ترجیحات شهروندان با توجه به اصول برای تصمیم گیری در تخصیص سلامت مراقبت در تایلند

Objectives The objective of this study was to investigate the extent to which five principles of rationing (lottery, rule of rescue, health maximization, fair innings, and choicism) were preferred by a sample of Thai citizens for selecting patients to receive high-cost therapies. Methods A self-administered survey was used for collecting data from a sample of 1000 individuals living in Thailand. Descriptive statistics, factor analysis, and multinomial logistic regression analysis were used for describing and validating the data. Out of the 1000 sample members, 780 (78%) provided usable responses. Results The results showed that within specific situations under budget constraints, Thai people used each of the criteria we studied to ration health care including: 1) lottery principle; 2) rule of rescue; 3) health maximization; 4) fair innings; and 5) choicism. Conclusions The extent to which the criteria were applied depended on the specific situation placed before the decision-maker. “Choicism” (equalizing opportunity for health) was the most preferred method for rationing when compared to each of the other four principles.

All countries encounter situations in which resources are limited and health care cannot be provided for all who need it. Even for countries in which universal health coverage (UC) is provided by the government, issues related to gaining access to high-cost health care can be contentious [1]. On many occasions, governments or the agencies that are responsible for financing, organizing, managing, and providing health services have faced challenges related to budget constraints, in which they had to choose whether to provide treatments at all or to choose a limited number of patients to whom care was provided [2–5]. Since 2001, the Thai government has implemented UC under the 30-baht policy that aims to provide health-care coverage for all Thai people who have no other health insurance [6,7]. Because of its financial and implementation structure, a challenge to the policy has emerged as the budget for providing high-cost care (e.g., renal replacement therapy [RRT] for endstage renal disease [ESRD]) to all eligible patients has become constrained [5,8]. This has raised the difficult choice of whether the government should strive to support this very high-cost service at all. Conforming to ethical codes of individual practitioners at the micro level, one might argue that the government should cover this high-cost care for all patients who need it. On the other hand, policymakers might choose not to provide any care at all to stabilize the financial solvency of the UC program. Moreover, policymakers could claim that if high-cost care cannot be provided to all eligible patients, it would be most equitable to deny access to everyone for an unaffordable treatment. A third option would be to provide care for some patients, but not all of them. The challenge with this approach is identifying the most suitable patients for the high-cost care. To do this, the government would need to decide 1) who the most suitable patients are; 2) what selection criteria to utilize; and 3) how a legitimate selection process would be implemented. Fair processes to allocate health resources could help legitimize the use of rationing criteria and could win support from the Thai public. Nevertheless, the concept of fairness may not be a universal value and might vary from society to society. Thai people may have a unique set of values regarding criteria that should be used to select patients for high-cost health care. Thus, consulting with the Thai people is a requisite first step in starting to ration high-cost health care. Our overall goal for this study was to identify acceptable criteria by which decisions could be made regarding the allocation of high-cost health-care services under budget constraints in Thailand.

The findings showed that Choicism was the preferred principle in each of its four paired comparisons, Fair innings was the preferred principle in three out of its four paired comparisons, rule of rescue was preferred in two out its four paired comparisons, and health maximization was preferred in one out of its four paired comparisons. Only the lottery principle was not preferred in any of its four paired comparisons. The lottery principle seemed to be the weakest decision criteria, but from multinomial logistic regression results, the average score on this principle was significantly associated with decisions of respondents in several scenarios that contained this principle. Therefore, it would not be wise to conclude that the weakest principle among the five had no influence on these decisions. From the results of this study, we conclude that all five principles could be used as acceptable criteria for health-care decisions under budget constraints from the perspective of a group of Thai people. Our findings suggest that most respondents were able to make a decision concerning the choice to give a treatment to one patient over another using several criteria, including: cause of the disease (choicism), age differences (fair innings), immediate needs of patients (rule of rescue), health outcomes after treatments (health maximization), and time on waiting list (lottery). The findings provide insight about which principles are preferred over others in certain scenarios. Nevertheless, the number of possible scenarios is so large and each scenario so unique, it is difficult to conclude with any certainty which rationing method could be applied to every situation. The results provided some further insight into this dilemma and are discussed next.