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This paper examines the relationship between disability and poverty at a health-demographic surveillance site in Viet Nam using alternative measures of disability severity. Analysis of the site population (n = 65 400) is combined with interviews of 27 households containing members with disabilities. Results show that disability severity is positively associated with poverty. Results support recent efforts of the Vietnamese government to extend programmes of social protection for households containing members with severe disabilities. However, a higher level of disability targeting is required, both in terms of eligibility and of benefit levels. Copyright © 2010 John Wiley & Sons, Ltd.
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DISABILITY MEASURES AS AN INDICATOR
OF POVERTY: A CASE STUDY FROM
VIET NAM
MICHAEL G. PALMER
1
*, NGUYEN THI MINH THUY
2
, QUACH THI NGOC QUYEN
3
,
DANG SY DUY
4
, HOANG VAN HUYNH
5
and HELEN L. BERRY
1
1
National Centre for Epidemiology & Population Health, Australian National University,
Canberra, Australia
2
Department of Community-Based Rehabilitation, Hanoi School of Public Health, Hanoi, Viet Nam
3
Catholic Relief Services, Hanoi Office, Hanoi, Viet Nam
4
Long Bien District Health Centre, Hanoi, Viet Nam
5
Hai Duong Provincial Health Department, Hai Duong, Viet Nam
Abstract: This paper examines the relationship between disability and poverty at a health-
demographic surveillance site in Viet Nam using alternative measures of disability severity.
Analysis of the site population (n¼65 400) is combined with interviews of 27 households
containing members with disabilities. Results show that disability severity is positively
associated with poverty. Results support recent efforts of the Vietnamese government to
extend programmes of social protection for households containing members with severe
disabilities. However, a higher level of disability targeting is required, both in terms of
eligibility and of benefit levels. Copyright #2010 John Wiley & Sons, Ltd.
Keywords: people with disabilities; poverty; social protection; Viet Nam
1 INTRODUCTION
People with disabilities (PWDs) are thought to represent a disproportionately high
proportion of the world’s poor population (United Nations, 2006). Disability has thus been
flagged as a key development issue in meeting the United Nations Millennium
Development Goals and eradicating world poverty (Kett et al., 2009). Despite the
acknowledged links between disability and poverty, few empirical studies have
systematically examined the economic costs of disability and their implication for
household welfare (Elwan, 1999; Haveman and Wolfe, 2000; Braithwaite and Mont,
2008). This is particularly the case in low- and middle-income countries where the majority
Journal of International Development
J. Int. Dev. (2010)
Published online in Wiley InterScience
(www.interscience.wiley.com) DOI: 10.1002/jid.1715
*Correspondence to: Michael G. Palmer, PhD Candidate, NCEPH, Building 62, ANU, Canberra ACT 0200,
Australia. E-mail: michael.palmer@anu.edu.au
Copyright #2010 John Wiley & Sons, Ltd.
of PWDs live, representing a considerable information gap to formulate programmes of
social protection.
A less recognised problem is that PWDs are typically treated as a homogenous group
despite evidence that disability severity is a significant correlate with poverty (Braithwaite
and Mont, 2008). Furthermore, severe disability is a common eligibility requirement of
social protection programmes. As Gooding and Marriot (2009) noted in a special issue of
this journal, statistics on disability are generally collected using criteria different to those
used for eligibility for social protection programmes. The efficacy of disability targeting in
programmes has thus been limited (Mitra, 2005; Gooding and Marriot, 2009). In high-
income countries discrete disability programmes are common. However, in settings where
resources and administrative capacity is limited disability targeting is typically
incorporated into mainstream social protection programmes (Mitra, 2005).
Using data from a health-demographic surveillance site in northern Viet Nam, known as
the CHILILAB, this paper examines the relationship between disability and poverty using
alternative measures of disability severity. The effectiveness of current mainstream social
protection programmes for PWDs is subsequently assessed. The study combines
descriptive analysis of the disabled versus non-disabled site population with semi-
structured interviews of 27 households with disabled members. Two measures of disability
are applied including a broad measure of functioning, based upon contemporary
international classification, and a higher order functioning measure of the ability to
perform a selection of daily activities.
2 OVERVIEW OF DISABILITY, POVERTY AND SOCIAL PROTECTION IN
VIET NAM
Viet Nam has a large disabled population. The government estimates at least 5.3 million
Vietnamese people (6.6 per cent of the population) are living with a disability (MOLISA,
2006). An alternative estimate, using an international general measure of disability
contained in the Viet Nam Household Living Standards Survey 2006, puts this number at
12.9 million people (15.3 per cent of the population) (GSO, 2008). Viet Nam is susceptible
to disabling conditions due to disease, accident, deprivation and low use of formal
healthcare. Lack of rehabilitation services also contribute substantially to disability
(MOLISA, 2006). Injuries acquired as a result of war are estimated to account for
approximately one-quarter of the disabled population (estimate includes post-war victims
of Agent Orange, landmines and unexploded ordinance) (MOLISA, 2006).
