1. Universal Coverage in Access to Health Care: National experiences of Thailand Chantana Boon-Arj Chief of International Affairs Social Security Office Ministry of Labour Chantana Boon-Arj Chief of International Affairs Social Security Office Ministry of Labour Social Security Office, Thailand

2. 2  Location: Thailand is situated in the heart of the Southeast Asian mainland, covering an area of 513,115 sq.km. and extends about 1,620 kilometres from north to south and 775 kilometres from east to west. Thailand borders the Lao People's Democratic Republic and the Union of Myanmar to the North, the Kingdom of Cambodia and the Gulf of Thailand to the East, the Union of Myanmar and the Indian Ocean to the West, and Malaysia to the south.  Capital: Bangkok  Official language : Thai  Government : Parliamentary democracy and Constitutional monarchy - King Bhumibol Adulyadej - Prime Minister Abhisit Vejjajiva Country Profile Social Security Office, Thailand

3. 3  Ethic: Thai (75 %), Chinese (14 %), Malay (3 %) Minority groups (8%)  Religion: Buddism (94.7 %), Muslim (4.6 %), Other religions (0.7 %)  Climate: Thailand is a warm and rather humid tropical country with monsoonal climate. Temperatures are highest in March and April with average temperature of 28 degree Celsius to 38 degrees Celsius and humidity averaging between 82.8 percent to 73 percent  Seasons: Dry : March to May, Rainy: June to October, Cool: November to February.  Ethic: Thai (75 %), Chinese (14 %), Malay (3 %) Minority groups (8%)  Religion: Buddism (94.7 %), Muslim (4.6 %), Other religions (0.7 %)  Climate: Thailand is a warm and rather humid tropical country with monsoonal climate. Temperatures are highest in March and April with average temperature of 28 degree Celsius to 38 degrees Celsius and humidity averaging between 82.8 percent to 73 percent  Seasons: Dry : March to May, Rainy: June to October, Cool: November to February. Country Profile (cont.) Social Security Office, Thailand

4. 4  GDP: 2,179.7 billion baht (Quater1,2009)  Population66.9 Million Persons (Aug 09) - Male32.8 Million Persons - Male32.8 Million Persons - Female34.0 million Persons - Female34.0 million Persons Country Profile (cont.) 2005201020152020202520302035204020452050 0-1416.215.213.412.311.711.410.810.09.38.7 15-5943.846.047.848.447.746.144.342.440.338.2 60+6.07.18.710.813.315.818.120.121.522.3 TOTAL65.968.370.071.572.673.273.272.471.169.2 Table Population projection Source UN pop 2000 Social Security Office, Thailand

5. 5 Chart of Population by Labour Force Total population 67.66 Million Person under 15 15.03 Million Person 15 year old 52.56 Million Total labour force (Available for work) 46.76 Million Employed person 36.50 Million Seasonally in active 2.47 Million Unemployed person 7.79 Million Person not in labour force (not available for work) 15.02 Million Household work 4.92 Million Studies 4.40 Million Others 5.70 Million National Statistical Office of Thailand Quarter 1, Jan-Mar 2009 Social Security Office, Thailand

6. 6 Policy to Implementation Health Policy Implementation Before 1961 health care was used to strengthen state power Expansion of public health facilities and health protection scheme employee e.g. CSMBS, SSS NationalSocioeconomic Plan 1961 - health is an important part of long- term investment for economic growth 1973Constitution health services for the poor should be provided free of charge Low income scheme 1977Constitution health is considered as an entitlement of Thai citizens and equal access to basic health services should be guaranteed Universal coverage for health care NATOINAL HEALTH SECURITY OFFICE (NHSO)

7. 7 Health Care Financing: Current Social Health Protection Schemes Major Schemes Civil Servant Medical Benefit Scheme (CSMBS) Social Security Scheme (SSS) Universal Coverage (UC) Introduced in1960s1990s2002s Target beneficiariesGovt employees & dependents, retirees Private sector employees: To whom which not covered by CSMBS nor SHI, Pop Coverage7%13%80% FundingGovt budgetPayroll contribution, Tripartite Govt budget Payment to health facilities Fee-for-service for OP, and DRG for IP Capitation (use DRG in risk adjusted part) Capitation + DRG Social health protection schemes have covered all Thai citizen since 2002 NATOINAL HEALTH SECURITY OFFICE (NHSO)

