1. Monitoring progresses of health equity and the impact of achieving universal health coverage (UHC): Lessons from Thailand
Phusit Prakongsai, MD. Ph.D.
Bureau of International Health (BIH)
Ministry of Public Health (MOPH), Thailand
Presentation to the International Meeting on Public Health Development Index (PHDI)
As a monitoring tool to monitor inequity of health development
The Parklane Jakarta Hotel, Indonesia
6th October 2015 1

2. Why health equity?
Consistent evidence indicating that disadvantaged groups have poorer survival chances;
Large gaps in mortality can also be seen between urban and rural populations and between different regions in the same country;
There are great differences in the experience of illness  disadvantaged groups not only suffer the heavier burden of illness, but also experience the onset of chronic illness and disability at younger ages;
In Thailand, health equity has been raised in a number of policy statements and legal documents:
Thai Constitution 2550(B.E.) Chapter 9 Section 51 & 80,
The Statute on National Health System 2008, Chapter 3, Section 16,
Patient’s and Human Rights,
Government policy on health.

3. Possible consequences of scaling up health interventions
Service coverage 52%
(Population-weighted. average)
Scaled up to 75%
Option B
Option A

4. Percentage of birth with professional attendant
among different income quintiles in selected countries
Source: Houweling et al. (2007)

5. Definition of Health Equity
The International Society for Equity in Health (ISEqH) defined equity in health as
“The absence of systematic and potentially remediable differences which are unnecessary and avoidable, but in addition, are also considered unfair and unjust,
in one or more aspects of health across populations or population subgroups defined socially, economically, demographically, or geographically”
Inequity in health or ‘health inequity’ is differences in health that are avoidable, unjust, and unfair (Whitehead 1992). 5

6. Equality vs equity

7. Philosophies of health equity
Characteristics
Libertarianism
Emphasize a respect for natural right – the rights to life and possessions
A minimum standard of health care should be provided to all people, while additional health care can be obtained depending on individual’s purchasing power and preferences.
Utilitarianism
Maximize the sum of individual utilities and welfare,
Concerns on efficiency and likelihood of medical success.
Egalitarianism
Aims to reduce health inequality,
Health care should be financed according to ability to pay,
Delivery of health care should be allocated according to health need.

8. How to measure health (in)equity?

9. Health workforce density by provinces, 2004
Per 100,000 population
1-10
11-20
21-30
31-40
41+
1-100
251+
Doctors Nurses

10. Lorenz curve Progressivity of population income
100 80
Equality line 60
Income (cumulative %, L)
L(p) 40 20 20 40 60 80
100
Population (cumulative %, p), ranked by income
Accumulation of a variable of interest (here, income)
with respect to cumulative ranking of this variable
Lorenz MO. Methods for measuring the concentration of wealth. J Am Stat Assoc. 1905; 9.

11. The concentration curve
The concentration curve graphs on the x-axis the cumulative percentage of the sample ranked by living standards, beginning with the poorest, and on the y-axis the cumulative percentage of the health service use corresponding to each cumulative percentage of the distribution of the living standard variable.

12. The concentration index
Concentration index (CI) = 2 x shaded area
CI lies in range (-1,1)
CI < 0 because variable is “concentrated” among the poor
75% of disease burden
Cumulative proportion of illness
Poorest 50% of population

13. Health equity dimensions
Equity in health care finance
Equity in access to health care and health care use
Equity in health status
Equity in the distribution of government subsidy on health (benefit incidence analyses)
Equity in health risk distribution
Equity in quality of health services recieved

14. Dimensions and determinants of health equity
Health financing
Healthcare
utilization
Quality & responsive-ness
Health
status
Government subsidy on health
Health risk
Geographic
Region
Urban vs. Rural
Demographic
Gender
Age group
Social
Education
Occupation
Economic
Income
Wealth index 15

15. Data availability for H equity analysis and monitoring in Thailand (1)
Input
Output
Outcome
Impact
HCF
HRH
Infra structure
Gover
nance
Med/
Health tech
HIS
access
quality
safety
efficiency
Interven coverage
Risk factors H
outcome
Responsive
Equity
Finan protect
ion
Civil registration and vital statistics 
Biennial SES
Biennial HWS
Census / SPC
NHES
MICS
Reproductive H survey
NHA
Note: SES = household socio-economic survey, HWS= Health and Welfare survey, NHES = National Health Examination survey,
MICS = Multiple Indicator Cluster survey, NHA = National Health Accounts, HA = Hospital accreditation, SPC= Survey of Population Changes

16. Data availability for H equity analysis and monitoring in Thailand (2)
Input
Output
Outcome
Impact
HCF
HRH
Infra structure
Gover
nance
Med/
Health tech
HIS
access
quality
safety
efficiency
Interven coverage
Risk factors H
outcome
Responsive
Equity
Finan protect
ion
Facility-based report 
H resource survey
HIS electronic IP database
Dis surveillance
Behavioral H survey
Sero-sentinel
Survey
Specific dis registration
Quality assurance (HA)

