Costs-effectiveness of the urban health center in Nakhon Ratchasima: a case study on diabetes and hypertension.

Health care reforms in Thailand are looking for a better health infrastructure within the urban setting. The urban health center is one of the models tried in many provinces. This study compared the costs--effectiveness of the urban health center in Nakhon Ratchsima with the Maharaj Nakhon Ratchasima Hospital, using diabetes and hypertension as tracer conditions. The point estimates by a retrospective review and cross-sectional study revealed that the overall costs (provider plus patient costs) of the urban health center for these tracers were lower than the costs of the Maharaj Hospital. The effectiveness of treatment at the urban health center was also better. It was concluded that the urban health center should be considered as a better alternative of primary care institution within the urban area.

Implementing the universal health coverage: which source of information is more reliable?

The implementation of universal health coverage needs accurate data on the distribution of health benefit coverage, particularly the uninsured. The national surveys and routine reports are two important sources of information ready for use. This study shows the validation of data from two sources. The data from national household surveys on the medical welfare, the health card and the social security schemes were validated with the routine report data of the Ministry of Public Health (MOPH) and the Social Security Office (SSO) by provinces. There were considerable differences between these data sets. The national survey data gave a 1.5 times higher estimate than the report data of the MOPH and the SSO. Financial implications of using inaccurate data to implement the universal health coverage could be huge, depending on the capitation rate.

The present situation of paragonimiasis in endemic area in Phitsanulok Province.

A cross-sectional survey and evaluation of paragonimiasis situation from endemic area in Phitsanulok Province was studied. Studies on the species and prevalence of parasites which infected people in Noen Maprang, Phitsanulok Province were also conducted during October 1999-March 2000. The sputum specimens were collected and examined to identify Paragonimus heterotremus eggs. In addition fecal samples were collected and examined for parasites by the formalin-ethyl acetate concentration technique. P. heterotremus eggs were detected in 2 out of 391 sputum specimens; a prevalence of 0.51%. A total of 584 stool specimens were obtained and examined. It was found that the prevalence of parasitic infection was 36.30%. Opisthorchis viverrini infection was the most prevalent (10.78%), followed by Strongyloides stercoralis (9.59%), hookworm (8.22%), Echinostoma spp (2.23%), minute intestinal flukes (1.54%), Taenia species (1.37%), Enterobius vermicularis (0.68%), Entamoeba coli (1.03%) and Giardia lamblia (0.86%). The prevalent rate of paragonimiasis in this endemic area in Phitsanulok Province has decreased during the past decade. However, there were other important parasite infections, especially opisthorchiasis and strongylodiasis and these should be studied further.

Benchmarks of fairness for health care reform: A policy tool for developing countries

"…We report here on progress we have made toward developing the benchmarks of fairness into a policy tool that will be useful in developing countries for analyzing the overall fairness of health care reforms…"

Financing reforms for the Thai health card scheme.

The Thai health card scheme originated from a pilot study on community financing and primary health care in maternal and child health in 1983. The scheme later changed to one of voluntary health insurance and finally received a matching subsidy from the government. The coverage of the scheme is described by a U-curve, i.e. it started with 5% of the total population in 1987, declined to 3% in 1992, with an upturn to 14% in 1997. The upturn has been the result of concerns about universal coverage policy, together with reforms of fund management. The provincial fund is responsible for basic health, basic medical, referral, and accident and emergency services. The central fund takes 2.5% of the total fund to manage cross-boundary services and high cost care (a reinsurance policy). On average, the utilization rate of the voluntary health card was higher than that of the compulsory (social security) scheme. And amongst three variants of health cards, the voluntary health card holders used health services twice to three times more than the community and health volunteer card holders. Cost recovery was low, especially in the provinces with low coverage. In the province with highest coverage, cost recovery was as high as 90% of the non-labour recurrent cost. Only 10% of the budgeted fund for reinsurance was disbursed, implying considerable management inefficiency. The management information system as well as the management capacity of the Health Insurance Office should be strengthened. After comparing the health card with other insurance schemes in terms of coverage, cost recovery, utilization and management cost, it is recommended that this voluntary health insurance should be modified to be a compulsory insurance, with some other means of premium collection and minimal co-payment at the point of delivery.

Benchmarks of fairness for health care reform: a policy tool for developing countries.

