1 IMPACT OF THE 30-BAHT HEALTH INSURANCE POLICY ON HOSPITAL DRUG UTILIZATION IN THAILAND By PENKARN KANJANARAT A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA 2005
2 Copyright 2005 by Penkarn Kanjanarat
3 To my father, mother, brother, sister, niece, and my husband for their great love and selfless support
4 ACKNOWLEDGMENTS I would like to express my gratitude to my major advisor, Dr. Almut Winterstein, for her guidance, encouragement, support, and friendship during my pursuit of the Ph.D. This study would not have been completed without her guidance and dedication. I would like to thank Dr. Earlene Lipowski who provided a broad perspective of healthcare systems and guided discussions about the applicability of this study. Dr. Lipowski also provided input from her working experiences in Thailand to refine my study. Her encouragement and respect are greatly appreciated. I would like to thank Dr. Abraham Hartzema, who shaped my research idea. His vision in pharmacoepidemiology and international research experiences also helped guide my research. I deeply appreciate his challenging questions. I greatly appreciate Dr. Lili Tian for her suggestions for the analysis of my study. With her help, I have greatly extended my knowledge in Time Series Analysis in health service research, which will greatly benefit me in my future research. I could not express my gratitude enough to the Department of Pharmacy Health Care Administration and the College of Pharmacy for their support. I appreciate the infinite support of Dr. Richard Segal, Dr. Carole Kimberlin, and Dr. Donna Berardo. I would like to express my gratitude to the College of Pharmacy, Chiang Mai University, for their support of my Ph.D. study. iv
5 I would like to extend my gratitude to Dr. Jeffery Crane for his helps, encouragement, and friendship. I could not have achieved this goal without his indefinite support. This study is funded by a P.A. Foote Small Research Grant from the Perry A. Foote Health Outcomes and Pharmacoeconomics, University of Florida. v
6 TABLE OF CONTENTS Page ACKNOWLEDGMENTS... iv LIST OF TABLES...x LIST OF FIGURES... xii ABSTRACT... xiv CHAPTER 1 INTRODUCTION...1 Background...1 Need for Study...2 Purposes of Study...4 Study Objectives...5 Research Questions...5 Significance REVIEW OF LITERATURE...7 Healthcare Care System in Thailand...7 Health-Seeking Behavior and Healthcare Utilization...7 Access to Drugs...8 Healthcare Financing...9 The civil servant medical benefit scheme...10 The 30-Baht health insurance policy...11 Evaluating Health Policy...12 Methodology in Evaluating Health Policy...13 Time series in observational design...14 Nonconcurrent time series design...15 Concurrent time series design...16 Quantitative and Qualitative Measurement of Drug Use...20 Quantitative Approach to Measuring Drug Utilization...21 Measurement Units of Drug Utilization...22 The defined daily dose (DDD)...22 Strengths of the DDD...23 Limitation of the DDD...24 vi
7 Defined daily dose in drug utilization research...24 Alternatives measurements to the DDD...26 Qualitative Approaches in Measuring Drug Utilization...29 Concept of quality of care and its measurements...29 Approaches in measuring appropriateness of drug use...33 Measuring quality of drug utilization using explicit criteria...34 Measuring quality of drug use by quality indicators (QIs)...35 Challenges of Measuring Quality of Drug Use...38 Validity of the measures...38 Reliability of the measures...39 Sensitivity and specificity...39 Validating Computerized Administrative Databases...39 Data Validation Methods...40 External data validation...41 Internal validation methods VALIDATING DATA QUALITY...49 Interview of Hospital Directors...52 Interviews of Hospital Database Managers...52 Quantitative Assessment of Data Quality...52 Database Characteristics...53 Missing Data and Outliers...53 Face Validity (Plausibility of the Data)...54 Data Coherence...54 Validating disease diagnosis codes (ICD-10)...56 Drug data DATA VALIDATION RESULTS...58 Hospitals Demographics...58 Database Characteristics...61 Face Validity...63 Missing Data...66 Data Coherence...69 Disease Diagnosis and Gender...69 Disease Diagnosis and Drugs...69 Diabetes and antidiabetic drugs...69 Hypertension and antihypertensive drugs...72 Bacterial pneumonia and antibiotics...74 Drugs and Disease Diagnosis...76 Antidiabetic drugs and diabetes...76 Results from the Expert Interviews METHODS...80 Hypotheses...81 vii
