Determinants Of Health Care Utilization Health And Social Care Essay

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1st Jan 1970 Health And Social Care Reference this

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All people around the world could not access to health care service as there is a significant unmet need for health care. In order to improve the quality of human life, the health care providers and policy makers should have a better understanding of why people utilize or not utilize the health care services. In the changing of global environment such as population growth, increased health problems, higher demand for medical care and advanced medical technologies, health care expenditure is increasing in every country around the world. As health care expenditure has been escalating, financing for health care is becoming one of the challenges for governments especially in low and middle income countries.

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In many developing countries, the financial source for health care is dominated by private sector as house-hold out of pocket payment. However health insurance schemes are becoming an increasingly recognized tool in recent decades to finance low and middle income countries. As one of the poorest countries in South-East Asia, Myanmar health care financing mainly relies on private financing source in a form of out-of pocket payment. According to (NHA 2008-2009), 85% of total health expenditure comes from private household.

In Myanmar, there are some financial schemes initiated by the government in order to protect the financial lost and impoverishment of the people. Among those health financing schemes, Social Security Scheme (SSS) plays a role to pool the risk of financial burden among insured workers. Myanmar government started the social health insurance in 1956 to provide social assistances and health care services to the insured workers. Regardless of the long period of implementation, the coverage of social health insurance is only 0.97% of total population and 1.96% of working population. There are 93 clinics in 110 townships to provide health care services to insured workers (Social Security Board 2012). The clinic time is from 8:00 am to 4:00pm which is during working hours of insured workers (Social Security Board 2012). The social security clinic’s locations are mostly not closed with the work places. The director of Social Security Board (SSB) mentioned about health care services in the news interview that, “The current health care system is not enough for workers as the social security clinics cannot provide 24-hour service. Social security clinics cannot be found all over the country so workers in areas where there are no social security clinics can face difficulties.”(The Myanmar Times, April 16-22, 2012).

Apart from the difficulty in accessibility, the insured workers have to bear travelling cost and time cost to access health services from social security clinics. Moreover, there is very limited in equipments, medicines and facilities to provide enough health services to the insured workers. So some insured workers don’t visit to social security clinics and get the medical care from nearby clinics and treat with traditional medicines. One of the SSB member expressed her experience from a board’s clinic in Yangon as not be pleasant. She mentioned, “There was a long queue of patients and I was particularly upset by the poor service from the doctors and nurses and I really don’t trust them they don’t have specialists, they have only general practitioners. I only went there to claim the cost of my medicines.”(The Myanmar Times, April 16-22, 2012).

Because of difficulties for workers to visit the clinics, health care teams from clinics have been trying to provide health care services in work places; however the very limited number of vehicle and cost of patrol are the big challenging issue for the health care providers. Despite of monthly contribution from their salary, because of hardly to access health care facility from social security, the insured workers could not get their benefit from social security board.

However, Myanmar has been opening a new chapter of reform after 2010 general election and adopting democratic system in the country. As the country opening up, there are many reforms have been doing in order to move along with the ASEAN and global community. Myanmar SSS has been reformed to extend its coverage not only in formal but also to informal sectors. A new Social Security Law has been enacted in 2012 and will be implemented in 2013. Currently, the board has been preparing to introduce the new law for the insured workers.

Along with the reform process, understanding the behaviors and factors affecting health care utilization is very important for the policy makers to improve the quality of services in order to attract the private workers to enroll in the scheme. By studying determinant health care utilization among insured private workers, we could observe that who pay for and who get benefit from the scheme. Apart from this we could also determine the most influencing factors which hinder and encourage the insured workers to utilize health care services from social security scheme.

RESEARCH QUESTIONS

General research questions

What are the determinants of health care utilization among insured private workers under Social Security Scheme in Hlaing Thayar Township, Yangon, Myanmar in 2012?

Specific research questions

What are the barriers to access health care services for insured private workers under Social Security Scheme in Hlaing Thayar Township, Yangon, Myanmar in 2012?

Research Objectives

To identity the determinants of health care utilization among insured private workers under Social Security Scheme in Hlaing Thayar Township, Yangon, Myanmar in 2012

To identify the barriers for insured private workers to access health services from Social Security Scheme in Hlaing Thaya Township, Yangon, Myanmar in 2012

Scope of the study

This study will be focused on insured private workers under the Social Security Scheme in Hlaing Thayar industrial zone, Hlaing Thayar Township, Yangon, Myanmar. The insured workers with the age of over 18 years and currently employed by private owned factories and firms will be included in this study. The cross-sectional data will be collected in February and March 2013.

Hypothesis

The age, gender, marital status, number of children, ethnicity, religion, educational status, occupation, income, distance from work place to health facilities, perceived travelling cost, hospitality of the health care personnel, satisfaction to the services, number of health facilities other than social security’ health facilities in the area, perceived health status and presence of underlying illness or disabilities influence the health care utilization among insured private workers under Social Security Scheme in Yangon, Myanmar.

Myanmar Health care system

Myanmar health care system is pluralistic with the mix of public and private providers. As the country’s administrative system has been changed, the key providers in health care services also have changed. However, ministry of health is still the major provider of the health care services through public health facilities while other ministries also provide some health care services (Ministry of Health, 2012).

Ministry of Health is taking responsible to implement holistic health care including preventive, curative and rehabilitative care to the people according to social objectives of the country laid down by National Health Committee. There are 7 departments under Ministry of Health and Department of Health is one of the departments to provide comprehensive health care to all citizens. Apart from Ministry of Health, other ministries such as Ministry of Defense, Railway, Mine, Industry, Energy, Home and Transportation also provide health care to their employees. Ministry of Labor, Employment and Social Security established Social Security Board with 3 general hospitals and 93 clinics across the country to take care of insured workers under Social Security Scheme. Myanmar Pharmaceutical Factory which is under the Ministry of Industry supplies medicine and therapeutic agents for domestic market. One thing special for Myanmar health care system is that there is traditional medicine along allopathic or modern medicine. Apart from public health facilities, local NGO such as Myanmar Maternal and Child Welfare Association and Myanmar Red Cross Society and international donors are also provide some fragments of health services to fill up the gap in the community (Ministry of Health 2012).

