Considering the economic and legislative changes in healthcare

In many developing countries, including Vietnam, out-of-pocket payment is the principal source of health financing. The economic growth is widening the gap between rich and poor people in many aspects, including health care utilization.

While inequities in health between high- and low-income groups have been well investigated, this study aims to investigate how the health care utilization changes when the economic condition is changing at a household level. We analysed a panel data of 11, households in a rural district of Vietnam. Of the sample, We used a double-differences propensity score matching technique to compare the changes in health care expenditure as percentage of total expenditure and health care utilization from to , from to , and from to , between households with and without economic growth.

The differences were statistically significant. The results suggest that households with economic growth are better off also in terms of health services utilization. Efforts for reducing inequalities in health should therefore consider the inequality in income growth over time.

Health is considered as a fundamental human right and the achievement of the highest possible level of health is one of the most important worldwide social goals [ 1 ]. This can be partly attributed to the fact that poor health can have a significant economic impact on any households. Poor health can make households property exhausted, indebted, and reduce their essential consumption [ 2 ] because people with poor health are not only having productivity and income losses, but also out-of-pocket OOP expenses for needed healthcare services.

The implementation of user fees is likely a barrier to access adequate health services in poor settings. In many low- and middle-income countries, the level of government spending on health is low compared with other sectors and OOP expenditure is the principal source of health financing in those nations.

Vietnamese households have not been able to hold their food and non-food consumption constant due to income reductions and extra medical care expenditure [ 8 , 9 ]. Hence, healthcare expenses have become a financial burden and influenced healthcare service seeking behavior, especially among the poor. There are four different levels of healthcare services, including central, provincial, district, and commune level, where central is the highest and commune is the lowest level of care.

People are encouraged to firstly use services at the commune level for both preventive and curative care and they will be referred to a higher level of care if needed. The private healthcare services in Vietnam have developed rapidly since when the law on private pharmaceutical and medical practice was launched.

Since , when there were no private health services, this sector has grown to about 83 private hospitals, 30, private clinics and 9, private pharmacies in With a growing number, the private sector plays an increasingly important role in the Vietnam health system [ 10 ]. Living standards have also been changed as the result of economic growth and the gap between rich and poor people has been increased as the consequence of the market economy.

The poor is a high-risk group of people in many aspects in the society, including health and healthcare. Several studies indicate that the gap between the rich and the poor is large in healthcare spending and utilization, and that the higher socioeconomic status is correlated with better health and longer life [ 12 — 14 ]; however, little is known about how people use healthcare services when their economic condition changes year by year.

Ba Vi is a rural district located in the North of Vietnam with a population of approximately , and covering an area of km2 with various geographies, including lowland, midland and mountainous areas. Children under one year of age comprise 1. The mMajor products are wet rice, cassava, corn, soya beans, green beans and fruits such as pineapple, mandarin orange and papaya. There is only one district healthcare center, 3 policlinics, and 32 commune health stations.

All communes have implemented the primary healthcare programs, including expanded immunization and acute respiratory infections, family planning, and antenatal care. In addition, there were approximately 90 licensed private health facilities private clinics and pharmacies in Ba Vi in [ 16 — 18 ]. Sample size of FilaBavi was calculated based on an estimated infant mortality rate IMR of 45 per 1, live births aiming to detect a change in IMR of 15 per 1, after three years of study.

A random sampling of clusters each cluster is generally a village , with probability proportional to population size in each unit, was performed, and 67 clusters with a reported population size of 51, inhabitants in 11, households were selected from the total clusters in the district [ 15 , 18 ]. The total number of households has changed each year due to migration. The baseline survey started in January , from which the re-census surveys were performed every second year, gathering information on socio-economic characteristics of households, including housing conditions, water resources, latrines, healthcare expenditure, total expenditure, total income, agricultural land, access to the nearest commune health station and hospital, and household socio-economic status SES as classified by the local leaders.

The follow-up surveys were performed quarterly gathering information on demographic e. A detail of the FilaBavi longitudinal demographic surveillance site has been published elsewhere [ 15 ]. In this study, we used the data of 3 re-censuses and 12 quarterly follow-up surveys in , and In total, this study followed 11, households continuously from to We analyzed data at a household level using a double-difference propensity matching technique [ 19 — 21 ].

Based on the change of income between and we grouped the sample into two groups: households with and without economic growth EG.

This was done by matching the propensity scores. This score is the probability of a household not having EG. The two groups should be as similar as possible in pre-treatment characteristics, implying that differences in outcomes can be attributed to the treatment.

