1. Reducing impoverishment from health payments: impact of universal health care coverage in Thailand Phusit Prakongsai 1 Supon Limwattananon 1,2 Viroj Tangcharoensathien 1 1 International Health Policy Program (IHPP) 2 Faculty of Pharmacy, Khon Kaen University The First Annual Conference of HTAsiaLink Grand Pacific Sovereign Hotel, Petchaburi,Thailand May 14 ‐ 16, 2012

2. International Health Policy Program -Thailand Background information Methodology Research findings Discussion Policy recommendations 2 Outline of presentation

3. International Health Policy Program -Thailand 3 Background

4. 4 Universal Health Coverage – system changes - Removal of financial barriers to access health services, - Shift of the main source of health care finance from out-of-pocket payments to general taxation, - Promoting the use of primary care by contracting a primary care unit (PCU) as the main contractor and gatekeeper, - Changing provider payment mechanisms from historical allocations to close-ended payments, - Increased access to, availability of and utilisation of quality health services, with a strong health infrastructure staffed by committed health professionals, - Hospital Accreditation for all hospitals.

5. International Health Policy Program -Thailand 5 Objectives To assess impact of the universal health care coverage (UHC) on  household impoverishment due to direct health payments,  households facing catastrophic health spending (when household health expenditure exceeds 10% of total household consumption or income) Health impoverishment of households refers to Total consumption expenditure – Health payments < Poverty lines

6. International Health Policy Program -Thailand 6 Methodology Comparing pre-UC (1996-2000) vs. post-UC (2002-2009) - Descriptive analyses of health service use and household health spending, Health impoverishment and catastrophic health spending – Expenditure-based poverty lines as reported annually by NESDB Specific to urban-rural areas in 4 regions + Bangkok – Consumption expenditures based on nationally representative household Socio-economic Survey (SES) by National Statistical Office (NSO) – Health payment including Medicines/medical supplies OP + IP services Household is the unit of analysis

7. International Health Policy Program -Thailand Research findings

8. 8 Increased access to and utilization of health services with very low unmet needs Prevalence of unmet needOPIP National average1.44%0.4% CSMBS0.8%0.26% SSS0.98%0.2% UCS1.61%0.45% Source: NSO 2009 Panel SES, application of OECD unmet need definitions

9. Distribution of government subsidies for health: BIA from 2001 to 2007 More pro-poor health care system and distribution of government subsidies for health after achieving UHC in 2002

10. 10 Incidence of catastrophic health spending OOP>10% total consumption expenditure Source: Analysis of Socio-economic Survey (SES)

11. 11 UHC achieved Protection against health impoverishment

12. International Health Policy Program -Thailand 12

14. Reduction in health-impoverishment* Reduction in health-impoverishment* (A difference-in-difference approach) Employment sector 19982000200220042006200720082009 All-informal-0.099.65-4.85-5.23-9.87-11.73-10.56-12.32 Mixed-1.130.75-2.68-5.70-6.73-8.62-6.50-7.07 All-private-3.461.40-4.07-4.27-6.47-6.86-6.12-6.95 all-public employee households *Absolute difference from 1996, as compared with all-public employee households in number of health-impoverished households per 1,000 non-poor households

15. International Health Policy Program -Thailand 15 Results 1.National level 2.Sub-national level Regional level (urban / rural / Bangkok) Provincial level

16. 16 Sub-national health impoverishment 1996 to 2008

17. International Health Policy Program -Thailand 17

18. How health equity and efficiency were achieved? 1. Long term financial sustainability 2. Technical efficiency, rational use of services at primary health care Functioning primary health care at district level, wide geographical coverage of services, referral back up to tertiary care where needed, close-to-client services with minimum traveling cost In-feasible for informal sector (equally 25% belong to Q1 and Q2) to adopt contributory scheme 1. Equity in financial contribution Tax financed scheme, adequate financing of primary healthcare 2. Minimum catastrophic health expenditure 3. Minimum level of impoverishment Breadth and depth coverage, comprehensive benefit package, free at point of services 4. Equity in use of services 5. Equity in government subsidies Provider payment method: capitation contract model and global budget + DRG EQUITY GOALS EFFICIENCY GOALS

19. International Health Policy Program -Thailand 19 Conclusions (1) Reduction in health-impoverishment in the informal sector and mixed groups was stronger than in the public sector. UCS-mitigated health impoverishment was also found at the sub- national level Comprehensive benefit package and zero copayment at points of services are key contributing factors of health financing arrangement in reducing health impoverishment, In addition, the extensive geographical coverage of health infrastructure, adequate finance and functioning primary healthcare are other contributing factors.

20. International Health Policy Program -Thailand 20 Conclusions (2) Effective implementation: enabling factors System design focusing on equity and efficiency Strengthening supply side capacity to deliver services – Extensive geographical coverage of functioning primary health care, and district health systems  need strong PHC and health infrastructure and health workforce, – Long-standing policy on government bonding of new graduates health workforce for rural services since 1972. Strong leadership with sustained commitment – Continued political support despite changes in governments, – Capable technocrats, – Active civil society, Strong institutional capacity – Long term investment in health information system, – Health technology assessment (HTA), – Health system and policy research, – Good collaboration among researchers, reformists, and advocacy, – Key platform for evidence to inform policy making decisions.

21. International Health Policy Program -Thailand Ministry of Public Health (MOPH) of Thailand, National Health Security Office (NHSO), National Statistical Office (NSO) of Thailand, Health Systems Research Institute (HSRI) 21 Acknowledgement