The impact of the universal coverage policy on equity of the Thai health care system

In 2001, the government of Thailand implemented a universal coverage (UC) policy for access to health care by introducing a tax-funded health insurance scheme, the UC scheme, to approximately 47 million people who were not previous beneficiaries of the Civil Servant Medical Benefit Scheme (CSMBS) or the Social Security Scheme (SSS). The UC policy resulted in a significant change in health care financing arrangements and financial barriers to health services. The purpose of this research was to explore the likely impact of the UC policy in terms of the following factors: changes in health care use, equity in health care finance, and the distribution of public subsidies on health among different socio-economic groups of Thais. In addition, the effectiveness of the UC policy in protecting households against financial hardship as a result of medical care costs was explored at the household level. Benefit incidence analysis (BIA) was employed as a tool to assess equity in health service use and the distribution of public subsidies. Two case studies of renal replacement therapy (RR T) for end-stage renal disease (ESRD) patients and cardiac operations for heart disease patients were employed as tracers to explore the impact of the UC scheme's benefit package for better-off and less well-off households. Different choices of socio-economic group indicators (household income per capita or an asset index) and the use of aggregate and regional unit subsidies to calculate benefit incidence were also applied. Research results indicate that the UC policy did expand health care coverage to include nearly all Thais and increased the pro-poor nature of the Thai health care system, as well as the distribution of public health-related subsidies. Ambulatory service use and hospitalization of poorer quintiles significantly increased after the UC policy was implemented. The poorest quintiles gained the highest amount and proportion of public subsidies both prior to and after implementation of the UC policy. There was no change in conclusions regarding the distribution of public subsidies among different socioeconomic groups when different choices of socio-economic indicators or different levels of government unit subsidies were used. The analysis of financing incidence between 2000 and 2002 also showed less regressive overall health care finance, a greater decrease in household expenditure for health care among poorer quintiles, and a decrease in the catastrophic expenditure incidence in 2002, compared to 2000. The decision to exclude RRT from the UC benefit package resulted in a considerable financial barrier to health services and a substantial economic impact on poorer ESRD patients. Infrequent access to haemodialysis and the inability to obtain essential and expensive medication (erythropoietin) was shown to be a major cause of patients' death. Financial barriers to RR T prevented poorer ESRD patients from benefiting from access to essential health services, and the financial burden of RR T meant all poorer patients were inevitably faced with financial catastrophe as a result. Poorer ESRD patients adopted various financial strategies to cope with high health care expenditures, which impacted not only the ESRD patients themselves, but also other household members and relatives who had to provide supplemental financial support to help cover the costs of RRT. In contrast, neither poorer nor richer heart disease patients under the UC scheme experienced significant payments for the health care costs of open heart surgery due to the effectiveness of the scheme in financial risk protection. During the operation, a few poorer heart disease patients experienced financial burdens for travel costs and food expenditures for their relatives, but they were able to manage this financial burden by using their savings or taking loans, all without a significant financial impact on household living standards. In conclusion, the UC policy does appear to have overall improved equity in health care use and health care finance, and the distribution of public subsidies. Achievements of the UC policy in Thailand were most likely caused by the following three financing strategies: 1) the expansion of public health insurance to nearly universal coverage; 2) the removal of financial barriers to health services; and 3) the promotion of primary care use which is preferentially accessed and utilized by the poor in rural areas.EThOS - Electronic Theses Online ServiceGBUnited Kingdo

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

Factors contributing to the voluntary counseling and HIV testing for persons at risk of HIV infection in Thailand

Thailand has a policy to support access to voluntary HIV counseling and testing (VCT) for all its citizens.  Thais are eligible for two free VCT sessions per year and this has increased clinic uptake, but the total is still well below the target coverage (10% testing for the general population and 90% for the higher-risk populations). The objective of this research was to study the factors which enabled persons at risk of HIV to obtain VCT in Thailand. This research was a cross-sectional study and used questionnaires to ask respondents about risk behavior, self-risk assessment, benefits coverage, measures and service system, attitudes toward VCT, self-stigma, prejudice toward others, and experience of discrimination.  Data were collected during May to July 2013 in eight, purposively-selected provinces which are the part of the focus area for the 2012-16 National AIDS Program Plan (NAP). The method for selecting respondents used time-location quota sampling to achieve a total sample of 751 persons. This study found that proportion who had VCT in the year prior to the survey was 56%.   The significant enabling factors associated with VCT were having someone encourage them to go for testing and receiving information about VCT.  In addition, other significant factors for FSW were self-assessed risk for HIV and having had risk behavior. Other significant factors for MSM were awareness of eligibility for VCT and age 24 years or older. Thus, in order to achieve the VCT target for higher-risk populations by 2016, there should be special mechanisms to inform the different groups about the VCT service and motivation to go for VCT, along with improvements in outreach services to make VCT more convenient for Key affected populations include an annual health check

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

Missing: Where Are the Migrants in Pandemic Influenza Preparedness Plans?

Influenza pandemics are perennial global health security threats, with novel and seasonal influenza affecting a large proportion of the world’s population, causing enormous economic and social destruction. Novel viruses such as influenza A(H7N9) continue to emerge, posing zoonotic and potential pandemic threats. Many countries have developed pandemic influenza preparedness plans (PIPPs) aimed at guiding actions and investments to respond to such outbreak events. Migrant and mobile population groups—such as migrant workers, cross-border frontier workers, refugees, asylum seekers, and other non-citizen categories residing within national boundaries—may be disproportionately affected in the event of health emergencies, with irregular/undocumented migrants experiencing even greater vulnerabilities. Because of a combination of political, sociocultural, economic, and legal barriers, many migrants have limited access to and awareness of health and welfare services, as well as their legal rights. The conditions in which migrants travel, live, and work often carry exceptional risks to their physical and mental well-being. Even if certain migrant groups have access to health services, they tend to avoid them due to fear of deportation, xenophobic and discriminatory attitudes within society, and other linguistic, cultural, and economic barriers. Evidence indicates that social stigmatization and anxieties generated by restrictive immigration policies hinder undocumented immigrants’ access to health rights and minimizes immigrants’ sense of entitlement to such rights

Universal Coverage on a Budget: Impacts on Health Care Utilization and Out-Of-Pocket Expenditures in Thailand

We estimate the impact on health care utilization and out-of-pocket (OOP) expenditures of a major reform in Thailand that extended health insurance to one-quarter of the population to achieve universal coverage while keeping health spending below 4% of GDP. Identification is through comparison of changes in outcomes of groups to whom coverage was extended with those of public sector employees and their dependents whose coverage was not affected. The reform is estimated to have reduced the probability that a sick person goes without formal treatment by 3.2 percentage points (11%). It increased the probability of receiving public ambulatory care by 2.7 ppt (5%) and of admission to a public hospital by 1 ppt (18%). OOP expenditures were reduced by one-third on average, as was the probability of spending more than 10% of the household budget on health care, while spending at the very top of the OOP distribution was reduced by one-half representing substantial reductio ns in exposure to medical expenditure risk. Supply-side measures implemented with the coverage extension are likely to have helped realize these effects from an increased, but still very tight, budget

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

Abstract 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

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