Although a number of studies have examined poverty among the general population and
subpopulations including ethnic minority people and the elderly in Viet Nam (van-de-
Walle, 2001; Joint Donor Group, 2003; Glewwe et al., 2004; Giang and Pfau, 2009),
detailed poverty analysis is yet to be performed for PWDs. According to a government
report, 32.5 per cent of households with PWDs are living below the poverty line (MOLISA,
2006). Poverty estimates are derived from household income equivalised per capita. They
do not delineate the loss of household income attributable to incapacity and care-giving nor
account for additional costs associated with disability, such as healthcare, which can
greatly accentuate poverty status. Furthermore, there is no breakdown by disability severity
or other poverty correlates.
In Viet Nam, the legal responsibility to protect and assist PWDs is shared between the
family, state and community (Ordinance on Disabled Persons, 1998). During the last
Copyright #2010 John Wiley & Sons, Ltd. J. Int. Dev. (2010)
DOI: 10.1002/jid
M. G. Palmer et al.
decade, the government has implemented social protection measures designed to improve
access to healthcare and protect the livelihoods of certain target groups (Le et al., 2005).
PWDs are among a list of policy beneficiaries including meritorious persons, orphans, the
elderly (85 years above) and persons living with HIV/AIDS, etc. (Regulation 67, 2007).
Like other policy beneficiaries, people with severe disabilities that live in poor families are
entitled to some free healthcare and monthly income support (Ordinance on Disabled
Persons, 1998). The coverage and effectiveness of these programmes for PWDs is not
clearly documented.
3 METHODS
3.1 Study Site
Established in July 2004, the CHILILAB is 1 of 37 health-demographic surveillance sites
in 18 developing countries in Africa, Asia and Oceania under the INDEPTH Network
whose mission is to ‘provide a better, empirical understanding of health and social issues,
and to apply this understanding to alleviate the most severe health and social challenges’.
1
The CHILILAB is located in the district of Chi Linh, Hai Duong province, a mountainous
region approximately 60 km northeast of Viet Nam’s capital, Hanoi (HSPH, 2008). The site
consists of seven communes (three urban, four rural) with a population of approximately
65 400 and 17 900 households. Baseline demographic and socio-economic data on the site
population is collected every 2 years with quarterly updates of immigration, reproduction,
marital status, morbidity, mortality and injury. Research findings, including risk factors for
non-communicable diseases, prenatal healthcare service utilisation, burden of disease and
others, have been published by the Hanoi School of Public Health (HSPH, 2008).
Characteristics of the site are typical of many regions in Viet Nam (HSPH, 2008). Urban
areas are densely populated with arterial bitumen roads and small-scale trading as the
primary economic activity amid local industries of thermal power, glass manufacture, clay
mining and shoe leather processing. Rural areas are more sparsely populated with limited
infrastructure and mostly gravel roads. Agriculture is the main source of income in
rural areas with irrigation provided by the Kinh Thay River. The main food crop is rice
with subsidiary dry-food crops of maize and groundnuts. Over the last 10 years the
growing of commercial fruit trees such as lychee, longan and custard apple has expanded.
All households at the site have access to electricity and the overwhelming majority
(99.6 per cent) of people are Kinh (the main ethnic group of Viet Nam). Health facilities
consist of commune health stations and a district public hospital, as well as numerous
private clinics and pharmacies (Figure 1).
3.2 Data
Data derived from a disability survey of the site population conducted in 2007 for a project
supported by the China Medical Board of New York into the social and health needs of
PWDs. The survey collected extensive information on healthcare usage (including
1
For further information on the CHILILAB and INDEPTH Network refer http://chililab.org and http://www.
indepth-network.org/index.php?option=com_content&task=view&id=13&Itemid=28.
Copyright #2010 John Wiley & Sons, Ltd. J. Int. Dev. (2010)
DOI: 10.1002/jid
Disability Measures as an Indicator of Poverty
rehabilitation and assist devices), daily caring requirements, informal and formal supports
received, and level of participation in production-related activities. Baseline site socio-
economic data, including age, sex, education level, occupation, household assets and
poverty, was merged with disability data. In addition, 27 households with PWDs of
working age (18–50 years) in two communes (one urban and one rural) participated in
semi-structured interview to detail the processes linking disability and poverty. The
majority (22) of PWDs were severe in degree with five persons with non-severe disabilities
included as a control.
2
Interviews were structured around four inter-connecting themes: (i)
economic costs of disability, (ii) household coping mechanisms, (iii) informal and formal
supports and (iv) household health and welfare. Consistent with Glendinning and Baldwin
(1988) three main economic costs of disability were examined including foregone income
from disabled member/s, foregone income from primary carers and additional costs
attributable to disability which we limit to healthcare utilisation as a significant cost
commonly associated with disability (Haveman and Wolfe, 2000). An important factor
affecting household poverty and welfare relates to the coping mechanisms employed to
manage the economic costs of disability including the uptake of informal and formal
protections.
Figure 1. Chi Linh district, Hai Duong province This figure is available in colour online at
www.interscience.wiley.com/journal/jid
2
Other selection criteria included impairment type, sex and rural/urban location as reported determinants of
poverty (Elwan, 1999). Consistent with national distribution, impairment types were mostly mobility (11) and
mental (13) with the remainder hearing and speaking (2) and epilepsy (1) (MOLISA, 2006). Approximately half of
PWDs were female and half were from urban areas. Most (all but two) households participating in this study
contained only one PWD in line with the national and site average.
