**2.1 The precede-proceed planning model**

The Precede-Proceed Planning Model embodies assessment, planning, implementation, and evaluation interventions [10]. The Precede part includes phases that are the social assessment, epidemiological assessment, educational and ecological assessment, administrative and policy assessment, and intervention alignment [10]. The Proceed part consists of implementation, process evaluation, impact evaluation, and outcome evaluation [10]. The social assessment aims to identify the quality-of-life issues and to formulate the quality-of-life goals of a community [10]. Then, epidemiological assessment comprises epidemiological, behavioral, and environmental assessment [10]. Epidemiological assessment seeks to create measurable objectives related to the health quality of life outcomes. Behavioral assessment plans to transform behaviors that influence the health outcomes to sub-objectives. Environmental

*The Innovation of Six-Dimensional Pooling Risk Framework in Universal Health Insurance… DOI: http://dx.doi.org/10.5772/intechopen.106963*

assessment plans to transform physical, social, culture, political, and family environments that influence the health outcomes to sub-objectives [10]. Next, educational and ecological assessments plan to figure out hypothesized mediators of the behaviors identified [10]. They are classified to predisposing factors, reinforcing factors, and enabling factors, and they seek to develop sub-objectives [10]. After that, administrative and policy assessment and intervention alignment seek to evaluate the capacity and resources available to implement programs and transform policies based on the assessed needs [10].

### **2.2 The types of prevention**

The types of prevention are categorized to health promotion, primary, secondary, and tertiary prevention [11]. Health promotion "enables people to increase control over their own health. It covers a wide range of social and environmental interventions that are designed to benefit and protect individual people's health and quality of life by addressing and preventing the root causes of ill health, not just focusing on treatment and cure [12]." Primary prevention is to prevent disease and injury from occurring in the individual and the community [11]. Secondary prevention is to make early diagnosis and promote treatment of a disease or injury stopping the progress or shortening the duration and preventing the complications from the present disease process [11]. Tertiary prevention aims to prevent the severity and the complications of the disease [11].

#### **2.3 The district health system**

The UHC framework of Thailand depends on the district health system to accomplish equity to access healthcare services [13]. It has been developed throughout the nation. A district hospital services a population of about 50,000 people, and it consists of 30–120 beds and 100–300 staff. Its staff comprises general doctors, nurses, dentists, pharmacists, and other professionals [13]. The district health system is covered by 10–15 subdistrict health centers [13]. The UHC framework of Thailand reforms strengthened primary care throughout, providing local primary care networks greater management of financial resources, and being "close to the home, close to the heart" community facilities [14]. The Thai framework integrates medical and public healthcare services, so the system provides health promotion, disease prevention, and treatment healthcare services [14]. The UHC framework in 2001, "the district health networks received capitation-based funding for their population that covered services provided within the network and also the costs of referral to secondary care" [14]. Therefore, the local managers are empowered [14]. Health and social services are integrated in Thai district health system to encourage participation of all sectors to cooperate to enhance their local people's quality of life [15].

#### **2.4 The district division administrative disaggregation data framework**

The District Division Administrative Disaggregation of Data (DDADD) framework figured out the effect of the density of the insured population in the catchment area distribution of healthcare centers to detect districts left behind [16] (**Figure 2**). It determined the effect the density of the insured population had on the catchment areas cost of healthcare services (**Figure 2**) [16]. It found out the effect of the catchment

#### **Figure 2.**

*The district division administrative catchment area disaggregation of data framework. Source: district division administrative disaggregation data framework.*

areas distribution of healthcare centers on income-insured accessibility, to identify who is left behind (**Figure 2**) [16]. It discovered the effect of income-insured catchment area accessibility on the income-insured utilization of healthcare services to identify who was left behind [16]. The DDADD framework identified the insured poor were protected by the equitable distribution of healthcare services in high-density insured population districts [16]. However, the insured poor were left behind by the inequitable distribution in low-density insured population districts [16]. It found out the majority of the population living in low-density population districts were insured poor, and these districts lacked healthcare facilities with high cost of healthcare services [16]. It concluded that low-density-population districts determine health equity outcomes.

The DDADD suggests a premium equation of health insurance scheme that requires transformation based on equity and the probability of illness [16]. This transformation functions to mobilize healthcare resources toward low-density-population districts. Thus, subsidization is needed from the insured population living in highdensity-population districts, to those who live in low-density-population districts.

#### **2.5 The existing three-dimension pooling risk framework**

The Bismarckian model is a sickness fund approach, and it is state social insurance based on prepayment by workers and their employers [9]. The insured worker utilizes the healthcare services and the state social insurance provides payment to healthcare providers such as physicians, hospitals, or other providers [9]. The framework is organized by prepayment that means participants pay before they are ill, then they depend on the pooled funds from the health insurance scheme when they fall sick [17]. In many health financing systems, prepayment is combined with cost sharing from participants to service providers, and cost sharing is the direct payment [17]. The cost sharing means that the health insurance scheme does not cover all healthcare services costs and the insured person still has to pay a percentage of his or her costs out of pocket [17].

The three-dimension pooling risk framework of the health insurance–Bismarck model aims to accumulate and to manage the financial resources, ensuring that the financial payment risk for health care is carried by all participants of the pool and not by the individuals who become sick [17]. The prepayment is formulated by a large number of people, with pooling of funds to cover everyone's healthcare costs [17]. The framework spreads the financial risk related with the need to use health services [17, 18]. The existing cross-subsidization of the framework composes of the rich

#### *The Innovation of Six-Dimensional Pooling Risk Framework in Universal Health Insurance… DOI: http://dx.doi.org/10.5772/intechopen.106963*

subsidizing the poor [19, 20], the healthy subsidizing the sick [19, 20], and the young subsidizing the elderly [17, 20]. Evidence shows the good-quality design and implementation of a subsidization framework have contributed to financial protection, decreasing inequities in access to healthcare services among different income groups, and utilization improvement for the subsidized [21].

The equitable financial mechanism collects the contributions of the health insurance-Bismarck model based on progression, which means higher-income people pay progressively higher proportions of their revenue [22]. In low- and middle-income countries, health insurance is a sustainable healthcare financing model for offering financial risk protection for the majority of the population [23]. In Germany, Statutory Health Insurance has been compulsory for all citizens and the premium for permanent residents is a uniform contribution of 15.5% of their revenue with 118 sickness funds in 2009 and 85 percentage of the population are covered by Statutory Health Insurance [9]. In Nigeria, the contributions to the health insurance are calculated from 15% of the employee's basic salary, and they are divided between the employee contributing 5% and employers contributing 10% [24]. As the result, the three-dimension pooling risk framework operates to provide all of the insured population with access to needed healthcare treatment services and to protect them from out-of-pocket spending on health.
