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Since 2002, Thailand's Universal Coverage Scheme (UCS) has adopted a comprehensive benefits package with few exclusions. A positive-list approach has gradually been applied, with pre-exposure prophylaxis (PrEP) of HIV recently being included. Disagreements resulting from competing values and diverging interests necessitate an emphasis on procedural fairness when making any decisions. This qualitative study analyses agenda setting, policy formulation and early implementation of PrEP from a procedural fairness lens. Literature reviews and in-depth interviews with 13 key stakeholders involved in PrEP policy processes were conducted. Civil society organizations (CSOs) and academia piloted PrEP service models and co-produced evidence on programmatic feasibility and outcomes. Through a broad stakeholder representation process, the Department of Disease Control proposed PrEP for inclusion in UCS benefits package in 2017. PrEP was shown to be cost-effective and affordable through rigorous health technology assessment, peer review, use of up-to-date evidence and safe-guards against conflicts of interest. In 2021, Thailand's National Health Security Board decided to include PrEP as a prevention and promotion package, free of charge, for the populations at risk. Favourable conditions for procedural fairness were created by Thailand's legislative provisions that enable responsive governance, notably inclusiveness, transparency, safeguarding public interest and accountable budget allocations; longstanding institutional capacity to generate local evidence; and implementation capacity for realisation of procedural fairness criteria. Multiple stakeholders including CSOs, academia and the government deliberated in the policy process through working groups and sub-committees. However, a key lesson from Thailand's deliberative process concerns a possible 'over interpretation' of conflicts of interest, intended to promote impartial decision-making, which inadvertently limited the voices of key populations represented in the decision processes. Finally, this case study underscores the value of examining the full policy cycle when assessing procedural fairness, since some stages of the process may be more amenable to certain procedural criteria than others.
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Infecciones por VIH , Profilaxis Pre-Exposición , Humanos , Tailandia , Cobertura Universal del Seguro de Salud , Atención a la Salud , Infecciones por VIH/prevención & control , Infecciones por VIH/tratamiento farmacológicoRESUMEN
Background: Additional billing is commonly and legally practiced in some countries for patients covered by health insurance. However, knowledge and understanding of the additional billings are limited. This study reviews evidence on additional billing practices including definition, scope of practice, regulations and their effects on insured patients. Methods: A systematic search of the full-text papers that provided the details of balance billing for health services, written in English, and published between 2000 and 2021 was carried out in Scopus, MEDLINE, EMBASE and Web of Science. Articles were screened independently by at least 2 reviewers for eligibility. Thematic analysis was applied. Results: In total, 94 studies were selected for the final analysis. Most of the included articles (83%) reported findings from the United States (US). Numerous terms of additional billings were used across countries such as balance billing, surprise billing, extra billing, supplements and out-of-pocket (OOP) spending. The range of services incurred these additional bills also varied across countries, insurance plans, and healthcare facilities; the frequently reported were emergency services, surgeries, and specialist consultation. There were a few positive though more studies reported negative effects of the substantial additional bills which undermined universal health coverage (UHC) goals by causing financial hardship and reducing access to care. A range of government measures had been applied to mitigate these adverse effects, but some difficulties still exist. Conclusion: Additional billings varied in terms of terminology, definitions, practices, profiles, regulations, and outcomes. There were a set of policy tools aimed to control substantial billing to insured patients despite some limitations and challenges. Governments should apply multiple policy measures to improve financial risk protection to the insured population.