Copyright #2010 John Wiley & Sons, Ltd. J. Int. Dev. (2010)
DOI: 10.1002/jid
M. G. Palmer et al.
3.3 Methodology
3.3.1 Methods
Since many of the basic facts of disability and poverty in developing countries are unknown
or have not been systematically addressed, the goal of this paper is descriptive. The
analysis is performed in three stages. First, we provide socio-economic profile of the
disabled versus non-disabled population using alternative measures of disability severity.
Second, descriptive statistics of various need indicators among the disabled population are
presented by disability severity. Third, qualitative findings are presented according to the
four above-listed themes. The approach is justified to aid understanding of the dynamic
relationship between disability and poverty while providing empirical data which are
statistically generalisable to the site population.
3
The life experience and opinions of
PWDs and their families are given voice to best ensure that the research reflects their
interests (Barnes, 2003).
3.3.2 Measuring disability
Two disability measures are applied to reflect different orders of functioning: a general
disability measure and a severe disability measure. Influenced by the International
Classification of Functioning, Disability and Health (ICF) (WHO, 2001), the general
disability measure included a range of questions relating to body impairments, functions,
activities and participation. PWDs were classified as those who experienced functioning
difficulty (‘yes’ or ‘no’) in any 1 of 30 questions across 7 domains: mobility, hearing and
speaking, vision, learning difficulties, strange behaviour (mental or psychiatric illness),
epilepsy and leprosy. This meets a broad policy aim of understanding the extent of
disability, but is insufficient to assess the proportion of the population who require
rehabilitation and social services. Activities of daily living (ADLs) are a higher order of
functioning routinely used as a predictor of a range of health behaviours (including
disability) and eligibility for insurance benefits, rehabilitation services and assisted-
care living (Weiner et al., 1990; Jette, 1994). Persons experiencing activity limitation
were those that required assistance or could not perform with assistance at least 1 of
10 activities.
4
A human assistance scale was applied as that most suitable to determine
service needs: (i) can perform without assistance, (ii) can perform with assistance and
(iii) cannot perform (with assistance) (Weiner et al., 1990; Jette, 1994). Note use of aids
was not included to measure disability and we excluded people that wear glasses whose
only disability was refractive error (long-sighted or short-sighted). The sample included
only people aged 6 years and above.
3.3.3 Measuring poverty
Two measures of poverty are applied including an asset index and a list of poor households
provided by commune officials. An index of asset ownership and housing conditions are at
least as reliable as conventional money-metric measures of economic status (Filmer and
Pritchett, 2001). The index was based upon ownership of 12 private household assets plus
3
The approach is advocated by Kett et al. (2009, p. 658) who write: ‘Something that has become increasingly
apparent is the need to understand that the multidimensional aspects of poverty and exclusion for PWDs requires
both quantitative and qualitative approaches in order to fully understand the nuances of inclusion and exclusion’.
4
List of 10 activities include (1) transfer from lying position, (2) transfer from sitting position, (3) walk 10 steps,
(4) move about the house, (5) move outside the house, (6) eat and drink, (7) shower, (8) get dressed, (9) go to the
toilet and (10) express wants and needs.
Copyright #2010 John Wiley & Sons, Ltd. J. Int. Dev. (2010)
DOI: 10.1002/jid
Disability Measures as an Indicator of Poverty
those relating to housing conditions.
5
Assets were weighted using factor analysis and
summarised as an index of ascending welfare between 1 and þ1 with a mean of zero
(refer description Booysen et al., 2008). Households were ranked into asset index quintiles
with the lowest 20th percentile serving as an alternative poverty line to methods applied by
local authorities.
3.3.4 Survey administration and ethical considerations
The disability survey was administered by 42 local interviewers employed and trained by
the CHILILAB. The response rate was 100 per cent for the survey. Two households
declined to participate and a further household could not be located for further semi-
structured interview. Consent to participate was obtained from the household head with
information collected from the person with the most knowledge on household matters.
Ethical approval for the study was provided by the Vietnamese Ministry of Health and
Hanoi School of Public Health (Protocol no.: 62/2007/YTCC-DH3) and the Australian
National University (Protocol no.: 2006/0318).
4 RESULTS
4.1 Summary Statistics
Approximately 18.5 per cent of persons over 5 years of age experienced functioning
difficulties and 2.1 per cent required assistance in performing activities (hereafter referred
as the general total disabled population and people with severe disabilities, respectively,
Table 1). By both poverty measures, PWDs experienced higher rates of poverty than their
counterparts without disabilities (55–75 per cent higher depending upon the measure).
Absolute rates of poverty across subpopulations were approximately double for the asset
index measure compared with the local authority measure. Poverty rates were slightly
higher among persons with severe disability.
