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VIETNAM ACADEMY OF SOCIAL SCIENCES GRADUATE ACADEMY OF SOCIAL SCIENCES NGUYEN THI MINH CHAU PEOPLE'S ACCESS TO MEDICAL EXAMINATION AND TREATMENT SERVICES COVERED BY HEALTH INSURANCE AT THE GRASSROOTS LEVEL AND FACTORS INFLUENCING ACCESS (CASE STUDY IN HAI DUONG AND BINH DINH) Major: Sociology Code: 91.31.04.01 SUMMARY OF DOCTORAL THESIS Ha Noi, 2019 THIS WORK IS COMPLETED AT GRADUATE ACADEMY OF SOCIAL SCIENCES MENTOR: PROF DR NGUYEN HUU MINH Reviewer No.1: Reviewer No.2: Reviewer No.3: The thesis is defended before the thesis appraisal board of the Academy at the Graduate Academy of Social Sciences at: hours, date month 2019 This thesis can be found at: - Library of Graduate Academy of Social Sciences - National Library of Vietnam LIST OF PUBLISHED ARTICLES AND WORKS RELATED TO THE THESIS Nguyen Thi Minh Chau (2014) Concepts of access to health services and measurement: Review of International Researches Practical Medicine Journal, No 11 (940) 2014, pages 24-27 Nguyen Thi Minh Chau (2015) Access to medical examination and treatment covered by health insurance in Vietnam: Analytical review from the policy implication and policy implementation perspective Journal of family and gender studies No (25) 2015, pages 23-34 Nguyen Thi Minh Chau (2016) Access to medical examination and treatment covered by health insurance in Vietnam: Critical review from demand and supply perspectives Journal of family and gender studies No (26) 2016, pages 26-38 PREAMBLE The necessity of the study: Health is a fundamental factor and also a goal in the socio-economic development process of each country Access to health services is basically a basic human right (Alma Ata, 1978) But it is not always guaranteed in everywhere There is a difference in access to health services between regions, communities and individuals with different demographic characteristics, perceptions, awareness and understanding of health For studies in Vietnam, recently there have not been many studies using a comprehensive approach to evaluate people’s access to medical examination and treatment services in the context of many new policies in this area The role of family and individual factors as well as service delivery factors with regard to people's access need to be considered in the overall relationship Moreover, studying the level of access and use of services by a community is a topic that is of great concern to policy makers, particularly in the context of transition from a centrally planned economic system to a market mechanism that entails profound changes in the health system from having no or only one option to many options while the state continues to invest in public health In order to use resources effectively, maintain advantages in service delivery, especially to the disadvantaged, medical facilities must adapt to the new situation Therefore, the research: ''People’s access to medical examination and treatment services with health insurance at the grassroots level and factors influencing access (case study in Hai Duong and Binh Dinh) '' is carried out to answer the following research questions: • What is the situation of access to medical examination and treatment services for the health insurance at the grassroots level in the study area? • How the policy/ institutional, service delivery and user factors influence access to medical examination and treatment services for the health insurance card holders at the grassroots level? Research objectives and tasks 2.1 Research objectives The purposes of this study are (i) to understand people’s access to medical examination and treatment with health insurance at the grassroots level, (ii) to analyze relevant factors from a policy perspective and that of service provider, service users to make policy suggestions to enhance the level of access in the study area in particular and for the grassroots level in general 2.2 Research tasks • Develop a theoretical basis to learn about the status of access to medical examination and treatment services for the health insure at the grassroots level based on clarifying key concepts related to the research • Apply basic theoretical approaches, including structural-functional theory, theory of rational choice and selectively apply appropriate elements of common analytical models used in health policy and service research in the study of access to medical examination and treatment services for the health insurance card holders at the grassroots level • Carry out sociological survey using quantitative and qualitative methods to analyze and evaluate the status of access to medical examination and treatment services for the HI participants at the grassroots level and social differences in access as well as explains the factors affecting the access of people in Binh Dinh and Hai Duong provinces • Propose feasible solutions to increase access to medical examination and treatment services for people with health insurance at the grassroots level Research objects and scope 3.1 Research objects Access to medical examination and treatment services for the HI participants at the grassroots level and influencing factors 3.2 Research scope The study area was in Tuy Phuoc and Hoai Nhon districts of Binh Dinh province and Gia Loc and Kim Thanh districts, Hai Duong province The study duration: 2014 to 2018 Field survey was conducted in 2014 The study focused on understanding the access to medical examination and treatment services at the grassroots level of people with HI Those who did not have HI were