Willingness to use and pay for options of care for community-dwelling older people in rural Vietnam

The world's elderly population has been growing for centuries. With the increase in life expectancy that followed improvement of health care and nutrition over the last century, this portion of the population is increasing more rapidly. The growth rate of older people in developing countries began to rise in the early 1960s and has doubled that of developed countries and the total world population [1]. In 2007, the number of people aged 60 and older was 793 million worldwide, and accounted for 11.7% of the world population [2]. This number is projected to increase to almost two billion by 2050 [1].

Vietnam has experienced rapid aging with declines in both fertility and mortality [3]. The proportion of people aged 60 years and older within the general population increased from 6.7% in 1979 to 9.2% in 2006 [4], and is projected to be 26.1% by 2050 [5]. The Vietnamese ageing index, the number of persons 60 years or older per hundred persons under age 15, increased from 18.2% in 1989 to 37.0% in 2007 [6]. At the same time, the old-age dependency ratio (the number of persons 60 years and over per one hundred persons 15 to 59 years) increased from 0.13 in 1989 to 0.15 in 2007 [7]. The total population of Vietnam reached 85 million in 2007, with 72.6% residing in rural areas [8]. The proportion of older people within the rural population increased from 7.4% in 1989 [9] to 10.3% in 2006 [10]. The rural elderly population accounted for 73.3% of the total elderly population in 2004 [11].

Among older people, there are more females than males. This sex imbalance is higher in rural than urban areas. The proportion of people aged 60-74 years among older people decreased while that of people aged 75 and over increased [11]. Most of older people are married or widowed. Divorce and permanent separation are relatively uncommon. Just over one-fourth of the elderly profess a religion. Three-fifths of them are Buddhist and approximately 20% are Catholic. The rural elderly are disadvantaged in terms of educational attainment, housing quality, access to media [11], poverty status [12], and access to health care [13].

A majority of the elderly are household heads and live with a child. Only 11.5% live with a spouse alone, and 5.8% live alone. Living with a child is more common in urban areas while living alone or with only a spouse is more common in rural areas. Most of those who live alone are women or living in rural areas [11]. The elderly, especially in rural areas, are more likely to rely on domestic sources of economic support than on the social security system [14] because the rural elderly are less likely to have paid into the social insurance system. There is an increasing trend of temporary migration from rural to urban areas among the young because of better employment opportunities [15]. This leaves more elderly living on their own with less physical and emotional support from family members [16].

Half of the rural elderly and one-third of the urban elderly remain economically active for a paid salary, in the household's agriculture production, or in other enterprises [11]. Older people's incomes are mainly from agriculture, earnings, trade or other business. Remittances (16%) and formal state transfers (11%) often account for part of the income. Rural people are less likely to live in households that receive formal transfers than are urban people. People living in households receiving social insurance pensions or social subsidies are twice as common in urban areas as rural areas [17] because the rural elderly are more likely to receive welfare payments.

Vietnamese life expectancy at birth increased from 66 to 72 years between1990 and 2006 [18, 19], with a projected further increase to 80.3 years by 2050 [5]. There is evidence [3] that life expectancy at age 60 increased overall in rural areas, but decreased among the most vulnerable groups such as older women living without children or grandchildren. Poverty status and living arrangements lead to a wide gap in life expectancy. The gender gap in the life expectancy is consistent across all socioeconomic groups and wider among the more disadvantaged populations.

Health related quality of life (HRQoL) at old age increases in rural areas and varies substantially according to socioeconomic factors [20]. Ageing has a primary influence on HRQoL, which is mainly due to reduction in physical functions rather than mental functions. Being a household head and working during old age are advantageous for attaining better HRQoL in physical but not psychological terms. Economic conditions affect HRQoL through sensory rather than physical roles. Long-term living conditions are more likely to affect HRQoL than are short-term economic conditions.

Although greater life expectancy in old age is an indicator of successful ageing [21], it also means that more elderly suffer from non-communicable diseases (NCDs) [22]. Vietnam is a country where the prevalence of NCD increases at older ages [23, 24]. The most common NCDs among elderly Vietnamese are cardiovascular diseases, diabetes, kidney disease, and cancer [25]. The elderly also suffer from accidents, frequent illnesses and multiple or concurrent health disorders. A survey found that 60% of older people were ill during the prior four weeks and 70% suffered from NCDs [25]. Using the INDEPTH WHO-SAGE questionnaire, elderly health among Vietnamese people is higher than among Bangladeshis, but lower than among Indonesians [26].

Health sector reform in Vietnam was initiated in 1989 with the introduction of user fees for public services and development of a private sector. Consequently, household health expenditures now consist predominantly of out-of-pocket payments that accounted for 67% of health expenditures in 2005 [27]. Disparities in health and health care are widening between socioeconomic groups, and between rural and urban areas, despite efforts by the government to improve access to health care. In particular, the rural elderly have less access to care than those in urban areas [13]. Elderly access to health services is often limited by mobility and an inability to afford healthcare services, especially for those who require prolonged care [25].