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Partnerships, particularly, South-South and Triangular Cooperation play an important role in the 2030 Agenda for Sustainable Development. The Partnership Project for Global Health and Universal Health Coverage (UHC) between Japan and Thailand (the Project) was launched in 2016 as a four-year flagship project for Triangular Cooperation and continued to the second phase in 2020. Participating countries include Asian and African countries who are striving to drive global health and to move towards UHC. However, the COVID-19 pandemic has made coordination of partnerships more difficult. The Project needed to find a "new normal" approach to conduct our collaborative work. Struggling with public health and social measures for COVID-19 has made us more resilient and has increased opportunities to collaborate more closely. In the past year and a half, during the COVID-19 pandemic, the Project successfully conducted a number of online activities between Thailand and Japan and with other countries on global health and UHC. Our "new normal" approach led continuing dialogue of networking both at the project implementation and policy levels, focusing on desk-based activities regarding the targets and the objectives of the project and creating a golden opportunity for pursuing a timely second phase. Our lessons learned include as follows: i) Closer prior consultation is required to hold satisfactory online meetings; ii) Effective "new normal" approaches include emphasizing practical and interactive discussions on each countrys priority issues and expanding target participants; iii) Commitment, trust, teamwork, and sharing common goals can enhance and sustain partnerships, especially amid the pandemic.
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This article is part of the Research Topic 'Health Systems Recovery in the Context of COVID-19 and Protracted Conflict'. The third quarter of 2022 saw COVID-19 cases and deaths in Thailand reduced significantly, and high levels of COVID-19 vaccine coverage. COVID-19 was declared an "endemic" disease, and economic activities resumed. This paper reviews pre-pandemic health systems capacity and identifies pandemic response strengths, weaknesses and lessons that guided resilient and equitable health system recovery. Robust health systems and adaptive strategies drive an effective pandemic response. To support health system recovery Thailand should (1) minimize vulnerability and extend universal health coverage to include migrant workers and dependents; (2) sustain provincial primary healthcare (PHC) capacity and strengthen PHC in greater Bangkok; (3) leverage information technology for telemedicine and teleconsultation; (4) enhance and extend case and event-based surveillance of notifiable diseases, and for public health threats, including pathogens with pandemic potential in wildlife and domesticated animals. This requires policy and financial commitment across successive governments, adequate numbers of committed and competent health workforce at all levels supported by over a million village health volunteers, strong social capital and community resilience. A strengthened global health architecture and international collaboration also have critical roles in establishing local capacities to develop and manufacture pandemic response products through transfer of technology and know-how. Countries should engage in the ongoing Inter-government Negotiating Body to ensure a legally binding instrument to safeguard the world from catastrophic impacts of future pandemics.
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COVID-19 , Animales , Humanos , COVID-19/epidemiología , COVID-19/prevención & control , Vacunas contra la COVID-19 , Pandemias/prevención & control , Tailandia/epidemiología , GobiernoRESUMEN
Progressive realization of universal health coverage (UHC) requires health systems capacity to provide quality service and financial risk protection which supports access to services without financial hardship. Government health spending in low-income countries (LICs) has been low and heavily relied on external donor resources and out-of-pocket payment. This has resulted in high prevalence of catastrophic health spending or foregone care by those who cannot afford. Under fiscal constraints posed by pandemic, reforms in LICs should focus on efficiency through health resource waste reduction. Targeting the poor even with low level of health spending can make a significant health gain. Investment in primary healthcare and health workforce is the foundation for realizing UHC which cannot be postponed. Innovative tax on health hazardous products, conditional debt relief can increase fiscal space for health; while international collaboration to accelerate coronavirus disease 2019 (COVID-19) vaccine coverage can bring LICs out of acute phase of pandemic.
