Laos’ health financing system has made remarkable progress towards universal health. The social health protection coverage was rapidly increased from merely 10.5% in 2008 to over 94% of the total population in 2018. Health financing in Laos was started when the government introduced the State Authority for Social Security (SASS) scheme, a compulsory plan for government officials, in 1995, followed by the Social Security Organization Scheme (SSO) for formal salaried workers under private enterprises in 2001. In 2002, the voluntary-based health insurance scheme targeting self-employed and informal economy workers was initialized through the initiative of Community-Based Health Insurance (CBHI). In addition, the government also introduced the Health Equity Fund (HEF) in 2004, focusing on the target group of poor and vulnerable people. In this case, the government purchased CBHI healthcare plans for poor people, certified by the heads of villages or local authorities. Besides, the Free Maternal Neonatal and Child Health (FMNCH) services policy has been implemented to support mother and child health 1,2. The idea of gathering all related schemes under one umbrella came up in 2012 when the Prime Minister issued the Decree 470/PM to develop the National Health Insurance (NHI) Fund. In 2016, the NHI was officially initialized under the CBHI, HEF, and FMNCH, under the Ministry of Health. In particular, between 2016 to 2017, the scheme was quickly expanded to all 17 provinces except Vientiane Capital, which protected informal employment through CBHI 3. The timeline of Lao health financing between 1995 to 2016 has been shown in Table 1.
Table 1
Timeline of health financing in Laos
|
Period
|
Health financing policy
|
Source of funding
|
1
|
1995
|
The State Authority for Social Security (SASS) for civil servants
|
Salary
|
2
|
2001
|
The Social Security Organization (SSO) for formal salaried workers
|
Salary
|
3
|
2002
|
Community – Based Health Insurance (CBHI) for self-employed and informal economy workers
|
Contribution rates
|
4
|
2010
|
Free Maternal Neonatal and Child Health (FMNCH) services policy
|
Various
|
5
|
2016
|
National Health Insurance (NHI)
|
Fixed copayment rates and government subsidy
|
Table 2
Respondents and their household sociodemographic and hospital admission
Respondent’s/ household’s sociodemographic
|
Hospital admission
|
Pearson X2
|
No
|
Yes
|
Total
|
Gender of respondent
Male
Female
Marital status
Single
Married
Age of respondents
18 -35
36-49
50 or above
Level of education
No schooling to lower secondary school
Lower secondary school to secondary school
College/ university degree
Size of household
1-4 people (small)
5 people or more (large)
Level of income
Less than 1 million LAK (US$100)
1– 2.5 million LAK (US$100 – US$250)
2.5 – 5 million LAK (US$250 – US$ 500)
More than 5 million LAK (US$ 500)
Respondents’ occupation
Business owner
Farmer
Street vendor
Laborer
Government official
City of residence
Capital (Kaysone Phomvihane district)
Others
Chronic condition
No
Yes
|
112 (58.6%)
79 (41.4%)
58 (30.4%)
133 (69.6%)
46 (24.1%)
99 (51.8%)
46 (24.1%)
22 (11.5%)
106 (55.5%)
63 (33%)
105 (55%)
86 (45%)
41 (21.5%)
40 (20.9%)
72 (37.7%)
38 (19.9%)
20 (10.5%)
50 (26.25%)
48 (25.1%)
48 (25.1%)
25 (13.1)
109 (57.1%)
82 (42.9%)
155 (81.2%)
36 (18.8%)
|
94 (62.3%)
57 (37.7%)
47 (31.1%)
104 (68.9%)
13 (8.6%)
15 (9.9%)
123 (81.5%)
16 (10.6%)
94 (62.3%)
41 (27.2%)
84 (55.6%)
67 (44.4%)
34 (22.5%)
30 (19.9%)
58 (38.4%)
29 (19.2%)
20 (13.2%)
36 (23.8%)
41 (27.2%)
34 (22.5%)
20 (13.2%)
91 (60.3%)
60 (39.7%)
119 (78.8%)
32 (21.2%)
|
206 (60.2%)
136 (39.8%)
105 (30.7%)
237 (69.3%)
59 (17.3%)
114 (33.3%)
