Do the more educated utilize more health care services? Evidence from Vietnam using a regression discontinuity design

Abstract

In 1991, Vietnam implemented a compulsory primary schooling reform that provides this study a natural experiment to estimate the causal effect of education on health care utilization with a regression discontinuity design. This paper finds that education causes statistically significant impacts on health care utilization, although the signs of the impacts change with specific types of health care services examined. In particular, education increases the inpatient utilization of the public health sector, but it reduces the outpatient utilization of both the public and private health sectors. The estimates are strongly robust to various windows of the sample choice. The paper also discovers that the links between education and the probability of health insurance and income play essential roles as potential mechanisms to explain the causal impact of education on health care utilization in Vietnam.

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Fig. 1

Notes

  1. 1.

    Previous studies also use LUPE as an instrument for exogenous changes in education to estimate the causal effects of education on political outcomes and labor market outcomes in Vietnam (Dang 2017a, b).

  2. 2.

    This paper uses a quadratic function of age to control for the possible effects of potential age-related confounding differences.

  3. 3.

    See Angrist and Pischke (2009) for a more detailed explaination.

  4. 4.

    The definitions of all variables are specifically presented in “Appendix 1”.

  5. 5.

    When using various sub-samples, the paper also finds statistically significant impacts of the 1991 compulsory primary schooling reform on schooling years, although the magnitudes of the impact are smaller than the estimates obtained using the main sample. The results of the first stage estimates using various sub-samples are presented in Table 10 of Appendices.

  6. 6.

    Exchange rate: VND/USD = 22.8 thousand at the time of the study.

References

  1. Albouy, V., & Lequien, L. (2009). Does compulsory education lower mortality? Journal of Health Economics, 28(1), 155–168.

    Article  PubMed  Google Scholar 

  2. Altindag, D., Cannonier, C., & Mocan, N. (2011). The impact of education on health knowledge. Economics of Education Review, 30(5), 792–812.

    Article  Google Scholar 

  3. Angrist, J. D., & Pischke, J.-S. (2009). Mostly harmless econometrics: An empiricist’s companion. Princeton, NJ: Princeton University Press.

    Google Scholar 

  4. Card, D., Dobkin, C., & Maestas, N. (2008). The impact of nearly universal insurance coverage on health care utilization: Evidence from medicare. American Economic Review, 98(5), 2242–2258.

    Article  PubMed  Google Scholar 

  5. Coxhead, I., & Phan, D. (2013). Princelings and paupers? State employment and the distribution of human capital investments among households in Viet Nam. Asian Development Review, 30(2), 26–48.

    Article  Google Scholar 

  6. Cutler, D., & Lleras-Muney, A. (2008). Education and health: Evaluating theories and evidence. In J. House, R. Schoeni, G. Kaplan, & H. Pollack (Eds.), Making Americans healthier: Social and economic policy as health policy. New York: Russell Sage Foundation.

    Google Scholar 

  7. Dang, T. (2017a). Quasi-experimental evidence on the political impacts of education in Vietnam. MPRA Paper 77641, University Library of Munich, Germany.

  8. Dang, T. (2017b). Education as protection? The effect of schooling on non-wage compensation in a developing country. MPRA Paper 79223, University Library of Munich, Germany.

  9. Dang, T. (2017c). The multiple effects of child health insurance in Vietnam. MPRA Paper 78614, University Library of Munich, Germany.

  10. Dickson, M., Gregg, P., & Robinson, H. (2016). Early, late or never? When does parental education impact child outcomes? The Economic Journal, 126, F184–F231.

    Article  PubMed  Google Scholar 

  11. Eide, E. R., & Showalter, M. H. (2011). Estimating the relation between health and education: What do we know and what do we need to know? Economics of Education Review, 30(5), 778–791.

    Article  Google Scholar 

  12. Ettner, S. L. (1996). New evidence on the relationship between income and health. Journal of Health Economics, 15(1), 67–85.

    Article  PubMed  CAS  Google Scholar 

  13. Frijters, P., Haisken-DeNew, J. P., & Shields, M. A. (2005). The causal effect of income on health: Evidence from German reunification. Journal Health Economics, 24(5), 997–1017.