17. Three public health insurance schemes in Thailand after achieving UHC in 2002
Civil Servant Medical Benefit Scheme
(CSMBS)
Social Security Scheme
(SSS)
Universal health coverage
(UHC)
Introduced in
1963
1990
2002
Target beneficiaries
Govt employees & dependents, retirees
Private sector employee
Informal sector who are neither covered by CSMBS nor SHI,
Population Coverage 7%
13%
78%
Funding
Govt budget
Payroll contribution, Tripartite
Payment to health facilities
Fee-for-service for OP, and DRG for IP
Capitation
(use DRG in risk adjusted part)
Capitation for OP
+ DRG with global budget for IP

18. UHC cube: what has been achieved in Thai universal health coverage?
X axis:
99% pop coverage by 3 schemes [UCS 78%, SHI 13%, CSMBS 7%]
Y axis:
Free at point of services, very minimum OOPs,
Low incidence of catastrophic health expenditure and health impoverishment,
Z axis:
Extensive and comprehensive benefit package, very small exclusion list,
Most high cost interventions were covered: dialysis, chemotherapy, major surgery, medicines including Essential Drug List (EDL).

19. Scheme beneficiaries by income quintile (2003 and 2007) UC scheme covers mostly the poor, approx 50% in Q1 & Q2
Source: Analysis of Health and Welfare Survey (various years)

20. Type of health facilities
The distribution of ambulatory service use among different income quintiles in 2001 and 2003, by types of health facilities
2003
2001
Concentration indices of ambulatory service use among different types of health facilities in 2001 & 2003
Type of health facilities
2001
2003
Health centers
Community hospitals
Provincial and regional hospitals
Private hospitals
0.4313
0.3484

21. Selected concentration curves of ambulatory service use among different types of health facilities in 2003

22. Distribution of government subsidies for health: Benefit incidence analysis (BIA), 2550-2007 B.E.

23. Financial risk protection (1) Household OOP as % household income, 1992-2008
Source: Analysis from household socio-economic surveys (SES) in various years , NSO

24. Incidence of catastrophic health spending OOP>10% total consumption expenditure
Source: Analysis of Socio-economic Survey (SES)

25. The analysis of household impoverishment from health care costs in 1996 shows that approximately 20% of informal sector households and 16% of all households were impoverished from health care payments in 1996.

27. Sub-national health impoverishment 1996 to 2008

28. Analysis of Cigarette Smoking and Alcohol Drinking Behavior Survey (CSAD) in Thailand, 2007
Regular (weekly) alcohol drinking prevalence, %
Binge alcohol drinking prevalence, %

29. Sources: Analyses from the 2002, 2004, and 2006 SES
Household expenditure: tobacco, alcohol and health Median household expenditure (Baht per month),
Sources: Analyses from the 2002, 2004, and 2006 SES

31. Equity in MCH from analysis of MICS3 data

32. Access to reproductive health services in Thailand in 2009, by region
Source: Access to reproductive health services in Thailand: is it equitable? Suratchada Kongsri et al (2011)

33. The impact of different provider payment methods on
use of expensive procedures across 3 public insurance schemes
Cesarean section Laparoscopic cholecystectomy
Source: Limwattananon et al. (2009)

34. FFS payment of CSMBS and use of expensive OP medicines
Variations across 3 public insurance schemes
Source: Limwattananon et al. (2009)

35. DATA & INFORMATION CYCLE
Essential indicators
Definitions
Tools
Collect
Feedback
Program changes
Policy changes
Resource allocation
Reporting: completeness
Verification: data checks
Adjustment
Use
Process
Multiple indicators
Context
Overall performance
Interpret
Analyze
Error and adjustment report
Indicator computation
Performance assessment
Present
Visualization of data
Formats for communication

36. Lessons learnt and key challenges
Despite political commitment and availability of several HH survey data,
Capacity in regularly analyzing, monitoring, and reporting the progress of health equity in Thailand is limited,
Multi-stakeholder’s participation, especially between data producers, researchers, and policy advocacy are needed,
Effective mechanisms to disseminate and simplify the research findings to policy makers and the public are needed,
There is a strong need for
Translation of research findings into policy and practice,
Adequate government budget and financial resources for developing the HH survey data and build up capacity,
Appropriate indicators for HH socio-economic status.

37. Acknowledgements Ministry of Public Health (MOPH) of Thailand
National Statistical Office of Thailand (NSO)
Health Systems Research Institute (HSRI)
Health Information System Development Office (HISO)
Thai Health Promotion Foundation (THPF)
National Health Security Office (NHSO)
Long-term fellowship program of WHO