Civil Servant Medical Benefit Scheme Research Articles

Socioeconomic inequalities in health outcomes among Thai older population in the era of Universal Health Coverage: trends and decomposition analysis

BackgroundThailand’s Universal Health Coverage (UHC) has been achieved since 2002 when the entire population are covered by three main public health security schemes: (1) Civil Servant Medical Benefit Scheme (CSMBS); (2) Social Security Scheme (SSS); and (3) Universal Coverage Scheme (UCS). Citizens have access to healthcare services at all life stages and are protected from catastrophic expenditure and medical impoverishment. However, there are health inequalities in both health outcomes and access to healthcare among older Thais. This study aims to: (1) assess the degrees of socioeconomic inequalities in health outcomes among the older Thai population during the period of Thailand’s UHC implementation (2003–2019), and (2) explain socioeconomic inequalities in health outcomes through decomposition of the contributions made by Thailand’s UHC policy and other health determinants.MethodsData sets come from a four-year series of the National Health and Welfare Survey (HWS) between 2003 and 2019. The health outcome of interest was obtained from the Thai EQ-5D index. The Erreygers’ concentration index (CI) was used to calculate the socioeconomic inequality in health outcomes. Multivariate methods were employed to decompose inequalities.ResultsFindings indicated Thai older adults (aged 50 and older) are healthier during the UHC implementation. Better health outcomes remain concentrated among the wealthier groups (pro-rich inequality). However, the degree of socioeconomic inequalities in health outcomes significantly declined by almost a factor-of-three (from CI = 0.061 in 2003 to CI = 0.024 in 2019) after the roll-out of the UHC. Decomposed results reported that Thailand’s UHC, urban residence, and household wealth were major contributors in explaining pro-rich inequalities in health outcomes among Thai older adults.ConclusionsOlder persons in Thailand have better health while health inequalities between the rich and the poor have substantially decreased. However, there is inequalities in health outcomes within all three national health security schemes in Thailand. Minimizing differences between schemes continues to be a crucial cornerstone to tackling health inequalities among the older population. At the same time, making Thailand’s UHC sustainable is necessary through preparing financial sustainability and developing health resources to better serve an ageing society.

Catastrophic and Socioeconomic Disparities Across Different Payment Schemes in Lung Cancer Treatment: A Cross-Sectional Single-Centre Analysis from Thailand

Objective: To identify the magnitude of catastrophic health expenditure (CHE) and medical impoverishment across three payment schemes and compare the within-scheme financial disparity. Material and Methods: A cross-sectional analysis of CHE and medical impoverishment among lung cancer patients was conducted at a university hospital in Thailand. A total of 367 lung cancer patients drawn from three payment schemes were included. The clinical data were collected from the hospital’s Electronic Medical Records, while the socioeconomic data, including cost details, were collected via an interview-based questionnaire from November 2020 to June 2022. Economic analyses were performed using concentration curves and logistic regression modeling. Results: There were 38%, 21% and 27% impoverished patients belonging to the Universal Coverage Scheme (UCS), Social Security Scheme (SSS) and Civil Servant Medical Benefit Scheme (CSMBS), respectively, and approximately further 30% in each scheme became impoverished owing to medical-related expenses. Socioeconomic disparities in CHE; concentration index; CI=-0.36 UCS, -0.59 CSMBS and -0.47 UCS, and medical impoverishment; CI=0.16 UCS, -0.15 CSMBS and 0.10 UCS, were evident in all schemes. These inequities were more pronounced among CSMBS patients. Moreover, if not impoverished already, the probability of medical impoverishment in all payment schemes peaked in the middle quintile and declined thereafter. Conclusion: Across all payment schemes, CHE and medical impoverishment occurred at rates of around 60% and 30%, respectively, among lung cancer patients in Thailand. The gradient of CHE probability was more prominent among CSMBS patients.

Desires and Attitudes towards Telepharmacy Medicine Delivery.

