CLOSING THE HEALTH GAPS FOR THE ELDERLY: Promoting Health Equity and Social Inclusion in Thailand Closing the Health Gaps for the Elderly: Promoting Health Equity and Social Inclusion in Thailand CLOSING THE HEALTH GAPS FOR THE ELDERLY: Promoting Health Equity and Social Inclusion in Thailand April 2016 Standard Disclaimer: This volume is a product of the staff of the International Bank for Reconstruction and Development / The World Bank. The findings, interpretations, and conclusions expressed in this paper do not necessarily reflect the views of the Executive Directors of The World Bank or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgment on the part of The World Bank concerning the legal status of any territory or the endorsement or acceptance of such boundaries. 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All other queries on rights and licenses, including subsidiary rights, should be addressed to the Office of the Publisher, The World Bank, 1818 H Street NW, Washington, DC 20433, USA, fax 202-522-2422, e-mail pubrights@worldbank.org. 4 Closing the Health Gaps for the Elderly: Promoting Health Equity and Social Inclusion in Thailand Table of Contents Acknowledgements 7 Abbreviation 8 Executive Summary 9 Background and Rationale 10 Objective 13 Methodology 13 Key Findings on Utilization of Health Services 15 Key Findings on Financial Protection 20 Recommendations 26 Closing the Health Gaps for the Elderly: Promoting Health Equity and Social Inclusion in Thailand 5 List of Tables Table 1: Summary of research instruments (FGDs and IDIs) and number of elderly participants 13 Table 2: Average of health and medical expenditures among those elderly who paid out-of-pocket health expenditures per year 22 Table 3: Out-of-pocket payment per each visit to a health facility paid by patients who need dialysis services 22 Table 4: Patients’ opinion whether the related healthcare cost affect their families economically 23 Table 5: Patients’ opinion whether the related healthcare cost affect their families economically, by health insurance schemes 23 Table 6: Average health-related expenditures per year by urban and rural residents (from qualitative study) 23 Table 7: Universal Social Pension by Age 24 List of Figures Figure 1: Utilization of out-patient and in-patient care data of UC, SSS, and CSMBS by Age 10 Figure 2: Utilization of out-patient and in-patient care data of UC by gender 11 Figure 3: Utilization of out-patient and in-patient care data of CSMBS by gender 11 Figure 4: Share of the elderly (60+) living in households with at least one out-patient visit and in-patient visit 15 Figure 5: Share of the elderly (60+) living in households with at least one out-patient visit and in-patient visit, disaggregated by co-residence and non co-residence with adult children 16 Figure 6: Incidence of catastrophic health expenditures among elderly people 20 Figure 7: Share of elderly in Thailand with co-residence with adult children (SES 1990, 1996, 2006 and 2011) 21 6 Closing the Health Gaps for the Elderly: Promoting Health Equity and Social Inclusion in Thailand Acknowledgements This report was prepared and led by Sutayut Osornprasop. Research assistance was provided by Noppakwan Inthapan, Sakulrat Sirikul, Theepakorn Jitthitikulchai, Sukanya Kulkaew, Jarmmaree Sornboot, Nateerai Jandprook, Thitinan Tanyuwattana, and Apisit Kullanit. The team appreciated Emily Sinnott, Toomas Palu, Lars Sondergaard, Philip O’Keefe, Aparnaa Somanathan, and Yang Huang for reviewing and providing valuable contribution that helped improve the quality of this report.The team appreciated valuable inputs from Dr. Michele Gragnolati, Global Lead on Population and Development of the World Bank, Dr. Thaworn Sakulphanit and Orawan Prasitsiriphon of the Health Insurance System Research Office, Dr. Chanvit Tharathep of Ministry of Public Health, Dr. Samrit Srithamrongsawat from the National Health Security Office, Dr. Wittaya Chadbanchachai of Khon Kaen Regional Hospital, Dr. Supat Hasuwannakit of Jana Hospital, Dr. Bhumisuk Khananurak of National Economic and Social Development Board, Dr. Ladda Damrikanlert of the Foundation of Thai Gerontology Research and Development Institute, Dr. Somsak Chunharas of National Health Foundation, Dr. Prakasit Kayasit and Mr. Nuttapon Theskayan of Thai Health Promotion Foundation, Dr. Siriwan Arunthippaitoon of Ministry of Social Development and Human Security, Dr. Jiruth Sriratanaban and Dr. Piya Hanvoravongchai of Faculty of Medicine, Chulalongkorn University, Dr. Sirintorn Charnsirikarnjana of Faculty of Medicine Ramathibodi Hospital and Mr. Sawang Kaewkantha of the Foundation for Older Persons’s Development (FOPDEV). Most importantly, the team are grateful to all elderly participants, Ministry of Public Health officials, dedicated health providers at university, regional, provincial, community, and health promotion hospitals, as well as village health volunteers who participated and provided much valuable inputs during the study. The team appreciated Ms. Leonora Aquino Gonzales, Ms. Kanitha Kongrukgreatiyos, Ben Alex Manser, Buntarika Sangarun, Paul Daniel Risley and Mr. Yanawit Dechpanyawat from the External Relations Team of the World Bank for their much valuable contribution to the dissemination of this report. Closing the Health Gaps for the Elderly: Promoting Health Equity and Social Inclusion in Thailand 7 Abbreviations CSMBS Civil Servant Medical Benefits Scheme DRG Diagnosis-related group FGDs Focus-group discussions FOPDEV Foundation for Older Persons’s Development HH Households HISRO Health Insurance System Research Office HITAP Health Intervention and Technology Assessment Program IDIs In-depth interviews IP In-patient LAOs Local administrative organizations NCDs Non-communicable diseases OP Out-patient PHO Provincial Health Office SES Socio-Economic Survey SSS Social Security Scheme THB Thai Baht UC Universal Health Coverage scheme VHVs Village Health Volunteers 8 Closing the Health Gaps for the Elderly: Promoting Health Equity and Social Inclusion in Thailand Executive Summary Thailand’s health insurance and health protection schemes cover all Thai citizens and provide relatively comprehensive benefits coverage. The universal health coverage (UC) scheme, in particular, offers good practices to other countries that experience rapidly aging and NCDs transition, notably its provider payment mechanisms as well as drug and medical technology assessment and prioritization mechanism that can help slow down rapidly rising costs, contributing to sustainability of the scheme. However, there are still significant gaps with regard to non-medical costs and social support to facilitate access to and utilization of health care services, e.g. the lack of caretakers, lack of affordable transportation options to access health facilities. These gaps particularly affect poor elderly individuals and the elderly in the oldest old group (over 80 years of age). This is supported by recent data that shows declining health utilization rates among the members of the UC scheme in the oldest old group. A key reason that contributes to the drop in utilization of health services among the oldest old group appears to be the dependence on availability of caretakers and relatives to bring the elderly patients to a health facility. Other reasons include the change of health-seeking behaviors after having been living and receiving treatments for NCDs for 10-15 years and the unwillingness to bother relatives to bring them to health facilities. Lack of public and affordable transportation