Dr. Suwit Wibulpolprasert Achieving Universal Health Coverage: The Roles of Evidence, Social Movements and Policy Commitment Ladies adies and gentlemen, It is my great honor to present to you the Thai Universal Health Coverage within 10 minutes. Dr. Suwit Wibulpolprasert Senior Adviser on Disease Control, MoPH, Thailand, PHA3, July 9th, 2012 University of Western Cape, South Africa

Thailand at a glance (2011) Lower middle income with good health status - Gross National Income: US$ 3,760 per capita Poverty – 2% of population Gini index 42.5 - MMR 30/100,000 LB and IMR 20 per 1,000 LB UHC achieved in 2001 under three schemes – the CSMBS, the Social Security and the UC Health expenditure (THE): US$ 300 per capita – 6% GDP Half from public – 13% of National Budget Less than 50% out of pocket health expense Thailand is a lower middle income country, with low level of poverty, moderate income inequity, and fair health status, especially for mother and children. We have achieved Universal Health Coverage since 2001, with only 6% of our GDP spent on health and 14% of national budget for health. The out of pocket health expenses reduced from more than 75% in early 1980s to less than 50% after the UHC.

Five important points UHC is for poverty reduction not only health benefits UHC can be started at low level of income The need to ensure availability of satisfactory services. Mobilizing more resources for UHC Getting more health for the existing resources My presentation today will focus on 5 key issues as shown in this slide.

1. UHC for Poverty reduction (MDG 1) Prediction without UC Actual situation Households with catastrophic illnesses Firstly, the aim of the UHC is not only for health benefit, it is actually for social equity and poverty reduction. The first elected democratic government after the student revolution started to provide free medical care to the poor in 1975. in mid 1980s, the World Bank concluded that the free medical care for the poor was the most successful poverty reduction policy in Thailand. This figure shows that In 2008, 6 years after we achieve Universal Health Coverage, it protected almost 40,000 households from poverty due to catastrophic illnesses, a 37.4% reduction as compare to without UHC. The more high cost benefits we cover, the higher the reduction of poverty. Universal access to antiretroviral drugs for AIDs patient in 2004 and free services for Renal Replacement Therapy in 2006 have clearly further reduce the poverty. In conclusion, UHC is for MDG 1 not only for MDG 4, 5 and 6. 1996 1998 2000 2002 2004 2006 2007 2008

2. We can start UHC when we are still low income GDP/capita 2. We can start UHC when we are still low income Second, you don’t have to wait until you become a high income country to start and achieve the UHC. Thailand started to cover the poor with free health services when the GDP per capita was less than 400 USD. Then in 1983, we moved to cover the near poor when the GDP per capita was 760 USD. With the rapid economic growth, we moved further to cover the regular employees with social security health insurance in 1992. The decision to cover the children, and the elderly in 1995-6 had moved the coverage up to 71% in 2001. The UHC had become one of the main issue for political campaign in the 2000 general election, and the new government, the same ruling party as the current government, decided to move from 71% to 100% coverage in 2001. At that time our GDP per capita was less than 2,000 USD. year

Long march towards Thai UHC: You don’t have to wait until you are rich to start and achieve UHC The historical milestone is described against the economic capacity of the country measured in term of Gross National Income per capita between 1970 and 2009 Our experiences showed that even we were low income country, in 1975 we introduced low income scheme when the GNI per capita was 390 US Dollar. Community based health insurance scheme was introduced in 1983 when GNI was 760 US dollar, Thailand had proved that universal coverage can be achieved despite the GNI per capita of less than 2000 US Dollar. While the USA whose income was 13 times richer than Thailand, they still cannot reach UC. I would say, reaching UC is the real political and financial commitment National Health Security Act was proposed by 50,000 Thai citizens and it has 5 influential board members from civil society organizations

The Three Schemes of UHC - 2010 “Public / Private Providers Gold card Civil servants Employees TAX 2001 1963 1991 NHSO CSMBS SSO Contribution 48 mil. 6.0 mil. 9.0 mil. NHSO Comptroller SSO Capitation 80 $US/y “Fee for service” 350 $US/y Capitation 75/y There are now three health insurance schemes that cover the entire population with more or less the same comprehensive health package. The benefits range from primary care to general inpatient services and very high cost care, including anti-retroviral treatment for AIDs patients, cardiac surgery, neurosurgery, chemotherapy, renal replacement therapy, and some organ transplant, but not cosmetic surgery. The three schemes include the Civil Servant Medical Benefits Scheme, paid totally by General Tax Revenue. It covers around 6 millions or 9 percent of the population. the Social Security Health Insurance Scheme, paid equally by the three parties, the General Tax Revenue, the employers, and the employees. It covers another 9 millions people or around 14% of the population. Finally the UC or the 30 Baht Scheme, paid by the general tax revenue. It covers the rest of the population which is around 48 millions. Services Insurees, Right holders “Public / Private Providers Private room non- ED Suwit Wibulpolprasert, MD., Ministry of Public Health, Thailand 7

