Preference and willingness to pay for reproductive health services among adults in Urban–Rural transition settings of a developing country: evidence from a cross-sectional study in a rural district of Hanoi, Vietnam

Since the introduction of economic modifications in 1986, Vietnam’s economy has shifted from a centrally planned to a market economy. Its health services underwent a similar transition in 1989 with the introduction of fee-for-service models in public hospitals and the legalization of private health services [1]. Despite its financial barriers to low-income patients, private health services have become increasingly popular [2]. To counter these changes, the Vietnamese government instituted the National Strategy for Reproductive Health Care between 2001–2010, which aimed to provide universal low-cost reproductive health services (RHS) including family planning, antenatal care, and treatment of sexually transmitted infections [3]. One of the ways in which the country has expanded RHS to ensure access to low-income people is through local commune health stations, where local residents can receive subsidized or free services [4]. Though private health insurance is available, the country has also expanded its public program in the past three decades to subsidize medical costs for vulnerable groups including the poor, ethnic minorities, children, and the elderly [5].

As a result of these efforts and other factors, Vietnam has seen an improvement in the population’s overall reproductive health. Maternal mortality, for example, has decreased from 68 per 100,000 live births in 2000 to 43 per 100,000 in 2017 [6]. Antenatal care utilization has also increased from 68.6% in 2000 to 95.9% in 2014. Similarly, more women have utilized skilled staff during labor—from approximately 70% in 2000 to 90% in 2014 [7]. However, those improvements have not been equally distributed across all demographics. Despite the country’s efforts to expand access to RHS, certain demographics including higher economic status, higher education, urban residence, and Kinh ethnic majority continue to be associated with greater utilization of RHS [7‐9]. The measurement of preferences for reproductive health services in both men and women is crucial, especially in countries going through a transition stage, such as Vietnam. Despite the commonly held belief that reproductive health services are geared toward women, it is important to acknowledge that reproductive health issues are not limited to females alone. Men's preferences and attitudes can have a significant impact on reproductive health outcomes for both genders [10]. In Vietnam, where traditional gender roles persist, and taboos surrounding candid discussions on sensitive issues exist, incorporating both men and women in the study would offer a more accurate reflection of reproductive health preferences and needs [11]. As such, the participation of both genders in the study is critical to developing effective reproductive health policies in Vietnam and other developing countries.

In light of these inequities in access and increasing privatization of the healthcare infrastructure, further research is required to assess the financial barriers to RHS. Prior studies in Vietnam have reported on willingness to pay (WTP) for various individual RHS, including WTP for hepatitis B virus (HBV) and human papillomavirus (HPV) vaccination. These studies found that the average price participants were willing to pay was half and two-thirds of the actual price for the HBV and HPV vaccines, respectively, highlighting the need for financial subsidization to improve access, especially for low-income people [12, 13]. However, similar analyses have not been performed for other important RHS including family planning, antenatal care (ANC), and treatment of sexually transmitted diseases. As such, this study aims to further elucidate WTP for RHS to identify barriers to care among adults with a focus on those living in a rural district of Hanoi. With the increasing privatization of healthcare in low- and middle-income countries [14] and a knowledge gap regarding WTP for RHS in those settings, this study aims to create a framework to guide future evaluations in similar settings outside of Vietnam as well.

Table 1 demonstrates the demographics of the 883 participants. The average age was 41.7 (SD = 11.9) years. Most participants were female (58.8%), and the vast majority had health insurance (74.2%) and were living with their partners (89.6%). The 25.8% who did not have either private or public health insurance paid out of pocket for their medical costs. Overall, 59.1% of participants were willing to pay for RHS. There were significant differences in WTP for RHS across all demographics including age group, sex, education level, marital status, occupation, health insurance status, and household income quintile.

Table 2 describes the health status and health behaviors of participants. Most participants (70.9%) had an underweight BMI (< 18.5 kg/m²). Approximately half of the participants (48.5%) reported at least one chronic disease. In terms of health behaviors, 80.7% of participants did not report tobacco use, and 79.2% had one sex partner. Most participants believed that RHS is necessary (69.8%), desired RHS (59.7%), and have used RHS in the past (53.6%). Factors significantly associated with WTP for RHS were number of sex partners, belief in the necessity of RHS, desirability of RHS, and prior use of RHS.