To estimate the propensity scores we used a logistic regression. We used a balance test to make sure the bias was reduced after matching. Variables for estimating the propensity scores to match the treated with the control households were household-head characteristics, including sex, age, religion, ethnicity, marital status, education, and occupation; and household characteristics, including total household expenditure, distance to CHS km , to DH km , households economic status, number of members, number of males, number of children under 6 years old, number of people 60 years or older, number of sick episodes, number of sick person, number of restricted days cause by sickness, etc.

These variables were selected based on potential association between them and the probability of being treated, but also on their availability in the dataset. Permission was obtained from the Ministry of Health of Vietnam, and local authorities.

Additionally, informed consent was obtained from inhabitants as well. Ethical approval for the overall surveillance activities, including data collection on vital statistics, was approved by the Research Ethics Committee at Umea University.

In total, there were 11, households that have information in all the 3 years for analysis. Of these, 2, households did not have income growth between and Households with EG used slightly more services than households without EG in both public and private health facilities in and ; however, their expenditure for health accounted for a smaller percentage of total household expenditure.

Logistic regression estimating the propensity scores for matching is shown in Table 2. Table 3 shows the differences between households with and without EG in terms of the changes in healthcare utilization from to , from to , and from to The differences in changes of the total number of healthcare utilization between households with and without EG were not significant in all the three periods. Some significant differences were found in the utilization of health services, though.

In the first period — , only the difference in the change of HCE as percentage of total household expenditure was statistically significant. Households without EG spent significantly more percentage of their expenditure, for healthcare, than households with EG. In the period between and , the significance was found in the change of utilization of the higher level of healthcare. In the long-term, from to , significant results were found in both HCE as percentage of total expenditure and the utilization of the higher level of healthcare.

This study provides a different viewpoint of the close link between economic status and healthcare utilization of households in rural Vietnam. Unlike others studies demonstrating a cross-sectional association between economic status and healthcare utilization [ 2 , 3 , 22 ], our results demonstrate a longitudinal relationship showing how healthcare utilization changes when the economic status is changing.

Households with EG are better off in comparison with those without EG, in terms of both the healthcare expenditure as a percentage of total expenditure and the utilization of higher levels of healthcare provincial or central hospitals where the quality of care is higher. This result is consistent with other studies indicated that the better income groups typically utilize a higher level of public health services [ 13 , 23 ]. The poor health and the smaller share of expenditure for economic investment may in turn negatively impact their further earnings.

The most disadvantage group of people is the poor according to the classification of local government who have non-EG over time. This group accounted for They face a double barrier accessing health services; one is of course the poverty and another is non-EG. It is shown that poor people have more health problems but less assess to health services even for those who are provided a health insurance for the poor card. This is because of indirect costs, including traveling, accommodation, food and so on, since they usually live in remote areas [ 22 ].

This suggests health insurance only may not be sufficient help such individuals access health services. Shortage of staff is mostly felt at the nursing level because nurses are in the front line of service delivery in health care Coovadia et al. The health facilities in urban areas were designed and built to cater for a certain number of people. The sudden influx of people into cities forces health facilities to function beyond their intended capacity.

This leads to inadequate staffing and overcrowding, which in turn cause a drop in the quality of healthcare delivery in urban hospitals Kamndaya et al. In addition to patient influx and a quadruple burden of diseases on the South African health system Ngomane , South Africa is also experiencing a particularly debilitating shortage of professionals and skilled people in the public sector compared to the private sector Heywood Also exacerbating the shortage of human resources in South Africa has been the closure of many nursing colleges in the late s and an exodus of professionals to work for better income either overseas or in the private sector.

Job dissatisfaction also leads to loss of healthcare workers Heywood In addition, South Africa, as a developing country, has been attracting increasing numbers of often unregistered immigrants crossing the porous borders for a range of political and economic reasons Mokoele — Statistics suggest that there are between half and one million undocumented migrants in South Africa Baker Health outcome reports in South Africa indicate a complete failure in public sector healthcare delivery, with outcomes worse than that of some lower income countries Centre for Development and Enterprise , Pillay-van Wyk et al.

Leadership crises can be traced back to the early days of democracy, following the implementation of government policies to improve living conditions in poor households Franks Affirmative action policy resulted in loss of institutional memory, and many problems in the healthcare system are associated with the placement of inexperienced managers in senior positions Coovadia et al.

The affirmative action in South Africa is reported to have led to poor-quality service delivery because it was characterised by nepotism and affiliation rather than skills and merit Twala Poor service delivery is also exacerbated by tolerance of misconduct, lack of performance management and monitoring strategies that led to many employees ignoring the law Siddle A study by Kilonzo and Ikamari concluded, however, that affirmative action opportunities had positive impact on the quality of service delivery and that proper application of affirmative action programmes leads to improvement in the quality of service delivery in public institutions.

