Around The World in HTAs: Thailand – An Ever-Evolving Policy Tool

The health system in the country

Universal Health Coverage (UHC) is not just a promise but a reality in Thailand. Renowned for its strong public health system, Thailand achieved UHC in 2002 and spends around 5% of its GDP on healthcare – of which over 70% comes from the government. Despite spending less on health compared to other upper-middle-income countries, Thailand manages to get a great bang for its buck. Between 2000 to 2021, life expectancy at birth has increased from 72.3 to 78.7, infant mortality is down from 1.67% to 0.62%, UHC index has rocketed from 43.2 to 82.0, and out-of-pocket  payments have plummeted from 34.2% to just 9% – statistics that are comparable with or outperform many high-income countries.

So, how did Thailand achieve this success? Thailand has three main public health insurance schemes which cover almost the entire population. These include: (i) the Civil Servant Health Benefit Scheme (CSMBS), covering government employees and their direct relatives financed through general taxation, and managed by the Ministry of Finance; (ii) the Social Security Scheme (SSS), covering those in the formal private sector with tripartite financing from employer, employee, and the government, and managed by the Ministry of Labour; and (iii) the Universal Coverage Scheme (UCS), covering the rest and majority of the population financed through general taxation, and managed by the National Health Security Office (NHSO). The Ministry of Public Health serves as the provider of care, while NHSO acts as the purchaser of care for the UCS, ensuring buying power and efficiency in delivery of care.

A roadmap for new technologies

The use of Health Technology Assessment (HTA) in Thailand dates back to the early 1980s. However, it was the 2007 cost-effectiveness study which informed Thailand’s “Peritoneal Dialysis First Policy” for the management of end-stage renal disease which institutionalized its use. This led to the creation of the Thailand’s HTA agency, the Health Intervention and Technology Assessment Program (HITAP), and HTA has since become a requirement before making reimbursement decisions for the UCS. The other two schemes, CSMBS and SSS, do not employ HTA processes.

Health interventions and technologies to be included in the UCS undergo three separate processes: (i) the National List of Essential Medicines (NLEM), (ii) the Universal Coverage Benefits Package (UCBP) which includes non-pharmaceutical technologies, and (iii) National List of Essential Vaccines (NLEV). Medicines under NLEM are divided into several categories and HTA is only required for the E2 category, which is expensive drugs with implications for the UCS budget.

Thailand’s use of HTA is informed by its process guidelines. In Step 1, topics are nominated on an annual basis. For UCBP, nine stakeholder groups such as policymakers, academics, industry, health professionals, civil society (i.e. organised groups of citizens), lay citizens (i.e. individual citizens) and patient groups suggest topics through the UCBP website or public hearing forum. For NLEM and NLEV, topics are usually nominated by medical experts and the industry.

In Step 2, topics are selected by relevant working groups (from UCBP, NLEM, NLEV) who apply six pre-defined prioritization criteria (disease burden, severity, effectiveness of the technology, variation in practice across the three public schemes, impact on household expenditure, and equity, social, and ethical considerations) to score and rank the technologies. Each year, up to 35 topics (with highest scores) are selected for assessment and at least one topic must be related to health promotion and prevention, and another on effective coverage or access to care. However, minor variations may exist in prioritisation criteria and number of topics selected across UCBP, NLEM, and NLEV.

Step 3 involves commissioning the assessments to research teams and evaluating the evidence. Researchers must follow the methods guidelines when conducting cost-effectiveness and budget impact analyses, host stakeholder consultations to solicit feedback, and present findings to respective evaluating committees.

Step 4 is decision-making, where relevant committees will provide recommendations based on five pre-defined criteria (cost-effectiveness, availability of clinical practice guidelines, health system readiness, budget impact, ethical and social issues). Thailand uses 160,000 Baht per QALY as its explicit willingness-to-pay (WTP) threshold (~ USD 5,000 or ~1.3 its GDP per capita). The final decision is then made and announced by the National Health Security Board for the UCBP and the National Drug System Development Committee for the NLEM and NLEV.