    Article  Google Scholar 

  14. Gathmann, C., Jürges, H., & Reinhold, S. (2015). Compulsory schooling reforms, education and mortality in twentieth century Europe. Social Science & Medicine, 127, 74–82.

    Article  Google Scholar 

  15. Grépina, K. A., & Bharadwaj, P. (2015). Maternal education and child mortality in Zimbabwe. Journal of Health Economics, 44, 97–117.

    Article  Google Scholar 

  16. Grossman, M. (1972). On the concept of health capital and the demand for health. Journal of Political Economy, 80(2), 223–255.

    Article  Google Scholar 

  17. Grossman, M. (1976). The correlation between Health and schooling. In Household production and consumption. National Bureau of Economic Research, pp. 147–224.

  18. Grossman, M. (2000). The human capital model. In A. J. Culyer & J. P. Newhouse (Eds.), Handbook of health economics. Amsterdam: Elsevier.

    Google Scholar 

  19. Grossman, M. (2006). Education and nonmarket outcomes. In E. Hanushek & F. Welch (Eds.), Handbook of the economics of education. Amsterdam: North-Holland.

    Google Scholar 

  20. Grossman, M. (2008). The relationship between health and schooling. Eastern Economic Journal, 34(3), 281–292.

    Article  Google Scholar 

  21. Hoai, N. T., & Dang, T. (2017). The determinants of self-medication: Evidence from urban Vietnam. Social Work in Health Care, 56(4), 260–282.

    Article  PubMed  Google Scholar 

  22. Imbens, G. W., & Lemieux, T. (2008). Regression discontinuity designs: A guide to practice. Journal of Econometrics, 142, 615–635.

    Article  Google Scholar 

  23. Kondo, A., & Shigeoka, H. (2013). Effects of universal health insurance on health care utilization, and supply-side responses: Evidence from Japan. Journal of Public Economics, 99, 1–23.

    Article  Google Scholar 

  24. Kruk, M. E., & Freedman, L. P. (2008). Assessing health system performance in developing countries: A review of the literature. Health Policy, 85, 263–276.

    Article  PubMed  Google Scholar 

  25. Ladinsky, J. L., & Levine, R. E. (1985). The organization of health services in Vietnam. Journal of Public Health Policy, 6(2), 255–268.

    Article  PubMed  CAS  Google Scholar 

  26. Ladinsky, J. L., Nguyen, H. T., & Volk, N. D. (2000). Changes in the health care system of Vietnam in response to the emerging market economy. Journal of Public Health Policy, 21(1), 82–98.

    Article  PubMed  CAS  Google Scholar 

  27. Lee, D. S., & Lemieux, T. (2010). Regression discontinuity designs in economics. Journal of Economic Literature, 48, 281–355.

    Article  Google Scholar 

  28. Leuven, E., Plug, E., & Rønning, M. (2016). Education and cancer risk. Labour Economics, 43, 106–121.

    Article  Google Scholar 

  29. Li, J., & Powdthavee, N. (2015). Does more education lead to better health habits? Evidence from the school reforms in Australia. Social Science & Medicine, 127, 83–91.

    Article  Google Scholar 

  30. Lönnroth, K., Thuong, L. M., Linh, P. D., & Diwan, V. (1998). Risks and benefits of private health care: exploring physicians’ views on private health care in Ho Chi Minh City, Vietnam. Health Policy, 45(2), 81–97.

    Article  PubMed  Google Scholar 

  31. Marmot, M. (2002). The influence of income on health: Views of an epidemiologist. Health Affairs, 21(2), 31–46.

    Article  PubMed  Google Scholar 

  32. Matsuda, S. (1997). An introduction to the health system in Vietnam. Environmental Health and Preventive Medicine, 2(3), 99–104.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  33. Ministry of Health of Vietnam. (2007). Vietnam health care report 2006: Equity, efficiency, and development in new situation. Retrieved December 23, 2016 from: http://jahr.org.vn/downloads/Nghien%20cuu/Khac/Vietnam%20National%20Health%20Report%202006.pdf.

