Our study clarified the health-seeking behaviors, especially in chronic disease and related financial burdens of households in Bolikhamxay province, one of the provinces in Loa PDR where all individuals are covered by the current NHI system. Regarding the positive aspects of the NHI, most patients (non-chronic 69.9%, chronic 78.8%) said that they visited a health facility for treatment. Still, our study does not clarify whether this trend is an effect of the NHI because we did not have data from before NHI. Still, we highlight that in Bolikhamxay province, where the NHI has been implemented, more than 75% of the households in the poorer income household group visited a health facility when one of the members had an illness, even though there are some gaps between income groups. Our study concurs with two past studies conducted in a different province [16–17] that found NHI has had positive impacts on access to health care.
Nonetheless, this study found financial problems for households under the current NHI scheme. We observed that 25% and 16% of the households with at least one member with any self-reported health problem were found to be experiencing CHE (20%) and serious CHE (40%) per month, respectively. Furthermore, CHE was more likely to occur in households with at least one member with a chronic disease and hospitalization. Out-of-pocket health expenditure for chronic and severe diseases was found to be a big burden on households, especially poorer ones, and it is very important for the design of future CHE prevention interventions to take these factors into account [37–40]. Hence, our evidence indicates that the financial burden of households under the NHI remain high, especially when they have a member with a chronic and/or severe disease. Moreover, our analysis of sample demographics showed that even among households covered by the NHI system, the reality is that out-of-pocket health expenditure is greatly polarized between small payments (i.e., within the value covered by the NHI) and very large payments (i.e., which greatly exceeds the value covered by the NHI) among the households.
We offer the following reasons for these results. First, there are many households who prefer or may be forced to visit private facilities, because our result showed that households with members who used private facilities are more likely in CHE than those who used only public facilities. A previous study confirms this assumption; it showed that people in Lao PDR preferred to utilize private health services as their first choice regardless of socioeconomic status, opting for private clinics and treatment abroad for those with high socioeconomic status , and utilization of government services is low, with a high likelihood of an individual seeking care from a modern health provider when ill . Another study found that many people from Lao PDR sometimes use health services from Thailand provinces, where most health workers speak Isan Thai (a dialect of the Lao language) as their native tongue . Furthermore, our results demonstrated that a large percentage of the households chose to visit private facilities in foreign countries, even with NHI coverage. For these households, we hypothesize that the members may have diseases that are difficult to treat, or can only be treated in private facilities, or it could be that people still preferred to use private facility even if costlier and not covered by NHI. Therefore, to avoid CHE in Lao PDR households covered by the NHI, we see the need for stakeholders to ensure that effective treatment of these differential, and often more complex, patients can be provided at facilities covered by the NHI scheme. To achieve that, they need to find ways to attract the population and increase their willingness to visit public facilities, mainly by improving service quality and coverage in public hospitals.
Furthermore, our study revealed that, among patients with NCDs, the proportion of main NCDs was relatively lower than that of other NCDs. Nonetheless, we highlight that the variety of diseases  among the households that had at least one member who visited a health facility in our sample was quite large. Thus, we suggest that local public hospitals strengthen their human and structural resources to ensure that they can deliver care to all patients.
Our results also showed that many households experienced CHE even at public hospitals. This may be due to the existence of additional costs related to visiting a health facility that go beyond those covered by the NHI co-payment scheme, including the indirect transportation costs. Previous research has also pointed out the existence of additional expenditures for patients visiting public health facilities, including those related to medications or supplies not available at the public health facilities or not covered by the NHI .44], Thus, to prevent CHE among households covered by the NHI, we see the need to expand the scope of the insurance coverage, especially for chronic patients (mainly those with NCDs), who require more complex and often prolonged treatments.
Among chronic patients in our sample, most visited the provincial, top referral hospital; importantly, there is only one such hospital in Bolikhamxay province. This denotes that travelling to the hospital entails a high cost (both in time and money) for some households [44, 45]. Coupled with the abovementioned CHE rate, this becomes a critical area of concern for stakeholders. For achieving UHC, primary care must be emphasized . However, this emphasis in primary care may lead patients to continue to suffer from complex and/or life-threatening problems if they are not referred to higher level facilities, especially in aging societies, such as that of Lao PDR [47, 48]. These patients require advanced treatment, which often entails high costs and leads to CHE. Hence, we see the need for stakeholders to place additional focus on methods for providing NHI patients with advanced care while considering the realistic financial situation, and constraints of the NHI. The results of the study, which show that the groups in medical expenditure and ratio of medical expenditure to income are polarized, suggest the importance of supporting high medical expenditures. For example, in the Japanese NHI, not only is there a set percentage (10–30%) for co-payments by treatment but also a maximum amount of total co-payment per month called “ceiling amount application” . We see the possibility of considering a similar financial system for the NHI in Laos PDR, which may help prevent CHE among households with chronic patients.
To achieve UHC, it is important to enhance population and service coverage, as well as financial protection. In Lao PDR, the NHI was initially introduced with the aim of covering the entire population of the specific provinces in which it was implemented, as well as to provide financial protection through a fixed payment system. Nonetheless, this aim did not necessarily consider the enhancement of service provision; accordingly, we believe that the potential preventive effect of NHI on CHE was limited.
Even in poor households, it is common for people to seek better medical services when they become sick. Our findings underpin that CHE was more likely to occur in households with lower incomes. Similarly, previous international studies have highlighted the importance of ensuring a reasonable distribution of health services across different community-based and socioeconomic strata, especially for patients with chronic diseases . Accordingly, our discussion suggests that the NHI requires additional improvements regarding health facility placement; patients especially need to be able to access reasonably located health facilities that deliver quality services. This is valid for facilities aimed at treating chronic patients, which often require long-term and frequent care delivery. To achieve UHC in Lao PDR, the government needs to take a comprehensive approach related to the NHI that better reflects its current situation.
This study has some limitations. First, we obtained information regarding household finance (i.e., health expenditure and income) by interviewing the household heads; this methodology may have caused issues regarding data preciseness. Second, diagnoses based on self-reporting was included for those who did not visit a health facility, and estimates (prevalence) were not weighted to obtain province-representative evidence, and a longitudinal design was not followed to assess the difference between pre and post NHI situations.
Nevertheless, to the best of our knowledge, this is the first study to investigate the health-seeking behaviors and financial burdens of households covered by the NHI in Lao PDR, including those with chronic patients. Most past studies related to the NHI in Lao PDR were conducted by targeting only patients who visited health facilities ; their study design did not allow for collecting evidence from patients who did not visit or could not access a health facility. We felt it was important to understand the situation of households who did not/could not visit health facilities for assessing the effectiveness of interventions aimed at achieving UHC, such as the NHI in Lao PDR. This is because the main purpose of the NHI is to improve the access of the general population to health facilities while ensuring they do not incur major financial burdens related to health care.
In conclusion, our results provide a clear picture of the current status of the general population in provinces covered by the NHI regarding access to health services and their financial burden. We hope that our evidence provides a valuable theoretical framework for stakeholders and policymakers, who may use our data to conduct well-informed decision-making that facilitates the achievement of UHC in the future of Lao PDR.