is the most important barrier to accessing health services among the elderly in rural areas. These affect particularly the elderly poor, and the elderly who do not live nearby major highways and roads on which public buses operate. The cost of renting private cars to take them to hospitals is simply not affordable by many elderly households, even those who live above the poverty line. The elderly poor who live on allowances from universal pension alone is the most vulnerable, as they need to use all of the monthly allowance to pay for room rent and food, and these people do not have extra resources to travel to health facilities in time of sickness. Special attention and support should be given to poor bed-ridden elderly and poor elderly with mobility constraints. These elderly poor tend to suffer from chronic diseases that need intensive care and support but often they are not able to travel to health facilities frequently due to difficulties to move, dependence on availability of caretakers to take them to health facilities, and transportation costs. Hence, regular home visits by relevant health facility staff and village health volunteers targeting these bed-ridden and poor elderly should be promoted, and support for transportation from health centers or from LAOs should be provided to this group of the elderly to travel to health facilities as needed. More balanced policy options to promote outreach and home visit services by health professionals and to facilitate travel to health facilities when needed for the elderly should be considered. Local Administrative Organizations (LAOs) can play an instrumental role in promoting access to health services for the elderly, including providing health emergency vans for the community and arrange transportation for elderly poor to access health facilities, as necessary. Furthermore, Village Health Volunteers (VHVs) are instrumental to the provision of health-related support to the elderly in communities, particularly through home visits as well as organizing physical exercise and health education sessions. Nevertheless, performance of LAOs and VHVs in providing social support to improve access to health services for the elderly vary from communities to communities, depending on the local leadership and their interests. Hence, efforts should be made for good practices from LAOs and VHVs to be shared and promoted, as well as to utilize non-financial and financial incentives to encourage the replication of these good practices in all communities across the country. Closing the Health Gaps for the Elderly: Promoting Health Equity and Social Inclusion in Thailand 9 Closing the Health Gaps for the Elderly: Promoting Health Equity and Social Inclusion in Thailand Background and rationale Thailand has succeeded in expanding coverage While Thailand’s achievement of universal health of publicly-funded and publicly-managed health coverage is well noted, recent researches and insurance schemes, following the introduction studies have indicated that there are still gaps in of universal health coverage policy in 2001. health utilization and financial protection. Today, 100% of Thai citizens are statistically A recent study by Thailand’s Health Insurance covered by one of the publicly-managed health System Research Office (HISRO) shows that insurance schemes, mainly the Universal utilization of health services by patients of three Health Coverage scheme (UC), Social Security main health insurance schemes combined Scheme (SSS), Civil Servant Medical Benefits increased markedly after age 45 for both Scheme (CSMBS), and medical benefits for out-patient care and in-patient care but later state enterprise employees. These arrangements dropped during an advanced age1. Utilization have broadened access to health services, of out-patient care services decreases among contributed to higher and more equitable patterns patients who are over 75 years of age while that of utilization, and helped reduce the financial of in-patient care services decreases after 85 burden and risk of impoverishment associated years of age, as per the graphs below. with health care expenses. Figure 1 Utilization of out-patient and in-patient care data of UC, SSS, and CSMBS by age Source: Utilization of out-patient and in-patient care data of UC, SSS, and CSMBS (provided by HISRO) 1 Performance of Health Care for Elderly and Impact on Public Health Care Financing during 2011-2022, HISRO, 2011, p.33. 10 Closing the Health Gaps for the Elderly: Promoting Health Equity and Social Inclusion in Thailand Breakdowns of utilization by schemes indicate after the age of 50. However, the decline of major disparity in utilization of in-patient care utilization by UC patients started from around the by schemes. While utilization of in-patient care age of 75 and the rates went down very sharply. services by CSMBS patients rises with age, The decline in utilization by CSMBS patients utilization by UC patients starts to decrease after started at around the age of 80, but the rates did the age of 82. As for out-patient care, utilization not go down as sharply as UC patients. by both UC and CSMBS patients rises sharply Figure 2 Utilization of out-patient and in-patient care data of UC by gender Source: Utilization of out-patient care data of UC by gender (provided by HISRO) Figure 3 Utilization of out-patient and in-patient care data of CSMBS by gender Source: Utilization of in-patient care data of CSMBS by gender (provided by HISRO) These findings raise several important questions: eldest old group? Given that the UC members Why did the utilization of out-patient care by generally comprise of population with lower UC members drop after the age of 75, while the socio-economic status (compared with CSMBS elderly people are more likely to have higher and SSS), it is important to raise a question health care needs when they are older? Why on whether there were problems with financial did utilization of in-patient care services by UC protection in utilizing health services among the patients drop after the age of 82 while that of elderly members of the UC scheme, particularly CSMBS patients continue to rise? Were there among the elderly poor? problems with access to health care among the Closing the Health Gaps for the Elderly: Promoting Health Equity and Social Inclusion in Thailand 11 12 Closing the Health Gaps for the Elderly: Promoting Health Equity and Social Inclusion in Thailand Objective The objective of the study is to identify the gaps of accessing universal health coverage scheme’s care system by the elderly population, focusing on utilization and financial protection aspects. Methodology The team conducted small-scale area-based nationally representative, but served the purpose qualitative case studies, focusing on elderly UC of this small study in providing preliminary members who live in selected urban and rural information on key utilization and financial areas in four different geographical regions protection issues that elderly UC members could of Thailand – Central, North, Northeastern, have encountered in accessing health care and South. The case studies are not designed services. to generate quantitative results and are not Key research questions are: 1. Why does out-patient utilization drop after the age of 75 for all health care schemes in Thailand? 2. Why does in-patient utilization of patients on the Universal Healthcare Coverage drop after age of 82 while it continues to rise for patients with the Civil Servant Medical Benefits Scheme? 