PWDs also diverged from the site population across a number of poverty correlates
(Table 2). PWDs were substantially older (53 years versus 30 years) with 32 per cent over
the age of 60 compared with 5 per cent of persons without disabilities. Higher proportion of
PWDs were female (59 per cent versus 48 per cent). Illiteracy rates were higher for PWDs
(7 per cent versus 0 per cent) and they were half as likely to have finished upper secondary
Table 1. Disability prevalence and poverty incidence, CHILILAB, 2007
Non-disabled Disabled
Total Severe
Prevalence rate (%) 81.5 18.5 2.1
(N) (49 523) (11 214) (1275)
Poverty measure 1 – local authority register 8.3 14.6
15.2
Poverty measure 2 – lowest 20th asset percentile 18.0 27.9
30.1
p<0.001. Estimates apply to persons aged >5 years.
5
Private assets (television, refrigerator, radio, video, cupboard, sewing machine, telephone, mobile phone,
computer, bicycle, motorbike and car); floor types (tile, cement, earth, other); sanitation types (flush toilet,
latrine, other, none) and water sources (piped, well, rain, other).
Copyright #2010 John Wiley & Sons, Ltd. J. Int. Dev. (2010)
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school or above. PWDs were approximately twice as likely to report no occupation and
those that were working were more likely to be farmers (49 per cent versus 30 per cent).
PWDs also had fewer household assets and, in contrast to non-disabled residents, the
majority lived in rural areas (54 per cent versus 44 per cent).
Whilst little difference in poverty rates was observed by disability degree, persons with
severe disabilities differed from the general disabled population across a number of socio-
economic indicators (Table 2). Persons with severe disabilities had higher proportion above
60 years of age (51 per cent versus 32 per cent), illiterate (18 per cent versus 7 per cent),
working in ‘other’ occupations (17 per cent versus 6 per cent) and living in rural areas
(58 per cent versus 54 per cent) whereas secondary school completion (8 per cent versus
11 per cent) and household assets were lower.
Disability severity was positively associated with selected need indicators (Table 3).
Two-thirds of persons with severe disabilities had consulted a doctor compared with half of
Table 2. Poverty correlates among the disabled and non-disabled population, CHILILAB, 2007
Non-disabled Disabled
Total Severe
Age (years) 30.3 53.4
59.4
Age groups (%) p<0.001
1. 6–17 years 23.3 3.7 4.7
2. 18–60 years 72.2 64.4 44.4
3. >60 years 4.5 31.9 50.9
Sex (%) p<0.001
1. Female 48.3 59.1 59.1
2. Male 51.7 40.9 40.9
Education level completed (%) p<0.001
1. Illiterate 0.4 7.2 17.5
2. Read and write 0.8 8.0 14.1
3. Primary 13.2 17.3 19.2
4. Lower-secondary 42.1 43.9 30.7
5. Upper-secondary 22.4 11.0 7.7
6. Above secondary 21.1 12.6 10.8
Main occupation (%) p<0.001
1. None 8.3 15.3 16.7
2. Farmer 30.3 49.1 41.8
3. Government official 11.6 5.9 6.5
4. Worker 14.8 5.2 5.4
5. Handicrafts worker 3.8 3.2 2.2
6. Salesperson 19.8 15.6 10.8
7. Other 11.4 5.7 16.6
Asset Index
a
0.066 0.247
0.274
Rural/urban location (%) p<0.001
1. Urban 56.3 45.6 41.6
2. Rural 43.7 54.4 58.4
p<0.001. Estimates apply to persons aged >5 years.
a
Assets include television, refrigerator, radio, video, cupboard, sewing machine, telephone, mobile phone,
computer, bicycle, motorbike, car, floor type (tile, cement, earth, other), water source (piped, well, rain, other),
toilet type (flush, latrine, other, none). The index was computed using principal-components factor analysis. The
percentage of the covariance explained by the first principal-components factor was 19.6%. The first Eigenvalue
was 4.71, the second Eigenvalue was 1.94.
Copyright #2010 John Wiley & Sons, Ltd. J. Int. Dev. (2010)
DOI: 10.1002/jid
Disability Measures as an Indicator of Poverty
all PWDs. The district hospital was the most common point of contact. Persons with severe
disabilities reported higher use of all facility types, particularly high-level hospitals
(provincial and central) and private clinics. Consultation and medication services were
most commonly sought among PWDs, with the severely disabled more likely to access
rehabilitation and medication services.
