From principle to practice: Experience from Thailand in Amending the social security law: Training Seminar on Social Security Standards, Policy and Implementation Luang Prabang, Lao PDR 28 August 2013 Dr. Thaworn Sakunphanit Boonyawee Aueasiriwon

Thai Social Security Act (SSA) Situation in 1990 (Enact of the SSA) Expansion to Universal Health Coverage Forecast of Financial Status of the Social Security Scheme

Development of Thai Social Security Act Did not implement Amend SSA 1954 SSA 1990 SSA 1994 SSA 1999 40 Years Merge? Amend Workmen’s Compensation Announcement 1972 Workmen’s Compensation Announcement Act 1994

Summary of SSS implementation coverage benefit mandatory voluntary 2010 - Informal sector Sickness (cash benefit only), invalidity, death, OAP 2004 Unemployment 2002 1 employee 1996 OAP, child allowance 1994 Self employed Maternity, invalidity, death (had been revoked in 2010) 1993 10 employees 1991 20 employees Sickness, maternity, invalidity, death

Situation in 1990

Centralized (Public) health care coverage Low-income Country Low-income Country Decade of hosp 1977- 1986 Decade of health centre 1992-2001 Low-income Country Low-income Country 1000 (1986) -> 1300 (2005) Dr. 10,000 (1986) -> 20,000 (2005) 1: 1000 -> 1: 800 Nurese 50% 1: 5000 1:4000 Source: Patcharanarumol W et al (2011). Why and how did Thailand achieve good health at low cost?10

Step by Step Approach Health - A few trained health policy analysts Card Health Care Facilities - No computers - Simple report, no coders - A few trained health policy analysts - Short course training on Health Economics for director of community hospitals -Two Cost accounting Studies Exiting Schemes

Challenge of Implementation Social Security Act was enacted in 1990 Implementation of 4 short term benefits (Sickness, Maternity, Invalidity and Death benefits) had to started in 1991 Regarding Social Health Insurance Established responsible unit in the Social Security Office (SSO) Registration/ Contribution collection Benefit package / Service provision Payment mechanism Information system

Overcome Challenges: Registration/ Contribution collection Lack of trained staff, equipment, office building and operating procedures tremendous increasing of workload SSO decided to implement centralized registration system using its own ID number. Since the Citizen ID was not completed at that time

Overcome Challenges: Benefit package / Service provision Using “Exclusive” List approach for Benefit package Working with the ILO and Ministry of Public Health on actuarial issue Using existed public and private health care facilities Cabinet Order Force every public health care facilities providing services for member of SHI Lead to amendment for more flexible financial procedure in public health facilities include compensation to staffs Competition among Public and Private Providers

Overcome Challenges: Payment mechanism Debate between payment mechanisms Fee for services, which is used under Civil Servant Medical Benefits Scheme and Workmen Compensation Fund Moral hazard: High risk to SSO->workload to adjudication and utilization review Capitation High risk to provider-> decrease quality Case Based (DRG) Data was in paper-based discharge summary

Overcome Challenges: Information System Ministry of Public Health (MOPH) officially announced to use ICD10 (2nd country in the world) SSO decided to asking computerized report from contracted health care providers Every contracted providers got a PC computer A stand alone computer application for contracted providers was developed Nation wide training for using the application with the new standard coding system by SSO and MOPH

Expansion to Universal Health Coverage

Hurdles Social Security Act has potential to expand for UHC Hurdles Mission for UHC is not clear Vision and leadership of Secretary General Flexibility of orgnisation to new demand of member and new initiative e.g. new payment mechanism Composition of Triparty Committee, Ownership of the funds Specific scheme for specific population VS Universal Representative of new member (self-employed, government officers) Result: Expansion to other group of population is very slow Sickness benefit for spouse in the law was suspend Voluntary insurance for informal employee was delay

Result New Law is enacted Impact to the Social Security Act National Health Security Act Only member of SSS has to pay contribution for sickness benefits, the rest enjoy health care benefit using tax Impact to the Social Security Act Argument from members why do they have to pay contribution and tax?

There Should be The New Amendment of The Social Security Act.

Forecast of Financial Status of the Social Security Scheme

Projection Health Care Expenditure: From Actuarial Model Source: Health Care Reform Project (2008)

Contribution for Pension From Actuarial Models