8. 8 Budget of The Universal Coverage 2004200520062007 GDP nominal (Million Baht) 6,489,4767,092,8937,841,2978,493,311 Government budget (Million Baht) (Million Baht)1,163,5001,250,0001,360,0001,566,200 CSMBS Expenditure (Million Baht) (Million Baht)26,04329,38037,00446,481 SSS Expenditure (Million Baht) 11,60414,29615,82016,979 UC Budget (Million Baht) 61,21267,48382,02391,367 Total98,859111,159134,847154,827 As percent of GDP 1.5% 1.6% 1.7% 1.8% As percent of Government budget 7.8% 8.1% 9.1% 9.2% NATOINAL HEALTH SECURITY OFFICE (NHSO)

9. 9 1) Fringe benefit schemes Health care coverage in Thailand 2) Social Health Insurance under the Social Security Scheme (SSS) 3) Universal Health Care Scheme (UC) Social Security Office, Thailand

10. 10 Fringe benefit schemes Civil Servant Medical Benefit Scheme - Covers government employees, pensioners and dependents (spouse, parents, not more than three children under 20 years of age) around 4.5 million. Civil Servant Medical Benefit Scheme - Covers government employees, pensioners and dependents (spouse, parents, not more than three children under 20 years of age) around 4.5 million. Social Security Office, Thailand

11. 11 - -Benefit package includes ambulatory and inpatient care at public hospitals with minimum co – payments, inpatient care at private hospitals with more than 50% co-payments, reimbursement for drug prescription in case of out-patient. - -Public financing through general tax revenue. - -Providers are paid on a fee for service basis. - -The responsible organization is Comptroller General’s Department, Ministry of Finance. - -Benefit package includes ambulatory and inpatient care at public hospitals with minimum co – payments, inpatient care at private hospitals with more than 50% co-payments, reimbursement for drug prescription in case of out-patient. - -Public financing through general tax revenue. - -Providers are paid on a fee for service basis. - -The responsible organization is Comptroller General’s Department, Ministry of Finance. Social Security Office, Thailand

12. 12 1) Financing of the Scheme 1) Financing of the Scheme - Contribution and compulsory system - Contribution and compulsory system - Sickness include medical care and cash benefit - Sickness include medical care and cash benefit Insurance Social Health Insurance under the Social Security Scheme (SSS) Social Security Office, Thailand

13. 13 Contribution Rates (Contributions are calculated from wage base 1,650-15,000 baht / month) Employers Employees Government Categories Sickness Maternity Invalidity Death Child Allowance Old Age Pension Unemployment Sickness Maternity Invalidity Death Child Allowance Old Age Pension Unemployment 1.5% 1.5% 1.5% 3% 3% 1% 0.5% 0.5% 0.25% Social Security Office, Thailand

14. 14 Summary of Current Benefits Medical Care Free of charge at registered hospital (includes prescribed medicines) Cash Benefit 50% of wages 90 days each time max. 180 days/year max. 365 days for chronic cases Types Qualifying Conditions 3 months contribution within last 15 months Sickness Social Security Office, Thailand

15. 15 2) The Medical Benefit Package 2) The Medical Benefit Package - Ambulance and transportation services; and - Ambulance and transportation services; and - Ancillary services - Ancillary services - Drug and pharmaceutical as determined by - Drug and pharmaceutical as determined by the National Drug List the National Drug List - Drug and pharmaceutical as determined by - Drug and pharmaceutical as determined by the National Drug List the National Drug List - General practitioner and specialist care; - General practitioner and specialist care; - Outpatient and inpatient care; - Outpatient and inpatient care; Social Security Office, Thailand

16. 16 The following illnesses/treatments are not covered: 1.Psychosis except acute attacks 2.Drug addiction 3.Long-term hospitalization (more than 180 days in a year) 4.Hemodialysis, except for acute renal failure which requires immediate treatment for not more than 60 days and end stage of chronic renal failure 5.Cosmetic surgery 6.Researching treatment 1.Psychosis except acute attacks 2.Drug addiction 3.Long-term hospitalization (more than 180 days in a year) 4.Hemodialysis, except for acute renal failure which requires immediate treatment for not more than 60 days and end stage of chronic renal failure 5.Cosmetic surgery 6.Researching treatment Social Security Office, Thailand