Use of rehabilitation services, however, remained low with only 15 per cent of persons
with severe disabilities reporting access. Among people with mobility, visual or hearing
Table 3. Need indicators for persons with disabilities by disability measure, CHILILAB, 2007
PWDs
Total Severe
Mean Std. error Mean Std. error
Have consulted a doctor (by facility type) 46.2 (0.5) 68.1 (1.3)
1. Commune health station 8.9 (0.3) 10.6 (0.9)
2. District hospital 22.7 (0.4) 33.9 (1.3)
3. Provincial hospital 12.6 (0.3) 19.8 (1.1)
4. Central hospital 11.0 (0.3) 20.1 (1.1)
5. Private clinic 8.3 (0.3) 13.5 (1.0)
Services used by those that sought healthcare
1. Consultation 49.1 (0.7) 50.8 (1.7)
2. Rehabilitation 7.6 (0.4) 15.1 (1.2)
3. Surgery 12.9 (0.5) 13.6 (1.2)
4. Acupuncture 34.5 (0.6) 31.3 (1.6)
5. Medication 52.5 (0.7) 60.7 (1.7)
Use an assistive device
a
12.5 (0.3) 29.7 (1.3)
1. Mobility disability 10.3 (0.4) 28.9 (1.3)
a. Crutches 8.3 (0.4) 21.5 (1.2)
b. Wheelchair 1.0 (0.1) 4.5 (0.6)
2. Visual disability (glasses)
b
12.6 (0.4) 9.7 (1.4)
3. Hearing and speaking disability (hearing aid) 2.0 (0.3) 1.1 (0.6)
Regularly participate in production-related activities 71.9 (0.5) 49.8 (1.2)
1. Sometimes 14.7 (0.3) 15.0 (1.0)
2. Never 13.4 (0.4) 35.2 (1.4)
Require daily care-giving assistance (hours per day) 5.3 (0.2) 25.0 (1.2)
1. <1 2.6 (0.1) 9.7 (0.6)
2. 1–3 1.0 (0.1) 5.3 (0.6)
3. >3 1.7 (0.1) 10.0 (0.9)
Receive support from others (by source) 8.6 (0.3) 17.8 (1.1)
1. Income 3.8 (0.2) 9.1 (0.8)
2. Healthcare card 3.7 (0.2) 5.8 (0.7)
3. Assist device 0.3 (0.1) 1.6 (0.3)
4. Gift 2.8 (0.2) 8.2 (0.8)
5. Emotional 2.3 (0.1) 6.7 (0.7)
Income support by source
1. Government 2.5 (0.1) 4.9 (0.6)
2. Relatives 1.2 (0.1) 3.5 (0.5)
3. Neighbours 0.4 (0.1) 2.0 (0.4)
4. Community organisation 0.6 (0.1) 2.3 (0.4)
a
Includes people with mobility, visual, and hearing and speaking disabilities only.
b
Includes persons with refractive error as the only disability.
Note: Estimates may not sum to total as respondents could enlist more than one category. Estimates apply for
persons aged >5 years.
Copyright #2010 John Wiley & Sons, Ltd. J. Int. Dev. (2010)
DOI: 10.1002/jid
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and speaking disabilities, approximately 13 per cent used an aid. Eye glasses and
crutches were most common with wheelchairs and hearing aids less prevalent. Assistive
device usage was more than double among the equivalent severely disabled population
(30 per cent) due to increased use of crutches among persons with severe mobility
disabilities.
Five per cent of all PWDs required daily care assistance. Severe disabilities were fivefold
more likely to require care and at a higher level (>1 h). Half of persons with severe
disabilities participated regularly in work compared with around three-quarters of the
general disabled population; 35 per cent of persons with severe disabilities never
participated in work (more than double the general disabled population).
Receipt of formal and informal supports was low. Income, healthcare, assist device, gifts
or emotional support were received by 9 per cent of the general disabled population and
18 per cent of the severely disabled population. Income was the most common support
sourced from government, relatives, community organisations and neighbours in
descending order. Five per cent of persons with severe disabilities received government
cash transfers and 6 per cent received a free health insurance card.
4.2 Thematic Analyses
4.2.1 Costs of disability
Healthcare utilisation. Interviews reveal that PWDs were only likely to see a doctor once
or twice in their lifetime. Two mentally challenged people have never consulted a doctor. In
almost all cases, doctors have informed the family that the disabilities could not be ‘cured’
and the family had decided not to continue consultations. Economic factors remained an
important consideration in determining whether to access healthcare, particularly for
people with severe mobility disabilities who were most at risk of positive health
expenditures (8/11). Among this group, direct medical expenditures ranged from 3 months
to 2½ year’s family income.
6
At first I went to the Chi Linh hospital but the doctor didn’t diagnose anything and
said that I had heat exhaustion [say nang]. Later I went to the emergency department
at Hai Duong hospital and they said I had suffered a stroke. The hospital fee for a
two-month stay was 25 million dong which included 400,000 dong per day for
medicine. The Western medicine [antibiotics] didn’t work and these days I am taking
herbal medicine [thuoc Nam] at 30,000 dong per day which I have been using for
about one year now. The tally of my medical fees to date is 30 million dong. I didn’t
have an insurance card so I had to pay all of the hospital fees. We borrowed
the money from the bank [25 million] but we haven’t paid it back yet. (Minh, Man,
29 years, Le Loi)
Antibiotic purchases, particularly imported antibiotics, were prohibitively expensive.
Instead participants resorted to cheaper, and in some cases less effective, traditional pain
relievers.
6
An average monthly income of one million dong was applied, slightly higher than the average annual income
quoted in the rural commune (0.86 million dong) and slightly lower than the overall average (1.3 million dong).
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Disability Measures as an Indicator of Poverty
Before we bought medicine [antibiotics] that prevented the disease from developing
but that medicine was very expensive so now we just use medicine [herbal] to reduce
the pain. (Woman, 41 years, Sao Do)
Health expenditures were considerably lower among persons with severe mental
disabilities. The majority of these persons (9/13) had no major medical expenditures with
remaining expenditures ranging from 6 days to 4 months’ family income. Low spending
was in part because of lack of treatment options. Medications were mostly herbal and two
people were treating their condition with Paracetamol. A young woman with speaking
difficulties had not undergone speech therapy and was treating her condition with daily
acupuncture sessions.