3. What are the causes of high out-of-pocket among the poor elderly? 4. What is the level of transportation cost paid by poor elderly to access health services? 5. To what extent have the transportation costs posed burdens to poor elderly to access health services? Is transportation a barrier to access health services by elderly patients? 6. What are key diseases that are not adequately covered by the current UC coverage, that require out-of-pocket expenditures? The study followed standard qualitative research also interviewed when the elderly people had methods, including focus-group discussions difficulties in communication. Relevant health (FGDs) and in-depth interviews (IDIs) with elderly providers and local government units were also people who are members of the universal health interviewed. Below were the study sites coverage scheme. Families of the elderly were 1. An urban and a rural district in Nonthaburi province (Central Thailand) 2. An urban and a rural district in Lopburi province (Central Thailand) 3. An urban and a rural district in Nakorn Sawan province (Northern Thailand) 4. An urban and a rural district in Chiang Mai province (Northern Thailand) 5. An urban and a rural district in Kalasin province (Northeastern Thailand - poorest province in Thailand), with referral hospitals in Khon Kaen province 6. An urban and a rural district in Songkhla province (Southern Thailand) 7. An urban and a rural district in Surat Thani province (Southern Thailand) 8. Chulalongkorn University Hospital in Bangkok In each district, separate FGDs focusing on elderly individuals were selected to participate two different issues were conducted. One FGD in IDIs. In each district, the team also conducted focused on utilization and access to health care IDIs with approximately 5 bed-ridden patients at services, in which general elderly people aged their respective homes to understand utilization 75 and above were participants (to understand and access to health care issues. Additional IDIs why utilization drops after age 75). The other were also conducted with health facility staff, FGD focused on financial protection, in which the village health volunteers, and representatives elderly (60 years and over) who were admitted of local administrative organizations. Summary (being in-patient) in a hospital during the past of research instruments and number of elderly Table 1: one year were invited as participants. The participants (with overlaps in participants Summary of research instruments (FGDs and IDIs) and number of number of participants in each FGD is between between FGDs and IDIs of the same issue) is elderly participants 20 and 30. Following each FGD, around 5-10 outlined in the table below. Reserch instruments Central North Northeast South Total FGD utilization and access 76 86 54 56 272 FGD financial protection 62 105 42 66 275 IDI utilization and access 33 33 7 19 92 IDI financial protection 30 20 27 17 94 IDI bed-ridden 19 19 9 17 64 Total 220 263 139 175 797 Closing the Health Gaps for the Elderly: Promoting Health Equity and Social Inclusion in Thailand 13 To provide a big picture on utilization of health care services at the national level, the team analyzed Socio-Economic Survey (SES) 2011, which is the national household survey in Thailand that collected information on household income as well as health expenditures. However, it must be cautioned that there is no direct health care utilization information available at the individual level in SES, and hence the analysis indicates the health utilization based on the health expenditures on in-patient or out-patient services of households with elderly members (aged 60 years and over), and not exactly health utilization of elderly individuals. In other words, the information presented here is the share of the elderly who are living in a household with any health service utilization. Similarly, analyses on incidence of catastrophic health expenditures among the Elderly (60+) show the share of the elderly (60+) living in households with catastrophic payment. 14 Closing the Health Gaps for the Elderly: Promoting Health Equity and Social Inclusion in Thailand Key findings on utilization of health services 1. According to SES 2011, there are gaps in utilization of out-patient care services, with the utilization of out-patient and in-patient care utilization rates of the richest households doubled services among households with elderly that of the poorest households in both urban and members from the poorer and richer quintiles in rural areas, as indicated in Figure 4. both urban and rural areas. The gap is largest in Share of the elderly living in HHs with at least one OP visit Figure 4 Share of the elderly (60+) living in households with at least one out-patient visit and in-patient visit2 20 15 % of People 10 5 0 Poorest 2 3 4 Richest Poorest 2 3 4 Richest Urban Rural Source: NSO, Social and Economic Survey 2011 Share of the elderly living in HHs with at least one IP visit 20 15 % of People 105 0 Poorest 2 3 4 Richest Poorest 2 3 4 Richest Urban Rural Source: NSO, Social and Economic Survey 2011 SES 2011 also indicates that co-residence with care services among the elderly with higher adult children played a significant factor in the incomes (top two quintiles), as illustrated in level of utilization of out-patient and in-patient Figure 5. This might partly be attributed to the care services among poorer households with ability of the richer elderly who do not live with elderly members (two bottom poorest quintiles) in adult children being able to hire caretakers to both urban and rural areas. This could partly be bring them to receive health care services when attributed to the lack of caretakers to help bring needed. In summary, this indicates that the poor poor elderly that do not live with adult children to elderly who do not live with adult children are receive health services when needed. most vulnerable and have more probability to not Co-residence with adult children does not appear being able to access health care services when to influence significantly the utilization of health needed. 2 This figure was prepared by Yang Huang. For SES, there is no health care utilization information at individual level, which means the team could not disaggregate the figures by gender. The team plotted household in-patient admission rates and household out-patient visit rates against household expenditure per capita quintiles for people aged 60 and above. In other words, the team shows here the share of the elderly who are living in a household with any health service utilization. The team ranked expenditure per capita at household level to define quintiles. Closing the Health Gaps for the Elderly: Promoting Health Equity and Social Inclusion in Thailand 15 Share of the elderly (60+) living in households with at least one OP visit Figure 5 Share of the elderly (60+) living in households with at least one out-patient visit and in-patient visit, disaggregated by co-residence and 20 non co-residence with adult children3 15 % of People 10 5 0 Poorest 2 3 4 Richest Poorest 2 3 4 Richest Urban, w/o Child Urban, w/ Child Source: NSO, Social and Economic Survey 2011 20 % of People 10 5 0 15 Poorest 2 3 4 Richest Poorest 2 3 4 Richest Rural, w/o Child Rural, w/ Child Source: NSO, Social and Economic Survey 2011 Share of the elderly (60+) living in households with at least one IP visit 20 15 % of People 105 0 Poorest 2 3 4 Richest Poorest 2 3 4 Richest Urban, w/o Child Urban, w/ Child Source: NSO, Social and Economic Survey 2011 20 15 % of People 105 0 Poorest 2 3 