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Original Investigation
July 2018

Association Between a Centrally Reimbursed Fee Schedule Policy and Access to Cataract Surgery in the Universal Coverage Scheme in Thailand

Author Affiliations
  • 1Faculty of Pharmaceutical Sciences, Khon Kaen University, Khon Kaen, Thailand
  • 2Monitoring and Evaluation Division, National Health Security Office, Bangkok, Thailand
JAMA Ophthalmol. 2018;136(7):796-802. doi:10.1001/jamaophthalmol.2018.1843
Key Points

Question  What are the trends and variations in cataract surgery access associated with a central reimbursement policy in Thailand?

Findings  In this time series analysis, after implementing a central reimbursement policy, the national cataract surgery rate increased substantially to 765.3 cases per 100 000 population in 2015. The subnational cataract surgery rate gap widened because of rapid uptake in areas with high rates of cataract surgery initially and decreased as overall coverage became adequately large.

Meaning  A central reimbursement policy that mitigated financial constraints of individual health care professionals in a developing country reduced backlogs for cataract surgery and was associated with improved access.


Importance  Uptake of cataract surgery in developing countries is much lower than that in developed countries. Cataract unawareness and financial barriers have been cited as the main causes. Under the Universal Coverage Scheme (UCS), Thailand introduced a central reimbursement (CR) system for cataract surgery. It is unknown if this financial arrangement could incentivize service provision (private or public) in areas that are hard to reach.

Objective  To examine the association between the CR policy and access to cataract surgery in Thailand.

Design, Setting, and Participants  Using time series analysis, hospitalization data during 2005 to 2015 for UCS members were analyzed for time trends and subnational variations in the cataract surgery rate (CSR) before and after the CR implementation.

Main Outcomes and Measures  The annual growth in access was estimated using segmented regression. The CSR gap across regions was determined by the slope index of inequality (SII). Unequal access across districts was represented by the gap between the top and bottom quintiles.

Results  During 2005 to 2015, a total of 0.98 million UCS members (mean [SD] age, 67.4 [11.2] years; 58.7% female) received cataract surgery. The number of cases increased from 77 897 in 2005 to 192 290 in 2015. At the national level, the CSR per 100 000 population increased from 352.0 to 378.7 cases in 2005 to 2008, to 716.3 cases in 2013, and then to 765.3 cases in 2015. With the use of mobile services through an exclusive CR, 3 private hospitals took the lead in service growth, sharing 79.2% of cases in the private sector in 2009. From 2010, the number of cases in public hospitals grew yearly by 12.6% to 13.6% until 2012, rose 21.7% in 2013, and then the rate of increase declined to that of 8.2% to 8.3% in 2014-2015. During the periods of an increase in overall access, the CSR gap across regions widened as indicated by the SII of 755.4 cases per 100 000 population in 2010 because of rapid uptake in areas with mobile services. When the national CSR became adequately large and mobile services were discouraged in 2013, the gap in 2014-2015 narrowed.

Conclusions and Relevance  This study found that the appropriate payment and service designs helped reduce the cataract surgery backlog. With an adequately high CSR, Thailand is on track to reach the VISION 2020 goal, aiming for blindness elimination by the year 2020, which has been achieved by most developed countries.