Phusit Prakongsai

Catastrophic and poverty impacts of health payments: results from national household surveys in Thailand

OBJECTIVE To estimate the incidence and describe the profile of catastrophic expenditures and impoverishment due to household out-of-pocket payments, comparing the periods before and after the introduction of universal health care coverage (UC). METHODS Secondary data analyses of socioeconomic surveys on nationally representative households pre-UC in 2000 (n = 24,747) and post-UC in 2002 (n = 34,785) and 2004 (n = 34,843). FINDINGS Households using inpatient care experienced catastrophic expenditures most often (31.0% in 2000, compared with 15.1% and 14.6% in 2002 and 2004, respectively). During the two post-UC periods, the incidence of catastrophic expenditures for inpatient services at private hospitals was 32.1% for 2002 and 27.8% for 2004. For those using inpatient care at district hospitals, the corresponding catastrophic expenditures figures were 6.5% and 7.3% in 2002 and 2004, respectively. The catastrophic expenditures incidence for outpatient services from private hospitals moved from 27.9% to 28.5% between 2002 and 2004. In 2000, before universal coverage was introduced, the percentages of Thai households who used private hospitals and faced catastrophic expenditures were 35.8% for inpatient care and 36.0% for outpatient care. Impoverishment increased for poor households because of payments for inpatient services by 84.0% in 2002, by 71.5% in 2004 and by 95.6% in 2000. The relative increase in out-of-pocket impoverishment was found in 98.8% to 100% of those who were poor following payments made to private hospitals, regardless of type of care. CONCLUSION Households using inpatient services, especially at private hospitals, were more likely to face catastrophic expenditures and impoverishment from out-of-pocket payments. Use of services not covered by the UC benefit package and bypassing the designated providers (prohibited under the capitation contract model without proper referrals) are major causes of catastrophic expenditures and impoverishment.

Dual job holding by public sector health professionals in highly resource-constrained settings: problem or solution?

This paper examines the policy options for the regulation of dual job holding by medical professionals in highly resource-constrained settings. Such activity is generally driven by a lack of resources in the public sector and low pay, and has been associated with the unauthorized use of public resources and corruption. It is also typically poorly regulated; regulations are either lacking, or when they exist, are vague or poorly implemented because of low regulatory capacity. This paper draws on the limited evidence available on this topic to assess a number of regulatory options in relation to the objectives of quality of care and access to services, as well as some of the policy constraints that can undermine implementation in resource-poor settings. The approach taken in highlighting these broader social objectives seeks to avoid the value judgements regarding dual working and some of its associated forms of behaviour that have tended to characterize previous analyses. Dual practice is viewed as a possible system solution to issues such as limited public sector resources (and incomes), low regulatory capacity and the interplay between market forces and human resources. This paper therefore offers some support for policies that allow for the official recognition of such activity and embrace a degree of professional self-regulation. In providing clearer policy guidance, future research in this area needs to adopt a more evaluative approach than that which has been used to date.

Equity in maternal and child health in Thailand

OBJECTIVE To assess equity in health outcomes and interventions for maternal and child health (MCH) services in Thailand. METHODS Women of reproductive age in 40 000 nationally representative households responded to the Multiple Indicator Cluster Survey in 2005-2006. We used a concentration index (CI) to assess distribution of nine MCH indicator groups across the household wealth index. For each indicator we also compared the richest and poorest quintiles or deciles, urban and rural domiciles, and mothers or caregivers with or without secondary school education. FINDINGS CHILD UNDERWEIGHT (CI: -0.2192; P < 0.01) and stunting (CI: -0.1767; P < 0.01) were least equitably distributed, being disproportionately concentrated among the poor; these were followed by teenage pregnancy (CI: -0.1073; P < 0.01), and child pneumonia (CI: -0.0896; P < 0.05) and diarrhoea (CI: -0.0531; P < 0.1). Distribution of the MCH interventions was fairly equitable, but richer women were more likely to receive prenatal care and delivery by a skilled health worker or in a health facility. The most equitably distributed interventions were child immunization and family planning. All undesirable health outcomes were more prevalent among rural residents, although the urban-rural gap in MCH services was small. Where mothers or caregivers had no formal education, all outcome indicators were worse than in the group with the highest level of education. CONCLUSION Equity of coverage in key MCH services is high throughout Thailand. Inequitable health outcomes are largely due to socioeconomic factors, especially differences in the educational level of mothers or caregivers.

Why has the Universal Coverage Scheme in Thailand achieved a pro-poor public subsidy for health care?