4 Richest Poorest 2 3 4 Richest Rural, w/o Child Rural, w/ Child Source: NSO, Social and Economic Survey 2011 3 This figure was prepared by Yang Huang. An adult child is defined as child aged 24 and over. 16 Closing the Health Gaps for the Elderly: Promoting Health Equity and Social Inclusion in Thailand 2. According to the qualitative assessment, 43% 5. The main factors that most likely contribute to of elderly interviewees are fully satisfied with the the differing trends in in-patient utilization rates services provided by health facilities under the of UC and CSMBS scheme members are the universal health coverage scheme, and do not differences in living location and wealth of the encounter any key barriers to utilizing health care UC and CSMBS scheme members. On average, services. Of those who have identified barriers to CSMBS members and their families tend to utilizing health care services, “long waiting time” have higher incomes than UC members, and is the top barrier among elderly interviewees in tend to live in cities and urban areas. Having urban areas, while “long distance to a health higher incomes allows CSMBS members more facility” and “lack of public and affordable opportunities to own private cars and hire transportation to health facilities” are top barriers caretakers, making it easier to bring elderly to accessing services in rural areas. patients to health facilities when it is needed. This is further complemented by the fact that 3. Among frail and bed-ridden elderly most CSMBS members live in cities and urban interviewees, the key barrier to accessing health areas, giving them an easy access to services is the unavailability of caretakers/ higher-level hospitals where an in-patient relatives and transportation to bring them to services are needed. health facilities, and that this barrier tends to have greater effects on elderly interviewees who Another reason which contributes to the do not live with adult children, who live in rural continuing rise in utilization of in-patient services areas, and who are females, particularly widows. among CSMBS members is that due to the relatively more generous CSMBS benefits 4. There is a trend that utilization of out-patient package and fee-for-service provider payment services increases as people grow older, method, it is practically possible for CSMBS particularly after age 55-60, but then utilization members to utilize in-patient services for frequency decreases after age 75-80. A key long-term care purposes. This is not possible for reason that contributes to the drop in utilization UC members. of out-patient care services after the age of 75 appears to be the dependence on availability 6. Lack of public and affordable transportation of caretakers and relatives to bring the elderly is the most important barrier to accessing health patients to a health facility. At age 55-65, services among the elderly interviewees who most of the elderly interviewees were able to live in rural areas and far from major highways travel independently to utilize out-patient care and roads where public buses and taxis operate. services at different level of health facilities. This is a major problem even in such area that However, as they grow older, they become is as adjacent to Bangkok as Sai Noi district frail and start to have health conditions that in Nontaburi province. Elderly farmers working prevent them from travelling to health facilities in orchards in Sai Noi district who do not have independently. Once the elderly people become private cars have experienced enormous dependent and need others to bring them to difficulties in getting taxis to pick elderly health facilities, frequency of their utilizing passengers up from their homes during health services at health facilities generally drops. This emergencies, particularly during night times. tends to affect more elderly people who live in rural areas, particularly those that need to visit Elderly people without private cars who reside higher-level health facilities which are located in outside of Greater Bangkok and major cities most bigger cities further away from their homes. likely do not have access to taxis and need to rely on public buses or renting private cars. Use Cataracts appear to be the most common of public buses is a cheap and affordable option disease that affect mobility of the elderly people for many elderly interviewees who live next to and make them dependent of relatives and major roads and highways. However, the routes caretakers to bring them to health facilities. As and frequency of public bus services are limited, cataracts progress with age, it disproportionately and hence it may serve those who need out-patient affects the eldest old group. services, but not in health emergency circumstances. Several elderly interviewees also shared that they It is also important to note that public buses started to be diagnosed with non-communicable mainly benefit the elderly who live near the major diseases (NCDs) in their mid-50s and 60s, that highways and roads where public buses are they were worried at the time, and that this led operated. A large number of elderly interviewees to frequent visits to health facilities to treat these who do not have access to public buses identify emerging NCDs. But after they have lived with that the cost of renting private vehicles is a major the diseases and received treatments for 10-15 impediment for their accessing health services, years, they feel that this has become part of and this point will be discussed in more details in their normal lives and are not enthusiastic to visit the financial protection section below. health facilities as often as before. Closing the Health Gaps for the Elderly: Promoting Health Equity and Social Inclusion in Thailand 17 7. Village Health Volunteers (VHVs) / Village In Kalasin province, the Provincial Health Office Elderly Volunteers have played a crucial role in (PHO) has provided unique and extra support for supporting the health and utilization of health the elderly in the community. First, they set up services by the elderly, particularly in rural Suksala, which is a small health center (a unit communities. They serve as a strong linkage under the health promotion hospital) manned between the elderly in communities and health by VHVs in every village in the province. Each care professionals at health promotion hospitals Suksala is equipped with basic medical supplies, and high-level health facilities, particularly and VHVs are trained to dispense them at no through home visits, organizing health education cost to the villagers. There are approximately sessions as well as physical exercise sessions 8-15 VHVs in each village (1 VHV per 10-15 for the elderly in the communities. households), and they take turn to man the center. Each Suksala usually operates early in There are good practices in several communities the morning and later in the evening, outside the whereby health promotion hospitals and elderly operating hours of health promotion hospitals, members prioritize elderly population for their providing the elderly and village residents more services, including conducting mapping of elderly options to utilize health services. Second, VHVs in the communities into three groups: are given the opportunity to receive specialized (i) Tid Sangkom, which refers to the elderly who training on geriatric care (among other few are physically fit enough to go out and socialize areas of specialized training), and these trained regularly with friends; (ii) Tid Ban, which refers VHVs