Vietnam

Article, Published version

This version is available at http://nbn-resolving.de/urn:nbn:de:kobv:83-opus4-70081.

Suggested Citation

Vuong, Duong Anh ; Flessa, Steffen ; Marschall, Paul ; Ha, Son Thai ; Luong, Khue Ngoc ; Busse ,

Reinhard : Determining the impacts of hospital cost-sharing on the uninsured near-poor households in

Vietnam. - In: International Journal for Equity in Health. - ISSN 1475-9276 (online). - 13 (2014), art. 40. -

doi:10.1186/1475-9276-13-40.

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RESEARCH Open Access

Determining the impacts of hospital cost-sharing

on the uninsured near-poor households in

Vietnam

Duong Anh Vuong

, Steffen Flessa

, Paul Marschall

, Son Thai Ha

, Khue Ngoc Luong

and Reinhard Busse

Abstract

Objectives: The study objective was to identify the size of different hospital financing sources for different hospital

services and their impact on the uninsured.

Methods: A panel dataset of 84 public general hospitals (2005–2008) with cross-section data on hospital activity

and hospital revenue was created and used to calculate unit costs of different hospital services by applying multiple

regression models. The resulting risk of catastrophic health expenditure (CHE) was estimated based on official

income statistics.

Results: Average user fees (UF) for outpatient visits and inpatient bed days were US$4.13 and US$20.27, while

actual full costs (AFC) were US$8.41 and US$36.66, respectively. These unit costs were 2.5 times higher in hospitals

at the central versus the provincial level. UF for surgical inpatient bed days were 3.6 times that of non-surgical

treatments (US$47.50 vs. 12.87) and AFC 5.0 times (US$101.72 vs. 20.08). UF accounted for 44.6%-77.9% of the AFC,

the rest (22.1%-55.4%) was provided by direct government support (DGS). One surgical inpatient treatment at either

central or provincial hospital level and one non-surgical inpatient treatment at central hospital level, immediately

pushed uninsured near-poor households at risk of CHE.

Conclusions: Around 45% of hospital AFC was paid by DGS, the larger rest by UF. UF have become a great

financial burden on the uninsured near-poor households, who have to pay for these out-of-pocket and therefore

may not utilize even necessary services. If the rate of DGS were reduced, this would have the effect of increasing

UF, but the savings to Government could be spent on subsidizing insurance to ensure that a larger part of the

population can cover UF through insurance, especially the near-poor households.

Keywords: Cost-sharing, Hospital unit cost, User fee, Catastrophic health expenditure, Vietnam

Introduction

The Socialist Republic of Vietnam is currently in the

process of implementing major health care reforms. One

major element of these reforms is a shift from a centrally

planned system where health care services were pro-

vided to the population free of charge, to the decentra-

lized and contracted social health insurance (SHI)

model. The introduction of hospital cost-sharing under

the mechanism of a fee-for-service scheme was started

in 1989 [1,2], which aimed to improve financial capacity

and sustainability of these health care institutions result-

ing in higher quality and reliability of care. There have

been major achievements, such as new health technol-

ogy development, better health care service provision,

increasing financial support for hospital performance

and relief of the financial burden on the government.

However, in the process of ongoing reform, a mix of

payments for health care services consisting of contribu-

tions from the state budget and “user fees”, which are

either covered by SHI as third party payments (TPP) or

out-of-pocket (OOP), developed, which caused a major

controversy. Objections to the reform include (i) that it

might reduce necessary utilization by the poor, who may

not be able to afford the health care services; and (ii)

* Correspondence: [email protected]

Department of Medical Service Administration, Vietnam Ministry of Health,

Hanoi, Vietnam

Full list of author information is available at the end of the article

Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and

reproduction in any medium, provided the original work is properly credited.