8 Patient Selection...85 Data Source...87 Measures...87 Drug Utilization Rate (DR)...88 Percentage of Appropriate Prescribing (Drug Use Quality, DQ)...89 Hospital Visit Rates (HR)...90 Hospital Admission Rates (AR)...90 Statistical Analyses...92 Analysis of the Effects of the 30-Baht HI Policy on the Study Measures...92 Changes of Drug Disparity Associated with the 30-Baht HI Policy RESULTS...95 Patient Demographics...95 Diabetes...96 Drug Utilization Rates...96 Hospital Visit Rates...97 Impact of the 30-Baht HI Policy on the Study Measures...99 Hypertension Drug Utilization Rates Hospital Visit Rates Impact of the 30-Baht HI Policy on the Study Measures Infectious Diarrhea Drug Utilization Rates Percent Appropriate Prescribing Hospital Visit and Admission Rates Impact of 30-Baht HI Policy on the Study Measures Bacterial Pneumonia Drug Utilization Rates Hospital Visit and Admission rates Impact of the 30 Bath HI Policy on the Study Measures Disparity of Drug Utilization Rates Disparity of the Percent Appropriate Prescribing for Infectious Diarrhea DISCUSSION The Effect of the 30-Baht HI Policy on Drug and Hospital Service Utilization Drug Utilization and Access to Care Effectiveness of the Implementation of the 30-Baht HI Policy Suggestions to Improve the Evaluation of 30-Baht HI Policy on Drug Utilization and Hospital Service Utilization Time Series Design The Defined Daily Dose Quality of the Data in the HI database Study Limitations Recommendations for Future Research Contribution to Scientific Society viii
9 Conclusions APPENDIX A TERMINOLOGY AND DEFINITIONS B HEALTH INSURANCE CODES C RECORD LINKAGE D E DRUG LISTS FOR CALCULATING DRUG UTILIZATION RATES EXPERT INTERVIEWS LIST OF REFERENCES BIOGRAPHICAL SKETCH ix
10 LIST OF TABLES Table page 2-1 Alternative units for measuring drug utilization Types, definitions, and policy purposes of access to healthcare services Hospital information, numbers of hospital visits, hospital admissions, and prescriptions from 2000 to Five most prevalent dispensed drugs for inpatient and outpatient use of the eight included hospitals (A-H) during from 2000 to Provincial Disease Statistics (2002) on the 10 most common causes of morbidity for outpatient services, Ubonratchatani province, Thailand Missing data on patient demographics Hospital Missing data Missing data on disease diagnosis codes for inpatient and outpatient data of eight studied hospitals ( ) Missing data on prescribed drugs of eight studied hospitals over four years ( ) Expected populations eligible for the 30-Baht HI policy and the CSMBS in 8 selected government community hospitals, Ubonratchatani province, Thailand (2003) Patient demographics Regression parameters for drug utilization and hospital visit rates of diabetes Rates of drug utilization and hospital visits related to diabetes of the 30-Baht health insurance beneficiaries Regression parameters for drug utilization and hospital visit rates of hypertension Monthly rates of drug utilization and hospital visit related to hypertension of the 30-Baht health insurance beneficiaries x
11 6-7 Regression paramerters for drug utilization, prescribing quality, hospital visit, and hospital admission rates of infectious diarrhea Monthly rates of drug utilization, hospital visit, hospital admission, and the percent prescribing appropriateness of the 30-Baht group Regression parameters for drug utilization, prescribing quality, hospital visit, and hospital admission rates of bacterial pneumonia Monthly rates of drug utilization, hospital visit, hospital admission related to bacterial pneumonia B-1 Codes for health insurance status for the Health Insurance database D-1 Antidiabetic drugs for calculating drug utilization rates D-2 Antihypertensive drugs for calculating drug utilization rates D-3 Antibiotics for calculating drug utilization rates xi