In South Africa, most managers are promoted to senior positions because of their length of service in the institution, not because of their skill, and they often apply for promotion because it goes with an increase in salary Pillay This widens the gap between management team and clinical outcomes Pillay Lack of accountability, coupled with corruption and misconduct among Department of Health officials Siddle :6 , has also caused the government to fail in fulfilling its constitutional mandate to deliver quality health care.

A contrary opinion by Baker contends that the crisis in the healthcare system is more than simply a reflection of corruption and poor domestic governance, and that blame ultimately rests on the structures of apartheid; however, irrespective of the cause, the quality of health care still suffers. Like every developing country, South Africa faces high burden of disease and seems to be failing to combat it Kahn The impact of HIV and AIDS in Africa, and in sub-Saharan Africa particularly, has devastated healthcare systems to the extent that they are unable to cope with the demands of high-quality delivery Naidoo Multiple deficiencies and inadequacies caused by fragmentation of the healthcare system, coupled with racial and socio-economic issues, have led to further proliferation of diseases in South Africa, including HIV and AIDS Van Rensburg South Africa currently faces a multiple burden of disease, with the HIV and AIDS epidemic coinciding with high burden of tuberculosis, high maternal and child mortality, high levels of violence and injuries and a growing burden of non-communicable diseases e.

There is a particularly crucial need in South Africa for government to improve infrastructure in rural communities, where some primary healthcare centres even lack piped water — a clear sign that the public health system is overburdened and incapable of providing consistent quality care Heywood This makes patient care more complex, with unavoidable demand for high-quality care delivery, while resource shrinkage continues Lateef All issues identified indicate low levels of service delivery quality in public health facilities, threatening the health and lives of all patients and adding cost to the healthcare system Cullinan The change to a democratically elected government in South Africa in brought with it a push for change in the health care system, signalled by a number of policy documents.

The first step that was taken by the democratic government was decentralisation of the health care system. South Africa, like other developing countries, has adopted a process of decentralisation in restructuring health care services Hendricks et al. Several studies revealed that decentralisation has produced positive effects in developing countries Alves et al. In these instances, decentralisation strengthened the capacity of local organisations to negotiate with central government structures for increased resource allocation to previously neglected groups Alves et al.

However, other authors believe that decentralisation has intensified problems of disparity in vulnerable populations, leading to poor-quality health care delivery Regmi et al. According to Surender , separating policy determinants from policy implementers in South Africa has led to a crisis in health delivery. Policy implementers failed to restrict health funds at provincial level, which has led to health funds being re-directed to other spending based on political priorities Surender One such notable piece of legislation is the Constitution of the Republic of South Africa , approved by the Constitutional Court on 04 February , and the supreme law of the Republic.

The Constitution spells out the rights and duties of its citizens and describes the structure of the government. The National Department of Health leads public health in South Africa and is responsible for overall health policy and coordination, deriving its mandate from the Constitution and the National Health Act No.

Among other priority programmes and policies introduced by the democratic government include free-health policies and the district-based primary health care system Van Rensburg Various approaches have been developed in South Africa to monitor quality health care delivery. One notable approach has been the development of accreditation as initiated by Dr Whittaker in the pilot Accreditation Programme for South Africa launched in at the University of Stellenbosch. This research project revealed that many institutions did not comply with minimum standards, calling for new emphasis on continuous quality improvement Whittaker et al.

COHSASA is organised as a national cooperative effort involving consumers, state and private organisations and health care providers and is the only body implementing accreditation in South Africa. The National Department of Health has shown strong commitment to improve the quality of health care delivery in public settings Whittaker et al. Evidence of this commitment was the development of the Ten Point Plan Strategic Framework, as outlined in the Hospital Revitalisation Programme, which pursued improvement of hospital infrastructure, health technology, administrative management and quality service National Department of Health As previously noted, there has also been the Negotiated Service Delivery Agreement signed by the Minister of Health, which is intended to ensure effective health care delivery for improving health outcomes and strengthening the health system for all South Africans National Department of Health To this effect, the Office of Health Standards Compliance OHSC was established by government in National Department of Health :4 to introduce a quality assurance mechanism which will regulate the quality of health services according to a set of norms and standards prescribed by the National Health Amendment Act No.

The aim of accreditation is to provide confidence to end users that health service providers are, in fact, competent to provide service ECONEX The first three are domains involved directly with the core health system business of delivering quality health care: patient rights and safety, clinical governance and care, and clinical support services.