Vuong et al. International Journal for Equity in Health 2014, 13:40

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that the role of the government in supporting population

access to hospital services is unclear, since there is no

clear policy to demarcate responsibility among the state,

health insurance and service users [3-5]. The question

remains of how much of the hospital service costs is

now financed by user fees and what the impacts of this

are on the service users, in particular those who are

uninsured and have to pay by OOP. Does it lead to

“catastrophic health expenditure”(CHE)? This question

will be explored and answered in this paper by looking

at the revenues and costs of two main hospital services,

namely outpatient visits and inpatient stays for both

surgical and non-surgical patients and for both central

and provincial hospitals.

Background

The current health care system was established in the

northern part of Vietnam by the late 1950s, then in the

south after reunification in 1975. The health care system

was formed according to the four administrative levels

of the state. These are, firstly, the central level, then the

provinces, which are in turn divided into districts and

communes. At the central level there are 41 hospitals

(18 general and 23 specialized); at the provincial level

there are 340 hospitals (124 general and 216 specialized);

and there are 609 district general hospitals. One health

commune station exists in each commune at the grass-

roots [6-8].

As in most countries in Central-Eastern Europe and

Central Asia, after the collapse of the Soviet Union in

the late 1980s, the country faced a socio-economic

crisis due to a sudden cut of foreign aid, and free health

care provision to the whole population was no longer

available. The state budget is only sufficient to support

for public health facilities in some main categories of

salaries, administrative management, equipment, main-

tenance, consumables, and a small number of hospital

fee exemptions for the very poor or vulnerable groups of

patients [9-11]. The rest has been covered by the so called

‘User Fee’, which was introduced by the Vietnamese

Government by the Ordinance of Private Medical and

Pharmaceutical Practices and the Policy on Hospital

Partial Fees. The user fee was first introduced in 1989

for inpatient services, with a partial hospital fee, then

expanded to all in- and outpatient services. It allows

hospitals to collect a fee, according to a fee-for-service

(FFS) scheme, for certain services including consult-

ation, drugs, consumables, blood infusions, diagnostic

procedures, operative procedures, and hospital bed

utilization [11]. The ranges of these services’fee were

issued by the Ministry of Health, with the basic thresh-

old determined for each relevant administrative level.

The local authorities take it as a basis to specify the

precise fee for each service, in relation to the technical

capacity of their hospital and their local community’s

ability to pay [3,4,12,]. The hospitals at the central level

normally receive more investment and are better equipped

with technology; and being the highest level in the referral

hierarchy, they logically receive patients with more severe

illnesses. Consequently, the highest level of the central

hospitals has a higher cost rate compared to provincial or

district hospital levels for the same service [13].

In short, funding to hospitals is a combination of two

main sources: state budget (bed-norm based provision)

and user fees [12]. The state budget is, as in most devel-

oping and some industrialized countries, transferred to

the hospitals in the form of line-item allocations from

government health authorities, the rate of provision

depending on the wealth of each province [14,15]; these

allocations are meant to cover the fixed costs of the hos-

pitals, especially for personnel and maintenance. There

are two main sources of UF payments, which are meant

to cover the variable costs: TPP and OOP payments. In

2007, TPP comprised 49% of population, which was

made up by statutory health insurance for employees

with 9% of the population, free health care for the poor

(HCFP) with 18%, free health care for children under

6 years of age with 11%, and another 11% by voluntary

health insurance [16]; OOP payments are made by those

with no health insurance.

The free HCFP policy was started since following

“Decision 139”of the Prime Minister on “health exam-

ination and treatment for the poor”in 2002 which

provides free health insurance for the poor who were

defined as those with a total income per year under

2,400,000VND in rural and 3,120,000VND in urban

areas (by purchasing power parity [PPP] in 2002, equal to

US$405; US$527, respectively) [17,18]. The HCFP was

rather successful in achieving positive outcomes with a

positive impact on increasing overall health care service

utilization; reducing OOP expenditure for health care of

the poor and the risk of catastrophic OOP spending

[5,19]. However, aside from the defined poor households

who were provided free health insurance, the near-poor

households are now of the greatest concern for the gov-

ernment in regard to health insurance provision.

