Equity in health: the need for and the use of public and private health services in an urban area in Thailand

The 'sun-rise' industry of private health care, especially private hospitals, in Thailand throws many questions to the health policy forum. Will the growth of the private health sector reduce public health expenditure, or will it increase total expenditure on health? The focus of this study is on equity in health and health care: in a country where private expenditure dominates total health expenditure and the government lets the private health sector flourish, in this scenario, are the poor or the underprivileged the victims of this limited privatisation policy? The main research objective was to assess the equity of coverage of public and private health in an urban area in order to identify policies of promotion and regulation which would lead to an equitable and efficient health service system. The study used Phitsanulok municipal area as a model to develop policy recommendations for other urban areas. There were three main methods of data collection: general household survey, health diary plus household health interview and a one-day bed census of patients in public and private hospitals in the municipality. The first two methods employed multi-stage random sampling with clusters of 12 and 3 households, respectively, as smallest sampling units and these neighbourhood households were divided into three groups to represent each season in a year. The main findings were that inequalities in health existed among different household income, education and occupational groups, including these attributes of the education and occupational groups adjusted according to the household head. Unequal accessibility to health care seemed to affect both reported rates of illness within the past two weeks and hospitalisation during the past 12 months. Inequity of health care financing was obvious in that the underprivileged (the poor, the uninsured and underinsured) paid out of pocket as a percentage of their household income higher sums than the privileged groups. 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. Users of public facilities were the lower income groups and civil servants, while users of the private health sector were the higher income groups, the higher occupational groups and the younger age groups. Inpatients of private hospitals were more likely to be covered by health benefit schemes (civil servant benefit, private insurance, etc.) than inpatients of public hospitals. Information on the utilisation and financing pattern of private health services reconfirmed inequity of health care financing. It is obvious that the Thai health care system needs changes to reduce inequity in health and health care. Universal coverage is a way towards more equitable health care financing. While Thai citizens (in urban areas) have enjoyed a wide choice of health utilisation, a public competition model could be applied to the public health sector to make public services more competitive and more efficient

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

Integrated strategies to tackle the inequitable distribution of doctors in Thailand: four decades of experience

Inequitable distribution of doctors with high concentration in urban cities negatively affects the public health objective of Health for All. Thus it is one of the main concerns for most health policy makers, particularly in developing countries. This paper aims to summarize strategies to solve inequitable distribution of human resources for health (HRH) between urban and rural areas, by using four decades of experience in Thailand as a case study for analysis

Investigating determinants of out-of-pocket spending and strategies for coping with payments for healthcare in southeast Nigeria

<p>Abstract</p> <p>Background</p> <p>Out-of-pocket spending (OOPS) is the major payment strategy for healthcare in Nigeria. Hence, the paper assessed the determinants socio-economic status (SES) of OOPS and strategies for coping with payments for healthcare in urban, semi-urban and rural areas of southeast Nigeria. This paper provides information that would be required to improve financial accessibility and equity in financing within the public health care system.</p> <p>Methods</p> <p>The study areas were three rural and three urban areas from Ebonyi and Enugu states in South-east Nigeria. Cross-sectional survey using interviewer-administered questionnaires to randomly selected householders was the study tool. A socio-economic status (SES) index that was developed using principal components analysis was used to examine levels of inequity in OOPS and regression analysis was used to examine the determinants of use of OOPS.</p> <p>Results</p> <p>All the SES groups equally sought healthcare when they needed to. However, the poorest households were most likely to use low level and informal providers such as traditional healers, whilst the least poor households were more likely to use the services of higher level and formal providers such as health centres and hospitals. The better-off SES more than worse-off SES groups used OOPS to pay for healthcare. The use of own money was the commonest payment-coping mechanism in the three communities. The sales of movable household assets or land were not commonly used as payment-coping mechanisms. Decreasing SES was associated with increased sale of household assets to cope with payment for healthcare in one of the communities. Fee exemptions and subsidies were almost non-existent as coping mechanisms in this study</p> <p>Conclusions</p> <p>There is the need to reduce OOPS and channel and improve equity in healthcare financing by designing and implementing payment strategies that will assure financial risk protection of the poor such pre-payment mechanisms with government paying for the poor.</p

Measuring and decomposing inequity in self-reported morbidity and self-assessed health in Thailand