BackgroundThailand has achieved universal health coverage since 2002 through the implementation of the Universal Coverage Scheme (UCS) for 47 million of the population who were neither private sector employees nor government employees. A well performing UCS should achieve health equity goals in terms of health service use and distribution of government subsidy on health. With these goals in mind, this paper assesses the magnitude and trend of government health budget benefiting the poor as compared to the rich UCS members.MethodBenefit incidence analysis was conducted using the nationally representative household surveys, Health and Welfare Surveys, between 2003 and 2009. UCS members are grouped into five different socio-economic status using asset indexes and wealth quintiles.FindingsThe total government subsidy, net of direct household payment, for combined outpatient (OP) and inpatient (IP) services to public hospitals and health facilities provided to UCS members, had increased from 30 billion Baht (US

Using health technology assessment for informing coverage decisions in Thailand

1 billion) in 2003 to 40-46 billion Baht in 2004-2009. In 2003 for 23% and 12% of the UCS members who belonged to the poorest and richest quintiles of the whole-country populations respectively, the share of public subsidies for OP service was 28% and 7% for the poorest and the richest quintiles, whereby for IP services the share was 27% and 6% for the poorest and richest quintiles respectively. This reflects a pro-poor outcome of public subsidies to healthcare. The OP and IP public subsidies remained consistently pro-poor in subsequent years.The pro-poor benefit incidence is determined by higher utilization by the poorest than the richest quintiles, especially at health centres and district hospitals. Thus the probability and the amount of household direct health payment for public facilities by the poorest UCS members were less than their richest counterparts.ConclusionsHigher utilization and better financial risk protection benefiting the poor UCS members are the results of extensive geographical coverage of health service infrastructure especially at district level, adequate finance and functioning primary healthcare, comprehensive benefit package and zero copayment at points of services.

Promoting universal financial protection: how the Thai universal coverage scheme was designed to ensure equity

This article aims to illustrate and critically analyze the results from the 1-year experience of using health technology assessment (HTA) in the development of the Thai Universal Coverage health benefit package. We review the relevant documents and give a descriptive analysis of outcomes resulting from the development process in 2009-2010. Out of 30 topics nominated by stakeholders for prioritization, 12 were selected for further assessment. A total of five new interventions were recommended for inclusion in the benefit package based on value for money, budget impact, feasibility and equity reasons. Different stakeholders have diverse interests and capabilities to participate in the process. In conclusion, HTA is helpful for informing coverage decisions for health benefit packages because it enhances the legitimacy of policy decisions by increasing the transparency, inclusiveness and accountability of the process. There is room for improvement of the current use of HTA, including providing technical support for patient representatives and civic groups, better communication between health professionals, and focusing more on health promotion and disease prevention.

Challenges in the provision of healthcare services for migrants: a systematic review through providers’ lens

BackgroundEmpirical evidence demonstrates that the Thai Universal Coverage Scheme (UCS) has improved equity of health financing and provided a relatively high level of financial risk protection. Several UCS design features contribute to these outcomes: a tax-financed scheme, a comprehensive benefit package and gradual extension of coverage to illnesses that can lead to catastrophic household costs, and capacity of the National Health Security Office (NHSO) to mobilise adequate resources. This study assesses the policy processes related to making decisions on these features.MethodsThe study employs qualitative methods including reviews of relevant documents, in-depth interviews of 25 key informants, and triangulation amongst information sources.ResultsContinued political and financial commitments to the UCS, despite political rivalry, played a key role. The Thai Rak Thai (TRT)-led coalition government introduced UCS; staying in power 8 of the 11 years between 2001 and 2011 was long enough to nurture and strengthen the UCS and overcome resistance from various opponents. Prime Minister Surayud’s government, replacing the ousted TRT government, introduced universal renal replacement therapy, which deepened financial risk protection.Commitment to their manifesto and fiscal capacity pushed the TRT to adopt a general tax-financed universal scheme; collecting premiums from people engaged in the informal sector was neither politically palatable nor technically feasible. The relatively stable tenure of NHSO Secretary Generals and the chairs of the Financing and the Benefit Package subcommittees provided a platform for continued deepening of financial risk protection. NHSO exerted monopsonistic purchasing power to control prices, resulting in greater patient access and better systems efficiency than might have been the case with a different design.The approach of proposing an annual per capita budget changed the conventional line-item programme budgeting system by basing negotiations between the Bureau of Budget, the NHSO and other stakeholders on evidence of service utilization and unit costs.ConclusionsFuture success of Thai UCS requires coverage of effective interventions that address primary and secondary prevention of non-communicable diseases and long-term care policies in view of epidemiologic and demographic transitions. Lessons for other countries include the importance of continued political support, evidence informed decisions, and a capable purchaser organization.

