Financial risk protection of Thailand's universal health coverage: results from series of national household surveys between 1996 and 2015.

BACKGROUND: Thailand, an upper-middle income country, has demonstrated exemplary outcomes of Universal Health Coverage (UHC). The country achieved full population coverage and a high level of financial risk protection since 2002, through implementing three public health insurance schemes. UHC has two explicit goals of improved access to health services and financial protection where use of these services does not create financial hardship. Prior studies in Thailand do not provide evidence of long-term UHC financial risk protection. This study assessed financial risk protection as measured by the incidence of catastrophic health spending and impoverishment in Thai households prior to and after UHC in 2002. METHODS: We used data from a 15-year series of annual national household socioeconomic surveys (SES) between 1996 and 2015, which were conducted by the National Statistic Office (NSO). The survey covered about 52,000 nationally representative households in each round. Descriptive statistics were used to assess the incidence of catastrophic payment as measured by the share of out-of-pocket payment (OOP) for health by households exceeding 10 and 25% of household total consumption expenditure, and the incidence of impoverishment as determined by the additional number of non-poor households falling below the national and international poverty lines after making health payments. RESULTS: Using the 10% threshold, the incidence of catastrophic spending dropped from 6.0% in 1996 to 2% in 2015. This incidence reduced more significantly when the 25% threshold was applied from 1.8 to 0.4% during the same period. The incidence of impoverishment against the national poverty line reduced considerably from 2.2% in 1996 to approximately 0.3% in 2015. When the international poverty line of US$ 3.1 per capita per day was applied, the incidence of impoverishment was 1.4 and 0.4% in 1996 and 2015 respectively; and when US$ 1.9 per day was applied, the incidence was negligibly low. CONCLUSION: The significant decline in the incidence of catastrophic health spending and impoverishment was attributed to the deliberate design of Thailand's UHC, which provides a comprehensive benefits package and zero co-payment at point of services. The well-founded healthcare delivery system and favourable benefits package concertedly support the achievement of UHC goals of access and financial risk protection.

Budget impact analysis of the new reimbursement policy for day surgery in Thailand.

INTRODUCTION: In 2017 the Thai Ministry of Public Health proposed a new financing mechanism to promote day surgery under the Universal Coverage Scheme - the main public insurance arrangement for Thais. The key feature of the policy is health facilities performing day surgery can claim the treatment expense based on relative weight (RW) instead of adjusted RW (adjRW). Procedures for 12 diseases (so-called "candidate procedures") are eligible for the new reimbursement. The objective of this study was to assess the current day surgery situation in Thailand and analyze potential budget impact from the new policy. METHODS: A quantitative cross-section design was employed. Individual inpatient records of the Universal Coverage Scheme during 2014-2016 were analyzed. Descriptive statistics and simulation analyses were applied. The analyses were divided into three subtopics: 1) case volume and expense claim, 2) utilization across facilities, and 3) case mix index and budget impact. RESULTS: Overall, day surgery accounted for 4.8% of admissions with candidate procedures. Inguinal hernias, hemorrhoids, and common bile duct stones caused the largest sum of admission numbers and admission days. Currently, the annual reimbursement for candidate procedures treated as inpatient cases is around 290.8 million Baht (US$ 8.8 million), with about 12.4 million Baht (US$ 0.38 million) for day surgery cases. If all candidate procedures were performed as day surgery and diagnostic-related groups (DRG) version 6 was applied, the incremental budget would amount to 1.9 million Baht (US$ 58,903). CONCLUSIONS: The new reimbursement policy will likely lead to minimal budget burden. Even in the case of maximal uptake of the policy, the needed budget would increase by just 15%. The marginal budget increment was explained by the infinitesimal RW-adjRW difference. Apart from the financial measure, other qualitative aspects of the policy, such as infrastructure and health staff readiness, should be explored.

Childhood stunting in Thailand: when prolonged breastfeeding interacts with household poverty.

BACKGROUND: Childhood stunting, defined as the height-for-age standardized score lower than minus two, is one of the key indicators for assessing well-being and health of a child; and can be used for monitoring child health inequalities. Thailand has been successful in improving health and providing financial protection for its population. A better understanding of the determinants of stunting will help fill both knowledge and policy gaps which promote children's health and well-being. This study assesses the factors contributing to stunting among Thai children aged less than five years. METHODS: This study obtained data from the Multiple Indicator Cluster Survey Round 4 (MICS4), conducted in Thailand in 2012. Data analysis consisted of three steps. First, descriptive statistics provided an overview of data. Second, a Chi-square test determined the association between each covariate and stunting. Finally, multivariable logistic regression assessed the likelihood of stunting from all independent variables. Interaction effects between breastfeeding and household economy were added in the multivariable logistic regression. RESULTS: In the analysis without interaction effects, while the perceived size of children at birth as 'small' were positively associated with stunting, children in the well-off households were less likely to experience stunting. The analysis of the interactions between 'duration of breastfeeding' and 'household's economic level' found that the odds of stunting in children who were breastfed longer than 12 months in the poorest household quintile were 1.8 fold (95% Confidence interval: 1.3-2.6) higher than the odds found in mothers from the same poorest quintiles, but without prolonged breastfeeding. However prolonged breastfeeding in most well-off households (those between the second quintile and the fifth wealth quintile) did not show a tendency towards stunting. CONCLUSIONS: Childhood stunting was significantly associated with several factors. Prolonged breastfeeding beyond 12 months when interacting with poor economic status of a household potentiated stunting. Children living in the least well-off households were more prone to stunting than others. We recommend that the MICS survey questionnaire be amended to capture details on quantity, quality and practices of supplementary feeding. Multi-sectoral nutrition policies targeting poor households are required to address stunting challenges.

