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The 2nd Workshop on Equity Indicator Analysis
EQUITAP Project
27-31 July 2009
International Health Policy Programme, Ministry of Public Health, Thailand
Background of Lao PDR
• Lao People's Democratic Republic (Lao PDR) is a small, land-locked country in the heart of South-East Asia
• Encompassing 236,800 Square kilometers
• Sharing borders with Thailand to the west, Viet Nam to the east, China and Myanmar to the north and Cambodia to the south
• Source: NSC, Lao Census, 2005
Background of Lao PDR• According to the 2005 Population and
Housing Census, In March 2005, Lao PDR had a total population of 5.62 million
• Growth rate of 2.5 % per year• The population comprises 49 ethnic groups• The population density is 24 persons per
square kilometre• 73 % of the population lives in rural area
• Source: NSC, Lao Census, 2005
•
Background of Lao PDR
• The adult literacy rate is 73 percent• Life expectancy at birth is 59 years for
males and 63 years for females• The average household size was 5.9
persons• The major cities are Vientiane Capital,
Savannakhet, Champasack and Luangphrabang
• Source: NSC, Lao Census, 2005
Background of Lao PDR
• Buddhism is the dominant religion with more than 65 % of the population as believers
• The official language is Lao
• The administrative system of the country includes about 11,000 villages in 142 districts in 16 provinces, 1 city (Vientiane) and 1 Special region (Xaisomboun)
• Source: NSC, Lao Census, 2005
Health care system of Lao• In Lao PDR, there are two categories of health
care providers– formal health care– non-formal / informal health care.
• The system of formal health care:– (1) services/cares, provided by hospital (hospital
system)– (2) services/cares, provided by primary health
care (PHC system)– (3) services/cares, provided by vertical
programme (vertical programmes)
– Source: NIOPH, Lao Health Survey as apart of WHS, 2006
Health care system of Lao
• The system of non formal/informal health care provision includes:– traditional healers– traditional herbalists– traditional birth attendants– registered pharmacies (including informal
advisers), drug sellers– village health volunteers
– Source: NIOPH, Lao Health Survey as apart of WHS, 2006
Health Facilities in Laos
• 4 central hospitals (Mahosot, Mittaphab, Sethathirath, and Mother & child health)
• 9 specialized centers (Ophthalmology, Tuberculosis, Dermatology, Orthopaedic and Rehabilitation, Mother & Child Health, Malaria-parasitology and entomology, Traditional Medicine Research, Laboratory and epidemiology, HIV/AIDS centers)
• 16 provincial hospitals• 126 district hospitals• 734 health centers
• Source: NIOPH, Lao Health Survey as apart of WHS, 2006
Health Facilities in Laos
• 308 private clinics• 2,132 private pharmacies• 6 pharmaceutical factories• no private hospital
• Source: NSC, Lao Census, 2005
10
Health insurance schemes in Lao
• Civil Servant Scheme (CSS)
• Social Health Insurance (SHI or Social Security Office)
• Community-based health insurance schemes (CBHI)
• Health Equity Fund
• Private health insurance
• Source: NIOPH, Lao Health Survey as apart of WHS, 2006
Objectives
• To explore the incidence of catastrophic health expenditure of Lao
• To assess the magnitude of impoverishment from health care expenditure
• To compute Benefit Incidence Analysis (BIA)
• To compute Financial Incidence Analysis (FIA)
Catastrophic health expenditure
• A situation where household out-of-pocket payments for health are higher than 10% of household resources (income or expenditure)
• This study uses HH expenditure due to the limitation of reported HH income that tend to underreported