The COVID-19 pandemic has limited healthcare services for patients with non-communicable diseases (NCDs). Hospital pharmacy departments in Thailand apply a new normal pharmacy service known as “telepharmacy” to serve remote pharmacy practice and deliver medication to patients. Current knowledge clearly shows the benefit of each medicine delivery method, but the study of patient’s desires and attitudes towards all drug delivery methods is still limited. To fill the gap, this study aims to investigate desires and attitudes about drug delivery methods among Thai patients living with NCDs who need regular and continuous care. The sample was included by accidentally randomized technique at NCD clinics of the southern Thailand tertiary care hospital. Data were collected between January and March 2021 by a questionnaire that contained three sections: the currently received medicine delivery method, the desires and attitudes about the medicine delivery system, and patients’ demographic information. The majority of patients were women aged 60 years who earned less than 10,000 THB (263.85 USD), were enrolled in the Civil Servant Medical Benefit Scheme (CSMBS), lived 0–15 km from the hospital, living with hypertension, had 1–4 prescribed medications, visited the doctor every 3 months, and received the conventional drug delivery method. The result showed that only the subdistrict health promotion hospital (SHPH) medicine delivery method was at a high level of desire, while the rest including conventional, drug store, postal pharmacy, and drive-thru medicine delivery methods were at medium. Attitudes toward the quality of medicine delivery methods consisted of five dimensions: confidence, timeliness, reliability, empathy, and facilities. Thai NCD patients had positive attitudes toward SHPH and drug store medicine delivery methods that could be seen from the high level of attitude score across all dimensions, while postal pharmacy and drive-thru delivery methods received medium-level attitude scores across all five dimensions.

EP08.02-083 Real World Treatment and Outcomes in EGFR-mutated Advanced Non-small Cell Lung Cancer Patients: A Nationwide Cohort for 1,932 Thai Patients

Epidermal growth factor receptor tyrosine kinase inhibitors (EGFR TKIs) are a standard of care for patients with advanced EGFR mutated non-small cell lung cancer (NSCLC). In Thailand, gefitinib has been approved for reimbursement under the Civil Servant Medical Benefit Scheme (CSMBS) for the treatment in these patients. Therefore, this retrospective cohort study examined the patient characteristics and clinical outcomes of Thai patients with EGFR-mutated NSCLC in a real-world setting.

Outcome disparities in patients with atrial fibrillation based on insurance plan and educational attainment: a nationwide, multicenter and prospective cohort trial

BackgroundAtrial fibrillation (AF) is a complex disease. The management of AF requires continuous patient engagement and integrative healthcare.ObjectivesTo explore the association between adverse AF-related clinical outcomes and the following two...

Factors associated with access to palliative home care in palliative patients at Lampang Hospital.

Existing literature has shown the importance of palliative home care to improve quality of life among end-stage patients. However, access to palliative home care remains an issue. This study explores factors associated with successful delivery of palliative home care in palliative patients. A retrospective study was conducted among patients who were referred to the palliative care team for consultation at Lampang Hospital from April 2020 to March 2021. Data from electronic medical records, including successful delivery of palliative home care, age, gender, public health insurance, admission department, primary disease (cancer, non-cancer), presenting symptoms (pain, dyspnea), palliative performance scale score and morphine use, were retrieved. Multiple logistic regression analysis was applied to explore the association, adjusting for covariates. A total of 370 patients were identified, with 88 (23.8%) receiving palliative home care. Results showed that being female, having low palliative performance scale score, morphine use, and having Civil Servant Medical Benefit Scheme insurance are associated with a higher chance of having access to palliative home care, compared with their counterparts. Results of this study pointed out health disparities among palliative patients who required palliative home care. This information can be in part used to redesign palliative home care system with the aim of improving access to care and patients' and caregivers' quality of life as a consequence.

Thailand UHC in Action: Universal Access to Comprehensive COVID-19 Services by Thai and Non-Thai Population

Thailand achieved Universal Health Coverage (UHC) in 2002 through three main public health insurance schemes; the tax-financed Civil Servant Medical Benefit Scheme (CSMBS) covers public sector employees and dependants (7.1% of total population), payroll-tax financed Social Health Insurance (SHI) Scheme covers private sector employees (17.2%), and the tax-financed Universal Coverage Scheme (UCS) covers the remaining majority (75.7%) [1,2]. Registered migrant workers are covered by the SHI while voluntary premium-contribution migrant health insurance, managed by Ministry of Public Health (MOPH), covers undocumented migrants and their dependants. Hence, many unregistered migrant workers and their family members are not covered by any financial risk protection systems; services are paid for out-of-pocket [3]. Extensive geographical coverage of district health systems facilitates adequate and equitable access [4] with low levels of unmet needs [5]. The comprehensive benefit package [2] and free-at-point of services result in low and continually decreasing prevalence of catastrophic health spending [6] (6.7% in 1994 to 2.2% in 2017 [7]) and incidence of impoverishment (1.4% in 1996 to 0.4% in 2015 (using international poverty line of US$ 3.1 per capita per day)) [8]. This perspective analyses how Thailand has responded to the COVID-19 pandemic through the UHC lens, covering all Thai and non-Thai populations, including migrant workers, with a comprehensive set of COVID-19-related services for everyone--a key contributing factor to pandemic containment.