Teams of collaborators from Colombia, Mexico, Pakistan, and Thailand have adapted a policy tool originally developed for evaluating health insurance reforms in the United States into "benchmarks of fairness" for assessing health system reform in developing countries. We describe briefly the history of the benchmark approach, the tool itself, and the uses to which it may be put. Fairness is a wide term that includes exposure to risk factors, access to all forms of care, and to financing. It also includes efficiency of management and resource allocation, accountability, and patient and provider autonomy. The benchmarks standardize the criteria for fairness. Reforms are then evaluated by scoring according to the degree to which they improve the situation, i.e. on a scale of -5 to 5, with zero representing the status quo. The object is to promote discussion about fairness across the disciplinary divisions that keep policy analysts and the public from understanding how trade-offs between different effects of reforms can affect the overall fairness of the reform. The benchmarks can be used at both national and provincial or district levels, and we describe plans for such uses in the collaborating sites. A striking feature of the adaptation process is that there was wide agreement on this ethical framework among the collaborating sites despite their large historical, political and cultural differences.

Inequalities in health care use and expenditures: empirical data from eight developing countries and countries in transition.

This paper summarizes eight country studies of inequality in the health sector. The analyses use household data to examine the distribution of service use and health expenditures. Each study divides the population into "income" quintiles, estimated using consumption expenditures. The studies measure inequality in the use of and spending on health services. Richer groups are found to have a higher probability of obtaining care when sick, to be more likely to be seen by a doctor, and to have a higher probability of receiving medicines when they are ill, than the poorer groups. The richer also spend more in absolute terms on care. In several instances there are unexpected findings. There is no consistent pattern in the use of private providers. Richer households do not devote a consistently higher percentage of their consumption expenditures to health care. The analyses indicate that intuition concerning inequalities could result in misguided decisions. It would thus be worthwhile to measure inequality to inform policy-making. Additional research could be performed using a common methodology for the collection of data and applying more sophisticated analytical techniques. These analyses could be used to measure the impact of health policy changes on inequality.

PIP: This paper summarizes results from eight country studies of inequality in the health sector. The analyses included household data to examine the distribution of service use and health expenditures. In each case, the results were presented by income quintiles, estimated using consumption expenditures. Results revealed that the rich groups have a higher probability of obtaining care when sick, to be more likely to be seen by physicians, and have a higher probability of receiving medicines, than the poor groups. The rich also spend more in absolute terms on care. There was no consistent pattern in the use of private providers. Wealthier households do not devote a consistently higher percentage of their consumption expenditures to health care. The analyses indicated that intuition concerning inequalities could result in misguided decisions. Thus, it would be worthwhile to measure the direction and extent of inequality in order to identify problems and to gauge the success of policy-making. Implications for further research are discussed.

Researching the public/private mix in health care in a Thai urban area: methodological approaches.

The private health sector has been growing rapidly in many low and middle income countries, yet not enough is known about its sources of finance or characteristics of its users. Moreover, health care reform measures are leading to alterations in the mix of public and private finance and provision, increasing further the need for information. This paper presents and evaluates some research methods which can be used to collect information relevant to considering policies on the public/private mix. They comprise a household survey, a health diary and interview survey, a bed census, and a health resource survey. Each method is described as it was used in a study in a large urban setting in Thailand, and strengths and weaknesses of the methods are identified. The use of data to estimate the shares of public and private finance and provision, and particularly private sources of finance of public hospitals and public sources of finance for private hospitals, is demonstrated. Policy issues highlighted by the data are identified.

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.

Nosocomial infection control activities in Thailand 1989.

The study on the infection control activities was done in 89 general regional and community hospitals. Seventy-seven hospitals responded to the questionnaire (87%). All hospitals had set up infection control committees. Infection control nurses had been appointed in 84 per cent; 45 and 39 per cent were part-time and full-time ICNs respectively. Reports of surveillance were sent to the committees in 74 of the hospitals. Doctors took part in infection control in 75 per cent of the hospitals. Isolation units were available in 86 per cent and incinerators were installed in 13 per cent of the hospitals. These results indicate that the allocation of manpower and resources are not sufficient for effective nosocomial infection control.

PIP: Nosocomial infection control activities were initiated in Thailand in 1982, but have suffered from a shortage of manpower and lack of administrative support. The HIV epidemic, however, points to the need to strengthen hospital infection control. This study was, therefore, conducted to assess the current state of infection control activities in general and regional hospitals. A questionnaire on hospital infection control was distributed to 17 regional, 69 general, and 3 community hospitals. 77 hospitals (87%) responded. All respondents had set up infection control committees; 74 hospitals had surveillance reports sent to the committees. Full- or part-time infection control nurses had been appointed in 84% of the hospitals. Further, doctors took part in infection control in 75% of hospitals; isolation units were available in 86%; and incinerators were installed in 13%. These results indicate that manpower and resources are insufficient for the effective control of nosocomial infections.