Ardeshir Sepehri

How important are individual, household and commune characteristics in explaining utilization of maternal health services in Vietnam?

Using Vietnams latest National Household Survey data for 2001-2002 this paper assesses the influence of individual, household and commune-level characteristics on a womans decision to seek prenatal care, on the number of prenatal visits, and on the choice between giving birth at a health facility or at home. The decision to use any care and the number of prenatal visits is modeled using a two-part model. A random intercept logistic model is used to capture the influence of unobserved commune-specific factors found in the data regarding a womans decision to give birth at a health facility rather than at home. The results show that access to prenatal care and delivery assistance is limited by observed barriers such as low income, low education, ethnicity, geographical isolation and a high poverty rate in the community. More specifically, more prenatal visits increase the likelihood of giving birth at a health facility. Having compulsory health insurance increases the odds of giving birth at a health facility for middle and high income women. In contrast, health insurance for the poor increases the likelihood of having more prenatal visits but has little effect on the place of delivery. These results suggest that the existing safe motherhood programs should be linked with the objectives of social development programs such as poverty reduction, and that policy makers need to view both the individual and the commune as appropriate units for policy targeting.

If They Get Sick, They are in Trouble: Health Care Restructuring, User Charges, and Equity in Vietnam:

The transition from a centrally planned economy in the 1980s and the implementation of a series of neoliberal health policy reform measures in 1989 affected the delivery and financing of Vietnams health care services. More specifically, legalization of private medical practice, liberalization of the pharmaceutical industry, and introduction of user charges at public health facilities have effectively transformed Vietnams near universal, publicly funded and provided health services into a highly unregulated private-public mix system, with serious consequences for Vietnams health system. Using Vietnams most recent household survey data and published facility-based data, this article examines some of the problems faced by Vietnams health sector, with particular reference to efficiency, access, and equity. The data reveal four important findings: self-treatment is the dominant mode of treatment for both the poor and nonpoor; there is little or no regulation to protect patients from financial abuse by private medical providers, pharmacies, and drug vendors; in the face of a dwindling share of the state health budget in public hospital revenues and low salaries, hospitals increasingly rely on user charges and insurance premiums to finance services, including generous staff bonuses; and health care costs, especially hospital costs, are substantial for many low- and middle-income households.

What impact does contact with the prenatal care system have on women's use of facility delivery? Evidence from low-income countries

Prenatal and delivery care are critical both for maternal and newborn health. Using the Demographic and Health Surveys (DHS) data for thirty-two low-income countries across Asia, sub-Saharan Africa and Latin America, and employing a two-level random-intercept model, this paper empirically assesses the influence of prenatal attendance and a wide array of observed individual-, household- and community-level characteristics on a womans decision to give birth at a health facility or at home. The results show that prenatal attendance does appreciably influence the use of facility delivery in all three geographical regions, with women having four visits being 7.3 times more likely than those with no prenatal care to deliver at a health facility. These variations are more pronounced for Sub-Saharan Africa. The influence of the number of prenatal visits, maternal age and education, parity level, and economic status of the birthing women on the place of delivery is found to vary across the three geographical regions. The results also indicate that obstetrics care is geographically and economically more accessible to urban and rural women from the non-poor households than those from the poor households. The strong influence of number of visits, household wealth, education and regional poverty on the site of delivery setting suggests that policies aimed at increasing the use of obstetric care programs should be linked with the objectives of social development programs such as poverty reduction, enhancing the status of women, and increasing primary and secondary school enrollment rate among girls.

Taking Account of Context: How Important Are Household Characteristics in Explaining Adult Health-Seeking Behaviour? The Case of Vietnam

Understanding the factors affecting the utilization of health services is essential for health planners, especially in low income countries where increasing access to and use of health services is one of the main policy goals of government. While much has been written on adult health-seeking behaviour, there is comparatively little known about the influence of the broader context such as the effects of family and community on individual use of health care services in low income countries. Using Vietnams latest National Household Survey data, this paper empirically assesses the influence of individual- and household-level factors on the use of health care services, while controlling for the unobserved household-level effects. The estimates obtained from a multilevel logistic regression model suggest that the individuals likelihood of seeking treatment is jointly determined by the observed individual- and household-level characteristics as well as unobserved household-level effects. The chance of seeking medical treatment when ill varies strongly with the observed individual- and household-level covariates, including health insurance status, income, the type and severity of illness, the number of other household members with an ailment and the presence of young children in the household. However, the variability implied by the unobservable household-level effects outweighs the variability implied by the observed covariates, indicating a high degree of homogeneity in health-seeking behaviour among the household members. Failure to take account of homogeneity in health-seeking behaviour among the household members leads not only to biased results but also to inefficient policy targeting. Policies aimed at increasing access to and the use of medical services need to be sympathetic to both individuals and households.

Inflation-Growth Profiles Across Countries: Evidence from Developing and Developed Countries

There is growing evidence from multi‐country studies indicating that there is a turning point in the relationship between inflation and economic growth beyond which the detrimental effects of high inflation offset the stimulating effects of mild inflation on growth. However, it is not clear whether it is appropriate to assume an identical turning point in the inflation and growth relation across countries at various stages of development. Using a non‐linear specification and the data from four groups of countries at various stages of development, this paper examines the possibility for a family rather than a single inverted U relation across countries at various stages of development. The estimated turning points are found to vary widely from as high as 15% per year for the lower‐middle‐income countries to 11% for the low‐income countries, and 5% for the upper‐middle‐income countries. No statistically detectable, long‐run relationship between inflation and growth is evident for the OECD countries. The results indicate the potential bias in the estimation of inflation–growth nexus that may result from combining various countries at different levels of development. The existence of such a degree of heterogeneity across countries at various stages of development also suggests the inappropriateness of setting a single, uniform numerical policy target applicable to all (developing) countries.