Income generation. Households containing a member with severe disabilities were most
at risk of income deprivation. This risk was most severe if the person was a main earner
with children to support, particularly for rural households which relied upon small cash
flows from agriculture. A small number of persons with severe disabilities were able to
work around the house, feeding chickens and other livestock, which provided income and
was valued by the household.
My left side of my body is paralyzed so I cannot work. My wife works in the field, she
has no occupation, and we only have ten lychee trees so it is not enough to meet daily
living costs and school fees for my family [two young children]. We don’t have
anything to sell and we don’t have any savings so we have no choice but to borrow
from the bank, another 10 million dong. (Minh, Man, 29 years, Le Loi)
Care-giving. The most common care-giving assistance for persons with severe
disabilities was bathing which could take 30–60 minutes (13/22). Generally, caring did
not impact upon household income; however, there existed potential for persons that
required a high level of care (assistance with bathing, toileting, and eating and drinking)
(2/13). Persons with severe mental disabilities were more likely to require daily care, and
higher levels of care. There was also indication that persons requiring high care placed
significantly more psychological stress upon household members. Care giving was a
universally accepted family responsibility with the exception of one family who wanted to
hire help as the primary carer was too old (84 years).
I must care for her every day. Sometimes I lost sleep because I must take her to go to
the toilet during the night. She was very heavy, so it was very difficult to lift her. For
forty years I cared for her, I could not work other jobs and it affected our economic
situation. It was my responsibility because I am her mother. (Woman, 67 years,
Le Loi)
4.2.2 Coping mechanisms
Borrowing was the main mechanism employed by households with severely disabled
members to meet medical and daily living expenses (16/22). Generally, assets were
insufficient in value to sell and households had few savings. The preference was to borrow
(interest-free) from relatives and neighbours (11/16) though finance was available from the
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‘bank’ (commune credit fund) at 1.28 per cent interest per month. Loans were significant
relative to monthly incomes, ranging from 1.5 months to 6 years family income. Large
loans were typically to finance healthcare costs of the PWD. Reduction of consumption
expenditures was common among household with severely disabled members (20/22) and
included food, education, shelter and technology.
When you have little you eat little, when you have much you eat much. In difficult
times we just eat rice with vegetables and fish sauce. (Woman, 58 years, Le Loi)
Our economic situation is very miserable. We don’t know if we can find the money to
send her [eldest daughter] to upper secondary school next year – she is the smart one,
number one in her class. (Woman, 44 years, Le Loi)
I would like to buy a computer for my son and repair the house but where can I find
the money. (Woman, 42 years, Le Loi)
Labour substitution within the household was not common due to the availability of
finance. However, a woman with an unemployed husband and daughter with multiple
disabilities reported working additional hours in the evening at a local restaurant to make
ends meet. In another case, two daughters were withdrawn from school to work and care for
their incapacitated father whilst their mother went to work in Malaysia to finance costs of
disability treatment and debt.
4.2.3 Informal and formal supports
Support from relatives, friends or the community was not common. Gifts and money were
infrequent, often on the occasion of new year, and not significant in value. Government
programmes of monthly income support and free health insurance was the main source of
support received by approximately one-third of working age people with severe
disabilities. Households, on the whole, were appreciative of the monthly income transfers
although acknowledged that the payments were small in value.
Income support is 65,000 dong per month which we receive quarterly. It does have
value and helps in one part but is encouragement [dong vien] only. I think the amount
should be raised; to eat at the very basic level is 10,000 dong for one person for one
day so I think this should be used as the level; that is, 300,000 dong per month is the
minimum just to eat. (Man, 52 years, Sao Do)
Health insurance was valued because it exempted certain fees; however, problems of
capped benefits, poor quality services and medication, waiting times and administration
procedures for members were reported.
The card [healthcare] is good because it exempts consultation and bed fees. Without
it, you are dead. But there are some problems. I use the card but I still must pay
money to buy medicine and high-level procedures. I do not use the card for medicine
because the medicine is not good; if you want good medicine, you must buy it. That is
the main problem. The other problem is the waiting time. Cardholders must consult
in a separate area, which is crowded. Sometimes I must wait a whole morning to see a
doctor and, if I can’t see a doctor in the morning, then I must return in the afternoon.
Also, at the hospital, when you carry a card, you must pass through many procedures
and waste a lot of time. Therefore, not to use the card and go to a private doctor is
better. You know, generally, to enter a hospital in Viet Nam is not easy. So I just use
Copyright #2010 John Wiley & Sons, Ltd. J. Int. Dev. (2010)
DOI: 10.1002/jid
Disability Measures as an Indicator of Poverty
the card when I have to stay in hospital. I do not have to pay bed fees and that is very
good. (Man, 42 years, Sao Do)
4.2.4 Health and welfare
All but three households with severely disabled members reported that their physical or
mental health was affected by living with a severely disabled member (19/22). Regular
sleep loss was reported in one-third of cases, two households reported weight loss and three
households reported taking medication to assist with sleep or headaches. Worry over the
immediate economic situation of the household and that of the future, when there may be
nobody to care for and support the PWD, were cited as the main contributing factors
affecting household welfare.
