tmi12032.pdf

Financial burden of health care for HIV/AIDS patients in

Vietnam

Bach X. Tran1,2, Anh T. Duong3, Long T. Nguyen3, Jongnam Hwang1, Binh T. Nguyen3, Quynh T. Nguyen4,

Vuong M. Nong2, Phu X. Vu6 and Arto Ohinmaa1,5

1 School of Public Health, University of Alberta, Edmonton, Alberta, Canada2 Institute for Preventive Medicine and Public Health, Hanoi Medical University, Hanoi, Vietnam3 Authority of HIV/AIDS Control, Ministry of Health, Hanoi, Vietnam4 University of Nantes at Foreign Trade University, Hanoi, Vietnam5 Institute of Health Economics, Alberta, Edmonton, Canada6 Department of Health Economics, Hanoi School of Public Health, Hanoi, Vietnam

Abstract objective To assess the out-of-pocket (OOP) payments for health-care services of HIV/AIDSpatients, and identify associated factors in Vietnam.

methods Cross-sectional multisite survey of 1016 HIV/AIDS patients attending 7 hospitals andhealth centres in Ha Noi, Hai Phong and Ho Chi Minh City in 2012.

results HIV/AIDS patients used inpatient and outpatient care on average 5.1 times (95%CI = 4.75.4) besides ART services. Inpatient care cost US$ 461 on average and outpatient care US$50. Mean annual health-care expenditure for HIV/AIDS patients was US$ 188 (95% CI = 148229).35.1% of households (95% CI = 32.238.1) experienced catastrophic health expenditure; 73.3%(95% CI = 70.676.1) of households would be affected if ART were not subsidised. Being a patient ata provincial clinic, male sex, unstable employment, being in the poorest income quintile, a CD4 count

of

payments prevail among patients with HIV/AIDS, there is

little evidence on the economic impact of HIV/AIDS in

Vietnam. In this study, we sought to evaluate the finan-

cial burden of health care for HIV/AIDS patients in a

multisite survey. Specifically, we assessed the rate of

health service use and OOP health payments of HIV/

AIDS patients, and identified associated factors.

Methods

Study settings and participants

We conducted a cross-sectional multisite survey in Ha

Noi, Hai Phong and Ho Chi Minh City from January to

February, 2012. These cities were selected because they

experienced the countrys largest HIV epidemics, and they

have been implementing comprehensive HIV/AIDS inter-

ventions. The present study is a part of a greater effort,

namely the 2012 HIV Service Users Survey, to assess the

effectiveness and performance of HIV/AIDS services to

inform policy development in Vietnam (Tran 2012). In

each city, we selected study sites based on the following

criteria: (i) Central, provincial and district clinics were

involved; (ii) hospitals/health centres have been providing

ART services; and (iii) there was a sufficient number of

HIV/AIDS patients in each clinic. There were seven sites

purposively selected, including one central hospital

(National Hospital of Tropical Diseases), three provincial

hospitals (Dong Da, Viet Tiep and Ho Chi Minh Hospital

for Tropical Diseases) and three district health centres

(Tu Liem, Binh Tan and Le Chan District Health Centres).

As constructing a sample frame was not possible due to

confidentiality; we selected patients on a convenient basis.

Subjects were HIV-positive inpatients and outpatients

who were registering for care or taking ART at selected

sites. All patients present at the clinics during the study

period were invited to participate in the survey, and gave

written consent if they agreed. We recruited patients until

a sufficient sample size of at least 100 was reached per site.

