1. International Health Policy Program -Thailand 1 The implications of benefit package design: the impact on poor Thai households of excluding renal replacement therapy Phusit Prakongsai, MD. Ph.D. Viroj Tangcharoensathien, MD. Ph.D. International Health Policy Program (IHPP) Presentation to the ISPOR 3 rd Asia-Pacific Conference Grand Hilton Hotel, Seoul, South Korea September 9, 2008

2. International Health Policy Program -Thailand 2 Outline of presentation Introduction The universal coverage health insurance (UC) scheme, the UC benefit package, Objectives and methods Findings of the study Discussion and key challenges for future research

3. 1945 2000 2001 Informal exemption 1980 1970 User fees 1-3 rd NHP 1962-76 Provincial hospitals Health Infrastructure Thailand: historical development of achieving universal coverage 1975 LIC 1990 Establishment ofprepayment schemes Expansion ofprepayment schemes 1980 CSMBS 1983 CHF 1990 SSS 4 th -5 th NHP (1977-86) District hospitals Health centers UniversalCoverage CSMBS SSS 2001 Universal Coverage SSS LIC  MWS 1994 PVHI

4. Health care finance and service provision of Thailand after achieving universal coverage (UC) General tax General tax Standard Benefit package Tripartite contributions Payroll taxes Risk related contributions Capitation Capitation & global Co-payment budget with DRG for IP Services Fee for services Fee for services - OP Population Patients Ministry of Finance - CSMBS (6 million beneficiaries) National Health Insurance Office The UC scheme (47 millions of pop.) Social Security Office - SSS (9 millions of formal employees) Voluntary private insurance Public & Private Contractor networks

5. International Health Policy Program -Thailand 5 Objectives In 2001 Implementation of a policy on universal coverage in access to health care Comprehensive benefit package including ambulatory care, hospitalization, and expensive services Objectives 1. To investigate the economic impact on Thai households of different socio-economic status of high costs of RRT in three issues: Access to and utilization of RRT; Financial burden for costs of RRT; Household coping strategies for illness costs between richer and poorer ESRD patients. 2. To explore appropriate criteria for including health interventions into the UC benefit package. Renal replacement therapy (HD, CAPD, KT) was excluded from the UC benefit package due to limited financial resources, and this treatment was not cost-effective.

6. Investigating tools wk0wk1wk2wk3wk4wk5wk6wk7wk8wk9wk10wk11wk12 T1 T2 T3 T4 T1 = tool for exploring household members and their relationships T2 = tool for exploring patient’s life history and drawing a life-line T3 = tool for in-depth interviews to obtain illness narratives T4 = tool for collecting data on household income and expenditure Selection of poorer and richer ESRD patients Four investigating tools for data collection A census of ESRD patients in NK Province registered with public and private dialysis centers Selected poorer and richer ESRD patients in municipal and rural areas guided by registration and health care providers An introductory visit to assess household SE status Rural areas Ten ESRD patients in poorer and richer hhs Municipality Ten ESRD patients in poorer and richer hhs

7. Findings from qualitative household visits (1) Excluding RRT from the UC benefit package posed considerable financial barriers and a substantial economic impact on poorer ESRD patients, Infrequent access to haemodialysis and inability to obtain erythropoietin injection was likely to be a major cause of the death of poorer ESRD patients, The financial burden for costs of RRT did not only impact on ESRD patients, but also created a significant economic impact on household members and patients’ relatives,

8. Findings from qualitative household visits (2) The financial burden for RRT captured 25-68% of household income, and 31-52% of household expenditure  all ESRD patients faced catastrophic health spending, Coping strategies for high costs of RRT: – Reducing frequency of haemodialysis and denial of erythropoietin injection – Reducing food consumption and travelling costs; – Using saving and selling assets; – Taking loans with a high interest; – Diversifying financial resources from other relatives.

9. International Health Policy Program -Thailand 9 Discussion (1) Excluding RRT from the UC benefit package undermined achievements of key UC policy goals:  universal access to life-saving health services (RRT),  financial risk protection from health care costs, Appropriate criteria for selection of health interventions into the benefit package of public health insurance schemes, RRT is not cost-effective, but can forced HH to be financially catastrophic, and potential impoverishment, Comprehensive covering OP and IP vs catastrophic benefit package,

10. International Health Policy Program -Thailand 10 Discussion (2) In Thai context, two policy questions: How to finance universal access to RRT in a sustainable way; What forms of therapy should be made available, Thai policy makers’ decision to cover RRT in the UC benefit package in December 2007, not only consider evidence on cost-effectiveness, but also ethical and equity considerations across different health insurance schemes, and Financial risk protection against catastrophic health expenditure Methodological limitation Difficulties in finding poorer and richer ESRD patients Accurate data of household income and expenditure Interpretation of cost burden for RRT, esp in poorer households

11. International Health Policy Program -Thailand 11 Key challenges and future research The increasing incidence of DM and HT, two major determinants of ESRD, posed financial constraint to universal access to RRT, also the increase in sero-prevalence of high level of chronic kidney disease (CKD) Long-term financial sustainability of universal access to RRT: high cost and increasing number of ESRD, Cost-effective interventions to prevent the advancement of kidney damage towards end-stage renal disease, Capacity to improve the supply of kidney donation and accelerate the performance of kidney transplantation, and also reduce costs of PD solution through local production.

12. International Health Policy Program -Thailand 12 Acknowledgements Ministry of Public Health (MOPH) Health Systems Research Institute (HSRI) World Health Organization (WHO) The Consortium for Research on Equitable Health Systems (CREHS) Professor Anne Mills, and Dr. Natasha Palmer from London School of Hygiene & Tropical Medicine (LSHTM), UK Dr. Samroeng Yaengkratok, Chief Medical Officer of NK province The hospital director of Maharat Hospital, NK province