  34. Ministry of Health of Vietnam and Health Partnership Group. (2008). Joint annual health review 2008. Health financing in Vietnam. Retrieved December 23, 2016 from: http://jahr.org.vn/index.php?option=com_content&view=frontpage&lang=en.

  35. Murray, C. J., & Frenk, J. A. (2000). Framework for assessing the performance of health systems. Bulletin of the World Health Organization, 78, 717–731.

    PubMed  PubMed Central  CAS  Google Scholar 

  36. Nguyen, C. (2016). The impact of health insurance programs for children: Evidence from Vietnam. Health Economics Review, 6(1), 6–34.

    Article  Google Scholar 

  37. Nguyen, C. V. (2012). The impact of voluntary health insurance on health care utilization and out-of-pocket payments: new evidence for Vietnam. Health Economics, 21, 946–966.

    Article  PubMed  Google Scholar 

  38. O’Donnell, O., van Doorslaer, E., Rannan-Eliya, R. P., Somanathan, A., Adhikari, S. R., Akkazieva, B., et al. (2008). Who pays for health care in Asia? Journal of Health Economics, 27, 460–475.

    Article  PubMed  Google Scholar 

  39. Palmer, M., Mitra, S., Mont, D., & Groce, N. (2015). The impact of health insurance for children under age 6 in Vietnam: A regression discontinuity approach. Social Science & Medicine, 145, 217–226.

    Article  Google Scholar 

  40. Sepehri, A., Simpson, W., & Sarma, S. (2006). The influence of health insurance on hospital admission and length of stay: The case of Vietnam. Social Science & Medicine, 63, 1757–1770.

    Article  Google Scholar 

  41. Silles, M. A. (2009). The causal effect of education on health: Evidence from the United Kingdom. Economics of Education Review, 28(1), 122–128.

    Article  Google Scholar 

  42. Stock, J. H., Wright, J. H., & Yogo, M. (2002). A survey of weak instruments and weak identification in generalized method of moments. Journal of Business and Economic Statistics, 20(4), 518–529.

    Article  Google Scholar 

  43. Tat, S., & Barr, D. (2006). Healthcare in the New Vietnam: Comparing patients’ satisfaction with outpatient care in a traditional neighborhood clinic and a new, western-style clinic in Ho Chi Minh City. Social Science & Medicine, 62, 1229–1236.

    Article  Google Scholar 

  44. Thanh, N. X., Tran, B. X., Waye, A., Harstall, C., & Lindholm, L. (2014). Socialization of health care in Vietnam: What is it and what are its pros and cons? Value in Health Regional, 3C, 24–26.

    Article  Google Scholar 

  45. Thoa, N. T., Thanh, N. X., Chuc, N. T., & Lindholm, L. (2013). The impact of economic growth on health care utilization: A longitudinal study in rural Vietnam. International Journal for Equity in Health, 12(19), 1–6.

    Google Scholar 

  46. United Nations. (2015). Millennium development goals and beyond 2015. Retrieved December 23, 2016 from: http://www.un.org/millenniumgoals/.

  47. Uplekar, M. W. (2000). Private health care. Social Science & Medicine, 51(6), 897–904.

    Article  CAS  Google Scholar 

  48. Webbink, D., Martin, N. G., & Visscher, P. M. (2010). Does education reduce the probability of being overweight? Journal of Health Economics, 29(1), 29–38.

    Article  PubMed  Google Scholar 

  49. Wolffers, I. (1995). The role of pharmaceuticals in the privatization process in Vietnam’s health-care system. Social Science & Medicine, 41(9), 1325–1332.

    Article  CAS  Google Scholar 

  50. World Bank. (2007). Vietnam development report 2008: Social protection, joint donor report to the Vietnam consultative group meeting. Hanoi: World Bank.

  51. World Bank. (2017). The statistics for Vietnam.

  52. World Health Organization. (2011). Investing in health for Africa: The case for strengthening systems for better health outcomes.

  53. World Health Organization. (2017). Global health observatory: Vietnam. Retrieved November 21, 2017 from: http://www.who.int/gho/countries/vnm/country_profiles/en/.

