Article Text

Utilisation, out-of-pocket payments and access before and after COVID-19: Thailand’s Universal Health Coverage Scheme
  1. Kannika Damrongplasit1,
  2. Glenn Melnick2
  1. 1Faculty of Economics and Center of Excellence for Health Economics, Chulalongkorn University, Bangkok, Thailand
  2. 2Sol Price School of Public Policy and Center for Health Financing, Policy and Management, University of Southern California, Los Angeles, California, USA
  1. Correspondence to Dr Kannika Damrongplasit; kannika.d{at}chula.ac.th

Abstract

The goal of Universal Health Coverage (UHC) is that everyone needing healthcare can access quality services without financial hardship. Recent research covering countries with UHC systems documents the emergence, and acceleration following the COVID-19 pandemic of unapproved informal payment systems by providers that collect under-the-table payments from patients. In 2001, Thailand extended its ‘30 Baht’ government-financed coverage to all uninsured people with little or no cost sharing. In this paper, we update the literature on the performance of Thailand’s Universal Health Coverage Scheme (UCS) with data covering 2019 (pre-COVID-19) through 2021. We find that access to care for Thailand’s UCS-covered population (53 million) is similar to access provided to populations covered by the other major public health insurance schemes covering government and private sector workers, and that, unlike reports from other UHC countries, no evidence that informal side payments have emerged, even in the face of COVID-19 related pressures. However, we do find that nearly one out of eight Thailand’s UCS-covered patients seek care outside the UCS delivery system where they will incur out-of-pocket payments. This finding predates the COVID-19 pandemic and suggests the need for further research into the performance of the UHC-sponsored delivery system.

  • Health economics
  • Health insurance
  • Health policy

Data availability statement

Data may be obtained from a third party and are not publicly available.

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Summary box

  • Unlike many other countries with government financed universal health insurance programmes, members of Thailand’s Universal Health Coverage Scheme (UCS) have not been asked to make informal payments that exceed government policies, even during COVID-19.

  • Contact rates for members covered by Thailand UCS are robust and remained stable during the COVID-19 pandemic.

  • There is a growing number of Universal Health Coverage (UHC) members seeking care outside the UHC system requiring higher out-of-pocket costs suggesting the need to evaluate access and quality.

Introduction and overview

The goal of Universal Health Coverage (UHC) is that everyone needing healthcare can access and use quality services without financial hardship.1 Countries with UHC systems face ongoing challenges, exacerbated by the COVID-19 pandemic, to assure access to needed healthcare services for their covered populations. There is literature documenting the growth of informal, under-the-table out-of-pocket side payments by patients collected by healthcare providers under UHC systems.2–7 While informal, off-the-record payments are typically deemed inappropriate and illegal, they are frequently overlooked by governments. This leniency exists because these payments serve as an additional source of funding, which can complement the subsidies provided by governments. In some cases, governments aspire to provide universal coverage but lack the necessary resources or political backing to fully finance the programme. As a result, they allow these unregulated payments as a means of filling the financial gap.

Patient informal out-of-pocket payments under UHC systems are widespread, especially in Asia. These informal payments can represent a large share of total health spending in some countries and may have grown as a result of the shock and pressures of the COVID-19 pandemic. Another important challenge for UHC systems is to ensure that patients can have their healthcare needs met within the UHC-funded delivery system and do not need to seek care outside the system—so-called ‘leakage’—where members will incur increased out-of-pocket costs to receive care from providers that are outside the UHC delivery system. Finally, though not limited to countries with UHC systems, there is a growing literature that shows that many countries experienced significant declines in healthcare utilisation for both outpatient and inpatient services as related to the COVID-19 pandemic.8–12

We analysed data covering before (2019) and after COVID-19 emerged (2021) from a very large, nationally representative sample of individuals in Thailand to explore whether Thailand’s ‘30 Baht’ Universal Health Coverage Scheme (UCS) has been able to avoid the problems of COVID-19 driven reduced utilisation seen in other countries and/or increased out-of-pocket costs to patients by increased use of informal payments to providers. In addition, we explore whether the Thailand’s UCS programme has experienced an increase in members seeking care outside of the UHC delivery system—so-called ‘leakage’—resulting in increased out-of-pocket spending by UCS covered population. Detailed description of the data as well as the methodology and variables used in this study are provided in online supplemental technical appendix.