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COVID-19 , Cobertura Universal del Seguro de Salud , Humanos , Uganda , COVID-19/epidemiología , COVID-19/prevención & control , Gastos en Salud , Recursos en SaludRESUMEN
OBJECTIVES: This study assesses effective coverage of diabetes and hypertension in Thailand during 2016-2019. DESIGN: Mixed method, analysis of National health insurance database 2016-2019 and in-depth interviews. SETTING: Beneficiaries of Universal Coverage Scheme residing outside Bangkok. PARTICIPANTS: Quantitative analysis was performed by acquiring individual patient data of diabetes and hypertension cases in the Universal Coverage Scheme residing outside bangkok in 2016-2019. Qualitative analysis was conducted by in-depth interview of 85 multi-stakeholder key informants to identify challenges. OUTCOMES: Estimate three indicators: detected need (diagnosed/total estimated cases), crude coverage (received health services/total estimated cases) and effective coverage (controlled/total estimated cases) were compared. Controlled diabetes was defined as haemoglobin A1C (HbA1C) below 7% and controlled hypertension as blood pressure below 140/90 mm Hg. RESULTS: Estimated cases were 3.1-3.2 million for diabetes and 8.7-9.2 million for hypertension. For diabetes, all indicators have shown slow improvement between 2016 and 2019 (67.4%, 69.9%, 71.9% and 74.7% for detected need; 38.7%, 43.1%, 45.1% and 49.8% for crude coverage and 8.1%, 10.5%, 11.8% and 11.7% for effective coverage). For hypertension, the performance was poorer for detection (48.9%, 50.3%, 51.8% and 53.3%) and crude coverage (22.3%, 24.7%, 26.5% and 29.2%) but was better for effective coverage (11.3%, 13.2%, 15.1% and 15.7%) than diabetes. Results were better for the women and older age groups in both diseases. Complex interplays between supply and demand side were a key challenge. Database challenges also hamper regular assessment of effective coverage. Sensitivity analysis when using at least three annual visits shows slight improvement of effective coverage. CONCLUSION: Effective coverage was low for both diseases, though improving in 2016-2019, especially among men and ัyounger populations. The increasing rate of effective coverage was significantly smaller than crude coverage. Health information systems limitation is a major barrier to comprehensive measurement. To maximise effective coverage, long-term actions should address primary prevention of non-communicable disease risk factors, while short-term actions focus on improving Chronic Care Model.
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Diabetes Mellitus , Hipertensión , Seguro , Masculino , Femenino , Humanos , Anciano , Tailandia/epidemiología , Diabetes Mellitus/epidemiología , Hipertensión/epidemiología , Bases de Datos FactualesRESUMEN
Despite Thailand having had universal health coverage (UHC) with comprehensive benefit packages since 2002, services are neither listed nor budget earmarked for COVID-19 responses. Policy decisions were made immediately after the first outbreak in 2020 to fully fund a comprehensive benefit package for COVID-19. The Cabinet approved significant additional budget to respond to the unfolding pandemic. The comprehensive benefit package includes laboratory tests, contact tracing, active case findings, 14-day quarantine measures (including tests, food and lodging), field hospitals, ambulance services for referral, clinical services both at hospitals and in home and community isolation, vaccines and vaccination cost, all without copayment by users. No-fault compensation for adverse events or deaths following vaccination is also provided. Services were purchased from qualified public and private providers using the same rate, terms and conditions. The benefit package applies to everyone living in Thailand including Thai citizens and migrant workers. A standardised and comprehensive COVID-19 benefit package for Thai and non-Thai population without copayment facilitates universal and equitable access to care irrespective of capacity to pay and social status and nationality, all while aiming to supporting pandemic containment. Making essential services available, notably laboratory tests, through the engagement of qualified both public and private sectors boost supply side capacity. These policies and implementations in this paper are useful lessons for other low-income and middle-income countries on how UHC reinforces pandemic containment.
