This study provides clear and consistent evidence of pro-poor government health budget subsidies for OP and IP services between 2003 and 2009, which preferentially benefited the poorer quintiles compared to the relative size of their respective population. Three contributing factors explain the pro-poor government health subsidies.
First, the pro-poor utilization is the result of improved access to heath services provided by district health systems for the poor, a majority of who reside in rural areas. The district health system consists of a 30 to 90 bed district hospital and an average of 10 health centres per approximately 50,000 populations in the catchment area. Health centres and district hospital form a contractor provider network for UCS members through contractual arrangement with the National Health Security Office. This network provides a comprehensive set of OP and IP services to UCS members. The fully functioning district health system is a strategic hub of achieving pro-poor utilization for OP and IP due to its geographical proximity, so called “close-to-client services” where indirect cost of travelling and access is low [9
]. District health systems are functioning due to adequate budget support, three years mandatory rural health services by all new graduate doctors since 1972, and later extended to cover nurses, dentists, pharmacists and other paramedics [10
]. Such rural mandatory policies have resulted in a substantial reduction in regional gaps in the density of human resources over the last four decades [11
]. Also the availability of private health providers for the rich reduces competition from the rich for services provided by public sector.
Second, the very low level of out-of-pocket payment is the result of two factors; a comprehensive benefit package entitled to all UCS members including OP, IP which covers all medicines with reference to the national drug list, high cost care such as chemotherapy, radiation therapy, prevention and health promotion services. Although there was a minimum level of flat rate copayment of 30 Baht (US$ 1) per visit or per admission; this was terminated in 2006. The out-of- pocket payments are for services either not covered by the benefit package such as private clinics or bypassing the registered providers without referral procedures. The minimum level of out-of-pocket payment are in favour of the poor; this is reflected by the probability and level of payment for both OP and IP services is consistently low among the poorer than the richer quintiles.
Our additional analysis found the 88-96% of UCS members actually used UC services; the poorest quintile had higher rate of using their entitlements, 70-80% for OP visit and 90-95% for admission, while the among the richest counterparts, 40-60% of them used OP entitlement, 45-80% used IP entitlement [12
Third, government financial commitment was significant, not only the rhetoric in Parliament or at press conferences. The 36.2% real term increase between 2003 and 2009 is significant. Evidence from National Health Account shows the general government expenditure on health increased from 50% to 67% of total health expenditure, and out of pocket payment reduced from 33% in 2001 to 18% of in 2008. The low level of out of pocket payment is on par with the average of OECD countries. Despite a favourable benefit package, share of total health expenditure in GDP is minimum, increased from 3.3% of GDP in 2001 to 4.0% in 2008. The per capita health spending was US$ 61 in 2001 and US$ 173 in 2008 [13
It is interesting to see if the pro-poor public subsidy and health utilization have been translated into an equitable achievement of health outcomes. National IP dataset shows that the top-80% deadly diseases and the conditions of which death is amenable to health care revealed no increasing trends in both in-hospital and 30-day mortalities over the post-UCS period [14
]. Our additional analysis of the same HWS datasets found 19-26% of the poorest quintiles of the UCS members reported at least one illness episode during a prior month, whereas 14-19% of the richest quintile did so; reflecting higher health needs among the poor. Even after controlling for a higher health need among the poorer population, health services provided by district health systems still disproportionately concentrated among the poor [15
The pro-poor government health spending is homogeneously distributed across four geographical regions; this is a result of the homogeneity of district health systems development nationwide. The rural mandatory services are enforced to the whole country with financial incentives such as hardship allowance, lump sum per diem, non-private practice incentives and workload allowance as well as other non-financial incentives such as housing and social recognition. These interventions are effective and recommended by WHO for rural retention [16
Countries with high level of out of pocket payment and no effective policies protecting the poor from health payment have benefit incidence is in favour of the rich. For example the poorer groups in Vietnam [17
] get much less than their population share of hospital-based care and other public care but more than a proportionate share of care provided at commune health centers. Pro-rich bias in the distribution of hospital-based care is a common finding across several countries [18
]. Government health spending in African countries was in favour of the rich; for example, the poorest quintiles in Ghana benefited 10%, 13% and 11% at primary facilities, hospital outpatient and inpatient services respectively; while the richest Ghanaian’s benefited 31%, 35% and 32% at these facilities. Also similar findings were reported from Kenya, Tanzania, Madagascar and Guinea [22
]. The Indonesian poorest quintiles benefited 7% and 5% from hospital outpatient and inpatient services while the richest counterparts all benefited 41% from these services.
Among eleven countries in Asia, with the exception of Hong Kong, Malaysia, Sri Lanka and Thailand, the poor get much less than their population share of the public health subsidy. The pro-poor benefit incidence in some of these Asian countries are the results of limiting the use of user fees, effective protection of the poor from payment, and building a wide network of health facilities [23
] so that the poor can effectively use these services.