December 2007, Vol. 13, No. 3

Poverty, Gender, and Youth
Vietnamese Health Policies to Improve Fairness May Miss Ethnic Minorities, Study Finds

Since the 1950s, the government of Vietnam has established a vast network of primary health facilities. In addition to improving the health of individuals, this system aims to promote healthcare equity throughout the country. Services include comprehensive prenatal care and delivery services, care throughout early childhood, and services for basic health needs throughout a person’s life. Evidence suggests that these services have lowered infant and child mortality rates and improved life expectancy at all ages. However, recent research by the Population Council suggests that progress has been more rapid among the ethnic majority population than among ethnic minority groups in Vietnam. The country’s early health initiatives for the poor may have failed to offset equity problems confronting impoverished ethnic minority families.  

Ethnic groups in Vietnam
About 85 percent of Vietnam’s 84 million people belong to the Kinh ethnic group. In this study, the researchers combined ethnic Chinese, who account for only 1 percent of the population, with Kinh as a category because of the similarity of their social and economic characteristics. In contrast, cultural, social, and economic characteristics significantly differentiate other ethnic groups—of which there are more than 50 in Vietnam—from the majority of Vietnamese. Evidence from national surveys and other studies indicates that these minority groups are generally poorer than the Kinh majority. Social indicators, such as levels of educational attainment, show that minorities are disadvantaged. Moreover, studies of health indicators demonstrate that minorities have higher morbidity and mortality rates than Kinh of equivalent ages. Population Council researchers Bussarawan Teerawichitchainan and James F. Phillips used data from the 2001–2002 Vietnam National Health Survey (VNHS) to assess parental recall of illness among their children under age 5 and analyze details of parents’ care-seeking once they reported that their children were sick. The VNHS data were collected from a population-based nationally representative sample of 36,000 households containing 160,000 individuals from 1,200 communes nationwide. The sample included 11,355 children younger than age 5.

Each household in the survey was visited twice, the second visit taking place four weeks after the first. During the first visit, interviewers asked key people in the household to keep a record of any illnesses lasting more than 24 hours for every member of the household during the next four weeks. These recordkeepers were also asked to make note of any healthcare use and spending, including self-care. At the second visit the survey takers used the diaries to prompt discussions about the illnesses that had occurred in the past month. In the survey, respiratory infection and diarrhea—two of the biggest killers of children under age 5—were distinguished from other childhood illnesses. These maladies accounted for 31 and 11 percent respectively of all reported illnesses among under-5 children.

Reporting illness and seeking care
Teerawichitchainan and Phillips used the survey data to analyze both the incidence of childhood illness and the types of care parents sought for these illnesses. Care-seeking included both consulting a healthcare professional and self-prescribing care with available medicines. When neither of these two types of care was sought, the child was classified as not receiving care.

The researchers found that, regardless of severity of illness, Kinh and Chinese parents were significantly more likely than minority parents to report child illness episodes. This finding held true even when analyses controlled for each child’s ethnicity, age, sex, position in the birth order, the mother’s age and education, the family’s socioeconomic status, and the household’s location. However, this finding does not mean that children from minority families were significantly healthier than children from Kinh and Chinese families. Separate research has shown that minority families in Vietnam are very likely to suffer from malnutrition; there are strong links between malnutrition and childhood illness. The authors suggest that the most likely explanation for the lower reported incidence of childhood illness is a parental inability to report illness.

The researchers found that at all levels of illness severity, literate mothers and mothers with some education were much more likely to report their children’s illness episodes. “Such findings attest to the need for further investigation into the factors that affect parental recall of illness, since under-reported incidence could lead to spurious conclusions about the social epidemiology of risk, for example that minority children are less likely to fall ill,” said Phillips. This attests to the need for research that incorporates biomedical markers of health and indicators of nutritional status in survey data, to ensure that parental reports are supplemented with information that is free of recall bias

The results showed that self-prescribed care was the most common response of both Kinh-Chinese and minority parents to childhood illness. “One of the most striking findings is that a substantial number of poor minority parents reported that they did not seek any care for their sick children,” said Teerawichitchainan. “These results are consistent with the possibility that economic factors remain an important consideration when parents decide to seek professional consultation or give self-prescribed care to their children. They also show that poverty was not entirely offset by the health policies in place at the time of the survey.”

In fact, the researchers argue, pro-poor policies that eliminated user fees in order to encourage low-income populations to seek medical services may have achieved the opposite. The survey results show that these health initiatives increased the likelihood that better-off parents in remote disadvantaged communes would seek professional care for their sick children, but there is no corresponding evidence that free healthcare provision benefited children from poor families.  

Economic or social factors?
Vietnam’s healthcare policy has tended to focus on the economic elements of access. However, the research by Teerawichitchainan and Phillips indicates that social factors related to ethnic minority status play an important role in parental decisions to seek care for a sick child. “Parents of ethnic minority children at all income levels were less likely to report that their children were sick,” explained Teerawichitchainan. “When they recognized illness episodes, they were less likely to seek care, whether self-prescribed care or professional help.” The study did show that maternal education among ethnic minorities may have had pronounced effects in increasing care-seeking behavior for childhood illnesses. A relatively recent official emphasis on extending maternal education among minorities may eventually contribute to bridging the health equity gap between Kinh-Chinese and ethnic minorities.

Furthermore, since 2002, the government of Vietnam has launched major targeted health policies to improve healthcare access for the poor, and these policies are soon to be evaluated in national survey research. Until these new policies are evaluated, however, evidence from this study suggests that health policies intended to benefit the children of the poor and most vulnerable have yet to do so appreciably.

Source
Teerawichitchainan, Bussarawan and James F. Phillips. 2007. “Ethnic differentials in parental health seeking for childhood illness in Vietnam,” Poverty, Gender, and Youth Working Paper no. 3. New York: Population Council. (abstract) (PDF)

Outside funding
Anonymous and the Atlantic Philanthropies

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Related Projects

• Findings from Recent and Ongoing Youth and Family Studies in Vietnam
• Vietnam: Findings from Recent and Ongoing Youth and Family Studies

See Also

• Vietnam

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