The Thai Experience on Achieving Universal Healthcare Coverage Samrit Srithamrongsawat Health Insurance System Research Office CHF best practice workshop Dar les Salaam 31 Jan – 2 Feb 2007

Thailand: Country Background Population in million (2006)63 Administrative areas (provinces)76 % Population in urban area31 GNI / Capita ($ in 2005)$2,750 % Growth GDP (2005)4.5 % Gov. revenue from direct taxes (2001) 30 %Total health exp. of GDP in % public financing in Per capita expense/ year 2005$98

Informal exemption User fees 1-3 rd NHP Provincial hospitals Health Infrastructure Thailand: historical development 1975 LIC 1990 Establishment ofprepayment schemes Expansion ofprepayment schemes 1980 CSMBS 1983 HC(CHF) 1990 SSS 4 th -5 th NHP ( ) District hospitals Health centers UniversalCoverage CSMBS SSS 2001 Universal Coverage LIC  MWS 1994 HC(PVHI) SSS

Coverage of health insurance: Source: HWS 1991, 1996, 2001, 2003

System design: ensuring sustainability Close-end budgets – Capitation Purchaser-Provider split Financial management reform –Capitation for OP –DRG weighted global budget for IP –Capitation and performance for prevention and promotion services –Reinsurance for accident and emergency services and high cost services Strengthening primary care: establishment of primary care unit (PCU) Prevention and promotion services Quality improvement: HA, service practice guideline Consumer protection: no-fault liability, call center

Characteristic of the UCS NatureEntitlement, tax-based system Financing modelPublic contracted model, capitation 1,899 THB in 2007 BeneficiariesThai citizens uncovered by SSS and CSMBS Benefit packageComprehensive package including prevention and promotion services (PP) and accredited alternative medicines with an exclusion list of some services Service providersContracted public and private hospitals and requiring all hospital to establish one primary care unit (PCU) for every 10,000-15,000 registered population Payment methodCapitation for OP,PP; DRG weighted global budget for IP Reinsurance for A/E and High cost care Co-payment30 Baht per visit with exemption for those previously under the Medical Welfare Scheme (it was abolished in 2006)

Some policy achievements 80% of UC members are those residing in rural areas and 60% are those in the two bottom quintiles Shifting utilization of service toward primary care Increase in access to high cost services i.e. open-heart surgery, malignancy, cataract Reduce catastrophic expenditure cases by 25% and prevent impoverishment according to paying medical care ~300,000 people in 2003 Decrease in the gap of burden of health expenditure between the poor and the rich

Utilization: increase access and use of PCU and district hospitals source: NSO HWS2001, 2003 and 2004

Improved fairness of financial contributions Source: Socio-Economic Survey conducted by NSO. Declining of gap

Declining of financial catastrophic illnesses in Thailand Source: National Statistic Office, Household Socio-economic Survey, 1996, 1998, 2000, 2002

Major constraints and further development Competing with other social objectives as depending totally government budgets Inequitable distribution of health infrastructure Fragmentation of health insurance schemes  harmonization Long term financial sustainability of the scheme need further exploration

Approved vs estimated capitation

TanzaniaThailand ContextsLimited basic health infrastructure Limited resources for health User fee in public facilities and collected fees were retained at facilities Low-Income scheme CHF  1994 PVHI -Well-establishment of basic health infrastructure ObjectivesMobilize resources for health Enable access to essential services Risk sharing Comparison of Tanzania & Thai CHF_1

TanzaniaThailand ContributionsVaries by districtA flat rate for all (500 THB) Matching fundEqual matching funds equal matching -increase public subsidy Cross-subsidy the poor ?Responsibility of the government. (Low Income scheme) Management of funds District-Province (~ district here) -National fund 2.5% for reinsurance policy covering A/E and high cost services MembersFamilyFamily up to five persons Benefit packageLimited benefits and varies by district Comprehensive package no limitation of use and ceiling -Referral care -High cost services -Portability of benefits Comparison of Tanzania & Thai CHF_2

TanzaniaThailand Enrollment-Health volunteers/ health centers - set a certain period of enrollment, 1- 2 per year, after the harvest season, divided payments -Provide incentives for sellers 2.5% -Mass media advertisement -Strong policy support from MOPH Coverage1-40% (total 15% of pop. In 1999) UtilizationOP 3 visits per year, IP 12% (1999) Cost recovery55% (1999) ProblemAdverse selection Comparison of Tanzania & Thai CHF_3