Among rural elderly, dependence in instrumental or intellectual activities of ADLs is more common than in basic ADLs [28]. Almost one-third of rural older people need help in one or more specific ADLs. At least one-third of those who need help do not receive enough support. Children and grandchildren are the main caregivers of elderly ADLs. Age group, sex, educational level, marital status, household membership, working status, household size, living arrangement, residential area, household wealth, poverty status, and chronic illnesses are determinants of the daily care needs in old age.

The ordinance on elderly people issued in 2003. It was replaced by the law on elderly people in 2010. The law indicates that health care should be developed for elderly people in the community. Commune health centres and local authorities are key stakeholders responsible for organizing the care. Health insurance for all was determined as a main mechanism of health financing. The government is in the process of expanding its support for accessing health insurance by the poor and other vulnerable groups. Currently, people aged 95 years and over are covered by the support.

Responding to the unmet daily care needs of older people, community-centric long-term care was initiated recently to meet the individualized needs of the elderly. However, there is still limited knowledge about the demands of the elderly and their families for various models of care. This is especially true in rural settings. This study was conducted to assess willingness to use (WTU) and willingness to pay (WTP) for particular models of care, and their socioeconomic determinants among elderly and their families in a rural setting. Such data can provide evidence for the design of appropriate health and social policies in Vietnam.

Willingness to use the services decreased when potential fees were higher. As a 68 year old daughter said, "If we have to contribute money, we will do that. However, we can only pay a little." Almost two-fifths of the elderly were willing to use mobile team care at full cost. But only one third were willing to pay full cost for day care centre services, and only 15% for nursing centre services. The proportion of respondents who expect to use care if it is free-of-charge is much higher than those willing to pay at full cost: 1.7-2.2 times higher for household representatives, and 2.0-2.7 times higher among the elderly.

The most demanded day care centre services are physical exercises, health consultations, relaxation and nursing care. The least required services are relationship exchanges and drinks. The elderly and their household representatives have almost the same expectation of service types that would be provided in either care model. One exception was that a higher percentage of household members expect their elders to need nursing care at day care centres than did the elderly themselves.

Those who are younger elderly, men, married, with educational levels of elementary/secondary school, living with grandchildren, or living in the highlands, state that they are more likely to use care services. Those who are separated/divorced, live with a spouse or alone, live with a son or daughter, live in the lowlands, work until an older age, live under the national poverty line, or are in the poorest quintile are less likely to use services. People with an educational level of high school or higher are more likely to use free services from a day care centre but less likely to use services from a nursing centre.

The elderly in the richest two quintiles are less likely to use free services from a nursing center. Those in the richest quintile are less likely to use free service from a mobile team but more likely to use services from a day care centre requiring partial payment. Those in the wealthiest quintile are less likely to use free services but more likely to use mobile team services requiring partial payment. Respondents who were in the middle wealth quintile were more likely to use free services but less likely to use day care services at full price.

During the Vietnamese transition to a modern society, the need for community-based long-term elderly care is acknowledged by the elderly, their households and representatives from the village and commune levels. This unanimity is the most interesting finding of this study. Willingness to use care services is affected by elderly ADL dependence, socioeconomic status, living arrangement and required payment level. The study respondents were willing to pay for care services at certain levels but indicated that society or associations have a responsibility to provide elderly care. There currently are no comparative figures on the need for community-centric long-term elderly care in Vietnam.

Older people in Vietnam prefer to receive care at home. This is in accordance with tradition and consistent with patterns in other countries [34]. The majority of households and elderly only expect to stay intermittently in a nursing centre, such as 1-3 weeks/month, rather than using more long-term care as do elderly in many developed countries. The frequency of using services from any model was not dependent on the payment levels. This may be because willingness to pay was asked as a monthly payment rather than by episode of service use.

In spite of household representative expectations that their elderly would use services more often than the elderly themselves, the consensus is surprising. The findings indicate a trend of expansion of elderly care from family caregivers to a social network. This trend is likely the result of demographic pressures and socioeconomic transitions within the country. Willingness to use free services was 2-3 times higher than willingness to pay full price. This suggests a large gap between household needs and affordability of care for the rural elderly. Health insurance and medical fee exemption in Vietnam cover 33.5% of older people aged 60-89 and 37.1% of those aged 90 years and above [25]. With this coverage, additional social and health policies to promote the formulation and use of community-centric care models are necessary. Further expanding the support for accessing free-of-charge health insurance for elderly people at younger ages, and including long-term care services in reimbursement schemes of health insurance would compensate for the limited affordability of care.

The elderly expect to receive professional care, including curative, preventive and rehabilitative services from a mobile team more than they expect informal care with tasks of daily living at home. "I suggest to the authorities that there be regular check-ups for old people" was a common view from the elderly. This opinion was supported by village leaders: "The best thing we can do is organize regular check-ups for the elderly". Medical doctors, medical doctor assistants, and nurses, working together with informal caregivers, will be essential for future provision of home care. Current estimates are 5.9 physicians and 5.6 nurses per 10,000 inhabitants in the public and private health sectors [35]. Therefore, capacity building of a network between health professionals and informal caregivers should be addressed in strategies to expand community-centric elderly care. Social associations are also willing to contribute: "If they need builders, our members can help. Moreover, we can contribute some money".