FIA and BIA
• BIA– An approach to examine who benefits from
public spending (on health),
– It indicates how well government health resources are targeted and gained by different socio-economic groups, especially the poor and the disadvantaged
• FIA– Who pays for health care among different
socio-economic groups
RESEARCH METHODOLOGYSources of data
1. Lao Expenditure and Consumption Survey (LECS3), 2002-2003 that has already officially permitted to use data from the Department of Statistics, Ministry of Planning and Investment
2. Socio-economic profile and satisfaction of insured and un-insured people in Lao P.D.R. with contracted health care providers, 2007, NIOPH-IHPP
Plausible Data sources using for health equity analysis
Survey Year
Institution conducting
surveyNationally
Representative? Sample Size Unit of Analysis
Socio-economic profile and satisfaction of insured and un-insured people in Lao P.D.R. with contracted health care providers 2006/2007
National Institute of
Public Health (NIOPH) NO 1,350
Individual and Household
Lao Expenditure and Consumption Survey
(LECS III) 2002/2003
National Statistical
Department Yes 8,092Individual and
Household
Poverty and Illness Survey (POVILL) 2007 NIOPH NO 3,000
Individual and Household
World Health Survey 2003 NIOPH, NSC Yes 5,000Individual and
Household
MICS 2006NSC, MOH Yes 6,000
Individual (Mother-
Children)and Household
Findings Catastrophic analysis
Impoverishment analysis
Financial incidence analysis (FIA)
Benefit incidence analysis (BIA)
Catastrophic incidence
Monthly out of pocket payment for health per
household, LECS3
5387.858
10929.02
18153.35
27355.86
32734.45
0
5000
10000
15000
20000
25000
30000
35000
Quintile1 Quintile2 Quintile3 Quintile4 Quintile5
Me
an
ou
t o
f p
oc
ke
t p
aym
en
t
Average out of pocket payment by quintile
Series1
Catastrophic health expenditure 2003
Catastrophic incidence by region (LECS3)
1.82
2.58
3.66
2.52
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
Northern Central Southern National
LECS3
Catastrophic health expenditure 2007, Health Insurance Survey, NIOPH/IHPP
Catastrophic incidence by selected provinces (NIOPH)
9.508.30
12.00
9.00
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
Luangprabang Vientiane andCapital
Champhasack Overall
NIOPH
Catastrophic health expenditure 2003
Catastrophic incidence by quintile 2003
1.52.0
3.8 4.0
1.4
0.0
1.0
2.0
3.0
4.0
5.0
Quintile1 Quintile2 Quintile3 Quintile4 Quintile5
LECS3
Catastrophic health expenditure 2007
Catastrophic incidence by quintile 2003
9.411.0
11.9
6.6
11.0
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
Quintile1 Quintile2 Quintile3 Quintile4 Quintile5
NIOPH
Catastrophic health expenditure 2003
Catastrophic incidence of helth payment in 2003 (LECS3)
1.1
2.4 2.62.22.0
2.7
3.9
2.7
0
1
2
3
4
5
Northern Central Southern National
cata
stro
phic
inci
denc
e
urban
rural
Impoverishment
Impoverishment incidenceLECS3
Pre - oop Post-oopQuintile1 18.96 19.27Quintile2 0.46Quintile3 0.05Quintile4Quintile5Total 18.96 19.78
The effect of health payment on per capital consumption
0
50000
100000
150000
200000
250000
1 2457 4913 7369 9825 12281 14737 17193 19649 22105 24561 27017 29473 31929
Pre OOP HH Expenditure Post OOP HH Expenditure Poverty line
The effect of health payment on poverty headcount by region in Lao
PDR
Poverty headcount by regoin 2007 (NIOPH)
11.0
22.0
14.2
21.523.0
11.9
24.0
15.3
0.0
5.0
10.0
15.0
20.0
25.0
30.0
Luangprabang Vientiane andCapital
Champhasack Overall
Pre-oop
Post-oop
Financial incidence analysis (FIA)
Gini coefficient 0
.2.4
.6.8
1
L(p
)
0 .2 .4 .6 .8 1Percentiles (p)
45° line pce
Lorenz Curve
Gini = 0.74
Concentration and Kakwani index
0.2
.4.6
.81
L(p
) &
C(p