Current challenges

There are four topics that may require a review of HTA practices in most countries around the world – and Thailand is not an exception.

First, while HTA is well established, the use of early HTA in promoting health innovation development (which is a complex process with high uncertainties) is less clear. Early HTA can inform the development of innovations by evaluating them at their developmental stages, scan and streamline the innovation process by identifying health needs and gaps and estimate and maximise their value early on. However, no guidelines currently exist for early HTA. Furthermore, there is a lack of capacity and awareness about its use case and value.

Second, there are challenges in providing access to and reimburse high-cost drugs, although there is a growing demand to do so for the UCS. Several hurdles exist: there is no universally accepted definition of high-cost drug; they are often not considered cost-effective at current WTP threshold; potentially have high budget impact (unless it is a rare disease); and there is no standard reimbursement model to follow. A study led by HITAP provides some ways forward and these recommendations are currently being discussed at the national level.

Third, although equity is considered an important issue in Thailand (as reflected by its inclusion in HTA criteria), it is not explicitly accounted for in economic evaluations. Thus, health technologies are introduced without an understanding of their impact on health equity, i.e., how are the costs and benefits distributed across target population, and who gains and who loses in the process. Therefore, there is a risk that cost-effective health technologies might not enhance welfare in society.

Finally, environmental impacts of health technologies are ignored. “If healthcare were a country, it would be the fifth largest emitter of greenhouse gases (GHG),” and this alarming finding suggests that the health sector may be responsible for creating its own patients by contributing to environmental degradation and climate change. This occurs throughout the life cycle of health technologies – from R&D, manufacturing, supply-chain, all the way to service delivery and waste management. At present, environmental impacts of health technologies are neither considered in the HTA decision-making process in Thailand, nor is there international guidance on how to do so.

Next steps for HTA in Thailand

To promote early HTA in Thailand, five leading agencies have signed a Memorandum of Understanding (MOU) on “Collaboration on Priority Setting and Early Health Technology Assessment of Health Innovation in Thailand”, including HITAP, Thailand Science Research and Innovation (TSRI), Thailand Center of Excellence for Life Sciences (TCELS), NHSO, and the National University of Singapore (NUS). Medical Innovation Development (MIDAS), a research unit operated by researchers from HITAP and NUS, are advancing this work by understanding the health innovation landscape in Thailand, supporting medical innovators in product development, and developing guidelines and training to build early HTA capacities (and awareness). Collaboration between researchers, innovators, and government agencies will remain crucial for a thriving health innovation ecosystem and the adoption of early HTA in Thailand.

With support from policymakers from the NLEM, UCBP, and pioneers of Distributional Cost-Effectiveness Analysis (DCEA), Thailand is working towards explicitly accounting for the equity impacts of health technologies. To this end, Thailand’s first DCEA study, using dialysis as a case study, is underway. A pre-requisite to undertaking DCEA is the evidence on the level of aversion to health inequality in the country. Preliminary findings from the ongoing study suggest that both policymakers and the public are averse to health inequality in the country and are willing to trade-off some level of total health gains to reduce the inequality gap. However, DCEA can be data hungry, methodologically complex, and can prolong assessment period. Thus, ongoing efforts focus on developing a more pragmatic approach of DCEA.

Lastly, Thailand has pledged to achieve carbon neutrality by 2050 and net zero by 2065. It is imperative to ensure the reimbursed health technologies are not only cost-effective and equity enhancing, but also environmentally sustainable. As such, the Environmental Economics Unit (e²u) (has been established to deliver a health sector response. A preliminary study suggests the existence of significant greenhouse gases (GHG) emissions from the Thai health system. Hence, the e²u and the Health Administration Division are working to establish a system to report annual GHG emissions from all public healthcare facilities and a database of emissions from all health technologies and services. Simultaneously, e²u is working with Environmental Sustainability in HTA (ESHTA) – a Health Technology Assessment International (HTAi) working group, to develop guidance to incorporate environmental impacts of technologies into HTA decision-making process.

HTA in Thailand has come a long way since the 1980s and its journey continues to evolve to support the dynamic needs of a modern Thai society.