also investigated to find out if there were any difference with regard to HI status Methodology and research methods 4.1 Methodology The study uses structural-functional theory and rational choice theory to serve the analysis 4.2 Research Methods The study uses the commonly used research design, which is a cross-sectional survey, combining methods of quantitative information collection (household survey) and qualitative (in-depth interviews, group discussions) New scientific contributions of the thesis The study uses a holistic approach to analyze people’s access to health insurance (HI) medical services at the grassroots level, both from the supply and demand perspectives in the context of the policy environment that governs them The findings show that the rate of HI coverage was relatively high but there were differences in demographic characteristics, economic conditions and resident locations People had a tendency of using private services more than public ones The high HI rate did not transform into effective coverage when the rate of people using HI cards for medical services was not high For those who came to public health facilities, mostly to commune health stations and district hospitals, the majority of them used HI medical services The level of satisfaction among those people was very high The study uses a holistic approach, which is to consider people’s access to HI medical services at the grassroots level, both from the supply and demand perspectives and the policy environment that governs them The analysis, explanation and findings of the research contribute to a common understanding of this research area, providing a basis for policy planning and adjustment to help remove access barriers The theoretical and practical signification of the thesis Applying the structural-functional theory to indentify and analyze the grassroots health structure’s components and their interaction, the findings show that not many private health facilities providing HI medical services resulted in users’ limited choice of access Meanwhile, the grassroots health had not yet performed well HI medical service delivery function due to its limited capacity, weak system management and inadequate health financing Through the lens of the rational choice theory, empirical results provide evidences that gender, age, education, occupation, living standards, resident locations had a relation with the HI enrolment rate while place registered for HI primary medical care, place the service was consumed had a relation with HI card holders’ decision of using HI medical services This can be considered as one of reference sources for individuals, organizations operating in or paying concerns to policies and practices related to grassroots health Structure of the thesis In addition to the Introduction and Conclusion, the thesis consists of four chapters: Chapter Overview of research issues; Chapter Theoretical basis and research methods; Chapter Status of access to medical examination and treatment services for the health insurance participants at the grassroots level in the study area; Chapter Factors affecting the access to medical examination and treatment services for the health insurance participants at the grassroots level in the study area CHAPTER RESEARCH OVERVIEW ON ACCESS TO HEALTH SERVICES 1.1 Views and policies to increase access to health services Global trend There is a qualitative transition from the right of access under the Alma Ata Declaration on primary health care to equity in access in the global move for universal health coverage to ensure access to health services and financial protection against risks from health service consumption Viewpoints and orientations of Vietnam The Constitution stipulates the right to health care of all citizens The view of equity in health care is reflected in the Politburo Resolution No 46 on the protection, care and improvement of people's health in the new situation Resolution No 20 of the 12th Central Committee of the Party on strengthening the protection, care and improvement of people's health in the new situation emphasizes "grassroots health is the foundation" to build a medical system towards equity, quality, efficiency and integration Health insurance policy (HI) has been implemented since 1992, Health Insurance Law issued in 2008, amended and supplemented in 2014 Regulations, guidelines on HI, grassroots health as well as policies to support specific groups are in place, relatively comprehensive and always adjusted and supplemented to ensure access to medical examination and treatment for all people at the grassroots level However, there are still inadequacies in policy implications, policy enforcement and adverse impact 1.2 Overview of Vietnam's health system Organization of the health system The health system is divided into levels: central, provincial and grassroots (district and commune) The current service delivery system is a public-private mix with the public sector playing a leading role Service delivery capacity The Government has invested resources for the service delivery system, especially for the grassroots health network, implemented many measures to strengthen human resources, improve the quality of medical examination and treatment towards people's satisfaction Capacity of the service delivery system has been improved with more medical services including HI examination and treatment services delivered, service quality improved, examination and treatment procedures reduced However, the capacity of grassroots health has not yet met