Improving Health-Related Information Systems to Monitor Equity in Health: Lessons from Thailand

BackgroundIn recent years, cross-border migration has gained significant attention in high-level policy dialogues in numerous countries. While there exists some literature describing the health status of migrants, and exploring migrants’ perceptions of service utilisation in receiving countries, there is still little evidence that examines the issue of health services for migrants through the lens of providers. This study therefore aims to systematically review the latest literature, which investigated perceptions and attitudes of healthcare providers in managing care for migrants, as well as examining the challenges and barriers faced in their practices.MethodsA systematic review was performed by gathering evidence from three main online databases: Medline, Embase and Scopus, plus a purposive search from the World Health Organization’s website and grey literature sources. The articles, published in English since 2000, were reviewed according to the following topics: (1) how healthcare providers interacted with individual migrant patients, (2) how workplace factors shaped services for migrants, and (3) how the external environment, specifically laws and professional norms influenced their practices. Key message of the articles were analysed by thematic analysis.ResultsThirty seven articles were recruited for the final review. Key findings of the selected articles were synthesised and presented in the data extraction form. Quality of retrieved articles varied substantially. Almost all the selected articles had congruent findings regarding language andcultural challenges, and a lack of knowledge of a host countrys health system amongst migrant patients. Most respondents expressed concerns over in-house constraints resulting from heavy workloads and the inadequacy of human resources. Professional norms strongly influenced the behaviours and attitudes of healthcare providers despite conflicting with laws that limited right to health services access for illegal migrants.DiscussionThe perceptions, attitudes and practices of practitioners in the provision of healthcare services for migrants were mainly influenced by: (1) diverse cultural beliefs and language differences, (2) limited institutional capacity, in terms of time and/or resource constraints, (3) the contradiction between professional ethics and laws that limited migrants’ right to health care. Nevertheless, healthcare providers addressedsuch problems by partially ignoring the immigrants’precarious legal status, and using numerous tactics, including seeking help from civil society groups, to support their clinical practice.ConclusionIt was evident that healthcare providers faced several challenges in managing care for migrants, which included not only language and cultural barriers, but also resource constraints within their workplaces, and disharmony between the law and their professional norms. Further studies, which explore health care management for migrants in countries with different health insurance models, are recommended.

Universal Coverage on a Budget: Impacts on Health Care Utilization and Out-of-Pocket Expenditures in Thailand

In 2001, Thailand achieved universal coverage in access to health care. This led to a more equitable health care system, and a significant impact on the reduction in household out-of-pocket payments for health care. Empirical evidence from health information systems shows that there is now more equitable health care use across economic strata, the pro-poor nature of health care subsidies, especially for district health services provided by the Ministry of Public Health (MOPH), and a further reduction in the incidence of catastrophic and poverty impacts of health care expenditure. This is in line with the results of opinion surveys of public health administrators nationwide. The country-initiated National Health Accounts (NHA) compiled since 1994, are the backbone of resource tracking according to health care functions. In addition to the time-series NHA, monitoring and evaluation of equity in health care financial contributions is possible because of the long-standing, nationally representative household surveys conducted by the National Statistical Office (NSO), namely the Socio-Economic Survey (SES) and Health and Welfare Survey (HWS). Based on trust and mutual recognition and interests, a genuine partnership to improve the policy utility and equity monitoring capability of these two national databases has been fostered between the main user (MOPH) and data producer (NSO). Other large-scale regular surveys, conducted by health research institutes and various departments in the MOPH, contain quantitative data on health service use, payments for health care services, illnesses and health conditions and general and specific health behaviour. Other major data sources include disease surveillance and registry systems, and information on health care use in administrative data and routine reports, which all suffer from a lack of data on the social determinants of health. The time-series NSO national datasets have ample parameters for monitoring health equity and are a real national asset in Thailand for evidence-based, equity-related policy formulation and evaluation.

Innovative Financing of Health Promotion

We estimate the impact on health care utilization and out-of-pocket (OOP) expenditures of a major reform in Thailand that extended health insurance to one-quarter of the population to achieve universal coverage while keeping health spending below 4% of GDP. Identification is through comparison of changes in outcomes of groups to whom coverage was extended with those of public sector employees and their dependents whose coverage was not affected. The reform is estimated to have reduced the probability that a sick person goes without formal treatment by 3.2 percentage points (11%). It increased the probability of receiving public ambulatory care by 2.7 ppt (5%) and of admission to a public hospital by 1 ppt (18%). OOP expenditures were reduced by one-third on average, as was the probability of spending more than 10% of the household budget on health care, while spending at the very top of the OOP distribution was reduced by one-half representing substantial reductions in exposure to medical expenditure risk. Supply-side measures implemented with the coverage extension are likely to have helped realize these effects from an increased, but still very tight, budget.