Measures

Socio-economic background and HIV-related characteris-

tics of patients were collected using face-to-face interviews

with structured questionnaires. Monthly household

income was self-reported including all sources of each

household members income in 2011, such as salary,

wages, pensions, relatives supports, interests and reve-

nues. Households expenditure was estimated including

recurring expenses in the last month (e.g. food, utility,

rent, education and others), and non-recurring expenses in

the last 12 months (e.g. construction, health care,

furniture, travels, community events and others). Seven

hundred and ninety (77.8%) patients responded to the

questions regarding household expenditure. The OOP

health expenditure of household included the total

expenses for health-care services of all family members

including HIV-positive individuals. Healthcare service

utilisation of HIV-positive individuals included any inpa-

tient and outpatient care received during the past

3 months, excluding regular HIV outpatient clinic visits

for ARV medications. The 3-month recall of health service

use was commonly applied in previous national surveys

(Chaudhuri & Roy 2008). For the convenience of report-

ing, we converted the frequency of health service use for

1 year. Although patients at different disease stages or

periods of ART could use healthcare services differently,

this conversion did not distort the mean rate of use. Unit

costs were estimated for the last inpatient- and outpatient

care. Patients were asked about any expenses incurring

during their last use of healthcare services. It included

(i) medical expenditures (non-ARV medications, lab tests,

hospital fees and others) and (ii) non-medical expenditures

(transportations, accommodation and special meals if

any). OOP health payments for HIV/AIDS patients were

estimated by multiplying the rate of health service use by

the mean costs of each visit. All expenditures and incomes

were converted from Vietnam Dong to US$ using the

exchange rate in 2011 (1 US$ = 20,500 Vietnam Dong).

Data analysis

Analysis of variance test was used to examine the differ-

ences between means. Household expenditure categories

were presented in both means (95% CI) and medians (in-

terquartile ranges). Catastrophic health expenditure was

defined at the threshold of 40% total households

monthly non-subsistence expenditure (Xu et al. 2003).

Multivariable logistic was used to determine correlates of

experiencing catastrophic OOP health expenditure. Zero-

inflated Poisson models were constructed to examine the

correlates of the rate of health service use. Candidate

independent variables included socio-economic and HIV-

related characteristics of respondents at the time of the

interview. Collinearity was examined using the variance

inflation factors. We applied a stepwise forward model

building strategy that selected variables based on the log-

likelihood ratio test at a P-value 0.2 (Hosmer & Lemeshow 2000).

Ethics

This is a part of the research project on Cost and cost-

effectiveness of HIV/AIDS care and treatment policy

2012 Blackwell Publishing Ltd 213

Tropical Medicine and International Health volume 18 no 2 pp 212218 february 2013

B. X. Tran et al. Financial burden of HIV in Vietnam

options in Vietnam. The use of data was approved by

the Authority of HIV/AIDS Control, Ministry of Health

of Vietnam. Ethical approval was granted by the Univer-

sity of Albertas Health Research Ethics Board.

Results

The response rate was 85-90% in different clinics. We

interviewed 1016 patients, accounting for 17% of total

HIV patients in selected sites. Mean age was 35.4

(SD = 7.0) years, 36.2% were female, 45.0% had com-pleted high school, 64.0% were living with spouses or

partners and more than 70% were freelancers or had sta-

ble jobs. The mean monthly household income was US$

346.5 (SD = 293.1) or US$ 99.6 (SD = 79.6) per capita(household size was 3.8 people). Besides ART, HIV/AIDS

patients reported an average number of inpatient and

outpatient care of 0.3 and 4.8 times in the past

12 months, respectively. As shown in Table 1, patients at

central clinics reported a significantly lower rate of health

service use (1.8 times) than those at provincial (5.8 times)

and district (5.9 times) clinics (P < 0.01). Patients whowere on the 1st year ART and who had not yet received

ART also had a higher rate of health service use.

In Table 2, the monthly household expenditure was US$

289 (95% CI = 262; 317), of which 47% was food, 5%was health care for HIV/AIDS individuals and 6% was

health care for other members. There were 33.8% HIV/

AIDS patients reported having inpatients care, and 32.0%

having outpatient care over the past 3 months besides

monthly visits to HIV/AIDS outpatient clinics to receive

ARV medications (Table 3). The cost of inpatient and out-

patient care was US$ 461 and US$ 50 on average. Direct

medical costs accounted for about 60% of the total, half of

Table 1 Characteristics of respondents and frequency of healthcare service utilisation

N %

Heath service utilisation rate per year

Outpatient Inpatient All

Mean 95% CI Mean 95% CI Mean 95% CI P-value

Level of health service administration

Central 201 19.8 1.4 0.92.0 0.3 0.20.5 1.8 1.22.4 0.00Provincial 406 40.0 5.4 4.85.9 0.4 0.30.5 5.8 5.26.4District 409 40.3 5.8 5.26.3 0.2 0.10.2 5.9 5.46.5

IDU

No 548 53.9 4.9 4.45.4 0.3 0.20.3 5.1 4.75.6 0.42Yes 468 46.1 4.6 4.15.1 0.4 0.30.4 5.0 4.45.5

HIV/AIDS stages

Asymptomatic 126 12.4 4.8 3.85.7 0.2 0.10.3 4.9 4.05.8 0.14Symptomatic 508 50.0 4.8 4.35.3 0.3 0.20.4 5.1 4.65.6AIDS 382 37.6 4.7 4.15.3 0.3 0.30.4 5.0 4.45.6