the changes in disease pattern and the needs of the people All public and private health facilities must have a certificate and practice license to participate in HI examination and treatment The number of health facilities participating in HI examination and treatment is relatively stable over the years Almost 100% of commune health stations (CHSs) participate in while only one fifth of the private sector join There is fierce competition between hospitals and those of the grassroots network, between different technical levels instead of coordination, especially when removal of technical routes implemented Research hypothesis (i) The rate of people participating in HI is relatively high but there are differences among groups according to demographic characteristics, economic conditions, living areas; (ii) People have more diversity in access with the trend of using private sector services than public ones; (iii) Most people go to public health facilities using HI services despite differences in demographic characteristics, economic conditions and living areas; (iv) Social security policies, communication activities have major impacts on access to health services of HI card holders; (v) The service delivery system has a great impact on people's access to HI examination and treatment; (vi) Individual and family factors also influence the decision to use HI examination and treatment services at the grassroots level 2.4 Research methods and research data Research design Cross-sectional survey combining quantitative, qualitative methods and literature review Quantitative sample The study deliberately selected Binh Dinh and Hai Duong provinces according to the following criteria: (i) a rural plain province; (ii) one in the North and one in the Central region (to ensure financial feasibility); (iii) Having 100% of CHSs implementing HI examination and treatment In each province, districts were selected The criteria for district selection include: (i) average socio-economic conditions; (ii) engaging with HI examination and treatment: (iii) local government paying attention to health activities At each district, randomly selected communes, each commune randomly selected 02 villages At each village, 50 households were selected by systematic random method The sample size surveyed in the descriptive study was calculated using 1,398 households The total number of households surveyed was 1,600 to 10 ensure the sample size in case a household does not agree to participate or data missing due to insufficient response from some household In fact, the study has investigated 1,588 households Qualitative samples Qualitative research using in-depth interview (IDI) and focus group discussion (FGD): 04 IDIs of HI patients at district hospitals (one per district hospital); 04 FGDs for HI patients at district hospitals (8-10 HI patients per one FGD); 08 FGDs with HI people (one per commune, each of 8-10 people with health insurance); 08 FGDs for people without health insurance (one per commune); 02 FGDs with provincial department of health; 04 FGDs with district hospitals; 04 FGDs of management agencies at district level (district health unit, Social Insurance); 08 IDIs with heads of commune health stations selected for the study and 04 FGDs with all heads of commune health stations in the study district 2.5 Variable analysis system and data processing techniques Dependent variable  Participation in health insurance: 1: yes; 0: no  Having consumed any form of examination and treatment services when falling sick: 1: yes; 0: no  Use of HI cards for examination and treatment: 1: yes; 0: no  Having satisficed with HI examination & treatment: 1: yes; 0: no  Where to go for medical service if not using services at grassroots level: Other public health facilities; Private health facilities; Selfpurchase medication Independent variables From demand perspective, variables include gender, age, education level, occupation, household economic status and variables related to community factors, which are living locations 11 From supply perspective, variables include: (i) Availability of services (health facilities providing HI services; types of services); (ii) Quality of service, including professional quality (capacity and qualifications of health workers, infrastructure, equipment, medicine) and service quality (health workers’attitude, examination procedures); (iii) Geographical factors (distance, travel time); and (iv) Financial factors (including method of payment and settlement of HI reimbursement) Processing and analyzing data Information from the quantitative survey will be entered into the computer by Epi-Data software and analyzed by social science statistics software Quantitative data and information are encoded and analyzed by SPSS 17.0 software according to basic statistics (frequency, correlation) Qualitative data is collected through available documents, observations, in-depth interviews and group discussions, recorded or hand noted, processed and analyzed using open coding method Information obtained from qualitative research is processed by the open coding method according to each subject group Qualitative results help to better explain quantitative results and reflect the views and consensus or disagreement of people on health insurance and help identify issues that people concern 2.6 Research limitations Due to selection of the sample intentionally to ensure the feasibility of the budget, data collected may not be well representative Some variables need to be included in the analysis are not available