focus on serving the elderly population to the elderly who are frail and that their physical in their own communities. This not only helps conditions do not allow them to go out of their create community health cadres with relevant homes to socialize with friends regularly; knowledge on how to support health care for the (iii) Tid Tieng, which refers to bed-ridden elderly elderly, but it also empowers the cadres to be who are very frail and spend most of their times confident and proud in what they do. on the bed. VHVs then prioritize their services to these different groups accordingly. For Tid Overall, the performance of VHVs in Thailand Sangkom group, the elderly are usually invited varies from communities to communities, but the to participate in physical exercise and health key success factors are regular supervision by education sessions. For Tid Ban group, the health promotion hospitals as well as collaboration VHVs make plan for home visits occasionally to with local administration organizations, which check on their health and other needs. For Tid can provide additional resources for the activities Tieng group, the VHVs make plan for home visits conducted by VHVs to support the elderly regularly, provide physical therapy sessions, as population in local communities. well as perform health check-ups along with staff from health promotion hospitals. 18 Closing the Health Gaps for the Elderly: Promoting Health Equity and Social Inclusion in Thailand Closing the Health Gaps for the Elderly: Promoting Health Equity and Social Inclusion in Thailand 19 Key findings on financial protection 1. The UC scheme has provided a high level of minority of elderly UC members. To provide a financial protection against catastrophic health big picture on financial protection at the national care costs for its members, which account for level, the team analyzed SES 2011. As per over 75% of Thai population; specifically the Figure 6 below, the incidence of catastrophic UC scheme covers all Thai citizens who are health expenditures among the two poorest not covered by SSS (formal sector workers), quintiles of elderly people is about 1% and 2% CSMBS (civil servants and their immediate family respectively.5 Among these bottom 40%, it is members), and other medical benefits provided important to note that there is a higher incidence by state enterprises for their employees and of catastrophic health expenditure among the immediate family members. This level of financial elderly people who live in rural areas compared protection is rarely achieved by other countries with those who live in urban areas. with similar development and income level as Thailand. With only very limited exceptions, all We have also noticed a relationship between out-patient care and in-patient care services co-residence with adult children and catastrophic provided by lower-level health facilities, including health expenditures. Elderly individuals who live health promotion hospitals (formerly health with adult children across all wealth quintiles centers) and district hospitals, are free for have lower catastrophic health expenditures elderly UC members.4 Out-of-pocket medical compared with their peers who do not live with expenses for UC members do sometimes take adult children. It is important to note that the place at higher-level health facilities such as incidence of catastrophic health expenditures provincial, regional, and university hospitals, of elderly individuals living in rural areas without and yet a large number of UC patients do not co-residence with adult children doubled that of experience catastrophic health expenditures the elderly individuals in rural areas who live with nor do they become impoverished due to health adult children. This problem is likely to grow in expenditures. the future, as the proportion of Thai elderly living with adult children is on the decline, from nearly Nevertheless, the UC system is not without any 80% in 1990 to less than 60% in 2011 (shown in gaps on financial protection, and catastrophic Figure 7), while more and more Thai elderly do health expenditures do incur among the small not live with their adult children. Figure 6 Incidence of catastrophic health expenditures among elderly people6 4 Non-elderly UC members are expected to contribute THB 30 per each visit to a health facility, but they have an option to sign a declaration that they are not willing/able to contribute THB 30 per each visit at the health facility. 5 Catastrophic health expenditures in the study are defined as having health expenditures higher than 10% of total expenditures. 6 This figure was prepared by Yang Huang. Due to the limitation of SES as mentioned earlier, the figures show the share of the elderly (60+) living in households with catastrophic health payment, which is taken as a proxy for incidence of catastrophic health expenditures among elderly people. 20 Closing the Health Gaps for the Elderly: Promoting Health Equity and Social Inclusion in Thailand Figure 7 Share of elderly in Thailand with co-residence with adult children (SES 1990, 1996, 2006 and 2011)7 Note: Adult child here is defined as child aged 24+ Source: Thailand Socio-economic Survey (SES) 1990, 1996, 2006 and 2011 2. While the low incidence of catastrophic health areas. SES 2011 also indicates that co-residence expenditures among the elderly people in poorest with adult children played a significant factor in income quintiles can partly be attributed to the the level of utilization of out-patient and in-patient effectiveness of the UC scheme in providing care services among poorer households with financial protection to the poor, it may also be elderly members (two bottom poorest quintiles) in attributed to “foregone” care – that some poor both urban and rural areas8. This could partly be elderly individuals may not access health care attributed to the lack of caretakers to help bring services when needed, contributing to low poor elderly to receive health services when catastrophic health expenditures. The factor needed. “foregone” care is partly supported by SES 2011 analysis (more information is provided in the 3. It is important to note that less than half of utilization section above), which indicates that those surveyed under SES 2011 paid out-of- there are gaps in utilization of out-patient and pocket health expenditures. Hence, the team in-patient care services among households with has analyzed average out-of-pocket health elderly members from the poorer and richer expenditures, as shown in Table 2. The analysis quintiles in both urban and rural areas, and that confirms that there are poor elderly people who the gap is largest in out-patient care services still need to pay for the costs of out-patient and utilization, with the utilization rates of the poorest in-patient care services at publicly run health households (bottom two income quintiles) lower facilities. It is to note that SES does not provide than half of that of the richest households (top information on transportation costs to health two income quintiles) in both urban and rural facilities, so this information is not part of the table. 7 This figure was prepared by Yang Huang. 