The near-poor households are defined as having an

income between 201–260,000VND/head/month in rural

and 261–338,000VND/head/month in urban areas; in

the estimation of the average annual income of the near-

poor by PPP, in 2008 it was equal to US$420 per head

for both urban and rural groups [20]. The near-poor are

roughly estimated to account for 14% of the population

[21]. The risk of this group for CHE is now at the higher

than for the poor; Nguyen and colleagues found that 24%

of them have to borrow money to pay for outpatient treat-

ment, compared to 20% of the poor and 12% of others

[22]. The government made a policy to subsidize 50% of

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the health insurance premium for the near-poor house-

holds, but 90% of them are not yet covered [23].

Methods

Data set

As no patient-level data were available, we had to use

aggregate statistics from hospitals, which formed the basis

for our analysis. The data used in this study are thus

facility-based data of annual statistical reports, extracted

from the annual hospital statistical reports collected and

administered by Ministry of Health (Department of

Medical Service Administration), over 4 years (2005–2008).

By regulation, every hospital has to annually submit

the hospital statistical report to the Ministry of Health

(by electronic mail or on paper). However, each year

about 15-20% of the observations were not available.

The missing reports were those sent by post where the

address may have been incorrect or the data adminis-

trators were not able to manually enter all data into

the database at the MOH. General hospitals at the

central and provincial levels which have submitted a

minimum of 4 year reports to the Ministry of Health

were selected for this study. The set of available data

included 84 general hospitals (76 provincial hospitals,

8 central hospitals) with a total of 336 observations.

Private hospitals were excluded as our purpose is to

establish the share of different financial sources for the

public hospital unit costs.

A panel dataset was generated including out- and in-

patient flows; treatment and care procedures; and

hospital revenue from user fees and state budget. To

balance the value of local currency (VND) by years and

to be suitable for international benchmarking, hospital

income figures were adjusted by PPP to US dollars

(PPP in 2008: 7,688; 2007: 6,484; 2006: 6,158; 2005:

5,919) [17]. Unit costs of hospital services are defined

inthecurrentstudyasunitcostofoutpatientvisits

and hospital stays (operationalized as inpatient bed

days). The inpatient bed days were further categorized

into surgical and non-surgical cases, depending on

whether patients had received an operation or not

[24,25]. A further division was done between hospitals

at provincial and central level.

As the data provided only contained aggregate revenue

received by the hospitals, we had to rely on the following

assumption to calculate costs from revenue: Based on

the fact that (a) all financial sources in the processing

procedures that can contribute to final outputs are

value-added [26] and (b) all public hospitals are non-

profit organizations and must therefore balance revenue

and costs, the revenue was substituted for costs in ana-

lyzing cost units. Costs were classified into three differ-

ent categories: revenue from user fees (UF) as a proxy

for variable costs, the state budget revenue as a proxy

for fixed costs, especially maintenance and personnel,

and actual full cost (AFC) as additionally including

depreciation of capital.

The hospital revenue from UF revenue was available

as being collected by TPP or OOP; and total revenue

was equally available as the combination of UF revenue,

bed-norm based provision of state budget, donation and

others (generally called state budget). To calculate AFC,

based on previous studies, we estimated that the annual

depreciation rate of capital investment on equipment and

buildings added 8.5% to total revenue [13,27,28]. The state

budget plus the annual depreciation of capital investment

(as these are only public hospitals) accounted for the

direct share contributed by the government (the so-

called direct government support (DGS)).

The three different categories of revenue, and respect-

ive costs, can be displayed by formulas as follows:

UF R≈PVariable costs ¼PCost of consultation;drug;consumable;

infusion;blood;diagnosed test procedures;operation

procedures;hospital bed use

Total R¼UF RþStateBudget R≈PVariable costsþPFixcosts1¼PVariable costs

þPCost of maintenance;salaries=wages;management=operation

AFC¼Total Rx1:085≈

PVariable costsþ

PFixcosts1þ

PFixcosts2¼PVariable costs

PFixcosts1þ

PCost of depreciation on equipments;depreciation on buildings

The results of UF for each unit of hospital services

were judged in relation to the concept of households at

risk of CHE, especially for those who have to pay for the

hospital services OOP. The risk of CHE is immanent if

OOP payments exceed 15-20% of a household’s annual

income, depending on the threshold used [29-32]. The

income was taken here as the average income per capita

in 2008 (11,942,400VND) adjusted to US$ by PPP (equal

to US$1,553). With the average number of persons in

one household is 3.8 person [33] the average national

household income was equal to US$5,901 and average

near-poor household income was equal to US$1,596.