The remaining four domains are the support system that ensures that the system is delivering its core business: leadership and corporate governance, operational management, public health, and facilities and infrastructure. Within each domain are sub-domains that are further divided into subsections or critical areas National Department of Health In calling on leadership in health care establishments to facilitate inventiveness and change in practice, the National Department of Health promotes application of NCS as a benchmarking tool for quality of care Lourens The NCS are to be used as a guide for managers at all levels, indicating the expected service delivery and how to plan for quality care delivery.

The NCS tool is also used to assess the quality of health care delivery in health establishments in preparation for the introduction of the NHI.

Although much has been done over many years to restructure the health care system and to improve the quality of care being rendered to users, the literature reveals that millions of people in South Africa still suffer preventable harm every day. Medical litigation has dramatically increased both in frequency and in the size of the damages Malherbe Therefore, still much needs to be done by government, and society at large, to address the issues of poor-quality service delivery.

The literature also reveals that the drive to improve the quality of health care in South Africa has not been lacking in interventions or in powerful ideas. It seems, however, that corruption and lack of leadership skills continue to cause long delay in the achievement of quality health care delivery Siddle Nevertheless, South Africa has the potential to draw on its experiences of health inequalities and of the detrimental consequences of historical segregation to build high-quality service delivery for the benefit of all its citizens.

Particular suggestions made by authors on how to improve the quality of health care delivery in South Africa are the following:.

The South African Medical Association agrees that the current physical state of public facilities is disgraceful and not favourable to the delivery of quality health services. Decentralisation must therefore be implemented cautiously, after confirmation that there is sufficient managerial capacity at district level, and senior officials must be held accountable when they fail to deliver quality as required by their job description.

Sithole and Mathonsi contend that for local government to deliver on its constitutional mandate, government needs to strengthen human and material resource in terms of quantity and quality. Government must also commit to root out nepotism and corruption in areas such as recruitment for positions and awarding of tenders for services South African Medical Association According to the Standards Council of Canada, accreditation bodies need to perform their work independently ECONEX :6 because the primary purpose of accreditation is to eradicate biased assessment.

According to Tana , the Government of South Africa seems to be unable to deliver the quality of health care as promised. It cannot claim to be providing quality health care service to all patients, while patients remain displeased with health care service delivery. Further research is therefore needed to assess the efficiency of the strategies used to evaluate health care outcomes.

The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. M was responsible for the literature search and drafted the article. How to cite this article: Maphumulo, W. Published online May Winnie T. Maphumulo 1 and Busisiwe R. Bhengu 1. Busisiwe R. Author information Article notes Copyright and License information Disclaimer. Corresponding author. Corresponding author: Winnie Maphumulo, moc.

Received Jan 15; Accepted Oct The Authors. This work is licensed under the Creative Commons Attribution License. Abstract Background There is overwhelming evidence that the quality of health care in South Africa has been compromised by various challenges that impact negatively on healthcare quality.

Objectives The purpose of this study was to identify challenges that are being incurred in practice that compromise quality in the healthcare sector, including strategies employed by government to improve the quality of health delivery.

Results Seventy-four articles were selected from retrieved. Conclusion The findings revealed that there were many quality improvement programmes that had been initiated, adapted, modified and then tested but did not produce the required level of quality service delivery as desired.

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Complex and slow-to-change policies are an obvious factor, but environmental and technological factors also contribute to changes in healthcare.

Illness trends, doctor demographics, and technology also contribute to shifts in our overall healthcare system. As our society evolves, our healthcare requirements naturally evolve. Healthcare reform has often been proposed but has rarely been accomplished.

Speaker of the House Thaddeus Sweet vetoed the bill in committee. In , after 20 years of congressional debate, President Lyndon B. Johnson enacted legislation that introduced Medicare and Medicaid into law as part of the Great Society Legislation. Since becoming law, additional rules and regulations have expanded upon the Patient Protection and Affordable Health Care for America Act. Choosing a healthcare plan illustrates the complexity of health insurance plans in the U. About half of Americans who have private health insurance are covered under self-insured plans, each with their own design.

The one commonality among all insurance plans is how dramatically they vary. Deductibles, co-insurance, co-payments, and maximum out-of-pocket expenses are a few of the inconsistent variables among insurance plans. Additionally, some insurance companies are for-profit and others are not-for-profit, indicating another point of confusion. Insurance is not the only complexity within the system.

The Affordable Care Act added more agencies to this list, including state insurance exchanges and the Center for Medicare and Medicaid Innovation. Each area of healthcare has its own complexities.

