Abstract
Economic evaluation is an essential tool to support the development of the universal
coverage benefit package (UCBP) under the universal health coverage in Thailand since 2008.
The National Drug Subcommittee (for the National List of Essential Medicine or NLEM) has
started using the economic evidence (e.g. cost-effectiveness and budget impact) to support
the selection of high-cost medications (in the category of E2), and, in the subsequent year,
the UCBP Subcommittee under the National Health Security Office also incorporated the
consideration of economic evidence for non-pharmaceutical products. The use of economic
evidence has, to a certain level, improved the efficiency of our healthcare system as health
interventions with lower cost and more effectiveness would have higher chance to be
included in the benefit package than those with higher cost and lower effectiveness. It has
now been over 15 years since Thailand has incorporated economic evidence to support the
policy- and decision-making process to support our communities.
Economic evaluation does have a limitation in that, with the focus on efficiency, this
approach may not objectively have considered health equity. For example, health
interventions targeting to assist those with higher income (more asset or wealth) may require
lower cost than interventions to help those with lower income. Consequently, more health
selected interventions were supporting those with higher income than lower income. To
respond to this limitation, a method was created which aims to objectively incorporate health
inequity into economic evaluation and the method is now known as a distributional cost effectiveness analysis or DCEA.
DCEA is an innovative area where very few countries have explored. Therefore, the
Health Intervention and Technology Assessment Program (HITAP) under the Thai Ministry of
Public Health (a research organization with one of the missions to support the conduct of
economic evaluations for UCBP and NLEM) aims to build capacity for our country to conduct
DCEA in Thailand in collaboration with researchers from the National University of Singapore,
the Hitotsubashi University in Japan, and the University of York in United Kingdom.
To complete a DCEA, the first step would be to obtain information on baseline health
distribution by asset index (from a secondary data analysis) and to estimate a health inequality
aversion index (from a survey).
The analysis of baseline health distribution showed that people in the lowest quintile
of asset index (people with lower asset and subsequently income) reported lower life
expectancy than those in the highest quintile with a difference of approximately 14 years. This
finding may represent an evidence of health inequity in the Thai community today.
From the health inequality aversion survey on both policy-makers and the general
public in both in-person and online format, the Thai people have reported strong support for
health equality. The people were even willing to trade off efficiency if it were to mean lower
health inequality. Specifically, when compared to policy-makers, the general public were more
willing to trade off efficiency for equality.
This study is the first step for our community to seriously consider health inequity in
the decision-making process through the conduct of an economic evaluation. The next phase
will focus on applying the findings from this phase (on baseline health distribution and health
inequality aversion index) into an economic model to complete the first DCEA in Thailand
where the evidence could assist policy-makers in ensuring that everyone in Thailand has
access to health equally.