Regression models

Using the equation of multiple regressions on hospital

cost functions to calculate the final hospital unit costs:

Ri;t¼boþXbi;tXi;tþei

In which, R

i,t

stands for the revenue of hospital i at

time t;

i,t

1,t

is predictor variable of inpatient bed day at

time t and X

2,t

is predictor variable of outpatient visit at

time t;

: the plane’s reference position (intercept) defines

the value of R when all X

=0;

: a regression coefficient of the variable X

on the

total revenue R

that quantify the effects of inpatient bed

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day (X

) and outpatient visit (X

) upon the hospital

revenue R

respectively; e

error term [34,35].

Statistical analysis

The linear regression on the longitudinal/panel data

methodology was applied in STATA 10.0. Firstly, UF

revenue was regressed (fixed-effect) on the output vari-

ables of inpatient bed days (InpBD) and outpatient

visits (OutpV). Then, a similar regression was applied

for total revenue (i.e. UF and state budget) in the rela-

tionship with InpBD and OutpV. Those two models

resulted in the ratios of regression coefficients between

InpBD and OutpV interactions on UF revenue and on

total revenue respectively which suggests cost comple-

mentarities between InpBD, OutpV on UF revenue and

those on total revenue. These ratios were in turn used to

estimate the UF revenue/total revenue allocated relevant

to the unit costs of InpBD and OutpV (Table 1).

Similarly, the Regression Model (fixed-effect) was run

for InpBD on two variables of surgical and non-surgical

inpatient cases, to find the regression coefficient ratios

of length of stay (LOS) for one surgical case (SurInpC)

versus one non-surgical inpatient case (OtherInpC), that

were used to calculate the number of surgical inpatient

bed days (SurInpBD) and number of non-surgical bed

days (OtherInpBD). Those two variables (SurInpBD,

OtherInpBD) were then regressed on the UF revenue/

total revenue to find the ratios of regression coeffi-

cients of one SurInpBD and one OtherInpBD inter-

action on the cost of inpatient bed days in regard to UF

revenue and to total revenue, respectively. Then, rely-

ing on those regression coefficient ratios the total cost of

surgical and non-surgical inpatient bed days were calcu-

lated (Table 1).

All fixed-effect (within) regression were tested by a

Hausman Fixed Random test to make sure the difference

in coefficients between fixed-effect (within) regression and

random-effect GLS regression is not systematic [35,36].

Results

From the baseline data:

The percentage of patients paying user fees through

OOP was 46.7% on average for out- and inpatient visits;

it declined from 56.2% in 2005 to 41.8% in 2008.

Conversely, the percentage of patients covered by TPP

increased from 43.8% to 58.2%. The LOS was almost

stable, in the range of 7.3-7.6 days at the provincial hos-

pital level and 9.6-10.4 days at the central hospital level

(Table 2).

From the Regression Model:

A significant linear regression was found between UF

revenue and two variables of InpBD and OutpV (both

variables, p < .001) and accounted for 63% of the vari-

ance in UF revenue (R

= .63). Similar observations were

found for total revenue in the relationship with InpBD

and OutpV (R

= .71; both variables, p < .001). The ratio

of regression coefficients between InpBD and OutpV

interactions on UF revenue is 75.71/15.42 and on total

revenue is 87.69/20.15 (Table 1).

