Financial protection and enabling access to care for Thai elderly: the role of public insurance

Abstract

Improvement of health status and increased access to modem medical care among Thai elderly was apparent during the 1990s. Various factors explained this including improved socioeconomic conditions, availability of services, improved physical access, and expansion of health insurance. Nevertheless, differences in health status and access to care have persisted across socioeconomic groups and geographical areas. Despite the policy of free medical care for the elderly launched in Thailand in 1992, a substantial number of elderly were still uninsured in 2001, mainly among those residing in urban areas. In 2002, a universal coverage (UC) policy was introduced, to include the approximately 18 million Thais not covered by formal public insurance schemes. The UC scheme is tax funded, with a budget allocated to each province according to the number of beneficiaries (who must register for a UC card and at a primary health care unit). The aim of the study was to assess how effectively the UC scheme has been implemented, and performed the functions of financial protection and enabling access to care for the elderly across all socioeconomic groups and urban and rural geographical areas. Both quantitative and qualitative approaches were employed: document review, cross-sectional household survey, in-depth interviews, and focus group discussions. The study site was Yasothon province, one of the poorest provinces in the Northeast of Thailand. The main constraints in UC policy implementation included lack of appropriate health personnel to provide care in primary care units and lack of management capabilities in purchasing services. Registration of beneficiaries was almost 100%. Access to overall ambulatory care was quite equitable and was solely determined by health need. However, less emphasis was placed on services specific to the needs of the elderly. For hospitalization, urban respondents were admitted more frequently than rural respondents. Take-up of UC benefits was high among cardholding beneficiaries especially for hospitalization. A gradient of burden of out-of-pocket payment across income groups existed, due to the relatively high illness amongst the poor, their extremely low income, and the burden of non-medical expenditure. A few individuals experienced catastrophic payments as a result of non medical care expenditure, noncompliance with the requirements for accessing free care, and informal payments. The study concluded that the UC scheme was quite successful in its implementation; however, inequity in out-of-pocket payment remained and income inequity itself played a substantial role. To improve equity of access and financial protection, attention should be paid to primary geriatric care, non-medical care expenditure and physical access, insurance management and human resources, and the broader policy context relating to income inequity.