Payment mechanism and hospital admission: New evidence from Thailand healthcare reform

In 2007, Thailand's Civil Servant Medical Benefit Scheme (CSMBS), one of the three main public health insurers, adopted a new payment mechanism for hospital admission. There has been a shift from fee-for-service toward Diagnostic Related Group (DRG)-based payment that transfers financial risk from the government to health care providers. This study investigates the effects of this policy change on hospital admission, frequency of admission, length of stay (LOS), type of hospital admitted, and out-of-pocket (OOP) inpatient medical expenditure. By employing nationally representative micro-level data (Health and Welfare surveys) and difference-in-difference approach, this study finds a 1 percentage point decline in hospitalization, a 10% higher chance of admission at community hospitals (the lowest level inpatient public health care facility), and a 7% less chance of admission at higher level public health care facilities like general hospitals. No significant change was observed in LOS, frequency of admission, or OOP inpatient medical expenditure associated with the post-2007 payment mechanism change. Our results emphasize the effectiveness of a close-ended payment mechanism for health care in developing countries. This study also adds to the limited literature on using micro-level data to investigate payment mechanism change in the context of low- and middle-income countries.

WS05.03 Treatment of Advanced and Metastatic NSCLC without Oncogenic Drivers: Balancing Cost and Efficacy

WS05.03 Treatment of Advanced and Metastatic NSCLC without Oncogenic Drivers: Balancing Cost and Efficacy

Inequalities in Periodontal Disease According to Insurance Schemes in Thailand.

Few studies have considered the effects of insurance on periodontal disease. We aimed to investigate the association between insurance schemes and periodontal disease among adults, using Thailand’s National Oral Health Survey (2017) data. A modified Community Periodontal Index was used to measure periodontal disease. Insurance schemes were categorized into the Universal Coverage Scheme (UCS), Civil Servant Medical Benefit Scheme (CSMBS), Social Security Scheme (SSS), and “others”. Poisson regression was applied to estimate the prevalence ratios (PRs) of insurance schemes for periodontal disease, with adjustment for age, gender, residential location, education attainment, and income. The data of 4534 participants (mean age, 39.6 ± 2.9 years; 2194 men, 2340 women) were analyzed. The proportions of participants with gingivitis or periodontitis were 87.6% and 25.9%, respectively. In covariate adjusted models, lowest education (PRs, 1.03; 95% CI, 1.01–1.06) and UCS (PRs, 1.05; 95% CI, 1.02–1.08) yielded significantly higher PRs for gingivitis, whereas lowest education (PRs, 1.20; 95% CI, 1.05–1.37) and UCS (PRs, 1.17; 95% CI, 1.02–1.34) yielded substantially higher PRs for periodontitis. Insurance schemes may be social predictors of periodontal disease. For better oral health, reduced insurance inequalities are required to increase access to regular dental visits and utilization in Thailand.

Participatory and responsive governance in universal health coverage: an analysis of legislative provisions in Thailand

Participatory and responsive governance in universal health coverage (UHC) systems synergistically ensure the needs of citizens are protected and met. In Thailand, UHC constitutes of three public insurance schemes: Civil...

The Impact of a Billing System on Healthcare Utilization: Evidence from the Thai Civil Servant Medical Benefit Scheme

AbstractThis study examines how a new billing process of the Thai Civil Servant Medical Benefit Scheme affects outpatient care utilization. Unlike policy changes considered in most existing studies, there is no change in cost‐sharing for the scheme considered here. Previously, the beneficiaries had to pay out of pocket and receive their reimbursement later. The new billing system allows hospitals to charge the government directly. Using patient‐level data from a large hospital, we find that the change affects outpatient utilization through both visiting rates and treatment intensity. These positive impacts are moderate, but persistent. The estimates are not sensitive to our choice of a time window, but their magnitudes can be sensitive to model specifications. Our analysis also suggests that patients with lower utilization rates (conditional on illnesses) prior to the change in the billing process increase their healthcare utilization more proportionally.