169 (49.4%)
38 (11.1%)
200 (58.5%)
104 (30.4%)
189 (53.3%)
153 (44.7%)
75 (21.9%)
70 (20.5%)
130 (38%)
67 (19.6%)
40 (11.7%)
86 (25.1%)
89 (26.0%)
82 (24.0%)
45 (13.2%)
200 (58.5%)
142 (41.5%)
274 (80.1%)
68 (19.9%)
|
0.507
0.906
0.01*
0.435
0.913
0.989
0.892
0.582
0.589
|
Table 3
Respondents and their household sociodemographic and catastrophic health expenditure
Respondent’s/ household’s sociodemographic
|
Catastrophic Health expenditure
|
Pearson X2
|
No
|
Yes
|
Total
|
Gender of respondent
Male
Female
Marital status
Single
Married
Age of respondents
18 -35
36-49
50 or above
Level of education
Primary school
Lower secondary school to secondary school
College/ university degree
Size of household
1-4 people (small)
5 people or more (large)
Level of income
Less than 1 million LAK (US$100)
1– 2.5 million LAK (US$100 – US$250)
2.5 – 5 million LAK (US$250 – US$ 500)
More than 5 million LAK (US$ 500)
Respondents’ occupation
Business owner
Farmer
Street vendor
Laborer
Government official
City of resident
Capital (Kaysone Phomvihane district)
Others
Chronic condition
No
Yes
|
110 (56.4%)
85 (43.6%)
56 (28.7%)
139 (73.7%)
38 (19.5%)
67 (34.4%)
90 (46.2%)
16 (8.2%)
140 (71.8%)
39 (20%)
100 (51.3%)
95 (48.7%)
11 (5.6%)
26 (13.3%)
99 (50.8%)
59 (30.3%)
33 (16.9%)
37 (19.0%)
51 (26.2%)
42 (21.5%)
32 (16.4%)
132 (67.7%)
63 (32.3%)
190 (97.4%)
5 (2.6%)
|
96 (65.3%)
51 (34.7%)
49 (33.3%)
98 (66.7%)
21 (14.3%)
47 (32%)
79 (53.7%)
22 (15%)
60 (40.8%)
65 (44.2%)
89 (60.5%)
58 (39.5%)
64 (43.5%)
44 (29.9%)
31 (21.1%)
8 (5.4%)
7 (4.8%)
49 (33.3%)
38 (25.9%)
40 (27.2%)
13 (8.8%)
68 (46.3%)
79 (53.7%)
84 (57.1%)
63 (42.9%)
|
206 (60.2%)
136 (39.8%)
105 (30.7%)
237 (69.3%)
59 (17.3%)
114 (33.3%)
169 (49.4%)
38 (11.1%)
200 (58.5%)
104 (30.4%)
189 (55.3%)
153 (44.7%)
75 (21.9%)
70 (20.5%)
130 (38.0%)
67 (19.6%)
40 (11.7%)
86 (25.1%)
89 (26.0%)
82 (24.0%)
45 (13.2%)
200 (58.5%)
142 (41.5%)
274 (80.1%)
68 (19.9%)
|
0.118
0.407
0.296
0.00*
0.088
0.001*
0.001*
0.001*
0.001*
|
Table 4
Probability of hospitalization under National Health Insurance (NHI) scheme
Independent variable
(based on Andersen’s Behavioral Model)
|
Binary logistic regression model 1:probalbity of hospitalization
|
NHI 2018
|
NHI 2021*
|
Nagelkerke R2 = 0.248
|
Nagelkerke R2 = 0.411
|
OR
|
P-value
|
OR
|
P-value
|
Predisposing factors
Gender of respondent
Male
Female
Age of respondent
18-35
36-69
50 or above
Marital status
Single
Married
Level of education (2018 study)
Never attended school
Primary school
Lower secondary or higher
Level of education (2021 study)
Never attended school to Primary school
Lower secondary to Secondary school
College/ university degree
Size of household
1-4 people (small)
5 people or more (large)
Enabling factors
Level of income (2018 study)
Less than 1 million LAK (US$100)
1– 2.5 million LAK (US$100 – US$250)
2.5 million LAK (US$300) or more
Level of income (2021 study)
Less than 1 million LAK (US$100)
1– 2.5 million LAK (US$100 – US$250)
2.5 – 5 million LAK (US$250 – US$ 500)
More than 5 million LAK (US$ 500)
City of residence
Capital (Kaysone Phomvihane district)
Others districts
Need factors
Chronic condition
No
Yes
|
0.882
1.524
2
3.610
1.371
3.205
---
---
5.128
0.516
0.135
---
---
---
---
0.960
|
0.815
0.357
0.648
0.050*
0.150
0.188
---
---
0.02*
0.037*
0.08
---
---
---
---
0.935
|
0.992
0.518
9.763
1.104
---
---
1.330
0.803
0.766
---
---
0.793
0.924
1.024
0.833
1.716
|
0.976
0.125
0.001*
0.737
---
---
0.531
0.656
0.371
---
---
0.584
0.831
0.958
0.519
0.163
|
Table 5
Probability of entering to catastrophic health expenditure under National Health Insurance (NHI) scheme
Independent variable
(based on Andersen’s Behavioral Model)
