واکنش تعادل مشکل: دیدگاه سیاست بازیگران در استفاده از ارزیابی اقتصادی برای اطلاع رسانی به تصمیم گیری های بهداشت و درمان، مراقبت تحت پوشش طرح جهانی بیمه سلامت تحت پوشش در تایلند

Objectives In Thailand, policymakers have come under increasing pressure to use economic evaluation to inform health-care resource allocation decisions, especially after the introduction of the Universal Health Insurance Coverage (UC) scheme. This article presents qualitative findings from research that assessed a range of policymakers' perspectives on the acceptability of using economic evaluation for the development of health-care benefit packages in Thailand. The policy analysis examined their opinions about existing decision-making processes for including health interventions in the UC benefit package, their understanding of health economic evaluation, and their attitudes, acceptance, and values relating to the use of the method. Methods Semistructured interviews were conducted with 36 policy actors who play a major role or have some input into health resource allocation decisions within the Thai health-care system. These included 14 senior policymakers at the national level, 5 hospital directors, 10 health professionals, and 7 academics. Results and Conclusions Policy actors thought that economic evaluation information was relevant for decision-making because of the increasing need for rationing and more transparent criteria for making UC coverage decisions. Nevertheless, they raised several difficulties with using economic evaluation that would pose barriers to its introduction, including distrust in the method, conflicting philosophical positions and priorities compared to that of “health maximization,” organizational allegiances, existing decision-making procedures that would be hard to change, and concerns about political pressure and acceptability.

Health economic evaluation is designed to guide explicit health resource allocation decisions by comparing the marginal costs and consequences of alternative health-care interventions. In some industrial countries, economic evaluation studies are increasingly being used to inform more explicit and transparent health-care coverage decisions [1]. Nevertheless, in low- and middle-income countries, economic evaluation has rarely been used as a tool to inform decisions about the content of health-care benefit packages [2,3]. In Thailand in recent years, as in other Asian countries, policymakers have come under increasing pressure to justify resource allocation decisions in the health sector [4,5]. The Universal Health Insurance Coverage (UC) policy implemented in 2001 offers a package of health-care interventions at public facilities to all Thai citizens not covered by other benefit packages [6]. Nevertheless, as a result of rapid implementation, only limited evidence was used to guide decisions on the services included in the UC package. The government now needs to clarify and make more transparent the benefit package, especially for highcost interventions, which are likely to absorb a disproportionate amount of resources and are an attractive target for providers to cut provision to contain costs. Two broad types of barrier to the introduction of economic evaluation into policy decision-making can be envisaged for middle-income countries like Thailand. First, there is a very limited supply of good quality economic evaluation studies [7,8]; In Thailand, policymakers face these informational barriers [9]. Second, even if economic evaluation data were available, decision-makers may not understand, accept, or be willing to use economic evaluation as a tool in their decision-making on resource allocation. As analysts have argued for many years, policy decisions are notjust technical questions but are inherently political processes, involving questions of power and resources [10]; for example, decision-makers will be aware that the exclusion or inclusion of an expensive treatment in the UC package will have important implications for sections of the public, government expenditure, their colleagues who have to implement the decision, and perhaps the government’s political standing. In industrial countries, there have been a small number of studies on policy actors’ attitudes to economic evaluation as a tool in decision-making for health-care priority setting [11,12]. In middle-income countries, where the pressure for more explicit rationing is growing, there have been even fewer studies to explore decision-makers’ attitudes toward and acceptance of economic evaluation [3]. This article presents findings from a larger piece of research that assessed the feasibility of doing economic evaluation studies in Thailand (by undertaking economic evaluation studies for two high-cost interventions) and the acceptability of using economic evaluation as a tool for the development of health-care benefit package. It focuses on Thai policy actors’ general understanding, acceptance and valuation of economic evaluation, the multiple factors that they must weigh up in their decision-making about healthcare coverage, and therefore the difficulties of introducing economic evaluation into this decision-making.

This study demonstrates that introducing economic evaluation into health-care decision-making in settings like Thailand is more complicated and likely to be more difficult than is commonly presumed to be in the economic academic literature. In-depth interviews with 36 policy actors located in different positions in the health sector showed their lack of understanding in the method. A basic policy measure to encourage the use of economic evaluation among policymakers would therefore be to offer awareness and educationprograms aimed at making policymakers more confident in using and interpreting economic evaluation evidence and more able to explain it to others. In addition, many policy actors questioned the ethical values underpinning QALY maximization. QALY maximization may not be the only goal for resource allocation and economic evaluation may not be the only tool for decision-makers to ration health care. Equity, necessity (severity of disease), social solidarity (helping the poor and vulnerable), and protection against catastrophic expenditure also play a significant role. These criteria are particularly important in the context of the UC in Thailand because an explicit objective of the UC policy was to increase equity of coverage and reduce catastrophic spending. Therefore, proposals to use economic evaluation should not disregard or eliminate other criteria concerning resource allocation, and a priority is to develop an alternative approach for economic evaluation, which incorporates criteria like equity and social solidarity to enhance political and public acceptance of a health-care package. This exploratory research has highlighted two areas for further research. First, the opportunities and difficulties of introducing economic evaluation into the specific context of Thailand may be different in other settings due to differences in health-care infrastructure, institutions and incentives, and different policy processes and political pressures. It would therefore be valuable to learn to what extent the barriers to the use of economic evaluation identified in Thailand are distinctive or similar to those operating in other low- and middle-income countries. Second, the findings revealed that public involvement of some sort in coverage decisions was necessary because decision-makers and health professionals were sensitive to the public’s responses to their decisions. Nevertheless, the study did not explore public or patient perspectives on priority setting. Public perspectives on health-care rationing cannot be ignored if economic evaluation is to be accepted and trusted as a legitimate means of resource allocation. More research is therefore required to examine the public’s acceptance of using economic evaluation or alternative resource allocation criteria for health-care coverage decisions, and to examine possible mechanisms for incorporating these public perspectives into decision-making.