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COVID-19 , Atención a la Salud , Humanos , Sector Privado , Tailandia/epidemiología , Cobertura Universal del Seguro de SaludRESUMEN
INTRODUCTION: In 2019, only 14% of mothers in Thailand performed six-month exclusive breastfeeding. This study sought to understand the pathways that mothers in Bangkok Metropolitan took to achieve successful six-month exclusive breastfeeding. METHODS: A total of 50 mothers living in Bangkok with children aged 6-12 months, who achieved and not achieved 6-month exclusive breastfeeding, were recruited for in-depth interviews during February to July 2020. Inductive thematic analysis of participants' viewpoints was applied for data analysis and interpretation. RESULTS: Four themes that contributed to six-month exclusive breastfeeding were i) â¯maternal breastfeeding self-efficacy; â¯ii) â¯support provided by family members; â¯iii)⯠engagement with and support from healthcare professionals; and iv)⯠employers' support and workplace environments. Mothers with strong breastfeeding intentions and "perceived capability" to succeed at breastfeeding tended to prioritize breastfeeding and overcome and cope well with unforeseen breastfeeding challenges. Supportive family members, who were convinced of the benefits of breastfeeding, engaged in maternal decision-making, and provided optimal support, contributed to successful exclusive breastfeeding. Health professionals were key in supporting mothers throughout pregnancy until the postpartum period. Lactating-mother-friendly working conditions, flexible working hours and enabling workplace environments, including the provision of breastfeeding breaks and a dedicate space for breast milk expression, were enabling factors for successful exclusive breastfeeding among working mothers. CONCLUSION: We recommend that all mothers and their family members are fully informed and convinced of the benefit from breastfeeding and trained with practical skill during their visit to antenatal care clinics. These interventions aim to develop mothers' self-efficacy for breastfeeding and to prepare them to manage common breastfeeding challenges. Health professionals should provide regular follow-up and counseling sessions on breastfeeding practices to mothers and families throughout the lactating period, especially working mothers for breastfeeding continuation after resume to work. Enhanced societal collective actions such as breastfeeding-friendly policy in workplace, including breastfeeding break-time and corner, can create enabling environments for successful exclusive breastfeeding.
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The rapid economic growth in low and middle-income countries provides the opportunity of translating political commitment into action for achieving Universal Health Coverage. However, this is not straightforward. High donor dependence in low income countries; the lack of fiscal space; the inadequacy of attention to primary health care and under-developed pre-payment systems all pose challenges. Windows of political opportunity open up and ensuring that Universal Health Coverage makes it into the agenda of parties and subsequent holding them accountable by citizens can address political inertia. Not only is more money for health needed, but governments also need to gain more health for money through effective strategic purchasing and addressing the main drivers of inefficiency. Moving Universal Health Coverage from political aspiration to reality requires approaching it as a citizen's rights and entitlement to health, through full subsidies for the poor and vulnerable.
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Pobreza , Cobertura Universal del Seguro de Salud , HumanosRESUMEN
BACKGROUND: In response to an increased health burden from non-communicable diseases (NCDs), primary health care (PHC) is effective platform to support NCDs prevention and control. This study aims to assess Thailand's PHC capacity in providing NCDs services, identify enabling factors and challenges and provide policy recommendations for improvement. METHODS: This cross-sectional mixed-method study was conducted between October 2019 and May 2020. Two provinces, one rich and one poor, were randomly selected and then a city and rural district from each province were randomly selected. From these 4 sites in the 2 provinces, all 56 PHC centres responded to a self-administrative questionnaire survey on their capacities and practices related to NCDs. A total of 79 participants from Provincial and District Health Offices, provincial and district hospitals, and PHC centres who are involved with NCDs participated in focus group discussions or in-depth interviews. RESULTS: Strong health infrastructure, competent staff (however not with increased workload), essential medicines and secured budget boost PHC capacity to address NCDs prevention, control, case management, referral and rehabilitation. Community engagement through village health volunteers improves NCDs awareness, supports enrolment in screening and raises adherence to interventions. Village health volunteers, the crucial link between the health system and the community, are key in supporting health promotion and NCDs prevention and control. Collaboration between provincial and district hospitals in providing resources and technical support enhance the capacity of PHC centres to provide NCDs services. However, inconsistent national policy directions and uncertainty related to key performance indicators hamper progress in NCDs management at the operational level. The dynamic of urbanization and socialization, especially living in obesogenic environments, is one of the greatest challenges for dealing with NCDs. CONCLUSION: PHC centres play a vital role in NCDs prevention and control. Adequate human and financial resources and policy guidance are required to improve PHC performance in managing NCDs. Implementing best buy measures at national level provides synergies for NCDS control at PHC level.