Determinants of prenatal care use: evidence from 32 low-income countries across Asia, Sub-Saharan Africa and Latin America

While much has been written on the determinants of prenatal care attendance in low-income countries, comparatively little is known about the determinants of the frequency of prenatal visits in general and whether there are separate processes generating the decisions to use prenatal care and the frequency of use. Using the Demographic and Health Surveys data for 32 low-income countries (across Asia, Sub-Saharan Africa and Latin America) and appropriate two-part and multilevel models, this article empirically assesses the influence of a wide array of observed individual-, household- and community-level characteristics on a womans decision to use prenatal care and the frequency of that use, while controlling for unobserved community level factors. The results suggest that, though both the decision to use care and the number of prenatal visits are influenced by a range of observed individual-, household- and community-level characteristics, the influence of these determinants vary in magnitude for prenatal care attendance and the frequency of prenatal visits. Despite remarkable consistency among regions in the association of individual, household and community indicators with prenatal care utilization, the estimated coefficients of the risk factors vary greatly across the three world regions. The strong influence of household wealth, education and regional poverty on the use of prenatal care suggests that safe motherhood programmes should be linked with the objectives of social development programmes such as poverty reduction, enhancing the status of women and increasing primary and secondary school enrolment rate among girls. Finally, the finding that teenage mothers and unmarried women and those with unintended pregnancies are less likely to use prenatal care and have fewer visits suggests that safe mother programmes need to pay particular attention to the disadvantaged and vulnerable subgroups of population whose reproductive health issues are often fraught with controversy.

Who is giving up the free lunch? The insured patients' decision to access health insurance benefits and its determinants: evidence from a low-income country.

OBJECTIVES This paper examines the determinants of the insureds decision to use their health insurance card when seeking outpatient and inpatient health care in Vietnam. METHODS Uses Vietnams latest Household Living Standard Survey data and random-intercept logistic regression to assess the influence of the observed individual, household and commune/ward factors on the insureds decision to access health insurance benefits while controlling for the unobserved commune/ward-specific factors. RESULTS Compared to the compulsory enrollees, the voluntary enrollees and the beneficiaries of the Health Care Fund for the Poor are less likely to use their card when seeking inpatient care. An individuals likelihood of accessing insurance benefits varies inversely with income and the level of education, suggesting that the outpatient care provided to the insured is of inferior quality. CONCLUSIONS Although health insurance has the potential of increasing access and reducing the financial burden of health care utilization, Vietnams experience clearly suggests that these benefits may not be fully realized as long as the quality of care remains low and the high opportunity costs of accessing insurance benefits deter the insured from accessing benefits.

Does the financial protection of health insurance vary across providers? Vietnam's experience

Using household panel data from Vietnam, this paper compares out-of-pocket health expenditures on outpatient care at a health facility between insured and uninsured patients as well as across various providers. In the random effects model, the estimated coefficient of the insurance status variable suggests that insurance reduces out-of-pocket spending by 24% for those with the compulsory and voluntary coverage and by about 15% for those with the health insurance for the poor coverage. However, the modest financial protection of the compulsory and voluntary schemes disappears once we control for time-invariant unobserved individual effects using the fixed effects model. Additional analysis of the interaction terms involving the type of insurance and health facility suggests that the overall insignificant reduction in out-of-pocket expenditures as a result of the insurance schemes masks wide variations in the reduction in out-of-pocket sending across various providers. Insurance reduces out-of-pocket expenditures more for those enrollees using district and higher level public health facilities than those using commune health centers. Compared to the uninsured patients using district hospitals, compulsory and voluntary insurance schemes reduce out-of-pocket expenditures by 40 and 32%, respectively. However, for contacts at the commune health centers, both the compulsory health scheme and the voluntary health insurance scheme schemes have little influence on out-of-pocket spending while the health insurance scheme for the poor reduces out-of-pocket spending by about 15%.

Who Paid for the Canadian Welfare State Between 1955-1988?

This paper attempts to examine the impact of state taxation and expenditure activities on Canadian labor and non-labor. Using state expenditure and revenue data for the period 1955-1986, the Canadian transfer ratio is estimated and then it is compared and contrasted with the transfer ratio for the United States. This inter-country comparison also enables us to isolate the influence of a crisis-induced rise in unemployment on the net transfer from arguments that the social wage grew because of the growing power of labor over capital and the state.

Back to the future? A critical review of 'Adjustment in Africa: reforms, results and the road ahead'

The World Banks report, Adjustment in Africa, Reforms, Results, and the Road Ahead (hereafter A in A), provides the most comprehensive data so far on policy changes and results for adjusting Sub‐Sahara African countries. The report selectively uses data to prove that adjustment is working, payoffs to policy reforms are large, and the region is on the road to a sustained, poverty‐reducing growth path. A re‐evaluation of the reports own data suggests that there is sufficient evidence to be concerned about the sustainablity of adjustment results. After many years of experience with adjustment policies, growth rates are still low, as are saving and investment rates — even for the strong adjusters. Modest GDP, agricultural and industrial growth rates, combined with a deterioration in social services all cast doubt on the regions prospect for checking the growth of poverty before the next two or three decades.