Impact of the health insurance scheme for stateless people on inpatient utilization in Kraburi Hospital, Thailand

‘We are inferior, we have no rights’: Statelessness and mental health among ethnic minorities in Northern Thailand

Research has shown that asylum seekers, refugees, and internally displaced persons, including stateless persons, are at increased risk of poor mental health. Yet, only a few studies explicitly focus on stateless persons. This article examines the association between legal status and mental health among Akha, Lahu and Tai-Yai people in Northern Thailand. A convergent parallel mixed-methods design was adopted and primary data were collected in June 2020 by face-to-face, semi-structured interviews with persons who do not hold a nationality (n = 108). A distinction was made between registered (nationalityless) and unregistered (stateless) persons since only the former have a legal status in Thailand. The correlates of mental health were analyzed using descriptive statistics and logistic regression. Qualitative thematic analysis was employed to gain deeper insights into the relationship between legal status, ethnicity and mental health. The quantitative results weakly suggest that stateless persons are more likely to have poorer mental health than nationalityless persons, who are recognized as habitually resident in Thailand and are recorded in the country's civil registry. The qualitative results, however, show that the legal status afforded to nationalityless persons is considered important as it gives rise to hope and increases livelihood opportunities. Yet, respondents also pointed out that it is not comparable to citizenship. The odds of having poorer mental health are significantly higher for Lahu and Tai-Yai respondents. The importance of ethnicity is confirmed by the qualitative results. These further indicate that citizenship problems and ethnicity are deeply interrelated. Stigma, discrimination, and lack of social support are key risk factors identified by respondents. Disaggregating data to better understand the heterogeneity of persons without nationality could play a key role in accelerating efforts to resolve protracted citizenship problems and close ethnic gaps.

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Legal recognition and ethnicity affect the mental health of persons without nationality.

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Stigma, discrimination, and lack of social support are key risk factors.

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Disaggregated data are essential for identifying and addressing existing gaps.

Making Health Insurance Pro-poor: Lessons from 20 Developing Countries

The last 20 years have seen a substantial growth in research on the extent to which health sector reforms are pro-poor or pro-rich. What has been missing is knowledge synthesis work to derive operational lessons from the empirical research. This article fills the gap for the most popular form of health financing reform, health insurance. Based on publications covering 20 developing countries, we find that health insurance is no panacea for improving equity in the health sector. More importantly, we find certain design elements of health insurance can increase the likelihood of tackling inequality in the health sector in developing countries.

Healthcare Policies for Stateless Populations in ASEAN Countries: A Scoping Review

This study aimed at summarizing the existing health policies for stateless populations living in the 10 ASEAN countries: Brunei, Cambodia, Lao PDR, Indonesia, Malaysia, Myanmar, the Philippines, Singapore, Thailand, and Vietnam. We followed scoping review method recommended by Arksey and O'Malley. Our inclusion criteria were based on three concepts: populations (stateless and undocumented people), issues (healthcare policies and regulations), and settings (10 ASEAN countries). Our findings suggest that none of the ASEAN countries have explicit healthcare policies for stateless people except Thailand. We also observed that ratification of international human rights treaties relating to the right to health does not necessarily translate into the provision of healthcare policies for stateless population. Although Thailand seems like the only country among 10 ASIAN countries having health policies for stateless populations in the country, the question remains whether having a policy would lead to a proper implementation by ensuring right to health.

The impact of the stateless health insurance scheme on inpatient service utilization of stateless children at the four selected district hospitals in Tak Province, Thailand

OBJECTIVE

The objective of this study was to assess the impact of the stateless insurance scheme on inpatient service utilization of stateless patients in comparison to the universal coverage scheme (UCS) insurees and the uninsured.

DESIGN

The retrospective study used the routinely collected health data (eg, 43-file database) from January 1,2013, to December 31,2017. The study took a sample of 9528 child patients aged 0to 18years who had an inpatient (IP)admission at the four selected district hospitals in Tak Province. The outcome variable was IP utilization rate (admissions/person/year), while the exposure was the three-insurance status: uninsured, stateless, and UCS. With the counted outcome data, the researchers applied the Poisson regression, taking confounders into account, to measure the effect of exposure on outcome.

RESULTS

The overall median IP utilization rate was one admissions/person/year. Compared with the uninsured group, the stateless and the UCS insurees had 98% (incidence rate ratio [IRR]=1.980, 95% confidence interval [CI] = 1.250, 2.710) and 67% (IRR=1.670, 95% CI = 0.949, 2.390) higher IP admissions, respectively. The younger stateless insurees (2-3 years) had 16% (IRR=0.837, 95% CI=-0.036, 1.710) fewer admissions while oldest stateless insurees had 6% (IRR = 1.060, 95% CI = 0.235, 1.880) more admissions compared withtheir youngest uninsured counterpart (0-1 year). Stateless females had 21% (IRR=0.789, 95% CI = 0.344, 1.230) fewer IP admissions compared with their uninsured males counterparts. Overall IP utilization rate increased from 4% (IRR=1.040, 95% CI = 0.981,1.090) in 2014 to 14% (IRR=1.140, 95% CI = 1.070, 1.210) in 2017 compared with IP utilization in 2013.

CONCLUSIONS

The study suggests that inpatient utilization rate differs by insurance status with statistical significance. Further experimental studies are needed to understand the causal effect of the stateless insurance on adverse health outcomes in stateless children in the country.

Leaving no one behind? Social inclusion of health insurance in low- and middle-income countries: a systematic review

BACKGROUND

One way to achieve universal health coverage (UHC) in low- and middle-income countries (LMIC) is the implementation of health insurance schemes. A robust and up to date overview of empirical evidence assessing and substantiating health equity impact of health insurance schemes among specific vulnerable populations in LMICs beyond the more common parameters, such as income level, is lacking. We fill this gap by conducting a systematic review of how social inclusion affects access to equitable health financing arrangements in LMIC.

METHODS

We searched 11 databases to identify peer-reviewed studies published in English between January 1995 and January 2018 that addressed the enrolment and impact of health insurance in LMIC for the following vulnerable groups: female-headed households, children with special needs, older adults, youth, ethnic minorities, migrants, and those with a disability or chronic illness. We assessed health insurance enrolment patterns of these population groups and its impact on health care utilization, financial protection, health outcomes and quality of care.

RESULTS

The comprehensive database search resulted in 44 studies, in which chronically ill were mostly reported (67%), followed by older adults (33%). Scarce and inconsistent evidence is available for individuals with disabilities, female-headed households, ethnic minorities and displaced populations, and no studies were yielded reporting on youth or children with special needs. Enrolment rates seemed higher among chronically ill and mixed or insufficient results are observed for the other groups. Most studies reporting on health care utilization found an increase in health care utilization for insured individuals with a disability or chronic illness and older adults. In general, health insurance schemes seemed to prevent catastrophic health expenditures to a certain extent. However, reimbursements rates were very low and vulnerable individuals had increased out of pocket payments.

CONCLUSION

Despite a sizeable literature published on health insurance, there is a dearth of good quality evidence, especially on equity and the inclusion of specific vulnerable groups in LMIC. Evidence should be strengthened within health care reform to achieve UHC, by redefining and assessing vulnerability as a multidimensional process and the investigation of mechanisms that are more context specific.