Financing of health care services are from three main sources; government as general taxation, private household contribution as out-of pocket payment, social security system and community contribution. External donation in form of assistances is also play a role in Myanmar health care financing.

Community Cost Sharing Scheme

Community Cost Sharing (CCS) scheme is established in 1992. It is simply a user fees system with the intention to charge curative cost for health care services from the rich and provide exemption to those who could not effort for their health care expenditure. According to SSC scheme, the cost for laboratory, radio imaging, private room, drug and medical equipments are asked to pay for those who can effort. The revenue from CCS scheme is broken down into three portions 1) 50 percent is for government revenue, 2) 15 percent go for purchasing medicine and medical equipments and 3) the last 15 percent use for maintenance. However, there are no clear criteria for the poor to provide exemption and many challenges are coming up in the implementation level.(Aye et al.)

Revolving Drug Fund

Revolving Drug Fund was introduced in 1990 by Myanmar Essential Drug Program. The program started in 9 townships as pilot project and then extended into 100 townships in 1995. The fund is started by WHO, UNICEF, Sasakawa Foundation and the fund is used as a seed grant.(Aye et al.)

Trust Fund

Trust Fund is another finance source for health care and the objective is to finance to poor patient who cannot pay the cost of health care at public hospitals. The policy for Trust Fund is “ONE BED ONE LAKH”; and it is raised 100,000 Kyat per bed to hospital by the donation from community. Trust fund are normally kept as saving count at bank and the annual interest from that is utilized according to trust fund management committee or hospital management committee(Aye et al.).

Social Security Scheme

Social Security Scheme (SSS) is the solely health insurance scheme in Myanmar. It was introduced in 1956 according to 1954 Social Security Act. The SSS is implemented by SSB under the Ministry of Labor which has recently transformed into Ministry of Labor, Employment and Social Security. The objectives of SSB are; to improve the health of the insured workers, to enhance their working ability and to boost productivity, to provide effective benefit in times of social contingencies such as sickness, maternity and employment injury, unemployment, old-age, and death etc, to support the insured workers and family members for living when the formers are unable to work and to make the social security scheme concern the entire population. In order to achieve these objectives, social security board is carrying its duty and functions by ensuring workers enjoy rights and protection granted under the various labor laws, providing social services for the workers, promoting higher productivity of labors and participating in international labor affair ( Social Security Board, 2012).

The premium for Social Security Scheme is mandatory contribution from employee and employer. The contribution is based on tripartite contribution by 2.5 % of the worker’s salary from employer, 1.5% from the employee and government supports the capital investments as necessary. The contribution is collected according to 15 wage classes. The coverage groups are state enterprise employees, temporary and permanent employees of public or private firms with five or more employees in certain establishments such as railways, ports, mines and oilfields. The employment with less than five employees, construction workers, agricultural workers and fishermen are excluded from the coverage of social security scheme (Social Security Board, 2012).

At first, it is started from the cities and then extended into other towns gradually. One 250 bedded worker’s hospital in Yangon, one 150 bedded hospital in Mandalay and one 100 bedded TB hospital and 93 clinics have being run under the Social Security Board in order to provide health care services to insured workers.(Social Security Board, 2012).

In benefit package, it is divided into cash sickness benefit, maternal benefit, and medical benefit. For cash sickness benefit, 50% of the insured worker’s average earning will be included from the first day of illness up to 26 weeks for one illness. Benefit of temporary and permanent disability and survival benefits are also included in cash benefit. As funeral grant, 40,000 (Kyat) is paid to the deceased’s surviving spouse and child. The maternal cash benefit includes 66% of insured worker’s average earning for 12 weeks (6 weeks before and 6 weeks after delivery). For medical benefit, free medical services are directly provided by Social Security Board’s clinics. Medical services include the medical care at the clinic, emergency home care, specialist and laboratory services at diagnostic center, necessary hospitalization, maternity care and medicine(“Social Security Program Throughout the World : Asia and the Pacific 2010,” 2011).

Literature review

The literature review for this study will be broken down into empirical studies on health care utilization and determinants of health care utilization.

Health Care Utilization

A study in Canada(Curtis & MacMinn, 2008) about health care utilization in twenty-five years of evidence to identify the relationship between the socio-economic status and utilization, controlling and demographic characteristics. The study describes pattern of health care utilization under public health insurance scheme. They investigated about physician, specialist and hospital care utilization between 1978 and 2003. The data from Canada Health Survey (1978), General Social Survey (1991), and Canadian Community Health Survey (2001 and 2003) were extracted to analyze the different in utilization over 25 years period. It shows that health care utilization is growing through time. The populations with lower level socio-economic status (income, education, or employment) have on average less likelihood of visiting physician than those with middle socio-economic status. Individuals with lower levels socio-economic status have lower utilization of specialist care than those with higher economic status. For hospitalization, poorer individuals have slightly longer stay than with middle and higher income groups. The results also shows that health care utilization of publicly insured individual have strongly related with the health status of them.

A Vietnamese scholar(Nguyen, 2012) analyzed the impact voluntary health insurance on health care utilization in Vietnam by using a descriptive and modeling study with secondary data. He looked at the trend of voluntary health insurance members, categories, revenues and expenditures and health care utilization in the whole country for 5 years period (1993-1997). The study shows that the trend of health care utilization is increasing during 5 year period but the number of hospital visit of voluntary health insurance members is lower than those paying by out-of pocket payment. The results of the study only can predict the utilization rate based on the macro factors and could not include other factors that could affect health care utilization among insured individuals.