17. 17 7.Infertility condition 8.Tissue biopsy for organ transplantation except for bone marrow transplantation 9.Non-medical indicated procedure 10.Organ transplantation except for bone marrow and corneal transplantation 11.Transsexual Surgery 12.Reproductive surgery 13.Recovering period care 14.Dental services (except extraction, filling, scaling and false teeh the at rate specified by SSO) 15.Glasses and lens 7.Infertility condition 8.Tissue biopsy for organ transplantation except for bone marrow transplantation 9.Non-medical indicated procedure 10.Organ transplantation except for bone marrow and corneal transplantation 11.Transsexual Surgery 12.Reproductive surgery 13.Recovering period care 14.Dental services (except extraction, filling, scaling and false teeh the at rate specified by SSO) 15.Glasses and lens Social Security Office, Thailand

18. 18 3) Health care provider 3) Health care provider Requirement on hospital standards, - a minimum of 100 beds - a minimum of 100 beds - 11 standards - 11 standards - referral system - referral system Social Security Office, Thailand

19. 19 Hospitals standards 1.General medical standard 2.Accident and emergency care standard 3.Outpatient care standard 4.Inpatient care standard 5.Intensive care standard 6.Medical Record Standard 7.Surgical care standard 8.Anesthesiology standard 9.Radiology Standard 10.Pathology standard 11.Pharmaceutical practice standard 1.General medical standard 2.Accident and emergency care standard 3.Outpatient care standard 4.Inpatient care standard 5.Intensive care standard 6.Medical Record Standard 7.Surgical care standard 8.Anesthesiology standard 9.Radiology Standard 10.Pathology standard 11.Pharmaceutical practice standard Social Security Office, Thailand

20. 20 4) Payment mechanism Capitation Payment Capitation Payment - based on the number of registered insured persons - based on the number of registered insured persons - 1,250 bahts per person per year - 1,250 bahts per person per year - Monthly payment - Monthly payment - At the beginning of the month – 75% - At the beginning of the month – 75% - At the end of the month – 25% - At the end of the month – 25% Social Security Office, Thailand

21. 21 Additional payment for special high cost services Additional payment for special high cost services - Reimbursement with fixed fee schedules such as - Reimbursement with fixed fee schedules such as - Open heart surgery - Coronary bypass - Brain surgery - Acute renal failure : Hemodialysis and peritonesl Dialysis etc. - Reimbursement with fixed fee schedules such as - Reimbursement with fixed fee schedules such as - Open heart surgery - Coronary bypass - Brain surgery - Acute renal failure : Hemodialysis and peritonesl Dialysis etc. Social Security Office, Thailand

22. 22 Additional payment for utilization incentives -extra capitation payments to hospitals whose caseloads are within the specific percentile rank -Payment is made on a yearly basis (within three months after the end of the year). -extra capitation payments to hospitals whose caseloads are within the specific percentile rank -Payment is made on a yearly basis (within three months after the end of the year). Social Security Office, Thailand

23. 23 Additional payment for risk adjusted capitation - payment for risk adjusted capitation due to the 25 chronic diseases that occurred to the insured persons (out patient) - payment for risk adjusted capitation due to the 25 chronic diseases that occurred to the insured persons (out patient) - In case of inpatients, the SSO used DRGs for all admission. - In case of inpatients, the SSO used DRGs for all admission. - payment for risk adjusted capitation due to the 25 chronic diseases that occurred to the insured persons (out patient) - payment for risk adjusted capitation due to the 25 chronic diseases that occurred to the insured persons (out patient) - In case of inpatients, the SSO used DRGs for all admission. - In case of inpatients, the SSO used DRGs for all admission. Social Security Office, Thailand

24. 24  For emergency cases, insured patients who seek medical treatment from outside registered hospital will be entitled to reimbursement at the rates set by the SSO.  After three days or if the life threatening condition of the insured patients no longer exists, they can be transferred free of charge to a registered hospital for continued treatment.  For emergency cases, insured patients who seek medical treatment from outside registered hospital will be entitled to reimbursement at the rates set by the SSO.  After three days or if the life threatening condition of the insured patients no longer exists, they can be transferred free of charge to a registered hospital for continued treatment. Payment for care arising from emergencies and accidents Social Security Office, Thailand

25. 25 5) Quality Assurance System 1. Pre-audit Hospital accreditation before entering SSO scheme. entering SSO scheme. 2. Post-audit Hospital quality assurance project. 3. Maintaining of quality/service standards. Periodic quality checking/inspection. Complaint and grievances management 1. Pre-audit Hospital accreditation before entering SSO scheme. entering SSO scheme. 2. Post-audit Hospital quality assurance project. 3. Maintaining of quality/service standards. Periodic quality checking/inspection. Complaint and grievances management Social Security Office, Thailand

