Which households are at risk of catastrophic health spending: Experience in Thailand after universal coverage

Health Affairs

Volumn 28, Issue 3, 2009, Pages

  Somkotra, Tewarit ^a   Lagrada, Leizel P ^b  

^a CHULALONGKORN UNIVERSITY   (Thailand)

^b TOKYO MEDICAL AND DENTAL UNIVERSITY   (Japan)

Author keywords

[No Author keywords available]

Indexed keywords

ARTICLE; CHRONIC DISEASE; DISABILITY; ELDERLY CARE; FINANCIAL MANAGEMENT; HEALTH CARE COST; HEALTH CARE POLICY; HEALTH INSURANCE; HOSPITALIZATION; HOUSEHOLD; PRIVATE HEALTH INSURANCE; RISK ASSESSMENT; THAILAND;

CATASTROPHIC ILLNESS; COST SHARING; DEVELOPING COUNTRIES; FINANCING, PERSONAL; HEALTH CARE REFORM; HEALTH EXPENDITURES; HEALTH POLICY; HEALTH SERVICES; HUMANS; INSURANCE, MAJOR MEDICAL; REFERRAL AND CONSULTATION; RISK FACTORS; RISK SHARING, FINANCIAL; SOCIOECONOMIC FACTORS; THAILAND; UNCOMPENSATED CARE; UNIVERSAL COVERAGE;

EID: 66749129699     PISSN: 02782715     EISSN: 15445208     Source Type: Journal    
DOI: 10.1377/hlthaff.28.3.w467     Document Type: Article

References (70)

