1. Valerie Schmitt, ILO Bangkok 4 March 2014
Session 1 – Current situation of Health purchasers and legal framework in S-E Asia
Valerie Schmitt, ILO Bangkok
4 March 2014

2. Key points
Course (1h30)
Objectives & principles of social health protection
Activity (30 minutes)
Sources of funding
Variety of situations and systems in ASEAN
In-Tray exercise (1h30) on drafting SHI laws/regulations, followed by presentations to the class (15-20 minutes per group)

3. Social health protection
People face contingencies during their life cycle, which have financial consequences
Maternity
Sickness / ill health
Unemployment
Work injury
Medical care
Families with children
Invalidity
Death of the breadwinner
Old age
Life cycle
Social Health Protection

4. Objectives of SHP 1/ Provide access to affordable quality medical care
2/ Provide financial protection in case of sickness or ill health resulting in a loss of productivity or loss of earnings

5. Principles of SHP Activity (30 minutes):
Define and discuss the principles of SHP
Think about the situation in your own country
Select at least one of these principles that is not yet a reality in your country
Share with the others your country example, and provide evidence

6. Principles of SHP Availability of services Financial protection
Universal coverage
Equality of treatment (residents/migrants)
Collective financing
State’s responsibility
Adequacy of coverage
Right to appeal
Flexibility (no unique model)
Affordability
Quality of care
Solidarity
Predictability
Responsiveness to needs Non-discrimination
Representation

7. Sources of funding: which one do you prefer? And why?
Out-of-Pocket payments
Indirect taxes
Direct taxes
Contributions
Premiums
+ additional Government revenues
The worse is OOP = no financial protection !! ILO does not consider them as a means of financing social health protection.
Direct taxes levied on individuals & enterprises; indirect taxes: VAT, sin tax
Allocation for health care subject to annual public spending negotiations
Contributions are mandatory, not risk-related, based on earned income, shared by employers and workers
Premiums (CBHI, private HI) flat-rate, sometimes risk-based
Payments directly made to the HC provider at the point of delivery
Partial/full cost sharing

8. Sources of funding & types of schemes
Out-of-Pocket payments
Indirect taxes
Direct taxes
Contributions
Premiums
+ additional Government revenues
Subsidies
National HC services
Vouchers
Health Equity Funds
Social health insurance schemes
Community based health insurance
Private HIS
Health care providers

9. Sources of funding & types of schemes
All countries have established systems based on multiple financing mechanisms that combine two or more of the mentioned sources of funding
Activity (30 minutes):
Think about the situation in your own country
Share with others a description of existing schemes and financing mechanisms

10. Variety of situations
Source: ILO Social Security Inquiry Database (2010)

11. Variety of systems in ASEAN
Indonesia
Cambodia
Lao PDR
Thailand
Viet Nam …

12. Development of a HIS for the formal sector in Cambodia
Some poor and near poor have access to HEFs and CBHI schemes; no coverage of the formal sector
Master Plan for Social Health Insurance (SHI), 2005:
Compulsory insurance for the private sector (NSSF) and civil servants (NSSFC)
Voluntary CBHI for non poor informal sector
Health equity funds and health vouchers for the poor
Progressive development of the HI branch of NSSF based on the pilot health insurance project
Coverage: 3.2 million people from HEFs, 170,000 people from CBHIs and 5,000 from HIP ; extension to 700,000 people with the establishment of the HI branch of NSSF
Diversity of financing methods:
Civil servants: government funding
Private sector employees: NSSF (workers and employers contributions)
Non poor informal sector: CBHI (insurance premiums & partial donor funding for admin costs)
Poor and near poor: Health equity funds (donor funding)
Out of pocket spending still very high

13. Recent SHP reform in Indonesia
New legal framework:
National Social Security System Act in 2004
Social Security Providers Act in 2011
Merger of the 3 health insurance providers (Jamkesmas/Jamkesda, Jamsostek and Askes) into one: BPJS Kesehatan since January 2014
Objective: from 59 per cent of coverage in 2010 to universal health care coverage by 2019
Diversity of financing methods:
Civil servant: contributory scheme (5%; 3% borne by employer and 2% by worker)
Private sector employees: contributory scheme (4.5%; 4% borne by employer and 0.5% by worker)
Poor and near poor: subsidized scheme
Non-poor informal workers can register to the programme and pay contribution between 25,500 rupiah (around $2) and 59,500 rupiah (around $5) per month

14. The NHI in Lao PDR SHP is one of the Government’s top priorities
Coverage: from 27.5% of the population in 2012 to 100% by 2020
Four HI schemes & one programme:
State Authority for Social Security (SASS) scheme for civil servants
Social Security Organisation (SSO) scheme for private sector employees
Community-based health insurance (CBHI) scheme for the self-employed
Donor-supported Health Equity Fund (HEF) programmes for the poorest population
MNCH programme piloted by the MoH as well as several international agencies
Towards a National Health Insurance scheme that will integrate the main four social health protection schemes
Prime Minister’s Decree No.470 on the National Health Insurance Scheme, issued on 17 October 2012
Economies of scale & administrative efficiency
Consolidation of risk pools
Extension of coverage

15. The UCS in Thailand Flagship country with almost universal coverage
Three main programmes:
Non-contributory Civil Servants Medical Benefit Scheme (CSMBS) – 6.7 per cent of the population
Health Branch of the Social Security Fund (SSF) for private sector employees (art. 33) and workers leaving the formal sector (art. 39) – 15.4 per cent
Universal Coverage Scheme (UCS) since 2002 for all people not covered by other public health protection schemes – 75.1 per cent

16. From a tax based system to SHI in Viet Nam
Three main programmes:
Compulsory Health Insurance – formal sector, beneficiaries of social assistance, the poor, dependants of army and public security officers.
Voluntary Health Insurance – for those not covered by Compulsory HI
Free Health Card for children and the poor (i.e. fully subsidised health insurance card that covers a comprehensive package of services)
The Law on Health Insurance of 2008 aims to achieving universal health insurance by It shows the commitment of the Government to close the coverage gap through partial/full subsidy of insurance contributions for the poor and vulnerable groups.

17. Developing a legal framework
Activity (1 hour 30 minutes, followed by 15 minutes presentation per group) – IN-TRAY exercise
The Minister of Health of Coresia aims at developing an integrated National Health Insurance System, and you were asked to support the Ministry in the development of a new social health insurance legislation (law and regulations) to achieve this objective.
Your responsibility:
Draft a detailed outline of the new Law (chapters, articles),
Draft several draft articles: (a) Objectives of the SHI; (b) Persons covered; (c) Definition of health care benefits; (d) Institutional design & governance of the system; (e) Financing methods and sources of the SHI.