Utilization of Primary Health Care Under National Health Insurance in Samarinda Municipality, East Kalimantan Province, Indonesia.

Aim: In Indonesia, basic community health services are provided to all citizens through Primary Health Care (PHC) settings under the National Health Insurance (NHI) scheme. The insurance is compulsory and provides basic community health needs. Based on a gatekeeper concept, the PHC is deemed to be the first contact point for all basic healthcare needs. Despite the commencement of services through PHC settings in 2014 under this concept, utilization in PHC settings remains lower than in hospital settings. This study aimed to assess factors associated with utilization of PHC under National Health Insurance in Samarinda Municipality, East Kalimantan Province, Indonesia. Materials and Methods: The research examined the utilization of services over six months. It employed a cross-sectional method and included 382 NHI participants in 10 districts of Samarinda Municipality. Each district was divided into urban and semi-urban areas based upon local government indicators representing the whole research area. A two-stage random sampling and purposive sampling approach was implemented to select the sample. The participants were interviewed using a structured questionnaire. Chi-square and multiple logistic regressions were conducted to determine the impact of factors on the utilization of PHC. Results: Only 17.3% of participants used PHC services regularly. Three constitutive factors, type of NHI participants (Adj. OR: 2.62; p<0.005), accommodation (Adj. OR: 2.18; p<0.005) and awareness (Adj. OR: 3.27; p<0.005) most profoundly influenced the under-utilization of PHC by NHI participants. Conclusion: The study found that the type of NHI participant and the utilization factors of accommodation and awareness significantly influenced the degree of utilization of PHC facilities by NHI participants and that the differences arose from variations in knowledge and experience. Strengthening these factors will rely upon an expanded role of government and community collaboration, emphasizing the needs of NHI participants.

The Devil Is in the Detail-Understanding Divergence between Intention and Implementation of Health Policy for Undocumented Migrants in Thailand.

Migrants' access to healthcare has attracted attention from policy makers in Thailand for many years. The most relevant policies have been (i) the Health Insurance Card Scheme (HICS) and (ii) the One Stop Service (OSS) registration measure, targeting undocumented migrants from neighbouring countries. This study sought to examine gaps and dissonance between de jure policy intention and de facto implementation through qualitative methods. In-depth interviews with policy makers and local implementers and document reviews of migrant-related laws and regulations were undertaken. Framework analysis with inductive and deductive coding was undertaken. Ranong province was chosen as the study area as it had the largest proportion of migrants. Though the government required undocumented migrants to buy the insurance card and undertake nationality verification (NV) through the OSS, in reality a large number of migrants were left uninsured and the NV made limited progress. Unclear policy messages, bureaucratic hurdles, and inadequate inter-ministerial coordination were key challenges. Some frontline implementers adapted the policies to cope with their routine problems resulting in divergence from the initial policy objectives. The study highlighted that though Thailand has been recognized for its success in expanding insurance coverage to undocumented migrants, there were still unsolved operational challenges. To tackle these, in the short term the government should resolve policy ambiguities and promote inter-ministerial coordination. In the long-term the government should explore the feasibility of facilitating lawful cross-border travel and streamlining health system functions between Thailand and its neighbours.

Evolution and complexity of government policies to protect the health of undocumented/illegal migrants in Thailand - the unsolved challenges.

BACKGROUND: Of the 65 million residents in Thailand, >1.5 million are undocumented/illegal migrants from neighboring countries. Despite several policies being launched to improve access to care for these migrants, policy implementation has always faced numerous challenges. This study aimed to investigate the policy makers' views on the challenges of implementing policies to protect the health of undocumented/illegal migrants in light of the dynamics of all of the migrant policies in Thailand. METHODS: This study used a qualitative approach. Data were collected by document review, from related laws/regulations concerning migration policy over the past 40 years, and from in-depth interviews with seven key policy-level officials. Thematic analysis was applied. RESULTS: Three critical themes emerged, namely, national security, economic necessity, and health protection. The national security discourse played a dominant role from the early 1900s up to the 1980s as Thailand attempted to defend itself from the threats of colonialism and communism. The economic boom of the 1990s created a pronounced labor shortage, which required a large migrant labor force to drive the growing economy. The first significant attempt to protect the health of migrants materialized in the early 2000s, after Thailand achieved universal health coverage. During that period, public insurance for undocumented/illegal migrants was introduced. The insurance used premium-based financing. However, the majority of migrants remained uninsured. Recently, the government attempted to overhaul the entire migrant registry system by introducing a new measure, namely the One Stop Service. In principle, the One Stop Service aimed to integrate the functions of all responsible authorities, but several challenges still remained; these included ambiguous policy messages and the slow progress of the nationality verification process. CONCLUSION: The root causes of the challenges in migrant health policy are incoherent policy direction and objectives across government authorities and unclear policy messages. In addition, the health sector, especially the Ministry of Public Health, has been de facto powerless and, due to its outdated bureaucracy, has lacked the capacity to keep pace with the problems regarding human mobility.

