International Health Policy Program -Thailand International Health Policy Program (IHPP), Thailand 13 March 2013 Post Enumeration Survey (PES) of the household Socio-Economic Survey (SES) in Thailand An adjustment of household out-of-pocket payments

International Health Policy Program -Thailand Outline of presentation 1.What is PES ? 2.Problems in HH out-of-pocket payments 3.Objectives of the study 4.Methods and conceptual framework 5.Results 6.Discussion and policy recommendations 2

International Health Policy Program -Thailand What is PES ? An independent survey replicating a census or a national HH survey aiming to evaluate quality and accuracies of the census or the national survey data, PES results can be compared with the results of census or national HH surveys, and permit estimates to be made of: – Coverage errors; – Content errors; PES is worth conducting if it is carefully planned and well implemented. 3

International Health Policy Program -Thailand Problems of HH out-of-pocket payments OOP, a major component of total health expenditure (THE) in developing countries, Potential under-reporting by households due to: – Sampling bias; – Non-sampling bias; Respondents Proxy respondents tend to be under-reporting in morbidity, utilization, and health expenditure, The use of proxy respondents instead of interviews of all eligible household members. Interviewers 4

International Health Policy Program -Thailand Objectives To identify discrepancy among morbidity (OP and IP), health service utilization, and out-of-pocket payments (OOP) between NSO and IHPP interviewers in three options: Full proxy situation The most knowledgeable HH members provide information on behalf of all respondents, Real life situation Interviews of all members on the interview day and proxy respondents for non-presence members, Gold standard Interviews of all eligible members, until exhausted in three visits, Eligible members, age 15-60, proxy allowed proxy respondents for those 60 years. To consider applying discrepancies indexes for the adjustment of OOP reported by SES 5

International Health Policy Program -Thailand Methodology 1 NSO SES 2002 National representative, a 12-months HH survey Health module available Interviewers were instructed to use gold standard approach, However 2.5 hours to complete one SES Q’naire, might slip to real life or full proxy. IHPP-PES Post-enumeration survey in 23 provinces in 3 months (Mar-May 03) in the randomly selected households, two weeks after ending SES interviewed by NSO field staffs IHPP 20 trained interviewers, instructed to do gold standard interviews of all eligible respondents until exhausted in the 3rd visit. 6

Methodology 2 IHPP methodological testing Three methods were applied in the same household by the same IHPP interviewer: Full Proxy by interviews of the most knowledgeable person; Real life, interviews all eligible present on the first visit and allow proxy respondents for non-presence members; Gold standard, three repeated visits to interview the eligible member. Last visit allow proxy respondents. PES of the SES completed households in 5 provinces in 1 month (July 03) To produce 3 adjusting factors IHPP Gold standard to NSO real life IHPP Gold standard to NSO Gold standard IHPP Gold standard to NSO full proxy 7

Conceptual framework of PES SES 2002 Household sample head member < 15 member > 15 IHPP Interview another set of sample HH Full proxy Real life Gold std PQ approach to estimate national household spending on H=62 mil pop x morbid rate x choice x baht OOP/visit or admission Discrepancy index II Discrepancy index III Three factor of morbid rate, choice and hh spending OOP Factor 1: Gold std / Full proxy Factor 2: Gold std / Real life Factor 3: Real life / Full proxy Use factor2 adjust NSO-Real life version To be gold standard Use 1/factor3 adjust NSO-Real life version To be Full proxy 2 wk time lag same recall period OP: last mo IP: last year Morbid OP IP Choices OP IP HH spending OP IP Argument for NSO “Real life” Interview KI: Key Informant Training NSO staff 2003, it must be gold standard  slip  Real life. Nosy interviewees join the interview. Household sample head member < 15 member > 15 IHPP Gold standard A billion baht NSO Real life B billion baht NSO Gold standard C billion baht NSO Full proxy D billion baht Discrepancy index I Morbid OP IP Choices OP IP HH spending OP IP NSO “Real life” Interview IHPP “Gold std” Interview 8

International Health Policy Program -Thailand Results PES-SES Total 855 households in 23 provinces, in three months, 559 municipality and 296 non-municipality households, IHPP methodological testing Total 150 households in 5 provinces in 1 month 80 municipality and 70 non-municipality households 9

PQ approach Discrepancy index II 1.05 Discrepancy index III 1.14 Discrepancy index I 1.13 ABCD IHPPNSO "Gold std""Real life""Gold std""Full proxy" OP (mil baht)40,54837,49940,08937,780 IP (mil baht)12,374 9,26410,109 8,741 Total (mil baht)52,92146,76450,19846,521 ratio of OP77%80% 81% ratio of IP23%20% 19% HH spending on health expenditure 10

Final adjustment for SES2002 Percentage of OOPs increased from 32.7% to 33.8% and 35.7% respectively. 11 SES 2000 Adjust with 1.05 Adjust with 1.14 New ratio (min) New ratio (max) OOP Other THE100%101.64%104.58%100%

International Health Policy Program -Thailand Discussion OOPs reported by biennial SES (even years) which discrepancy index should be used to adjust OOP: – Depends on NSO interviewers behaviors (real life or full proxy), – NSO gold standard is unlikely – costly, lengthy q’naire of SES, average 2.5 hours We decided not use this correcting factor for OOP adjustment due to small sample size of SES. 12

International Health Policy Program -Thailand Policy recommendations PES is quite expensive, and needs carefully plan and well implementation, Discussion with Secretary General of NSO – Decided to conduct national PES for the next population and housing census. 13

International Health Policy Program -Thailand Acknowledgements National Statistical Office (NSO) National Health Security Office (NHSO) Ministry of Public Health Health Systems Research Institute (HSRI) 14

International Health Policy Program -Thailand Sawasdee Thank you for your attention 15