Health insurance does effect the health care utilization and it is revealed in a study from Burkina Faso by (Gnawali et al., 2009). They investigated the impact of community-based health insurance on health care utilization in rural Burkina Fuso. The results show that the individuals who insured under community-based health insurance scheme utilized out- patient services 40% more than those who are not insured however in-patient utilization rate is not significantly changed. Moreover, the study explains that low income groups are less likely to enroll in the scheme and even though they are once insured, health care services utilization is still lower than middle and higher income groups. Health insurance has a statistically significant effect on utilization of health care.

In Sri Lanka, (Priyanjith H. 2008) studied the factors affecting health care utilization with three common diseases; Bronchial Asthma, Ischemic Heart Disease, Viral Fever. He has conducted cross-sectional descriptive survey and the respondents were selected randomly. The results demonstrate that patient’s age, health care expenditure and household monthly income, number of dependents in the family and religion have significant relationship with utilization of health care facilities. Age, family income level, perception and religion (Buddhist and Sinhala) have positive influence on health service utilization while health care expenditure, distance to access health facilities, number of family members and dependents in the family negatively correlated with health care utilization.

Determinants of health care utilization

Socio-demographic Factors

Age

A study in Ethiopia by (Girma, Jira, & Girma, 2011) shows that children the age under five-year old used health facilities 3.5 times than those above the age of 65. A study in Nigeria by (Aigbe & Osariemen, 2011) concluded that maternal age is the main predisposing factor to utilize antenatal care service. The women with age of 15-19, 40-44 and 45 years old utilized unorthodox source (traditional birth attendants, home assistance and church) 63.6 %, 65% and 55.6% respectively and the middle age pregnant women with the age of 20-39 used unorthodox source between 30 to 40.5%. The middle age pregnant women have significantly lower rate of using unorthodox sources for antenatal care. The individuals older than 24 years old were significantly more likely to utilize health care services than younger age (Hu & Podhisita, 2008). A study in New Mexico counties, USA by (Anderson, 1973) shows that age has negative effect on hospital admission rate.

Gender

In Nepal, when holding other variables constant, boys have 43% more likelihood to seek external health care given illness than girls (Pokhrel et al., 2005). Men were 0.46 times tendency to utilize health care services than women(Girma, Jira, & Girma, 2011). In Myanmar culture, women are usually given equal chance and not regarded as socially inferior. There is strong relationship between gender and using health care facilities and women visited health services more than men among Myanmar migrant workers in Ranong, Thailand (Aung, 2008).

Marital Status

In Ethiopia, married individual were 8.1 times more likely to visit health facilities than those unmarried one. (Girma, Jira, & Girma, 2011).

Ethnicity

A study by (Anderson, 1973) conclude that ethnicity is one of predisposing factors for health care utilization. Hospital bed-population ratios are higher in the counties with larger ethnic minority group. However (Hu & Podhisita, 2008) reveals that if the ethnic groups have the same opportunities(predisposing, enabling factors), health care utilization will be likely similar.

Educational status

In Nigeria, the choice of antenatal care sources between orthodox and unorthodox is associated with the education of mother. They pointed out that the usage of unorthodox sources of antenatal care is 83% among with primary education level. The choice for orthodox source is 53% among the mother with secondary education and which is tripled with those of primary education(Aigbe & Osariemen, 2011). In Curacao, Netherland, educational level is strongly related with utilization of dentist and physiotherapist. The results indicates that people with the highest educational level in the study utilized dental service a year almost five times than those with the lowest educational level(Alberts, J, Eimers, & Den, 1997).

Income

Annual household income is associated with the level of utilization of health care services. Low income group was 0.26 times likely to use health care facilities (Girma, Jira, & Girma, 2011)

Accessibility to Health Care Services

Distance to the health facilities

A study by (Nemet & Bailey, 2000) shows the relationship between distance and utilization that as the distance increase, health care utilization is reduced. Another study in Nigeria by (Aigbe & Osariemen, 2011) concludes that distance to health facility from their residence is important factors for women to seek ante natal care. They found out that majority of women (76%) utilized the nearby health center which takes less than 30 minute with vehicular transportation from their residence while only 5.9% of women travelled to access health care services from facilities that need more than 45 minute to arrived. In Ethiopia, distance to the nearest health facilities is one of important factors on utilization of health facilities, the study concluded that the individuals who live in 10 kilometers or less to the nearby institution were 1.5 time more likely to use health facilities.

Waiting time at health facilities

Almost two-third (62.8%) of pregnant women who visited primary health care or private hospitals for antenatal care is for the reason of promptness of the services (Aigbe & Osariemen, 2011).

Perceived travelling cost

In comparison, among the individuals who perceived travelling cost as “cheap” ,the health services utilization were 2.5 times likely to be higher than those perceived it as “expensive”.

Need Factors

Perceived health status

A study in Ethiopia by (Girma et al., 2011) revealed health care utilization was associated with individual’s perceived health status. They mentioned that in compared to individuals with good health status, those with poor and very poor health status, utilized 11.7 and 13.1 times more respectively. A study by (Fernandez-Olano et al., 2006) shows that perceived health status affected the health care utilization pattern among elderly people. It can be concluded that 36% of elderly users and 60.2% of non-users graded their health status as good and they reported their health status as fair 46% and 29% respectively.

Presence of underlying disease or disability

The individuals with disability are 3.3 times likely to use health care services and those who had health problems utilized health care 28 times(Girma et al., 2011). (Liu, Tian, & Yao, 2012) studied the effects of health profile on health care services utilization in Taiwan. Health profiles were divided into 4 groups: Relatively Healthy, High Co morbidity, Frail Group and Functional Impairment and they found that, High Co morbidity group had more likely to utilize health care services heavily than Frail Group and Functional Impairment while Relatively Healthy regarded as a reference group.

A study in Philippine shows that the need factors have strongly associated with the hospital stay. The patients with intensive cases stayed at hospital longer than ordinary cases(Loquias, Kittisopee, & Sakulbamrungsil, 2006)

Summary

The literature review shows some variables influence the health care utilization of individuals. This study will be included the variables that could possibly affect health care utilization decision of insured workers under Social Security Scheme.