|
Binary logistic regression model 1:probalbity of catastrophic health expenditure
|
NHI 2018
|
NHI 2021*
|
Nagelkerke R2 = 0.301
|
Nagelkerke R2 = 0.703
|
OR
|
P-value
|
OR
|
P-value
|
Predisposing factors
Gender of respondent
Male
Female
Age of respondent
18-35
36-69
50 or above
Marital status
Single
Married
Level of education (2018 study)
Never attended school
Primary school
Lower secondary or higher
Level of education (2021 study)
Never attended school to Primary school
Lower secondary to Secondary school
College/ university degree
Size of household
1-4 people (small)
5 people or more (large)
Enabling factors
Level of income (2018 study)
Less than 1 million LAK (US$100)
1– 2.5 million LAK (US$100 – US$250)
2.5 million LAK (US$300) or more
Level of income (2021 study)
Less than 1 million LAK (US$100)
1– 2.5 million LAK (US$100 – US$250)
2.5 – 5 million LAK (US$250 – US$ 500)
More than 5 million LAK (US$ 500)
City of residence
Capital (Kaysone Phomvihane district)
Others districts
Need factors
Chronic condition
No
Yes
|
0.662
1.223
0.803
0.643
0.943
1.156
---
---
0.946
1.166
1.117
---
---
---
---
8.695
|
0.601
0.211
0.457
0.144
0.505
0.792
---
---
0.836
0.894
0.900
---
---
---
---
0.000*
|
1.108
1.392
2.848
0.755
---
---
0.269
0.548
0.228
---
---
0.224
0.021
0.005
3.766
107.908
|
0.782
0.065
0.481
---
---
0.027*
0.352
0.001*
---
---
0.004*
0.001*
0.001*
0.001*
0.001*
|
Source: Social Health Protection Network2
Several studies were conducted to assess CBHI and NHI's impact on their effectiveness and improvement on accessibility and financial protection against catastrophic health expenditures. The results of these previous studies reveal that CBHI significantly improves access to health service utilization for households with chronic conditions. Most insured households under the CBHI scheme were able to avoid financial catastrophe due to health service utilization. However, poor households still retained the highest probability of entering catastrophic health expenditures related to health service utilization 1,4 . As a voluntary health financing scheme, members were required to pay membership or contribution rates. As there was no medical check before enrolling in the system, households' existing chronic conditions strongly affected health service utilization. In other words, households with a chronic illness or health problem are more likely to enroll or acquire health insurance 5 . Under the NHI’s coverage, the benefits package provides most health service in public/ government health care facilities. Few exceptions correspond to health services, such as VIP rooms, medicines not categorized in the essential medicine list, and traffic and work accidents. Services under the coverage of other vertical projects (AIDS, tuberculosis, and malaria) and non-essential services (plastic surgery, detail care, and other services) are not included in the NHI’s coverage. Unlike its predecessor, under the coverage of NHI, patients or their households are required to pay 25% (as a co-payment) for health services exceeding LAK 5 million (US$ 500). The introduction of NHI immensely increases the effectiveness of health service utilization for households in poorest income groups. Without a monthly or yearly contribution rate as the CBHI scheme, there was a massive increase in hospital visits. As a result, without physical hospitals’ physical expansion, health facilities become crowded and overutilized, with long waiting times, and were overloaded. As a result, the majority of patients in the top income quintiles opt to seek treatment in neighboring countries (in the notion that they will receive better health care) 2,6 .
