Challenges to universal health coverage in Thailand Phusit Prakongsai, M.D. Ph.D. Viroj Tangcharoensathien, M.D. Ph.D. International Health Policy Program (IHPP) Ministry of Public Health of Thailand Presentation to the 13th Annual Scientific Conference (ASCON XIII) ICDDR,B, Dhaka, Bangladesh 15 March 2011

Health financing arrangements and three public health insurance schemes in Thailand after achieving UC in 2002 Full capitation Capitation for OP DRG with global budget FFSuntil 2006, DRG for IP Direct billing FFS(2006+) for OP Traditional FFS for OP Source: Tangcharoensathien et al. (2010)

Informal user fee exemption Historical development of the Thai health system: Infrastructure development + expansion of financial risk protection Establishment of prepayment schemes User fees Informal user fee exemption 1945 Expansion consolidation of prepayment schemes 1970 1975 LIC 1980 CSMBS 1-3rd NHP 1962-76 Provincial hospitals 1990 SSS 1980 1983 CBHI SSS CSMBS LIC  MWS Universal Coverage 4th -5th NHP (1977-86) District hospitals Health centers 1990 1994 Pub VHI SSS Before 2001, health care system in Thailand is a public-private mixed system. A user fee was introduced at the beginning of establishment of government health facilities in 1945. At the early phase of development, the government put emphasis on expansion of basic health infrastructure starting by establishing provincial hospitals in all provinces, expanding district hospital to cover all districts and health center in all sub-districts throughout the country, For social health protection, various health insurance and welfare schemes were established for specific target population during 1970 – 1990. Private employees were the first group being protected for work-related illness in 1974 followed by the poor in 1975 and government workers and their dependents in 1980. A voluntary community health insurance started in 1983 as a choice for those who were not eligible to the Low Income scheme. For those in private sector, the social security scheme was established in 1990 to cover non-work related illness. From 1990 onward, there was rapid expansion of health insurance coverage according to the expansion of low income scheme to cover other groups i.e. older people, children under 12, students, disabled persons, veterans, monks, evolving of the Health Card scheme from a community financing to be a publicly subsidized voluntary health insurance scheme , and expansion of the Social Security Scheme to cover workers in small enterprises. In addition, there were strong social movements toward universal healthcare coverage during this period and after the 2001 general election, the government announced the UC policy by incorporating the Low Income Scheme with the Health Card Scheme and extend to cover those previously uninsured. 2000 2002 full achieve Universal Coverage CSMBS Health Infrastructure extension--wide geographical coverage 2002

Significant reduction in catastrophic health expenditure and gaps of household out-of-pocket payments for health between rich and poor Source: Analysis from household socio-economic surveys (SES) in various years 1992-2008, NSO - Thailand

Inequity in geographical distribution of doctors and nurses in 2007 280 - 652 653 - 904 905 - 1,156 1,157 – 1,408 Physicians 800-3,305 3,306-6,274 6,245-9,272 9,243-12,300

Use of expensive procedures Variations across 3 public insurance schemes Cesarean section Laparoscopic cholecystectomy Greater access to selective care by the CS patients is also obvious for two selected health interventions based on the national IP data from all types of hospitals during 2004-2007. Both Cesarean section and laparoscopic cholecystectomy are much more common in CS than in UC and SS. These CS-UC and CS-SS gaps are consistent over the 4-year period. Source: Limwattananon et al. (2009)

Use of expensive OP medicines Variations across 3 public insurance schemes Propensity to receive expensive drugs is shown by these monthly time-series over five years, one for each insurance scheme. Obviously, CS has a higher utilization for all three expensive drug groups than SS and UC since the very beginning, for example in ARB, 20% for CS and 1-2% for SS and UC. Even before the direct disbursement policy in CS, the proportional use of ARB grew by 0.35 percentage points per month. In contrast, the ARB growth for UC and SS are much slower and became reverse a little after 2006. Use of the single-source statins and other new antilipidemics even though started with a huge insurance gap at baseline, the trends before and after 2006 are decreasing. The CS-UC and CS-SS gaps in the use of clopidogrel (an innovative anti-platelet) are lower and the increasing trend in all three schemes is also slower. After 2006, the growth diminished. Source: Limwattananon et al. (2009)

Double-digit cost escalation CSMBS’ OP-IP health expenditures (1988-2010) 2006 implementation: - IP DRG system - OP direct billing 1997 Asian economic crisis and conservative reform It would reach the ‘double expenditure’ milestone every 6 years if the annual growth was 12.5% The growth is real term, the expenditure here is a current-year nominal term. One slide nominal term both exp and growth, another slide in real term. There is a bit of work but very useful as future reference in HCF work krub. An asset for the country krub. Another key parameter is Baht per beneficiary comparision 3 schemes which is utmost important, perhaps in another slide krub. Any possible explanations of -2% annual growth 2009-2010? This is mainly due to slow increase in OP exp, while IP expenses were stabilized, although it's a conventional DRG where Baht per RW was given upfront. There is also limited as it is already full capacity of public hosp private wards to accommodate more admissions. If private admission is allowed, it would stir IP expenditure due to abuse and unnecessary admission. (Expenditures in nominal term) 8 Source: Comptroller General Department, Ministry of Finance

Medium- and long-term HCF modeling by ILO experts in 2008

Mismatch between increasing burden of disease from NCD and pattern of health expenditure DALYs attributable to risk factors

Structure of Health Information System Development in Thailand MOPH Thai Health Promotion Foundation Health System Research Institute (HSRI) NHSO NESDB Health Information System Development Plan and Networking NSO Civil societies Academics Steering committee NGOs Management office Data owners Professionals

Key challenges of the Thai health care system Need strong political commitment and support New health technologies and expensive services  long-term sustainability of health care finance for the UC scheme and primary care, An increasing disease burden from chronic NCD and the situation of aging society  reallocate more resources to HP and disease prevention, Inefficiency and inequitable access to quality health services among beneficiaries of different health insurance schemes  harmonization, The pandemic of new emerging infectious disease and unsuccessful control of tuberculosis and HIV/AIDS  need revitalization, Poor governance of the Thai health systems, Mal-distribution and internal brain drain of human resources for health, The impact of economic crisis and international trade/agreement on health of the Thai population, Adequate investment in health information system  M&E, Long-term capacity building of health system and policy research. 12

Conclusion Health outcome Good Poor Cost Low Good Health Low Cost Poor Health High High Cost 13

Acknowledgements Ministry of Public Health (MOPH) of Thailand National Statistical Office (NSO) of Thailand National Health Security Office (NHSO) of Thailand Health Systems Research Institute (HSRI), Health Insurance System Research Office (HISRO) of Thailand, World Health Organization (WHO) London School of Hygiene and Tropical Medicine (LSHTM), United Kingdom