Building the evidence base for stigma and discrimination-reduction programming in Thailand: development of tools to measure healthcare stigma and discrimination.

BACKGROUND: HIV-related stigma and discrimination (S&D) are recognized as key impediments to controlling the HIV epidemic. S&D are particularly detrimental within health care settings because people who are at risk of HIV and people living with HIV (PLHIV) must seek services from health care facilities. Standardized tools and monitoring systems are needed to inform S&D reduction efforts, measure progress, and monitor trends. This article describes the processes followed to adapt and refine a standardized global health facility staff S&D questionnaire for the context of Thailand and develop a similar questionnaire measuring health facility stigma experienced by PLHIV. Both questionnaires are currently being used for the routine monitoring of HIV-related S&D in the Thai healthcare system. METHODS: The questionnaires were adapted through a series of consultative meetings, pre-testing, and revision. The revised questionnaires then underwent field testing, and the data and field experiences were analyzed. RESULTS: Two brief questionnaires were finalized and are now being used by the Department of Disease Control to collect national routine data for monitoring health facility S&D: 1) a health facility staff questionnaire that collects data on key drivers of S&D in health facilities (i.e., fear of HIV infection, attitudes toward PLHIV and key populations, and health facility policy and environment) and observed enacted stigma and 2) a brief PLHIV questionnaire that captures data on experienced discriminatory practices at health care facilities. CONCLUSIONS: This effort provides an example of how a country can adapt global S&D measurement tools to a local context for use in national routine monitoring. Such data helps to strengthen the national response to HIV through the provision of evidence to shape S&D-reduction programming.

Analysis of health promotion and prevention financing mechanisms in Thailand.

In the transition to the post-2015 agenda, many countries are striving towards universal health coverage (UHC). Achieving this, governments need to shift from curative care to promotion and prevention services. This research analyses Thailand's financing system for health promotion and prevention, and assesses policy options for health financing reforms. The study employed a mixed-methods approach and integrates multiple sources of evidence, including scientific and grey literature, expenditure data, and semi-structured interviews with key stakeholders in Thailand. The analysis was underpinned by the use of a well-known health financing framework. In Thailand, three agencies plus local governments share major funding roles for health promotion and prevention services: the Ministry of Public Health (MOPH), the National Health Security Office, the Thai Health Promotion Foundation and Tambon Health Insurance Funds. The total expenditure on prevention and public health in 2010 was 10.8% of the total health expenditure, greater than many middle-income countries that average 7.0-9.2%. MOPH was the largest contributor at 32.9%, the Universal Coverage scheme was the second at 23.1%, followed by the local governments and ThaiHealth at 22.8 and 7.3%, respectively. Thailand's health financing system for promotion and prevention is strategic and innovative due to the three complementary mechanisms in operation. There are several methodological limitations to determine the adequate level of spending. The health financing reforms in Thailand could usefully inform policymakers on ways to increase spending on promotion and prevention. Further comparative policy research is needed to generate evidence to support efforts towards UHC.

Making Fair Choices on the Path to Universal Health Coverage: Applying Principles to Difficult Cases.

Abstract-Progress toward universal health coverage (UHC) requires making difficult trade-offs. In this journal, Dr. Margaret Chan, the World Health Organization (WHO) Director-General, has endorsed the principles for making such decisions put forward by the WHO Consultative Group on Equity and UHC. These principles include maximizing population health, priority for the worse off, and shielding people from health-related financial risks. But how should one apply these principles in particular cases, and how should one adjudicate between them when their demands conflict? This article by some members of the Consultative Group and a diverse group of health policy professionals addresses these questions. It considers three stylized versions of actual policy dilemmas. Each of these cases pertains to one of the three key dimensions of progress toward UHC: which services to cover first, which populations to prioritize for coverage, and how to move from out-of-pocket expenditures to prepayment with pooling of funds. Our cases are simplified to highlight common trade-offs. Though we make specific recommendations, our primary aim is to demonstrate both the form and substance of the reasoning involved in striking a fair balance between competing interests on the road to UHC.

Impact of the health insurance scheme for stateless people on inpatient utilization in Kraburi Hospital, Thailand.