12 LIST OF FIGURES Figure page 2-1 Health seeking behavior, Thailand 1999 (23) Nonconcurrent control group in observational design (27) Concurrent control group in observational design (27) Formulas for calculating sensitivity, specificity Geographic locations of the included eight community government hospitals in Ubonratchatani province, Thailand Percent of patients with two or more disease diagnosis codes assigned in the HI database (Hospital F) Linkage among the selected patient data in the HI database AN: scrambled hospital admission number Percent data coherence between disease diagnosis of diabetes and antidiabetic drugs of outpatient data among eight hospitals, Percent data coherence between disease diagnosis of diabetes and antidiabetic drugs of inpatient data among eight hospitals, Percent data coherence between disease diagnosis of hypertension and antihypertensive drugs of outpatient data among eight hospitals, Percent data coherence between disease diagnosis of hypertension and antihypertensive drugs of inpatient data among eight hospitals, Percent data coherence between disease diagnosis of bacterial pneumonia and antibiotics of outpatient data among eight hospitals, Percent data coherence between disease diagnosis of bacterial pneumonia and antibiotics of inpatient data among eight hospitals, Percent data coherence between antidiabetic drugs and disease diagnosis of diabetes among eight hospitals, xii
13 5-1 Algorithm to assess quality of drug utilization (DQ) using community-acquired pneumonia as an example.(169;170) Interrupted time series analysis of a drug utilization rate in the 30-Baht HI group and the control group before and after the policy Monthly drug utilization rates for diabetes in the 30-Baht HI population and of the CSMBS population from January 2000 to December Monthly hospital visit rates for diabetes in the 30-Baht health insurance population and of the CSMBS population from January 2000 to December Drug utilization rates for hypertension of the 30-Baht health insurance benefit group from January 2000 to December Monthly hospital visit rates for hypertension of the 30-Baht health insurance benefit group from January 2000 to December Monthly drug utilization rates for infectious diarrhea of the 30-Baht HI from January 2000 to December Percentages of prescribing appropriateness for infectious diarrhea of the 30-Baht HI from January 2000 to December Monthly hospital visit rates for infectious diarrhea of the 30-Baht HI from January 2000 to December Monthly hospital admission rates for infectious diarrhea of the 30-Baht HI group January 2000 to December Monthly drug utilization rates for bacterial pneumonia of the 30-Baht HI from January 2000 to December Monthly hospital visit rates for bacterial pneumonia of the 30-Baht HI from January 2000 to December Monthly hospital admission rates for bacterial pneumonia of the 30-Baht HI from January 2000 to December C-1 Two tables identify patients who visited outpatient clinic during the study period139 C-2 Two tables identify patients admitted to the hospital for inpatient services during the study period, and length of stay C-3 Patient demographic table identifies patient s age, gender, marital status, types of health insurance C-4 Two tables contain drug data xiii
14 Abstract of Dissertation Presented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy IMPACT OF THE 30-BAHT HEALTH INSURANCE POLICY ON HOSPITAL DRUG UTILIZATION IN THAILAND By PENKARN KANJANARAT August 2005 Chair: Almut G. Winterstein Major Department: Pharmacy Health Care Administration Thailand implemented the national 30-Baht health insurance policy in June 2001 to provide healthcare coverage (including drugs) for the uninsured population. We retrospectively assessed the impact of this policy on drug utilization in community government hospitals using computerized patient-specific data from 8 hospitals in Ubonratchatani province. Cross-sectional data from January 2000 to December 2003 included all inpatients and outpatients with bacterial pneumonia (CAP), gastrointestinal (GI) infections, diabetes (DM), and hypertension (HTN). We confirmed the internal validity of the database and conducted interviews of hospital personnel. The primary measure was drug utilization rate (DUR), measured as the Defined Daily Dose (DDD)/10,000 population/month. The secondary measures were percent prescribing appropriateness, hospital visit and admission rates. Monthly observations (N=48) were analyzed using segmented time series regression analysis (SARIMA model). xiv