My wife worries a lot about our economic situation. She cannot sleep and must take
medicine [thuoc than kinh (tranquilisers)] to help her sleep. (Man, 29 years, Le Loi)
We worry about when there will be no one to take care of her [daughter with
disabilities]. Sometimes my wife wakes in the night and cannot sleep. So now we are
trying our best to get treatment for her [daughter]. (Man, 52 years, Sao Do)
5 DISCUSSION
5.1 Disability and Poverty
Relative to other site residents, PWDs experience higher rates of poverty by both measures.
Absolute poverty rates are approximately double for the derived measure and more closely
reflect national estimates, which suggest local methods of identifying poor households are
stringent. There is little difference in poverty by disability degree. This is likely because
measures are determined for the household as a whole, and appropriated per capita in the
case of the asset index measure, hence do not directly measure individual poverty levels.
This explanation of measurement bias is further supported by marked differences in
individual poverty-correlates and need-indicators between persons with severe disabilities
and the general disabled population. This is also observed in qualitative interviews. Five
persons with non-severe disabilities experienced no significant economic costs associated
with their disability.
Interviews among households containing severely disabled members provided valuable
insights into the processes linking disability and poverty. Healthcare expenditures pose
significant economic burden. This is particularly the case for households with members
with severe mobility disabilities, consistent with report from India (Erb and Harriss-White,
2002). Medical expenditures among people with severe mental disabilities are low owing
to fewer treatment options, as commonly reported in developing countries (Das et al.,
2007). Medication usage is limited to herbal remedies and Paracetamol provided free of
charge by the commune health station. There exists a psychiatric hospital in a neighbouring
province but few persons sought specialist treatment. This may be because doctors are
more likely to label mental disabilities as ‘incurable’ and or reluctance on the part of
families to explore treatment options for mental illness.
Copyright #2010 John Wiley & Sons, Ltd. J. Int. Dev. (2010)
DOI: 10.1002/jid
M. G. Palmer et al.
Income deprivation is most serious if the household loses a main earner through
disability and has children to support, similar to findings in India and Bangladesh (Erb and
Harriss-White, 2002; Foley and Chowdhury, 2007). School fees are particularly
burdensome. Interviews reveal that there is potential to impact on the earnings of
primary carers for persons which require a high level of care (>1 h daily) representing
approximately 15 per cent of persons with severe disabilities or 3 per cent of the general
disabled population. Similarly, in India, care-giving duties do not constitute a major
economic burden for the majority of households (Erb and Harriss-White, 2002). Four per
cent of cases were sufficiently disabled to be completely unable to look after themselves
and caring is assumed to be coped with by an increase in female domestic labour (Erb and
Harriss-White, 2002). However, carers are likely precluded from formal-wage positions to
form an additional indirect cost associated with disability.
Common coping strategies employed by households to manage the economic costs of
disability include treatment avoidance, debt-financing and reducing consumption
expenditures, consistent with other low-income settings (Erb and Harriss-White, 2002;
Foley and Chowdhury, 2007). Although most PWDs at the study site report consulting a
doctor in their lifetime, interviews reveal that the frequency of visits is small (generally
once or twice). Treatment avoidance can contribute to disability and thereby household
vulnerability. The majority of loans are sourced interest-free through social networks yet
almost all households reduce consumption expenditures and experience adverse health
affects which suggests that loans threaten welfare. Households lacking social capital, or
those with medical bills too large to be sourced informally, undertake interest bearing
loans, placing them at greatest risk of adverse consumption and health effects.
5.2 Social Protection
Site coverage of formal social protection programmes is surprisingly low. This was thought
as due to high number of persons with severe disabilities above programme eligibility age
(60 years). However, recipient rates change little for adults below 60 years of age. Site
coverage is significantly lower than reported in qualitative interviews likely because the
two communes chosen for survey have the highest recipient rates among the seven
site communes. Low overall coverage likely reflects local administrative capacities.
Commune officials identify beneficiaries, yet it remains unclear how eligibility is
determined. Programmes address primary needs of income and healthcare support but are
formulated at a high level of generality. Cash transfers are insufficient to cover minimum
daily food intake whereas health insurance provides protection against low-grade
outpatient expenditures but is unsatisfactory for inpatient and medication expenditures to
which severely disabled persons are prone. Of particular concern is the relatively high use
of costly provincial and central hospital services among the severely disabled population.
5.3 Study Limitations
This study is limited by the geographic homogeneity of one district in one northern
province. Methods of analysis are descriptive and do not control for the presence of
confounding factors. Results should therefore be viewed as preliminary. Furthermore, the
study is not exhaustive in the measurement of disability costs (Jones and O’Donnell, 1995;
Copyright #2010 John Wiley & Sons, Ltd. J. Int. Dev. (2010)
DOI: 10.1002/jid
Disability Measures as an Indicator of Poverty
Erb and Harriss-White, 2002), coping mechanisms (Sauerborn et al., 1996) or the range of
factors enabling or constraining access to support systems (Goudge et al., 2009). We are
unable to give due attention to the gendered and spatial aspects of disability and poverty
(Erb and Harriss-White, 2002; Hoogeveen, 2005; Foley and Chowdhury, 2007).