CD4 cell count

200 249 24.5 4.8 4.15.5 0.5 0.40.7 5.4 4.76.1 0.54200 < cd4 350 249 24.5 5.6 4.86.3 0.2 0.10.3 5.8 5.06.5350 < cd4 500 194 19.1 4.5 3.75.3 0.2 0.10.2 4.7 3.85.5>500 109 10.7 4.3 3.35.3 0.2 0.10.3 4.6 3.55.6Not reported 215 21.2 4.2 3.55.0 0.3 0.20.4 4.5 3.85.3

Length of ARTNone 114 11.2 5.2 4.36.1 0.2 0.10.4 5.4 4.56.4 0.081 year 196 19.3 4.8 4.05.6 0.6 0.40.7 5.4 4.66.21; 2 144 14.2 4.4 3.55.3 0.2 0.10.3 4.6 3.85.52; 4 270 26.6 4.8 4.15.5 0.2 0.20.3 5.1 4.35.84; 7 292 28.7 4.7 4.05.4 0.2 0.20.3 4.9 4.25.6

Household expenditure quintiles

Poorest 158 15.6 5.2 4.26.1 0.3 0.20.4 5.5 4.56.4 0.04Poor 158 15.6 4.1 3.24.9 0.3 0.20.4 4.4 3.65.2Middle 158 15.6 4.9 3.95.8 0.3 0.20.4 5.1 4.26.1Rich 158 15.6 4.0 3.24.9 0.4 0.30.6 4.4 3.65.3Richest 158 15.6 3.6 2.84.4 0.3 0.20.4 3.9 3.14.7Not reported 226 22.2 6.2 5.47.0 0.3 0.20.3 6.4 5.67.2

214 2012 Blackwell Publishing Ltd



which was medications (excluding ARV) as the greatest

proportion of the total costs. The mean total expenditure

for healthcare services for HIV/AIDS individuals was US$

188 (95% CI = 148229) per annum or US$16 per month(Table 3). There were 35.1% (95% CI = 32.238.1)households with catastrophic OOP payments for health

care. In a scenario of non-ART subsidy where patients bear

ART costs, the proportion of household experiencing cata-

strophic health expenditure would be 73.3% (95%

CI = 70.676.1). In other words, the free-of-charge ARTprogramme had prevented 52.1% HIV-affected house-

holds from catastrophic OOP health expenditure.

Table 4 presents the correlates of catastrophic OOP

health expenditure and the expected differences in the

rate of health service use in various patient groups.

Increased likelihood of incurring catastrophic health

expenditures was observed in patients at provincial

clinics, males, those with unstable jobs, those in the poor-

est income quintile, people with CD4 counts less than

200 cells/mL, and those not yet receiving ART. In the

post-estimation of Zero-inflated Poisson model, patients

who were at provincial and district clinics, female, with

unstable jobs, with CD4 counts less than 350 cells/mL,

or who had taken ART for more than 2 years had signifi-

cantly higher expected rates of health service use than

their counterparts.

Discussion

This study examined OOP expenditure and healthcare

service utilisation of HIV/AIDS patients in Vietnam.

Although ART services are offered free-of-charge, HIV/

AIDS patients had to pay US$ 188 a year for their health

care. This OOP health payment was catastrophic for

more than one-third of HIV-affected households. The

rate of health service use and its associated financial bur-

den were heterogeneous across central, provincial and

district clinics, and significantly associated with disease

severity and the duration of ART.

The mean income per capita of this patient sample (US

$99/month) was close to the national mean income

Table 2 Household monthly expenditures (US$)

N Median p25 p75 Mean 95% CI

% of

total

expenses

Food 790 122 73 146 135 128143 47Household utility 790 15 7 24 21 1923 7Rent 790 0 0 0 8 610 3Education 790 8 0 39 25 2328 9Other 790 0 0 24 24 2028 8

Health care

For others 790 2 0 12 17 1419 6For HIV/AIDS patients 790 0 0 6 16 1220 5

Non-recurring expenses

Construction 790 0 0 0 31 1052 11Furniture 790 0 0 0 4 26 1Travel 790 0 0 0 1 02 0Community events 790 2 0 8 7 68 2

Total expenditure 790 218 141 320 289 262317 100Expenditure per capita 790 62 42 94 84 7790