At the time of the survey, private sector has not engaged much in HI examination and treatment activities, this is a limitation but also a suggestion for the next research direction on the role and attraction of private sector and the promotion of public-private partnership Given the evolving changes with regard to HI examination and treatment, particularly policies, compared to the time of the survey, this is on the one hand considered as a limitation of 12 the research but on the other hand is an opportunity for the research to contribute to the verification of the appropriateness and righteousness of policies and regulations newly promulgated This also evokes the need for more policy impact assessments to provide evidence for policy adjustment CHAPTER CURRENT SITUATION OF ACCESS TO HI EXAMINATION AND TREATMENT SERVICES IN GRASSROOTS FACILITIES OF BINH DINH AND HAI DUONG 3.1 Situation of health insurance enrolment Compared to health insurance coverage of the whole country at the same time of the survey (71.5%), Binh Dinh had a higher rate of health insurance enrolment (72.9%) and Hai Duong was lower (68.4%) Overall, in the two provinces, female (73.6%) participated more than male (67.8%), HI policies were well implemented with regard to children under years of age, students, the retiree and the poor (over 98%) The groups with the high educational levels participated the most The problems of "the middle gap", the risk of "reverse selection" are of concern when the rate of HI enrolment in the informal sector was only about 50%, particulary the HI rate of the self-employed group is less than 30% The HI enrolment rate in rural areas (68.4%) was lower than in urban areas (74.2%) Illness situation in the surveyed areas Data from the household survey showed that there were more illness cases among women than men, the age group under years old and those aged 60 and older were the most ill The group of 50 - 59 years old also recorded a high rate of illness The rate of illness among people with HI was much higher than those without health insurance Health service seeking behavior of surveyed households 13 The most preveiling health service seeking behavior of households in Binh Dinh if acquiring illness was to look for services from pharmacies (54.2%), followed by private clinics (20.7%) and district hospitals (14.3%), only a few chose to come to CHSs (6.5%) The model of Hai Duong is different, though pharmacies still ranked the first (33.6%), CHSs came next at 26.9% followed by private clinics (21.7%), the number of households seeking services from district hospital was quite modest (6.3%) 3.3 Current situation of medical examination and treatment in the surveyed areas The level of access to health services The level of access to health services in the surveyed areas were considered very high (92% of the sick used health services) The most popular health service consumption model in Binh Dinh was to go to pharmacies (35.1%), to private clinics (30.3%), to district hospitals (21.3%) while coming to CHSs ( 5.3%) was the lowest and this model matches the pattern of health service seeking behavior Meanwhile, Hai Duong shows another picture with the most popular option being to CHSs (26.9%), followed by private clinics (25.9%), pharmacies (20.6 %) and district hospitals (17.1%) The level of access was different among population groups and between the two provinces People with minor illnesses often went to the pharmacy, the level of illness increased, the rate of going to the pharmacy reduced, and the rate of seeking for examination and treatment from hospitals increased People living in urban areas of Binh Dinh had more access to health services than those living in rural areas Health service consumption according to HI status In Binh Dinh, more than 80% of the sick without HI used private services compared to just over 50% of the group with HI Meanwhile HI group aquired services from grassroots health facilities (including district 14 hospitals - 22.6% and CHSs - 18.5%) tripled times higher than those without HI In Hai Duong, more than 75% of the sick without HI looked for services from private facilities, while more than 50% of those with HI went to the grassroots health facilities (33.1% in CHSs, 20.1% in district hospitals) 3.4 Current status of access to and use of HI curative services Among the sick who are health insured, only 41.9% of their visits was for HI medical examination and treatment, this rate of Binh Dinh (28.7%) was much lower than Hai Duong (55.9%) ) Although the rate of using health insurance card for medical examination and treatment was generally low, most of those who paid a visit to a facility eligible for providing HI curative services, chose to consume services covered by HI (Binh Dinh: 91.8%; Hai Duong: 89.5%) The group of children under years old and the group of 60 years and older used the most health insurance curative services Comparing the two provinces, the rate of medical examination and treatment with health insurance for each of all age groups of Hai Duong was higher than that of Binh Dinh Regarding the place of using the service, the sick in Binh Dinh had the highest level of HI curative service consumption at district hospitals, while in Hai Duong, more consumption were at CHSs According to the type of card, in Hai Duong those who consumed HI curative service the most were the poor, followed by the retiree, the elderly and people with meritorious services to the Revolution The group registered at CHSs for initial HI examination and treatment consumed the