Economic burden of bacteremic melioidosis in eastern and northeastern, Thailand.

Melioidosis is among the most common causes of septicemia in Thailand, but data on economic burden are limited. We describe the economic impact of bacteremic melioidosis hospitalizations in two Thailand provinces during 2006-2008. Costs are presented in US dollars ($1 = 30.49 Thai Baht). The average annual incidence of bacteremic melioidosis cases per 100,000 persons in Sa Kaeo and Nakhon Phanom was 4.6 and 14.4, respectively. The annual cost of bacteremic melioidosis hospitalizations from the societal perspective, including direct and indirect costs, was $152,159 in Sa Kaeo and $465,303 in Nakhon Phanom. The average cost per fatal case was $14,182 and $14,858 in Sa Kaeo and Nakhon Phanom, respectively. In addition to the high morbidity and mortality, the substantial economic burden of melioidosis further supports the need for investments to identify improved prevention and control strategies for melioidosis.

Prevalence and profiles of unmet healthcare need in Thailand.

BACKGROUND: In the light of the universal healthcare coverage that was achieved in Thailand in 2002, policy makers have raised concerns about whether there is still unmet need within the population. Our objectives were to assess the annual prevalence, characteristics and reasons for unmet healthcare need in the Thai population in 2010 and to compare our findings with relevant international literature. METHODS: A standard set of OECD unmet need questionnaires was used in a nationally-representative household survey conducted in 2010 by the National Statistical Office. The prevalence of unmet need among respondents with various socio-economic characteristics was estimated to determine an inequity in the unmet need and the reasons behind it. RESULTS: The annual prevalence of unmet need for outpatient and inpatient services in 2010 was 1.4% and 0.4%, respectively. Despite this low prevalence, there are inequities with relatively higher proportion of the unmet need among Universal Coverage Scheme members, and the poor and rural populations. There was less unmet need due to cost than there was due to geographical barriers. The prevalence of unmet need due to cost and geographical barriers among the richest and poorest quintiles were comparable to those of selected OECD countries. The geographical extension of healthcare infrastructure and of the distribution of health workers is a major contributing factor to the low prevalence of unmet need. CONCLUSIONS: The low prevalence of unmet need for both outpatient and inpatient services is a result of the availability of well-functioning health services at the most peripheral level, and of the comprehensive benefit package offered free of charge by all health insurance schemes. This assessment prompts a need for regular monitoring of unmet need in nationally-representative household surveys.

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

BACKGROUND: Thailand 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. METHOD: Benefit 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. FINDINGS: The 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$ 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. CONCLUSIONS: Higher 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.

Who pays for health care in Asia?

We estimate the distributional incidence of health care financing in 13 Asian territories that account for 55% of the Asian population. In all territories, higher-income households contribute more to the financing of health care. The better-off contribute more as a proportion of ability to pay in most low- and lower-middle-income territories. Health care financing is slightly regressive in three high-income economies with universal social insurance. Direct taxation is the most progressive source of finance and is most so in poorer economies. In universal systems, social insurance is proportional to regressive. In high-income economies, the out-of-pocket (OOP) payments are proportional or regressive while in low-income economies the better-off spend relatively more OOP. But in most low-/middle-income countries, the better-off not only pay more, they also get more health care.

Catastrophic payments for health care in Asia.

Out-of-pocket (OOP) payments are the principal means of financing health care throughout much of Asia. We estimate the magnitude and distribution of OOP payments for health care in fourteen countries and territories accounting for 81% of the Asian population. We focus on payments that are catastrophic, in the sense of severely disrupting household living standards, and approximate such payments by those absorbing a large fraction of household resources. Bangladesh, China, India, Nepal and Vietnam rely most heavily on OOP financing and have the highest incidence of catastrophic payments. Sri Lanka, Thailand and Malaysia stand out as low to middle income countries that have constrained both the OOP share of health financing and the catastrophic impact of direct payments. In most low/middle-income countries, the better-off are more likely to spend a large fraction of total household resources on health care. This may reflect the inability of the poorest of the poor to divert resources from other basic needs and possibly the protection of the poor from user charges offered in some countries. But in China, Kyrgyz and Vietnam, where there are no exemptions of the poor from charges, they are as, or even more, likely to incur catastrophic payments.

Effect of payments for health care on poverty estimates in 11 countries in Asia: an analysis of household survey data.

BACKGROUND: Conventional estimates of poverty do not take account of out-of-pocket payments to finance health care. We aimed to reassess measures of poverty in 11 low-to-middle income countries in Asia by calculating total household resources both with and without out-of-pocket payments for health care. METHODS: We obtained data on payments for health care from nationally representative surveys, and subtracted these payments from total household resources. We then calculated the number of individuals with less than the internationally accepted threshold of absolute poverty (US1 dollar per head per day) after making health payments. We also assessed the effect of health-care payments on the poverty gap--the amount by which household resources fell short of the 1 dollar poverty line in these countries. FINDINGS: Our estimate of the overall prevalence of absolute poverty in these countries was 14% higher than conventional estimates that do not take account of out-of-pocket payments for health care. We calculated that an additional 2.7% of the population under study (78 million people) ended up with less than 1 dollar per day after they had paid for health care. In Bangladesh, China, India, Nepal, and Vietnam, where more than 60% of health-care costs are paid out-of-pocket by households, our estimates of poverty were much higher than conventional figures, ranging from an additional 1.2% of the population in Vietnam to 3.8% in Bangladesh. INTERPRETATION: Out-of-pocket health payments exacerbate poverty. Policies to reduce the number of Asians living on less than 1 dollar per day need to include measures to reduce such payments.