Figure 2 demonstrates that among the 59.1% of subjects willing to pay for RHS, the median maximum amount they were willing to pay was US$21.5. At 107.7$US, only approximately 10% of participants were willing to pay for RHS. With an amount of 323.1 $US or higher, the willingness to pay for RHS is approximately 0%.

Table 3 shows that participants were willing to pay an average of $36.2 ± 2.0 for RHS. Broken.

down demographically, those with an education level above high school and from the highest income quintile were willing to pay the most in their groups at an average of $47.6 ± 8.0 and $64.0 ± 14.3, respectively. Conversely, farmers and uninsured individuals were willing to pay the least at an average of $19.2 ± 5.6 and $31.6 ± 7.5. Those who believed in the necessity of RHS, desired RHS, and had prior use of RHS were also willing to pay at a higher mean amount—$49.1, $51.8, and $49.9, respectively.

Table 4 shows that the odds of willingness to pay for RHS was lower among the freelancers (OR = 0.44; 95% CI = 0.20; 0.98) and farmers (OR = 0.23; 95%CI = 0.10; 0.49) than those in white-collar jobs. Tobacco use was a significant predictor of WTP for RHS when those had higher odds of willingness to pay for RHS (OR = 3.50; 95%CI = 1.83; 6.69). Participants who were absent of sex partners (OR = 0.39; 95% CI = 0.20; 0.76) had lower odds of WTP for RHS than those with one sex partner. Furthermore, compared to people indicating that the RHS was necessary, the odds of WTP for RHS among people believing RHS was unnecessary (OR = 0.22; 95% CI = 0.09; 0.55) or neutral (OR = 0.20; 95% CI = 0.11; 0.36) was significantly lower. Similarly, the odds of willingness to pay among people who did not have any demand to use RHS (OR = 0.05; 95% CI = 0.03; 0.10), or had never ever used RHS (OR = 0.58; 95% CI = 0.31; 1.09) was significantly lower than the other participants.

The findings also indicate that the amount willing to pay for RHS among people in middle-aged adults (Coef. = 13.45; 95% CI = 1.27; 25.64), those in the highest income quintile (Coef. = 29.30; 95% CI = 16.75; 41.85), and those with two or more sex partners (Coef. = 34.74; 95% CI = 11.56; 57.92) was significantly higher than those in other groups. Meanwhile, compared to males, participants who were females (Coef. = -10.13; 95% CI = -19.76; -0.50) were less amount willing to pay for RHS. Furthermore, the amount of willingness to pay for RHS was significantly lower among freelancers (Coef. = -13.13; 95% CI = -25.27; -0.99) and farmers (Coef. = -26.98; 95% CI = -39.28; -14.68) than their white-collar counterparts. Compared to people who believed that the RHS was necessary, the amount of WTP for RHS among people believing RHS was unnecessary (Coef. = -23.25; 95% CI = -38.77; -7.72) or neutral (Coef. = -28.09; 95% CI = -38.98; -17.19) was significantly lower. Moreover, people who did not have any demand to use RHS (Coef. = -16.95; 95% -28.54; -5.37) or had never ever used RHS (Coef. = -17.43; 95% CI = -28.03; -6.83) were also less amount of WTP for RHS than other participants.

Overall, this study found a moderate level of WTP among adults in a rural district of Hanoi, with 59.1% of participants willing to pay for RHS at an average maximum amount of US$36.2, significantly less than the current average price of US$86.2. This is nearly half of the average individual’s monthly income in Vietnam and a significant hardship for those in lower income quintiles [21]. Health insurance coverage for RHS varies though most patients are required to pay for a portion of their services. The percentage willing to pay is substantially less than the 86.6% and 80.8% found in previous studies willing to pay for HPV and HBV vaccinations, respectively [12, 13]. Though this may be partially explained by differences in study populations (the prior studies were performed among women of reproductive age), the proportion willing to pay remained low even after we adjusted for sex and age.