highest level of HI examination and treatment services Most services used was outpatient while inpatient services accounted for only 26% in Binh Dinh and 18.6% in Hai Duong 15 The level of satisfaction among HI medical service users was very high (Binh Dinh: 73.9%; Hai Duong: 88.3%) in all types of facilities that the sick accessed The main reasons for satisfation were not having to pay much thanks to HI, good attitude of health workers, adequate medicine, convenient procedures and health facilities close to home CHAPTER FACTORS AFFECTING CCESS TO HI EXAMINATION AND TREATMENT IN STUDY AREA 4.1 Policy and institutional factors Health insurance policy provides assurance on access to health services, especially for disadvantaged groups The participation of Party committees, authorities, locally tailored policies, appropriate propaganda and mobilization methods help expand HI coverage to the still less involved groups that are the near poor and those of the informal sector, entitling them access to HI examiniation and treatment services when needed However, inadequacies in policy implication, policy implementation make the capacity of the service delivery system limited, becoming an access barrier The reverse of supply-side incentives to stimulate demand negatively affects people's access to health services covered by HI 4.2 Factors from service delivery system Low participation of the private sector in delivery of HI examination and treatment services narrows down users’ choice The grassroot health facilities at the study area have not really done well the function of HI medical examination and treatment There are many reasons including difficulties in organizational structure and human resources, inadequacies in medical equipment and medicine supplies that limit the capacity and capability of grassroots health facilities, thus reducing people’s access Professional quality is not high due to limited capacity to deliver 16 technical services, procedures are yet troublesome while services are not enough to meet the diverse needs of the people, payment modes and reimbursement methods are still problematic These are access barriers because they make health facilities not function well, limit the benefits of HI card holders resulting in increasing bypass and disruption of the referral system, reducing people's confidence in grassroots health There are also optimistic signs that if grassroot health facilities well identify their competitive edge, they can make a good breakthrough With local people placing high importance on geographical accessibility, it is a right investment for CHS to improve service quality so that they can well perform the primary health care functions and help reduce overload for the higher levels However, the easily accessible location is not a guaranteed condition if there are many other options in the same area or nearby, especially when barrier on technical routes of medical examination and treatment removed It is the service quality that makes the difference.Improving technical quality requires investment of time and resources, but improving service quality, from a sense of attitude to information and adequate advice to make patients sastified is something that can be done right away 4.3 Factors affecting demand There are differences in health insurance participation, health insurance curative service consumption according to personal characteristics, families and living areas Verification by logistic regression model on people aged 18 and over in the study area confirm the results as gender, age, education, occupation, living standards, living areas are corelation with the rate of HI participation Regarding access to HI curative services, there are also certain differences in age, level of illness, living area, place of initial health care registration, place of medical examination and treatment 17 Most of the HI card holders participated in HI because they are supported for card purchase, whereas many non-participants said the reason was because there was no money, because of high fees Even the group of near poor households, despite having a high rate of participation in HI, are among groups that use HI curative services the least due to the limitation of co-payment People have knowledge about health insurance but only paying attention to specific benefits for themselves Awareness is not high is the cause of "reverse selection" situation, only the elderly and sick people will participate in health insurance The illness level not only affects the level of service use but also governs decisions about where to use the service CONCLUSION AND RECOMMENDATIONS Conclusion Situation of health insurance participation The HI rate is relatively high in the study area, equivalent to the national level at the same period, although there are differences between different groups, i.e women are more participated, groups of 50 years and older participate more, so is group with higher educational levels The health insurance policy is well implemented with children under 6, students, the retiree and the poor But many of the problems that other studies have shown are found in the study area, i.e low level of law compliance in the salaried group, a problem of "middle space" and the risk of "reverse selection" in the informal sector and the near poor group, low participation in rural areas compared to urban areas This result confirms the first hypothesis of the thesis: "The proportion of people participating in health insurance in the study area is relatively high but there are many