Effective coverage of diabetes and hypertension in Thailand: challenges and recommendations

Introduction Increased Disability Adjusted Life Year (DALY) of diabetes and hypertension draws policy attention to improve effective coverage. This study assesses effective coverage of the two conditions in Thailand between 2016 and 2019. Method We estimated total diabetes and hypertension cases using age and sex specific prevalence rates for respective populations. Individual data from public insurance databases (2016-2019) were retrieved to estimate three indicators: detected need (diagnosed/total estimated cases), crude coverage (received health services/total estimated cases) and effective coverage (controlled/total estimated cases). Controlled diabetes was defined as Haemoglobin A1C (HbA1C) below 7% and controlled hypertension as blood pressure below 140/90 mmHg. In-depth interview of 85 multi-stakeholder key informants was conducted to identify challenges to better effective coverage. Results In 2016-2019, among Universal Coverage Scheme members residing outside Bangkok, estimated cases were around 3.1-3.2 million for diabetes and 8.7-9.2 million for hypertension. For diabetes services, all three indicators have shown slow increase over the four years (67.4%, 69.9%, 71.9%, and 74.7% for detected need; 38.7%, 43.1%, 45.1%, 49.8% for crude coverage; and 8.1%, 10.5%, 11.8%, 11.7% for effective coverage). For hypertension services, the performance was poorer for detection (48.9%, 50.3%, 51.8%, 53.3%) and crude coverage (22.3%, 24.7%, 26.5%, 29.2%) but was better for effective coverage (11.3%, 13.2%, 15.1%, 15.7%) than diabetes service. For both diseases, the estimates were higher for the females and older age groups than their counterparts. Complex interplays between supply and demand side barriers were a key challenge. Database challenges remain which hamper regular assessment of effective coverage. Conclusion Given the increased diabetes and hypertension prevalence, strategic recommendations cover long term actions for primary prevention of known risk factors as unhealthy diet and sedentary behaviour. Short term actions aim to improve effective coverage through the application of Chronic Care Model, increase attention to non-pharmacological intervention and patient empowerment. Summary Box What is already known? As Effective coverage is the gains in health resulting from health interventions, the measure provides high granularity for assessing the performance of Universal Health Coverage. Non-Communicable Diseases (NCDs) account for more than two-thirds of global deaths, with Diabetes and hypertension as the two main drivers of NCD prevalence. The effective coverage of diabetes and hypertension are important measures of Thailand’s Universal Health Coverage performance. What are the new findings? The effective coverage of diabetes and hypertension in Thailand has shown slow increase over a period of four years, in every step of care. Interestingly, effective coverage among females and older populations are better than their counterparts. The key issues resulting in low effective coverage of both diabetes and hypertension are due to inconvenient hospital hours and high workload for health care workers leading to discontinuity of care, over-crowding and long waiting times; as well as patient unwillingness to modify behavioural aspects leading to NCD’s. The major barriers to measuring effective coverage in Thailand is the lack of valid, complete, and accurate data. What do the new findings imply? Despite 17 years of Universal Health Coverage, NCDs care in Thailand is still underperformed with slow improvement year by year. Policies to address the effective coverage of diabetes and hypertension should 1. Aim to increase patient awareness and screening of NCD’s; 2. Focus on non-pharmacological intervention and patient empowerment; 3. Utilize digital technology and innovations to support the current over-stretched health personnel; 4. Strengthen campaigns to modify patient lifestyles; 5. Initiate and support population-based strategies addressing NCD risk factors.