Economic impact of investment in maternal and newborn health care under the National Health Security Scheme of Thailand

After review and approval of the study protocol by the Institutional Review Board of the Faculty of Medicine, Chulalongkorn University (approval No. 332/2012, IRB No. 177/55) and permission from National Health Security Schemes Office, a cost-identification study was conducted by retrospective review of secondary data using the protocol as follows.

As shown in Table 2, the per capita operating costs of providing maternal and child health services related to the benefits under the universal coverage scheme (UCS)—or P1 in Table 2—comprising (P1a) family planning and antenatal care, and (P1b) in-patient care for prenatal conditions and prevention of premature labor increased year-on-year (with the sole exception of P1b in 2010). The 5-year costs of the key infrastructures and health personnel (P2), spent by the Ministry of Public Health did now show any particular trend. These costs included support for medical equipment, ultrasound, blood banks, ambulance for emergency obstetric care, and labor costs for specialized health personnel in obstetrics, pediatrics, and midwives. The appraisal costs remained quite stable, except for the year 2010 in which the per capita amount was almost doubled compared with the amount for 2009. Further investigation indicated that this increase was because of a one-year change in the P4P policy by the NHSO. Finally, the failure costs increased over the same period. The amounts reimbursed on inpatient care for complicated labors, postpartum conditions, and newborn problems (EF1), rose from US$1.83 per person per year in 2007 to 2.47 per person per year in 2011. However, the liability claims under the NHSO Act (EF2) remained stable.

Table 2

Amount of budget by type of Cost of Quality (US$ per Universal Coverage per person per year)

The linear regression analyses of the year-on-year changes in the failure costs and the year-on-year changes in prevention and appraisal costs for providing maternal and child health services, as shown in Table 3, demonstrated significant negative associations in 3 of 4 pairs—the cost changes between 2008 vs 2007, 2009–2008, and 2010–2009. The provincial increases in the prevention and appraisal costs tended to be associated the provincial decreases in the failure costs required for treating maternal and newborn complications, and liability costs for maternal and child care. Specifically, for every dollar of year-on-year increase in prevention and appraisal costs, the failure cost decreased by 1.16 dollars from 2007 to 2008, 1.28 dollars from 2008 to 2009, and 1.12 dollars from 2009 to 2010.

Table 3

Pairwise univariate linear regression analyses of the year-on-year changes of the failure costs and the year-on-year changes in prevention costs and appraisal costs (n = 75 provinces in Thailand)

In light of the Universal Health Coverage in Thailand, we found that at least over the period from 2007 to 2011, the country increased spending on maternal and child health services, both in preventing the MCH problems and in correcting the problems. Although the nation-wide numbers showed increases in all three categories of the prevention–appraisal–failure (PAF) costs, the negative associations between the year-on-year changes indicated that for each province, those with increases in prevention and appraisal costs, tended to have decreases in the failure costs. This implied effective allocation of MCH resources.

We demonstrated Thailand has had continuous improvement in maternal and child health outcomes. Table 2 shows that the allocated operating UCS budget to promote the health of pregnant women and prevent maternal and newborn morbidities and mortalities increased every year over the study period. The year-on-year increases in these amounts were 30.5% in 2007–2008, 2.9% in 2008–2009, 5.2% in 2009–2010, and 36.7% in 2010–2011. These well surpassed the general inflation rates of the Thai economy during that time (–0.9%–3.8%) [12]. However, the spending on service infrastructure varied without any definite trend. We hypothesized that the infrastructure for MCH was not expanded over the study period, but rather remained roughly the same, both in terms of health personnel and equipment. Further investigation is needed to determine whether there might be any significant deterioration of service infrastructure in any provinces or areas.

The overall failure costs in MCH also rose. Deep investigation of the reimbursement database showed that, during the 5-year period, there were increasing numbers of abortions and related complications, and ectopic and molar pregnancies, summed annual rates for O03–8 at 7.7%, 8.0%, 8.1%, 8.3%, and 8.4%, for the years 2007 to 2011 respectively. There were also increasing numbers of cesarean sections, from 21.1% to 23.7% of all deliveries. Although the increasing failure costs might indicate more problems in maternal and newborn care, the overall maternal mortality rates (MMR) during 2007 to 2011 decreased (62.51, 58.25, 46.69, 45.06, and 36.69 per 100,000 live births, respectively) [13].

The increase in the prevention and appraisal costs in each province were likely associated with reduction in the failure costs as indicated in Table 3. The relationships may appear confusing because all the PAF costs increased over time. However, the regression analyses focused on year-on-year changes, instead of the absolute annual numbers, to examine if an increase of prevention and appraisal costs over a year would correspond to a decrease in failure costs over the same year-on-year period. This hypothesis was confirmed in 3 of the 4 pairs of years. The findings appeared consistent with studies of health care financing and utilization of maternal health services in developing countries by Kruk et al. [2] and Liabsuetrakul et al. [14], which found that government financing was associated with better access to some essential maternal health services, and total health expenditure is significantly associated with utilization of skilled birth attendants and rate of cesarean section. As positive trends for the prevention costs might imply better access to care, or more care for prospective mothers, our study indirectly supported the findings by others [15, 16, 17, 18] from a resource perspective at the macro level that better service arrangements helped reduce maternal morbidity and mortality. However, it remains difficult to say much about the effects of investment in infrastructure because of the varying per capita amounts over the 5-year period.

Not only are the 3 coefficients with statistical significance in Table 3 all negative, they were larger than minus one. This means that every additional dollar that was allocated to preventing problems led to more than one dollar reduction of failure costs. The investment in prevention is clearly worthwhile. We believe that the benefit might be even more favorable if we could account more accurately for details of cost items in the infrastructure category. Some MCH resources were shared with other medical and surgical care specialties, such as the cost of blood banks. By contrast with this positive hypothesis, one might argue that the failure costs increased because the prevention and appraisal costs did not adequately increase, particularly those related to the infrastructure. If this was the case, we would expect other outcomes like MMR to also rise. Our counter-argument might be that the care was improved to a level where mortality was reduced. Therefore, higher survival rates would increase the costs of care, a situation found in other studies [1, 19]. The inability to quantify costs per death averted was a limitation of the present study.

There were some other limitations to our findings. Although using claim data might help us explore the entire situation in terms of resources spent, the question needs further study to examine epidemiological details not available in the database to provide us with greater insight into what did happen more, and what less. More information on resource allocation within each province would, then, provide opportunities to determine how to allocate and use resources efficiently to provide effective maternal and child care. Finally, we used the perspective of the payer, namely the National Health Security Office of Thailand and the Thai Ministry of Public Health, in studying costs. It is possible that looking at costs from a provider or patient consumer perspective might yield different conclusions. For example, the liability claims under the NHSO Act was only a proxy of the cost of damages caused by morbidity and mortality. The amounts of compensation were fixed by regulations and judgement of committees who performed assessments. Moreover, we did not account for how much preventing maternal and child morbidity and mortality might help reduce indirect costs for patients’ families. Future studies in these areas are warranted to determine best practices at the provincial level, to learn from and share among others nationally and internationally, and to add sufficient evidence to convince policy makers to invest more in MCH.