differences in demographic characteristics, economic conditions and living areas" Access to health services and HI examination and treatment 18 The rate of using HI benefits when seeking for health care among the ill is very modest in all groups, including pensioners and policy beneficiaries, even though HI fully pays them for examination & treatment The most popular model of using health services in Binh Dinh is to look for services from pharmacies, followed by from private clinics and district hospitals, very few people come to CHSs Hai Duong again shows another picture, the most popular option is to CHSs, followed by private health facilities and pharmacies, district hospitals were not used much People in urban areas of Binh Dinh have access to health services more than rural people Despite the low rate of using HI benefits in search for health services, most people, who come to public facilities, use HI examination and treatment services and there are differences in age, where the initial health care registration is, and where health care services are used Such research findings help test the validity of the second hypothesis: "People have a diversity in using health services with a tendency of using private services more than public ones" and the third hypothesis: “For those who come to public health facilities, mostly to commune health stations and district hospitals, most of them use HI examination and treatment services though differences in demographic characteristics, economic conditions and living areas are observed” Policy/ institutional influences From policy reviews, related document and research references to specific survey results in the study area, it shows that policy and institutional issues have a great impact on people’s access to HI examination and treatment services and this is in accordance with the fourth hypothesis of the thesis, specifically: HI policy provides assurance on access to health services, especially for disadvantaged groups The participation of Party committees, 19 authorities, locally tailored policies, appropriate propaganda and mobilization methods help expand HI coverage to the still less involved groups that are the near poor and those of the informal sector, entitling them access to HI examiniation and treatment services when needed Effect of service delivery system From the perspective of structural-functional theory that consider the grassroot health structure is basically the structure reflecting the linkage of and interation among actors involved and the functioning rightly of each actor in harmany with that of other actors and the whole system, i.e the grassroot health structre, make it functioning effectively Analysing the research results from that angle and with reference to other relevant research, the study may provide the following statements that test the fifth hypothesis: Not many private health facilities provding HI examination and treatment services results in users’ limited choice and less access Meanwhile, the grassroots health care system has not yet performed well the HI examination and treatment function due to its limited capacity, weak system management and inadequate health financing solutions Easily accessible location can be an advantage but not enough, it is the quality of the service that makes the difference, especially when removal of technical routes implemented Improvement in professional quality requires investment in time and resources but improving the quality of service is something that can be done right away These findings contribute to confirming the necessity and the rightousness of recently promulgated policies and regulations as well as efforts to strengthen capacity, improve quality of medical services and satisfaction of people that have been being deployed over the years Individual and household characteristics 20 With the sixth hypothesis related to service users - factors of personal characteristics and household status have an impact on the decision to participate and use health insurance when going to health care services of different target groups - empirical results help provide evidence that confirms this hypothesis: gender, age, education, occupation, living standards, living area have a relationship with the rate of HI participation and plcae to register for initial medical care, place to use HI services, is related to the use of HI for medical examination and treatment Considering people's choices through the lens of the theory of rational choice, the following statements are made: Regarding access to health insurance services, research shows that there are statistically significant differences in age, illness level, living area, place of initial medical examination and treatment registration, place where service is consumed People aged 60 and over in both provinces, especially in Hai Duong, uses HI curative care services the most among all age groups This is also a group that has high rate of HI participation, a rational choice from a perspective that the older the age is the more health problems they might acquire so is the higher dependance they are on the HI benefits to reduce curative care costs, if any Financial barriers can lead to improper health seeking behaviorstemming primarily from affordability rather than health care needs People's awareness of the benefits of HI has not yet been transformed into using HI cardwhen seeking for services because the use of health services is dominated by habits, prejudice and subjective feeling of health status The research results and