Table 3 Average costs per an inpatient and an outpatient care(US$)

Inpatient care

(n = 343,33.8%)

Outpatient care

(n = 325,32.0%)

Mean 95% CI Mean 95% CI

Costs for an inpatient and an outpatient care

Total 461 419502 50 4061Direct non-medical costsBoarding and lodging 105 90120 9 612Transportation 67 5777 14 1019

Direct medical costs 289 262315 29 2235Medication (excl. ARV) 159 119204 14 624Lab tests 31 2341 11 715User fee 64 4387 1 02Others 34 2149 4 26

Average annual costs for health care for an HIV/AIDS patient

Times of service used 0.3 0.30.3 4.8 4.45.1Total direct medical cost 54 4166 57 3479Total direct cost 90 69111 98 65131

Total annual costs 188 148229




per capita in 2011 (US$ 108/month). The OOP health pay-

ment for HIV/AIDS patients in this study was higher than

that of the general population, which was about US$ 10

per household in the 2008 Vietnam Living Standards Sur-

vey, or about US$ 40 per household in another estimate

(Van Minh 2011; Nguyen et al. 2012). The percentage of

households that experienced catastrophic health expendi-

ture due to HIV/AIDS care (35.1%) was substantially

higher than that of the general Vietnamese population

(5.7%) (Van Minh 2011). In fact, the OOP health payment

for an HIV/AIDS patient was as high as the total health

expenses of all other family members, and approximated

40% of the average costs for ART services (US$ 452, Tran

BX, 2012b).

As for health service use, we observed a smaller rate of

outpatient care, but higher rate of inpatient care and

OOP health payments in this study than in another

household survey in 2010 (US$ 131.9/year) (Glandon

2011). The difference may be explained by the fact that

we selected patients based on their clinic attendance.

High OOP payments for HIV/AIDS care, excluding ART,

were also found in other settings. In China, they ranged

from US$ 13 to 3939 in 2006 depending on disease

stages (Moon et al. 2008). In India, OOP direct costs for

HIV/AIDS care were US$ 244 in 2002. In terms of health

service utilisation, our findings were in line with previous

studies which found that the rates of health services use

decreased significantly in patients with better

immunological status (Luseno et al. 2010; Yehia et al.

2010). Moreover, women had a higher rate of outpatient

care than men. Drug users also used healthcare service

more often than non-drug users because they can have

Table 4 Correlates of catastrophic out-of-pocket (OOP) and healthcare service use

Catastrophic OOPExpected differences in health service use, times/year (Coef., 95% CI)

AOR, (95% CI) Inpatient care Outpatient care Total

Level of clinics (central)Provincial 0.7 (0.5; 1.0) 0.0 (0.2; 0.3) 1.2 (0.2; 2.5) 2.6* (1.4; 3.7)District 0.2 (0.4; 0.0) 0.6 (0.7; 2.0) 2.0* (0.8; 3.3)

Female vs. male 0.4* (0.3; 0.6) 0.0 (0.2; 0.3) 0.6 (0.0; 1.2) 0.7* (0.1; 1.4)Education: High school vs. below 0.3* (0.5; 0.1) 0.3 (0.9; 0.3) 0.2 (0.8; 0.4)Marital status (single)Live with spouse/partner 0.8 (0.6; 1.1) 0.2 (0.5; 0.0) 0.1 (0.7; 1.0) 0.2 (0.7; 1.1)Separated, divorced, widow(er) 0.0 (0.6; 0.6) 0.8 (1.8; 0.1) 0.8 (1.8; 0.2)

Employment (unemployed)Stable jobs 0.0 (0.2; 0.3) 0.2 (1.1; 0.6) 0.5 (1.4; 0.4)Unstable jobs 1.7 (1.0; 2.9) 0.1 (0.1; 0.3) 0.0 (0.9; 1.0) 0.2 (1.3; 0.8)

Income per capita (poorest)Poor 0.4* (0.3; 0.8) 0.0 (0.2; 0.3) 1.5* (2.4; 0.5) 1.3* (2.3; 0.4)Middle 0.6* (0.3; 0.9) 0.0 (0.3; 0.2) 1.2* (2.2; 0.3) 0.8 (1.8; 0.2)Rich 0.3* (0.2; 0.5) 0.0 (0.3; 0.3) 0.5 (1.4; 0.4) 0.1 (1.1; 0.8)Richest 0.4* (0.2; 0.7) 0.2 (0.4; 0.1) 0.1 (1.1; 0.8) 0.5 (0.5; 1.5)

