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The hidden costs of universal health coverage: solutions from the fight against catastrophic healthcare expenditure in Thailand
  1. Arnav Mahajan,
  2. Wuttipong Tirakotai,
  3. Patcharapim Masayaanon
  1. Department of Neurosurgery, Neurological Institute of Thailand, Bangkok, Thailand
  1. Correspondence to Dr Arnav Mahajan; arnavmahajan99{at}

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Summary box

  • Financial reimbursement factors that are not accounted for in a universal health coverage (UHC) system remain poorly understood and represent a burdensome hidden cost. Traditional paradigms of UHCs extending only to diagnosis and treatment are insufficient; we must consider the infrastructure that extends beyond the clinic walls in order to develop comprehensive systems of care. Literature search demonstrated that extant solutions in the literature to combat these factors fall short in addressing a few key aspects, namely: attrition, scalability, measurement of impact and sustainability.

  • Our study aims to demonstrate a successful example of synergistic implementation of solutions deployed at an institutional level to combat these hidden costs. We have done so by development of teams that coordinate housing, collective organisations with foundations that provide food and transportation, and building of teams to promote cross-institutional volunteer leaders that may co-ordinate such initiatives. We uniquely define how each one of our solutions can assist in developing comprehensive solutions by targeting the biggest setbacks currently demonstrated in the literature.

  • We comment on both our institutional changes, and indeed wider policy-level changes that can be implemented into countries developing UHC packages. The rapid digitisation of healthcare information and the use of community healthcare funds are viable, implementable solutions that we recommend for use.


Gaudin et al have presented a thought-provoking paper on the importance of incorporating cost data in healthcare policy decision-making.1 Their approach of relying on local cost teams to inform recommendations for universal health coverage (UHC) is novel and commendable. However, the paper also highlights a critical concern that has been long overlooked—the indirect costs of healthcare.1 These costs, which include transportation, lost wages and caregiver expenses, are often overlooked but can have a significant impact on the financial burden faced by patients and their families.

Historically, low-income and middle-income countries (LMICs) have adopted some interventions aimed at tackling aspects of these indirect costs.2 A literature search investigating all of the potential solutions was done and demonstrated many unique strategies, but we recognise how these interventions fall short in a few key aspects, namely: attrition of volunteers, scalability of solutions, measurement of impact and most importantly the sustainability of the interventions. Furthermore, these interventions are often not implemented synergistically and are developed in isolation to address a single aspect of hidden costs, rather than addressing multiple.

What is lacking is a comprehensive understanding of the unaccounted-for financial reimbursement factors in a UHC system, and how these may be applied synergistically. The failure to reimburse for these indirect costs, which we refer to as hidden costs, is not only a financial burden, but also an impediment to healthcare access. In this commentary, we aim to share our experiences of these hidden costs and offer recommendations for national and international bodies striving to develop comprehensive UHC systems. We seek to comment specifically on areas regarding impact measurement, retention, scalability and sustainability.

Thailand’s UHC system is considered one of the most robust in the world, with improved access to healthcare for the population since its implementation in 2002. According to the WHO, Thailand ranks 25th in the world for its UHC Service Coverage Index, leading among any South-East Asian nation, and an impressive 99.61% of the population is registered at health units and eligible for coverage.3 4

But beneath this veneer of excellence lies a dark reality: the hidden costs of universal coverage that still drive a significant proportion into catastrophic healthcare expenditure—a term used to describe the financial ruin caused by high healthcare costs. To prevent large portions of their populations from falling into financial ruin, every nation aiming to achieve UHC by 2030 will have to learn how to mitigate this unfortunate reality.5

The failure to address the hidden costs—including lack of reimbursement for travel, caregiver accommodation and food—has a tangible impact on human health and well-being, particularly in LMICs. Those living in rural areas, who often must travel long distances for care, are particularly affected by these indirect costs.6 In Thailand, patients’ have not been neglected, as each of the country’s 13 health service regions has at least one tertiary care centre to ensure some access; however, we have not directly met the patients’ needs to guarantee comprehensive coverage. Despite best efforts, this can be especially burdensome for those with chronic illnesses or specialised needs, who may require frequent hospital visits. The reality of a fragmented public healthcare system, siloed by specialty, region, and access to diagnostics and therapeutics, exacerbates the problem by requiring patients to hop from hospital to hospital without regard for the indirect costs incurred. These costs can quickly accumulate, placing an undue financial burden on families that are already vulnerable.