3. Ensuring universal availability of satisfactory health services Extensive expansion of rural health services in early 80s, as part of PHC/HFA and rural development policies – inspite of economic crisis How? - Freeze new capital investment in urban health facilities for 5 years and reallocate the budget to build rural health centers and district hospitals, with extensive production of Community Health Workers Extensively increased use of rural facilities The third issue is to make satisfactory health services universally available. It is useless to have free medical care, while the care is so far away and difficult to reach. In early 1980s, in spite of serious economic crisis, the Thai government made a bold decision, as part of the rural development policy, to freeze the new capital investment in urban hospitals for 5 years and shift the resources to build rural health centers and district hospitals to cover all rural communes and districts. This was a real courageous move. Dr. Suwit Wibulpolprasert, Ministry of Public Health, Thailand

Health Systems Strengthening as essential components of the UHC Useless to have financial protection when the quality essential health services are not universally available Adequate facilities, manned by dedicated well-trained HRH Retention of Health Professionals in the rural areas – multiple ‘supply’ and ‘demand’ side measures. Diabetic Conditions in some countries Dr. Suwit Wibulpolprasert, Ministry of Public Health, Thailand

Reallocation of budget during Economic Crisis in early 1980s, to build rural facilities and HRH Fast tracking rural health No investment in urban areas for 5 yrs. This slide shows the evidence that before 1982, the budget to urban health facilities was higher than those to the rural ones. But since 1983, the budget to the rural health facilities become prominent. Dr. Suwit Wibulpolprasert, Ministry of Public Health, Thailand

Adequate and appropriately manned rural health facilitieis Rural health centers with 3-6 nurses n CHWs cover 2,000-5,000 population Extensive production of appropriate cadres and motivated health personnel with mandatory public works and adequate support are essential. The results are well equipped and manned modern rural health centers and rural district hospitals. The government also provides housing, subsidized utilities, and food, as well as good communication facilities. Rural community hospital with 2-8 doctors cover 30-80,000 population Suwit Wibulpolprasert, MD., Ministry of Public Health, Thailand

From reverse to upright triangle: PHC utilization (OP visits) 46.2% (5.5) 29.4% (3.5) 24.4% (2.9) 1977 Provincial hospitals Rural health centers Community hospitals Budget shift 27.7% (10.9) 32.8% (12.9) 39.4% (15.5) 1989 Provincial hospitals Rural health centers Community hospitals Peace, econ gwt, democracy With good and well manned rural health facilities, more and more people used the rural health facilities and the structure of the out patient visits changed from that of a reverse triangle in late 1970s to that of an upright one, with broader and broader bases. Provincial hospitals Rural health centers Community hospitals 2000 46.1% (51.8) 35.7% (40.2) 18.2% (20.4) ( ) : Number of OPD visits (millions) Source: Rural Health Division, MoPH 12 Dr. Suwit Wibulpolprasert, Ministry of Public Health, Thailand 12 12

Satisfaction of UC people & provider Percent Expand financial incentives The patient satisfaction is high from the beginning of the UHC, but the provider satisfaction was initially low due to increasing workload and inadequate budget. However, it was improved after higher budget allocation and higher financial incentives.

Medical service Utilization OP visit The utilization rates increased in both outpatient, 2003 2004 2005 2006 2007 2008 2009 2010 2011 Source : Report 5, 0110 , Yr 2003 – 2011 14

Medical service Utilization IP visit and inpatients. 2003 2004 2005 2006 2007 2008 2009 2010 Source : NHSO IP data in Yr. 2003-2011 15 15

Source of finance 1994-2010 Increased public financing sources with less OOPs UHC achieved

4. Mobilize more resources Peace and Economic growth – less proportion of budget to security and serving public debt National public health expense increased from 5% of national budget in 1980s to 13% in 2010 ‘Community Health Development Fund’ – co-pay by local governments - $US 150 m in 2010 Dedicated Health Promotion Fund – 2% additional levy on tobacco and alcohol excise tax – $US 100 m in 2010 – ‘support HiTAP’ The UHC definitely requires more resources to health. From mid 1980s to mid 1990s, due to double digits export led economic growth as well as internal peace, we were able to free 20% of national budget from servicing public debt and 10% of national budget from national security. This has allowed higher proportion of national budget to health and social sector. The public health budget increased from mere 2% in early 1970s to 4% in early 1980s and now to 14% of national budget. We also established a Community Health Development Fund, co-financed by the UHC and the local government. This fund is used for public health and health promotion and disease prevention activities in each rural community. Finally, we also passed the Health Promotion Act, to collect 2% additional levy on tobacco and alcohol excise tax, to put into the Thai Health Promotion Foundation. This fund is used to tackle social determinants of ill health.