RESEARCHMethodology

Conceptual Framework

The conceptual framework for this study is based on the Anderson’s Behavior Model for health care utilization. Many studies on health care utilization have been done based on Adersen Behavior Model. The model composes of three main factors; predisposing, enabling and need factors. Predisposing factors are the individual’s tendency to utilize health care which include demographic characteristics (age, sex, marital status) and social structure (occupation, education, ethnicity, religion). Enabling factors refers to the ability of an individual to make use health services; they include the family and community resources that can affect health care utilization. Need factors is the individual’s need for health care by representing perceived health status and present of chronic disease and disability.

Predisposing Factors

(Socio-demographic)

Age

Gender

Marital status

Ethnicity

Religion

Education status

Occupation

Enabling Factors

Community Resources

Distance to health facilities

Waiting Time at the clinic

Perceived Travelling cost

Hospitality of health care personal

Satisfaction to the service

No. of other hospitals/ clinics near workplace

Family Resources

Income

No. of children (family size)

Health Care Utilization

Go to social security health facilities

Go to private health facilities

Go to public health facilities

Buy drug from drug store

Need Factors

Perceived health status

Present underlying disease or disabilities

Study Design

Cross- sectional descriptive quantitative design will be used for this study in order to explore health care utilization pattern among insured private workers under Social Security Scheme in tow industrial zones ( Hlaing Thaya and South Dagon) in Yangon, Myanamr.

Study Area

Yangon is the largest city and formal capital of Myanmar with population approximately 6 million in 2008. The population growth rate of Yangon division is 2.2 percent per annum in 2008 which is higher than national growth rate. The population density is 666 per square kilometer in 2008. As Yangon is logical site for export- oriented lighted manufacturing, it attracts the people from rural to immigrate and settle in the city. Yangon is located on a peninsula near the confluence of the Yangon and Bago rivers, about thirty kilometers north of the Gulf of Martaban. The city has been extended recently to the east, west, and north both for residential and industrial zones. In Yangon Division, there are 45 administrative townships and 33 of them are in Yangon city municipal and administered by Yangon City Development Committee (YCDC).

The study will conducted in Hlaing Tharyar Townships in Yangon city municipal area.

Study Duration

The study will be conduct from February to March 2013.

Study population

The study will be conducted among the insured private workers under the Social Security Scheme in two industrial zones Hlaing Thaya Township Yanagon, Myanmar

Sample size

The sample size for this study will be calculated based on Yamane (1967: 98-99) formula.

n= Nz 2 pq/Nd 2 +z2pq

If we assume z =2 (1.96 for the 95% level of reliability), then

n = N/ 1+Nd2

n = sample size

N= population size

d = precision (0.05)

z = reliability coefficient

p = proportion of the target population utilize health care (assuming that 50%)

q =1-p (so q= 50% too)

The population of insured workers in Yangon division is approximate 350,000. I calculated my sample size based on the total no. of population and I got 399.49 and 10% is added for non responded participants. So the sample size is 439.49 (340).

Sampling techniques

The multi-stage sampling method will be employed in this study. Hlaing Thayar industrial zone is purposively selected and the participants will be randomly selected from total study population.

Including Criteria

The workers from private sectors

The workers who are insured under Social Security Scheme (SSS)

The workers who are working in Hlaing Tharyar Industrial Zone, Yangon

The workers who are over 18 years old

Excluding Criteria

The workers who are not employed by private factors or firms

The workers who are not insured under social security scheme

The insured private workers who are not willing to participate in the interview

Study variables

Dependent Variable

The dependent variable will be multinomial variables. Health care utilization will be categorized into 4 categories; 1) go to social security health facilities 2) go to private health facilities 3) go to public health facilities 4) buy drug from drug store.

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Independent Variables

The independent variables are: age, gender, marital status, ethnicity, religion, educational status, occupation, family size, distance from work place to health center, waiting time, perceived travelling cost, hospitality of health care personnel, perceived health status, presence of underlying disease or disability

Summarized table of independent variables

#

Variables

Abbreviation

Expected Sign

11

Age ( continuous variables)

age

+/-

22

Gender (dummy variable male=1, female=0)

gen

+/-

33

Marital status (category dummy variable

ms

+

44

No. of children (continuous variables)

child

55

Ethnicity ( dummy variable Burma=1, other ethnicity=0)

eth

+/-

66

Religion(dummy variable Buddhist=1, Other religion=0)

rg

+/-

77

Educational status( category dummy variable primary=0, secondary=1, higher =1)

edu

+

88

Occupation (category dummy variable.

occ

+/-

99

Income( continue variable)

inc

+

110

Distance from work place to health facilities (continue variable)

dis

111

Waiting time at health facilities(continue variable)

wt

112

Perceived travelling cost (dummy variable expensive=1, cheap=0)

ptc

113

Hospitality of health care personnel (dummy variable yes=1, No=0)

hhp

+

114

Satisfaction to the services (dummy variable yes=1, No=0)

sts

+

115

No. of health facilities other than social security’s health facilities ( continue variable)

nhnw

+

116

Perceived health status (category dummy variable excellent=1, good=1, fair=0, poor=1, very poor=0)

phs

+

117

Presence of underlying disease (dummy variable yes=1, No=0)

pud

+

Multinomial Logistic Regression Model

Log(Pr(Y=yi)/Pr(y=0))=β0+β1age+β2gen+β3ms+β4eth+β5rg+β6edu+β7occ+β8 ln(inc)+ β9dis+ β10wt+ β11ptc+ β12hhp+ β13sts+β14nhnw+β15phs+β16pud +εi

Pilot Testing

The pilot test will be conducted in one of the townships in Yangon with the similar characteristic of insured workers before actual survey. The questionnaire will be revised and adjusted based on the results from pilot testing.