15 Prior to the policy, the average monthly DUR of the 30-Baht group for DM, HTN, Infectious diarrhea, and CAP were 2,727.8, 1,414.0, 40.3, and 7.8 DDDs/10,000 beneficiaries, hospital visit rates were 86.7, 25.8, 25.6, and 1.9 visits/10,000 beneficiaries, and hospital admission rates were 2.5 and 0.3 admissions/10,000 beneficiaries, respectively. After the policy, average monthly DUR for DM, HTN, Infectious diarrhea, and CAP were 3,105.6, 2,983.5, 52.8 and 12.4 DDDs/10,000 beneficiaries, monthly hospital visit rates were 87.4, 36.2, 26.5, and 1.9 visits/10,000 beneficiaries, while admission rates for Infectious diarrhea and CAP were 3.0 and 0.6 admissions/10,000 beneficiaries, respectively. Appropriate antibiotics were prescribed to less than one half of the patients with Infectious diarrhea (43.4% before and 47.5% after the policy). Analysis revealed no immediate or trend effect in DUR, hospital visit/admission rates for DM, HTN, infectious diarrhea, or CAP after the 30-Baht HI policy was implemented (p>.05 for all measures). There was no significant change on the percent appropriate antibiotic prescribing for Infectious diarrhea, p>.05. The study did not detect a change in drug and hospital service utilization associated with the 30-Bath HI policy, although there were positive trends in rates of drug utilization, hospital visit, and admission after the policy. Computerized hospital database prove valid and useful resource for research. xv
16 CHAPTER 1 INTRODUCTION Background The Institute of Medicine (IOM) Report 2002 (1) addressed significant health problems of the uninsured. The report stated that approximately 30 million Americans with no health insurance had a higher risk of poor health and shorter life-expectancy than people with health insurance. Poorer health in the uninsured was the consequence of limited access to care (1). Until the year 2000, approximately 30% of the Thai population had no health insurance coverage. In 2001, the Thai government, to improve access to care and reduce healthcare disparity between the insured and uninsured Thais, implemented the 30-Baht Health Insurance (HI) Policy for the uninsured Thai population. The uninsured were the poor, self-employed, and children 12 to 18 years of age, who did not have any benefits from the three existing governmental health insurance plans: the Civil Servant Medical Benefit Scheme (CSMBS), the Medical Welfare Scheme (MWS), and the Social Security Scheme (SSS). The 30-Baht HI policy offers coverage for most healthcare services and prescription drugs provided by government hospitals. The National Health Insurance Office evaluates eligibility based on the uninsured status of an individual. The 30-Baht HI beneficiaries are then registered with the government community hospital in their district as a main healthcare provider. The HI benefits are not extended to care received by other providers except when the patients are referred to that facility. Similarly, 1
17 2 prescription drugs are covered by the policy only if they are dispensed from the hospital pharmacy at the designated hospital. Our study aims to assess the impact of the 30-Baht HI policy on drug utilization because drug therapy is a core component of medical care. Although previous literature suggests that lack of drug benefits is associated with underutilization of prescription drugs (2-7) and that an increase of drug utilization was expected, our study evaluated any changes of drug utilization associated with this policy. Need for Study After this national policy was implemented in October 1, 2001, the government authorities, including the National Health Security Office (NHSO) and the National Health System Research Institute (HSRI), conducted various health policy evaluation studies to evaluate the effects of the policy on various aspects. However, most of the research from the NHSO and the HSRI focused only on administrative and economic issues, and patients and providers satisfaction with the policy (8-10). Few studies have yet examined the impact of the policy on drug utilization (8). Evaluating the effect of the new policy on drug utilization required identifying the effect of the policy on changes in the disparity of drug between subpopulations. While national healthcare expenditures in Thailand increased greatly over the last 2 decades (3.82% of GDP in 1978 to 6.21% in 1998) the distribution of this spending is skewed toward the insured. The increase mostly occurred in the insured population. Only a small proportion occurred in the uninsured, which indicates healthcare utilization disparity or unequal opportunity in healthcare service access and utilization among uninsured versus insured populations. The disparity was associated with various factors that inhibit access to care, including financial status (11).
