Who Benefits from Government Health Spending before and after Universal Coverage in Thailand?-ระหว่างคนจนกับคนรวยใครได้รับประโยชน์จากการสร้างหลักประกันสุขภาพถ้วนหน้า?

Abstract

         This study was aimed to answer public concern over a question on “who benefits from government health spending?” after implementation of the policy on universal coverage (UC) of health care in 2001. Changes in health service use and net government subsidies for health gained by different socio-economic groups of Thais prior to and after UC were investigated. The research
employed benefit incidence analysis (BIA) which included the analyses of health service use and out-of-pocket payments of nationally representative households from the 2001 and 2003 Health and Welfare Survey (HWS) conducted by the National Statistical Office, and the amount of government subsidies for ambulatory services and hospitalization at both public and private facilities. Socioeconomic status of Thais were categorized into five groups ranging from the richest to the poorest quintiles by using equivalent household income per capita and the asset index. Concentration index (CI) was used as a measure to assess equity in health service use and the distribution of government health subsidies. CI ranges from plus to minus 1, whereas minus indicates preferential benefit the poor, and the more minus value, the more pro-poor nature, and vice versa. This study was conducted from November 2004 to October 2005.      

         Results revealed that after implementation of the UC policy, health insurance coverage of Thais increased from 71 percent in 2001 to 95 percent in 2003. The majority of the poor in rural areas were covered by the UC scheme. From 2001 to 2003, ambulatory service use of the poorest quintile at health centers increased from 1.20 to 1.90 visits per capita per year, and that of community hospitals rose from 0.71 to 1.84 visits per capita per year. Hospitalization at community hospitals of the poorest category increased from 0.036 to 0.063 admissions per capita per year. The CI of ambulatory
service use at health centres, district hospitals, and provincial hospitals were more pro-poor after implementing UC (changing from -0.29, -0.26, and -0.04 in 2001 to -0.36, -0.32, and -0.08 in 2003, respectively). The CI of overall hospitalization increased their negative values from -0.079 in 2001 to -0.121 in 2003. Also, the distribution of net government subsidies for health showed a more pro-poor nature with a change in the concentration indices from -0.044 in 2001 to -0.123 in 2003. There was no significant difference in the distribution of government subsidies when equivalent household income per capita and the asset index were used as classifiers, or using national aggregated and regional unit costs of health services. In conclusion, the UC policy further improved
equity in access to and utilization of health services, and the distribution of net government subsidies. Key factors influencing the improvements of equity in the Thai health care system include 1) the expansion of health insurance coverage, 2) the removal of financial barriers, and 3) the promotion of primary care as the main contractor of the scheme.

Key words: government resource, benefit incidence, access to care, universal coverage