Longitudinal study design is necessary to assess the long-term implications of coping
mechanisms for household welfare. This is particularly pertinent due to the long-term
nature of disability.
6 CONCLUSION
Results support recent efforts of the Vietnamese government to extend formal mechanisms
of social protection for households containing members with severe disabilities.
Considerable challenges lie ahead in incorporating a higher level of disability targeting
into mainstream programmes, both in terms of eligibility and of benefit levels. The inability
to perform a selection of ADLs is tentatively proposed as a valid screening tool and is more
readily identifiable than poverty-based social protection eligibility criterion. However,
further testing is required. Other considerations arising from this research include
developing the provision of rehabilitation services (including assistive aids) particularly for
mental and sensory disabilities; ‘bare-foot doctor’ and CBR services in view of the
commonly encountered belief that impairments cannot be rehabilitated; low or no-interest
loans for households with low social capital; free education for dependents of persons with
severe disabilities; and supplementary income and respite services for households with
members requiring a high level of care.
ACKNOWLEDGEMENTS
The authors thank the CHILILAB and the Hanoi School of Public Health for facilitating
this research. Special thanks also go to the households who generously gave their time to
participate in this study. Comments from two anonymous referees are gratefully acknowl-
edged. This research was funded by the China Medical Board of New York, and an
Australian Post-graduate Award and supplementary scholarship from the National Centre
for Epidemiology and Population Health (The Australian National University) for the lead
author. The views expressed in this paper are those authors alone.
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... Those studies which included a measure of severity used either the WGQs or were data drawn from the Chinese National Sample Survey on Disability. The tools used and response options were diverse, including "disabled or extremely disabled," [77] and "mild or serious disability" [78] and when severity was included in the data collection tool, disaggregated numbers were not always reported. The heterogeneity of severity descriptors used, even with only two disability measures, made analysis across studies difficult. ...
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Viet Nam's ethnic minorities tend to be concentrated in remote areas and have lower living standards than the ethnic majority. How much is this due to poor economic characteristics versus low returns to characteristics? Is there a self-reinforcing culture of poverty in the minority group? We find that differences in returns to productive characteristics are an important explanation for ethnic inequality. There is evidence of compensating behavior on the part of the minorities. The results suggest that to redress ethnic inequality, policies need to reach minorities within poor areas and explicitly recognize behavioral patterns that have served them well in the short term, but intensify ethnic differentials in the longer term.
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The impact of disability on household welfare is estimated by equivalence scales using data from the 1986–1987 FES Disability Survey. Three methods of identifying scales from cross-section data are considered; these imply a series of restrictions that are tested on quadratic logarithmic Engel curves. The results indicate that there are substantial consumption costs associated with physical disability.
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Using comparable, nationally representative surveys and extending the work of [Sahn, D. E., & Stifel, D. C. (2000). Poverty comparisons over time and across countries in Africa. World Development, 28(12), 2123–2155], an asset index is used to investigate changes in poverty in seven African countries. Poverty declined in five of the seven countries. Improvements in the asset index are driven by progress in the accumulation of private assets, while access to public services has deteriorated. However, the method has some shortcomings. Assets are slow-changing and discrete. The index therefore may not capture changes in well-being accurately. The poor discrimination ability of the index at the lower end of the scale also makes it an inappropriate tool for studying ultra-poverty.
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We discuss and critique the main lines of economic research that address the economic status and behavior of the working-age population of people with disabilities. We define this population as those with physical or mental limitations that impede their daily activities or their productivity on the job. Using this definition, we assess the prevalence, trend, and composition of the population of disabled working-aged people in the United States and other Western societies, and document the extent of market work among this population. Such market work contributes to the economic well-being of the working-age disabled, but for most of them, income from public transfers and from the earnings of other household members are crucial in determining the level of family economic well-being. Relative to the nondisabled, those with disabilities have substantially lower levels of economic well-being in spite of public income support programs. While public income support is important in sustaining the level of well-being of the disabled, these policies also have serious incentive effects, especially labor supply disincentives. We document these incentive effects in US policy, and review the research studies that estimate the response of disabled people to these incentives. In addition to income support policy, we also describe public policy toward disabled people associated with antidiscrimination legislation, rehabilitation and training programs, income support for poor disabled children, and public regulations and financial support for special education in schools. We conclude by comparing US disability policy with that in other Western industrialized countries and identifying research issues that are relevant to all societies with advanced policies toward working-age people with disabilities.
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We identify determinants of elderly poverty in Vietnam using household survey data from 2004. The elderly living in urban and rural areas face significantly different conditions. Some factors impact poverty in both urban and rural areas (e.g. age, marital status, region and remittance receipts), some factors are insignificant in both areas (e.g. living arrangements and household head characteristics) and some factors have a differing impact in the two areas (e.g. gender, ethnicity, and household composition and size). With these findings, we formulate policy priorities, including reducing regional disparities, promoting the rural economy and reforming social security. Copyright 2009 The Authors. Journal compilation 2009 East Asian Economic Association and Blackwell Publishing Ltd..