Association Between User Fees and Dropout from Methadone Maintenance Therapy: Results of a Cohort Study in Vietnam

Figures & data

TABLE 1. Characteristics of Patients by Provincial User Fee Policy

		No User Fee Policy		User Fee Policy
Variable	n	Mean/Percentage	SE	Mean/Percentage	SE	p
Clinical
Dropped out of MMT care	1,005	7%	1.3%	5%	1.1%	0.34
Not retained in MMT care	1,009	12%	1.6%	12%	1.6%	0.88
Length of time on MMT before entering study	1,021					<0.001^***
One month or less		2%	0.6%	19%	1.9%
Less than one month to two months		7%	1.3%	10%	1.5%
Less than two months to three months		2%	0.6%	2%	0.5%
Less than three months to six months		30%	2.1%	16%	1.8%
Less than six months to 12 months		28%	2.2%	27%	2.1%
>12 months to 24 months		31%	2.0%	26%	2.2%
Methadone dosage at three months of MMT (mg)						<0.001^***
Less than 60		33%	2.5%	20%	1.9%
60 or more		63%	2.5%	72%	2.3%
Missing		4%	0.7%	7%	1.6%
Number of clients per clinic staff working in MMT clinic	35	8	1.0	16	2.8	0.01^*
Number of clients per clinic staff working in typical day	35	12	1.4	25	3.0	<0.001^***
Proportion of new staff to total staff	35	0.64	0.10	0.53	0.04	0.27
Proportion of staff trained on MMT to staff in MMT clinic	35	1.32	0.04	1.17	0.1	0.04^*
Year clinic opened	35					0.06
2008 to 2010		15%	8.2%	33%	12.6%
2011 to 2012		25%	9.9%	33%	12.6%
2013 to 2014		60%	11.2%	33%	12.6%
Open before 7 am (% yes)	35	75%	9.9%	80%	10.7%	0.73
Open in afternoon (% yes)	35	30%	10.5%	27%	11.8%	0.83
Financial
Travel more than 30 minutes (one way) to MMT clinic	1,021	18%	1.9%	7%	1.2%	<0.001^***
Amount paid for transport to MMT clinic at baseline (VND thousands)	1,021	16.4	7.5	29.7	23.1	0.48
Household expenditures at baseline (annual VND thousands)	1,021	19,587	1,487	11,607	900	0.009^**
Income below poverty line at baseline	1,021	32%	2.6%	48%	2.6%	<0.001^***
Socioeconomic
Age (years)	1,021	37.7	0.5	34.7	0.5	<0.001^***
Sex (percentage female)	1,021	1%	0.5%	4%	1.0%	0.03^*
Marital status at baseline	1,021					<0.001^***
Single		24%	2.4%	38%	2.5%
Married/long-term partner		64%	2.6%	46%	2.6%
Widowed/divorced/separated		12%	1.7%	16%	2.1%
Highest education achieved at baseline	1,021					0.003^**
No qualification		7%	1.4%	10%	1.7%
Primary school		21%	2.3%	32%	2.5%
Secondary/high school		62%	2.6%	55%	2.8%
Higher than high school		10%	1.7%	3%	1.1%
Employment status at baseline	1,021					<0.001^***
Full-time employment		22%	2.2%	27%	2.2%
Part-time employment		13%	1.9%	12%	1.7%
Self-employed		23%	2.3%	10%	1.6%
Not working (seeking or not)		23%	2.2%	23%	2.4%
Homemaker, retired, student		18%	1.9%	27%	2.1%
Change of employment status in year before start of study		32%	2.5%	39%	2.7%	0.053
Size of household (baseline)	1,021	5.0	0.1	5.0	0.1	0.54
HIV status at baseline (self-reported): Positive	1,021	21%	2.2%	31%	2.5%	0.005^**

* p < 0.05.

** p < 0.01.

*** p < 0.001.

FIGURE 1. Kaplan-Meier Survival Curves for Client Dropout, by Province and User Fee Status. Light-Colored Lines Indicate a Province with User Fees; Dark Lines Indicate a Province without User Fees