18 3 Assessments of national health policies in developing countries are often compromised by weak study designs that fail to establish a causal relationship between the policy, and health indicators and health outcomes (12). For example, various studies use cross-sectional designs, post-only intervention designs, or pre-post comparisons with no control group (13-19). Moreover, the selection of reliable and clinically significant outcomes measures is often compromised by data unavailability or inappropriate data format for the analysis (e.g., healthcare data was collected in paper format, with no record linkage among databases). Our study applied a sound study design (interrupted time series of impact analysis) to evaluate the causal association between the 30-Baht HI policy and drug use by the targeted population. Currently, Thailand has no standardized data source that contains drug utilization data at a national level. Available drug utilization data were derived from quarterly government hospital purchasing and inventory reports, which lack patient-level detail. Estimates of drug utilization can also be derived from drug importation and/or manufacturing reports put forward by pharmaceutical companies on an annual basis. No drug utilization data are available at a patient level, which would allow assessments of drug utilization in a certain disease state or across subpopulations. The opportunity for our study was offered by a novel computerized administrative database, Health Insurance (HI) database, used in every hospital in Ubonratchatani province since This database includes electronic medical records and drug dispensing data for every patient who received healthcare services (outpatient and inpatient) from the hospitals. Although never used in research, the database offers a
19 4 unique opportunity for health outcomes and drug utilization studies because of its level of detail and its uniform structure in all community hospitals of the province. Evaluating of the effect of the health policy on drug utilization would contribute to an objective assessment of healthcare services established by the Thai government. It would also offer suggestions to stakeholders for further improving access to drug utilization and eliminating disparities in healthcare. Purposes of Study We proposed to quantitatively evaluate the impact of the 30-Baht HI policy on drug utilization in terms of drug utilization rates and prescribing quality, using drug data from the HI database. Drug utilization rates are measured using the Defined Daily Dose (DDD) and prescribing quality is assessed based on the appropriateness of prescribing for a given disease state. Effects of the 30-Baht HI policy on access to hospital services were also measured as hospital outpatient visit rates and hospital admission rates. Four disease states (diabetes, hypertension, bacterial pneumonia, and infectious diarrhea) are studied. We selected the listed disease states for two reasons. First, they are prevalent and associated with high mortality rates in Thailand. Second, they represent acute and chronic conditions and allow a more comprehensive assessment of the policy impact on healthcare. From the computerized patient-specific healthcare database (HI database) of the government community hospitals in Ubonratchatani province, Thailand, we chose subjects who were eligible for the 30-Baht HI policy during 2000 and 2003 as a study group. The Civil Servant Medical Benefit Scheme (CSMBS) was selected as a control population because of its comprehensive healthcare and drug benefits. For the control group, access to care and choices of treatment were not limited by the patients ability to
20 5 pay for services. We analyzed the effect of the 30-Baht HI policy on drug utilization and access to hospital services using an interrupted time series analysis. By using a control group, we adjusted for the natural trend and other factors that might have an effect on drug utilization rather than the 30-Baht HI policy. In addition, we compared drug use disparity (difference of drug utilization between the 30-Baht HI beneficiaries and the CSMBS group) at one year before and after the implementation of the policy. Definitions and terminology used in our study are presented in Appendix A. This study was approved by the Institutional Review Board, University of Florida. Study Objectives To test the validity of the patient-specific healthcare data in the HI database of the community government hospitals in Ubonratchatani province, Thailand To assess the impact of the 30-Baht HI policy on drug utilization rates, the percent appropriate prescribing, hospital visit and hospital admission rates in the 30-Baht HI population controlling for longitudinal changes in the CSMBS group To evaluate the change of drug utilization disparity between the 30-Baht HI population and the CSMBS at one year before and after the policy was implemented. Research Questions Research question 1: Did drug utilization rates in the 30-Baht beneficiaries for the selected disease states change after the 30-Baht HI policy was implemented, controlling for trends of the drug utilization rates of the previously uninsured group and those of the CSMBS group? Research question 2: Did the prescribing quality in the 30-Baht beneficiaries change after the 30-Baht HI policy was implemented, controlling for the drug utilization quality of the previously uninsured group and those of the CSMBS group? Research question 3: Did hospital admission rates related to pneumonia and gastro intestinal infections for inpatient services in the 30-Baht beneficiaries change after the 30-Baht HI policy was implemented, controlling for the hospital admission rates of the previously uninsured before the policy and those of the CSMBS group? Research question 4: Did hospital outpatient visit rates related to diabetes and hypertension in 30-Baht beneficiaries change after the 30-Baht HI policy was implemented, controlling for the hospital visit rates of the previously uninsured before the policy and those of the CSMBS group?