1. See, for example, A. Wagstaff and E. van Doorslaer, "Catastrophe and Impoverishment in Paying for Health Care: With Applications to Vietnam 1993-1998," Health Economics 12, no. 11 (2003): 921-934;
2. K. Xu et al., "Household Catastrophic Health Expenditure: A Multicountry Analysis," Lancet 362, no. 9378 (2003): 111-117;
3. K. Xu et al., "Protecting Households from Catastrophic Health Spending," Health Affairs 26, no. 4 (2007): 972-983;
4. and F.M. Knaul et al., "Evidence Is Good for Your Health System: Policy Reform to Remedy Catastrophic and Impoverishing Health Spending in Mexico," Lancet 368, no. 9549 (2006): 1828-1841. (Pubitemid 44755396)
5. World Health Organization, The World Health Report 2000, Health Systems: Improving Performance (Geneva: WHO, 2000).
6. V. Tangcharoensathien, W. Teokul, and L. Chanwongpaisarn, "Challenges of Implementing Universal Health Care in Thailand," in Transforming the Developmental Welfare State in East Asia, ed. H.J. Kwon (New York: Palgrave Macmillan, 2005), 257-282;
7. and V. Tangcharoensathien and P. Jongudomsuk, eds., From Policy to Implementation: Historical Events during 2001-2004 Universal Coverage in Thailand (Nonthaburi: Health Systems Research Institute, 2005).
8. For a table containing more details on the Thai system, see Annex 1, online at http://content.healthaffairs.org/cgi/content/full/hlthaff.28.3.w467/ DC2.
9. Recently, a 30 baht copayment required when UCS beneficiaries use health care was abolished. See D. Hughes and S. Leethongdee, "Universal Coverage in the Land of Smiles: Lessons from Thailand's 30 Baht Health Reforms," Health Affairs 26, no. 4 (2007): 999-1008.
10. CSMBS beneficiaries are required to pay a copayment for drugs that are not on the national essential drugs list, unless their use is deemed necessary by a committee of doctors; they also pay a copay for admission to a private facility (except if the admission is for a life-threatening condition). The benefit packages for UCS and SSS beneficiaries exclude some diseases and treatments (such as organ transplantation, infertility treatment, drug addiction treatment, hemodialysis for the end stage of chronic renal failure, artificial insemination, obstetric delivery beyond two pregnancies, and hospitalization beyond 180 days in a year).
11. S. Limwattananon, V. Tangcharoensathien, and P. Prakongsai, "Catastrophic and Poverty Impacts of Health Payments: Results from National Household Surveys in Thailand," Bulletin of the World Health Organization 85, no. 8 (2007): 600-606;
12. and V. Tangcharoensathien, S. Wibulpholprasert, and S. Nitayaramphong, "Knowledge-Based Changes to Health Systems: The Thai Experience in Policy Development," Bulletin of the World Health Organization 82, no. 10 (2004): 750-756. (Pubitemid 39457825)
13. E. van Doorslaer et al., "Catastrophic Payments for Health Care in Asia," Health Economics 16, no. 11 (2007): 1159-1184.
14. Tangcharoensathien and Jongudomsuk, eds., From Policy to Implementation;
15. S. Wibulpolprasert, ed., Thailand Health Profile 2001-2004 (Bangkok: Express Transportation Organization Publishing, 2005);
16. O. O'Donnell et al., "The Incidence of Public Spending on Health Care: Comparative Evidence from Asia," World Bank Economic Review 21, no. 1 (2007): 93-123;
17. and O. O'Donnell et al., "Who Pays for Health Care In Asia?" Journal of Health Economics 27, no. 2 (2008): 460-475.
18. The National Economic and Social Development Board (NESDB) reported performance indicators on poverty and income distribution among Thai households over the period 1988-2007 consisting of poverty headcounts, the poverty gap ratio, the severity of poverty, and so on. These indicators revealed enormous progress in poverty reduction in Thailand. For instance, poverty headcounts declined from 17.46 percent of the population in 1998 to 8.48 percent in 2006. NESDB, Data and Indicators on Poverty and Income Distribution (1988-2007) (Bangkok: NESDB, 2008).
19. Xu et al., "Household Catastrophic Health Expenditure."
20. Knaul et al., "Evidence Is Good for Your Health System."
21. The National Statistical Office conducted the SES 2006 during the entire year; the data used for this study included only the first half-year round (January-June) with the accompanying Health and Welfare Survey (HWS) 2006.
22. See online Annex 1, as in Note 3.
23. The fluctuation of household consumption is less than that of household income over time, and data on consumption may be more reliable than income data, particularly in developing countries, where the informal employment sector is relatively large and where survey respondents may not wish to reveal their true incomes. A. Deaton, The Analysis of Household Surveys: A Microeconometric Approach to Development Policy (Baltimore: Johns Hopkins University Press, 1997).
24. h is number of children (younger than age fifteen). This equivalence scale was used in previous studies by EQUITAP. See O'Donnell et al., "The Incidence of Public Spending on Health Care";
25. and O'Donnell et al., "Who Pays for Health Care in Asia?"
26. The dependent variable takes a value of 1 if a household incurred catastrophic health expenditure, and 0 otherwise.
27. Xu et al., "Household Catastrophic Health Expenditure";
28. Xu et al., "Protecting Households from Catastrophic Health Spending";
29. Knaul et al., "Evidence Is Good for Your Health System";
30. K. Xu et al., "Understanding the Impact of Eliminating User Fees: Utilization and Catastrophic Health Expenditures in Uganda," Social Science and Medicine 62, no. 4 (2006): 866-876;
31. and T.T. Su, B. Kouyate, and S. Flessa, "Catastrophic Household Expenditure for Health Care in a Low-Income Society: A Study from Nouna District, Burkina Faso," Bulletin of the World Health Organization 84, no. 1 (2006): 21-27. (Pubitemid 43150857)
32. Subsistence expenditures were defined as food expenditures of households with the sample's median food share of total spending. To minimize measurement error, we used the average food spending of households whose food spending share was in the 45th-55th percentile range instead. Also, using estimated subsistence spending rather than actual food spending would not underestimate the capacity to pay, particularly among the better-off. As subsistence spending is fixed for all households, regardless of their consumption levels, the deduction of that spending affects the proportion of health spending in capacity to pay for poor households more than for others. It also means that if households pay the same proportion of their capacity to pay, the richer pay higher proportions of their total consumption than the poor. Xu et al., "Household Catastrophic Health Expenditure";
