A STUDY OF SATISFACTION AMONG POOR PATIENTS HOLDING HEALTH INSURANCE CARD WITH HEALTH CARE SERVICES AT TWO DISTRICT PUBLIC HOSPITALS IN VIETNAM

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1 Health and Population - Perspectives and Issues 7 (1&2), 50-56, 2014 A STUDY OF SATISFACTION AMONG POOR PATIENTS HOLDING HEALTH INSURANCE CARD WITH HEALTH CARE SERVICES AT TWO DISTRICT PUBLIC HOSPITALS IN VIETNAM Nguyen Thi Nhu Quynh* and Neera Dhar** ABSTRACT By 2008, the Health Insurance Law was passed in Vietnam to help the poor get access to formal health services. It stipulates that the poor are provided a free health insurance card that has a provision of 95 per cent reduction in hospital fees. However, since the introduction of the Health Insurance Law, no assessment has been done yet to know whether the poor patients are satisfied with the services. This study was conducted to assess the satisfaction of the poor patients holding the health insurance cards with regard to the health care services in two public hospitals at the district level, and to put up recommendations for developing appropriate policy in the future. The research only evaluated two aspects of satisfaction: (i) satisfaction with the hospital procedures prior to treatment that include scheduling an appointment, waiting time, costs, and procedure for payment; and (ii) satisfaction with the communication and interaction of health-care staff and doctor with patients. The results showed that the poor patients are not fully satisfied with the services they received. Overall, the mean scores of satisfaction were between and. in comparison to some foreign studies that have a satisfaction level score of over 4. It reflects that the Vietnamese poor are unsatisfied with the health-care services they are provided with. The poor patients are not really satisfied with the procedures prior to treatment, particularly the waiting time for registration and examination. This study also showed that there is no discrimination in the provision of health-care services between the two target groups i.e. the poor with health insurance cards and the general public. This nondiscrimination attitude is seen not only in the hospital regulations and procedures but also in the attitude of the medical staff and * PGDPHM Student; **Professor and Acting Head, Department of Communication, National Institute of Health and Family Welfare, Munirka, New Delhi

2 doctors at the hospitals towards the poor patients. Hence, it is observed that the government s health insurance policy for the poor is partly effective. It is suggested that two hospitals should introduce scheduled appointments for examination to reduce waiting times; must develop and maintain feedback systems in public hospitals to minimize the inappropriate attitude of medical staff in general and doctors in particular; and should introduce and implement a strict bonus and penalty system for the hospital staff based on the feedback. Key words: Health-care services, Satisfaction, Health insurance card, Poor-patients, General patients. Vietnam is a developing country with a population size that ranks 14th in the world. Of the 85 million people in 2009 in Vietnam, 10.2 per cent lives in poverty. However, the health service has always been sensitive to the issue of health care for the poor. In 2002, the government began setting up the Health Care Fund for the poor. By 2008, the Health Insurance Law was passed to help the poor get access to formal health services. The Health Insurance Law has clearly specified that the poor are issued a free health insurance card, enjoy 95 per cent reduction/ concession in hospital fees and should be taken care of as all other individuals who possess the health insurance card. This also means the poor people receive the same quality of health care services as other better-off individuals. In Vietnam, there have been a number of studies that evaluated the quality of health care services by assessing patient satisfaction with health-care services they receive but there is little assessment of their feedback against the health care services. To assess the effectiveness of the health care programme for the poor proposed by the government, a study on the satisfaction of poor patients using the insurance card with the health care services as well as the health care treatment they receive will reflect the quality of health care services they receive in the hospitals. As most of the poor patients were registered for a health insurance card at district/rural district/town hospitals, this research has been conducted at the General Hospital of Thanh Tri district, Hanoi and the General Hospital of Chi Linh town, Hai Duong province. OBJECTIVES The objectives of the study was to: assess the satisfaction of the poor patients holding Health Insurance Card with the health care services provided to them in two public hospitals at the district level; and 51