8 The team analyzed Socio-Economic Survey (SES) 2011, which is the only national household survey in Thailand that collected information on household income as well as health expenditures. However, it must be cautioned that there is no direct health care utilization information available at the individual level in SES, and hence the analysis indicates the health utilization based on the health expenditures on in-patient or out-patient services of households with elderly members (aged 60 years and over), and not exactly health utilization of the elderly individuals. In other words, the information presented here is the share of the elderly who are living in a household with any health service utilization. Hence, the information on health utilization of elderly individuals will be provided in the qualitative assessment results presented below. Closing the Health Gaps for the Elderly: Promoting Health Equity and Social Inclusion in Thailand 21 Table 2 Average of health and medical expenditures among those elderly who paid out-of-pocket health expenditures per year 4. Through interviews with elderly patients and In summary, while treatment of most diseases health facilities, while the UC’s coverage of are fully covered by the UC scheme, there are drugs and treatment is relatively comprehensive, specific diseases that are not adequately covered there are key cost items that are not covered by the current UC coverage and patients of by the UC scheme which are likely to be paid these diseases are required to pay out-of-pocket for by elderly patients such as drugs that expenditures. These include severe chronic renal are not on the essential drug list, selected disease, certain types of cancer that require medical equipment for knee/hip replacement, treatment and drugs that are outside of the UC hemodialysis for severe chronic renal disease scheme’s cancer treatment protocol (though patients (except for those who cannot receive it is to be noted that the UC scheme covers peritoneal dialysis), cost of setting up home- the cost of radiotherapy, surgery, and several based non-medical accessories for peritoneal types of chemotherapy for cancer patients), and dialysis patients, and all cancer therapies that dementia. are outside of UC scheme’s cancer treatment protocol, e.g. targeted therapy and selected A recent quantitative study led by Dr. Vijj Kasemsap drugs for chemotherapy. It is important to note also shows that UC patients with chronic renal that key drugs that are not covered by the UC diseases still need to pay out-of-pocket, even scheme include all drugs that treat (or slow down for peritoneal dialysis which is covered by the the progress of) dementia group of diseases UC scheme.10 This amount can impoverish poor that include Alzheimer. Dementia is the group elderly who need such treatment, as illustrated in of diseases that affect a significant number of Table 3, 4, and 5.11 elderly in Thailand – from about 7.1% of elderly in the 60-69 age group to one-third of the elderly in the 80 and over age group.9 Table 3 Fees paid Food / Total Total Out-of-pocket payment per each visit Cost Transportation to hospital Accommodation (per time) (per year) to a health facility paid by patients who need dialysis services Hemodialysis (335) 226 223 99 548 56,992 - 85,488 Peritoneal dialysis (1125) 327 140 124 591 7,092 Kidney transplant (16) 674 3,056 174 3,904 23,424 9 It should also be noted that dementia affects more female elderly than male elderly. Among the elderly that are in the 80 and over age group, the dementia prevalence in males is 22%, while that of female is 40%. Suwit Wibulpolprasert et al, Thailand Health Profile 2008-2010, Ministry of Public Health, April 2011, p. 234. 10 Vich Kasemsap et al, Assessment of Access and Service Delivery of Renal Replacement Therapy under the Universal Health Coverage Scheme, HISRO, 30 September 2013. 11 Ibid. 22 Closing the Health Gaps for the Elderly: Promoting Health Equity and Social Inclusion in Thailand Table 4 Have economic impact Have no economic Patients’ opinion on whether the Assessment on families (%) impacts on families (%) related healthcare cost affects their families economically Hemodialysis (335) 53.7 46.3 Peritoneal dialysis (1125) 44.9 54.9 Kidney transplant (16) 31.5 68.8 Table 5 Have economic impact Have no economic Patients’ opinion on whether the Assessment on families (%) impacts on families (%) related healthcare cost affects their families economically, by health UC (1275) 47.5 52.4 insurance schemes CSMBS (68) 26.5 73.5 SSO (35) 45.7 54.3 5. Transportation is a major cost for elderly rural The qualitative study identified several elderly residents to utilize health services. From the poor patients from remote districts who undergo qualitative study sample (which is not nationally cancer radiotherapy and chemotherapy at representative), the average transportation regional and university hospitals, far away from cost incurred by elderly rural residents is more their hometowns. Depending on the course of than 10 times that of elderly urban residents, as the therapy, they need to travel from remote per Table 3. The UC scheme does not provide districts to a regional or a university hospital support for transportation costs, making it the in another province every other day or every major gap. week for a period of up to several months.Even though the cost of these cancer treatments Transportation costs were identified as the are covered by the UC scheme, the cost of most important impediment to accessing health transportation was not, and there are several services by elderly rural residents. These affect elderly interviewees that suffered catastrophic particularly the elderly poor, and the elderly who health care expenditures as a result of related do not live nearby major highways and roads on transportation costs, and needed to borrow which public buses operate. The cost of renting money from neighbors to pay for such high private cars to take them to hospitals is simply transportation costs. not affordable by many elderly households, even those who live above the poverty line. The elderly Food is also a significant cost item for elderly poor who depend on allowances from universal patients who need to travel from rural areas to pension as the only source of income is the receive care at higher-level health facilities in most vulnerable, as they need to use all of the large towns and cities. Also, elderly patients from monthly allowance to pay for room rent and food, rural areas generally need to bring caretaker(s) and these people do not have extra resources to along to support them, and this also adds up the travel to health facilities in time of sickness. total cost of accessing care, as the caretaker(s) also need to spend on transportation, food, and residence if overnight stay is required. Table 6 Expenditure type Transportation Food Medicines Carer’s expenses Average health-related expenditures per year by urban and rural residents Urban 474 343 1,331 256 (from qualitative study) Rural 6,004 1,891 1,393 393 6. Affordable accommodation options for elderly require continuous out-patient care visits for patients and their caretakers at referral hospitals such treatments as hemodialysis, radiotherapy, are too limited. Regional and university hospitals or chemotherapy (these specialist services in Bangkok and major regional cities like Chiang are not available at lower-level hospitals) also Mai, Khon Kaen, Surat Thani, and Songkhla need overnight stays. Unfortunately, most of are tertiary hospitals that are responsible for the tertiary referral hospitals are located in big treating patients from several provinces in its cities in which accommodation tends to be much network. Oftentimes, elderly patients and their more expensive than in rural areas. Hence, caretakers need to travel for 6-7 hours from accommodation in referral hospitals has been their respective home districts to