Impact of poverty reduction policy on commune-level primary health care in Thai Nguyen province of Vietnam

Objectives: Although Vietnam leads the developing world in creating universal coverage of essential health services, economic restructuring and privitization of health services has been associated with emerging social and economic health care inequity. In response, the Government of Vietnam has promulgated “People's Decree 135” providing resources to poor communes for cost-free Commune Health Centers (CHC) services. This analysis aims to examine the service utilization equity effects of this policy and its interaction with health service investments in Thai Nguyen Province designed to achieve minimal quality “benchmark” standard investments in equipment, facilities, and staff.

Methods: Quarterly health management information system reports from all 180 communes of Thai Nguyen province are analyzed for the period from January 1, 2004 to March 31 2006 with generalized regression methods to explain caseload variance with commune exposure to poverty policies and CHC service benchmarks, controlling for poverty level, remoteness, and ethnic composition.

Outcomes: Fixed effect regression results show that poor and remote CHC have higher utilization rates than CHC located in communes that are less poor and less remote and that this effect that is amplified by Policy 135 exposure. Policy 135 effects are more pronounced if service quality standards are met at “benchmark” service input levels. Investments in staff, equipment and facilities directly affect overall and under-5 caseloads in all communes, irrespective of commune poverty status. In Policy 135 non-benchmark communes, caseloads increase directly with levels of commune poverty, suggesting that prosperous families abandon CHC care if quality is poor. Achieving benchmarks elevates caseloads in all exposed communes, reducing inequity by accelerating demand for CHC services among all segments of society.

Conclusion: Findings suggest that poverty policies promote utilization, particularly in poor communes. However, if quality is poor, the poor are left behind as the less poor seek services elsewhere. Combining policy 135 with quality investments reduces the gap between CHC caseloads in poor communes versus those that are less poor. Findings lend support to the hypothesis that Vietnam's CHC policies differentially benefit the relatively poor, but corresponding prioritization of investment in quality benchmark standards would further reduce inequity in health care services.