1. International Health Policy Program -Thailand The 3 rd Global Symposium on Health Systems Research Cape Town International Convention Center, Cape Town, South Africa October 1 st, 2014 Reducing impoverishment from health payments: Impact of universal health care coverage in Thailand Phusit Prakongsai 1 Supon Limwattananon 2 Viroj Tangcharoensathien 1 1 International Health Policy Program, Ministry of Public Health, Thailand 2 Faculty of Pharmaceutical Sciences, Khon Kaen University, Thailand

2. 2 Long march to achieve UHC in Thailand: from targeting to universality, GNI per capita, 1961-2009 1963: $120 CSMBS 1975: $390 Low Income Card 1983: $760 Voluntary Health Card 1990: $1490 SSS 1997: $2710 Asian financial crisis 2002: $1870 Achieving UHC

3. 3 Three health insurance schemes cover the entire population of Thais since 2002 Civil Servant medical benefit Scheme (CSMBS): – Tax financed scheme for government employees and dependants, around 5 millions, Social Security Scheme (SSS): – Payroll tax financed scheme for private sector employees, around 11 millions, Universal Coverage Scheme (UCS): – Tax financed scheme for the remaining population who are neither CSMBS nor SHI members, around 49 millions.

4. 4 UHC cube: Thailand status X axis: – 99% of population coverage Y axis: – Free at point of services, very minimum OOP, – Low incidence of catastrophic health expenditure and health impoverishment, Z axis: – Extensive comprehensive package, small exclusion list, almost all high cost interventions covered.

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 Our focus is on the informal sector households: - Economically inactive - Self-employed - Independent work - Family business

6. International Health Policy Program -Thailand 6 Methodology Comparing pre-UC (1996-2000) vs. post-UC (2002-2009) - Descriptive analyses - Difference-in-difference (DID) approach Health impoverishment refers to (Total consumption expenditure – Health payments) < Poverty lines – 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 7 Results (1) 1.At national level 2.At sub-national level Regional level (urban / rural / Bangkok) Provincial level

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9. Source: Limwattananon S et al. (2011) Distribution of 76 provinces in Thailand according to impoverished households (informal sector) (Year 1996 pre-UC) % Households with number of adult members in the informal employment sectors % Households impoverished by health payments

10. Scheme beneficiaries by income quintile (2003 - 2009) UHC scheme covers mostly the poor, approx 50% in Q1 & Q2

11. Household OOPs as percent household income in Thailand, 2000-2011 Source: Analysis from household socio-economic surveys (SES) in various years 2000-2011, NSO

12. 12 UHC achieved Number of Thai HH prevented from health impoverishment, 2002-2009

13. # Households (in thousands) - Not poor 12,971 13,234 13,177 14,120 15,071 16,476 16,720 17,396 18,191 - Poor2,066 2,522 2,904 2,199 1,690 1,573 1,457 1,597 1,388

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 (2) 1.At national level 2.At sub-national level Regional level (urban / rural / Bangkok) Provincial level

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17. 17 Sub-national health impoverishment 1996 to 2008

18. 18 Total Health Expenditure: 1994-2011 UHC inception Economic crisis Total health expenditure 3.49 to 4.1% of GDP (2003-2011) THE per capita US$ 218 (2011) Million Baht

19. International Health Policy Program -Thailand 19 Conclusions 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: – Impoverishment in the poorest rural Northeast dropped from 3.4% in 1996 to 2.3-2.4% in 2002-04 and 0.8-1.3% in 2006-09. Comprehensive benefit package and zero copayment at points of services are key contributing factors of health financing arrangements in reducing health impoverishment, In addition, the extensive geographical coverage of health infrastructure, adequate finance and functioning primary healthcare are other key contributing factors.

20. International Health Policy Program -Thailand 20 Phusit Prakongsai International Health Policy Program (IHPP) phusit@ihpp.thaigov.net Acknowledgement Ministry of Public Health (MOPH), Thailand National Statistical Office (NSO),Thailand National Health Security Office (NHSO), Thailand Health Equity and Financial Protection in Asia (HEFPA)