reach the cited by elderly rural residents as one of the regional referral hospital. In these cases, even major factors for their decisions whether or not an out-patient care visit requires an overnight to access out-patient specialist care services at stay. Elderly patients from remote districts who higher-level hospitals. Closing the Health Gaps for the Elderly: Promoting Health Equity and Social Inclusion in Thailand 23 7. Poor elderly respondents indicated they do and that they do not have other financial support not have the means to travel to health facilities, from relatives, from work, and do not have any as their only income is universal social pension,12 savings. The situation is worse among the oldest and that the current level of monthly allowance old: of the 272 elderly participants aged 75 and from the universal social pension is not sufficient over, as many as 101 or 37% indicated that the to sustain their minimum living expenses – they universal social pension is their only income do not have any money left after spending on source. It is important to note geographical food and accommodation, and do not have any disparity in terms of elderly incomes, as the savings (the level of universal social pension elderly in the North and the Northeast tend to is illustrated in Table 7). Out of 547 elderly be poorer and dependent on universal social participants of FGDs, 38% indicated that their pension and support from relatives, while the monthly incomes are insufficient to sustain their elderly from the South and central Thailand living standard. This group of elderly people on average tend to have higher incomes from tends to be those that depend on universal social continued employment or work in the agriculture pension as the main source of their incomes, sector in addition to the allowances from the universal social pension. Table 7 Age range Amount (THB) per month Universal Social Pension by Age 60-69 600 70-79 700 80-89 800 90 and older 1,000 8. Some of the local administrative organizations for the elderly and focus more on building (LAOs) visited during the qualitative study infrastructures for the communities, while some have played an instrumental role in promoting LAOs focus very much on health to the point access to health services for the elderly of establishing health clinics and hiring medical in rural communities. Several LAOs make doctors with LAO resources to serve the local available health emergency vans for people in population. the community free of charge. There are best practices from smaller LAOs (e.g. Tambon All the elderly participants in this qualitative study administrative organizations) with small amount were asked what they would like LAOs to support of budget that do not have sufficient resources them, and three most popular answers by far to purchase a proper health emergency van, are (i) for the health emergency van initiative to but were able to turn an old pick-up truck into a be expanded into more LAOs, (ii) for LAOs to well-equipped health emergency van at small provide free transportation for the poor to travel costs, and using the fees that they receive to health facilities when sick, and (iii) for LAOs from Emergency Medical Institute of Thailand to consider providing vehicles to bring elderly (with each valid health emergency delivery to a people from rural areas to receive out-patient health facility) to finance the operating costs of care services at hospitals once a week on a health emergency vans for both emergency and regular basis, as this will help boost health non-emergency cases (i.e. to bring poor elderly utilization. to hospitals in non-emergency cases). Several LAOs also arrange annual health check-up (in 9. It should be noted that several large public coordination with health promotion hospitals) for hospitals set up social welfare schemes, the elderly in the community so that the elderly drawing resources from donation and hospital’s residents do not need to travel to health facilities own funds. These social welfare schemes are for annual health check-ups. Some LAOs also expected to provide financial support to the poor set up health promotion centers for the elderly who do not have the means to pay for extra (e.g. Home Suk at Najarn Tambon Municipality healthcare costs that are not covered by the UC Office in Kalasin Provinice) to provide regular scheme, and also support transportation costs health check-up, physical therapy, and health for the poor to return home. The implementation exercise services for the elderly members in the of these social welfare schemes varies, but many communities. Moreover, some LAOs allow poor large hospitals that have such schemes do not elderly in the communities to request for use of promote them actively on the ground that the LAO vans to access health services at provincial resources are limited, and leave it to relevant or regional hospitals as needed, and that the use medical doctors and nurses to inform the patients is not limited to emergency cases. about the schemes. Several elderly poor patients whom the team interviewed at these large Nevertheless, the health-related supports for hospitals were not aware that such social welfare the elderly vary significantly from one LAO to schemes exist. another, depending on the interests and priorities set by LAOs’ chief executives and mayors. Some The fact that several hospitals have social LAOs do not provide any health-related supports welfare schemes but do not promote them 12 The universal social pension under the Old Age Act is responsible for covering Thai citizens aged 60 and above who are not covered by any other formal pension programs. 24 Closing the Health Gaps for the Elderly: Promoting Health Equity and Social Inclusion in Thailand actively lead to inequity in access to information. information about the transportation costs that As medical doctors and nurses in large public the patients needed to pay. hospitals need to attend to so many patients each day, it is very possible that they may not Another gap in these social welfare schemes is be able to detect all poor patients and inform that they support transportation costs for the poor them about the social welfare schemes. This is once the patients already arrive at the hospital, particularly true for patients whose treatment was and hence there is a challenge of how the poor fully covered by the UC scheme but needed to elderly can finance transportation costs to get to pay large amount of money for transportation, such hospitals in the first place. as these health professionals do not have Closing the Health Gaps for the Elderly: Promoting Health Equity and Social Inclusion in Thailand 25 Recommendations 1. Poor elderly individuals who do not live with drugs that are outside the essential drug list adult children are more likely to have lower may add up too much cost pressure to the utilization of health services but incur higher already steadily rising cost of the UC scheme. catastrophic health expenditures, compared This cost pressure constraint is relevant as the with their peers who live with adult children. share of government expenditures on health Poor elderly individuals in rural areas who do out of total government expenditures has not live with adult children (particularly females been rising steadily since the start of the UC and widows) are the most vulnerable and are scheme and has already reached 17%, making exposed to the highest risks of inadequate it challenging to identify fiscal space to expand health utilization and deepening impoverishment