Data collection tools

The primary data will be collected suing the structured questionnaires. About 5 interviewers will be hir

All people around the world could not access to health care service as there is a significant unmet need for health care. In order to improve the quality of human life, the health care providers and policy makers should have a better understanding of why people utilize or not utilize the health care services. In the changing of global environment such as population growth, increased health problems, higher demand for medical care and advanced medical technologies, health care expenditure is increasing in every country around the world. As health care expenditure has been escalating, financing for health care is becoming one of the challenges for governments especially in low and middle income countries.

In many developing countries, the financial source for health care is dominated by private sector as house-hold out of pocket payment. However health insurance schemes are becoming an increasingly recognized tool in recent decades to finance low and middle income countries. As one of the poorest countries in South-East Asia, Myanmar health care financing mainly relies on private financing source in a form of out-of pocket payment. According to (NHA 2008-2009), 85% of total health expenditure comes from private household.

In Myanmar, there are some financial schemes initiated by the government in order to protect the financial lost and impoverishment of the people. Among those health financing schemes, Social Security Scheme (SSS) plays a role to pool the risk of financial burden among insured workers. Myanmar government started the social health insurance in 1956 to provide social assistances and health care services to the insured workers. Regardless of the long period of implementation, the coverage of social health insurance is only 0.97% of total population and 1.96% of working population. There are 93 clinics in 110 townships to provide health care services to insured workers (Social Security Board 2012). The clinic time is from 8:00 am to 4:00pm which is during working hours of insured workers (Social Security Board 2012). The social security clinic’s locations are mostly not closed with the work places. The director of Social Security Board (SSB) mentioned about health care services in the news interview that, “The current health care system is not enough for workers as the social security clinics cannot provide 24-hour service. Social security clinics cannot be found all over the country so workers in areas where there are no social security clinics can face difficulties.”(The Myanmar Times, April 16-22, 2012).

Apart from the difficulty in accessibility, the insured workers have to bear travelling cost and time cost to access health services from social security clinics. Moreover, there is very limited in equipments, medicines and facilities to provide enough health services to the insured workers. So some insured workers don’t visit to social security clinics and get the medical care from nearby clinics and treat with traditional medicines. One of the SSB member expressed her experience from a board’s clinic in Yangon as not be pleasant. She mentioned, “There was a long queue of patients and I was particularly upset by the poor service from the doctors and nurses and I really don’t trust them they don’t have specialists, they have only general practitioners. I only went there to claim the cost of my medicines.”(The Myanmar Times, April 16-22, 2012).

Because of difficulties for workers to visit the clinics, health care teams from clinics have been trying to provide health care services in work places; however the very limited number of vehicle and cost of patrol are the big challenging issue for the health care providers. Despite of monthly contribution from their salary, because of hardly to access health care facility from social security, the insured workers could not get their benefit from social security board.

However, Myanmar has been opening a new chapter of reform after 2010 general election and adopting democratic system in the country. As the country opening up, there are many reforms have been doing in order to move along with the ASEAN and global community. Myanmar SSS has been reformed to extend its coverage not only in formal but also to informal sectors. A new Social Security Law has been enacted in 2012 and will be implemented in 2013. Currently, the board has been preparing to introduce the new law for the insured workers.

Along with the reform process, understanding the behaviors and factors affecting health care utilization is very important for the policy makers to improve the quality of services in order to attract the private workers to enroll in the scheme. By studying determinant health care utilization among insured private workers, we could observe that who pay for and who get benefit from the scheme. Apart from this we could also determine the most influencing factors which hinder and encourage the insured workers to utilize health care services from social security scheme.

RESEARCH QUESTIONS

General research questions

What are the determinants of health care utilization among insured private workers under Social Security Scheme in Hlaing Thayar Township, Yangon, Myanmar in 2012?

Specific research questions

What are the barriers to access health care services for insured private workers under Social Security Scheme in Hlaing Thayar Township, Yangon, Myanmar in 2012?

Research Objectives

To identity the determinants of health care utilization among insured private workers under Social Security Scheme in Hlaing Thayar Township, Yangon, Myanmar in 2012

To identify the barriers for insured private workers to access health services from Social Security Scheme in Hlaing Thaya Township, Yangon, Myanmar in 2012

Scope of the study

This study will be focused on insured private workers under the Social Security Scheme in Hlaing Thayar industrial zone, Hlaing Thayar Township, Yangon, Myanmar. The insured workers with the age of over 18 years and currently employed by private owned factories and firms will be included in this study. The cross-sectional data will be collected in February and March 2013.

Hypothesis

The age, gender, marital status, number of children, ethnicity, religion, educational status, occupation, income, distance from work place to health facilities, perceived travelling cost, hospitality of the health care personnel, satisfaction to the services, number of health facilities other than social security’ health facilities in the area, perceived health status and presence of underlying illness or disabilities influence the health care utilization among insured private workers under Social Security Scheme in Yangon, Myanmar.

Myanmar Health care system

Myanmar health care system is pluralistic with the mix of public and private providers. As the country’s administrative system has been changed, the key providers in health care services also have changed. However, ministry of health is still the major provider of the health care services through public health facilities while other ministries also provide some health care services (Ministry of Health, 2012).

Ministry of Health is taking responsible to implement holistic health care including preventive, curative and rehabilitative care to the people according to social objectives of the country laid down by National Health Committee. There are 7 departments under Ministry of Health and Department of Health is one of the departments to provide comprehensive health care to all citizens. Apart from Ministry of Health, other ministries such as Ministry of Defense, Railway, Mine, Industry, Energy, Home and Transportation also provide health care to their employees. Ministry of Labor, Employment and Social Security established Social Security Board with 3 general hospitals and 93 clinics across the country to take care of insured workers under Social Security Scheme. Myanmar Pharmaceutical Factory which is under the Ministry of Industry supplies medicine and therapeutic agents for domestic market. One thing special for Myanmar health care system is that there is traditional medicine along allopathic or modern medicine. Apart from public health facilities, local NGO such as Myanmar Maternal and Child Welfare Association and Myanmar Red Cross Society and international donors are also provide some fragments of health services to fill up the gap in the community (Ministry of Health 2012).