<p>Abstract</p> <p>Background</p> <p>In recent years, interest in the study of inequalities in health has not stopped at quantifying their magnitude; explaining the sources of inequalities has also become of great importance. This paper measures socioeconomic inequalities in self-reported morbidity and self-assessed health in Thailand, and the contributions of different population subgroups to those inequalities.</p> <p>Methods</p> <p>The Health and Welfare Survey 2003 conducted by the Thai National Statistical Office with 37,202 adult respondents is used for the analysis. The health outcomes of interest derive from three self-reported morbidity and two self-assessed health questions. Socioeconomic status is measured by adult-equivalent monthly income per household member. The concentration index (CI) of ill health is used as a measure of socioeconomic health inequalities, and is subsequently decomposed into contributing factors.</p> <p>Results</p> <p>The CIs reveal inequality gradients disadvantageous to the poor for both self-reported morbidity and self-assessed health in Thailand. The magnitudes of these inequalities were higher for the self-assessed health outcomes than for the self-reported morbidity outcomes. Age and sex played significant roles in accounting for the inequality in reported chronic illness (33.7 percent of the total inequality observed), hospital admission (27.8 percent), and self-assessed deterioration of health compared to a year ago (31.9 percent). The effect of being female and aged 60 years or older was by far the strongest demographic determinant of inequality across all five types of health outcome. Having a low socioeconomic status as measured by income quintile, education and work status were the main contributors disadvantaging the poor in self-rated health compared to a year ago (47.1 percent) and self-assessed health compared to peers (47.4 percent). Residence in the rural Northeast and rural North were the main regional contributors to inequality in self-reported recent and chronic illness, while residence in the rural Northeast was the major contributor to the tendency of the poor to report lower levels of self-assessed health compared to peers.</p> <p>Conclusion</p> <p>The findings confirm that substantial socioeconomic inequalities in health as measured by self-reported morbidity and self-assessed health exist in Thailand. Decomposition analysis shows that inequalities in health status are associated with particular demographic, socioeconomic and geographic population subgroups. Vulnerable subgroups which are prone to both ill health and relative poverty warrant targeted policy attention.</p

Health care utilisation under the 30-Baht Scheme among the urban poor in Mitrapap slum, Khon Kaen, Thailand: a cross-sectional study

Background: In 2001, the Government of Thailand introduced a universal coverage scheme with the aim of ensuring equitable health care access for even the poorest citizens. For a flat user fee of 30 Baht per consultation, or for free for those falling into exemption categories, every scheme participant may access registered health services. The exemption categories include children under 12 years of age, senior citizens aged 60 years and over, the very poor, and volunteer health workers. The functioning of these exemption mechanisms and the effect of the scheme on health service utilisation among the poor is controversial. Methods: This cross-sectional study investigated the prevalence of 30-Baht Scheme registration and subsequent self-reported health service utilisation among an urban poor population in the Teparuk community within the Mitrapap slum in Khon Kaen city, northeastern Thailand. Furthermore, the effectiveness of the exemption mechanisms in reaching the very poor and the elderly was examined. Factors for users' choice of health facilities were identified. Results: Overall, the proportion of the Teparuk community enrolled with the 30-Baht Scheme was high at 86%, with over one quarter of these exempted from paying the consultation fee. User fee exemption was significantly more frequent among households with an above-poverty-line income (64.7%) compared to those below the poverty line (35.3%), χ2 (df) = 5.251 (1); p-value = 0.018. In addition, one third of respondents over 60 years of age were found to be still paying user fees. Self-reported use of registered medical facilities in case of illness was stated to be predominantly due to the service being available through the scheme, with service quality not a chief consideration. Overall consumer satisfaction was high, especially among those not required to pay the 30 Baht user fee. Conclusion: Whilst the 30-Baht Scheme seems to cover most of the poor population of Mitrapap slum in Khon Kaen, the user fee exemption mechanism only works partially with regard to reaching the poorest and exempting senior citizens. Service utilisation and satisfaction are highest amongst those who are fee-exempt. Service quality was not an important factor influencing choice of health facility. Ways should be sought to improve the effectiveness of the current exemption mechanisms.Sophie Coronini-Cronberg, Wongsa Laohasiriwong and Christian A Gerick