)
0 .2 .4 .6 .8 1Percentiles (p)
45° line C(p): oop
L(p): pce
Lorenz and Concentration Curves
CI = 0.31 Kakwani index = - 0.43
Benefit incidence analysis (BIA)
Distribution of ambulatory service utilization in Lao PDR by quintiles and types
of health facilities, 2003
0.01 0.000.05 0.06
0.110.06 0.09
0.150.17
0.16
0.030.02
0.04
0.06
0.04
0.02
0.07
0.09
0.150.12
0.01
0.01
0.02
0.03 0.02
0.03
0.02
0.03
0.040.02
0.00
0.10
0.20
0.30
0.40
0.50
0.60
Q1 Q2 Q3 Q4 Q5
Am
bu
lato
ry v
isit
s p
er
ca
p p
er
ye
ar
Distribution of ambulatory service by quintiles and health facilities
other Abroad Private clinique HC Provincial/district Hs Central hs
Distribution of hospitalization in Lao PDR by quintiles and types of health facilities, 2003
0.000 0.001
0.0040.005
0.0100.011
0.016
0.019
0.022
0.026
0.003
0.004
0.002
0.002
0.001
0.002
0.003
0.003
0.003
0.001
0.001
0.002
0.002
0.002
0.002
0.0008
0.0057
0.0006
0.0018
0.0013
0.000
0.005
0.010
0.015
0.020
0.025
0.030
0.035
0.040
0.045
Q1 Q2 Q3 Q4 Q5
Ho
sp
ita
l ad
mis
sio
n p
er
ca
p p
er
yea
r
Distribution of hospitalization by quintiles and health facilities
Central hs Provincial/district Hs HC Private clinique Abroad other
Concentration curve of ambulatory service use by types of health facilities, 2003
0.2
.4.6
.81
C(p
)
0 .2 .4 .6 .8 1Percentiles (p)
45° line Central Hospital
Provincial/District hospital Health centers
Private health clinic Hospital/clinic abroad
Other
Concentration Curves of ambulatory service use by health facilities
Concentration curve of hospitalization by types of health facilities, 2003
0.2
.4.6
.81
C(p
)
0 .2 .4 .6 .8 1Percentiles (p)
45° line Central Hospital
Provincial/District hospital Health centers
Private health clinic Other
Hospital/clinic abroad
Concentration Curves
Concentration indices of ambulatory service use and hospitalization by
health facilities
Type of health facilities Concentration indices of ambulatory service
Concentration indices of hospitalization
Central Hospital 0.452 0.459
Provincial/District hospital 0.214 0.153
Health centers 0.158 - 0.1
Private health clinic 0.270 0.028
Hospital/clinic abroad 0.295 0.210
Other - 0.045 - 0.156
Mean Unit cost for hospitalization by type of health facilities in Lao PDR
IPD case 2002 2004
Central hosp - 517,140
Provincal hosp 214,610 378,328
District hosp 157,686 -
Health center 188, 531 -
Percent distribution of net government health subsidies among different health facilities in
2003
Percent distribution of net government health subsidy by quintile and IP health facility
0%
4%8% 8%
13%
7%
12%
15%13%
10%
3%
2%
2%
2%
2%
0%
5%
10%
15%
20%
25%
30%
Q1 Q2 Q3 Q4 Q5
Pe
rce
nt
Central Hs Provincial/district Hs Health center
Limitation of the study
• LECS3– Combination of Provincial
and district hospitals
– No data on OP expenditure
– Use expenditure replaced income
– Sequence of questionnaire
– Unspecified other health facilities
• Health Insurance (NIOPH/IHPP)– Not country
Representativeness– Utilization of health
services focused on urban areas
– Use expenditure replaced income
– Cannot compute BIA and FIA
Limitation of the study
• Lack of unit cost• Update of data• New knowledge of participants • Lack of experiences of participants
Discussion
• Low catastrophic:– Poor people tend to spend on food
consumption more than health care– Time period of data collection
• Access to central hospital and PH and DH
• Improving quality of care both public and private sectors and medical ethic of health care provider
Recommendation for further studies
• Improving instrument of health related national survey that can apply to equity in health
• Unit cost study at different levels
• Knowledge Transfer to Lao Health Staff
Thank you