findings also raise the question of equity in access to health care when HI enrolment and the consumption of HI medical examination and treatment are affected by favorable factors such 21 as income, HI status, residence, awareness, beliefs and habits rather than specific elements of age, gender, health status, health care needs Recommendation Fine tuning the policy/ institutional mechanism Examining the model of health insurance with differentiative rates of premium and benefits are compatible with the rates that many countries have applied to raise attractiveness, increase risk sharing and sustainability of the health insurance funds The results of the study also help affirm of the appropriateness and righteousness of policies currently being implemented and indicate that assessment and studies on policy impacts need to be conducted more in the context of many new policies and regulations currently in place They will provide evidence to help adjust and supplement policies and design appropriate interventions The study also suggests for more researches on social dimensions of high concerns relevant to access to HI medical examination and treatment, such as equity in access, quality of care, satisfaction and the like Strengthening the systems of service delivery and health financing Increasing the share of HI fund for CHSs and promoting the implementation of electronic medical records is the right direction for grassroots health to take on the role of “gate keeper”, to be the focal point to coordinate medical care for common diseases and continuous comprehensive health care according to family medicine principles This will help to best promote the grassroots health capacity, contributing to reducing the workload for the higher levels, ensuring the role, function and operational efficiency of each level and the whole system Considering the application of international experiences on provision of good outpatient benefit packages is an important strategy to increase access to health services by health insurance participants Service 22 packages need to be appropriately designed with a balance of both preventive and curative services such as health counseling, maternity and nutrition management, and non-communicable disease management that have been proven cost effective The prevailing modes of health seeking behavior which are more prone to the private health sector imply the need for more research on the role and attraction of the private sector in HI medical examination and treatment and the promotion of public-private partnership to increase access to services for people at grassroots level which help the local health system to accomplish the comprehensive and continuous health management in the community in line with the family medicine principles The situation of HI examination and treatment at the grassroots level also gives raise to suggestions that more research is needed on the role and attraction of private sector in HI medical examination and treatment at the grassroots level and promotion of public-private partnerships to increase access to services for people and help commune health stations to well perform comprehensive and continuous health care management in the community Strategic support for targeted groups There should be appropriate policies and measures, taking into account gender and age characteristics specifically, to attract and mobilize people from groups with low rates of HI enrolment to participate more, especially in the informal labor sector, mostly of those working in agriculture, forestry and fishery, small business and street vendors, having low and unstable incomes The study adds a common voice to the policy suggestions that the Government should continue investing more in grassroots health, where the poor and specific target groups such as children, women and the elderly more easily accessible The active involvement of the Party 23 committees, authorities, unions together with the good coordination between the actors involved in service delivery and the HI fund management are strongly recommended Promoting strategic communication towards target groups is necessary with the participation of the party committees, authorities, unions and good coordination between service providers and fund managers and mobilization of the private sector’s engagement in HI curative services as well as education and communication taking professional prestige advantages to promoting communication and advocacy The application of new communication tools such as social networks, forums, and community groups that are highly interactive should be done on the basis of surveys and experiments for proper design,feasible and effective implementation Applied research in this area can be considered as a promising research directionin the digital era contributing to promote effective communication on HI and HI medical examination and treatment 24 ... delivery system is a public-private mix with the public sector playing a leading role Service delivery capacity The Government has invested resources for the service delivery system, especially for... there were any difference with regard to HI status Methodology and research methods 4.1 Methodology The study uses structural-functional theory and rational choice theory to serve the analysis 4.2... based on clarifying key concepts related to the research • Apply basic theoretical approaches, including structural-functional theory, theory of rational choice and selectively apply appropriate
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