TABLE 2. Results of the Cox Survival Regression Analyses^a

	Model 1		Model 2		Model 3
Variable	Hazard Ratio (95% CI)	p	Hazard Ratio (95% CI)	P	Hazard Ratio (95% CI)	p
Clinical
Province had user fee policy
No
Yes	0.17 (0.02–1.29)	0.08	0.42 (0.06–3.15)	0.39	0.15 (0.02–1.06)	0.06
Length of time on MMT before entering study
>12 months to 24 months
One month or less	0.18 (0.03–1.12)	0.07	0.48 (0.05–4.67)	0.51	0.19 (0.03–1.05)	0.06
Less than one month to three months	0.53 (0.17–1.67)	0.27	0.62 (0.20–1.93)	0.39	0.55 (0.17–1.75)	0.30
Less than three months to 12 months	0.93 (0.43–2.02)	0.85	0.82 (0.40–1.68)	0.57	0.99 (0.45–2.17)	0.97
Methadone dosage at three months of MMT (mg)
60 or more
Less than 60	1.36 (0.56–3.29)	0.48	1.56 (0.64–3.79)	0.31	1.31 (0.54–3.22)	0.54
Missing	0.47 (0.10–2.12)	0.31	0.35 (0.07–1.69)	0.18	0.47 (0.11–2.08)	0.31
Number of clients per clinic staff working in MMT clinic			0.99 (0.97–1.02)	0.48
Proportion of new staff to total staff			4.15 (0.41–41.75)	0.22
Proportion of staff trained on MMT to staff in MMT clinic			0.27 (0.02–4.77)	0.36
Year clinic opened
2008 to 2010
2011 to 2012			0.45 (0.15–1.40)	0.16
2013 to 2014			1.85 (0.41–8.30)	0.41
Open before 7 am (% yes)
No
Yes			0.79 (0.14–4.38)	0.78
Open in afternoon (% yes)
No
Yes			0.97 (0.26–3.58)	0.96
Financial
Travel more than 30 minutes (one way) to MMT clinic
No
Yes	1.50 (0.51–4.42)	0.45	1.67 (0.57–4.94)	0.34	1.53 (0.51–4.62)	0.43
Amount paid for transport to MMT clinic at baseline (VND thousands)	1.04 (0.69–1.57)	0.85	0.99 (0.7–1.41)	0.97	1.02 (0.68–1.53)	0.92
Household expenditures at baseline (annual VND thousands)	0.95 (0.91–0.99)	0.03^*	0.96 (0.92–1.00)	0.04^*	0.95 (0.90–0.99)	0.03^*
Income below poverty line at baseline
No
Yes	1.17 (0.48–2.84)	0.72	1.20 (0.47–3.06)	0.69	0.94 (0.34–2.62)	0.90
Interaction between poverty (yes) and user fees (yes)					2.47 (0.47–13.00)	0.27
Socioeconomic
Age (years)
30–40
<30	1.58 (0.68–3.65)	0.27	1.36 (0.56–3.28)	0.48	1.63 (0.71–3.72)	0.24
>40	0.74 (0.28–1.99)	0.54	0.64 (0.25–1.66)	0.35	0.73 (0.27–1.97)	0.53
Sex (percentage female)
Male
Female	3.05 (0.41–22.50)	0.26	2.74 (0.35–21.28)	0.32	2.43 (0.28–21.14)	0.41
Marital status at baseline
Widowed/divorced/separated
Single	0.79 (0.30–2.12)	0.63	0.71 (0.24–2.08)	0.52	0.76 (0.28–2.04)	0.57
Married/long-term partner	0.29 (0.10–0.80)	0.02^*	0.30 (0.11–0.87)	0.03^*	0.28 (0.10–0.77)	0.02^*
Highest education achieved at baseline
Secondary/high school or more
Less than secondary school	1.26 (0.51–3.12)	0.61	1.15 (0.48–2.79)	0.75	1.21 (0.49–2.99)	0.67
Employment status at baseline
Full time, part time, or self-employment
Homemaker, retired, student	2.78 (1.54–4.99)	0.001^**	2.21 (1.09–4.47)	0.03^*	2.81 (1.53–5.17)	0.002^**
Not working (seeking or not)	0.49 (0.16–1.45)	0.19	0.46 (0.16–1.33)	0.14	0.47 (0.16–1.39)	0.17
Change of employment status in year before start of study
No
Yes	0.83 (0.41–1.68)	0.60	1.11 (0.55–2.23)	0.77	0.84 (0.42–1.68)	0.60
Size of household (baseline)	0.83 (0.07–0.97)	0.02^*	0.85 (0.73–1.00)	0.05^*	0.82 (0.69–0.97)	0.02^*
HIV status at baseline (self-reported): Positive
No
Yes	0.24 (0.09–0.66)	0.008^**	0.31 (0.13–0.75)	0.01^*	0.23 (0.08–0.67)	0.008^**

^a All models control for provincial fixed effects; model 1 and model 3 additionally control for facility fixed effects (results not shown).

* p < 0.05.

** p < 0.01.

*** p < 0.001.

TABLE 3. Catastrophic Payments Associated with Heroin and MMT

		Provinces with User Fees			Provinces without User Fees
Variable	n	Percentage	95% CI	n	Percentage	95% CI		p
Proportion with catastrophic payments for MMT at baseline, based on percentage of nonsubsistence expenditures
40%		15%	10%–19%		12%	8%–16%		0.38
30%		18%	13%–23%		14%	10%–19%		0.21
20%		23%	18%–28%		16%	12%–21%		0.07
Proportion with catastrophic payments for MMT at endline, based on percentage of nonsubsistence expenditures	368			358
40%		29%	23%–35%		11%		7%–16%	<0.001^***
30%		37%	31%–42%		13%		8%–18%	<0.001^***
20%		48%	43%–53%		15%		10%–20%	<0.001^***

*** p < 0.001.