Effect of Insurance Type on Stage at Presentation, Surgical Approach, Tumor Recurrence and Cancer-Specific Survival in Resectable Non-Small Lung Cancer Patients.

PurposeThe aim of this study was to identify the association between Thailand’s insurance types and stage at presentation, surgical approach, tumor recurrence and cancer-specific survival in resectable non-small cell lung cancer (NSCLC) patients in northern Thailand.Patients and MethodsMedical records of patients with NSCLC who underwent pulmonary resection at Chiang Mai University Hospital from January 2007 through December 2015 were retrospectively reviewed. Patients were divided into two groups: patients with the Universal Coverage Scheme (UCS) or Social Security Scheme (SSS) and patients with the Civil Servant Medical Benefit Scheme (CSMBS) or private insurance (PI). Patient characteristics were assessed. The primary outcome was cancer-specific survival while the secondary outcome was tumor recurrence. Cox’s regression and matching propensity score analysis was used to analyze data.ResultsThis study included 583 patients: 344 with UCS or SSS and 239 with CSMBS or PI. Patients with UCS or SSS were more likely to be active smokers, have a lower percent predicted FEV1, present with higher-stage tumors and worse differentiated tumors, present with tumor necrosis, and undergo an open surgical approach than those with CSMBS or PI. At multivariable analysis of all patients cohort, there were no significant differences in terms of early stage at presentation (adjusted odds ratio (ORadj) = 0.94, 95% confidence interval (CI) = 0.65–1.37), undergoing lobectomy (ORadj = 0.59, 95% CI = 0.24–1.46), and recurrent-free survival (adjusted hazard ratio (HRadj) =1.20, 95% CI = 0.88–1.65) between groups (UCS/SSS versus CSMBS/PI). However, patients with UCS or SSS had shorter cancer-specific survival (HRadj = 1.61, 95% CI = 1.22–2.15). The results from the propensity score matched patient cohort were not different from those analyses on the full patient cohort.ConclusionThai insurance types have an effect on cancer-specific survival. The Thai government should recognize the importance of these differences, and further multi-center studies with a larger sample size are warranted to confirm this result.

Health Insurance and Colorectal Cancer Survival in Khon Kaen, Thailand.

Background:Evidence from healthcare studies demonstrates that patients’ health insurance affects service accessibility and the outcome of treatment. However, assessment on how colorectal cancer survival relates to health insurance is limited. Objective:The study examined the association between health insurance and colorectal cancer survival in Khon Kaen, Thailand. Methods:The retrospective cohort study was conducted with 1,931 colorectal cancer patients from Khon Kaen cancer registry between January 1, 2003 and December 31, 2012, and was followed-up until December 31, 2015. Relative survival was used to estimate the survival rate. Cox proportional hazard regression was used to estimate the relationship between health insurance and colorectal cancer survival, represented with the hazard ratio. Result:Most of the participants were males, and the median age was 62 years. The median survival time was 2.25 years (95% CI: 2.00-2.51). The five-year observed survival rate and relative survival rate were 36.87 (95% CI: 34.66-39.08) and, 42.28 (95% CI: 39.75-44.81), respectively. The factors that showed significant associations with poorer survival after adjustment for gender and age were non-surgical treatments (HRadj=1.88;95%CI=1.45-2.45), advanced stage (III+IV) (HRadj=2.50; 95%CI=2.00-3.12), histological grading in poorly differentiated (HRadj=1.84; 95%CI=1.32-2.56), and Universal Coverage Scheme (HRadj=1.37;95%CI=1.09-1.72). Conclusion:The survival of colorectal cancer patients in the Universal Coverage Scheme was likely to be poorer than in the Civil Servant Medical Benefit Scheme. This indicates an urgent need for a national program for colorectal cancer screening in the general population and access to health insurance.

Impact of treatment and insurance on socioeconomic disparities on the survival of renal cancer patients in Thailand.

