Funding renal disease care in Thailand

When it started, Thailand’s universal health coverage scheme excluded treatment for end-stage renal disease on economic grounds. This had serious implications for poorer patients who could not afford expensive, life-saving treatment, and contradicted the principles of equity and protection from financial risk fundamental to the scheme. 

Research from the Thai Ministry of Public Health and the London School of Hygiene and Tropical Medicine assesses the medical and economic impacts of withholding free treatment for end-stage renal disease (ESRD). The authors offer alternatives that could help balance public policy goals of efficiency and equity.

Governments in low- and middle-income countries with limited health resources face the difficult decision of what to include in national health care benefit packages. Budget limitations, political pressure and public demand also influence these decisions. Thailand’s universal coverage (UC) scheme was set up in 2001 and covers 75 percent of the population.

Evidence suggested renal replacement therapy (RRT) was not cost-effective and could consume over 12 percent of national health expenditure. Therefore access to RRT for UC members depended on their ability to pay. The researchers studied 20 households affected by ESRD in urban and rural areas of Nakorn Ratchasima province. Findings included:

• On average, richer ESRD patients (with alternative insurance) had haemodialysis twice a week, while poorer patients (who paid themselves) had it once or less than once a week.
• Only one of the poorer ESRD patients received erythropoietin injections, while all of the richer patients who needed it did.
• Inadequate dialysis and erythropoietin injections to correct anaemia contributed to the premature death of four poorer patients.
• Richer patients had a higher survival rate and better quality of life than poorer people.
• Poorer households spent 25 to 68 percent of their total income or 31 to 52 percent of total household expenditure on RRT.   
• Poorer patients tried to cope by having less frequent dialysis, eating less, spending savings, selling assets, taking public transport to hospital and taking high-interest loans.

Excluding RRT from the health care scheme compromised UC policy goals. It was inequitable as beneficiaries under the two other public insurance schemes, Social Health Insurance and Civil Servant Medical Benefit Scheme, had full access to all RRT services. Since patients and their relatives were affected by medical costs, they were not protected from financial risk.

The Thai government should reconsider its decision not to support RRT, consulting with all major concerned groups. The researchers suggest four alternatives:

• If RRT is excluded from an essential benefit package, provide targeted financial support to those most in need of it.
• Provide ‘catastrophic packages’ for those in need with reduced prices for high-cost services; households could pay for low-cost, high-volume services (e.g. outpatient visits).
• Find alternative ways to finance RRT, for example through financial support from a non-profit foundation, related to the patient’s ability to pay.
• Look at more cost-effective options for publicly funded ESRD treatment, such as peritoneal dialysis and kidney transplantation.

Source(s):
‘The Implications of Benefit Package Design: The Impact on Poor Thai Households of Excluding Renal Replacement Therapy’, Journal of International Development Vol.21, Issue.2, pages 291 to 308, by Phusit Prakongsai, Natasha Palmer, Preecha Uay-Trakul, Viroj Tangcharoensathien and Anne Mills, 2009

Funded by: World Health Organization

id21 Research Highlight: 1 June 2009

Further Information:
Phusit Prakongsai
International Health Policy Program
Ministry of Public Health
Muang District
Nonthaburi Province
Thailand 11000

Tel: +66 2 590 2366
Fax: +66 2 590 2385
Contact the contributor: phusit@ihpp.thaigov.net

International Health Policy Program, Ministry of Public Health, Thailand

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