OBJECTIVES: This study sought to investigate the impact of the Thai "Health Insurance for People with Citizenship Problems" (HI-PCP) on access to care for stateless patients, compared to Universal Coverage Scheme patients and the uninsured, using inpatient utilization as a proxy for impact. METHODS: Secondary data analysis of inpatient records of Kraburi Hospital, Ranong province, between 2009 (pre-policy) and 2012 (post-policy) was employed. Descriptive statistics and multivariate analysis by difference-in-difference model were performed. RESULTS: The volume of inpatient service utilization by stateless patients expanded after the introduction of the HI-PCP. However, this increase did not appear to stem from the HI-PCP per se. After controlling for key covariates, including patients' characteristics, disease condition, and domicile, there was only a weak positive association between the HI-PCP and utilization. Critical factors contributing significantly to increased utilization were older age, proximity to the hospital, and presence of catastrophic illness. CONCLUSION: A potential explanation for the insignificant impact of the HI-PCP on access to inpatient care of stateless patients is likely to be a lack of awareness of the existence of the scheme among the stateless population and local health staff. This problem is likely to have been accentuated by operational constraints in policy implementation, including the poor performance of local offices in registering stateless people. A key limitation of this study is a lack of data on patients who did not visit the health facility at the first opportunity. Further study of health-seeking behavior of stateless people at the household level is recommended.

Three Case Studies in Making Fair Choices on the Path to Universal Health Coverage.

The goal of achieving Universal Health Coverage (UHC) can generally be realized only in stages. Moreover, resource, capacity, and political constraints mean governments often face difficult trade-offs on the path to UHC. In a 2014 report, Making fair choices on the path to UHC, the WHO Consultative Group on Equity and Universal Health Coverage articulated principles for making such trade-offs in an equitable manner. We present three case studies which illustrate how these principles can guide practical decision-making. These case studies show how progressive realization of the right to health can be effectively guided by priority-setting principles, including generating the greatest total health gain, priority for those who are worse off in a number of dimensions (including health, access to health services, and social and economic status), and financial risk protection. They also demonstrate the value of a fair and accountable process of priority setting.

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

BACKGROUND: In 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. METHODS: A 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. RESULTS: Thirty 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 country's 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. DISCUSSION: The 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. CONCLUSION: It 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.

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

BACKGROUND: Empirical 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. METHODS: The study employs qualitative methods including reviews of relevant documents, in-depth interviews of 25 key informants, and triangulation amongst information sources. RESULTS: Continued 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. CONCLUSIONS: Future 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.

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.

Using health technology assessment for informing coverage decisions in Thailand.

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.

Equity of access to and utilization of reproductive health services in Thailand: national Reproductive Health Survey data, 2006 and 2009.

This study assessed trends in equity of access to reproductive health services and service utilization in terms of coverage of family planning, antenatal care and skilled birth attendance in Thailand. Two health indicators were measured: the prevalence of low birthweight and exclusive breastfeeding. Equity was measured against the combined urban-rural areas and geographic regions, women's education level and quintiles of household assets index. The study used data from two nationally representative household surveys, the 2006 and 2009 Reproductive Health Surveys. Very high coverage of family planning (79.6%), universal antenatal care (98.9%) and skilled birth attendance (99.7%), with very small socioeconomic and geographic disparities, were observed. The public sector played a dominant role in maternity care (90.9% of all deliveries in 2009). The private sector also had a role among the higher educated, wealthier women living in urban areas. Public sector facilities, followed by drug stores, were a major supplier of contraception, which had a high use rate. High coverage and low inequity were the result of extensive investment in the health system by successive governments, in particular primary health care at district and sub-district levels, reaching universality by 2002. While maintaining these achievements, methodological improvements in measuring low birthweight and exclusive breastfeeding for future reproductive health surveys are recommended.

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.

The equity impact of the universal coverage policy: lessons from Thailand.

OBJECTIVE: This chapter assesses health equity achievements of the Thai health system before and after the introduction of the universal coverage (UC) policy. It examines five dimensions of equity: equity in financial contributions, the incidence of catastrophic health expenditure, the degree of impoverishment as a result of household out-of-pocket payments for health, equity in health service use and the incidence of public subsidies for health. METHODOLOGY: The standard methods proposed by O'Donnell, van Doorslaer, and Wagstaff (2008b) were used to measure equity in financial contribution, healthcare utilization and public subsidies, and in assessing the incidence of catastrophic health expenditure and impoverishment. Two major national representative household survey datasets were used: Socio-Economic Surveys and Health and Welfare Surveys. FINDINGS: General tax was the most progressive source of finance in Thailand. Because this source dominates total financing, the overall outcome was progressive, with the rich contributing a greater share of their income than the poor. The low incidence of catastrophic health expenditure and impoverishment before UC was further reduced after UC. Use of healthcare and the distribution of government subsidies were both pro-poor: in particular, the functioning of primary healthcare (PHC) at the district level serves as a "pro-poor hub" in translating policy into practice and equity outcomes. POLICY IMPLICATIONS: The Thai health financing reforms have been accompanied by nationwide extension of PHC coverage, mandatory rural health service by new graduates and systems redesign, especially the introduction of a contracting model and closed-ended provider payment methods. Together, these changes have led to a more equitable and more efficient health system. Institutional capacity to generate evidence and to translate it into policy decisions, effective implementation and comprehensive monitoring and evaluation are essential to successful system-level reforms.