Expanding access to high-cost medicines under the Universal Health Coverage scheme in Thailand: review of current practices and recommendations.

BACKGROUND: There has been an increasing demand to reimburse high-cost medicines, through public health insurance schemes in Thailand. METHODS: A mixed method approach was employed. First, a rapid review of select high-income countries was conducted, followed by expert consultations and an in-depth review of three countries: Australia, England and Republic of Korea to understand reimbursement mechanisms of high-cost medicines. In Thailand, current pathways for reimbursing high-cost medicines reviewed, the potential opportunity cost estimated, and stakeholder consultations were conducted to identify context specific considerations. RESULTS: High-income countries reviewed have implemented a variety of pathways and mechanisms for reimbursing high-cost medicines under specific eligibility criteria, listing processes, varying cost-effectiveness thresholds and special funding arrangements. In Thailand, high-cost medicines that do not offer good value-for-money are excluded from the reimbursement process. A framework for reimbursing high-cost medicines that are not cost-effective at the current willingness-to-pay threshold was proposed for Thailand. Under this framework, specific criteria are proposed to determine their eligibility for reimbursement such life-saving nature, treatment of conditions with no alternative treatment options, and affordability. CONCLUSION: High-cost medicines may become eligible for reimbursement through alternative mechanisms based on specific criteria which depend on each context. The application of HTA methods and processes is important in guiding these decisions to support sustainable access to affordable healthcare in pursuit of Universal Health Coverage (UHC).

Epidemiological Situation of Necrotizing Fasciitis and Factors in Thailand and Factors Associated with Its Morbidity and Mortality, 2014-2018.

INTRODUCTION: Necrotizing fasciitis (NF) is a rare skin and soft-tissue bacterial infection with high morbidity and mortality. Knowledge about the prevalence and incidence of NF in Thailand is quite sparse. The objective of this study was to determine the prevalence of NF in Thailand and factors that may be potentially associated with NF morbidity and mortality. METHODS: A cross-sectional study using secondary data from Thailand's national health databases between 2014 and 2018 was conducted. Descriptive statistics using median and percentage formats were used. This was complemented by multivariable logistic regression to determine the association between various factors (such as age and underlying diseases) with NF morbidity and mortality. Univariate spatial data analysis was exercised to identify the geographical hot spots in which the disease appeared. RESULTS: During 2014-2018, we found 90,683 NF cases. About 4.86% of the cases died. The median age for all cases was 59.39 years old. The annual incidence of NF demonstrated an upward trend (from 26.08 per 100,000 population in 2014 to 32.64 per 100,000 population in 2018). The monthly incidence was highest between May and August. A high incidence cluster (as indicated by local Moran's I) was found in the north-eastern region of Thailand. The most infected sites were on the ankles and feet (43.18%) with an amputation rate of 7.99% in all cases. Multivariable logistic regression indicated that the significant risk factor for amputation was a presence of underlying diseases, namely diabetes (OR 7.94, 95% CI 7.34-8.61). Risk factors for mortality included being elderly (OR 1.82, 95% CI 1.68-1.98) and a presence of underlying hypertension (OR 1.16, 95% CI 1.07-1.27), cirrhosis (OR 4.67, 95% CI 4.17-5.21), and malignancy (OR 1.88, 95% CI 1.55-2.26). DISCUSSION AND CONCLUSION: As the elderly and those with chronic underlying diseases are likely to face non-preferable health outcomes from NF, healthcare providers should pay great attention to these groups of patients. Early and intensive treatment might be considered in these groups of patients. Further studies that aim to validate the volume of actual NF cases and reported NF cases are recommended.

Cost Effectiveness and Budget Impact Analyses of Influenza Vaccination for Prisoners in Thailand: An Application of System Dynamic Modelling.

Influenza outbreaks in Thai prisons were increasing in number every year and to address this, the Thai Ministry of Public Health (MOPH) initiated a policy to promote vaccination for prisoners. The objective of this study was to assess the cost effectiveness and budget impact of the influenza vaccination policy for prisoners in Thailand. The study obtained data from the Division of Epidemiology, Department of Disease Control (DDC), MOPH. Deterministic system dynamic modelling was exercised to estimate the financial implication of the vaccination programme in comparison with routine outbreak control. The incremental cost-effectiveness ratio (ICER) was calculated via a DDC perspective. The reproductive number was estimated at 1.4. A total of 143 prisons across the country (375,763 prisoners) were analysed. In non-vaccination circumstances, the total healthcare cost amounted to 174.8 million Baht (US$ 5.6 million). Should all prisoners be vaccinated, the total healthcare cost would reduce to 90.9 million Baht (US$ 2.9 million), and 46.8 million Baht (US$ 1.5 million) of this is related to the vaccination. The ICER of vaccination (compared with routine outbreak control) varied between 39,738.0 to 61,688.3 Baht per disability-adjusted life year (DALY) averted (US$ 1281.9-1989.9). Should the vaccination cover 30% of the prisoners, the ICER would be equal to 46,866.8 Baht (US$ 1511.8) per DALY averted with the budget burden amounted to Baht (US$ 4.8 million). The vaccination programme would become more cost-effective if the routine outbreak control was intensified. In summary, the vaccination programme was a cost-effective measure to halt influenza outbreak amongst prisoners. Further primary studies that aim to assess the actual impact of the programme are recommended.

Using health technology assessment for informing coverage decisions in Thailand.

This article aims to illustrate and critically analyze the results from the 1-year experience of using health technology assessment (HTA) in the development of the Thai Universal Coverage health benefit package. We review the relevant documents and give a descriptive analysis of outcomes resulting from the development process in 2009-2010. Out of 30 topics nominated by stakeholders for prioritization, 12 were selected for further assessment. A total of five new interventions were recommended for inclusion in the benefit package based on value for money, budget impact, feasibility and equity reasons. Different stakeholders have diverse interests and capabilities to participate in the process. In conclusion, HTA is helpful for informing coverage decisions for health benefit packages because it enhances the legitimacy of policy decisions by increasing the transparency, inclusiveness and accountability of the process. There is room for improvement of the current use of HTA, including providing technical support for patient representatives and civic groups, better communication between health professionals, and focusing more on health promotion and disease prevention.