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Enfermedades no Transmisibles , Estudios Transversales , Personal de Salud , Humanos , Enfermedades no Transmisibles/prevención & control , Atención Primaria de Salud , TailandiaRESUMEN
Although the benefits of breastfeeding are widely recognized, only 14% of mothers in Thailand exclusively breastfed their children during the first six months of their lives in 2019, which dropped from 23% in 2016. This study aimed to assess the prevalence of exclusive breastfeeding (EBF) up to six months, current breastfeeding patterns, and key determinants that influence six-month EBF among mothers residing in Bangkok, Thailand. A cross-sectional study was conducted using a self-administered questionnaire survey. In total, 676 healthy mothers living in Bangkok, whose most recent child was between 6 and 18 months old, were recruited. Descriptive statistics, univariable analysis by Chi-square test, and multivariable logistic regression were performed to assess the association between six-month EBF and maternal characteristics and experiences of using maternal health services. The prevalence of six-month EBF of infants in Bangkok was 41%. The key determinants that influenced six-month EBF included: maternal age of more than 30 years; higher education level; higher maternal income; multi-parity; exposure to breastfeeding advice during pregnancy; intention to breastfeed for a long duration (≥6 months) during pregnancy; experience of six-month EBF in the previous child. This study draws health professionals' and policy makers' attention to further promote breastfeeding in particular types of mothers.
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Lactancia Materna , Madres , Adulto , Niño , Estudios Transversales , Femenino , Humanos , Lactante , Paridad , Embarazo , TailandiaRESUMEN
Efficiency has historically been considered a key mechanism to increase the amount of available revenues to the health sector, enabling countries to expand services and benefits to progress towards universal health coverage (UHC). Country experience indicates, however, that efficiency gains do not automatically translate into greater budget for health, to additional revenues for the sector. This article proposes a framework to assess whether and how efficiency interventions are likely to increase budgetary space in health systems Based on a review of the literature and country experiences, we suggest three enabling conditions that must be met in order to transform efficiency gains into budgetary gains for health. First there must be well-defined efficiency interventions that target health system inputs, implemented over a medium-term time frame. Second, efficiency interventions must generate financial gains that are quantifiable either pre- or post-intervention. Third, public financial management systems must allow those gains to be kept within the health sector and repurposed towards priority health needs. When these conditions are not met, efficiency gains do not lead to more budgetary space for health. Rather, the gains may instead result in budget cuts that can be detrimental to health systems' outputs and ultimately disincentivize further attempts to improve efficiency in the sector. The framework, when applied, offers an opportunity for policymakers to reconcile efficiency and budget expansion goals in health.
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Administración Financiera , Cobertura Universal del Seguro de Salud , Presupuestos , Prioridades en Salud , HumanosRESUMEN
Participatory and responsive governance in universal health coverage (UHC) systems synergistically ensure the needs of citizens are protected and met. In Thailand, UHC constitutes of three public insurance schemes: Civil Servant Medical Benefit Scheme, Social Health Insurance and Universal Coverage Scheme. Each scheme is governed through individual laws. This study aimed to identify, analyse and compare the legislative provisions related to participatory and responsive governance within the three public health insurance schemes and draw lessons that can be useful for other low-income and middle-income countries in their legislative process for UHC. The legislative provisions in each policy document were analysed using a conceptual framework derived from key literature. The results found that overall the UHC legislative provisions promote citizen representation and involvement in UHC governance, implementation and management, support citizens' ability to voice concerns and improve UHC, protect citizens' access to information as well as ensure access to and provision of quality care. Participatory governance is legislated in 33 sections, of which 23 are in the Universal Coverage Scheme, 4 in the Social Health Insurance and none in the Civil Servant Medical Benefit Scheme. Responsive governance is legislated in 24 sections, of which 18 are in the Universal Coverage Scheme, 2 in the Social Health Insurance and 4 in the Civil Servant Medical Benefit Scheme. Therefore, while several legislative provisions on both participatory and responsive governance exist in the Thai UHC, not all schemes equally bolster citizen participation and government responsiveness. In addition, as legislations are merely enabling factors, adequate implementation capacity and commitment to the legislative provisions are equally important.