As components of the larger healthcare system work together, the complex layers unfold. While change is expected in the coming years, it is likely to occur slowly. Changes in the healthcare industry usually occur at the legislative level, but once enacted these changes have a direct impact on facility operations and the use of resources. For example, the ways patients and administrators utilize resources such as Medicare and Medicaid have changed due to legislation.

Technology has had a further impact on how healthcare administrators handle resources and manage medical centers. Cultural shifts, cost of care, and policy adjustments have contributed to a more patient-empowered shift in care over the last century. Technological advancements contribute to a shift in our patient-centered healthcare system. This trend is expected to continue as new healthcare electronic technologies , such as 3D printing, wearable biometric devices, and GPS tracking, are tested and introduced for clinical use.

Policies and procedures in individual facilities may restrict how and when new technologies are introduced, but cutting-edge technology is expected to play an increasingly larger role in our healthcare system within the coming years.

As legislative and demographic changes trickle down into care facilities, the use of hospital services is expected to grow significantly between and This growth is due to an anticipated increase in Medicare beneficiaries in the coming decade. The cost of hospital care is expected to rise from 0. Since then, Congress has made Medicare and Medicaid changes to open eligibility to more people. For example, Medicare was expanded in to cover the disabled, people over 65, and others.

Medicare includes more benefits today, including limitless home health visits and quality standards for Medicare-approved nursing homes. Medicaid has also been expanded to cover a larger group than initially intended. This includes coverage for low-income families, pregnant women, people requiring long-term care, and people with disabilities.

Wide variations in Medicaid programs across the nation occur because individual states have the ability to tailor Medicaid programs to serve the needs of their residents. Potential consumers can now use the Marketplace website to determine their Medicaid eligibility. As the baby boomer generation approaches retirement, thus qualifying for Medicare, healthcare spending by federal, state, and local governments is projected to increase.

Assuming the government continues to subsidize Marketplace premiums for lower-income populations, this increased government healthcare spending will greatly affect the entire healthcare system in the U. Although Medicaid spending growth decelerated in due to reduced enrollment, spending is expected to accelerate at an average rate of 7. Along with policy and technological changes, the people who provide healthcare are also changing.

Providers are an important part of the healthcare system and any changes to their education, satisfaction or demographics are likely to affect how patients receive care. Future healthcare providers are also more likely to focus their education on business than ever before.

This growth may result in more private practices and healthcare administrators. In recent years, the demographics of the medical profession have shifted. Women currently make up the majority of healthcare providers in certain specialties, including pediatrics and obstetrics and gynecology. Nearly one-third of all practicing physicians are women. According to an Association of American Medical Colleges AAMC analysis, women comprise 46 percent of all physicians in training and nearly half of all medical students.

Based on these statistics, we can assume more women may enter the medical profession in the coming years. African-American women are more likely to become doctors than their male counterparts, according to AAMC data. While African-Americans comprise only four percent of the physician workforce, 55 percent of the African American physician workforce is female. This shift in demographics to include more women in healthcare supports diversity in the industry and represents overall population diversity.

The prevalence of malpractice lawsuits is one way to evaluate the competence of healthcare providers. The amount of malpractice claims in the U. As the trend of declining malpractice lawsuits continues, it may indicate that provider competence and patient care will continue to improve. Job satisfaction is one area that must improve.

Nurses report higher overall career satisfaction than doctors, based on results of the latest Survey of Registered Nurses conducted by AMN Healthcare and compared to the Physician Compensation Report.

Nine out of 10 nurses who participated in the survey said they were satisfied with their career choice. However, one out of every three nurses is unhappy with their current job.

It is difficult to say whether job satisfaction will increase in the coming years, but continued technological advancements designed to streamline the healthcare process offer hope to those who may be frustrated with the complexity of their jobs. Demands on healthcare change due to various reasons, including the needs of patients. Every year, new cures and treatments help manage common diseases. Congressional Timing In an effort to ensure Democratic support for both the Infrastructure Investment and Jobs Act and the budget reconciliation bill, House leadership chose to tie the vote on the Infrastructure Investment and Jobs Act to the development of the reconciliation bill.

Healthcare Policies in Budget Reconciliation The budget reconciliation package will likely include a broad range of healthcare policies Figure 2. Other Upcoming Congressional Activity Stakeholders should also be aware of other opportunities for healthcare-related legislation.

Legislative action is needed to prevent cuts such as Part B drug reimbursement returning to average sales price plus 4.

Physician Payment: On January 1, Medicare payments to physicians would reflect a reduced conversion factor and the expiration of the 3. Regulatory Agenda In addition to the significant legislative activity taking place in Congress, agency and regulatory actions are expected through the end of the year on other issues.

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