Based on UF revenue, the variable costs of one InpBD

and OutpV were US$20.27 and US$4.13, respectively;

one SurInpBD cost US$47.50 versus US$12.87 for an

OtherInpBD. Comparing unit costs between different

hospital levels, the hospitals at the central level cost 2.5

times more than the ones at the provincial level (out-

patient visit: US$9.22/3.59, inpatient bed day: US$45.28/

17.64) (Table 3 ).

Table 1 Results of the regression models

Independent variables Revenue through user fees (UF) Total revenue (UF plus state budget) = direct provider cost

Coefficient SE t/P-value Coefficient SE t/P-value

Dep Var: UF Revenue Dep Var: Total Revenue

R-sq: within = 0.63 R-sq: within = 0.71

InpBD 75.71 4.46 16.96/<.001 87.69 4.35 20.15/<.001

OutpV 15.42 4.26 3.61/<.001 20.15 4.16 4.84/<.001

Dep Var: InpBD

R-sq: within = 0.76

SurInpC 6.29 .624 10.07/<.001

OtherInpC 7.21 .320 22.53/<.001

Dep Var: Cost of inpatient bed days Dep Var: Cost of inpatient bed days

R-sq: within = 0.46 R-sq: within = 0.40

SurInpBD .0001646 .0000199 8.27/<.001 .0001859 .0000229 8.11/<.001

OtherInpBD .0000446 .0000091 5.59/<.001 .0000367 .0000091 4.00/<.001

(Abbreviations:InpBD inpatient bed day, OutpV outpatient visit, SurInpC Surgical inpatient case, OtherInpC non-surgical inpatient case, SurInpBD Surgical

inpatient bed day, OtherInpBD non-surgical inpatient bed day).

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Regarding AFC, one OutpV cost US$8.41 and one

InpBD cost US$36.66. Inpatient bed days for surgery

cost up to US$101.72 compared to US$20.08 for non-

surgery (Table 3). The share of user fees of the AFC dif-

fered among unit costs. On average, one OOP payment

or TPP covered 49.1% of the AFC of outpatient visits

and 55.2% of one inpatient bed day. The UF made up a

higher proportion of the AFC of different unit costs

at the central level compared to the provincial level,

ranging between 56.8 and 77.9% and 44.6 and 61.3%,

respectively. The highest share was for a non-surgical

bed day at the central level (77.9%) and the lowest share

for a surgical bed day at the provincial level (44.6%).

Impact implications:

In the estimation of the impact of sharing the unit

costs of hospital services, one inpatient treatment epi-

sode of surgical treatment at either central or provincial

hospital levels; and of a non-surgical treatment at central

hospital level immediately made the near-poor house-

holds who are uninsured and had to pay OOP for the

treatment at risk of CHE. Just one surgical inpatient

treatment at central hospital level exceeded the 15%

threshold of the household’s average annual income of

the whole population (in 2008) (Table 4).

Discussion

Information about hospital unit costs are key require-

ments for many types of decision making, serving as

input to assess the relative efficiency of treatment between

hospitals, and are essential for budgeting and planning

exercises [24]. The unit costs of inpatient bed days and

outpatient visits are often available in high-income coun-

tries. Unfortunately, it is rare in Vietnam or in similar

contexts in developing countries where the public hospital

cost data are mostly nonexistent [37]. To fill this gap,

using a large panel data of 4 consecutive years in 60% of

general hospitals in Vietnam, the results of the current

study reflect the real picture of Vietnam hospital health

care services. The main result found was that generally up

to 51% of outpatient visits and 45% of inpatient bed day

costs are directly supported by the government, either

through the state budget or through ownership and thus

being responsible for depreciation. This indicates a higher

proportion of hospital unit costs are covered by the gov-

ernment, compared to 30% of total health expenditure

covered by public expenditure on health [12]. The main

result in the current study was derived from a series of

results on different hospital unit costs, which were found

to be consistent with those of previous studies. The results

of studies conducted by the Ministry of Health in 2006

Table 2 Hospital characteristics by year

Year Average length of stay (in days) % of patients for

whom user fees are

covered by TTP (n = 84)

All (n = 84) Province

(n = 76)

Central

(n = 8)

