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.