3 suggest recommendations for developing an appropriate policy in the future to better the facilities and services. METHODOLOGY Data were collected from the two public hospitals in Vietnam. This research used a self-administered method to collect data. At the hospitals, the pharmacy department was the last department of examination in the treatment procedure for patients with health insurance cards. Hence, the research team asked the hospitals managers to grant permission to interview the research subjects (out-patients) at the pharmacy department. It was found that a subject code is mentioned on the health insurance card of each patient under which the particular patient is registered. For the poor patients, the insurance code is HN. The interviewees were distinguished by their pharmacists, and the interviews were conducted based on this code. However, the research applied a selfadministered method; some patients were conducted through an oral interview because patients had difficulties in reading the questionnaire. There were 195 patients who completed the questionnaires. Statistical Package for Social Sciences (SPSS) software was applied to analyse the collected data. FINDINGS AND DISCUSSION It was seen that the poor patients were not fully satisfied with the health care services they received at the two hospitals. In all the sub-scales of satisfaction in this study, the poor patients were not really satisfied with the procedures involved prior to availing of the health care services, particularly the waiting time for registration and examination. In fact, hither to, Vietnam has not implemented a timed examination procedure in state hospitals. Therefore, people come for examination at any time they want and usually get an examination in the morning during a.m. As a result, the registration and examination time is scheduled only in the morning, putting pressure on the registration systems, examinations and health care insurance payments. The researchers also observed the similar responses on interviewing the patients. The afternoon working hour starts at 10 p.m. and ends at p.m. But the number of patients coming for an examination in the afternoon is only one-third of that come in the morning hours. Thus, patients complain about waiting time only in the morning hours. The results show that the mean score of satisfaction for the communication and interaction of doctors with patients is higher than the health-care staff. Therefore, both hospitals need to devote some resources for improving the attitude as well as communication skills of the doctors as well as para-medics. It was seen that both the hospitals didn t have any comment/feedback box or mechanism for patient-feedback on the attitude of health staff, doctors and hospital leaders and vice-versa. This has limited the scope of improvement of the attitude of health staff and doctors towards patients in the two hospitals. 52

4 TABLE 1 PERCENTAGE OF POOR PATIENTS SATISFACTION WITH THE QUALITY OF HEALTH CARE SERVICES PROVIDED Procedural Approach to Health-care Services Communication and Interaction of Para-medics Communication and Interaction of Doctors Dissatisfied Satisfied Dissatisfied Satisfied Dissatisfied Satisfied Total Gender (n / %) Male 44 (89.8) 5 (10.2) Female 8 (79.2) 10 (20.8) Age (n / %) 12-4 Years 44 (89.8) 5 (10.2) Years 8 (79.2) 10 (20.8) Occupation (n / %) Farmer 46 (8) 9 (16.4) Others 6 (85.7) 6 (14.) 29 (59.2) 27 (56.2) 2 (65.) 24 (50.0) 2 (58.2) 24 (57.1) 20 (40.8) 21 (4.8) 17 (4.7) 24 (50.0) 2 (41.8) 18 (42.9) 8 (77.6) 1 (64.6) 8 (77.6) 1 (64.6) 11 (22.4) (5.4) (22.4) (5.4) 48 7 (67.) 18 (2.7) 56 2 (76.2) 10 (2.8) 42 Number of Times Visiting the Hospital for Medical Examination in 1 Year (n / %) 1-2 times 40 (81.6) 9 (18.4) Over times 42 (87.5) 6 (12.5) 28 (57.1) 28 (58.) 21 (42.9) 20 (41.7) 4 (69.4) 5 (72.9) 15 (0.6) 49 1 (27.1) 48 The study results show that there was no discrimination on the part of the hospitals in providing health-care services to the poor patients in comparison to the non-poor patients in the hospital. This non-discrimination attitude is shown not only in the hospital regulations and procedures but also in the attitude of the medical staff and doctors at the hospitals. 5

