Supasit Pannarunothai

The poor pay more: health-related inequality in Thailand.

This paper examines the equality of utilization for equal need and equity of out-of-pocket expenditure for health services in a large urban area in Thailand. Data from a household health interview survey were used to explore patterns of perceived morbidity, utilization of various treatment sources, and out-of-pocket payment. Financial access to health care, as reflected in medical benefit/ insurance cover, appeared to influence reported illness and hospitalization rates. Gross lack of access to health care amongst lower socio-economic groups was not the main problem in this densely populated urban area because people could choose and use alternative health services according to their ability and willingness to pay. The corollary, however, was an inequitable pattern of out-of-pocket health expenditure by income quintile and per capita. The underprivileged were more likely to pay out of their own pocket for their health problems, and to pay out of proportion to their household income when compared with more privileged groups. Furthermore, the underprivileged were least likely to be covered by government health benefit schemes, in contrast in particular to civil servants, who paid less out of pocket and did not contribute to their medical benefit fund. The private health sector (private clinics and private hospitals) was the major provider of health care to urban dwellers for both outpatient and inpatient services. Policy options for the short and long term to improve the equity of payment systems for health care are discussed.

An evidence-based approach to benchmarking the fairness of health-sector reform in developing countries

The Benchmarks of Fairness instrument is an evidence-based policy tool developed in generic form in 2000 for evaluating the effects of health-system reforms on equity, efficiency and accountability. By integrating measures of these effects on the central goal of fairness, the approach fills a gap that has hampered reform efforts for more than two decades. Over the past three years, projects in developing countries on three continents have adapted the generic version of these benchmarks for use at both national and subnational levels. Interdisciplinary teams of managers, providers, academics and advocates agree on the relevant criteria for assessing components of fairness and, depending on which aspects of reform they wish to evaluate, select appropriate indicators that rely on accessible information; they also agree on scoring rules for evaluating the diverse changes in the indicators. In contrast to a comprehensive index that aggregates all measured changes into a single evaluation or rank, the pattern of changes revealed by the benchmarks is used to inform policy deliberation aboutwhich aspects of the reforms have been successfully implemented, and it also allows for improvements to be made in the reforms. This approach permits useful evidence about reform to be gathered in settings where existing information is underused and where there is a weak information infrastructure. Brief descriptions of early results from Cameroon, Ecuador, Guatemala, Thailand and Zambia demonstrate that the method can produce results that are useful for policy and reveal the variety of purposes to which the approach can be put. Collaboration across sites can yield a catalogue of indicators that will facilitate further work.

Policy characteristics facilitating primary health care in Thailand: A pilot study in transitional country

BackgroundIn contrast to the considerable evidence of inequitable distribution of health, little is known about how health services (particularly primary care services) are distributed in less developed countries. Using a version of primary health care system questionnaire, this pilot study in Thailand assessed policies related to the provision of primary care, particularly with regard to attempts to distribute resources equitably, adequacy of resources, comprehensiveness of services, and co-payment requirement. Information on other main attributes of primary health care policy was also ascertained.MethodsQuestionnaire survey of 5 policymakers, 5 academicians, and 77 primary care practitioners who were attending a workshop on primary care. Descriptive statistics with Fischers exact test were used for data analysis.ResultsAll policymakers and academicians completed the mailed questionnaire; the response rate among the practitioners was 53.25% (41 out of 77). However, the responses from all three groups were consistent in reporting that (1) financial resources were allocated based on different health needs and special efforts were made to assure primary care services to the needy or underserved population, (2) the supply of essential drugs was adequate, (3) clinical services were distributed equitably, (4) out-of-pocket payment was low, and that some primary health care attributes, particularly longitudinality (patients are seen by same doctor or team each time they make a visit), coordination, and family- and community-orientation were satisfactory. Geographical variations were present, suggesting inequitable distribution of primary care across regions. The questionnaire was robust across key stakeholders and feasible for use in a transitional country.ConclusionA primary care systems questionnaire administered to different types of health professionals was able to show that resource distribution was equitable at a national level but some aspects of primary care practice across regions is still of concern, in at least in this transitional country.

Rehabilitation service development for Sub-Acute and Non-Acute Patient (SNAP) under universal coverage scheme in Thailand

The need of rehabilitation in sub-acute and non-acute patients has been continuously increased. Rehabilitation services in Thailand are considered only as part of acute care so that the providers are not motivated to provide intensive services to patients because the payment based on diagnosis related group focuses on acute phase. This study aimed to develop an appropriate model for SNAP Casemix including in-patient, out-patient, and home based care in 4 groups of patients: stroke, brain dysfunction (traumatic and non-traumatic), spinal cord dysfunction (traumatic and non-traumatic) and major multiple trauma. The expected results are improvement of accessibility, continuity, quality of care as well as the proper payment and information of activities, unit costs. Fifty five hospitals in five provinces were recruited voluntarily to develop rehabilitation services both facility-based and home-based care, referral system, structure, payment, information system etc. Three development steps were set up as follows: 1) setting the new desirable system, 2) implementation of the new system (according to context of each province) and 3) evaluation. The effectiveness will be assessed through functional status and quality of life gained compared to set target. The efficiency studies consist of cost per patient, cost per DRG and cost recovery. Barthel Index (assessment of 10 functions: feeding, transfer, grooming, toilet use, bathing, mobility, stairs climbing, dressing, bowels, and bladder) and EQ5D (Assessment of quality of life in 5 dimensions including: mobility, self-care, usual activities, pain/discomfort and anxiety/depression) will be used for functional assessment. The study will go on for 18 months.