How we have tackled it

Table 1

Table 1

A table demonstrating the hidden costs within the UHC system, our institutional solutions, their measured impact and the synergistic targets combatted with our solutions

Assistance for accommodation

The National Institute of Neurology in Thailand has developed a framework in which pain points of hidden costs are tackled in a comprehensive way. The stewards of this model are ‘Social Welfare Teams’ which are unfunded, volunteer-led projects that have a multidimensional role to play in securing patients access to all available care at the hospital. Most relevant to this context, they are essential in coordinating with various groups and organisations that can provide emergency housing to caregivers of patients attending the hospital. Currently, we have secured through several institutionally developed networks, emergency housing that is able to host families at an extremely low cost and occasionally free-of-cost depending on need. Other leading public hospitals in the area have also independently built housing for caregivers to eliminate this burden for their patient populations. While both are beneficial solutions, considering the national burden that accommodation imposes, these are not effective long-term solutions given the demand of human, financial and social resources needed to support these projects unfunded by the healthcare scheme. We have scaled this solution to other public hospitals in the region and have retained volunteers by integrating debriefing sessions.

Foundations for food and travel cost

Food and travel costs are a unique burden imposed on LMICs given the number of the population, both rural and urban, that lie below the poverty line. To support this, our institution has partnered with “มูลนิธิพุทธิกา ปันกันอิ่ม” (‘Puttika Foundation—Pan Kan Im’) to offer food coupons to patients and their families entering our hospital. We have developed an institutional link and scaled the purview of the foundation to develop a similar concept using volunteer groups in two other hospitals. We have been successfully developing this programme since 2019 and have retained 35 different communities. Our strategy is sustainable as the patients with the greatest need are offered the greatest supports, and it leverages cultural and religious attitudes within Thailand to direct funds from higher-income earners to those more in need. Scaling from these benefits, we have worked with the foundation to collect extra funds towards support patients travelling from distance to reach our hospital. It has been well demonstrated that travel cost and travel time are limiting factors for people seeking care in UHC systems.7 As existing structures do not account for this, our adaptive model has recognised the needs of patients and offers them a solution where existing systems fall short (figure 1).

Figure 1

This image provides information about the Puttika Foundation and how it operates in accordance with the Buddhist principle of merit. When a member of the public "donates" a meal to a food bank, it enables the organization to provide a free meal to someone in need. The organization accomplishes its goals through hospital food vendors and goes on to describe its structure, invite interested parties to join, and provide access codes to comprehensive publications on the subject. Infographic distributed to food merchants about Puttika Foundation in Thai with an adjacent translation.

Volunteers for caregivers and patients

As our hospital tackles the challenge of meeting the unmet needs of patients and families through a range of unfunded programmes, a major investment in human capital is necessary. We understand that we are not alone in facing this challenge and have taken a proactive approach by creating a comprehensive volunteer programme. The programme leverages teams of approximately 60 volunteers who work closely with patients and families to streamline their experience and optimise every interaction. Our novel approach has yielded 2500 volunteers over the past 4 years and has developed a scalable framework which was replicated by two hospitals facing comparable obstacles. Through the training and development of volunteer leaders, we are working towards cross-institutional coverage and are working towards a model that will be supported by the Thai Health Promotion Foundation for a ‘top-down’ approach. Although there are concerns with the efficacy of ‘top-down’ approaches, we believe our synergistic implementation will allow for seamless integration of our solution at the highest level. By approaching through the lens of patient-centricity, we have developed a model that can be adapted across different institutions. Uniquely, we have measured our impact by examining feedback forms filled by parents of teenage volunteers that have stated there has been a lasting change in attitudes of their children that has extended to support their own family, friends and wider community through altruistic action. By drawing on these valuable experiences, we strongly encourage policy-makers and healthcare leaders around the world to learn from these solutions such that we can help ensure that no citizen is left without access to the care they need.