Supplemental material

Health insurance schemes in Thailand

In 2001, Thailand sought to achieve universal coverage by extending health insurance coverage to the uninsured population to complement two pre-existing employment-based health insurance schemes in Thailand, resulting in the three major health insurance schemes operating in Thailand today:

‘30 Baht’ UCS: In 2021, 74% of the population is covered by this government-run health insurance programme. In 2001, the ‘30 Baht’ UCS was introduced and implemented nationwide by 2002. Its primary aim was to ensure equitable access to high-quality healthcare services, irrespective of an individual’s income or socioeconomic status. This initiative, funded by the government, extended coverage to individuals working in the informal sector and previously uninsured individuals. Initially, the programme required a nominal 30 Baht copayment (equivalent to approximately US$1.00) for each visit to a healthcare provider, whether for outpatient or inpatient care. In 2006, this copayment was eliminated but was reintroduced on 1 September 2012, although with many exceptions, including emergency cases, prevention and promotion activities, patients without prescription drugs, and individuals seeking care at healthcare facilities below the level of community hospitals.

Importantly, UCS covered population can access UCS-covered services only at designated public healthcare facilities that function as the primary point of contact by providing primary care to patients and referring them to higher levels of care when more complicated treatments are needed. This scheme has expanded the covered benefits over time to include more costly procedures and diseases including peritoneal dialysis, haemodialysis, kidney transplant in 2009; liver transplant in the youth and heart transplant in 2012; stem-cell transplant for patients with leukaemia and lymphoma in 2013; detect and treat HIV patients with any level of CD4 cell count in 2015.13

Social Security Scheme (SSS): In 2021, 18% of the population is covered by this mandatory health insurance programme for private sector employees. In 1990, the SSS was established with the primary objective of providing support to employees in the formal sector in the event of illness or accident. The SSS extends coverage to cover the expenses associated with medical treatment that is unrelated to work-related incidents. Funding for this scheme is derived from contributions made by employees, employers and the government. Individuals enrolled in the SSS programme have the option to receive healthcare services from both public and private providers. These healthcare providers have entered into agreements with the Social Security office to offer medical services to beneficiaries under this programme.

Civil Servant Medical Benefit Scheme (CSMBS): In 2021, 7% of the population is covered by this health insurance programme for government employees and their dependents. Established in 1980, the CSMBS covers public servants, their dependents and retired individuals from the public sector. This scheme’s funding primarily relies on general tax revenue and falls under the regulation of the Comptroller General’s Department within the Ministry of Finance. Covered members can access care from any public provider of their choice under this scheme.

In sum, Thailand has achieved nearly universal health insurance coverage, as these three programmes combined cover approximately 99% of Thailand’s population as of 2021.

The COVID-19 pandemic disrupted healthcare utilisation in many countries

The COVID-19 pandemic profoundly disrupted healthcare systems worldwide, causing a decrease in utilisation of healthcare services in many countries. Studies across multiple countries indicate a roughly one-third reduction in healthcare utilisation during the pandemic, particularly affecting those with less severe illnesses.12 14 15 In South Korea, the COVID-19 pandemic caused a reported reduction in monthly volume of outpatient utilisation by −15.7% and inpatient utilisation by −11.6%.16 In the USA, there was a significant drop in admission rates during the pandemic, further declining with the implementation of quarantine measures.8

The pandemic also altered work, social and leisure patterns, influencing routine healthcare service utilisation. Initially, there was a reluctance to seek non-COVID-19 care due to virus exposure fears, but as the pandemic persisted, untreated illnesses worsened, returning healthcare consumption to normal levels. Globally, the WHO reported substantial disruptions in non-emergency health services provision, with many countries experiencing partial or complete interruptions across various medical fields.17 Overall, the pandemic has highlighted the need for health systems and policymakers to address these challenges promptly, ensuring continued access to healthcare services during and after the pandemic while planning for disease prevention and control.

