1. Achievements and challenges in financing UHC in Thailand
Phusit Prakongsai, MD. Ph.D.
Supon Limwattananon, Bsc. Ph.D.
Viroj Tangcharoensathien, MD. Ph.D.
Wilailuk Wisasa, Bsc. Msc.
International Health Policy Program (IHPP)
Ministry of Public Health, Thailand
Regional Forum on Health Care Financing
Phnom Penh, Cambodia
2-4 May 2012

2. Outline of presentation
Health financing arrangements of universal health coverage (UHC) in Thailand
Achievements after achieving UHC
Equity improvements
Financial risk protection
Poverty reduction
Key challenges in financing UHC in Thailand
Conclusions 2

3. Informal user fee exemption
Historical development of the Thai health system: Infrastructure development + financial protection extension
Establishment of prepayment schemes
User fees
Informal user fee exemption
1945
Expansion consolidation of prepayment schemes
1970
1975
LIC
1980
CSMBS
1-3rd NHP
Provincial
hospitals
1990
SSS
1980
1983
CBHI
SSS
CSMBS
LIC  MWS
Universal Coverage
4th -5th NHP
( )
District hospitals
Health centers
1990
1994
Pub VHI
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 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 – 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 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.
SSS
2000
2002 full achieve
Universal Coverage
CSMBS
Health Infrastructure extension--wide geographical coverage
2002

4. How health care providers are paid by insurance
How health care providers are paid by insurance ? Financing sources and payment methods for CSMBS, UCS, and SSS
Full capitation
Capitation for OP
DRG under global budget
FFSuntil 2006, DRG for IP
Direct billing FFS(2006+) for OP
Traditional FFS for OP
Source: Tangcharoensathien et al. (2010)

5. Increased access to and utilization of health services with very low unmet needs
The worries that close end provider may result in under provision of services was removed by the fact of improved utilization both outpatient and inpatients.
OP utilization rate increased from 2.4 visit per person per year in 2003 to 3.6 in 2011
Also IP utilization rate increased
Another key evidence on unmet needs. When we applied OECD standard questionnaire, the unmet needs was low, 1.4% of OP and 0.4% of IP, on par with good performing OECD countries.
Prevalence of unmet need OP IP
National average
1.44%
0.4%
CSMBS
0.8%
0.26%
SSS
0.98%
0.2%
UCS
1.61%
0.45%
Source: NSO 2009 Panel SES, application of OECD unmet need definitions

6. 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
Distribution of government subsidies for health: BIA from 2001 to 2007
When we analyzed government subsidies on health gained by different income quintiles, we found that in 2003, the first and second quintiles gained higher percentage of net government health subsidies, compared to the situation before UC. In contrast, the proportion of the net government health subsidies in the third to the fifth quintiles decreased after implementation of universal coverage. The concentration indexes of the net government health subsidies in 2003 had a higher negative value than the subsidy in 2001, which means the poorer gained more government health subsidies in 2003 than the situation before UC.

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

8. Protection against health impoverishment
UHC achieved

9. Sub-national health impoverishment 1996 to 2008

10. Increased hospital accreditation status in 2005-2011
after Pay by quality based pay
before
Sources : Healthcare Accreditation Institute (Public Organization), 2011.
adapted by Bureau of Service Quality Development, NHSO.
หมายเหตุ ปี เป็นข้อมูล ณ ไตรมาส 2

11. Starting
special pay
*54 = estimation from Aug – Jul Source : IP individual record , NHSO

12. Starting Refer-back networking devlop.
Special pay
Starting Refer-back networking devlop.
*54 = estimation from Aug – Jul.2011
Source : IP individual record , NHSO

13. 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

14. Remaining key challenges in financing UCH in Thailand

15. Inequitable government subsidies among three public health insurance schemes
Harmonization of benefit package and provider payment methods among three schemes is urgently needed,
Ensuring equal distribution/access of services across regions
Ensuring good quality of health services 15

16. Inequity in quality of care and health service provision: Percentage of caesarian section to total deliveries by health insurance schemes
Clearly CSMBS had significant higher Caesarean section rate than the other two schemes and a clear trend of rapid increase in Caesarean rate. Members in SHI and UC scheme have similar Caesarean rate.
Source: Electronic claim database of inpatients from National Health Security Office,
(N=13,232,393 hospital admissions)

17. 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
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)

18. 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)