33. and K. Xu et al., "Household Health System Contributions and Capacity to Pay: Definitional, Empirical, and Technical Challenges," in Health Systems Performance Assessment: Debates, Methods and Empiricism, ed. C.J.L. Murray and D.B. Evans (Geneva: WHO, 2005), 533-542.
34. This threshold is commonly used in other studies and has been put forward to approximate the burden at which a household may sacrifice basic needs, deplete assets, incur debt, or become impoverished. Wagstaff and van Doorslaer, "Catastrophe and Impoverishment";
35. and Su et al., "Catastrophic Household Expenditure."
36. In the past, especially before the economic crisis, higher proportions of out-of-pocket payments for health care as a share of household resource were more concentrated among the poor Thai households than among better-off households; that is, the poor not only paid more for health care but also paid a disproportionate share of their resources. This changed after the onset of economic crisis: the better-off groups became the main spenders for health care through out-of-pocket payments, and such spending was found to be slightly progressive. However, it was noted that the payments made by the poor increased for self-medication but decreased for institutional care, presumably implying that they used less care at health facilities. S. Pannarunothai and A. Mills, "The Poor Pay More: Health-Related Inequality in Thailand," Social Science and Medicine 44, no. 12 (1997): 1781-1790;
37. V. Tangcharoensathien et al., "Health Impacts of Rapid Economic Changes in Thailand," Social Science and Medicine 51, no. 6 (2000): 789-807;
38. O'Donnell et al., "Who Pays for Health Care In Asia?";
39. and van Doorslaer et al., "Catastrophic Payments for Health Care."
40. J.P. Ruger and H.J. Kim, "Out-of-Pocket Healthcare Spending by the Poor and Chronically Ill in the Republic of Korea," American Journal of Public Health 97, no. 5 (2007): 804-811;
41. Su et al., "Catastrophic Household Expenditure";
42. Y.C. Shen and J. McFeeters, "Out-of-Pocket Health Spending between Low- and Higher-Income Populations: Who Is at Risk of Having High Expenses and High Burdens?" Medical Care 44, no. 3 (2006): 200-209;
43. and E.C. Ziller, A.F. Coburn, and A.E. Yousefian, "Out-of-Pocket Health Spending and the Rural Underinsured," Health Affairs 25, no. 6 (2006): 1688-1699.
44. V. Yiengprugsawan et al., "Measuring and Decomposing Inequity in Self-Reported Morbidity and Self-Assessed Health in Thailand," International Journal for Equity in Health 6 (2007): 23;
45. and V. Tangcharoensathien, S. Limwattananon, and P. Prakongsai, "Improving Health-Related Information Systems to Monitor Equity in Health: Lessons From Thailand," in The Economics of Health Equity, ed. D. McIntyre and G. Mooney (Cambridge: Cambridge University Press, 2007), 222-246.
46. Although the government has gradually improved the delivery system under universal coverage (such as through designating primary care units), the problems of limited quantities of primary care services, area coverage, service quality differentiation, network and referral systems, and lack of continuous development stemming from low budget support for infrastructure and human resource development persist. Hence, the primary care system development that will facilitate access to health care requires urgent action. S. Chunharas et al., Health Services Delivery and Health Insurance Systems: Problems and Recommendation for Development (in Thai) (Nonthaburi: Health Systems Research Institute, 2006);
47. and C. Suraratdecha, S. Saithanu, and V. Tangcharoensathien, "Is Universal Coverage a Solution for Disparities in Health Care? Findings from Three Low-Income Provinces of Thailand," Health Policy 73, no. 3 (2005): 272-284. (Pubitemid 41019063)
48. G. Flores et al., "Coping with Health-Care Costs: Implications for the Measurement of Catastrophic Expenditures and Poverty," Health Economics 17, no. 12 (2008): 1393-1412;
49. and P. Gertler and J. Gruber, "Insuring Consumption against Illness," American Economic Review 92, no. 1 (2002): 51-70.
50. Suraratdecha et al., "Is Universal Coverage a Solution"; see also online Annex 1, as in Note 3.
51. D.R. Gwatkin, "Poverty and Inequalities in Health within Developing Countries: Filling the Information Gap," in Poverty, Inequality, and Health: An international Perspective, ed. D.A. Leon and G. Walt (Oxford: Oxford University Press, 2001), 217-246.
52. Y. Teerawattananon et al., "Health Sector Regulation in Thailand: Recent Progress and the Future Agenda," Health Policy 63, no. 3 (2003): 323-338. (Pubitemid 36197699)
53. Xu et al. "Protecting Households from Catastrophic Health Spending";
54. Knaul et al., "Evidence Is Good for Your Health System";
55. Xu et al., "Understanding the Impact of Eliminating User Fees";
56. and Shen and McFeeters, "Out-of-Pocket Health Spending."
57. Ruger and Kim., "Out-of-Pocket Healthcare Spending";
58. Su et al., "Catastrophic Household Expenditure for Health Care";
59. Shen and McFeeters, "Out-of-Pocket Health Spending";
60. and Ziller et al., "Out-of-Pocket Health Spending."
61. See online Annex 1, as in Note 3.
62. Population aging may result in a "pincer effect" on public finance - that is, a greater number of older people will require greater amounts of health care services and pensions, but relatively fewer people will be working to pay for them. Several policies from other countries to deal with population aging are directed at increasing workers' productivity, increasing workforce retention by delaying retirement, promoting self-funding of retirement, increasing national saving, and reducing the growth in demand for health care. W. Srithunyaratana et al., Knowledge Synthesis for Development of Recommendations for Health Service and Insurance System for Thai Elderly (in Thai) (Nonthaburi: Health Systems Research Institute, 2002).
63. See Limwattananon et al., "Catastrophic and Poverty Impact";
64. Xu et al., "Understanding the Impact of Eliminating User Fees";
65. and Ziller et al., "Out-of-Pocket Health Spending."
66. See online Annex 1, as in Note 3.
67. Xu et al., "Understanding the Impact of Eliminating User Fees."
68. M. Grossman, "The Demand for Health: A Theoretical and Empirical Investigation," National Bureau of Economic Research Occasional Paper no.119 (New York: Columbia University Press, 1972), 115.
69. Flores et al., "Coping with Health-Care Costs";
70. and Gerder and Gruber, "Insuring Consumption."