21 6 Research question 5: Did the extent of drug utilization disparity between the 30- Baht HI policy beneficiaries and the control group change at one year after the policy compared to the extent at one year before the policy? Significance We evaluates whether the 30-Baht HI policy improved drug utilization rates and quality of drug utilization as provided in governmental insurance schemes. Comparisons of drug utilization rates and quality between this population and the control population also addressed its effect on drug utilization disparity. Our results will complement other epidemiologic and/or economic evaluations of this policy and suggest areas of improvement of the health insurance benefit program to reach the goal of comprehensive national healthcare coverage. We used comprehensive electronic patient medical records from the HI databases that have never been validated or used for research purposes. Although this issue posed an additional challenge for main study objectives, we hope the validation of the HI databases facilitates future health service research and quality improvement activities.
22 CHAPTER 2 REVIEW OF LITERATURE Healthcare Care System in Thailand Most healthcare services in Thailand are provided to the population by the public sector. Most of these facilities are affiliated with the Ministry of Public Health, followed by the Ministry of Defense (veteran hospitals) and the Ministry of Internal Affairs (municipal hospitals). Healthcare services provided by the private sector include private hospitals, private outpatient clinics, and independent pharmacies. Additionally, many patients seek cures from traditional treatments, although modern medicine is widely available. Health-Seeking Behavior and Healthcare Utilization Even though self-medication (44.2% to 86.3%) (20;21) is commonly practiced in Thailand, it decreased from 54.1 to 17.62% (more than 36%) from 1970 to 1996, while healthcare utilization from public health services increased from % (almost 30%) (22). Socio-economic factors, the healthcare infrastructure, and type of health problems appear to affect health seeking behaviors. For example, the 1999 Health and Welfare Survey indicated that people living in rural areas mainly seek healthcare services from public settings, while people who live in urban areas are more likely to seek healthcare services from private clinics or hospitals than from the public facilities (23) (Figure 2-1). A study of health-seeking behavior of the villagers in rural areas of Thailand using health diary by Osaka et al.(24) found that most patients with chronic diseases were more 7
23 8 likely to receive treatment and medications from local health centers or community hospitals, while patients with severe and acute symptoms (e.g., high fever or abdominal pain) sought urgent care from private clinics. For minor illness, most villagers rarely used healthcare services from a local health center or a community hospital % of population Urban Rural 0 Folk doctor Others No treatment Self-treated Public facility Private clinic/hos pital Figure 2-1. Health seeking behavior, Thailand 1999 (23). Access to Drugs Regarding the current drug delivery systems, almost all classes of drugs are accessible for Thais, from prescription drugs to herbal medications. Drug distribution channels include hospitals, private clinics, pharmacies, health centers, public health centers, and even grocery stores. Prescription drugs are sold in drug stores with pharmacists and without pharmacists. Some pharmacies are open for service with no pharmacists on duty, thus patients receive drug products from the store owner or a store clerk. In 1999, nearly half of the drug stores (5,351 of 12,548 stores) were authorized to sell prescription and controlled-substances (e.g., corticosteroids, benzodiazepines, and
24 9 narcotics). The remaining drugstores were authorized to sell most of the commonly prescribed drugs, including antibiotics, with or without a pharmacist. Moreover, over 400,000 small grocery stores in villages around the country have prescription drugs available. Drug regulations and enforcement do not control this type of retail drugstores in Thailand (25). Not only pharmacists can dispense prescription drugs and controlled substances: Thai drug regulations allow physicians to dispense medications as well. It is commonly acknowledged that drugs are the major source of income of healthcare facilities. So every hospital has a hospital pharmacy department where most prescriptions are dispensed. While drugs can be obtained through various channels only government hospitals can dispensed drugs under the 30-Baht HI policy. Thus, the study databases can assess whether reimbursement for drugs from hospital improved, but it is not possible to assess whether overall drug access increased as a results of the 30-Baht HI policy. Healthcare Financing To understand how healthcare services are provided to Thai people, it is important to be familiar with existing healthcare financing schemes before the 30-Baht HI policy was implemented. The 30-Baht HI policy was created based on the four established health insurance schemes offered by the government, and targeted to fill the gap between the insured and uninsured. The four health insurance schemes offered by the Thai government included the Civil Servant Medical Benefit Scheme (CSMBS), the Social Security Scheme (SSS), the Medical Welfare Scheme (MWS), and the Health Card Scheme (HCS). Private Health Insurance (PHI) is also available for people who can afford it.
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