The low percentage of participants willing to pay for RHS is likely related to an overall low awareness of the necessity of RHS. Indeed, the relationship between knowledge of health services and WTP for those services has been well-demonstrated in the literature [22, 23]. In Vietnam, when it comes to reproductive tract infections, studies have shown a low level of knowledge in both urban and rural areas [24, 25]. Similarly, a study in Southern Vietnam estimated that only about half of women received adequate ANC, which was directly associated with the level of knowledge about ANC [26]. These data suggest persistent gaps in knowledge about RHS among the general population and the need for educational campaigns to increase public awareness and uptake of these services. Indeed, this study found a significant relationship between knowledge, prior use, and belief in the necessity of RHS and WTP for those services, suggesting that improved education could increase WTP with the caveat that services remain affordable for the general population. Other factors that may also contribute to low WTP may be related to issues of access and social norms, which should be explored in future studies.

When the data was broken down by demographics and health behaviors, we found socioeconomic status (SES) and smoking behavior to be strongly associated with WTP for RHS. There were significant differences in WTP for RHS across income quintiles. This suggests the need for both education and financial assistance for RHS, especially among those from lower household income quintiles. Actually, access inequalities in health due to financial restrictions in low-middle-income countries seem to still be a worldwide problem [27]. Hence, our study suggests that subsidized services for low-income people could be a potential solution to achieve equitable access to the RHS. Furthermore, the Government should publicly fund more types of services for reproductive health examination through health insurance. Because, up until now, health insurance in Vietnam has covered above 90% of the population, and health insurance is considered one of the key solutions to solving health inequalities problems [27, 28].

Likewise, white-collar workers demonstrated a higher WTP and were willing to pay a higher amount than freelancers and farmers. The impact of SES on WTP for health services is a trend that has been observed across other low- and middle-income countries [29, 30]. While education level may be a factor mediating these outcomes, these differences persisted even after adjusting for education. Another factor that should also be considered is income predictability, given that white-collar workers tend to have a steadier income than freelancers and farmers. This is a relationship that is underexplored in prior studies on WTP for health services and should be evaluated in future studies.

Notably, another finding of the current study is that tobacco use behavior is associated with a higher WTP for RHS. This finding is understandable when an array of previous studies has demonstrated the strong relationship between smoking behavior and decreased sexual function as well as delay in becoming pregnant or even infertility [31‐34]. Hence, our study again suggested that increasing health education programs to control harmful health behaviors as well as improving the accessibility and utilization of RHS for the community, especially vulnerable groups (such as smokers, and alcoholics) can be potential solutions.

The first limitations of this study include its cross-sectional nature, which only allowed us to test for association without insight into causative relationships. Secondly, this study involves self-reporting, which could predispose participants to recall or social desirability bias. Thirdly, the current study has lacked the assessment of some potential factors that could also affect the WTP for RHS such as the number of children, and desire for more children. Hence, further studies could be conducted to explore the association between these factors and the WTP for RHS. Furthermore, because convenience sampling was implemented, this data is not representative of the adult population in Vietnam—further studies should consider collecting data from other urban and rural areas. Moreover, the current study did not distinguish between types of health insurance that are owned by the participants. Therefore, the study's findings may not provide a generalization of the trend as well as the impact of each type of insurance on the willingness to pay decisions differently. Lastly, this study aimed to broadly evaluate WTP for RHS, which included a variety of services from family planning to treatment of sexually transmitted infections. Further studies, should consider examining the type of service, independently, given the heterogeneity of RHS.

This study found a moderate level of WTP among adults in a rural district of Hanoi with 59.1% of participants willing to pay for RHS at an average maximum amount of US$36.2, significantly less than the current average price of US$86.2. These findings are likely related to an overall low awareness of the necessity of RHS, and future education campaigns should specifically target those from lower-income backgrounds. Financial subsidization should also be considered, especially for those from the low-income group, to ensure equitable access to RHS. Lastly, given the heterogeneity of RHS, further studies should consider examining WTP for each type of service independently.