HIV stages (asymptomatic)Symptomatic 0.3* (0.1; 0.6) 1.3* (2.5; 0.0) 0.6 (1.8; 0.6)AIDS 1.3 (0.9; 1.8) 0.0 (0.1; 0.2) 1.1 (2.3; 0.1) 0.3 (1.5; 0.9)

IDU vs. Non-IDU 0.3* (0.1; 0.6) 0.3 (1.1; 0.5) 0.2 (1.0; 0.5)CD4 (a 200)200 < cd4 350 0.6* (0.4; 0.9) 0.5* (0.7; 0.2) 0.7 (0.4; 1.7) 0.0 (1.1; 1.0)350 < cd4 500 0.4* (0.3; 0.7) 0.3* (0.6; 0.1) 0.6 (1.7; 0.4) 1.2* (2.3; 0.2)>500 0.5* (0.3; 1.0) 0.2 (0.5; 0.1) 0.9 (2.1; 0.3) 1.4* (2.6; 0.3)

ART (not-yet)1 year 0.4* (0.2; 0.7) 0.4 (0.9; 0.1) 0.6 (0.3; 1.5) 0.1 (0.9; 1.0)1; 2 0.4* (0.2; 0.7) 0.6* (1.1; 0.2) 0.2 (0.6; 1.1) 0.0 (1.0; 0.9)2; 4 0.3* (0.2; 0.5) 0.5 (0.9; 0.0 1.8* (0.9; 2.7) 1.4* (0.4; 2.4)4; 7 0.3* (0.2; 0.6) 0.5* (1.0; 0.0) 2.5* (1.6; 3.5) 2.2* (1.1; 3.3)Constant 6.4* (2.9; 13.8)

Reference group.Adjusted odd ratio.*P < 0.05.




more severe comorbidities and poorer treatment out-

comes (Tran et al. 2012c,d).

Several policy implications arise from these results. First

of all, although ART is provided free-of-charge, a large

proportion of HIV/AIDS patients had high demand for

health care, and still faced catastrophic healthcare costs.

This emphasises the importance of a wide-scale expansion

of ART services along with impact mitigation pro-

grammes to improve health status and reduce economic

vulnerability of HIV/AIDS patients. Also, other protective

financial mechanisms, for instance, health insurance or

community-based funding sources, should be in place.

Secondly, patients who had better immunological status,

beyond the threshold of CD4 = 350 cells/mL, also usedand paid less for healthcare services than other patient

groups, suggesting an earlier initiation of ART. Besides, in

the breakdown of unit costs, transportation accounted for

15% and 28% of an inpatient and outpatient care, respec-

tively. This cost could be reduced by decentralising HIV/

AIDS-related services are to district level and putting more

integrative and comprehensive service delivery for HIV/

AIDS care, support and treatment in place.

The strengths of this study included the involvement of

multiple sites with a relatively large number of respon-

dents. Although these sites were not selected by a statisti-

cally derived algorithm and not nationally representative,

they are in different geographical regions and levels of

health service administration. However, the study was

subject to several limitations. First, we approached

patients during their visits to clinics; thus, the sample

might exclude patient groups who did not access to

healthcare services, for example, those who were not yet-

tested, or who did not yet know their HIV diagnosis, and

who were severely ill and stayed at home. Second, esti-

mates of spending for the last inpatient and outpatient

care were self-reported by patients that could be biased

and unverifiable without patients medical records. Simi-

larly, the household income and expenditure, which was

based on respondents recalls, could be under-reported

(Riyarto et al. 2010). Finally, the scope of this cost analy-

sis included only direct costs incurred by HIV/AIDS

patients, excluding ART and other indirect costs. Not-

withstanding, the study contributes to the understanding

of the economic impact of HIV/AIDS, and supports the

development of HIV/AIDS policies in Vietnam.

In conclusion, use and OOP payment for healthcare

services of HIV/AIDS patients were high and even

catastrophic to more than one-third of affected house-

holds. Scaling up free-of-charge ART services, earlier

access to and initiation of ART, and decentralisation and

integration of HIV/AIDS-related services could reduce the

financial burden of HIV care and treatment in Vietnam.

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Corresponding Author Bach Tran, Institute for Preventive Medicine and Public Health, Hanoi Medical University, Vietnam.

Tel.: + 84 98 222 8662; E-mail: [email protected] or [email protected]




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