Lessons from Thailand in achieving universal health coverage: Contributing factors and key challenges Phusit Prakongsai, MD. Ph.D. Director of Bureau of International Health (BIH) Ministry of Public Health, Thailand Presentation to the 2nd Thailand-Pacific Island Countries Forum(TPIF) 30th May 2015 Sukosol Hotel, Bangkok, Thailand

Long march to UHC: Health financing reform GNI per capita, 1961-2013 1997: $2710 Asian financial crisis 2002: $1870 Achieving UHC 1990: $1490 SSS 1983: $760 Voluntary Health Card 1975: $390 Low Income Card 1963: $120 CSMBS

Three public health insurance schemes in Thailand after achieving UHC in 2002 Civil Servant Medical Benefit Scheme (CSMBS) Social Security Scheme (SSS) Universal health coverage (UHC) Introduced in 1963 1990 2002 Target beneficiaries Govt employees & dependents, retirees Private sector employee Informal sector who are neither covered by CSMBS nor SHI, Population Coverage 7% 13% 78% Funding Govt budget Payroll contribution, Tripartite Payment to health facilities Fee-for-service for OP, and DRG for IP Capitation (use DRG in risk adjusted part) Capitation for OP + DRG with global budget for IP

UHC cube: what has been achieved in Thai universal health coverage? X axis: 99% pop coverage by 3 public H insurance schemes [UCS 78%, SHI 13%, CSMBS 7%] Y axis: Free at point of services, very minimum OOPs, Low incidence of catastrophic health expenditure and health impoverishment, Z axis: Extensive and comprehensive benefit package, very small exclusion list, Most high cost interventions were covered: dialysis, chemotherapy, major surgery, medicines including Essential Drug List (EDL).

Health interventions and medical treatments included into the UHC benefit package Basic health Care (on capitation basis) A very comprehensive benefit package with a very minimum exclusion list ARV drug Renal replacement therapy (2nd prevention for DM/HT) Mental health (medicines) Liver and heart transplantation Benefit starting year 2002 2006 2009 2010 2011 2012

Increased utilization, low unmet needs Prevalence of unmet need OP IP National average 1.44% 0.4% Civil Servant Medical Benefit Scheme (CSMBS) 0.8% 0.26% Social Security Scheme (SSS) 0.98% 0.2% Universal Health Coverage Scheme (UCS) 1.61% 0.45% What are the outcomes of Thai UHC?   National household surveys and routine reporting system from NHSO consistently demonstrated improved utilization both outpatient and inpatient services. OP utilization rate increased from 2.4 visits per person per year in 2003 to 3.6 in 2011. Annual per capita hospitalization rate increased significantly from 0.067 in 2003 0.115 in 2012 Unmet need was low when OECD standard questionnaire was applied; the unmet needs incidence was as low as 1.4% of OP and 0.4% of IP, on par with OECD good performer countries. Source: NSO 2009 Panel SES, application of OECD unmet need definitions

Changes in utilization: primary secondary and tertiary 1977-2010 46% (5.5) 29% (3.5) 24% (2.9) 1977 Regional H./General H. Rural Health Centres Community H. 27% (11.0) 35% (14.6) 38% (15.7) 1987 2000 46.1% (51.8) 35.7% (40.2) 18.2% (20.4) 2010 54.0% (78.0) 33.4% (33.4) 12.6% (18.1) As a result of investment in health infrastructure and gradually extend financial risk protection for target population; the service utilization had gradually reorient in favour of primary and secondary care, from the tertiary care dominance in 1977, to the primary care dominance in 2010.   This was clearly shown in an upside down triangle to the upright triangle.

Financial risk protection Protection Thai HH against health impoverishment UHC achieved High level of financial risk protection prevents a large number of non-poor household falling under poverty line as a result from out of pocket payment for health.   The Red dotted line is number of households would be impoverished if there were not UHC. The Blue solid line is the actual number of household impoverished from health payment, even with UHC. The difference is the number of household protected from being poor from health payment. This is one of the most exciting outcomes. All governments acknowledge this positive message and continue to fully support the UHC Scheme.