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Acknowledgements

The author would like to thank the editor, two anonymous reviewers and Thomas Cornelissen for helpful comments and suggestions.

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Correspondence to Thang Dang.

Appendices

Appendices

Appendix 1: Definition of variables

Health care utilization outcomes

Public health care services

Probability of an inpatient visit Probability of an inpatient visit to public health care services during the last 12 months (\(=1\) if yes, \(=0\) otherwise).

Probability of an outpatient visit Probability of an outpatient visit to public health care services during the last 12 months (\(=1\) if yes, \(=0\) otherwise).

Frequency of inpatient visits The number of inpatient visits to public health care services over the last 12 months (times).

Frequency of outpatient visits The number of outpatient visits to public health care services over the last 12 months (times).

Private health care services

Probability of an inpatient visit Probability of an inpatient visit to private health care services during the last 12 months (\(=1\) if yes, \(=0\) otherwise).

Probability of an outpatient visit Probability of an outpatient visit to private health care services during the last 12 months (\(=1\) if yes, \(=0\) otherwise).

Frequency of inpatient visits The number of inpatient visits to private health care services over the last 12 months (times).

Table 8 The impact of the 1991 compulsory schooling reform on the probability of a doctor visit: reduced-form (intent-to-treat) regressions

Frequency of outpatient visits The number of outpatient visits to private health care services over the last 12 months (times).

Main control variables

Male Respondent’s gender is male (\(=1\) if yes, \(=0\) otherwise).

Urban Respondent’s household is in an urban area (\(=1\) if yes, \(=0\) otherwise).

Majority Respondent’s ethnicity is the majorities, Kinh or Hoa (\(=1\) if yes, \(=0\) otherwise).

Red River delta The geographical region is Red River delta (\(=1\) if yes, \(=0\) otherwise).

Midlands and northern mountainous areas The geographical region is Midlands and northern mountainous areas (\(=1\) if yes, \(=0\) otherwise).

Northern and coastal central region The geographical region is Northern and coastal central region (\(=1\) if yes, \(=0\) otherwise).

Table 9 The impact of the 1991 compulsory schooling reform on the frequency of doctor visits: reduced-form (intent-to-treat) regressions
Table 10 The impact of the 1991 compulsory schooling reform on schooling years: robustness, various windows, first-stage
Table 11 The impact of the 1991 compulsory schooling reform on the probability of health insurance and monthly income: Reduce form (intent-to-treat) mechanisms

Central Highlands. The geographical region is Central Highlands (\(=1\) if yes, \(=0\) otherwise).

Southeastern area. The geographical region is the Southeastern area (\(=1\) if yes, \(=0\) otherwise).

Mekong river delta. The geographical region is Mekong River delta (\(=1\) if yes, \(=0\) otherwise).

Fig. 2
figure2

The impact of the 1991 compulsory schooling reform on probability of health insurance

Fig. 3
figure3

The impact of the 1991 compulsory schooling reform on income

Survey 2010 The survey year is 2010 (\(=1\) if yes, \(=0\) otherwise).

Survey 2012 The survey year is 2012 (\(=1\) if yes, \(=0\) otherwise).

Survey 2014 The survey year is 2014 (\(=1\) if yes, \(=0\) otherwise).

Potential mechanisms

Health insurance The probability of being insured with public or private health insurance (\(=1\) if yes, \(=0\) otherwise).

Income Respondent’s monthly income (1000 VND, 2010 price).

Schooling variables

Reform exposure Respondent’s probability of being exposed to the 1991 schooling reform that her or his age equals 14 or less than 14 in 1991 (\(=1\) if yes, \(=0\) otherwise).

Schooling years Respondent’s full schooling years at the year of survey (years).

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Dang, T. Do the more educated utilize more health care services? Evidence from Vietnam using a regression discontinuity design. Int J Health Econ Manag. 18, 277–299 (2018). https://doi.org/10.1007/s10754-018-9233-4

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Keywords

  • Education
  • Health care utilization
  • Regression discontinuity design
  • Vietnam

JEL Classification

  • I12
  • I21
  • J13