Access to healthcare in Thailand was largely unaffected by the COVID-19 pandemic

Analysis of contact rates for the three major health insurance schemes in Thailand for 2019 (pre-COVID-19) and 2021 provides insight into two important aspects of Thailand’s delivery system (figure 1). One is a test of the resiliency of Thailand’s healthcare system during the COVID-19 pandemic and whether patients covered by different health insurance programmes were affected differentially by the COVID-19 pandemic. When comparing the contact rates before and after COVID-19, we do not observe a reduction in the contact rates observed in other countries during the COVID-19 outbreak.8–12 14–17 Contact rates pre-COVID-19 and post-COVID-19 show very little change across the different health insurance programmes. Second, when comparing the UCS contact rate with the two other major public health insurance schemes we observe that UCS contact rates (74%–75%) are in the middle, between the CSMBS scheme (81%–83%) and the SSS programme (57%–63%).

Figure 1

Contact rates by source of health insurance coverage, 2019 and 2021. Source/Notes: Author’s calculations using data from 2019 and 2021 Thailand Health and Welfare Surveys (HWS). CSMBS, Civil Servant Medical Benefit Scheme; SSS, Social Security Scheme; UCS, Universal Health Coverage Scheme.

Thailand’s UCS protected patients from rising out-of-pocket costs

The COVID-19 pandemic significantly impacted healthcare systems globally, even in countries with universal healthcare. Despite the aim of providing affordable and accessible healthcare, the pandemic revealed and potentially exacerbated vulnerabilities in financial protection for patients. Research by the WHO and the World Bank shows that over one billion people faced catastrophic out-of-pocket health spending, surpassing 10% of household budgets.18 This led to approximately 1.3 billion individuals being pushed into poverty, including 300 million already living in extreme poverty. Studies in several countries demonstrated deterioration in maintaining healthcare access and financial protection. For instance, in Mexico and Peru, both a significant decrease in healthcare visits and a shift towards private healthcare providers, resulting in higher out-of-pocket costs.19 China experienced a decline in both outpatient and inpatient services utilisation during the pandemic followed by rebounds in utilisation as positive COVID-19 cases decreased.20 These challenges underscore the necessity for healthcare systems to enhance their capacity to respond to health crises while ensuring financial security for patients.

Our analysis of data on out-of-pocket payments for outpatient and inpatient services provided to the UCS-covered population by providers included in the UCS-approved delivery system (mainly government owned public health facilities) showed that the vast majority of patients covered under the UCS—‘30 Baht’ scheme paid zero and/or no more than 30 Baht out-of-pocket for outpatient care, both in 2019 and 2021. The median value is zero for all but one provider type, university-based hospitals, where the median value is 30 Baht. Out-of-pocket payments for outpatient care at the 75th percentile were zero in both 2019 and 2021 for all providers except university hospitals, where the value was 30 Baht in 2019. At the 90th percentile, we observed more frequent and higher out-of-pocket payments but again most of the increased payments occur in university-based hospitals (figure 2).

Figure 2

Out-of-pocket payments by Universal Health Coverage Scheme (UCS) covered population to UCS designated providers, 2019 and 2021. Source/Notes: Author’s calculations using data from 2019 and 2021 Thailand Health and Welfare Surveys (HWS).

‘Leakage’ from Thailand’s UCS remained stable during the COVID-19 pandemic but needs monitoring

Research has shown that supply-side factors, such as the limited availability and mal-distribution of healthcare services as well as long waiting times, staff shortages and medication stockouts in public healthcare facilities can increase out-of-pocket spending by households as shortages or inefficiencies in the public healthcare system can lead patients to seek private care, thus increasing their out-of-pocket expenses.21

Analysis of utilisation by UCS patients when they access services at non-UCS covered providers—the so-called leakage rate—shows that in 2019 (before COVID-19) 14% of patients sought care outside of the UCS delivery system and this rate declined to 11% during COVID-19. These findings suggest that while the leakage rate remained relatively stable before and during COVID-19 (during COVID-19 the leakage rate declined, but only slightly) a significant percentage of UCS covered patients seek care outside of the UCS delivery system even though they would incur out-of-pocket costs for these services (figure 3).