health benefits universally. For treatments and due to healthcare costs. Special attention to medical equipment that are not covered by the help improve health utilization and reduce UC scheme, it is fair for the hospitals to ask for catastrophic health expenditures needs to be financial contribution from patients who are able provided to this group of vulnerable population. to afford to pay. Nevertheless, the government should consider arrangements for these excess 2. Thailand’s health insurance and health health care costs to be covered for the poor, and protection schemes cover all Thai citizens hence identification of the poor to receive these and provide relatively comprehensive benefits benefits are worth considering. coverage. The universal health coverage scheme, in particular, offers good practices to 5. The issue of identification and targeting other countries that experience rapidly aging of the poor for benefits that address unmet and NCD transition. e.g. its provider payment health-related needs should be revisited, given mechanisms (capitation for out-patient care and the gaps in transportation costs and other case-based DRG payment for in-patient care) as health care costs that are not covered by the well as drug and medical technology assessment UC scheme. Since Thailand has successfully and prioritization mechanism (e.g. HITAP) launched the universal health coverage in that can help slow down rapidly rising costs, 2001, the formal system of targeting the poor contributing to sustainability of the scheme. has been dismissed from the policy agenda of However, there are still significant gaps with successive governments. Nevertheless, the regard to non-medical costs and social support health-related support from the universal health to facilitate access to and utilization of health coverage does not cover such key item as care services, e.g. the lack of caretakers, lack of transportation to health facilities, and this lack affordable transportation options to access health of support has negatively affected the access to facilities. These gaps particularly affect poor utilization of health services by poor elderly in elderly individuals and the elderly in the oldest Thailand, which account for around 10% of total old group (over 80 years of age). elderly population.13 Once the identification and targeting of the poor has been conducted, the list 3. Transportation cost to health facilities is of the poor could be used by the National Health the most important obstacle that prevents Security Office (that manages the UC scheme) elderly poor in rural areas to access health and a number of social welfares schemes care services. It is interesting to note that operated by large hospitals to provide needed health protection programs in countries that health-related benefits for the poor in their are much less developed than Thailand, e.g. coverage areas. Health Equity Funds in Lao PDR and Cambodia, often include support for both health care costs 6. To supplement the benefits provided by and transportation costs as part of the benefit the universal health coverage, social welfare package for the poor. While Thailand is able schemes currently operated by large hospitals to support free health care costs for all of its with the aim to provide necessary support on citizens, there is no national program that health care and transportation costs for the poor supports transportation costs for the Thai poor need to be expanded to all tertiary hospitals. to travel to health facilities. It is important for Furthermore, these social welfares schemes the government to consider options to support run by hospitals need to be promoted actively, transportation costs to health facilities for the and the hospitals should ensure that the elderly poor living in rural areas. information about their support for the poor is accessible to all poor patients. Several university 4. The health care coverage supported by the hospitals, including the Prince of Songkhla UC scheme is relatively comprehensive. While University Hospital, managed the social welfare there are still some diseases that may lead to scheme to support health care costs for the high out-of-pocket and catastrophic expenditures poor in a transparent and equitable way, with (e.g. some types of cancer, chronic renal clear guidelines and criteria. This kind of good diseases), extending the coverage universally to practices and lessons should be promoted and cover the costs of these high-cost treatments, shared with other hospitals. hi-tech medical equipment, and brand name 13 Reducing Elderly Poverty in Thailand: The Role of Thailand’s Pension and Social Assistance Programs, World Bank, 2012. 26 Closing the Health Gaps for the Elderly: Promoting Health Equity and Social Inclusion in Thailand 7. Special attention and support should be given 9. The VHVs are instrumental to the provision to bed-ridden elderly and elderly with mobility of health-related supports to the elderly in constraints who are poor. These elderly poor communities, particularly through home visits tend to suffer from chronic diseases that need as well as organizing physical exercise and intensive care and support but often they are not health education sessions. The experience able to travel to health facilities frequently due to from Kalasin’s Provincial Health Office, which difficulties to move, dependence on availability established Suksala in every village, as well as of caretakers to take them to health facilities, providing options to VHVs to receive specialized and transportation costs. Hence, regular home training on geriatric care are good lessons and visits by relevant health facility staff and village are worth exploring if it is worthwhile to expand health volunteers targeting these bed-ridden and such initiatives beyond the province. In any case, poor elderly should be promoted, and support for the performance of VHVs in Thailand varies transportation from health centers or from LAOs from communities to communities, but the key should be provided to this group of the elderly success factors are regular supervision by health to travel to health facilities as needed. More promotion hospitals as well as collaboration with balanced policy options to promote outreach and local administration organizations, which can home visit services by health professionals and provide additional resources for the activities to facilitate travel to health facilities when needed conducted by VHVs to support the elderly for the elderly should be considered. population in local communities. 8. LAOs can play an instrumental role in promoting access to health services for the elderly in rural communities. Several best practices from selected LAOs under the qualitative study include making available health emergency vans for the community and arranging annual health check-ups (in coordination with health promotion hospitals) for the elderly in the community so that the elderly residents do not need to travel to health facilities for annual health check-ups. These practices by LAOs should be promoted. Closing the Health Gaps for the Elderly: Promoting Health Equity and Social Inclusion in Thailand 27 28 Closing the Health Gaps for the Elderly: Promoting Health Equity and Social Inclusion in Thailand 30th Floor, Siam Tower 989 Rama I Road, Pathumwan Bangkok, Thailand 10330 Tel: +662 686-8300 Fax: +662 686-8301 Website: www.worldbank.org/thailand E-mail: thailand@worldbank.org Closing the Health Gaps for the Elderly: Promoting Health Equity and Social Inclusion in Thailand