5 FIGURE 2 COMPARISON OF THE MEAN SCORE OF POOR PATIENTS AND NON-POOR PATIENTS SATISFACTION WITH PROCEDURES PRIOR TO AVAILING OF HEALTHCARE SERVICES 6. Patient s satisfaction on approach to health care services.2 5. Cost 4. Payment procedure for health care insurance. Waiting time in specialized examination room 2. Waiting time in general examination room Non-poor patient Poor Patient 1. Waiting time in registration rooms FIGURE COMPARISON OF THE MEAN SCORES OF POOR PATIENTS AND NON-POOR PATIENTS SATISFACTION WITH COMMUNICATION AND INTERACTION OF THE PARA-MEDIC STAFF 6. Patient satisfaction with the communication and interaction of the 5. Attitude of medical staff in specialized clinics 4. Attitude of medical staff in test and X- ray rooms. Attitude of medical staff in general clinics 2. Instruction of medical staff in registration rooms 1. Attitude of medical staff in registration rooms Non-poor Poor Patient.2 54

6 FIGURE 4 COMPARISON OF THE MEAN SCORES OF POOR PATIENTS AND NON-POOR PATIENTS SATISFACTION ON COMMUNICATION/INTERACTION OF DOCTORS Non-poor patient Poor Patient The factors such as the devotion of the doctor, attention of the doctor towards the patient s health problem, explanation of testing and medical testing processes in the examination room, explanation of the doctor about the patient s health status, time taken for the health examination, explanation of testing and medical testing process for specialized examination, professional qualifications of the medical doctors, accuracy of the diagnosis and the patient s satisfaction with communication and interaction of doctors were included for the feedback from the patients. The policy on health insurance in Vietnam for the poor is specifically mentioned in the Health Insurance Law in Firstly, as mentioned in Section D, Item 1, Clause 1 of the Law, the monthly insurance premium is equal to 4.5 per cent of the minimum salary level and paid by the state budget. On this Clause, the study results show that all the interviewed poor patients knew about the policy on health-care insurance and all of them believed that they do not have to pay the cost for the issue of health insurance card. This reflects that the government s health insurance policy for the poor is actually effective, and it ensures that the poor have a chance to avail of the health care services as it is provided to others. Secondly, Section D, item 1, Clause 22 of the Law says that the poor patients are covered for 95 per cent of the costs towards medical examination by the State which was confirmed during the study. Therefore, the poor patients expressed satisfaction with the costs of examination, with the highest mean score of satisfaction of as compared to other factors on the same scale with the procedures involved prior to availing of health-care services. However, the 55

7 interviewed patients were treated at the district hospitals that do not require costly treatment techniques; thus, bearing 5 per cent of the total cost was found to be acceptable for all the patients. For high-tech medical treatment, the total amount of cost is capped at VND while the current minimum wage is in Vietnam id VND/month. So, it is assumed that the poor will not be able to bear even 5 per cent of the highest cost as fixed in the Law. Thirdly, Clause 4 of Health Insurance Law specifies the responsibility of healthcare units for health insurance. This clause clearly specifies that each healthcare unit must ensure quality with simple and convenient procedures for people holding health-care insurance. The study findings show both the poor and nonpoor patients reported rather low mean scores of satisfaction with the procedures involved on health insurance payment which is for the poor and points for the non-poor patients. One of the reasons might be the long waiting time in the payment area. Thus, this procedure is not endorsed by most of the poor patients. Most of the subjects had the view to simplify the payment procedure and wanted the concerned authorities to take steps to shorten the waiting time for the payments. This situation was witnessed in all other hospitals as well. Therefore, this aspect of clearing payments for medical costs needs to be focused for those using the health insurance card. CONCLUSION Research findings of the current study show that poor patients are not fully satisfied with the waiting time, attitude of health staff, as well as health insurance payment procedures. It was found that on both the aspects such as procedures involved prior to availing of health-care services; and communication and interaction of health staff with the patients; the later aspect particularly the communication and interaction of doctors with the patients received the mean score of lower than four points. However, the waiting time, insurance payment procedures and attitudes of medical staff are three elements with the lowest average satisfaction point ranging from.0 to points. The mean scores of poor patients satisfaction on all the aspects are no different from non-poor patients that ranged between.2 and points. On all the subsections, no difference is observed between the two groups of patients. This shows that there is no discriminatory approach by the medical staff and doctors towards the poor patients that proves the in-discriminatory nature of the Vietnam Health Insurance Policy has been effective. 56