576 Background: Access to care is an important aspect of high-quality cancer care. Patients' health insurance status is a factor influencing an individual's ability to access high-quality cancer care. The increased costs of cancer care are negatively impacting patients. 75% of Thai people use the Thailand’s Universal Coverage Scheme (UCS), about 15% use the Civil Servant Medical Benefit Scheme (CSMBS) or the Social Security Scheme (SSS). Only CSMBS can reimburse cost of the targeted therapy. Multiple new therapies have emerged for the treatment of metastatic renal cell carcinoma (mRCC) that showed OS increased in following introduction of targeted therapies and immunotherapy. However, many patients lack access to affordable, high-quality cancer care. Aim: To determine the relationship between treatment affordability, insurance status and RCC cancer survival. Methods: Retrospectively reviewed 281 medical records of RCC patients at the Ramathibodi hospital between January 2009 and December 2017. We searched the Surveillance, Epidemiology, and End Results dataset. Kaplan–Meier methods and multivariable Cox regression models were used to analyze survival outcomes and risk factors. Results: 281 RCC patients, and 127 metastasis were identified. Median age was 59.1 years, and 74.7% were male gender. There were clear cell carcinoma (77.9%), and non-clear cell was 17.1%. IMDC prognostic model categorized as favorable/intermediate/poor risk group as 14.2%/51.2%/29.1%. 41.7% has health insurance status as CSMBS, 7% in SSS and 50.9% in UCS. Only 50% of SSS and UCS paid out of their pocket of mRCC treatment. First line treatment for mRCC were targeted therapy with VEGFR TKI 73.9%, but 26.8% received only supportive care. Median OS was 24 months in the treatment group and only 4.1 months in the best supportive care group (p <0.05). Health insurance status and medication affordability was confirmed as an independent prognostic factor for mRCC patients. Conclusions: Insurance status and medication affordability are important predictive factors for mRCC, and improving access to affordable targeted therapies is likely to improve outcomes in mRCC.

Patients\u2019 perspectives regarding hospital visits in the universal health coverage system of Thailand: a qualitative study

BackgroundA universal health coverage policy was implemented in Thailand in 2002 and led to an increase in accessibility to, and equity of, healthcare services. The Thai government and academics have focused on the large-scale aspects, including effectiveness and impacts, of universal health coverage over one decade. Here, we aimed to identify patients’ perspectives on hospital visits under universal health coverage.MethodsA qualitative study was carried out in four public hospitals in rural Thailand. We collected data through focus group discussions (FGDs) and in-depth interviews (IDIs). The semi-structured interview guide was designed to elicit perspectives on hospital visits among participants covered by the Universal Coverage Scheme, Social Security Scheme or Civil Servant Medical Benefit Scheme. Data were transcribed and analysed using a thematic approach.ResultsTwenty-nine participants (mean age, 56.76 ± 16.65 years) participated in five FGDs and one IDI. The emerging themes and sub-themes were identified. Factors influencing decisions to visit hospitals were free healthcare services, perception of serious illness, the need for special tests, and continuity of care. Long waiting times were barriers to hospital visits. Employees, who could not leave their work during office hours, could not access some services such as health check-ups. From the viewpoint of participants, public hospitals provided quality and equitable healthcare services. Nevertheless, shared decision making for treatment plans was not common.ConclusionsThe factors and barriers to utilisation of healthcare services provide exploratory data to understand the healthcare-seeking behaviours of patients. Perceptions towards free services under universal health coverage are positive, but participation in decision making is rare. Future studies should focus on finding ways to balance the needs and barriers to hospital visits and to introduce the concept of shared decision making to both doctors and patients.

PCV61 - Impacts Of ACC/AHA Cholesterol Management Guideline On Statin Consumptions: A Preliminary Study

To evaluate the effects of ACC/AHA cholesterol management guideline on cost of treatment in patients with statins Hospital electronic databases of a university hospital in Thailand were used to determine the impacts of ACC/AHA guideline on utilization of statins. Statin consumptions of outpatient during six-year period (2012-2017), before and after of ACC/AHA guideline implementation, were identified by using Interrupted time-series analysis. Average cost of statin consumptions per prescription in each payment mechanism of health insurance schemes were identified to measure the change of stain consumptions before and after the guidelines’ publication. Based on the estimation of interrupted time- series technique, the intervention was not statistically significant but the trends of statin consumptions were changed dramatically in patients with Universal Healthcare Coverage (UC) scheme and with Social Security (SS) Health insurance scheme. Cost of statin treatment in both schemes were increased after the implementation of ACC/AHA guideline. Controversy, the statin treatment cost per patient under the Civil Servant Medical Benefit Scheme (CSMBS) was declined during short term period after the guidelines’ publication. Policies related quality of care especially clinical practice guidelines might increase access to necessary high price medicines in the UC and SS patients. Moreover, the impacts of the policies could urged rational drug use in patients with all health insurance schemes.