Financing of health care services are from three main sources; government as general taxation, private household contribution as out-of pocket payment, social security system and community contribution. External donation in form of assistances is also play a role in Myanmar health care financing.

Community Cost Sharing Scheme

Community Cost Sharing (CCS) scheme is established in 1992. It is simply a user fees system with the intention to charge curative cost for health care services from the rich and provide exemption to those who could not effort for their health care expenditure. According to SSC scheme, the cost for laboratory, radio imaging, private room, drug and medical equipments are asked to pay for those who can effort. The revenue from CCS scheme is broken down into three portions 1) 50 percent is for government revenue, 2) 15 percent go for purchasing medicine and medical equipments and 3) the last 15 percent use for maintenance. However, there are no clear criteria for the poor to provide exemption and many challenges are coming up in the implementation level.(Aye et al.)

Revolving Drug Fund

Revolving Drug Fund was introduced in 1990 by Myanmar Essential Drug Program. The program started in 9 townships as pilot project and then extended into 100 townships in 1995. The fund is started by WHO, UNICEF, Sasakawa Foundation and the fund is used as a seed grant.(Aye et al.)

Trust Fund

Trust Fund is another finance source for health care and the objective is to finance to poor patient who cannot pay the cost of health care at public hospitals. The policy for Trust Fund is “ONE BED ONE LAKH”; and it is raised 100,000 Kyat per bed to hospital by the donation from community. Trust fund are normally kept as saving count at bank and the annual interest from that is utilized according to trust fund management committee or hospital management committee(Aye et al.).

Social Security Scheme

Social Security Scheme (SSS) is the solely health insurance scheme in Myanmar. It was introduced in 1956 according to 1954 Social Security Act. The SSS is implemented by SSB under the Ministry of Labor which has recently transformed into Ministry of Labor, Employment and Social Security. The objectives of SSB are; to improve the health of the insured workers, to enhance their working ability and to boost productivity, to provide effective benefit in times of social contingencies such as sickness, maternity and employment injury, unemployment, old-age, and death etc, to support the insured workers and family members for living when the formers are unable to work and to make the social security scheme concern the entire population. In order to achieve these objectives, social security board is carrying its duty and functions by ensuring workers enjoy rights and protection granted under the various labor laws, providing social services for the workers, promoting higher productivity of labors and participating in international labor affair ( Social Security Board, 2012).

The premium for Social Security Scheme is mandatory contribution from employee and employer. The contribution is based on tripartite contribution by 2.5 % of the worker’s salary from employer, 1.5% from the employee and government supports the capital investments as necessary. The contribution is collected according to 15 wage classes. The coverage groups are state enterprise employees, temporary and permanent employees of public or private firms with five or more employees in certain establishments such as railways, ports, mines and oilfields. The employment with less than five employees, construction workers, agricultural workers and fishermen are excluded from the coverage of social security scheme (Social Security Board, 2012).

At first, it is started from the cities and then extended into other towns gradually. One 250 bedded worker’s hospital in Yangon, one 150 bedded hospital in Mandalay and one 100 bedded TB hospital and 93 clinics have being run under the Social Security Board in order to provide health care services to insured workers.(Social Security Board, 2012).

In benefit package, it is divided into cash sickness benefit, maternal benefit, and medical benefit. For cash sickness benefit, 50% of the insured worker’s average earning will be included from the first day of illness up to 26 weeks for one illness. Benefit of temporary and permanent disability and survival benefits are also included in cash benefit. As funeral grant, 40,000 (Kyat) is paid to the deceased’s surviving spouse and child. The maternal cash benefit includes 66% of insured worker’s average earning for 12 weeks (6 weeks before and 6 weeks after delivery). For medical benefit, free medical services are directly provided by Social Security Board’s clinics. Medical services include the medical care at the clinic, emergency home care, specialist and laboratory services at diagnostic center, necessary hospitalization, maternity care and medicine(“Social Security Program Throughout the World : Asia and the Pacific 2010,” 2011).

Literature review

The literature review for this study will be broken down into empirical studies on health care utilization and determinants of health care utilization.

Health Care Utilization

A study in Canada(Curtis & MacMinn, 2008) about health care utilization in twenty-five years of evidence to identify the relationship between the socio-economic status and utilization, controlling and demographic characteristics. The study describes pattern of health care utilization under public health insurance scheme. They investigated about physician, specialist and hospital care utilization between 1978 and 2003. The data from Canada Health Survey (1978), General Social Survey (1991), and Canadian Community Health Survey (2001 and 2003) were extracted to analyze the different in utilization over 25 years period. It shows that health care utilization is growing through time. The populations with lower level socio-economic status (income, education, or employment) have on average less likelihood of visiting physician than those with middle socio-economic status. Individuals with lower levels socio-economic status have lower utilization of specialist care than those with higher economic status. For hospitalization, poorer individuals have slightly longer stay than with middle and higher income groups. The results also shows that health care utilization of publicly insured individual have strongly related with the health status of them.

A Vietnamese scholar(Nguyen, 2012) analyzed the impact voluntary health insurance on health care utilization in Vietnam by using a descriptive and modeling study with secondary data. He looked at the trend of voluntary health insurance members, categories, revenues and expenditures and health care utilization in the whole country for 5 years period (1993-1997). The study shows that the trend of health care utilization is increasing during 5 year period but the number of hospital visit of voluntary health insurance members is lower than those paying by out-of pocket payment. The results of the study only can predict the utilization rate based on the macro factors and could not include other factors that could affect health care utilization among insured individuals.