26. 26 ChallengesChallenges Possibility to extend the health care coverage to spouse and children (5.88 millionpersons) Social Security Office, Thailand

27. 27 Universal Health Care Scheme (UC) Financing of the scheme UC is financed by general tax revenue with 8 sources of income  Other cash income earned  Other cash income earned  General revenues  General revenues  Contributions from local governments  Contributions from local governments  Interest on assets  Interest on assets  Donations  Donations  Fines from violation of the act  Fines from violation of the act Social Security Office, Thailand

28. 28 Main Features of UC Scheme  Beneficiaries  Thai citizens who are not covered by SSS and CSMBS.  Benefit package  Reference to SSS package (except cash benefit) including OP, IP, AE, HC (comprehensive package)  ARV policy was implemented in 2006  ESRD policy will be started in 2009  Personal preventive and health promotion services (PP)  No copayment  Health care provider  Public and private health care providers (accreditation and registration are needed to participate the system)  Primary care (Contracted Unit for Primary Care: CUP) is a unit for population registration and functions as a gatekeeper (referral is needed to access hospital care) NATOINAL HEALTH SECURITY OFFICE (NHSO)

29. 29 Main Features of UC Scheme  Financing  Tax based financing (general tax revenue): budget is calculated and obtained on a per capita basis.  Budget for system administration is totally separated from the health insurance fund and its amount is based on negotiation year by year.  Provider payment  Mix but capitation and DRG are predominant.  Capitation for outpatient services plus some fee for service payment for specific items  DRG within global budget for inpatient services plus some fee for service payment for specific items  Specific “disease management” programs e.g.  AIDS  Leukemia and lymphoma  Cardiovascular surgery NATOINAL HEALTH SECURITY OFFICE (NHSO)

30. 30 Primary care unit Excellent Center Gate Keeper Role PCU Secon dary Care Tertiary Care PCU Quality Standard Providers contract and Quality Assurance NATOINAL HEALTH SECURITY OFFICE (NHSO)

31. 31ChallengesChallenges  Short term  Economic crisis  Long term  Practical “Primary Care” and referral system  The use of “disease management” approach to improve access to specific services  The use of vertical approach to improve effective implementation of PP  Increase of confidence of consumer on quality of care  Insurance coverage of some marginalized groups  Harmonization of public health insurance schemes  Explore new sources of health care financing which are more stable and sustainable  Short term  Economic crisis  Long term  Practical “Primary Care” and referral system  The use of “disease management” approach to improve access to specific services  The use of vertical approach to improve effective implementation of PP  Increase of confidence of consumer on quality of care  Insurance coverage of some marginalized groups  Harmonization of public health insurance schemes  Explore new sources of health care financing which are more stable and sustainable NATOINAL HEALTH SECURITY OFFICE (NHSO)

32. 32 How had health system goals achieved?  Geographical coverage of health care infrastructure  Capacity building in health care financing  Appropriate system design  Comprehensive service package  Contract primary care and better referral system  Money follow patients (purchaser-provider split)  Closed-ended provider payment method with specific payment mechanism for different benefit types  Link specific services (diseases) with clinical protocol and payment to enhance both improvement of quality and cost containmwnt  Support from civil societies and politicians  Geographical coverage of health care infrastructure  Capacity building in health care financing  Appropriate system design  Comprehensive service package  Contract primary care and better referral system  Money follow patients (purchaser-provider split)  Closed-ended provider payment method with specific payment mechanism for different benefit types  Link specific services (diseases) with clinical protocol and payment to enhance both improvement of quality and cost containmwnt  Support from civil societies and politicians NATOINAL HEALTH SECURITY OFFICE (NHSO)

33. 33 What had health system goals achieved?  Coverage  Almost all Thai population are covered  Accessibility  Better access to health services especially catastrophic diseases  Equity  Low income people spend less  Efficiency  Strengthen primary care and referral system  Responsiveness to expectation of beneficiaries  High people satisfaction  Coverage  Almost all Thai population are covered  Accessibility  Better access to health services especially catastrophic diseases  Equity  Low income people spend less  Efficiency  Strengthen primary care and referral system  Responsiveness to expectation of beneficiaries  High people satisfaction NATOINAL HEALTH SECURITY OFFICE (NHSO)

34. Thank you