Survival Analysis and Associated Factors in THAI Patients on Peritoneal Dialysis under the PD-First Policy

The peritoneal dialysis First (PD-First) policy means that PD is the first modality of dialysis chosen for patients with end-stage renal disease (ESRD), as put forth by the Universal Health Coverage (UHC) scheme. It was initiated in Thailand in 2008. Our aim is to analyze patient survival, technique survival, and associated factors. Data of PD patients from January 2008 to November 2016 were studied. We calculated patient and technique survival rates (censored for death and kidney transplantation). Factors associated with survival were analyzed by the Cox proportional hazard model. Patient and technique survival rates between 2008 - 2012 and 2013 - 2016 were compared. Our study included 11,477 patients. The mean (standard deviation [SD]) age at initiation of PD was 54.0 (14.4) years. The level of education in 85.2% of cases was illiterate or primary school. A total of 60.9% of patients developed ESRD secondary to diabetes. The 1- to 5-year patient survival rates were 82.6, 71.8, 64.0, 58.5, and 54.0%, respectively. The first-year technique survival rate was 94.8%. The patient and technique survival rates during 2013 - 2016 were better than those seen during 2008 - 2012. Factors associated with lower patient survival rates were: female gender, increased age at start of PD, coverage with civil servant medical benefit scheme, low educational levels, and a history of diabetes. Most patients had diabetes and low educational levels as seen in the outcomes in the previous literature. These factors impacted the survival of patients under the PD-First policy.

Inpatient care expenditure of the elderly with chronic diseases who use public health insurance: Disparity in their last year of life

The Thai elderly are eligible for the Civil Servant Medical Benefit Scheme (CS) or Universal Coverage Scheme (UCS) depending on their pre-retirement or their children work status. This study aimed to investigate the disparity in inpatient care expenditures in the last year of life among Thai elderly individuals who used the two public health insurance schemes. Using death registration and inpatient administrative data from 2007 to 2011, our subpopulation group included the elderly with four chronic disease groups: diabetes mellitus, hypertension and cardiovascular disease, heart disease, and cancer. Among 1,242,150 elderly decedents, about 40% of them had at least one of the four chronic disease conditions and were hospitalized in their last year of life. The results showed that the means of inpatient care expenditures in the last year of life paid by CS and UCS per decedent were 99,672 Thai Baht and 52,472 Thai Baht, respectively. On average, UCS used higher healthcare resources by diagnosis-related group relative weight measure per decedent compared with CS. In all cases, the rates of payment for inpatient treatment per diagnosis-related group adjusted relative weight were higher for CS than UCS. This study found that the disparities in inpatient care expenditures in the last year of life stemmed mainly from the difference in payment rates. To mitigate this disparity, unified payment rates for various types of treatment that reflect costs of hospital care across insurance schemes were recommended.

Strategic purchasing and health system efficiency: A comparison of two financing schemes in Thailand.

Strategic purchasing is an essential health financing function. This paper compares the strategic purchasing practices of Thailand’s two tax-financed health insurance schemes, the Universal Coverage Scheme (UCS) and the Civil Servant Medical Benefit Scheme (CSMBS), and identifies factors contributing to successful universal health coverage outcomes by analysing the relationships between the purchaser and government, providers and members. The study uses a cross-sectional mixed-methods design, including document review and interviews with 56 key informants. The Comptroller General Department (CGD) of Ministry of Finance manages CSMBS as one among civil servant welfare programmes. Their purchasing is passive. Fee for service payment for outpatient care has resulted in rapid cost escalation and overspending of their annual budget. In contrast, National Health Security Office (NHSO) manages purchasing for UCS, which undertakes a range of strategic purchasing actions, including applying closed ended provider payment, promoting primary healthcare’s gate keeping functions, exercising collective purchasing power and engaging views of members in decision making process. This difference in purchasing arrangements resulted in expenditure per CSMBS member being 4 times higher than UCS in 2014. The governance of the purchaser organization, the design of the purchasing arrangements including incentives and use of information, and the institutional capacities to implement purchasing functions are essential for effective strategic purchasing which can improve health system efficiency as a whole.