Exploration of the hidden financial hardship of chronic kidney disease under universal coverage in Thailand

Abstract

Introduction Chronic kidney disease (CKD) is prevalent in Thailand and has a significant economic burden to both patients and country level. The Universal Health Coverage policy in Thailand has expanded to include dialysis cost for all CKD patients since 2008 through ‘PD First’ policy. The ‘PD First’ program has often been cited as a successful model of kidney failure care for low and middle-income countries. However, Thai CKD patients still need to constantly pay out-of-pocket for health care service which may exhaust patients and family resources and result in catastrophe and poverty. The financial hardship from the patients’ perspective remains unknown. This study aimed to estimate the residual financial burden of chronic kidney disease (CKD) patients under Universal Health Coverage.

Materials and Methods This multicenter nationwide cross-sectional study was conducted in Thailand between June 2019 and January 2021. This study enrolled 1,224 CKD patients from 11 regional and university hospitals. These patients were covered by three health schemes; Universal Coverage Scheme (UCS), Social Security System (SSS), Civil Servant Monetary Benefit Scheme (CSMBS). The study population consisted of four groups of CKD patients as the followings; CKD with eGFR 15-60 ml/min/1.73m2 (CKD15-60), CKD with eGFR <15 ml/min/1.73m2 (CKD<15), peritoneal dialysis (PD) and hemodialysis (HD). We collected medical and non-medical out-of-pocket expenditure for healthcare service by direct patient interview. The financial burden was estimated by calculation the proportion of patients with catastrophic health expenditure (CHE) and medical impoverishment. The financial burden was compared among CKD groups, health schemes and quintiles of socioeconomic status. The multivariable logistic regression model was used to assess the factors associated with catastrophic health expenditure.

Result The study participants included 435 (35.5%) CKD15-60, 213 (17.5%) CKD<15, 257 (21%) PD and 319 (26%) HD, with mean (SD) age was 63.8 (14.3) years and 44% female. The percentage of patients under UCS, SSS and CSMBS were 44.1, 8.9 and 47%, respectively. Hypertension was the most common comorbidity, followed by dyslipidemia, diabetes and cardiovascular disease. Under UCS and CSMBS, HD patients suffered from CHE and medical impoverishment the most, especially among the poorest. Travel cost was the main driver of CHE in HD in all health care schemes. The adjusted probability of CHE under UCS was higher in HD than PD (53% vs. 22%, p < 0.05). The other associated factors with CHE were age (adjusted OR = 1.027, 95%CI: 1.013-1.019), cardiovascular disease (adjusted OR = 1.767, 95% CI:1.147-1.829) and household size (adjusted OR =0.806, 95 %CI: 0.718-0.863). CKD patients from the Central region suffered from CHE the most.

Conclusion Despite universal health coverage, there was substantial financial hardship in CKD patients, increasing from pre-dialysis to dialysis. HD patients under UCS suffer CHE and medical impoverishment the most, despite the fact that they need to use it. This is the area that policy makers should consider strategies to minimize any CHE and potentially inequitable effect of this on their financial status.