Sub-national health impoverishment 1996 to 2008

Government and non-government financing sources, 1994-2011 UHC inception Million Baht Economic crisis Data from the National Health Accounts of Thailand shows that after achieving UHC, the share of public financing increased from 56% of total health expenditure in 2001 to 77% in 2011.   Total health expenditure during 2003-2011 ranged from 3.5 to 4.1% of GDP, and per capita health spending in 2011 was 218 USD. Health expenditure for UHC beneficiaries in 2010 was approximately 82 USD per capita. These financial indicators reflect the affordability of our economy to continue to support UHC. The good news is the significant reduction of out of pocket payment to 14% of total spending in 2012. Total health expenditure 2003-2011 ranged from 3.49% to 4.1% of GDP THE per capita in 2011 was 218 USD, Expenditure for UC beneficiary in 2014 = 90 USD per capita

enabling factors of good UHC outcomes Reflections enabling factors of good UHC outcomes

Strong and expanded leadership with continuous evolution: Systems design focus on equity and efficiency – diverse institutional arrangement for health policy and system development Dynamic evolution over decades of rural focus integrated health system development and HRD Extensive geographical coverage of functioning PHC and district health systems; Rural compulsory services of new graduates medical doctors for three-years since 1972, rural based nursing production since 1980 Strong and expanded leadership with continuous evolution: Continued political support despite changes in government, Capable technocrats, Active civil society – from VHV to CS for policy advocates Institutional capacities re knowledge and evidence production and utilization: Information systems for policy formulation and M&E, Health economics and health systems research. Health technology assessment

Mandatory rural services Evolution of the Thai Health System CSMBS 1980 Health Card 1983 SSS 1990 UCS NHSO Low Income Scheme 1997 Constitution Economic crisis 1980s 1968 1975 2001 2007/08/09 1828 1888 1918 1942 1990s 1946 1978 1999 2006 King Rama 3 started the Western medicine Department of Public Health, MoI Mandatory rural services HFA/ PHC policy 1992 HSRI Local Health Funds HIA LGs EMIT MoPH Scaling up District Health System (DH + HC) 1992 A decade of health center development ThaiHealth Siriraj Hospital established First MoPH nursing college NHCO MoPH = Ministry of Public Health, HSRI = Health System Research Institute, LGs = local governments ThaiHealth = Thai Health Promotion Foundation, NHSO = National Health Security Office, NHCO = National Health Commission Office, EMIT = Emergency Medical Institute of Thailand, HAI = Hospital Accreditation Institute

Four decades of infrastructure and workforce development The advent of district hospitals (1977) First batch of two-year technical nurses (1982) Now fully upgraded to RNs Public service mandate of new MDs (1972) This slide shows how important the health systems readiness as key success factor for implementing UHC   As a result of four decade government investment in health infrastructure focusing at district health system (including district hospitals and health centres) and government mandatory rural services for key health workforces not only contributed to good health at low cost, which was published in Lancet in 2012, it is the solid foundation for UHC implementation in 2002. Source: Health Resource Surveys (various years)

KEY CHALLENGES

Proportion of elderly (>65 years old) Japan China Thailand Korea World Source: Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat,  World Population Prospects: The 2010 Revision 16

Changes in population pyramid of Thais from 1990 to 2030

Sources: Analyses from the 2002, 2004, and 2006 SES Household expenditure: tobacco, alcohol and health Median household expenditure (Baht per month), 2002-2006 Sources: Analyses from the 2002, 2004, and 2006 SES

DALYs attributable to risk factors Mismatch between increasing burden of disease from NCD and low investment in HP and disease prevention DALYs attributable to risk factors

Framework of adult health development in 2015 Framework for health development in adults Targets in 2015 Reduction in alcohol consumption for 10% Reduction in tobacco consumption for 30% Reduction in high blood pressure for 25% Risk group of CVD can access to medicines and consultation for 50% Reduction in premature deaths from NCDs 25% Reduction in physical inactivity for 10% Reduction in sodium intake for 30% No increase in diabetes and obesity Access to essential medicines and health technology 80% Promoting healthy life styles in general population Prevention of NCDs in high risk groups Prevention and delay in disease complications Reduction in health risk behaviors Health management district - law enforcement - Improving NCDs clinics and disease management - Qualified NCD clinics DHS + system manager at provincial and district levels

Acknowledgements Ministry of Public Health (MOPH) of Thailand, National Statistical Office (NSO) of Thailand, National Health Security Office (NHSO), Thailand, Health Systems Research Institute (HSRI), Thailand, World Health Organization (WHO) Thank you for your kind attention.