2005 7.7 7.4 10.4 43.8

2006 7.8 7.6 10.1 51.9

2007 7.7 7.5 10.0 57.2

2008 7.6 7.3 9.6 58.2

Table 3 Means of unit costs for hospital services and percentage of UF per AFC of each unit cost

Hospital service and level Mean of unit costs (US$) UF as%

of AFC

By UF ≈variable

costs [95% CI]

By total revenue ≈variable

plus fixed costs [95% CI]

Actual full

costs (AFC)

Outpatient visit

All 4.13 [3.76-4.49] 7.76 [7.32-8.20] 8.41 49.10

Provincial level 3.59 [3.35-3.83] 7.04 [6.72-7.35] 7.63 47.05

Central level 9.22 [6.59-11.85] 14.64 [12.03-17.25] 15.88 58.06

Inpatient bed day

All 20.27 [18.47-22.08] 33.79 [31.87-35.70] 36.66 55.29

Provincial level 17.64 [16.46-18.82] 30.63 [29.27-31.99] 33.23 53.08

Central level 45.28 [32.38-58.18] 63.74 [52.38-75.10] 69.15 65.48

Surgical inpatient bed day

All 47.50 [43.59-51.40] 93.76 [88.93-98.58] 101.72 46.69

Provincial level 41.70 [39.25-44.16] 86.10 [82.73-89.47] 93.41 44.64

Central level 102.53 [74.08-130.97] 166.46 [136.03-196.89] 180.60 56.77

Non-surgical inpatient bed day

All 12.87 [11.81-13.92] 18.51 [17.55-19.46] 20.08 64.09

Provincial level 11.30 [10.63-11.96] 16.99 [16.33-17.66] 18.43 61.31

Central level 27.78 [20.07-35.48] 32.86 [26.85-38.86] 35.65 77.92

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(data for 2005) found the total cost per bed day (within 29

inpatient episodes) in provincial general hospitals to be

218,363VND (equal to US$36.8) [11]. Other studies by

the Ministry of Health in 2005 (data from 2003 from 30

provincial hospitals) found that one inpatient bed day

for surgery treatment (childbirth and appendicitis) cost

195,000VND (equal to US$33) and for internal treat-

ment in the range of 94,000-340,000VND (US$15.8-

57.4) [27]. At the central level, to our knowledge, there

is only one study by Flessa & Dung from 2004 which

gave results from Bachmai hospital, indicating that one

outpatient visit costs US$0.86 and one inpatient bed day

US$13.40 (those costs were converted to USD accord-

ing to the exchange rate, and by PPP they were equal

to US$2.3 for an outpatient visit and US$35.3 for an

inpatient bed day), of which the inpatient bed day cost

is consistent with our current results [13]. In compari-

son with other countries, our result is similar to the unit

costs of secondary level hospitals in the much higher GDP

per capita countries like Indonesia (cost of inpatient bed

day: US$35.1), Equador (US$35.9), and Romania (US

$39.0); and higher than those countries which have

approximately the same GDP per capita, such as Algeria

(cost of inpatient bed day: US$19.28) [37,1]. In compari-

son to the WHO categorized regions, our result is rela-

tively lower than that of Western Pacific Region B

(Vietnam belongs to this region) where an inpatient bed day

costs US$63, and an outpatient visit costs US$34. It is simi-

lar to the Eastern Mediterranean Region D (Afghanistan,

Pakistan, Iraq and Sudan, etc.) averages, though [38].

In consideration of DGS, for only one inpatient day of

surgery at the central level the government has to subsidize

up to US$78.07, that is as much as 10 outpatient visits at

the provincial level. This support could be crucial for the

poor or near-poor who have to pay for hospital services

by OOP payment. However, the use of medical services

(hospital admission) by the better off is 2.5-4.5 times

greater than that of the poor [12]. The insured have

almost twice the rate of admission than the uninsured

[7], and insurance coverage was higher among those

who have a higher ability to pay for health care [39].

