1. Abt Associates Inc. In collaboration with: I Aga Khan Foundation I Bitrán y Asociados I BRAC University I Broad Branch Associates I Deloitte Consulting, LLP I Forum One Communications I RTI International I Training Resources Group I Tulane Universitys School of Public Health 4 th National Scientific Conference on HIV/AIDS hosted by: Vietnam Administration of HIV/AIDS Control (VAAC) Survey of People Living With HIV/AIDS: Preliminary results on health service utilization & out-of-pocket expenditures Nguyen Tuan Phong¹; Ha Nguyen²; Nguyen Duy Tung¹ Douglas Glandon²; Nguyen Mai Huong³; Theodore M. Hammett¹ Hanoi, Vietnam 3rd December, 2010 1) Health Policy Initiative Vietnam, Abt Associates 2) Health Systems 20/20, Abt Associates 3) Center for Community Health Research and Development, Vietnam

2. 2 Outline Objectives Methodology Sample description Health services utilization Out-of-pocket (OOP) expenditure on HIV/AIDS Main conclusions Limitations Implications

3. 3 Objectives To explore health seeking behaviors of people living with HIV/AIDS (PLHIV); To document OOP expenditures on HIV/AIDS; To understand the role of different HIV service providers; To help inform financing and policy decisions for the National HIV/AIDS Strategic Plan for 2011-2015.

4. 4 Methodology Survey of 1,206 PLHA representing 17 Estimation & Projection Package clusters Within each cluster, one province selected with Probability Proportional to Size Participants selected using systematic sampling Analysis adjusted for sampling weights Approved by Institutional Review Boards of Abt Associates, HSPH, & Boston University

5. 5 Sample Size #ProvinceSample (PLHIV) 1 An Giang28 2 Ba Ria- Vung Tau90 3 Bac Ninh51 4 Can Tho22 5 Dong Thap122 6 Ha Noi122 7 Ha Tinh6 8 Hai Phong50 9 Khanh Hoa10 Lam Dong19 11 Nam Dinh102 12 Nghe An119 13 Quang Nam20 14 Quang Ninh27 15 Thai Nguyen39 16 Ho Chi Minh City313 17 Yen Bai66 Total 1206

6. 6 Sample Description Sample Characteristics% Urban62.5 Male61.5 OPC registered83.9 On ARV68.5 Have Health Insurance33.4

7. 7 Type of health insurance possessed by PLHIV Largest component of HI possessed is from HI for the poor scheme

8. 8 Incidence of service utilization among PLHIV versus the general population Type of service utilizationPLHIV (%) General Population* (%) Outpatient contact over last 4 weeks 73.131.0 Hospitalization over last 12 months 15.36.5 Self-medication over last 4weeks 38.5 Rates of health service utilization were much higher for PLHIV than among the general population * Source: Vietnam Household Living Standard Survey 2008

9. 9 Service utilization among PLHIV Similar average number of self-medication episodes and outpatient visits to a healthcare provider Volume of Service Utilization # Average # of outpatient visits over last 12mos per PLHIV11.1 Average # of hospitalizations over last 12mos per PLHIV0.2 Average # of self-medications over last 12mos per PLHIV9.2

10. 10 Service utilization over last 12 months by ARV status

11. 11 Provider of last outpatient visit during last 4 weeks preceding survey Service providers used are predominantly public hospitals and public centers (PACs & PHC)

12. 12 Provider of last hospitalization during last 12 months preceding survey Service providers used are predominantly public hospitals

13. 13 Supplier for last self-medication episode during last 4 weeks preceding survey

14. 14 OOP health expenditure over last 12 months preceding survey Mean health expenditure over last 12 months VND amount% Condoms & Syringes 50,8001% Outpatient contacts (excl transportation) 1,140,50027% Hospitalization (excl transportation) 1,023,20025% Self-medication (excl transportation) 767,90018% Transportation 1,187,40028% Total expenditure 4,169,800100% Transportation is the single largest component of health expenses

15. 15 HIV/AIDS OOP expenditure versus general OOP health expenditure* OOP health expenditures by PLHIV are much higher than in general population *Source: Vietnam Household Living Standard Survey 2008 PLHIV General Population

16. 16 Structure of outpatient OOP expenditure over last 12 months (VND) ItemsAmount% Consultation 23,800 2.1% Lab test 57,100 5.0% ARV 6,300 0.6% OI 126,500 11.1% TB 1,000 0.1% VCT 3,800 0.3% Extra drugs, instruments 823,300 72.2% Gift 1,700 0.1% Care giver 12,100 1.1% Others 84,900 7.4% Total 1,140,500 100% Opportunistic infections & extra drugs account for majority of outpatient health expenses

17. 17 Structure of inpatient expenditure over last 12 months (VND) ItemsVND% Direct fee to facility862,60084.3% Extra drugs, food, instruments bought outside facility 99,8009.8% Fee for faster service4,3000.4% Gifts to providers19,8001.9% Food and lodging for care giver36,7003.6% Total1,023,200100% Direct fee to facility that covers consultation, drugs, lab tests, bed, and other consumables incurred makes up most of inpatient health expenses

18. 18 Health expenditure over last 12 months, by ARV status Health expenses on both outpatient & inpatient are higher for those on ART

19. 19 Health expenditure over last 12 months, by residential area Health expenditures, esp. outpatient, are higher for urban dwellers

20. 20 Health expenditure over last 12 months, by sex Health expenditures, esp. inpatient, are higher for males

21. 21 Health expenditure over last 12 months, by health insurance status Health expenditures by those with HI is quite similar to those without HI Those using HI spent less on outpatient, more on inpatient

22. 22 Main Conclusions Insurance coverage among PLHIV is lower than among the general population. Outpatient and self-medication account for much more of service utilization than hospitalization Public hospitals and centers are predominant providers of HIV care and treatment. Transportation cost accounts for a large share of OOP exp Health expenses are higher for male, ARV patients, and urban dwellers. Insured PLHIV have lower OOP expenditure, but the difference is small Service use & expenses are much higher in PLHIV than in general population

23. 23 Limitations PLHIV are a difficult population to survey. People who refused to participate may be systematically different from people who agreed to participate. Sample contains high % of PLHIV registering at OPC and on ARV: may have captured people who are more advanced in disease status => may have overestimated service utilization and OOP

24. 24 Policy Considerations HIV/AIDS remains a major financial burden to PLHIV & health sector High expense for travel low accessibility of service: consider decentralization to increase outpatient care service delivery points Large cost of drugs bought outside facility, OI, and lab, even with insurance need for more comprehensive benefit package for PLHIV Mobilize private sector (already very active in non-HIV services) to lessen burden to public sector (vouchers, insurance, training, direct support). HI coverage remains low expand PLHIV health insurance coverage

25. Abt Associates Inc. In collaboration with: I Aga Khan Foundation I Bitrán y Asociados I BRAC University I Broad Branch Associates I Deloitte Consulting, LLP I Forum One Communications I RTI International I Training Resources Group I Tulane Universitys School of Public Health Thank you for your attention!