Health insurance does effect the health care utilization and it is revealed in a study from Burkina Faso by (Gnawali et al., 2009). They investigated the impact of community-based health insurance on health care utilization in rural Burkina Fuso. The results show that the individuals who insured under community-based health insurance scheme utilized out- patient services 40% more than those who are not insured however in-patient utilization rate is not significantly changed. Moreover, the study explains that low income groups are less likely to enroll in the scheme and even though they are once insured, health care services utilization is still lower than middle and higher income groups. Health insurance has a statistically significant effect on utilization of health care.

In Sri Lanka, (Priyanjith H. 2008) studied the factors affecting health care utilization with three common diseases; Bronchial Asthma, Ischemic Heart Disease, Viral Fever. He has conducted cross-sectional descriptive survey and the respondents were selected randomly. The results demonstrate that patient’s age, health care expenditure and household monthly income, number of dependents in the family and religion have significant relationship with utilization of health care facilities. Age, family income level, perception and religion (Buddhist and Sinhala) have positive influence on health service utilization while health care expenditure, distance to access health facilities, number of family members and dependents in the family negatively correlated with health care utilization.

Determinants of health care utilization

Socio-demographic Factors

Age

A study in Ethiopia by (Girma, Jira, & Girma, 2011) shows that children the age under five-year old used health facilities 3.5 times than those above the age of 65. A study in Nigeria by (Aigbe & Osariemen, 2011) concluded that maternal age is the main predisposing factor to utilize antenatal care service. The women with age of 15-19, 40-44 and 45 years old utilized unorthodox source (traditional birth attendants, home assistance and church) 63.6 %, 65% and 55.6% respectively and the middle age pregnant women with the age of 20-39 used unorthodox source between 30 to 40.5%. The middle age pregnant women have significantly lower rate of using unorthodox sources for antenatal care. The individuals older than 24 years old were significantly more likely to utilize health care services than younger age (Hu & Podhisita, 2008). A study in New Mexico counties, USA by (Anderson, 1973) shows that age has negative effect on hospital admission rate.

Gender

In Nepal, when holding other variables constant, boys have 43% more likelihood to seek external health care given illness than girls (Pokhrel et al., 2005). Men were 0.46 times tendency to utilize health care services than women(Girma, Jira, & Girma, 2011). In Myanmar culture, women are usually given equal chance and not regarded as socially inferior. There is strong relationship between gender and using health care facilities and women visited health services more than men among Myanmar migrant workers in Ranong, Thailand (Aung, 2008).

Marital Status

In Ethiopia, married individual were 8.1 times more likely to visit health facilities than those unmarried one. (Girma, Jira, & Girma, 2011).

Ethnicity

A study by (Anderson, 1973) conclude that ethnicity is one of predisposing factors for health care utilization. Hospital bed-population ratios are higher in the counties with larger ethnic minority group. However (Hu & Podhisita, 2008) reveals that if the ethnic groups have the same opportunities(predisposing, enabling factors), health care utilization will be likely similar.

Educational status

In Nigeria, the choice of antenatal care sources between orthodox and unorthodox is associated with the education of mother. They pointed out that the usage of unorthodox sources of antenatal care is 83% among with primary education level. The choice for orthodox source is 53% among the mother with secondary education and which is tripled with those of primary education(Aigbe & Osariemen, 2011). In Curacao, Netherland, educational level is strongly related with utilization of dentist and physiotherapist. The results indicates that people with the highest educational level in the study utilized dental service a year almost five times than those with the lowest educational level(Alberts, J, Eimers, & Den, 1997).

Income

Annual household income is associated with the level of utilization of health care services. Low income group was 0.26 times likely to use health care facilities (Girma, Jira, & Girma, 2011)

Accessibility to Health Care Services

Distance to the health facilities

A study by (Nemet & Bailey, 2000) shows the relationship between distance and utilization that as the distance increase, health care utilization is reduced. Another study in Nigeria by (Aigbe & Osariemen, 2011) concludes that distance to health facility from their residence is important factors for women to seek ante natal care. They found out that majority of women (76%) utilized the nearby health center which takes less than 30 minute with vehicular transportation from their residence while only 5.9% of women travelled to access health care services from facilities that need more than 45 minute to arrived. In Ethiopia, distance to the nearest health facilities is one of important factors on utilization of health facilities, the study concluded that the individuals who live in 10 kilometers or less to the nearby institution were 1.5 time more likely to use health facilities.

Waiting time at health facilities

Almost two-third (62.8%) of pregnant women who visited primary health care or private hospitals for antenatal care is for the reason of promptness of the services (Aigbe & Osariemen, 2011).

Perceived travelling cost

In comparison, among the individuals who perceived travelling cost as “cheap” ,the health services utilization were 2.5 times likely to be higher than those perceived it as “expensive”.

Need Factors

Perceived health status

A study in Ethiopia by (Girma et al., 2011) revealed health care utilization was associated with individual’s perceived health status. They mentioned that in compared to individuals with good health status, those with poor and very poor health status, utilized 11.7 and 13.1 times more respectively. A study by (Fernandez-Olano et al., 2006) shows that perceived health status affected the health care utilization pattern among elderly people. It can be concluded that 36% of elderly users and 60.2% of non-users graded their health status as good and they reported their health status as fair 46% and 29% respectively.

Presence of underlying disease or disability

The individuals with disability are 3.3 times likely to use health care services and those who had health problems utilized health care 28 times(Girma et al., 2011). (Liu, Tian, & Yao, 2012) studied the effects of health profile on health care services utilization in Taiwan. Health profiles were divided into 4 groups: Relatively Healthy, High Co morbidity, Frail Group and Functional Impairment and they found that, High Co morbidity group had more likely to utilize health care services heavily than Frail Group and Functional Impairment while Relatively Healthy regarded as a reference group.

A study in Philippine shows that the need factors have strongly associated with the hospital stay. The patients with intensive cases stayed at hospital longer than ordinary cases(Loquias, Kittisopee, & Sakulbamrungsil, 2006)

Summary

The literature review shows some variables influence the health care utilization of individuals. This study will be included the variables that could possibly affect health care utilization decision of insured workers under Social Security Scheme.