How we hope it will be tackled in the future

Although we have developed initiatives trying to help alleviate these hidden costs, these are only band-aid solutions that do not address the root cause of the problem: a lack of reimbursement for additional expenses in the UCS system. In this section, we hope to provide actionable solutions that may be implemented and accepted with wide support.

Leveraging digitisation in centralised health applications

Another hidden cost, though not financial, is the cost of waiting time. 44.49% of patients who did not apply for UHC benefits after visiting a hospital cited long waiting times as the reason.4 In response, the National Health Security Office (NHSO) has implemented various digital protocols, including the development of a digital health wallet and an NHSO application, which have increased coverage, reduced hospital congestion and enabled beneficiaries to check their benefits online and request transfers to different regions and units of care. This platform could be expanded to include requesting travel reimbursement by describing a journey prior to a hospital visit the day before. By extending this platform to include the ability to request travel reimbursement and detail a journey prior to a hospital visit, it would be easier for patients to receive the necessary care without incurring additional expenses. We believe that variants of this proposed concept may be prioritised, implemented and its benefits communicated owing to the rapid digitisation that has occurred during the COVID-19 pandemic, even if these platforms are not necessarily prevalent at the national level.8

Rethinking community healthcare funds to be more prorural

To further reduce the hidden costs of universal coverage programmes, it is essential to evaluate the role of community healthcare funds and the distribution of funding for specialised care and chronic illness. Participation of stakeholders is crucial to this process because it enables local administrative organisations to have a say in how local funds are allocated and used. In Thailand, the majority of these funds are distributed unequally, with the highest concentration in the two largest metropolitan areas—a stark contrast to the country’s prorural orientation.4 By expanding the reach of these organisations to more rural areas, it would ensure that everyone has access to the care they need, regardless of where they live. Resources are pooled locally through Ministries of Internal Affairs, Social Development and Human Security, and Health. We recommend an integrated approach to community funding that links within existing government bodies that may have a deeper understanding of specific rural communities and can offer comprehensive financial solutions to mitigate hidden costs.


While UHC systems have been successful in providing coverage for diagnosis and treatments, they have an opportunity to evolve past their current paradigm. All infrastructure is healthcare infrastructure, and the burden placed on citizens of a nation with one of the most robust UCS systems is an unjustice that is occurring due to a lack of coverage for many various externalities that are truly representative of an average patient journey seeking care in this country.9 We urge our local governments to consider our circumstances and recognise the importance of reimbursement. In the absence of this, we propose a number of local strategies that may be implemented at the national and international levels. In addition, we hope that this will serve as a call to action for many nations contemplating the adoption of a UHC system, demonstrating the importance of putting patient journeys and experiences at the centre of healthcare coverage as opposed to the traditional paradigm of diagnosis and treatment. A key factor in the public health transformation that has indeed set the standard for comprehensive medical coverage has been a ‘catalyst’—the ability to seize the window of opportunity, as described in a policy briefing from the NHSO.10 We hope that this paper acts as that very catalyst to urge readers to consider the patient journey and experiences when thinking about UHC packages. The traditional paradigm of diagnosis and treatment is not enough. We must also consider the infrastructure that surrounds the clinic walls, and ensure that patients are able to access the care they need without incurring catastrophic expenditures on healthcare.

Data availability statement

Data is available upon request.

Ethics statements

Patient consent for publication



  • Handling editor Seye Abimbola

  • Contributors AM and WT wrote the draft version of the manuscript. WT and PM helped refine the draft and shape the conceptual framework design. All authors have read and approved of the final version of the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.