Chronic Kidney Disease (CKD) is increasingly becoming a global public health problem, which disproportionately burdens low and middle countries, where detection and diagnostic rate remain low, with an approximate overall prevalence of 8-16% 7. This corresponds to almost 500 million individuals with kidney-related health issues, in which more than 78%, or nearly 390 million people, resides in low and middle-income countries 8. In particular, the mortality rate attributable to CKD between 1990 and 2010 has almost doubled, escalating to the 18th leading cause of mortality in 2012 9. Regardless of the fact that the exact public health burden of CKD in lower and middle income has not been carefully elucidated, the previous study has found that the incidence rate could be four times more than those observed in developed countries 7.
Hemodialysis (HD) was initially included in the voluntary-based CBHI scheme. It has been under the coverage of NHI since its introduction. However, only five HD sessions are under the coverage of the NHI. After the fifth HD session, patients or their families are expected to pay US$55-US$60 per session in out-pocket-expenditure. Laos is still in the initial stage for the development of Continuous Ambulatory Peritoneal Dialysis (CAPD). Human resources (dietitians or clinical engineers) are still in shortage, as most Lao patients prefer to go to neighboring countries for health service utilization. End State Renal Disease (ESRD) patients are not an exception; most Lao patients seek their first HD in Thailand and Vietnam, then those patients come back and receive maintenance HD locally 10 . NHI in Savannakhet provinces devised a policy that covers unlimited HD sessions in order to increase accessibility and avoid financial disasters that may have happened after the fifth HD session. Under this policy, patients are expected to pay as low as the IPD flat rate of LAK 30,000 (US$3) for each HD session. The HD session is provided only at Savannakhet Provincial Hospital and 109 Hospital in Outhoumphone district, where the first hospital has thirteen HD machines and the second hospital has one HD machine. However, only HD sessions at Savannakhet Provincial hospital in Kaysone Phomvihane district are under the NHI's coverage. In terms of operation, the HD machines operate from Monday to Friday; each machine is in charge of two HD sessions daily. In other words, the Savannakhet Provincial Hospital could hold up to 26 patients on a daily basis. Undoubtedly, with more government subsidies, this policy enhances accessibility and financial protection for patients and their households. However, without physical expansion, the hospital could end up being overloaded with a longer waiting time. Without the Covid-19 travel restriction, wealthier households prefer to seek health service utilization in private hospitals, hospitals in other provinces, and neighboring countries, predominantly Thailand and Vietnam
Regardless of the NHI coverage, there is a possibility for patients and their households to encounter catastrophic health expenditures due to non-medical spending. Catastrophic health expenditure or financial catastrophe is a situation where patients’ health expenditure needs to pay or copay more than or equal to 40% of non-subsistence income their households 11. In many cases, a patient must seek an organ transplant to improve their quality of living. Since medical services in Laos do not offer organ transplants, patients have sought organ transplants in neighboring countries using out-of-pocket expenditure when needed. The limited number of organ donors and health service utilization costs prevent most patients from accessing organ transplants. This study aims to carefully analyze the role of Laos' National Health Insurance on accessibility and the possibility of encountering catastrophic health expenditure for chronic kidney disease patients. In addition, this study is also willing to provide policy recommendations for policymakers in promoting the coverage of organ transplantation under NHI in the future.