Valerie Schmitt, ILO Bangkok 4 March 2014 Session 1 – Current situation of Health purchasers and legal framework in S-E Asia Valerie Schmitt, ILO Bangkok 4 March 2014

Key points Course (1h30) Objectives & principles of social health protection Activity (30 minutes) Sources of funding Variety of situations and systems in ASEAN In-Tray exercise (1h30) on drafting SHI laws/regulations, followed by presentations to the class (15-20 minutes per group)

Social health protection People face contingencies during their life cycle, which have financial consequences Maternity Sickness / ill health Unemployment Work injury Medical care Families with children Invalidity Death of the breadwinner Old age Life cycle Social Health Protection

Objectives of SHP 1/ Provide access to affordable quality medical care 2/ Provide financial protection in case of sickness or ill health resulting in a loss of productivity or loss of earnings

Principles of SHP Activity (30 minutes): Define and discuss the principles of SHP Think about the situation in your own country Select at least one of these principles that is not yet a reality in your country Share with the others your country example, and provide evidence

Principles of SHP Availability of services Financial protection Universal coverage Equality of treatment (residents/migrants) Collective financing State’s responsibility Adequacy of coverage Right to appeal Flexibility (no unique model) Affordability Quality of care Solidarity Predictability Responsiveness to needs Non-discrimination Representation

Sources of funding: which one do you prefer? And why? Out-of-Pocket payments Indirect taxes Direct taxes Contributions Premiums + additional Government revenues The worse is OOP = no financial protection !! ILO does not consider them as a means of financing social health protection. Direct taxes levied on individuals & enterprises; indirect taxes: VAT, sin tax Allocation for health care subject to annual public spending negotiations Contributions are mandatory, not risk-related, based on earned income, shared by employers and workers Premiums (CBHI, private HI) flat-rate, sometimes risk-based Payments directly made to the HC provider at the point of delivery Partial/full cost sharing

Sources of funding & types of schemes Out-of-Pocket payments Indirect taxes Direct taxes Contributions Premiums + additional Government revenues Subsidies National HC services Vouchers Health Equity Funds Social health insurance schemes Community based health insurance Private HIS Health care providers

Sources of funding & types of schemes All countries have established systems based on multiple financing mechanisms that combine two or more of the mentioned sources of funding Activity (30 minutes): Think about the situation in your own country Share with others a description of existing schemes and financing mechanisms

Variety of situations Source: ILO Social Security Inquiry Database (2010)

Variety of systems in ASEAN Indonesia Cambodia Lao PDR Thailand Viet Nam …

Development of a HIS for the formal sector in Cambodia Some poor and near poor have access to HEFs and CBHI schemes; no coverage of the formal sector Master Plan for Social Health Insurance (SHI), 2005: Compulsory insurance for the private sector (NSSF) and civil servants (NSSFC) Voluntary CBHI for non poor informal sector Health equity funds and health vouchers for the poor Progressive development of the HI branch of NSSF based on the pilot health insurance project Coverage: 3.2 million people from HEFs, 170,000 people from CBHIs and 5,000 from HIP ; extension to 700,000 people with the establishment of the HI branch of NSSF Diversity of financing methods: Civil servants: government funding Private sector employees: NSSF (workers and employers contributions) Non poor informal sector: CBHI (insurance premiums & partial donor funding for admin costs) Poor and near poor: Health equity funds (donor funding) Out of pocket spending still very high

Recent SHP reform in Indonesia New legal framework: National Social Security System Act in 2004 Social Security Providers Act in 2011 Merger of the 3 health insurance providers (Jamkesmas/Jamkesda, Jamsostek and Askes) into one: BPJS Kesehatan since January 2014 Objective: from 59 per cent of coverage in 2010 to universal health care coverage by 2019 Diversity of financing methods: Civil servant: contributory scheme (5%; 3% borne by employer and 2% by worker) Private sector employees: contributory scheme (4.5%; 4% borne by employer and 0.5% by worker) Poor and near poor: subsidized scheme Non-poor informal workers can register to the programme and pay contribution between 25,500 rupiah (around $2) and 59,500 rupiah (around $5) per month

The NHI in Lao PDR SHP is one of the Government’s top priorities Coverage: from 27.5% of the population in 2012 to 100% by 2020 Four HI schemes & one programme: State Authority for Social Security (SASS) scheme for civil servants Social Security Organisation (SSO) scheme for private sector employees Community-based health insurance (CBHI) scheme for the self-employed Donor-supported Health Equity Fund (HEF) programmes for the poorest population MNCH programme piloted by the MoH as well as several international agencies Towards a National Health Insurance scheme that will integrate the main four social health protection schemes Prime Minister’s Decree No.470 on the National Health Insurance Scheme, issued on 17 October 2012 Economies of scale & administrative efficiency Consolidation of risk pools Extension of coverage

The UCS in Thailand Flagship country with almost universal coverage Three main programmes: Non-contributory Civil Servants Medical Benefit Scheme (CSMBS) – 6.7 per cent of the population Health Branch of the Social Security Fund (SSF) for private sector employees (art. 33) and workers leaving the formal sector (art. 39) – 15.4 per cent Universal Coverage Scheme (UCS) since 2002 for all people not covered by other public health protection schemes – 75.1 per cent

From a tax based system to SHI in Viet Nam Three main programmes: Compulsory Health Insurance – formal sector, beneficiaries of social assistance, the poor, dependants of army and public security officers. Voluntary Health Insurance – for those not covered by Compulsory HI Free Health Card for children and the poor (i.e. fully subsidised health insurance card that covers a comprehensive package of services) The Law on Health Insurance of 2008 aims to achieving universal health insurance by 2014. It shows the commitment of the Government to close the coverage gap through partial/full subsidy of insurance contributions for the poor and vulnerable groups.

Developing a legal framework Activity (1 hour 30 minutes, followed by 15 minutes presentation per group) – IN-TRAY exercise The Minister of Health of Coresia aims at developing an integrated National Health Insurance System, and you were asked to support the Ministry in the development of a new social health insurance legislation (law and regulations) to achieve this objective. Your responsibility: Draft a detailed outline of the new Law (chapters, articles), Draft several draft articles: (a) Objectives of the SHI; (b) Persons covered; (c) Definition of health care benefits; (d) Institutional design & governance of the system; (e) Financing methods and sources of the SHI.