Treatment seeking and health financing in selected poor urban neighbourhoods in India, Indonesia and Thailand

This article presents a comparative analysis of socio-economic disparities in relation to treatment-seeking strategies and healthcare expenditures in poor neighbourhoods within larger health systems in four cities in India, Indonesia and Thailand. About 200 households in New Delhi, Bhubaneswar, Jogjakarta and Phitsanulok were repeatedly interviewed over 12 months to relate health problems with health seeking and health financing at household level. Quantitative data were complemented with ethnographic studies involving the same neighbourhoods and a number of private practitioners at each site. Within each site, the higher and lower income groups among the poor were compared. The lower income group was more likely than the higher income group to seek care from less qualified health providers and incur catastrophic health spending. The study recommends linking quality control mechanisms with universal health coverage (UHC) policies; to monitor the impact of UHC among the poorest; intervention research to reach the poorest with UHC; and inclusion of private providers without formal medical qualification in basic healthcare.

Harmonization of three public health insurance schemes on emergency medical services

Materials and methods The study used a telephone interview survey with semistructured questionnaire. The population sample was selected by using simple random sampling with personal identification number of emergency patients who accessed health services under the policy during August-October 2012, and were also in the Emergency Claim online (EMCO) database. There were 292 emergency patients who were interviewed, which consisted of 105 cases of Universal Coverage Scheme, 95 cases of Social Security Scheme, and 92 cases of Civil Servant Medical Benefit Scheme.

Public expenditure on road safety policy and programmes: right or wrong direction to achieve the decade of action on road safety goal in Thailand

Materials and methods The government budget documents from 5 ministries including Ministry of Transport, Education, Interior, Public Health and Royal Thai Police were reviewed. Two researchers identified budget used in road safety projects with 5-E strategies independently; the kappa analysis was used to test inter-rater reliability. Information from Thai Health Promotion Foundation and Road Safety Fund was also gathered using a developed excel-based template. Semi-structured interviews were conducted among road safety experts. Some mathematical and statistical analyses were applied to evaluate the efficiency of road safety policy.

Economic Evaluation of Rehabilitation Services for Inpatients with Stroke in Thailand: A Prospective Cohort Study

OBJECTIVE Rehabilitation can restore function and prevent permanent disability in patients with stroke. There is, however, only one study on cost-effectiveness of rehabilitation in Thailand. Our objective was to evaluate the cost-utility of rehabilitation for inpatients with stroke under Thai settings. METHODS This was a prospective observational cohort study with a 4-month follow-up in two regional hospitals. The sample consisted of 207 first-episode stroke inpatients divided into rehabilitation and unexposed groups. Rehabilitation services during the subacute and nonacute phase were the intervention of concern. Main outcomes were patients Barthel index for functional status and the EuroQol five-dimensional questionnaire as utility scores. A microcosting approach was employed considering a societal perspective. Effectiveness was defined as the improvement in functional status and quality-adjusted life-year (QALY). We used a longitudinal logistic model and multiple regressions. Cost-effectiveness ratios per QALY gained were presented. A probabilistic sensitivity analysis was conducted to estimate the uncertainty range. RESULTS Compared with the unexposed group, the Barthel index and QALY of patients with rehabilitation were significantly improved (P < 0.010). The incremental cost-effectiveness ratio of rehabilitation services for patients with stroke was 24,571 baht per QALY. Cost-effectiveness acceptability curves suggested that the rehabilitation services were likely to represent good value for money at the ceiling ratio of 70,000 baht per QALY (compared with the threshold of 1 time per-capita gross domestic product per QALY gain or 100,000 baht per QALY). CONCLUSION The rehabilitation services for stroke survivors were cost-effective under the Thai health care setting.

Casemix adjustment for outpatient service: a tool for resource allocation of social security population in Thailand

Address: 1Faculty of Pharmaceutical Sciences, Naresuan University, Phitsanulok, Thailand and Centre for Health Equity Monitoring, Faculty of Medicine, Naresuan University, Phitsanulok, Thailand, 2Centre for Health Equity Monitoring, Faculty of Medicine, Naresuan University, Phitsanulok, Thailand, 3National Health Security Office, Nonthaburi, Thailand and 4Social Security Office, Nonthaburi, Thailand

Unfinished health systems and policy research agendas for ASEAN Economic Community

This Postgraduate Forum was originally a platform for postgraduate students in health systems and policy of Gadjah Mada University, Universiti Kebangsaan Malaysia, United Nations University International Institute for Global Health and Naresuan University to meet annually to exchange their research studies to strengthen their capacities in involving health policies in their countries. In 2013, the forum is taking place at Naresuan University to set the agenda for the 2015 target of economic integration among member countries of the Association of Southeast Asian Nations. The target is imminent, but the groundwork for the health systems and policy research of the AEC is limited. More collaborative works should be mapped to enhance good integration of economic policy with good health impacts especially for the vulnerable groups. More countries are welcome to join the forum for the most attainable health benefits of all members.