Figure 3

‘Leakage rate’—utilisation of non-Universal Health Coverage Scheme (UCS) providers by UCS members. Source/Notes: Author’s calculations using data from 2019 and 2021 Thailand Health and Welfare Surveys (HWS).

Discussion and conclusions

In 2001, Thailand implemented a programme of universal coverage by expanding government-funded health coverage to all uninsured citizens designed to ensure access to needed services while also limiting out-of-pocket payments to 30 Baht or less per encounter. Previous studies that as of 2015 no informal, under the table payment system had evolved under Thailand’s UHC.22 Our findings provide an update through 2021 including data from 2019 that predates the onset of the COVID-19 pandemic. The vast majority of UCS covered patients paid zero out-of-pocket payments when they accessed UCS covered providers both in 2019 (pre-COVID-19) and 2021 (post-COVID-19). This is in contrast to many other countries that have UHC programmes, out-of-pocket payments remain a major source of funding for healthcare, both before, during and after COVID-19. One such example is Indonesia, a neighbouring country with the same World Bank’s income classification as Thailand, that introduced national health insurance scheme called JKN in 2014. Even though more than 80% of its population were covered under JKN, it is estimated that over 30% of current health expenditure is accounted for by out-of-pocket expenses. Furthermore, the incidence of catastrophic health spending (defined as out-of-pocket payments exceeding 10% of total household expenditure) has actually increased in Indonesia from 3.6% in 2015 to 4.5% in 2017.23 24

Our analysis further reveals that UCS members have contact rates that are similar to the contact rates for populations covered by the other major public health insurance programmes that cover the employed population and their families. We find that the outpatient contact rate of the UCS group is even higher than that of the SSS group. One explanation is that SSS beneficiaries are mostly working-age individuals employed in the formal employment sector. The opportunity cost of taking time off from work to seek care from a provider may be high for them, leading to a lower contact rate for the SSS patient population. Overall, our data suggest that the UCS programme is holding its promise of assuring access to needed services for the UCS-covered population. There is one finding, however, that raises potential concerns regarding access to services. We find that nearly more than one out of eight UCS members sought care from private providers that are outside the UCS contracted delivery system where, despite having UCS coverage, these patients will incur out-of-pocket costs to receive their care. These findings are robust in that the trend predates the COVID-19 pandemic, where the leakage rate was 14% and, declined slightly to 11% in 2021.

Overall, the results paint a picture that indicates that Thailand’s UCS programme is working as intended to ensure access to needed healthcare services while limiting out-of-pocket payments for this otherwise uninsured population. At the same time, Thailand’s UCS programme is a large and important part of Thailand’s total government spending and as such is likely to face similar budgetary pressures seen in other countries where informal payments and reduced access have become a problem. In addition, Thailand, like many other countries is facing a demographic shift with a falling birth rate, contributing to an ageing population that will increase demand for healthcare services. As such, it will be important for Thailand to increase research funding including ongoing and expanded data collection, monitoring, and university-based research and analysis of the performance of its healthcare system as it affects the entire population including those in three of the major public health insurance programmes. For example, quality, waiting times, satisfaction and long-term sustainability are important dimensions of performance that need to be monitored and evaluated.

Data availability statement

Data may be obtained from a third party and are not publicly available.

Ethics statements

Patient consent for publication

Ethics approval

Not applicable.

Acknowledgments

Authors acknowledge National Statistical Office of Thailand for providing Health and Welfare Survey data.

References

Supplementary materials

  • Supplementary Data

    This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

Footnotes

  • Handling editor Lei Si

  • Contributors KD: conceptualisation, data curation, formal analysis, methodology, software, writing – original draft, writing – review and editing. GM: conceptualisation, formal analysis, writing – original draft, writing – review and editing.

  • 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.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.