RESEARCHMethodology

Conceptual Framework

The conceptual framework for this study is based on the Anderson’s Behavior Model for health care utilization. Many studies on health care utilization have been done based on Adersen Behavior Model. The model composes of three main factors; predisposing, enabling and need factors. Predisposing factors are the individual’s tendency to utilize health care which include demographic characteristics (age, sex, marital status) and social structure (occupation, education, ethnicity, religion). Enabling factors refers to the ability of an individual to make use health services; they include the family and community resources that can affect health care utilization. Need factors is the individual’s need for health care by representing perceived health status and present of chronic disease and disability.

Predisposing Factors

(Socio-demographic)

Age

Gender

Marital status

Ethnicity

Religion

Education status

Occupation

Enabling Factors

Community Resources

Distance to health facilities

Waiting Time at the clinic

Perceived Travelling cost

Hospitality of health care personal

Satisfaction to the service

No. of other hospitals/ clinics near workplace

Family Resources

Income

No. of children (family size)

Health Care Utilization

Go to social security health facilities

Go to private health facilities

Go to public health facilities

Buy drug from drug store

Need Factors

Perceived health status

Present underlying disease or disabilities

Study Design

Cross- sectional descriptive quantitative design will be used for this study in order to explore health care utilization pattern among insured private workers under Social Security Scheme in tow industrial zones ( Hlaing Thaya and South Dagon) in Yangon, Myanamr.

Study Area

Yangon is the largest city and formal capital of Myanmar with population approximately 6 million in 2008. The population growth rate of Yangon division is 2.2 percent per annum in 2008 which is higher than national growth rate. The population density is 666 per square kilometer in 2008. As Yangon is logical site for export- oriented lighted manufacturing, it attracts the people from rural to immigrate and settle in the city. Yangon is located on a peninsula near the confluence of the Yangon and Bago rivers, about thirty kilometers north of the Gulf of Martaban. The city has been extended recently to the east, west, and north both for residential and industrial zones. In Yangon Division, there are 45 administrative townships and 33 of them are in Yangon city municipal and administered by Yangon City Development Committee (YCDC).

The study will conducted in Hlaing Tharyar Townships in Yangon city municipal area.

Study Duration

The study will be conduct from February to March 2013.

Study population

The study will be conducted among the insured private workers under the Social Security Scheme in two industrial zones Hlaing Thaya Township Yanagon, Myanmar

Sample size

The sample size for this study will be calculated based on Yamane (1967: 98-99) formula.

n= Nz 2 pq/Nd 2 +z2pq

If we assume z =2 (1.96 for the 95% level of reliability), then

n = N/ 1+Nd2

n = sample size

N= population size

d = precision (0.05)

z = reliability coefficient

p = proportion of the target population utilize health care (assuming that 50%)

q =1-p (so q= 50% too)

The population of insured workers in Yangon division is approximate 350,000. I calculated my sample size based on the total no. of population and I got 399.49 and 10% is added for non responded participants. So the sample size is 439.49 (340).

Sampling techniques

The multi-stage sampling method will be employed in this study. Hlaing Thayar industrial zone is purposively selected and the participants will be randomly selected from total study population.

Including Criteria

The workers from private sectors

The workers who are insured under Social Security Scheme (SSS)

The workers who are working in Hlaing Tharyar Industrial Zone, Yangon

The workers who are over 18 years old

Excluding Criteria

The workers who are not employed by private factors or firms

The workers who are not insured under social security scheme

The insured private workers who are not willing to participate in the interview

Study variables

Dependent Variable

The dependent variable will be multinomial variables. Health care utilization will be categorized into 4 categories; 1) go to social security health facilities 2) go to private health facilities 3) go to public health facilities 4) buy drug from drug store.

Independent Variables

The independent variables are: age, gender, marital status, ethnicity, religion, educational status, occupation, family size, distance from work place to health center, waiting time, perceived travelling cost, hospitality of health care personnel, perceived health status, presence of underlying disease or disability

Summarized table of independent variables

#

Variables

Abbreviation

Expected Sign

11

Age ( continuous variables)

age

+/-

22

Gender (dummy variable male=1, female=0)

gen

+/-

33

Marital status (category dummy variable

ms

+

44

No. of children (continuous variables)

child

55

Ethnicity ( dummy variable Burma=1, other ethnicity=0)

eth

+/-

66

Religion(dummy variable Buddhist=1, Other religion=0)

rg

+/-

77

Educational status( category dummy variable primary=0, secondary=1, higher =1)

edu

+

88

Occupation (category dummy variable.

occ

+/-

99

Income( continue variable)

inc

+

110

Distance from work place to health facilities (continue variable)

dis

111

Waiting time at health facilities(continue variable)

wt

112

Perceived travelling cost (dummy variable expensive=1, cheap=0)

ptc

113

Hospitality of health care personnel (dummy variable yes=1, No=0)

hhp

+

114

Satisfaction to the services (dummy variable yes=1, No=0)

sts

+

115

No. of health facilities other than social security’s health facilities ( continue variable)

nhnw

+

116

Perceived health status (category dummy variable excellent=1, good=1, fair=0, poor=1, very poor=0)

phs

+

117

Presence of underlying disease (dummy variable yes=1, No=0)

pud

+

Multinomial Logistic Regression Model

Log(Pr(Y=yi)/Pr(y=0))=β0+β1age+β2gen+β3ms+β4eth+β5rg+β6edu+β7occ+β8 ln(inc)+ β9dis+ β10wt+ β11ptc+ β12hhp+ β13sts+β14nhnw+β15phs+β16pud +εi

Pilot Testing

The pilot test will be conducted in one of the townships in Yangon with the similar characteristic of insured workers before actual survey. The questionnaire will be revised and adjusted based on the results from pilot testing.

Data collection tools

The primary data will be collected suing the structured questionnaires. About 5 interviewers will be hir

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