19. Cost escalation: Consequence of fee for services in Civil Servant Medical Benefit Scheme
Evidence:
In 2010, billion THB total expenditure for 5 million CSMBS beneficiaries, US$ 416 per capita is 5.2 times that of UC member capitation US$ 80
CSMBS: OP applies fee for service direct disbursement to providers, DRG replaces FFS for IP since 2006, help stabilize expenditure

20. DALYs attributable to risk factors
Mismatch between increasing burden of disease from NCD and low investment in HP and disease prevention
DALYs attributable to risk factors

21. HIV/AIDS Financing (Source: UNGASS Reports 2008 & 2010)
2007
2008
2009
Total Expenditure:
Total AIDS expenditure, million Baht
6,728
6,928
7,208
Total Health Expenditure, million Baht
248,852
363,771
383,051
Total AIDS expenditure, as
per capita population, Baht
105
110
114
per capita PLWHA, Baht
11,600
14,275
14,417
% GDP
0.08%
% THE
2.7%
1.9%
Sources of Fund:
·         Domestic, % of Total AIDS Expenditure 83 85 93
·         International, % Total AIDS Expenditure 17 15 7
Types of Expenditure:
·         Treatment, % Total AIDS Expenditure
71.8
65.8
76.1
·         Prevention, % Total AIDS Expenditure
14.1
21.7
13.7
↑2.97%
↑4.01% 21

22. Sources: Analyses from the 2002, 2004, and 2006 SES
Household expenditure: tobacco, alcohol and health Median household expenditure (Baht per month),
Sources: Analyses from the 2002, 2004, and 2006 SES

23. Inequity in geographical distribution of Health workforce in 2007
Nurses
,156
1,157 – 1,408
Physicians
800-3,305
3,306-6,274
6,245-9,272
9,243-12,300
Dentists
5,500-15,143
15,144-25,767
25,768-36,390
36,391-47,011

24. Economic loss of 12 priorities BOD in Thailand for prioritization of health investment in the 10th NHDP
diseases
DALY loss
(1)
Curative
expenditure
(2)
Productivity loss due to premature death(3)
Productivity loss due to absenteeism (4)
Total
(2+3+4) 1
HIV/AIDS
19%
17%
35% 6%
30% 2
Traffic accidents
15%
31%
26%
27% 3
CVD
13% 7% 9% 5% 4 DM
18% 4%
32% 8% 5
Liver cancer 1%
10%
100%
Total top 12 disease burden
4,780,000 yr
61,936
million Baht
208,287 million Baht
11,273
281,497 million Baht
Percent by row
22%
74%
% of Thai GDP in 2005
4.0%
From 12 leading BOD, The top three diseases and illness was HIV/AIDS, traffic injuries, and cerebro-vascular disease. Traffic injuries resulted in the second rank of productivity loss from premature death and absenteeism in 2004, and they also led to the highest financial burden for health care cost (31% of top 12 BOD). HIV/AIDS resulted in the highest DALY loss and productivity loss from premature death, but got the third rank for financial burden on health care costs. Finally, DM was the second rank of financial burden on health care costs(18%), and resulted in the highest productivity loss of absenteeism from ambulatory services and hospitalization. Approximately 74% of economic loss was caused by premature death, and 22% was from Curative expenditure and just only 4% was from absenteeism.
Total economic loss from these 12 priority BOD was 281,497 million Baht or 4% GDP in 2005.
Note:
Little success in controlling and preventing road traffic injuries, increasing incidence and prevalence of MDR- and XDR-TB,
Revitalizing HIV control and prevention in the light of universal ART.
Controlling the incidence and prevalence of ESRD patients who require renal replacement therapy (hemodialysis, PD, and KT)

25. Conclusions 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.

26. Topic selection meeting Research working groups
Key stakeholders and participatory processes in topic selection for economic evaluation of UC benefit package
Focus group discussion
Topic selection meeting
Policy maker
Medical specialists
Academic group
Civil Society
General population
Patients
Industry
Academic
Medical specialists
Civil Society
Patients
Key stakeholders
Submission of topics of concerns for consideration
Key stakeholders
Research working groups
evidence on cost effectiveness,
- budget impact analysis,
- systems readiness to implement,
- equity and ethical considerations
UC Benefit Package
Subcommittee

27. Acknowledgement Ministry of Public Health (MOPH) of Thailand
National Statistical Office of Thailand (NSO)
Health Systems Research Institute (HSRI)
Health Information System Development Office (HISO)
Thai Health Promotion Foundation (THPF)
National Health Security Office (NHSO)
WHO long-term fellowship program of WHO-SEA region 27