That clearly implied an inequity in the benefits of

hospital service utilization among different groups

within the population. The richer could pay for the

services but actually they gain greater benefit from

the direct support of the government, which was

originally targeted at the lower income group in the

population [12,40,41].

Policy implications: The findings of the paper offer

some suggestions for evidence-based policy solutions

that will help decrease the prevalence of catastrophic

health spending in Vietnam. One of three fundamental

concerns of the government in health financing sources

is to protect people from the financial consequences of

ill health and having to pay for health services [42], aside

from the poor who have been provided with free health

insurance. The remaining near-poor households, will be

subject to the negative impact of the FFS regime, that is,

to be at risk of CHE. The government should shift from

direct support to hospitals to the prepaid regime with

free health insurance which would provide a larger pro-

portion of the vulnerable group of low income people or

households with the benefit of increased access to health

care services.

The strength of our study is that the results relied on

the panel data of quite a large number of hospitals (60%

of the total number of general hospitals) in 4 consecu-

tive years which allowed us to capture the outcome

variation among hospitals caused by the differences

of unobservable determinants and the correlation

between differences of unobservable and observable

determinants of behavior [35].

However, the limitations of this article are that, firstly,

with the limited information on the health care system,

poor quality of hospital statistics, and the multi-stage

regressions used to estimate the unit costs, we were only

able to relatively calculate some basic unit costs neces-

sary for hospital policy considerations [6]. Secondly, the

output measured here may provide a relatively poor fit,

because the two groups of hospitals would have quite

different total costs, while the total number of bed days,

and also the number of outpatient visits, are the same

Table 4 User fees for surgical and non-surgical inpatient cases and their impact on users having to pay for the hospital

service OOP

Hospital service

and level

UF per

day (US$)

Average

LOS (days)

UF for whole treatment

episode (US$)

UF/annual income of

near-poor household (%)

UF/average income per

household in 2008 (%)

Surgical inpatient treatment case

Province 41.7 6.6 275.2 17.2 4.5

Central 102.5 8.7 891.7 55.8 15.1

Non-surgical inpatient

treatment case

Province 11.3 7.5 84.2 5.2 1.4

Central 27.7 10.4 288.1 18.1 4.8

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[34]. Some of the cost may not be actually reflected such

as the estimation of under table payment, the drugs out

of hospital inventory which patient has to buy.

Conclusions

While around 45% of hospital AFC is paid by DGS, the

larger rest is covered by user fees. These have become

a great financial burden for the uninsured near-poor

households, as they have to pay for these out-of-pocket,

which either leads to CHE and/or to an under-utilization

of necessary services. If the rate of DGS were reduced, this

would have the effect of increasing UF, but the savings to

Government could be spent on subsidizing insurance to

ensure that a larger part of the population can cover UF

through insurance, especially the near-poor households,

and thus to reduce their risk of CHE and/or under-

utilization of services.

Competing interests

The authors declare that they have no competing interest.

Authors' contributions

DAV Initiating the idea for writing manuscript, Data collecting cleaning and

analysis, drafting manuscript. SF Advising methodology. PM Involved in

drafting manuscript. STH Data collection. KNL Involved in drafting manuscript,

Advising methodology. RB The idea and direction of constructing manuscript,

Correcting manuscript. All authors read and approved the final manuscript.

Acknowledgements

The authors would like to acknowledge MOH of Vietnam for kindly providing

the dataset. Any remaining errors are the responsibility of the authors.

Author details

Department of Medical Service Administration, Vietnam Ministry of Health,

Hanoi, Vietnam.

Department of Health Care Management, Berlin University

of Technology, Berlin, Germany.

Department of Business Administration and

Health Care Management, Ernst-Moritz-Arndt-University of Greifswald,

Greifswald, Germany.

Received: 10 April 2013 Accepted: 6 May 2014

Published: 17 May 2014

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doi:10.1186/1475-9276-13-40

Cite this article as: Vuong et al.:Determining the impacts of hospital

cost-sharing on the uninsured near-poor households in Vietnam.

International Journal for Equity in Health 2014 13:40.

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