From security and debt service budget to health Percentage This slide shows how the 30% fiscal space was created between mid 80s to mid 90s from internal peace and export led economic growth. Year 18 Source: Bureau of Budget Dr. Suwit Wibulpolprasert, Ministry of Public Health, Thailand

More Budget to Health 986.6 mil. ฿ (3.4%) 16,225.1 mil. ฿ (4.8%) 77,720.7 mil. ฿ (78x) (8.1%) 2010 PH budget rose to 14% of National buget 29,000 mil. ฿ 1972 335,000 mil ฿ 1,028,000 mil ฿ (35x)) It is clear from this figure that in addition to a bigger health budget from a bigger national budget, the proportion of national budget to Public Health is also increased almost three folds in the last three decades. 1990 National budget 2004 PH budget 19 Dr. Suwit Wibulpolprasert, Ministry of Public Health, Thailand 19 19

5. Better Value for Money Close end capitation based budget with mixed payment mechanisms mainly on capitation (OP) and Case Mix (IP) and some FFS and PC as gate keeper Base on National Essential Drug List and use of TRIPs flexibilities - article 31(b) and Doha declar, and strict control of high price EDs Base on intensive study on cost-effectiveness of health technologies – IHPP, HITAP, etc. Central bargaining and purchasing with VMI Drug price of all hospitals on web site My last point, your excellencies, is that the UHC must ensure ‘more health for money’. The UHC has established several mechanisms to ensure ‘better value for money’, including close end budget that also cover disease prevention and health promotion, the use of national essential drug lists, the implementation of TRIPs flexibility, the health and intervention technology assessment and central bargaining and procurement systems. This allow us to cover every one with adequate essential benefit package without much cost escalation.

Health Insurance coverage of three population groups in selected Asian countries in 2009 Source: Tangcharoensathien V et al, Health Financing Reform in South-East Asia (2009)

Comparing % of Out of Pocket Health Expense and % of Public Expenditure on Health The red bar presents that people had to pay themselves for health care cost as % of total health expenditure. UHC can reduce out-of-pocket expenditure for example the case of Japan and Thailand. We need to protect our people from paying too much health care cost which is uncertainty and may lead to the difficulty of the people. Nonetheless, there is no free lunch. Someone needs to pay. Government of Japan spent at 18.4 % of it budget for health and Thai government spent 12.7% for health. Not only adequate budget from the government but we also need to increase value of money for health too. For example we need to use money wisely, before invest money in the new technology we need to ensure that it is cost-effectiveness. in 2010

ASEAN plus three HMM Joint Statement July 6th, 2012 …….We commit to collectively accelerate the progress towards UHC in all countries by ……….the formation of an ASEAN Plus Three network on UHC. We concur and will collectively move the issue of UHC to be discussed and committed at the highest regional and global development forum, including the ASEAN Plus Three Summit, and the United Nations General Assembly. Dr. Suwit Wibulpolprasert, Ministry of Public Health, Thailand

10 ASEAN Plus China Health Minister Meeting – July 6th 2012 Most of them agreed with removal of Tobacco from the Free Trade Agreements All agreed to support ‘specifically dedicated fund from tobacco and alcohol tax to be used for tobacco and alcohol control and other health promotion activities’ Thai Health Promotion Foundation – 2% additional levy on top of the excise tax to tobacco and alcohol – 100 million per year Dr. Suwit Wibulpolprasert, Ministry of Public Health, Thailand

What we must reiterate to politicians and society “Because we are poor, we can not afford not to have primary health care based Universal Health Coverage” Dr. Suwit Wibulpolprasert, Ministry of Public Health, Thailand

“Triangle that move the mountain” “Tipping point” Knowledge generation & management Conductive Environment Three groups of people In conclusion, it took us 25 years to achieve UHC based on a gradual and incremental movements. Out successes depend on the inter-connectedness of three important powers, the policy or political power, the social power and the power of wisdom. This concept has been called the strategy of ‘The triangle that moves the mountain’, and has been applied to solve many difficult social problems. Thank you so much for your kind attention. Social movement Stickiness of the issue Political/ Policy linkages Dr. Suwit Wibulpolprasert, Ministry of Public Health, Thailand