The 2008 Vietnam Household Living Standard Survey [36] estimated that household per capita health care expenditure in rural areas accounts for 7% of the total household per capita expenditure. In the current study, elderly are willing to pay 2-4% of the monthly per capita household expenditure and their families were willing to pay 3-6% for services from each care model. Therefore, the maximum amount that respondents were willing to pay was almost equal to the per capita expenditure for health care.

Higher dependency in instrumental ADLs is related to higher WTU for a mobile team (except at full cost) or nursing centre (unless it is a free service). Dependent people may think they cannot afford the service at full cost price, and free-of-charge services may encourage the expectation of using services from both groups, regardless of need. This suggests that additional supports are needed for rural people to access enough care through future interventions.

A higher intellectual ADL index is associated with a lower WTU from all models of care, except free services from a mobile team. This may be because support for intellectual ADLs are mainly provided by family caregivers [28], rather than using day care, a nursing centre, or paying for services from a mobile team. People who are more dependent in basic ADLs are less likely to use services from a day care centre at any level of payment. This may be explained by the fact that physical exercises, health consultations and relaxation were examples of the services that could be provided in a day care centre rather than nursing care. Or, people in need of personal care preferred or relied on family support, particularly from their sons, daughters or grandchildren rather than from outsiders.

Being younger elderly is associated with interest in using a day care centre regardless of levels of payment. This could be because younger elderly are healthier and eager to participate in health promotion activities. The tendency among men to use more services can be attributed to rural women being more active in the care of grandchildren and housework, while men expect to care for themselves under the patrilineal and patrilocal culture [37] that remains strong in rural Vietnam. The observed trend of using more free services from a nursing centre or services with lower costs from a day care centre among people with low levels of education may be influenced by the lower incomes that are typical of this group [38].

It is notable that only 55.8% of married elderly are living with their spouse. The rest may live with the families of their children. People who live with a spouse are less likely to use services; widowed, divorced or single elders are more likely to use services. This may be explained by the spouse being one of the most important sources of emotional and practical support [39]. Married people have a tendency of using more services that are free-of-charge or with lower costs. This may be affected by the 44.5% of married people who do not live with a spouse. People who live in the lowlands usually have more geographic and economic access to health services than those living in mountainous areas. This may lead to a lower expected use of mobile teams and nursing centres.

The need to spend time generating income as well as a better general health status among people still working at older ages [20] may explain their lower expectation of using day care centre services. People who live under the national poverty line or belong to the lower wealth quintiles are more likely to request free services and less likely to use services with payment requirements. This indicates a need to subsidize access to care among the rural elderly, especially those in poor households. Poverty status is only related to use of services with payments, but household wealth is related to use of both free and paid services. This suggests that the household short-term economic status has less effect than long-term status on willingness to use care models. Whether the poorest quintile is less likely to use free services from a day care centre than the middle quintile, or is more likely than the poorer and middle quintiles to use services with full costs from a mobile team and day care centre is unknown.

"Three main limitations are lack of budget, knowledge and guidelines" was pointed out by a representative at the commune level. This implies that more must be learned about the implementation process. The current study identified a number of activities that would improve care models. However, information is limited about how to implement programs with constrained resources. Therefore, a well-designed pilot intervention is needed that focuses on the development of an intervention, the implementation process, and attitudes of users and providers.

Some methodological issues should be considered when interpreting and discussing this study. First, community-centric models of elderly care, especially mobile teams, are rare in Vietnam. Respondents had little or no experience in using or paying for such services. Therefore, pilot interventions are needed. Second, the analysis of willingness to use and pay for services is limited by certain socioeconomic determinants and does not currently cover the health issues that face the elderly. Third, ADLs do not cover all disability domains. Therefore, this assessment of elderly care needs may underestimate other care needs for functional impairments that were not assessed. Fourth, the economic data collected by the repeat census in 2007 may fluctuate by season in rural areas. Fifth, the study respondents were not provided with estimates of the prices. Most may have no experience in paying for these kinds of services. Thus, they might interpret levels of partial or full prices differently. Sixth, this cross-sectional survey could not detect causal relationships between willingness to use the service, ADL indices and socioeconomic factors.

There is a demand for community-centric elderly care in rural Vietnam. Households expect to use services for their elderly to a greater extent than do the elderly themselves for different models and payment levels. Willingness to use services decreases when the potential fees are increased. The proportion of people who would require services is 2-3 times higher than the proportion of those willing to pay for services. Households are willing to pay more than their elderly members for day care and nursing centre services. The elderly were willing to pay more for mobile teams than were their households.

ADL index, age group, sex, educational level, marital status, living arrangement, household head status, living area, working status, poverty status, and household wealth are factors related to the willingness to use services. Despite many differences, there is overall agreement that community-centric elderly care will be used, and partly paid for, if it is provided by the government or associations. Network capacity building of health professionals and informal caregivers, as well as expanding support for the most vulnerable elderly through social security policies, is needed to assess which care services are essential for building and expanding care models. Pilot interventions are needed to scrutinize how these should be implemented in rural Vietnam.